Orchipexy

Orchiopexy is a reconstructive surgery in male patients with a congenital anomaly in which one or both testicles (simply called testicles) are not detected in the scrotum, that is, with a diagnosis of cryptorchidism.

The pathology is diagnosed in the vast majority of cases (4/5) immediately at birth, and the operation is recommended to be performed in infancy and early childhood. According to the international protocol, the patient can be operated on already at 6-8 months. Most operations are performed before the age of two. Such an earlier intervention is considered advisable, firstly, in order to preserve potential fertility, secondly, because the likelihood of developing oncopathology of the undescended testicle or its torsion is significantly reduced, thirdly, the smaller the patient, the closer the scrotum is, that is, the testicle needs to be moved a short distance. The operation is not performed before the age of six months, since in most babies (approximately 66% of cases of diagnosed cryptorchidism), the testicles descend into the scrotum on their own. This usually happens in the first four months of life, but sometimes later - up to 6-8 months. After a year, spontaneous descent of the testicles is considered impossible. Isolated cryptorchidism is the most common congenital anomaly of the male genitalia, affecting almost 1% of full-term infants at 1 year of age. [ 1 ]

Thus, most cases of cryptorchidism are diagnosed in infancy and orchiopexy is performed at that time. However, sometimes the operation is performed on older children and even adults. This may happen due to the sluggishness of parents, but more often - for an objective reason. In a fifth of patients, as a rule, with ectopia of the guide ligament of the testicle or both, they are palpated in the scrotum at an early age, but then rise up with body growth, since they are attached higher, and this does not allow them to descend normally into place. In such a case, cryptorchidism is often detected in early adolescence after rapid growth during puberty, and the operation is performed on an adult. [ 2 ]

Indications for the procedure

Established unilateral or bilateral cryptorchidism.

Preparation

Orchiopexy is a planned operation. The patient undergoes general preoperative preparation, designed to reduce possible risks during and immediately after the operation. General preparation for a planned operation can be done on an outpatient basis, includes all studies related to the diagnosis of the condition requiring surgical intervention, and an assessment of the patient's general health. The patient's height and weight are measured, general blood and urine tests are done, and feces are examined for helminths. In addition, the blood type and Rh factor, blood clotting, glucose levels are determined, and dangerous infectious diseases are excluded in the patient: syphilis, tuberculosis, AIDS. During the survey, it is found out whether the patient has had allergic reactions. Additional studies may be prescribed at the discretion of the attending physician. [ 3 ]

Orchiopexy is most often performed in childhood, so written permission is obtained from parents for the surgical intervention to be performed under anesthesia, as well as for an orchiectomy, if such a need arises during the operation.

Since orchiopexy is performed under general anesthesia, it is necessary to follow a certain diet for three to four days before the operation, eating easily digestible foods and excluding those that cause bloating and flatulence. The night before and in the morning before the intervention, you cannot eat, you need to empty your bowels, and immediately before the operation, the patient needs to urinate so that the bladder is empty.

Technique orchipexies

Orchiopexy is most often performed on young children, preferably before the age of one. You can live a long time with undescended testicles, and some even manage to become fathers, but there is a high probability that the man will not retain reproductive function and will be infertile. The scrotum creates optimal conditions for the functioning of the testicles, which are very sensitive to changes in temperature. Histological studies of the testicles located outside the scrotum record significant changes in the spermatogenic epithelium even in children of the first year of life; by the end of the fourth year, it is already replaced by extensive growths of connective tissue; by six, pronounced fibrosis is noted. By the end of sexual development, the patient often suffers from infertility.

Therefore, it is recommended to eliminate cryptorchidism at the age of six months to two years. Preventive orchiopexy performed in early childhood, in which the testicle is lowered into the scrotum and sewn into place, allows it to develop normally. In addition, timely surgery helps to avoid acute surgical pathology - testicular torsion, which is common in people with cryptorchidism, and also reduces the risk of tumor development in the future.

The technique involves separating the spermatic cord and the undescended testicle (mobilization) from the vaginal process of the peritoneum, where it is usually located. In this case, all connective tissue strands accompanying the vessels are removed. Mobilization is performed until the testicle reaches the scrotum. This stage is practically the same for any method, the main difference is in the passage, placement of the testicle in the scrotum and fixation there. [ 4 ]

In addition, these interventions are divided into those performed in one or two stages. One-stage orchiopexy is currently considered preferable, when everything from mobilization to fixation is performed in one go.

Two-stage open surgeries are also divided into two types. Quite popular in the past (and in some clinics it is still performed) operation according to the Keatley-Baile-Torek-Hertsen method is performed in cases when the length of the spermatic cord allows the testicle to be moved to its place immediately. At stage I, a femoroscrotal anastomosis is created and the testicle, placed in it, is fixed to the broad femoral ligament. After three to six months, the testicle is surgically separated from the fascia, and the scrotum from the thigh. This method is now almost never used, since in addition to serious discomfort for the patient between the two operations, the spermatic cord bends at the level of the inguinal ring, which leads to a disruption of blood circulation in the vessels of the testicle. Moreover, in this case, its length allows for a one-stage operation. [ 5 ]

Another type of two-stage surgery is used if the testicle cannot be immediately lowered into the scrotum due to the insufficient length of the cord. It is attached where it can reach as freely (without excessive tension) as possible (usually at the level of the pubic tubercle), and after about six months to a year the testicle is already placed in the scrotum.

The general disadvantage of any two-stage method is a pronounced adhesion process after the first stage of the operation, developing in the zone of intermediate implantation of the testicle, which provokes negative morphofunctional changes in it.

A one-stage surgical technique is preferable. For example, the one-stage surgery by the Shumaker-Petrivalsky method, which is widespread throughout the world. This method provides open access to the inguinal canal by layer-by-layer dissection of soft tissues with a scalpel. Through it, the peritoneal process with the undescended testicle and the spermatic cord are isolated and processed according to the standard scheme. The technique used to guide the testicle to the scrotum and secure it there is unique. A tunnel is made with the index finger to guide the testicle to the place of attachment, for which it is inserted into the lower corner of the surgical incision and carefully carried to the bottom of the scrotum. Approximately in the middle of the bottom of the scrotum, a transverse incision is made to the depth of its skin to the fleshy membrane, approximately 2 cm long (so that the testicle passes). Through it, using a mosquito clamp, a cavity of the appropriate volume is created, into which the testicle will be lowered, separating the fleshy membrane of the scrotum from the skin. Using a finger, the same clamp is passed through the incision in the bottom to the surgical opening in the inguinal canal, the membrane of the testicle brought out there is grasped and it is pulled through the tunnel out through the incision on the bottom of the scrotum. When performing this manipulation, ensure that all components of the spermatic cord (vessels, nerves and the duct itself) pass freely through this opening. The testicle is placed in the prepared cavity and is grabbed with several sutures to the fleshy membrane by the remains of the vaginal process. Next, the necessary suturing of the scrotal tissues is performed and sutures are applied layer by layer to the surgical wound in the inguinal canal. [ 6 ]

Also popular is Sokolov's one-stage orchiopexy, the main feature of which is the passage of surgical threads through the skin of the scrotum when fixing the testicle.

There are many methods of performing operations, they differ mainly in the methods of fixing the testicle in the scrotum. In particular, a fixation method called funiculopexy has recently become popular. The testicle is fixed in place by suturing the spermatic cord along its entire length in the inguinal canal. The structural elements of the spermatic cord should not be too stretched with any fixation methods, and in addition, with all methods they try to avoid bending it.

In the case of a high position of the undescended testicle or short vessels, the autotransplantation method is used - a new arteriovenous pedicle is formed, connecting the vessels to a new source of blood supply (usually these are the lower epigastric vessels). The new microvascular technique has become a good alternative to the step-by-step lowering of the testicle.

A modern method is laparoscopic orchiopexy. This low-traumatic operation takes less time and requires a shorter rehabilitation period. It can be performed in several stages (with a high position of the testicle in the peritoneum or a short spermatic cord). Laparoscopic orchiopexy is suitable for patients of any age. [ 7 ]

Contraindications to the procedure

Operations are not performed on children and adults with severe systemic diseases, blood clotting disorders, during acute illnesses and exacerbations of chronic pathologies. If the patient's condition can be stabilized, he is allowed to undergo surgery.

Consequences after the procedure

If orchiopexy is performed on time, that is, before the age of two, the consequences of the operation are the most favorable. The testicle placed in the scrotum develops correctly, the prognosis for maintaining fertility is favorable. The older the patient, the worse the prognosis and the longer the rehabilitation. The functions of the testicle may not be restored at all. Although young patients after orchiopexy are examined and undergo treatment, which can be effective. Each case has an individual outcome.

Orchiopexy is an operation, in most cases open. Therefore, complications after the procedure are always possible. After any surgical intervention, the site of the operation is inflamed and swollen, there may be bleeding, the patient feels pain. During the procedure, the spermatic cord, blood vessels, and testicle may be damaged. Later complications include ischemia and atrophy of the testicle, its incorrect location in the scrotum.

Complications after the procedure

Complications occur not only due to doctors' mistakes. There are various individual anatomical features, and also - patients do not always comply with postoperative restrictions.

Care after the procedure

After an open operation, the patient spends from a week to ten days in the surgical hospital. During this time, he is under professional care of medical personnel. Dressings, wound treatment, and postoperative drug therapy are prescribed by the attending physician and are carried out under the supervision of nurses. The patient is allowed to get up the next day after a classic operation. He is discharged after the stitches are removed in a satisfactory condition. The rehabilitation period is three months, during which the patient must limit physical activity, avoid swimming in open water, pools, and not visit a sauna or steam bath.

Laparoscopic orchiopexy reduces the hospital stay and rehabilitation period. The skin holes are sealed with adhesive tape, a staple or one or two stitches are applied. Professional dressings are not required. The patient is discharged the day after the operation. The duration of the above restrictions is reduced to a month. [ 8 ]

Reviews

Mostly, mothers of small children who have undergone classic open surgery write. In general, everything goes well for them, without complications. It is noted that it is difficult to recover from general anesthesia, fear of doctors who hurt when changing bandages, which is natural - the children are small.

Often, a child, waking up after surgery, feels well and begins to understand that it only hurts during the dressing change the next day.

According to reviews, children are discharged the next day after open surgery. Then they come with them for dressings and to remove stitches on an outpatient basis.

Basically, everyone writes immediately after the operation, under impression.

Long-term results are rarely described, for example, three years after surgery (there was a hypertrophied testicle), it was not removed, it was lowered into the scrotum and now it is developing normally.

Some were prescribed hormone therapy after the operation, during which the child gained a lot of weight, but after the drugs were discontinued, everything was restored and development was normal.

There are no reviews from adult men who underwent surgery in early childhood.