Orchipexy

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

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 as early as 6-8 months. Most surgeries take up to two years. Such an earlier intervention is considered advisable, firstly, in order to preserve potential fertility, and secondly, because the likelihood of developing oncopathology of an undescended testicle or its torsion is significantly reduced, and thirdly, the smaller the patient, the closer the scrotum is, that is, to move the testicle needs a short distance. Until the age of six months, the operation is not performed, since in most babies (in about 66% of cases of diagnosed cryptorchidism), the testes themselves descend into the scrotum. This usually occurs in the first four months of life, but sometimes even later - up to 6-8 months. After a year, spontaneous prolapse of the testicles is considered impossible. Isolated cryptorchidism is the most common congenital malformation of the male genitalia, affecting almost 1% of term infants at 1 year of age. [1]

So, most cases of cryptorchidism are diagnosed in infancy and then orchipexy is done. However, sometimes the operation is performed on older children and even adults. This can happen due to the sluggishness of the parents, but more often - for an objective reason. In a fifth of patients, usually with ectopic testicular ligaments or both, they are palpated in the scrotum at an early age, but then rise upward with the growth of the body, since they are attached higher, and this does not allow them to fall into place normally. In this case, cryptorchidism is often found in early adolescence after a rapid growth in puberty, and the operation is performed already in an adult. [2]

Indications for the procedure

Established unilateral or bilateral cryptorchidism .

Preparation

Orchipexia is a planned operation. The patient undergoes a general preoperative preparation, designed to reduce possible risks during and immediately after the operation. General preparation for elective surgery can be carried out on an outpatient basis, includes all studies related to the diagnosis of a condition requiring surgery, and an assessment of the patient's general health. They measure his height and weight, do general blood and urine tests, examine his feces for the presence of helminths. In addition, they determine the blood group and the Rh factor, blood clotting, glucose levels, exclude dangerous infectious diseases in the patient: syphilis, tuberculosis, AIDS. When interviewing, they find out whether the patient has had allergic reactions. Additional examinations may be ordered at the discretion of the attending physician. [3]

Orchipexia is most often done in childhood, therefore, written permission is taken from the parents to perform surgery under anesthesia, as well as for orchiectomy, if such a need arises during the operation. 

Since orchipexia is performed under general anesthesia, it is necessary to follow a certain diet three to four days before the operation, using easily digestible foods and excluding those that cause bloating and flatulence. You should not eat the night before and in the morning before the intervention, you need to empty the intestines, and just before the operation, the patient needs to urinate so that the bladder is empty.

Technique orchipexy

Orchipexy is most often performed in young children, it is desirable to have time up to a year. You can live with undescended testicles for a long time and some even manage to become a father, but there is a high probability that a man will not retain reproductive function, and he will be sterile. The scrotum creates optimal conditions for the functioning of the testicles, which are very sensitive to changes in temperature. Histological examinations of the testicles 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 has already been replaced by extensive growths of connective tissue, by six - marked 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 orchipexy performed in early childhood, in which the testis is lowered into the scrotum and sutured into place, allows it to develop normally further. In addition, the operation performed on time allows to avoid acute surgical pathology - testicular torsion, to which persons with cryptorchidism are prone, and also to further reduce the risk of developing tumors.

The technique of execution is reduced to the isolation of the spermatic cord and the undescended testicle (mobilization) from the vaginal process of the peritoneum, in which it is usually located. In this case, all cords of connective tissue accompanying the vessels are removed. Mobilization is performed until the testis reaches the scrotum. This stage is practically the same with any method, the main difference is in conducting, placing the testis in the scrotum and fixing it there. [4]

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

Open surgery performed in two stages is also divided into two types. Quite popular in the past (and in some clinics it is still done now), the Keatley-Bail-Torek-Herzen method is performed in cases where the length of the spermatic cord makes it possible to move the testis to its place immediately. At stage I, a femoral-scrotal anastomosis is created and the testis, placed in it, is fixed to the wide 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, because in addition to serious discomfort for the patient between two operations, the spermatic cord is bent at the level of the inguinal ring, which leads to impaired blood circulation in the testis vessels. Moreover, in this case, its length allows a one-stage operation. [5]

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

A common disadvantage of any two-stage method is a pronounced adhesive process after the first stage of the operation, which develops in the area of intermediate testicular implantation, which provokes negative morphofunctional changes in it.

A one-step procedure is preferred. For example, a widespread worldwide one-stage operation according to the Shumaker-Petrivalsky method. This method provides open access to the inguinal canal by means of a layer-by-layer dissection of soft tissues with a scalpel. Through it, the peritoneal process with the undescended testis and the spermatic cord are isolated and processed according to the standard scheme. A unique technique is used to guide the testis to the scrotum and fix it there. A tunnel is laid with the index finger to guide the testis 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. In approximately in the middle of the bottom of the scrotum, a transverse incision is made to the depth of its skin to the darso about 2 cm long (so that the testis passes). Through it, using a "mosquito" -type clamp, a cavity of the corresponding volume is created, into which the testicle will be brought down, separating the scrotal meatus from the skin. With a finger through the incision in the bottom, the same clamp is carried out to the operating opening in the inguinal canal, the sheath of the testis brought out there is grasped and dragged out through the tunnel through the incision at the bottom of the scrotum. Performing this manipulation, make sure that all components of the spermatic cord (blood vessels, nerves and the duct itself) freely pass through this opening. The testes are placed in the prepared cavity and seized with several sutures to the dartos by the remnants of the processus vaginalis. Next, the necessary suturing of the scrotal tissue is performed and layer-by-layer sutures are applied to the operating wound in the inguinal canal. [6]

Orchipexia according to Sokolov, one-stage, is also popular, the main feature of which is the holding of surgical threads when fixing the testis through the skin of the scrotum.

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

With a high location of a non-descended testicle or short vessels, the method of autotransplantation is used - a new arteriovenous leg is formed, connecting the vessels to a new source of blood supply (as a rule, these are the lower epigastric vessels). The new microvascular technique has become a good alternative to the phased descent of the testicle.

The modern method is laparoscopic orchiopexy. Low-traumatic surgery takes less time and requires a shorter rehabilitation period. It can be carried out in several stages (with a high position of the testicle in the peritoneum or short spermatic cord). Laparoscopic orchiopexy is suitable for patients of all ages. [7]

Contraindications to the procedure

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

Consequences after the procedure

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

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

Complications after the procedure

Complications happen not only because of the flaws of doctors. 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 in a surgical hospital from a week to ten days. At this time, he is provided with professional care by medical personnel. Dressings, wound care, postoperative drug therapy are prescribed by the attending physician and are supervised by nurses. The patient is allowed to get up after the classic operation the next day. They are discharged after removing the stitches in a satisfactory condition. The rehabilitation period is three months, during which the patient must limit physical activity, avoid swimming in open water bodies, swimming pools, do not visit the sauna and steam bath.

With laparoscopic orchipexy, the length of stay in the hospital and the rehabilitation period are reduced. The holes in the skin are sealed with adhesive tape, a staple or one or two stitches are applied. No professional dressings are required. The patient is discharged the next day after the operation. The duration of the above restrictions is reduced to one month. [8]

Reviews

Mostly mothers of little children who have undergone classic open surgery write. In general, everything goes well with them, without complications. It is noted that there is a difficult way out of general anesthesia, a fear of doctors who hurt when bandaging, which is natural - children are small.

Often the child, waking up after the operation, feels good, and begins to understand that it hurts only during the dressing the next day.

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

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

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

After the operation, some were prescribed hormone therapy, during which the child gained a lot of weight, but after the drug was canceled, everything was restored and the development was normal.

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