Right Orchiopexy to Correct Undescended Testicle and Circumcision to Correct Phimosis
Main Text
Table of Contents
Cryptorchidism, or undescended testis, is a condition in which one or both testes fail to descend from the abdomen into the scrotum during fetal development. It is the most common congenital abnormality of the genitourinary tract,1 occurring in approximately 3% of full-term and up to 30% of premature male infants.2 The etiology of cryptorchidism is multifactorial, with genetic, environmental, maternal, and hormonal factors playing a role.3 Risk factors associated with cryptorchidism include prematurity, low birth weight, exposure to certain endocrine-disrupting chemicals during pregnancy, and genetic conditions such as Down syndrome.4–6
If left untreated, cryptorchidism can lead to various long-term complications. One of the most significant concerns is an increased risk of testicular cancer, particularly seminoma and non-seminomatous germ cell tumors.7 Studies have shown that men with a history of cryptorchidism have a higher risk of developing testicular cancer compared to those without the condition.7 Additionally, cryptorchidism is associated with a higher risk of infertility, as the undescended testis may have impaired spermatogenesis due to the temperature difference between the abdomen and the scrotum.8 Other potential complications include testicular torsion, inguinal hernia, and an increased risk of trauma to the undescended testis.
The management of cryptorchidism aims to relocate the undescended testis into the scrotum, typically through surgical intervention known as orchiopexy. This procedure is recommended to be performed between 6–12 months of age, as early treatment has been shown to reduce the risk of complications and improve fertility outcomes.9 Delaying treatment beyond this age range can increase the likelihood of testicular damage and the need for more complex surgical interventions.
Phimosis, on the other hand, is a condition characterized by the inability to retract the foreskin over the glans penis. It can be physiological, occurring in infancy and resolving naturally as the child grows older, or pathological, resulting from scarring, infection, or inflammation.10 Untreated pathological phimosis can lead to various complications, such as urinary tract infections, balanitis, paraphimosis, and an increased risk of penile cancer.11,12
The management of pathological phimosis may involve topical steroid creams or, in some cases, circumcision, which is the surgical removal of the foreskin. Circumcision is a relatively simple procedure that can effectively resolve phimosis and prevent potential complications.13–16
This video serves as a step-by-step guide on orchiopexy to correct an undescended testicle and circumcision to correct phimosis. It highlights the importance of proper dissection, identification, and mobilization of the undescended testis, as well as the techniques for lengthening and mobilizing the spermatic cord. It emphasizes the significance of separating and ligating the hernia sac, if present, to prevent future complications. Additionally, the video illustrates the critical steps involved in repositioning the testis within the scrotum. Furthermore, the video addresses the management of phimosis through circumcision, a procedure that may be performed simultaneously with orchiopexy.
The surgical procedure begins with an oblique skin incision made in the inguinal region, parallel to the inguinal ligament. After dissecting the underlying subcutaneous tissue and Scarpa’s fascia, the external oblique aponeurosis is identified. Then, the external oblique aponeurosis is opened along the direction of the fibers, taking care to avoid injuring the ilioinguinal nerve. The undescended testicle and spermatic cord are identified and dissected off the walls of the inguinal canal. The testicle is examined for viability. The processus vaginalis is then identified and dissected off the contents of the spermatic cord, ligated at the level of the internal ring, and excised. To facilitate the descent of the testis into the scrotum, the spermatic cord, containing the blood vessels, nerves, and vas deferens, must be lengthened. The cremasteric muscles and restraining adventitial tissue are safely dissected free to gain length. This is achieved by dividing the cremasteric fibers surrounding the spermatic cord using electrocautery or scissors. A subcutaneous tunnel is created from the inguinal incision site to the scrotum, allowing for the passage of the spermatic cord and testis into the scrotum. Within the scrotum, a pouch is created in the dartos muscle layer to accommodate the testis in its new position. The testis is guided through the tunnel and positioned within the pouch in the scrotum, ensuring no tension on the spermatic cord. The testis is secured in its new position by suturing the surrounding dartos layer and gubernaculum to the testis, preventing retraction. The external oblique aponeurosis is then closed, followed by the closure of the subcutaneous layer and the skin.
Afterwards, the foreskin is retracted forward and held with Kelly clamps. The skin is divided to expose the glans, excised, and sutured with simple interrupted sutures, concluding the circumcision procedure.
In the postoperative period, the patient is monitored for any complications, such as bleeding, infection, or testicular ischemia. Proper follow-up care and instructions are provided to ensure the success of the procedure and prevent potential complications.
The importance of this surgical intervention lies in the preservation of testicular function, fertility potential, and the prevention of long-term complications associated with cryptorchidism. Early treatment is crucial, as it significantly reduces the risk of testicular damage and associated complications.
The video presented in this case is of significant importance for practitioners, particularly urologists and pediatric surgeons, as it provides a detailed and comprehensive demonstration of the surgical techniques involved in the management of cryptorchidism and phimosis. The step-by-step approach, coupled with the surgeon's commentary, offers valuable insights and practical guidance for those performing these procedures. By providing a detailed visual representation of these procedures, the video can enhance the understanding and skill sets of surgeons, ultimately leading to improved patient outcomes and a higher standard of care.
The parents of the patient referred to in this video have given their informed consent for surgery to be filmed and were aware that information and images will be published online.
Citations
- Wood HM, Elder JS. Cryptorchidism and testicular cancer: separating fact from fiction. J Urol. 2009;181(2). doi:10.1016/j.juro.2008.10.074.
- Berkowitz GS, Lapinski RH, Dolgin SE, Gazella JG, Bodian CA, Holzman IR. Prevalence and natural history of cryptorchidism. Pediatrics. 1993;92(1). doi:10.1542/peds.92.1.44.
- Elamo HP, Virtanen HE, Toppari J. Genetics of cryptorchidism and testicular regression. Best Pract Res Clin Endocrinol Metab. 2022;36(1). doi:10.1016/j.beem.2022.101619.
- Bergbrant S, Omling E, Björk J, Hagander L. Cryptorchidism in Sweden: a nationwide study of prevalence, operative management, and complications. J Ped. 2018;194. doi:10.1016/j.jpeds.2017.09.062.
- Pierik FH, Burdorf A, Deddens JA, Juttmann RE, Weber RFA. Maternal and paternal risk factors for cryptorchidism and hypospadias: a case-control study in newborn boys. Environ Health Perspect. 2004;112(15). doi:10.1289/ehp.7243.
- Gurney JK, Mcglynn KA, Stanley J, et al. Risk factors for cryptorchidism. Nat Rev Urol. 2017;14(9). doi:10.1038/nrurol.2017.90.
- Thonneau PF, Gandia P, Mieusset R. Cryptorchidism: incidence, risk factors, and potential role of environment; an update. J Androl. 2003;24(2). doi:10.1002/j.1939-4640.2003.tb02654.x.
- Chung E, Brock GB. Cryptorchidism and its impact on male fertility: a state of art review of current literature. J Can Urol Assoc. 2011;5(3). doi:10.5489/cuaj.1010.
- Chan E, Wayne C, Nasr A. Ideal timing of orchiopexy: a systematic review. Pediatr Surg Int. 2014;30(1). doi:10.1007/s00383-013-3429-y.
- Sugita Y, Tanikaze S. Phimosis in children. Japan J Clin Urol. 2000;54(11). doi:10.5402/2012/707329.
- Cheng L, MacLennan GT, Bostwick DG. Urologic Surgical Pathology.; 2020. 4th Ed. doi:10.1016/C2016-0-03492-7.
- Morrison BF. Risk factors and prevalence of penile cancer. West Ind Med J. 2014;63(6). doi:10.7727/wimj.2015.381.
- Zhu D, Zhu H. Efficacy of three types of circumcision for children in the treatment of phimosis: A retrospective study. Medicine (United States). 2022;101(48). doi:10.1097/MD.0000000000032198.
- Steadman B, Ellsworth P. To circ or not to circ: indications, risks, and alternatives to circumcision in the pediatric population with phimosis. Urol Nurs: Off J Am Urol Assoc Allied. 2006;26(3).
- Moreno G, Corbalán J, Peñaloza B, Pantoja T. Topical corticosteroids for treating phimosis in boys. Cochrane Database Syst Rev. 2014;2014(9). doi:10.1002/14651858.CD008973.pub2.
- McGregor TB, Pike JG, Leonard MP. Pathologic and physiologic phimosis: approach to the phimotic foreskin. Can Fam Phys. 2007;53(3).
Cite this article
Henson L, Alvear D. Right orchiopexy to correct undescended testicle and circumcision to correct phimosis. J Med Insight. 2024;2024(268.7). doi:10.24296/jomi/268.7.
Procedure Outline
Table of Contents
- Incision
- Locate and Externalize Testis
- Lengthen and Mobilize Spermatic Cord by Dividing Cremasteric Fibers
- Locate and Separate Hernia Sac
- Ligate and Reduce Hernia Sac
- Create Tunnel into Scrotum
- Create Pouch for Testis
- Bring Testis Through Tunnel and into Scrotum
- Suture to Secure Testis in Place
Transcription
CHAPTER 1
Here you can see quite a disparity on the size of the scrotum. You don't even have to touch it, and the lump that they're seeing is his testicle, that's up here, that's in here. The testicle probably goes in the belly and then goes down. We're going to have brought the ring that - we're going to try to bring the testicle to the scrotum. We're going to try. And if it, if it doesn't go down, we might have to take it out because it can develop into cancer.
CHAPTER 2
Okay, cautery? Ah, it's right here. So I don't know whether we can bring his testicle down or not, we'll see. We'll find out how short - see what happens when the testicle is up in the belly, The - the one that doesn't grow or lengthen is the - artery, yeah the cord, the spermatic cord. So if, if you can't lengthen it, you can't bring the testicle down. Because young... Like I said the other day, they took a testicle out of a man with the same thing, and had developed cancer. So this is um... It's not even a testicle. Not yet sir. Yeah. Still there. Feel, I'm pulling on the scrotum. That might be where the testicle is. Right here, there it is. It's a good size testicle. Yes Actually, it's near here - it's the, the testicle can go down right here. You could go right here. Yeah. I think we can bring it down. Hopefully. So you can divide this attachment here, with the cautery right in here. Yeah, I think we can bring it down. It looks like a... There's the testicle, it's not a big. The testicle is smaller than this guy, see this guy is... There's a - the left side's testicle is uh - No. See, that's a small testicle compared to the other side. So it's underdeveloped, but at least it's better to have one and a half than one. One and a half testicle - wait, these are, divide these cremasteric fibers. More chances of winning sir? Yeah. One and a half is better than, than one. But all you need is one. Isn't that a song, all you need is one? Something like that. All you need is love? Oh. I thought... Yeah. See, what we do now is we are mobilizing, we call this mobilizing the cord by dividing all these muscles we call cremasteric fibers. And by doing so, you make the cord longer so that it will go down to the scrotum with ease, without tension. See, so far so good, we're doing good. Yeah, here, more. Wow, that's good. Now, the next thing is we're going to look for the sac, there's a hernia sac in here, and if we release that away from the cord, what will happen is the - the cord will be long enough for us to bring to the to the scrotum. Okay, good. Okay, here it is, now we're going to separate that. There's usually a space that you can find to get the sac away from the cord, but just by doing this maneuver here, just push this. And then eventually you'll see the... It's also your own maneuver sir? The sac. Hmm? Your own maneuver? Yeah. Get the, there. Starting to separate. That's the vas. The vas still there? Okay, we'll get the vas away. I think that's where it is. I found it. I'm going to get that vessel, there is a little vessel. There. Yeah. Part of that. And also... The vas is here, so we're good. That's the cord - that's the sac... Spermatic vessels, so we're good. Like that, okay? That's easy. Now we can divide this. You can divide it here. You can sacrifice that little vessel. Go ahead. Straight? Yeah, like that. Hemostat? Amazing. Hmm? Amazing. See how east that was, what I just did? Yes. You guys take so much trouble doing what I'm doing. You're painstakingly wasting time, and causing bleeding and all that, but I just did a very simple maneuver, you should never have seen in your whole life. Yes, and we use around ten hemostats. Huh? We use around ten hemostats to isolate the sac. What? What a waste. But look, look at this, I want to show you - Hemostat? - I want to show you the opening... Yes, I saw it. Yes. That goes in the belly. See, there? That goes in the belly. Like, see this? This goes in the belly. That's the one. See, see it? Right there? We only used 3 hemostats. That's correct. I use ten. Ten? What a waste. And also it takes forever, takes so much time. Hold this. Now you hold that, and now we're going to separate this whole thing so we can ligate it like we normally do like a regular hernia. Now we can - now it becomes easy. Like this, see? Yeah, like that. And what you do then, is you just slowly peel this off like this, slowly peel this off, with this maneuver, very nice and easy. Yes. Nice and easy. Nice and easy. And here's this trick, a little trick with the gauze. Just look, what you do is just lean with the gauze, down, and you'll see the opening. A little bleeding there. Stop that. Yeah, there's a - I think we have a little bleeder in here. But we'll stop the bleeding with just pressure. Okay, I obtained my objective, see? Now we can put a stitch there, like a 3-0 Vicryl. From here, to there. Okay? Good. Perfect. Okay, tie that. Okay, catch that again. Go towards you. As far as far down as you can. As far down as you can reach, that's it. Like that. Perfect. Excellent. Okay, I'll just go over. It has to do, that's to separate the sac from the cord easily with the forceps. And that's like, one minute? Scissors? Yeah. Sometimes it takes three hours to do this. Yes. Three hours to do this procedure by many people? Including me. Including me, including me. By many people. By many people See? But see how easy it is, now we have that all the way. Oh, that's a good length. See the length, that's plenty of length. And you have all the tissues sir. Everything. It takes about three hours to do this procedure by many people.
CHAPTER 3
Then you go, create a tunnel. Tunnel. Like that. And you go to the base of the scrotum, and then you create a pouch. In the skin. We call that Dartos pouch. We make a pouch so you can create a new house for the testicle. And we do it without bleeding. Is there any bleeding? Okay. No. Okay, here we go. So we're going to catch part of the testicle here that's safe, like this one, this gubernaculum. This is called the gubernaculum, you can grab this with a hemostat. And watch it, the testicle is going to come down to his new house. Here's the testicle, and you slowly bring it down where it belongs into his new house. Here it comes. Yeah, you can stretch with a hemostat, get a hemostat and stretch that opening. Go in and stretch. There it comes. Stretch, stretch. It's going to come out easily. Yeah, that's good. Here it comes, there he is - hello! There's the testicle. And there's no tension, you see? There's no tension, and the blood supply looks great. So now we get a - we suture this with a 5-0. Here's the dartos fascia. Right here. Okay, and suture this to the dartos fascia. The gubernaculum. Put about three stitches. The gubernaculum. Yeah, dartos. Good. Cut? Cut. Okay. Yeah, take - maybe excise that, trim that. Okay. That to that. Put one in between like, in between here. I guess this has been another chapter of the book that you're going to write for me? Yes. Yeah, yeah. Catch that one and to this one, right here. Here. Yeah, to this. Right here. Okay, good. See, we have no tension whatsoever on that after we mobilized that testicle. Okay, now we're going to put - bring me the Adson. Do you have an Adson pickup? So what you do now is we're going to put his testicle in his house. Okay, by just lifting this up. Hello! There you go, put the 5-0 again, just close the skin.
CHAPTER 4
Right there. You made it easy. One minutes to isolate the sac, one minute! I told you there's a space between the two structures, I told them, right? And this is how to find it with the forceps, and you have to do it this way and that way, and this way and then before you know it, you're done. I'm going to need Michelle's pictures for that. Okay, now we're going to close the external oblique, and then you can close. Yeah. There. Yeah, that's the one. Pick the other one, the other side, yeah, see? No that, right there. No, no, no. That. See that? There's the - there's what I'm looking at. There. Okay. Yeah. Yeah, that's the one. This is the one where I dug into the femoral area, so you don't want to do that. Yeah. Okay, sub-q. So you talked to the mother about the circumcision? Yes. Yeah, good. Alright. They had? Okay. They agreed? Yes, the mother agreed, yes. She said we'd do what's best for her son. It's okay. Already said that, that's fine. See that looks nice, see the scrotum now? It looks almost even now. We enlarged the scrotum somewhat by our tunneling.
CHAPTER 5
Okay, all we need to do is maybe just a slit, I don't know, we'll see. 3-0 chromic is what we'll be using for the circ. If not, we can use the 5-0. 5-0. Well we still have 4-0, you can use the same 4-0. Vicryl, Vicryl is fine. Okay. This is called phimosis because the end is tight, and you can't open it to expose the head of the penis, you have phimosis. Okay, let's see. It's best to cut this frenulum. Okay. Okay, good. Now you divide. Put a stitch right - Is that okay, or? You want to - yeah, just stitch it. Is this 4-0? Yeah, fine. You want to trim more? It's up to you. You cut, you cut this first if you want. Go through here up to here. Okay, put a Stitch. He's making a lot of noise. Okay, stitch. Hemostat? Go ahead, cut. In your opinion sir, why do people - what is the significance of circumcision? Circumcision? Yes. Mostly hygiene. But if you can pull your foreskin beyond the crown - corona, you don't need circumcision. No, no need to circumcise. If you have phimosis, that's the only indication. Okay? Okay sir. Otherwise - you don't have to, like I said if you... This kid has phimosis, so at this age, part of the skin should have been pulling back so you can see the head of the penis, but he didn't have, so he has to... Yeah. So, 1% of all males will have phimosis. 1%, only 1%, so only 1% require circumcision, and they don't even require, you know, removal of the skin. That's all they need in order for them to clean, and also have sex properly. Okay, cut.
CHAPTER 6
This case originally was diagnosed as having a hernia because he probably has, and it's well, but they didn't realize that this child had an undescended testicle because when I first saw him while he was on the table I noticed that this was a fully developed testicle, and the scrotum on this side was underdeveloped. And then when I started feeling, I could feel a mass right in here, which turned out to be the testicle. So the testicle was stuck. It didn't go down far enough into the scrotum. It was right in here. So, it's a good thing, because it was stuck, that means the testicle didn't go to the belly, so - it wasn't - it was developing somewhat abnormally because it's smaller than the other side. So what we did was we - we released the hernia away from the spermatic cord structures. We lengthened the cord by two things, two ways. you lengthen the cord by cutting the - the cremasteric muscles, these are muscles around the cord, and then we lengthen the cord by stripping the hernia sac away from the - from the cord structures, and then when you do that, the cord structures start to go down, and you can see where the vas deferens goes medial, and the vessels go lateral. And then we're able to bring it down into the scrotum without any tension. What I mean by no tension is that you're not stretching the blood vessels. Because if you do it in tension, you can stretch the blood vessels and then - phew! When the kids start walking, then they, it will disrupt, and then the testicle dies. So in this case we were able to do that. Then we also noticed that he has phimosis of his, on the penis. He was not circumcised so he can't pull back on the tip of the foreskin because it was tight with a ring, it has a tight ring. We call it preputial ring, which is called phimosis. So we circumcised him so he can stay clean. Thank you.