African Journal of Paediatric Surgery About APSON | PAPSA  
Home About us Editorial Board Current issue Search Archives Ahead Of Print Subscribe Instructions Submission Contact Login 
Users Online: 1711Print this page  Email this page Bookmark this page Small font size Default font size Increase font size 
 
 


 
ORIGINAL ARTICLE Table of Contents   
Year : 2011  |  Volume : 8  |  Issue : 2  |  Page : 203-205
A modified technique for scrotal fixation during orchiopexy


General Surgery Department, Mansoura Faculty of Medicine, Dakahlia, Egypt

Click here for correspondence address and email

Date of Web Publication14-Oct-2011
 

   Abstract 

Background: Undescended testes are a common problem, affecting up to 3% of newborn males. The goals of orchiopexy in humans are to provide adequate scrotal fixation, to prevent recurrent torsion of the testis and spermatic cord or ascent of the testis, and to achieve these goals with minimal trauma to the testis. The best method of achieving fixation remains controversial. Purpose: The aim of our study is to evaluate our modified extra Dartos pouch technique in retaining testis in the scrotum. Patients and Methods: A prospective randomized study included 159 patients with 185 orchiopexies age ranging from 5 months to 14 years with the mean age of 49.5 ΁ 33.3 months (4.08 years). They were divided into two groups: Group I for whom the extra Dartos pouch technique was applied were compared to Group II for whom classic sub-Dartos pouch technique was done. Results: Testis was located in the superficial inguinal pouch in 102 cases (64.1%) and intra-canalicular in 57 cases (35.6%). Hernial sac was found in 153 cases (96.2%), postoperative wound infection occurred in 3 cases (1.9%) and hematoma formation in three cases (1.9%); one case reported ascent of the testis and another one had testicular atrophy in the follow-up period which extends now up to 3 years and we are still in follow-up with those cases. Conclusion: Our modified technique for extra Dartos pouch fixation seems to be a fast reliable method for orchiopexy; however, comparative studies and long-term assessment is still needed to establish this method.

Keywords: Extra Dartos orchiopexy, orchiopexy, sub-Dartos pouch, surgery, undescended testis

How to cite this article:
Ghnnam WM, Saed B, Ghazy H. A modified technique for scrotal fixation during orchiopexy. Afr J Paediatr Surg 2011;8:203-5

How to cite this URL:
Ghnnam WM, Saed B, Ghazy H. A modified technique for scrotal fixation during orchiopexy. Afr J Paediatr Surg [serial online] 2011 [cited 2019 Nov 17];8:203-5. Available from: http://www.afrjpaedsurg.org/text.asp?2011/8/2/203/86063

   Introduction Top


Undescended testes are a common problem, affecting up to 3% of newborn males, [1] although spontaneous descent may occur, leaving a frequency of about 1% at 1 year of age. Transferring the testis to the scrotum is important to provide a normal genital appearance, to avoid complications (torsion, inguinal hernia), [2] possibly to preserve fertility [3] and to reduce the risk of malignancy. [4]

The majorities of undescended testes have a normal histological appearance at birth but develop progressive and irreversible changes after the end of the second year with a reduction in the number of spermatogonia. In the light of these factors it has become widely accepted that orchiopexy should be carried out before the age of 2 years. [5] The goals of orchiopexy in humans are to provide adequate scrotal fixation, to prevent recurrent torsion of the testis and spermatic cord or ascent of the testis, and to achieve these goals with minimal trauma to the testis. The best method of achieving fixation remains controversial. The methods in common use include classic transfixation orchiopexy, involved transfixation of the testicular wall at two different points and fixation of the dartos fascia, scarification, the "window" technique, eversion of the parietal tunica vaginalis, and true dartos pouch orchiopexy with creating a window in the dartos fascia, passage of the testicle, and closure of the window from both sides of the testicle. [6]

The Dartos pouch technique, in various forms, has been described by several investigators over the years, from Koop and Minor [7] to Benson and Lofti. [8] A modified Dartos pouch orchiopexy was reported by Ritchey and Bloom [9] as an alternative to transparenchymal suture fixation. Here we evaluate our modified extra Dartos pouch technique in retaining testis in the scrotum.


   Patients and Methods Top


Between November 2005 and September 2009, a total number of 185 inguinal orchiopexy operations were done for 159 patients who were included in this study and admitted to general surgery department and pediatric surgery unit, Mansoura University Hospital, Egypt. They were randomly divided into two groups: Group I (73 cases) with the modified extra Dartos pouch technique as illustrated below and Group II (a control group of 86 cases) for whom orchiopexy was done in the classic way according to Ritchey and Bloom [9] [Figure 1]. All patients were prepared on outpatient clinic and admitted on one day case surgery protocol for such cases in our department. Under general anesthesia, the patient was placed in supine position and groin crease incision of about 2-3 cm in length was created followed by opening the scarpa's fascia with identification of the testis. Dissection of the testis was done aiming to freeing it from surrounding tissues. Herniotomy was performed for associated hernial sac. If adequate length of the spermatic cord was achieved, a scrotal skin incision was done followed by passage of blunt-tipped artery forceps to dissect the subcutaneous tissue to produce a roomy subcutaneous pouch that will retain the freed testis. The artery forceps then was pushed upwards till the neck of the scrotum where it pierces the subcutaneous tissue to become in line with the opened groin space.Catch the mobilized testis in its normal anatomical direction and brought down to the created pouch where it was not usually fixed if it was resting with ease or the gubernaculum end was Fixed by stitch to the subcutaneous tissue. The scrotal skin and groin crease incision was sutured without drain and patient was discharged the next morning. Dressing was kept in place till removal of stitches in the next week follow-up visit Seven patients (9 orchiopexies) lost follow-up, hence were excluded from the study. Statistical analysis was done using SPSS 17 T test to compare means and non-parametric tests for other variables.
Figure 1: Diagram showing the difference in the course of spermatic cord from our technique to that of sub-Dartos one

Click here to view



   Results Top


Our studied groups [Table 1] included 159 patients with 185 orchiopexies age ranging from 5 months to 14 years with the mean age of 49.5 ± 33.3 months (4.08 years). Fifty four patients (34.9%) had unilateral left side, 79 patients (49.7%) had unilateral right side and 26 patients (16.4%) had bilateral undescended testis. Testis was located in the superficial inguinal pouch in 102 cases (64.1%), intra-canalicular in 57 cases (35.6%). Hernial sac was found in 153 cases (96.2%), postoperative wound infection occurred in three case (1.9%) and hematoma formation in three cases (1.9%). Ascent of the testis occurred in one case in group II and testicular atrophy was observed in one case of group II also [Table 2] during the follow-up period which extends up to three years. Our modified technique significantly had shorter operative time with fewer complications rather than sub-Dartos orchiopexy and long-term follow-up was still needed [Table 2].
Table 1: Clinical parameters in the studied groups

Click here to view
Table 2: Complications in the studied patients

Click here to view



   Discussion Top


Bevan in 1899 first reported orchiopexy as a treatment for the undescended testis. Little has changed in the principles of surgical technique and that he described hernia repair and adequate retroperitoneal mobilization were both stressed to ensure that the testis would easily reach the scrotum without undue tension. The most important determinants of whether the testis will remain in place after surgery are adequate mobilization of the testis with spermatic cord and tension-free placement within the scrotum. Not all surgeons use additional sutures during orchiopexy. [10] The most significant complication of orchiopexy is testicular atrophy. Injury to the spermatic vessels, or extensive downward traction during repair, can cause postoperative venous congestion or ischemia with resultant testicular atrophy. Although this is a rare complication of routine orchiopexy, published reports indicate an 8% failure rate of orchiopexy, even in the distally situated undescended testis, and failure of more than 25% for intraabdominal testes. Other infrequent complications include ascent of the testis, infection, and bleeding. [11]

In this preliminary report of our modified extra Dartos pouch technique we noticed no major complications (such as testicular atrophy, ascent nor loss) and no hernia recurrence up to 3 years of follow up, only minor complications in the form of wound sepsis in two cases (2.7%), hematoma of the scrotum resolved completely with conservative treatment in one case (1.4%). It has been a long-standing surgical dogma that undescended testis is always associated with a hernial sac making an inguinal approach mandatory. The reported incidence varied from 36% to more than 90%. [12],[13],[14],[15],[16] The total number of hernial sacs in our series was 153 cases (n=159) {96.2%} favoring this dogma.

In our modification we made long subcutaneous track for the cord till the testis lie down in the scrotum, so here we avoid the testis to be immediately facing the opening in the dartos and tunica thus decreasing the possibility for testicular ascent. Also we think that this path would induce some adhesions between the cord coverings and subcutaneous tissue, thus further preventing testicular ascent following this technique and also diminishing the need for suture fixation or narrowing of the window around the cord as done in the conventional orchiopexy.


   Conclusion Top


Our modified technique for extra Dartos pouch fixation seems to be a fast reliable and with less complications method for orchiopexy rather than the classic sub-Dartos one; however, further studies and long-term assessment is still needed to establish this method.


   Acknowledgment Top


Thanks to all patients for their contribution and assistance. Details of Ethics Approval and Funding: This research is approved by our university (Mansoura Faculty of Medicine Research Committee) no external funds.

 
   References Top

1.Berkowitz GS, Lapinski RH, Dolgin SE, Gazella JG, Bodian CA, Holzman IR. Prevalence and natural history of cryptorchidism. Pediatrics 1993;92:44-9.  Back to cited text no. 1
    
2.Bianchi A. The impalpable testis. Ann R Coll Surg Engl 1995;77:3-6.  Back to cited text no. 2
    
3.Taskinen S, Hovatta O, Wikstrom S. Early treatment of cryptorchidism, semen quality and testicular endocrinology. J Urol 1996;156:82-4.  Back to cited text no. 3
    
4.United Kingdom Testicular Cancer Study Group. Aetiology of testicular cancer: Association with congenital abnormalities, age at puberty, infertility and exercise. BMJ 1994;308:1393-9.  Back to cited text no. 4
    
5.Huff DS, Hadziselimovic F, Snyder HM 3 rd , Duckett JW, Keating MA. Postnatal testicular maldevelopment in unilateral cryptorchidism. J Urol 1989;143:546-8.  Back to cited text no. 5
    
6.Lotan G, Golan R, Efrati Y, Vigodner M, Lewin L, Shochat L, et al. An experimental study of the effect of two distinct surgical techniques of orchiopexy on spermatogenesis and testicular damage in cryptorchid testes. Fertil Steril 2005;84:749-55.   Back to cited text no. 6
    
7.Koop CE, Minor CL. Observations on undescended testis: The technique of surgical management. Arch Surg 1957;75:898-905.  Back to cited text no. 7
    
8.Benson CD, Lofti MW. The pouch technique in the surgical correction of cryptorchidism in infants and children. Surgery 1967;62:967-73.  Back to cited text no. 8
    
9.Ritchey ML, Bloom DA. Modified dartos pouch orchiopexy. Urology 1995;45:136-8.  Back to cited text no. 9
    
10.De Netto NF, Goldberg HM. A method of orchiopexy. Surg Gynecol Obstet 1964;118:840-2.  Back to cited text no. 10
    
11.Taran I, Elder JS. Results of orchiopexy for the undescended testis. World J Urol 2006;24:231-9.  Back to cited text no. 11
    
12.Dayanç M, Kibar Y, Tahmaz L, Yildirim I, Peker AF. Scrotal incision orchiopexy for undescended testis. Urology 2004;64:1216-8.  Back to cited text no. 12
    
13.Riquelme M, Aranda A, Rodriguez C, Cortinas J, Carmona G, Riquelme-Q M. Incidence and management of the inguinal hernia during laparoscopic orchiopexy in palpable cryptoorchidism: Preliminary report. Pediatr Surg Int 2007;23:301-4.  Back to cited text no. 13
    
14.Saw KC, Eardley I, Dennis MJ, Whitaker RH. Surgical outcome of orchiopexy. I. Previously unoperated testes. Br J Urol 1992;70:90-4.  Back to cited text no. 14
    
15.McKiernan MV, Murphy PD, Johnston JG. Ten year review of treatment of the undescended testis in the west of Ireland. Br J Urol 1992;70:84-9.  Back to cited text no. 15
    
16.Grosfeld JL. Current concepts in inguinal hernia in infants and children. World J Surg 1989;13:506-15.  Back to cited text no. 16
    

Top
Correspondence Address:
Wagih M Ghnnam
14 Gawad Hosney Street, Sherbin, Dakahlia
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0189-6725.86063

Rights and Permissions


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2]

This article has been cited by
1 Surgical approach to the palpable undescended testis
Reju J. Thomas,Andrew J. A. Holland
Pediatric Surgery International. 2014; 30(7): 707
[Pubmed] | [DOI]



 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  
 


    Abstract
   Introduction
   Patients and Methods
   Results
   Discussion
   Conclusion
   Acknowledgment
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed6666    
    Printed570    
    Emailed0    
    PDF Downloaded249    
    Comments [Add]    
    Cited by others 1    

Recommend this journal