Orchiopexy is a procedure in which a surgeon fastens an undescended testicle inside the scrotum, usually with absorbable sutures. It is done most often in male infants or very young children to correct cryptorchidism, which is the medical term for undescended testicles. Orchiopexy is also occasionally performed in adolescents or adults, and may involve one or both testicles. In adults, orchiopexy is most often done to treat testicular torsion, which is a urologic emergency resulting from the testicle's twisting around the spermatic cord and losing its blood supply.
Other names for orchiopexy include orchidopexy, inguinal orchiopexy, repair of undescended testicle, cryptorchidism repair, and testicular torsion repair.
Purpose
To understand the reasons for performing an orchiopexy in children, it is helpful to have an outline of the normal pattern of development of the testes in a male infant. The gubernaculum is an embryonic cord-like ligament that attaches the testes within the inguinal (groin) region of a male fetus up through the seventh month of pregnancy. Between the 28th and the 35th week of pregnancy, the gubernaculum migrates into the scrotum and creates space for the testes to descend. In normal development, the testes have followed the gubernaculum downward into the scrotum by the time the baby is born. The normal pattern may be interrupted by several possible factors, including inadequate androgen (male sex hormone) secretion, structural abnormalities in the boy's genitals, and defective nerves in the genital region.
Orchiopexy is performed in children for several reasons:
To minimize the risk of infertility. Adult males with cryptorchidism typically have lower sperm counts and produce sperm of poorer quality than men with normal testicles. The risk of infertility rises with increasing age at the time of orchiopexy and whether both testicles are affected. Men with one undescended testicle have a 40% chance of being infertile; this figure rises to 70% in men with bilateral cryptorchidism.
To lower the risk of testicular cancer. The incidence of malignant tumors in undescended testes has been estimated to be 48 times the incidence in normal testes. Men with cryptorchidism have a 10% chance of eventually developing testicular cancer.
To lower the risk of traumatic injury to the testicle. Undescended testicles that remain in the patient's groin area are vulnerable to sports injuries and pressure from car seat belts.
To prevent the development of an inguinal hernia. An inguinal hernia is a disorder that occurs when a portion of the contents of the abdomen pushes through an abnormal opening in the abdominal wall. It is likely to occur in a male infant with cryptorchidism because a sac known as the processus vaginalis, which connects the scrotum and the abdominal cavity, remains open after birth. In normal development, the processus vaginalis closes shortly after the testes descend into the scrotum. If the sac remains open, a section of the child's intestine can extend into the sac. It may become trapped (incarcerated) in the sac, forming what is called a strangulated hernia. The portion of the intestine that is trapped in the sac may die, which is a medical emergency.
To prevent testicular torsion in adolescence.
To maintain the appearance of a normal scrotum. Orchiopexy is considered a necessary procedure for psychological reasons, as boys with only one visible testicle are frequently subjected to teasing and ridicule after they start school.
The primary reason for performing an orchiopexy in an adolescent or adult male is treatment of testicular torsion, rather than cryptorchidism. Testicles that have not descended by the time a boy reaches puberty are usually removed by a complete orchiectomy.
Cryptorchidism
Hormonal therapy using gonadotropins to stimulate the production of more testosterone is effective in some children in causing the testes to descend into the scrotum without surgery. This approach, however, is usually successful only with undescended testes that are already close to the scrotum; its rate of success ranges from 10–50%. Undescended testes that are located higher almost never respond to hormonal therapy. In addition, treatment with hormones has several undesirable side effects, including aggressive behavior.
Some surgeons will, however, prescribe hormonal treatment before an orchiopexy in order to increase the size of the undescended testis and make it easier to identify during surgery.
Testicular torsion
Pain caused by testicular torsion can be relieved temporarily by manual detorsion. To perform this maneuver, the doctor stands at the patient's feet and gently rotates the affected testicle toward the outside of the patient's body in a sidewise direction. Manual detorsion is effective in relieving pain in 30–70% of patients; however, it is not considered an alternative to orchiopexy in preventing a recurrence of the torsion or loss of the testicle.
In a normal orchiopexy, the testicle remains in the scrotum without re-ascending. If the procedure has been successful, there is no damage to the blood vessels supplying the testicle, no loss of fertility, and no recurrence of torsion.
BOOKS
"Congenital Anomalies: Renal and Genitourinary Defects." Section 19, Chapter 261 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers and Robert Berkow. Whitehouse Station, NJ: Merck Research Laboratories, 1999.
PERIODICALS
Baker, L. A., et al. "A Multi-Institutional Analysis of Laparoscopic Orchidopexy." BJU International, 87 (April 2001): 484–489.
Chang, B., L. S. Palmer, and I. Franco. "Laparoscopic Orchidopexy: A Review of a Large Clinical Series." BJU International, 87 (April 2001): 490–493.
Docimo, S. G., R. I. Silver, and W. Cromie. "The Undescended Testicle: Diagnosis and Management." American Family Physician, 62 (November 1, 2000): 2037–2044, 2047–2048.
Dogra, Vikram S., and Hamid Mojibian. "Cryptorchidism." eMedicine, June 21, 2002 [April 4, 2003]. <www.emedicine.com/radio/topic201.htm>.
Jawdeh, Bassam Abu, and Samir Akel. "Cryptorchidism: An Update." American University of Beirut Surgery, (Summer 2002) [April 3, 2003]. <www.staff.aub.edu.lb/~websurgp/sc0a.html>.
Nair, S. G., and B. Rajan. "Seminoma Arising in Cryptorchid Testis 25 Years After Orchiopexy: Case Report." American Journal of Clinical Oncology, 25 (June 2002): 287–288.
Rupp, Timothy J., and Mark Zwanger. "Testicular Torsion." eMedicine, March 25, 2003 [April 4, 2003]. <www.emedicine.com/EMERG/topic573.htm>.
Sessions, A. E., et al. "Testicular Torsion: Direction, Degree, Duration, and Disinformation." Journal of Urology, 169 (February 2003): 663–665.
Shekarriz, B., and M. L. Stoller. "The Use of Fibrin Sealant in Urology." Journal of Urology, 167 (March 2002): 1218–1225.
Tsujihata, M., et al. "Laparoscopic Diagnosis and Treatment of Nonpalpable Testis." International Journal of Urology, 8 (December 2001): 692–696.
ORGANIZATIONS
American Academy of Pediatrics (AAP). 141 Northwest Point Boulevard, Elk Grove Village, IL 60007. (847) 434-4000. <http://www.aap.org>.
American Board of Urology (ABU). 2216 Ivy Road, Suite 210, Charlottesville, VA 22903. (434) 979-0059. <http://www.abu.org>.
National Organization for Rare Disorders (NORD). 55 Kenosia Avenue, P. O. Box 1968, Danbury, CT 06813-1968. (203) 744-0100. <http://www.rarediseases.org>.
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
A pediatric surgeon or pediatric urologist is the specialist most likely to perform an orchiopexy in an infant or small child. In an adult patient, the procedure is usually performed by a urologist after referral from the patient's primary physician or the emergency care physician.
An orchiopexy can be performed in the surgical unit of a children's hospital or an ambulatory surgical center. Most orchiopexies in adults are performed as outpatient procedures.
