CHAPTER 31 Cryptorchidism
Step 1: Surgical Anatomy
♦ An indirect inguinal hernia is often associated with cryptorchidism, and the hernia sac is usually thin and fragile.
Step 2: Preoperative Considerations
♦ The optimal timing of operation is at about 1 year of age; however, some surgeons advocate as early as 3 to 6 months.
♦ If the testis is nonpalpable, a preoperative ultrasound may identify a testis in the inguinal canal, thus avoiding laparoscopy. Magnetic resonance imaging and computed tomography are rarely helpful in identifying intra-abdominal testes, and laparoscopy is generally the most appropriate next step if the ultrasound fails to reveal a testis.
♦ In the case of bilateral nonpalpable testes, a positive testosterone response to human chorionic gonadotropin stimulation and low serum levels of follicle-stimulating hormone and inhibin B and the presence of serum müllerian inhibiting substance confirm the presence of functioning testicular tissue.
♦ In general, hormonal treatment for cryptorchidism is not recommended; it has poor immediate results and possible long-term negative effects on spermatogenesis.
♦ A physical examination clue for true cryptorchidism is a hypoplastic scrotum on the ipsilateral side or both sides if the condition is bilateral (Fig. 31-1).
Step 3: Operative Steps
Anesthetic Induction
Incision and Technique
♦ If the testis is palpable, the procedure is performed using a transverse groin incision. The incision is made approximately 1 cm longer than for repair of an inguinal hernia to allow for enhanced exposure.
♦ The incision is deepened to the level of the external ring, and the external oblique fascia is incised for a short distance to enable exposure to the upper spermatic cord.
♦ In general, the testis will be visible somewhere in the surgical field, or it can be pulled up into the incision by finding the peritoneal covering (tunica vaginalis) or the processus vaginalis (Fig. 31-2). At this point, an effort should be made to encircle the spermatic cord (and hernia sac if one is present) before opening the tunica vaginalis. The gubernacular remnant is divided, taking meticulous care to ensure that there is no long-loop variant of the vas deferens.
♦ If a hernia sac is present, it is carefully separated from the spermatic cord (Fig. 31-3), and a high ligation performed if possible. Absorbable suture is recommended. The ends of the sutures are clamped with a hemostat to allow countertraction on the peritoneal reflection, which allows easier cephalad dissection of the retroperitoneal testicular vessels.
♦ There is debate as to whether ligation of an associated hernia sac is necessary or whether simple division will suffice. It has become increasingly acceptable that peritoneal closure is not always necessary, as spontaneous closure occurs.
♦ Depending on the distance between the testis and scrotum, the spermatic cord may need to be skeletonized up the retroperitoneum to allow adequate length to bring the testis into the scrotum. Typically the length of the testicular vessels, rather than the vas deferens, is the limiting factor. There are fine investing layers around the testicular vessels that can be released to allow additional length, although this skeletonization process is associated with a later risk of ischemia and testicular atrophy.
♦ If the testis is nonpalpable, a laparoscopy is performed with an umbilical port first to determine whether the testis is intra-abdominal; additional working ports in the right and left abdomen are added if the testis is identified. Bladder decompression should be considered for any evaluative laparoscopic procedure to gain adequate visualization of the pelvis. Once the initial port is placed, the abdomen is insufflated with carbon dioxide to a pressure of 5 to 15 mm Hg (depending on the size of the patient) to visualize the inguinal floor. The patient is placed in the Trendelenburg position during the laparoscopic evaluation.
♦ If the vas deferens and vessels enter the inguinal canal via the internal inguinal ring, a groin exploration should be performed. A remnant testis should be removed, and a suitably sized gonad should be brought into the scrotum.
♦ If the vas deferens/vessels are both absent or they disappear before the inguinal ring, no further steps are needed because testicular agenesis is determined.
♦ If the testis is intra-abdominal, a Fowler-Stephens first-stage orchiopexy can be performed by clip ligature and division of the testicular vessels (Figs. 31-4 and 31-5). The second-stage orchiopexy is performed at approximately 3 to 6 months later (to allow the collateral circulation to develop) through an inguinal approach.
♦ Minimizing mobilization of the testis during the first stage minimizes the risk of testicular ischemia by allowing the deferential vessel of the testis to compensate for absence of testicular artery flow.
♦ Some surgeons prefer to perform the procedure in one stage even if the testis is intra-abdominal. The “stretching maneuver” has been described to predict the success of the single stage.
♦ Before the testis is mobilized, an attempt is made to displace the testis to a position overlying the opposite inguinal ring. If successful, it implies that there is sufficient cord length for a standard orchiopexy.
♦ Microvascular orchiopexy or autotransplantation between the testicular and the inferior epigastric vessels (both open and laparoscopic) is also an option in a very high intra-abdominal testis.
♦ A separate transverse incision on the mid to upper scrotum is needed when a scrotal orchiopexy is performed.
♦ Before making the incision, a finger or clamp is used to develop a plane from the inguinal incision to the scrotum, and the scrotal pouch is tented upward while the incision is made (Figs. 31-6 and 31-7).
♦ For the laparoscopic one stage technique, a clamp is placed through the scrotal incision and bluntly dissected toward the inguinal floor. Under direct laparoscopic visualization, a new opening is made through the internal ring or the anterior rectus sheath medial to the inferior epigastric vessels. The testicle is grasped and delivered into the scrotum. The vessels should be checked for proper orientation.
♦ The testis should be measured along its greatest diameter, along with an estimate of volume and turgor for future reference and dictated in the operative note (Fig. 31-8). A Prader orchidometer can be used for volume estimate. Also, one should be sure to record original position and obvious abnormalities.
♦ A dartos muscle pouch is developed with a fine hemostat by dissecting between the skin and dartos muscle inferiorly. The hemostat is then used to connect the scrotal pouch to the groin or peritoneal cavity, and the testis is brought down by the gubernacular remnant into the pouch, making sure that the spermatic cord is not twisted and the vas deferens is the most medial structure in the cord (Figs 31-9 and 31-10).
♦ The gubernacular remnant is anchored to the inferior scrotal fat pad; I prefer 5-0 Gore-Tex suture (Fig. 31-11). Suture of the tunica albuginea to the dartos muscle is usually not required in the absence of tension. The testis is placed in the dartos muscle pouch (Fig. 31-12). Some surgeons use no attaching sutures at all.
♦ If the external ring was opened in the groin, it can be closed with interrupted Vicryl sutures, depending on the length of the incision. It is better to leave a small defect than to impinge on the spermatic cord by closing the external ring. Scarpa’s fascia is reapproximated with Vicryl and the skin edges with absorbable suture reinforced with a waterproof sealant. A suture may be used to narrow the neck of the pouch laterally to prevent testicular retraction. The scrotal skin incision is closed with absorbable suture (Fig. 31-13).
Step 5: Pearls and Pitfalls
♦ Surgical success following orchiopexy can be defined as a testis occupying an intrascrotal position with no evidence of testicular atrophy.
♦ The diagnosis of cryptorchidism should be avoided until at least 3 months’ corrected age to avoid misdiagnosis of a testis that is still in transit and incompletely descended.
♦ A common pitfall is to confuse a retractile testis with an undescended testis. A retractile testis can be normal in a prepuberal boy. The conditions for retractility are as follows: (1) the testis must reside in the scrotum at least some of the time, (2) the testis must be able to be brought into the scrotum during examination, (3) the testis must stay in the scrotum during the examination after manipulating it to the scrotum for at least a short while, not immediately spring back into the groin.
♦ There is recent evidence that some retractile testes almost never spontaneously descend into the scrotum during childhood and descend into the scrotum only at puberty. Patients with such testes bilaterally may have impaired fertility, and it may be acceptable to operate on these testes early to improve fertility. The recommended age at operation is not well defined but may be based on repetitive serial abnormal examinations and surgical judgment.
♦ The ascending testis is one that is documented to be in the scrotum at birth or within the first year of life, and then is noted to be outside the scrotum. With somatic growth, the funiculus remains short, retracting the testis up. There is also correlation with a residual fibrous remnant of the patent processus vaginalis in some cases.
♦ One cannot always bring the testis to the bottom of the scrotum in one stage, in which case it is acceptable to bring it as low as possible and plan a second-stage operation up to a year later. In most cases, the testis will then easily be brought down to an acceptable intrascrotal position.
♦ Be aware of the possibility of the blind-ending vas with no apparent vessels and a testis located in an abnormal position in the retroperitoneum.
♦ In unilateral ectopic, canalicular, and emergent testes, fertility outcome is good if orchiopexy is carried out in early childhood and diminished if the procedure is done after puberty. Unilateral abdominal testes and unilateral absent or vanishing testes have favorable fertility potential. Bilateral cryptorchids have much lower fertility rates.
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