How is surgery performed for the treatment of cryptorchidism with palpable testis?

Updated: Dec 17, 2020
  • Author: Joel M Sumfest, MD; Chief Editor: Edward David Kim, MD, FACS  more...
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An incision is made over the inguinal canal along the Langer lines. For gonadal identification, care is taken when the Scarpa fascia is incised because the testis may be located in the superficial inguinal pouch rather than in the inguinal canal. Identification of the shelving edge of the inguinal ligament is helpful for orientation, especially in chubby infants.

The distal gubernacular attachments are divided. The cremasteric muscle fibers are then mobilized. (The author has found bipolar cautery to be helpful in this regard.) If the undescended testis is in a low position, incision of the external oblique fascia may be unnecessary. Separate the cord structures from the peritoneum above the internal inguinal ring during ligation of the hernia sac. Divide the lateral spermatic fascia to allow medial movement of the testis. Isolate and perform high ligation of the patent processus vaginalis on the anteromedial surface of the cord. Relocate the testis into the scrotum in a subdartos pouch.

The preferred method of testis fixation is controversial. Options are as follows:

  • A subcutaneous pouch with suture fixation versus a sutureless subdartos pouch
  • Absorbable versus permanent suture
  • Tunica vaginalis fixation versus tunica albuginea fixation

Considerations regarding those options include the following:

  • Bellinger et al (1989) [63] and Dixon (1993) [64] have shown that sutures through the tunica albuginea cause testicular parenchymal damage in rats
  • Chromic sutures produce more fibrosis than permanent sutures
  • A sutureless subdartos pouch offers the least fibrosis
  • Jarow determined that subtunical sutures may damage the testicular blood supply, more in the lower pole than in the upper. If sutures are used, they should be fine and nonabsorbable (eg, 5-0 Prolene) and placed with minimal depth in the tough tunica albuginea. [65]

Further maneuvers may be used to achieve adequate length of an inguinal testis. For the Prentiss maneuver, divide (or pass the testis under) the inferior epigastric artery and vein and open the transversalis fascial layer. Open the internal inguinal ring by dividing the internal oblique muscles and more of the lateral spermatic fascia. The inguinal incision may also be lengthened to enable this dissection.

Continue dissection in the retroperitoneal space. The Fowler-Stephens orchiopexy with division of the internal spermatic artery allows the testis to survive on the blood supply of the vas deferens and the cremasteric attachments. This may be used only if extensive dissection of the vas and cord has not already occurred.

The region of transection of the spermatic artery is controversial. Fowler and Stephens originally reviewed the vascular anatomy to the testis and determined that the spermatic artery is an end artery. Thus, the parenchyma of the testis supplied by this artery would become ischemic if it were transected close to the testis. The recommended ligation is as far from the testis as possible to maximize collateral blood flow.

Testicular autotransplantation by microvascular anastomosis of the testis to the ipsilateral inferior epigastric artery and vein may be used.

In rare cases, a 2-stage orchiopexy without division of the spermatic vessels is performed when the Prentiss maneuver and cord dissection have failed to gain adequate length. The testis is anchored in its most dependent position (high scrotum or pubic tubercle) with or without the cord covered by a silastic sheath. The second stage is performed 6-12 months later.

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