The Clinical Utility of Testicular Prosthesis Placement in Children With Genital and Testicular Disorders

Stanley Kogan

Disclosures

Transl Androl Urol. 2014;3(4):391-397. 

In This Article

Implantation Technique

Choice of Incision

There are several incisions utilized for prosthesis placement, each with varied benefits and disadvantages (Figure 3).

Figure 3.

Incision locations for testis prosthesis placement (ipsilateral scrotal, supra-scrotal, inguinal, and contra-lateral trans-raphe incisions).

Trans-scrotal placement through a mid-line or transverse scrotal incision is frequently used in adults allowing direct easy hemi-scrotal placement and layered closure. In children the thin pre-pubertal skin does not allow for a sound closure over the device and a small but significant risk of prosthesis erosion and extrusion exists. In the saline prosthesis study cited above, all erosions/extrusions occurred in children where the prosthesis was placed trans-scrotally.

Supra-scrotal prosthesis placement ("wink" incision) precludes this problem.[4] A curvilinear convex incision at the juncture of the scrotum and abdominal pubic skin allows for a reasonably direct placement but layered closure of the scrotal dartos, subcutaneous fat and Scarpa's fascia and skin (Figure 3). In young children an inguinal incision may be utilized, finding a pathway into the scrotum, then closing the scrotal neck above the prosthesis thereby insuring that prosthesis erosion will not occur because of the distance between incision and prosthesis. In older boys at times there is a long distance between an inguinally placed incision and a dependant scrotal position making this incision more disadvantageous.

A unique "compromise" incision is sometimes of great use, especially where an existing prosthesis is to be removed and replaced with a larger adult size, or where a very under-developed scrotum exists precluding satisfactory dependent scrotal placement and symmetry. In this instance a curvilinear incision is made at the junction of the scrotal and peri-genital pubic skin on the contra-lateral opposite side from the site of the prosthesis placement. The incision is deepened and a space is developed in that hemi-scrotal sac, retracting the testicle and spermatic cord laterally. Utilizing the existing prosthesis to be removed (or an underlying finger) for elevation, the midline raphe is divided and the existing prosthesis is removed. Both hemi-scrotal sacs are then widened and joined as one single space and the new prosthesis is placed in the appropriated space with or without fixation to the underlying dependant dartos (see below). This "trans-raphe contra-lateral" approach allows for complete dependant positioning of the prosthesis, excellent scrotal symmetry as well as layered closure of the incision site well away from the prosthesis, minimizing any risk of extrusion. I have utilized this approach many times without a single instance of extrusion or ultimate scrotal asymmetry.

Device Preparation and Placement

The saline-filled testis prosthesis is available in four sizes. The surgeon chooses the appropriate size based on clinical measurements with an orchidometer; measurement with a centimeter ruler offers a gross estimation of the appropriate dimensions as well (Figure 4). Peri-operative intravenous antibiotic coverage is administered and continued orally for 3 days. After completing the incision a plane is made into the scrotum, which is then progressively dilated by placement of antibiotic-soaked fully opened gauze sponges. These are left in place while the prosthesis is prepared. The device is filled with sterile saline through a self-sealing injection port on the sterile field according to manufacturer's provided specifications. After insertion it is important to "seat" the prosthesis in the most dependant portion of the previously developed scrotal space. This site can be marked externally with a marking pen and then inverted using a gauze peanut dissector, taking care to keep the previously marked site in place. A suture tab on the inferior aspect of the device may be utilized to fasten the prosthesis to the interior dartos taking extreme care not to perforate the adjacent scrotal skin, which may cause additional risk of infection subsequently. In many cases, however, this suture tab is not needed and the device may be left to find its own placement and position. The entire wound is irrigated with an antibiotic solution and the incision is closed. Though some choose to close the neck of the scrotum over the device to prevent upward displacement, I do not utilized this maneuver routinely as at times it may causes some deformity of the scrotum with upward prosthesis movement noted later only on eventual subsequent healing.

Figure 4.

Measurement dimensions for sizing saline testis prosthesis (from Coloplast Corporation, Minneapolis, Minnesota). Extra-small size: A 2.2 cm, B 3.0 cm; small size: A 2.5 cm, B 3.5 cm; medium size: A 2.7 cm, B 4.0 cm; large size: A 2.9 cm, B 4.5 cm.

The procedure for placement of the silicone carving block device is similar, though there is no fixation site present on this device.

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