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

Controversies

Patient Choice

It is clear that not all males with an absent testis need to have a testicular prosthesis.[6,7] The absence of a testis per se is not an indication since many males are not disturbed by its absence and are perfectly happy with their body image. The patient or parent should make the decision about prosthesis placement with full information provided regarding the benefits and risks. It is noted that there is a wide divergence of feelings among boys and men regarding the desire and need for prosthetic testicle placement.

Age at Implantation

Testis prostheses are often placed in adolescence, usually as a result of significant expressed concern about the appearance of his genitals and concerns about body image. During the time when prostheses were unavailable as cited previously, in my practice I cared for three adolescent boys who expressed suicidal ideations because of these above concerns. In more usual circumstances, adolescent boys express a curiosity or less drastic desire, which after consultations leads to a frequent choice to proceed with prosthesis placement.

A more difficult decision is encountered by parents in deciding whether a prosthesis should be placed at an early age. Consider the 1-year old who undergoes orchiectomy for acute testicular torsion. Should a prosthesis be placed at that time? Is there any merit? Is there benefit in placing a prosthesis subsequent to the acute episode, i.e., torsion, yet early-on? Controversy exists regarding early prosthesis placement for an absent testis, and clearly there are advantages and disadvantages, benefits and potential risks. Besides the need for subsequent surgery and anesthesia and for prosthesis change subsequently, as well as the potential risks of infection and extrusion, the effects on psychological well-being remain.

In following these boys with an empty scrotum, as time passes the scrotum usually becomes significantly shrunken and asymmetrical. Prosthesis placement early-on can minimize this in some though this preventative maneuver is not universally successful in accomplishing this goal (Figure 5), which clearly can be helpful in placing a proper size, dependant symmetrical prosthesis in adolescence subsequently. Choice of technique influences this desired outcome: placement of an oversized prosthesis early on leads to initial asymmetry, which at that time is far less noticeable and of less concern than the cosmetic appearance of the empty scrotum, i.e., in boys of high school age having a shrunken empty scrotum at that time. In these circumstances later satisfactory prosthesis placement is also more difficult because of the extreme asymmetry. As a result, in most cases, when feasible I favor prosthesis placement early on, which serves the patient well through puberty at which time an adult prosthesis is substituted.

Figure 5.

Older adolescent with high-riding previously placed prosthesis in early childhood, scrotal asymmetry, with indications for excision and replacement with adult-size prosthesis.

So clearly, there are advantages and disadvantages: for some parents, early initial synchronous or asynchronous prosthesis placement offers a psychological benefit, for others, this approach is unimportant. Proper counseling and information is essential in helping parents arrive at a personalized meaningful decision.

The Small Underdeveloped Scrotum

As mentioned, even though prosthesis placement may be achieved in an underdeveloped scrotum, the ultimate cosmetic appearance may be poor due to inadequate prosthesis dependency leading to frequent patient dissatisfaction. Little is gained when a prosthesis is successfully placed in the most dependant portion of the scrotum but visually is very high riding compared with the contra-lateral testis because of inadequate ipsilateral scrotal size. This event is a common cause for patient dissatisfaction after surgery.

This difficulty may be averted at times by utilizing the entire scrotum as the reservoir, as mentioned above. Striking symmetry is achieved by this maneuver. In some, staged tissue expansion may be attempted,[8] however this is difficult prepubertally due to the thin scrotal skin, risking erosion and extrusion of the expansion device. I have also utilized a single prosthesis to fill the scrotum fully and symmetrically in boys with bilateral testis absence, where two individual smaller prostheses appeared to give a less beneficial cosmetic appearance.

Simultaneous Versus Delayed Placement

The underlying condition as well as prosthesis availability affect the decision whether to place a prosthesis at the time of surgery. When conditions allow and an appropriate pre-operative discussion can take place, i.e., for known absent testes, low-grade neoplasms, orchiectomy for benign disease, etc., a prosthesis may be on hand for simultaneous placement; there is little risk described in using this approach as long as good hemostasis occurs and the scrotal skin is not violated.[9,10] In other instances, i.e., for situations of acute testis loss from torsion, trauma, etc., a prosthesis may not be available and pre-operative discussions are usually not undertaken for prosthesis placement, though one can certainly be placed in a staged procedure subsequently.

Placement in Previously Violated or Compromised Scrotum

If a previous prosthesis was extruded, previous scrotal surgery occurred, or if radiotherapy to the region severely compromised the scrotal skin, an increased risk of prosthesis extrusion exists. Prosthesis placement is not contra-indicated, however; rather, careful surgical planning and implementation should be undertaken. A supra-scrotal incision should be used for prosthesis placement in these instances. Extreme care needs to be done in dilating the scrotum so as to not perforate or thin the impaired scrotal skin. A prosthesis of suitable size should be utilized. This is not a situation where "the largest size possible" should be utilized.

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