Minimal invasive procedures

Testicular torsion is a true urologic emergency

and must be differentiated from other complaints of testicular pain because a delay in diagnosis and management can lead to loss of the testicle. Though testicular torsion can occur at any age, including the prenatal and perinatal periods, it most commonly occurs in adolescent males; it is the most frequent cause of testicle loss in that population.

In pediatric patients, the following features are associated with higher likelihood of torsion

• Pain duration of less than 24 hours
• Nausea or vomiting
• High position of the testicle
• Abnormal cremasteric reflex

Results of physical examination are imperfect in ruling out testicular torsion, however.

Imaging studies (eg, ultrasonography, nuclear scans) may be useful when a low suspicion of testicular torsion exists.A Doppler sonogram of an avascular testicle is shown

Surgical exploration should not be delayed for the sake of performing imaging studies.

If the diagnosis of torsion is suspected on clinical grounds, early urologic consultation is mandatory since definitive treatment is surgery for detorsion and orchiopexy or possible orchiectomy.

The procedure for manual detorsion of the testis is similar to the “opening of a book”

In the literature, the success rate of manual detorsion has varied widely. Success rates have ranged from 26.5% to more than 80%.

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

Cryptorchidism is the most common abnormality of the male genital tract, affecting 3–5% of full-term male infants and 30–32% of premature male infants. In most cases, the condition resolves during the first few months after delivery; only 0.8% of infants over three months of age still have undescended testicles. Because of the potentially serious consequences of cryptorchidism, however, doctors do not advise watchful waiting once the child is over six months old.