| Orchiopexy | |
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 Evolution of orchiopexy |
Orchiopexy (or orchidopexy) is a surgery to move and/or permanently fix a testicle into the scrotum. While orchiopexy typically describes the operation to surgically correct an undescended testicle, it is also used to resolve testicular torsion.
Undescended testicles affect 1% of males and are 10% bilateral. The cause is unknown, with a small percentage associated with developmental abnormalities or chromosomal aberrations.[ citation needed ]
Early orchiopexy reduces the risks for cancer and sterility in males with cryptorchidism, or undescended testes.[ citation needed ]
Cryptorchidism is definitively diagnosed after 1 year of age, as testicular descent may occur after birth. Surgical placement into the scrotum is recommended by 18 months to decrease the likelihood of testicular cancer, testicular atrophy, and sterility.
Cryptorchidism is associated with tubular atrophy and sterility. In addition, cryptorchid testes carry a three to five times higher risk for testicular cancer (germ cell neoplasia in situ within the atrophic tubules). Patients are at increased risk for the development of cancer and atrophy in the contralateral, normally descended testes as well.
There are multiple different orchiopexy techniques used to correct an undescended testicle due to the large variation in location where the testes may present. The procedures have a high overall success rate. [1]
Orchiopexy is performed in the event of testicular torsion, a urologic emergency presenting with intense pain and often without inciting injury.[ citation needed ]
While neonatal torsion occurs with no anatomic defect to account for its occurrence (occurring in utero or shortly after birth), adult torsion results from a bilateral congenital anomaly often called a "bell-clapper deformity", where the testis is abnormally anchored in the scrotal sac, leading to increased mobility. [1]
Twisting of the spermatic cord results in obstruction of the testicular venous drainage. Intense vascular engorgement and infarction may lead to testicular injury and sterility. If the cord is manually untwisted within approximately six hours the testis has a high chance of remaining viable. One in three cases results in dead testes, requiring orchiectomy. [2]
Surgical fixation in the form of orchiopexy is indicated to prevent the reoccurrence of torsion, and is usually performed bilaterally, even if only one testicle is affected by torsion. The procedure has a high success rate in preventing reoccurrence. [1]
For the management of palpable undescended testes (over 80% of undescended testes) the standard inguinal approach is the appropriate procedure. [3]
Approximately 50% of non-palpable testis are high in the inguinal canal or abdominal, while the other 50% are atrophic, and usually located in the scrotum. Diagnostic laparoscopy is often advised to determine the location of non-palpable testis. [4]
Two distinct techniques used for surgical fixation are the sutured point-fixation and Jaboulay tunica plication. Multiple studies have shown that both are effective techniques for fixation with limited evidence favoring either in acute torsion. [2]
Sutured fixation may be performed using either absorbable or non-absorbable sutures, with 3 point fixation sites being preferred. There are concerns regarding potential complications arising from suture fixation (and required breach of the tunica albuginea) like infarction and abscess formation, however this is not supported by data.[ citation needed ]
The Jaboulay procedure was developed later as a non-suture fixation method that avoids trans-parenchymal sutures and instead utilizes eversion, loose plication, and adhesion formation. this technique is criticized for potential security inadequacy.[ citation needed ]
Overall, there is considerable variation in surgical practice for testicular fixation for testicular torsion, with no significant difference in effectiveness between sutured and Jaboulay fixation in emergency re-presentations, post-operative complications, or returns to operation. [8]
The first attempts at surgical correction of cryptorchidism began in the early 1800s. Before this, inguinal testis were managed with the use of truss or castration, if at all.
The theory of orchiopexy is attributed to the observations of Baron Albrecht von Haller and John Hunter in the 1700s, who began to elucidate the anatomy and mechanism of testicular descent.
The first recorded attempt for surgical correction of an undescended testis was performed by James Adams in the London Hospital in 1871, although there are reports of attempts by several German doctors (J. F. Rosenmerkel in 1820 and M.J. von Chelius in 1837). The patient died due to infectious complications of the procedure.
Thomas Annandale completed the first successful orchiopexy in 1887 on a three-year-old boy. He discussed the care of this patient in The British Medical Journal, crediting Thomas Curling (who had worked with James Adams) with the idea of anchoring the testis to the bottom of the scrotum. Notably, Annadale was a close acquaintance of Joseph Lister, and practiced antiseptic techniques that had been absent from previous attempts by other physicians. The postoperative course was reported to be “satisfactory in every way”.
Max Schüller, Arthur Dean Bevan, and John K. Lattimer further contributed to the current techniques for orchiopexy between the late 1800s and early 1900s, with the steps for standard orchiopexy being established before the 1960s. At this point, the standard orchiopexy applied to most undescended testes had a high success rate ranging from 89% to 92%- Attention was then turned to the treatment of high undescended testes, which the standard orchiopexy did not adequately treat.
In 1979, Jones and Bagley suggested a high inguinal incision for high canalicular or intra-abdominal testes. Fowler and Stephens devised a means to preserve the blood supply of high undescended testes through collateral circulation. Their technique was modified into a two-staged operation. Later, one-stage laparoscopic orchiopexy was reported first to reveal the location of non-palpable testes and then as a therapeutic treatment. [9]
A testicle or testis is the male reproductive gland or gonad in all bilaterians, including humans. It is homologous to the female ovary. The functions of the testes are to produce both sperm and androgens, primarily testosterone. Testosterone release is controlled by the anterior pituitary luteinizing hormone, whereas sperm production is controlled both by the anterior pituitary follicle-stimulating hormone and gonadal testosterone.
Testicular torsion occurs when the spermatic cord twists, cutting off the blood supply to the testicle. The most common symptom in children is sudden, severe testicular pain. The testicle may be higher than usual in the scrotum and vomiting may occur. In newborns, pain is often absent and instead the scrotum may become discolored or the testicle may disappear from its usual place.
Testicular cancer is cancer that develops in the testicles, a part of the male reproductive system. Symptoms may include a lump in the testicle or swelling or pain in the scrotum. Treatment may result in infertility.
Cryptorchidism, also known as undescended testis, is the failure of one or both testes to descend into the scrotum. The word is from Greek κρυπτός 'hidden' and ὄρχις 'testicle'. It is the most common birth defect of the male genital tract. About 3% of full-term and 30% of premature infant boys are born with at least one undescended testis. However, about 80% of cryptorchid testes descend by the first year of life, making the true incidence of cryptorchidism around 1% overall. Cryptorchidism may develop after infancy, sometimes as late as young adulthood, but that is exceptional.
A hydrocele testis is an accumulation of clear fluid within the cavum vaginale, the potential space between the layers of the tunica vaginalis of the testicle. It is the most common form of hydrocele and is often referred to simply as a "hydrocele". A primary hydrocele testis causes a painless enlargement in the scrotum on the affected side and is thought to be due to the defective absorption of fluid secreted between the two layers of the tunica vaginalis. A secondary hydrocele is secondary to either inflammation or a neoplasm in the testis.
Epididymitis is a medical condition characterized by inflammation of the epididymis, a curved structure at the back of the testicle. Onset of pain is typically over a day or two. The pain may improve with raising the testicle. Other symptoms may include swelling of the testicle, burning with urination, or frequent urination. Inflammation of the testicle is commonly also present.
An inguinal hernia or groin hernia, is a hernia (protrusion) of abdominal cavity contents through the inguinal canal. Symptoms, which may include pain or discomfort especially with or following coughing, exercise, or bowel movements, are absent in about a third of patients. Symptoms often get worse throughout the day and improve when lying down. A bulging area may occur that becomes larger when bearing down. Inguinal hernias occur more often on the right than left side. The main concern is strangulation, where the blood supply to part of the intestine is blocked. This usually produces severe pain and tenderness of the area.
Monorchism is the state of having only one testicle within the scrotum.
Testicular atrophy is a medical condition in which one or both testicles diminish in size and may be accompanied by reduced testicular function. Testicular atrophy is not related to the temporary shrinkage of the surrounding scrotum, which might occur in response to cold temperature.
Polyorchidism is the incidence of more than two testicles. It is a very rare congenital disorder, with fewer than 200 cases reported in medical literature and six cases in veterinary literature.
A hydrocele is an accumulation of serous fluid in a body cavity. A hydrocele testis, the most common form of hydrocele, is the accumulation of fluids around a testicle. It is often caused by fluid collecting within a layer wrapped around the testicle, called the tunica vaginalis, which is derived from peritoneum. Provided there is no hernia present, it goes away without treatment in the first year. Although hydroceles usually develop in males, rare instances have been described in females in the Canal of Nuck.
The paired gubernacula also called the caudal genital ligament, are embryonic structures which begin as undifferentiated mesenchyme attaching to the caudal end of the gonads.
A hematocele is a collections of blood in a body cavity or potential space. The term most commonly refers to the collection of blood in the tunica vaginalis around the testes, known as a scrotal hematocele. Hematoceles can also occur in the abdominal cavity and other body cavities. Hematoceles are rare, making them harder to diagnose and treat. They are very common especially as slowly growing masses in the scrotum usually in men older than 50 years.
A Spigelian is the type of ventral hernia where aponeurotic fascia pushes through a hole in the junction of the linea semilunaris and the arcuate line creating a bulge. It appears in the abdomen lower quadrant between an area of dense fibrous tissue and abdominal wall muscles causing a.
Testicular sperm extraction (TESE) is a surgical procedure in which a small portion of tissue is removed from the testicle and any viable sperm cells from that tissue are extracted for use in further procedures, most commonly intracytoplasmic sperm injection (ICSI) as part of in vitro fertilisation (IVF). TESE is often recommended to patients who cannot produce sperm by ejaculation due to azoospermia.
The testicular vein, the male gonadal vein, carries deoxygenated blood from its corresponding testis to the inferior vena cava or one of its tributaries. It is the male equivalent of the ovarian vein, and is the venous counterpart of the testicular artery.
A testicular nubbin is the residual tissue of the human testis after a supposed perinatal vascular accident involving the testicular blood supply. The blood supply of the testis twists thereby cutting off the blood supply to the testis and results in testicular atrophy (shrinking). The nubbin is usually identified in childhood by the absence of a palpable testis in the scrotal sac. The tissue remnant usually includes fibrous tissue and signs of old infarction with hemosiderin deposition identified histologically. There is some disagreement as to whether these should be removed and whether there is a risk of future malignancy. They are typically removed surgically by pediatric urologists or pediatric general surgeons through either a scrotal or inguinal incision.
Orchiectomy is a surgical procedure in which one or both testicles are removed. The surgery is performed as treatment for testicular cancer, as part of surgery for transgender women, as management for advanced prostate cancer, and to remove damaged testes after testicular torsion. Less frequently, orchiectomy may be performed following a trauma, or due to wasting away of one or more testicles.
Scrotalultrasound is a medical ultrasound examination of the scrotum. It is used in the evaluation of testicular pain, and can help identify solid masses.
Male genital examination is a physical examination of the genital in males to detect ailments and to assess sexual development and is normally included in an annual physical examination. The examination includes checking the penis, scrotum, and urethral meatus. A comprehensive assessment of the male genitals assesses the pubic hair based on Sexual Maturity Rating and the size of the testicles and penis. The exam is conducted to detect various ailments, measure sexual development, or verify a person's age and biological sex. The genitourinary system can also be assessed as part of the male genital examination. During a genital examination, the doctor can detect any of the following: structural abnormalities, urethral opening abnormalities, problems related to uncircumcision, lumps, tumors, redness, excoriation, edema, lesions, swelling, cancer, hair-related issues and many others. In some instances where a physical examination of the male genitals is not sufficient to diagnose an individual than an internal genital examination using imaging or ultrasounds will be needed for further evaluation.
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