Overview of Orchiopexy
Undescended testicles, a condition where one or both of a male’s testicles have not moved down into the scrotum before birth, is relatively common. It occurs in about 3% of full-term male newborns and up to 30% of premature male newborns. It’s the most common birth defect that affects male genitals.
This move normally starts during the 28th week of pregnancy. About 80% of undescended testicles noted at birth will naturally move into the scrotum by 3 months old. However, if that doesn’t happen by 6 months old, a surgery is likely required. The condition can affect one or both testicles (10% of the cases affect both).
In cases where only one testicle is affected, it’s usually the left one. Around 70% of undescended testicles can be felt, with 90% located in the inguinal canal, a passage in the anterior abdominal wall. More than 90% of patients with this condition also have a concomitant patent processus vaginalis (a small, fluid-filled sac near the testicles) or indirect inguinal hernias (protrusion of abdominal content through the inguinal canal).
Without treatment, this condition can lead to long-term issues, including reduced male fertility, shriveled testicles, testicular torsion (twisting of the testicles), an increased risk of traumatic injury and a higher risk of testicular cancer. The exact cause is unclear, but it’s believed to be a mix of factors like maternal health, genetics, hormonal variations, mechanical issues, neurotransmitter levels, and exposure to certain environmental toxins.
Various known risk factors contribute to undescended testicles, including premature birth, low birth weight, and a family history of the condition. Other possible factors include, Down, Noonan or Prader-Willi syndromes, cerebral palsy, cosmetics use, exposure to certain drugs or toxins, genetic disorders, ibuprofen use, in vitro fertilization, excessive alcohol consumption during pregnancy, certain hormonal disorders, low placental weight, maternal diabetes or obesity, certain defects of the brain and spinal cord, pesticide exposure, certain syndromes, preeclampsia, being small for gestational age, smoking, and being a twin.
Anatomy and Physiology of Orchiopexy
The development and movement of the testicles in a male fetus is a complex process that starts as early as 8 weeks into the pregnancy. Initially, the testicles form near the kidneys, on the back wall of the abdomen. Over time, they begin to move down towards an area called the internal ring.
The journey of the testicle is assisted by a ligament, called the gubernaculum that shortens and helps to pull the testicle towards this ring by the 28th week of pregnancy. This ligament is about the same size as the testicle at this stage.
Around this time, a pocket is formed in the peritoneum (a membrane that covers abdominal organs). This pocket, called the processus vaginalis, connects with the gubernaculum. Together, they move into and widen a passageway, known as the inguinal canal, preparing it for the movement of the testicle.
By the 28th week of pregnancy, the gubernaculum contracts, aiding the testicle’s journey to the scrotum (the sack of skin that holds the testicles). This movement is also assisted by pressure within the abdomen which helps to push the testicle down the passageway. The processus vaginalis then usually disappears before birth. However, if it does not disappear and the testicle doesn’t complete its journey to the scrotum, it can lead to a type of hernia.
When performing surgery (orchiopexy) to correct the placement of the testicles, the blood supply to the testicles has to be considered. The main source of blood for the testicle is the testicular artery, which comes directly from the aorta, the largest artery in the body. If this artery is damaged during the surgery, other arteries can usually keep the testicle viable. These other arteries are the vasal and cremasteric arteries.
There are several types of conditions where the testicles do not descend properly:
1. Acquired: This happens when the spermatic cord (which contains blood vessels and other vital components for the testicles) doesn’t grow properly.
2. Ascendant: In this condition, a testicle that was initially in the scrotum goes back up into the inguinal canal.
3. Ectopic undescended testis: Here, the testicle takes an unusual path and can end up in different locations, such as the femoral canal, opposite scrotum, perineum (the area between the genitals and anus), or superficial suprapubic or inguinal area.
4. Dysgenetic: This is when the testicle doesn’t develop correctly due to problems during its formation process.
5. Hypoplastic: In this condition, the testicle is underdeveloped.
6. Retractile: Here, a testicle fluctuates, moving in and out of the scrotum.
7. True undescended testis: This occurs when the testicle is located along the correct path of descent but hasn’t reached the scrotum.
8. Vanished: In this condition, the testicle is absent due to issues such as twisting during late pregnancy or absence from birth. Not all cases of non-palpable testes (testicles that cannot be felt) truly lack the organ, sometimes, it might be hidden.
Why do People Need Orchiopexy
If your testicle hasn’t moved down into the scrotum on its own by the time you’re 6 months old, you might need a surgery called orchiopexy. This is also the case if your testicle gets twisted around in a painful condition called testicular torsion. If the torsion happens all of a sudden or comes and goes, the surgery can help fix the problem.
When a Person Should Avoid Orchiopexy
There are certain situations when orchiopexy, which is a procedure to move an undescended testicle into the scrotum, shouldn’t be performed. These include:
When the testicle has shrunk or is underdeveloped – in this case, a different operation called an orchiectomy might be done instead.
If the patient isn’t able to undergo anesthesia for any reason. Anesthesia is the medication used to make you sleep during the surgery.
If the patient currently has an infection in either the testicle or urinary tract. Operating under these conditions can be dangerous.
If the patient has a condition where their blood doesn’t clot well or if they’re on medication to stop blood clotting. This is because uncontrollable bleeding during surgery can pose a significant risk.
Who is needed to perform Orchiopexy?
Orchiopexy, which is a surgery to move an undescended testicle into the scrotum, requires a team of healthcare professionals. These include a pediatric surgeon or pediatric urologist, who are special types of doctors trained to perform surgeries in children. There’s also an anesthesiologist, who will make sure your child is asleep and pain-free during the procedure. The scrub tech or nurse helps the surgeon throughout the surgery, and a circulating nurse manages the operating room and provides extra assistance when needed. Together, this team works to ensure safe and successful operation for your child.
Preparing for Orchiopexy
The American Urological Association (AUA) does not suggest using ultrasound or CT scans to diagnose undescended testicles. Instead, the AUA advises that the most effective way to find these testicles is through a careful physical exam by an experienced doctor. With this method, the hidden testicles can be found in about 70% of cases.
In addition, the AUA advises against using hormone therapy to help the testicles descend. They argue that past trials and reviews have shown hormone therapy to be minimally effective in the long run. Other groups like the British and Canadian Urological Associations, and the European Association of Urology agree with this recommendation.
For patients who cannot physically feel both testicles, the AUA recommends further tests and scans. These tests help to understand the patient’s physical build-up better and identify any possible abnormalities. It’s also recommended for patients with a single undescended testicle and a condition that causes the urinary opening to be on the underside of the penis (hypospadias). These patients should be checked for possible chromosome disorders and given an ultrasound to assess their pelvic build-up. A blood test is also suggested to check the levels of certain reproductive hormones.
Another test that can help confirm the presence of functional testicle tissue is hormonal stimulation. This test involves giving a series of hormone injections and then measuring the levels of reproductive hormones to see how they change. This can provide strong evidence of whether or not testicle tissue is present in the body.
Other ways of checking for the absence of testicles (anorchia) include checking the levels of certain reproductive hormones in the blood. These hormone levels can provide a clear picture of whether the patient has functional testicular tissue or not.
While scans aren’t usually suggested for undescended testicles, they can be helpful in some cases. An ultrasound, for instance, can be used as a first step to evaluate if the testicle cannot be felt. This technique does not use harmful radiation, is cheap, and is readily available. However, for testicles that have not descended into the belly, the ultrasound will not be useful.
Scans from machines like MRIs and CT scanners can sometimes find undescended testicles within the abdomen. However, these scans are often not reliable due to the small size of the testicle and interference from the intestines. In cases where the testicles can’t be felt and are not found through an ultrasound, a procedure using a small camera inserted into the body (laparoscopy) is often the most reliable method. This procedure can also be used to move the undescended testicle to the proper location in the same operation. However, it is invasive and expensive and requires anesthesia.
To learn more about the evaluation process for an undescended testicle, you can refer to the related article titled “Cryptorchidism” on the StatPearls website.
How is Orchiopexy performed
In the past years, medical professionals have recommended that surgical procedures for certain conditions be done at an earlier age. The American Urological Association (AUA) guidelines now suggest that a type of surgery called orchiopexy, which is used to fix testicles that haven’t dropped down into the scrotum, should be done between 6 and 18 months of age.
Getting surgery around 6 months is optimal to reduce negative effects in the long run, like fertility problems and the risk of testicular cancer. For babies born prematurely, doctors use the corrected age, which is their age based on their due date, not their actual birthdate, to decide when to do the surgery.
Doing the surgery at 6 months of age is recommended because as more time passes, there is a higher chance for harm to the germ cells, which are necessary for making sperm. This can cause fertility problems in the future. For every 6-month delay in doing the surgery, there is an increased risk for problems like lowered fertility, increased need for assisted reproductive services, and a higher risk of testicular cancer.
Unfortunately, many patients do not get the necessary surgery within the recommended time period, The reasons for delays can vary, including family circumstances, insurance status, or the patient’s ethnic background. Additionally, sometimes a family doctor may not be familiar with the current recommendations for surgery age and might not refer the patient for the surgery in a timely manner.
For patients who are older when they are diagnosed, surgery should be done as soon as possible. For men between puberty and 32 years of age, a different type of surgery, called an orchiectomy, which removes the testicle, might be considered. If the condition hasn’t been treated in patients older than 32 years, they should be checked regularly with a physical examination. During surgery, any attachments to the testicle should also be removed.
There are a few different ways that a surgeon can do the orchiopexy. The approach will depend on where the testicle is located. The surgery could involve either going through the scrotum or through the groin.
If both testicles are undescended, which is called bilateral cryptorchidism, a surgeon will usually fix only one at a time to let it heal. This also reduces the chance of losing both testicles if something went wrong with the surgery or afterwards, like an infection.
Inguinal Approach: This is the most common technique where a surgeon makes a cut over the groin, like how they would for a hernia repair. Then, they visually spot the undescended testis and spermatic cord, which carries blood to and from the testicles. From there, they’ll dissect the cord and testicle until they can bring it down into the scrotum without tension.
Scrotal Approach: In this approach, a cut is made in the scrotum, and the surgeon dissects up towards the groin until the testicle is identified. Just like the inguinal approach, the testicle is then brought down with gentle retraction, and if necessary, the spermatic cord is untwisted. Then, the testicle is secured in the scrotum.
Regardless of the approach, the most important thing is that the testicle is secured in the correct place. After the procedure, the doctor will monitor and examine the patient to make sure everything is healing properly.
Possible Complications of Orchiopexy
Every surgery comes with its own set of potential problems, including infection, bleeding, and scars. Specific to orchiopexy, a surgery to move an undescended testicle into the scrotum, there are a few serious complications you should be aware of:
* Adhesions: This is when bands of scar tissue form. It could make a two-part laparoscopic procedure more difficult.
* Ascent of the testis: If the testicle is positioned in the scrotum under too much tension, it might move upwards. This can occur if the tissues around the testicle and spermatic cord aren’t properly freed during the procedure.
* Damage to the vas deferens: This tube that moves sperm can be damaged or accidentally blocked or cut during surgery.
* Epididymitis and orchitis: These are forms of inflammation in the testicle and the part of the testicle that stores and carries sperm.
* Herniation: Essentially, this is when an organ or other body part moves into a space where it doesn’t belong.
* Hydrocele: This is a fluid-filled sac around the testicle, most of which usually don’t communicate with the body and are diagnosed using ultrasound. They usually go away on their own, but they can be drained if they persist for over a year.
* Inadequate length: This refers to the testicle not being extended enough into the scrotum due to an insufficiently released connective tissue.
Infection is a risk to both testicles when two-sided orchiopexy is done, which could lead to the loss of both testicles. For this reason, if both testicles are undescended, each side might be done separately several months apart.
Other complications can include injury to the colon or bladder, disturbances in bowel movements (ileus), complications related to inguinal hernia (a type of hernia near the groin region), and testicular atrophy (shrinking of the testicles), which can be caused by overexposure of the testicle or cord during surgical exposure and affects up to 20% of patients.
It’s also critical to note the dreaded risk of volvulus, a condition in which a part of the intestine twists around itself and the tissue holding it in place, which can compromise blood flow.
What Else Should I Know About Orchiopexy?
If a male’s testicles haven’t descended (moved down into the scrotum) as they should, this can lead to higher risks of not being able to have children (infertility), getting testicular cancer, and having a condition called testicular torsion, where the testicle twists, cutting off its own blood supply. This risk is much higher if the condition isn’t treated. Although testicular cancer is rare, having undescended testicles increases the risk up to 40 times compared to men without this condition. Also, even the testicle that’s in the right place has a slightly higher risk of cancer.
If a testicle is stuck in the groin area, surgery can help it descend further. However, this process needs to be done carefully to avoid affecting blood flow to the testicle. ‘Seminoma,’ a specific type of testicular cancer, is the most common one linked to undescended testicles. Treating undescended testicles with surgery early can lower the risk of cancer, although it doesn’t eliminate the risk entirely. It also helps to monitor the testicles on an ongoing basis through physical exams. The ideal time frame for this surgery is between 6 to 18 months old, as it can help lower the chances of infertility, testicular torsion, and cancer.
Undescended testicles significantly increase the risk of testicular torsion – about 10 times more than for the average male. This can even happen to a testicle located within the abdomen, and it would cause severe abdominal pain. Some research shows that using a specific hormone therapy before the surgical treatment to move the testicle into place might improve fertility later in life. Testicle biopsies (taking a tiny sample of tissue to examine) are not commonly recommended during the surgery, but might be considered in some special cases, for instance, for adolescents or older men who haven’t been treated for undescended testicles before.
On the other hand, testicles that can move in and out of the scrotum, known as retractile testicles, don’t have the same risks as undescended testicles. They don’t enhance the risk of infertility or cancer and don’t necessitate surgery unless they cause problems or move upward. It’s crucial to examine retractile testicles regularly to catch any signs of a problem.
