Abstract

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Aim: A review was done to assess the preoperative evaluation, intraoperative findings and the postoperative outcomes of orchiopexy at a tertiary pediatric center over a two year period. We compared our results with the international literature which has shown a success rate of 89% for an open, inguinal approach and 50% to 100% for a variety of minimally invasive approaches.

Methods: A retrospective chart review was undertaken of all patients who had orchiopexy from January 2006 until December 2008. A successful orchiopexy was defined as the testis in a scrotal position and the absence of testicular atrophy.

Results: A total of 143 patients with 169 orchiopexies were included. The median age at surgery was 11 months (range 2 weeks to 11.4 years). The median followup period was 8 months (range 2 to 26 months). Preoperative examination demonstrated a clinical hernia in 22 patients (15.4%). On initial examination 101 testes (59.7%) were palpable but under anesthetic an additional 13 testes became palpable (114 testes, 67.5%). At the time of exploration testes were found in the following locations: 64 (37.9%) were intracanalicular, 56 (33.1%) in the superficial inguinal pouch, 29 (17.1%) intra-abdominal, 11 (6.5%) extracanalicular infrapubic and 3 (1.8%) were ectopic. Two (1.2%) were not found and the testicular position was not reported in 4 testes (2.4%). An atrophic testis (nubbin) was found in 20 patients (11.8%) and all were treated with an orchiectomy. In one clinically atrophic testis, viable germ cells were found. The overall success rate by procedure was 95.8% for an inguinal approach, 86.7% for laparoscopic one stage repair and 90% for laparoscopic staged Fowler-Stephens Orchiopexy. The post-operative complication rate was 4.2%.

Conclusion: This review confirms that our outcomes were similar to that reported in the international literature.

Introduction

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Undescended testis (UDT) is the most frequent congenital anomaly of the male genitalia. At birth, the incidence of cryptorchidism is around 4% to 5% (1). This figure falls to 1% to 2% at 12 months of age and remains fairly constant at 0.8% into adulthood (2) (3) (4). Approximately 20% of UDTs are impalpable and 10% are in an intra-abdominal position (5). It is generally accepted that an UDT increases the incidence of infertility, malignancy, torsion and trauma (5).

Testes that remain undescended are associated with progressive loss of germ and Leydig cells. There is a 2% risk of sever germ cell loss and 1% risk of Leydig cell depletion for each month a testis remains undescended (6). The relative risk of testicular cancer in an undescended testis is between 2.75 to 8 that of a normal male. The risk appears higher in patients with bilateral UDT and late (after age of 12) or uncorrected UDT (7). According to historical series, it has been estimated that an UDT increases the risk of testicular torsion by 10 times (8).  The mechanism of torsion in UDT is not well understood and the diagnosis can be challenging.

The fundamental principle for the management of UDT is operative. The initial treatment of neonates with UDT is typically observation, since it has been estimated that more than 70% of spontaneous testicular descent occurs in the first 3 month of life (9). Early surgical treatment has a beneficial effect on germ cells function and subsequent ‘catch-up’ testicular growth (10).

In 1995, Docimo reviewed his units success rates of several established open techniques of orchiopexy and compared this to the success rates in the literature over the last 70 years (11).  Based on anatomical position, successful orchiopexy was performed for 74% of abdominal, 82% of peeping, 87% of canalicular testes and 92% for those located beyond the external ring. The success rates by procedure were 89% for an inguinal orchiopexy, 67% for a single stage Fowler-Stephens (FS) orchiopexy and 77% for a two stage FS orchiopexy. The inguinal approach was considered the gold standard technique for a palpable UDT with a mean operative time of 64 minutes (12). In 1989 Bianchi and Squire introduced the single incision trans-scrotal technique. Since then several studies had been published with a success rate ranging from 94% to 100% and a mean operative time of 21 minutes (14 to 35 minutes) (12) (13) (14) (15) (16). The applicability of this technique and its objective comparison with inguinal orchiopexy remains unclear.

UDT was one of the early indications of diagnostic laparoscopy in 1970s. The first reported successful laparoscopic orchiopexy occurred in 1992 (17). Since then many series have been published about the success rate of different laparoscopic approaches and these range between 50% and 100% with an operative time ranging from 48 minutes to 135 minutes (18) (19) (20) (21) (22) (23) (24) (25) (26) (27).

We have, hence, undertaken this descriptive study in order to review the results of orchiopexy at the Children’s Hospital at Westmead (CHW), a tertiary pediatric center in Sydney, New South Wales, with the aims of: correlating the preoperative clinical findings to intraoperative findings and describing the outcomes of orchiopexy with respect to the testicular location and the choice of operative technique.

Methods

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CHW is a standalone tertiary university-affiliated pediatric center in Sydney, New South Wales, serving a population of approximately 3 million. The study was a retrospective chart review of all patients who had orchiopexy between 1st of January 2006 and 31st of December 2007 at our institution. Patients were identified using the operative codes for orchiopexy or inguinal exploration according to the Australian Modification of the International Classification of Disease (ICD – 10 AM). Data were collected from both hospital and private medical records.

Data collection and definitions: The medical history, physical examination, age at surgery, operative findings and followup notes were reviewed and entered into a database. Any delays in diagnosis and/or referral were noted.  Prematurity was defined as less than 37 weeks of gestation. Intraoperative testicular position, size and postoperative testicular size were recorded subjectively based on the surgeon’s assessment. Presence of patent processus Vaginalis or clinical hernia was noted. All pathology reports after the removal of an undescended testicular nubbin were reviewed and recorded. The overall quality of the operative notes was subjectively assessed. Successful orchiopexy was defined as a scrotal position of the testis and absence of testicular atrophy at the six month follow-up visit (11).

Of 167 patients initially identified, the following were excluded from subsequent analysis: revision orchiopexy following an initial procedure prior to 2006 (one patient); a testicular nubbin found within the scrotal sac during inguinal exploration (14 patients), deficient patient records (three patients) and those patients who were lost to postoperative review (6 patients).

Data collection and analysis was performed using SPSS software version 17 supplied by the hospital. For comparison of categorical data, a nonparametric chi-square test was used and p <0.05 was considered statistically significant. All p values were two sided. For dichotomous data, Odds ratios (OR) and confidence intervals (CI) were also calculated. For continuous variables mean with standard deviation were calculated. The study was approved by the Ethics Committee of our institution.

Results

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Patient details: A total of 143 patients who had 169 orchiopexies were included. One hundred and seven patients (74.8%) had a unilateral UDT (left side 51% and right side 49%). The median age at surgery was 11 months (range 2 weeks to 11.4 years). Three quarter of the patients had surgery before 2 years of age. The median postoperative followup period was 8 months (range 2 to 26 months). Twenty patients (14%) had history of premature.

Preoperative evaluation: A clinically manifest hernia was identified in 22 patients (15.4%) or in 25 UDT (14.8%). The median age at surgery for this group was 2 months. An UDT was palpable preoperatively in 101 testes (59.7%). During examination under anesthesia a further 13 (114, 67.5%) became palpable. The relationship between palpability and testicular size is tabulated in table 1. Only 19/85 (22%) palpable testes were found to be small in size whereas 21/23 (91%) non palpable testes (excluding intra-abdominal) were found to be small (p<0.001, X2 -49.41, 1df). On the other hand, 17/38 (45%) of the small testes were preoperatively palpable. Excluding the intra-abdominal testes, 80% of the testes had a PPV associated with it. 

Three patients (3/143, 2.1%) with an UDT presented with testicular torsion and had an emergency orchiopexy. The patient’s age at the time of the torsion was 2 months, 6 years and 11 years. At followup, testicular size at 1 year showed that one patient had significant loss of testicular volume but the other two had a good size testis.

Excluding these 3 patients, a total of 140 were admitted for an elective procedure; 118 patients as a day stay procedure and 22 patients were admitted overnight. The predictors for an overnight admission were presence of clinical hernia confounded by patient age (OR=19.8, 95% CI – 6.53 to 60.4, p <0.005), technical difficulties at the time of the procedure (OR=7.5, 95% CI – 1.17 to 47.97, p <0.05), and bilateralism (OR=2.9, 95% CI – 1.1 to 7.5, p < 0.05). The median age at surgery for an inpatients admission was 3 months and median age for a day stay was 11 months (p<0.005). 

Operative approach and findings: The operative techniques were an inguinal approach for 139 testes (82.2%), a one stage laparoscopic approach for 16 testes (9.5%), a two stage laparoscopic FS approach for 10 testes (5.9%), a scrotal approach for 3 testes (1.8%) and an open abdominal approach for 1 testis (0.6%). A total of 32 patients with an impalpable testis underwent a diagnostic laparoscopy. Of these 14 patients (44%) were converted to an open inguinal procedure based on the laparoscopic findings. Figure 1 shows the distribution of surgical techniques according to testicular location. The testicular positions at the time of exploration are shown in Table 2. The size of the testis was reported as normal in 108 testes (63.9%), 23 (13.6%) were small, 20 (11.8%) atrophic, 2 (1.2%) were not found and in 16 cases (9.5%) the size had not been recorded.

The mean operative times (SD) for scrotal approach, inguinal approach, one stage laparoscopic approach and two stages laparoscopic FS were 35.3 minutes (30.1), 52.6 minutes (27.5), 70.6 minutes (34.8) and 92 minutes (33.2), respectively, p <0.005.

Surgical outcome and followup: Success rates of orchiopexy in our study have been summarized in tables 3 and 4. The overall success rate was 94.5%. Twenty (11.8%) testes were removed (atrophic), 2 (1.2%) were not found and 1 testis (0.6%) was avulsed during an attempted one stage laparoscopic orchiopexy. All removed testis were histological examined and in one of 20 atrophic testes (5%), viable germ cells were found.

The success rate of the procedure was influenced by the original anatomical location of the UDT (table 3). Thus 100% of ectopic testes were fixed in the scrotum compared to 96.4% of those in the SIP, 95.5% of intracanalicular testes, 91% of extracanalicular infrapubic testes and 89% of intra-abdominal testes.  This was similarly reflected in the operative technique chosen, with 100% of testes operated via a scrotal approach successfully fixed in the scrotum compared to 86.7% fixed via a one stage laparoscopic orchiopexy (table 4).

Postoperative complications were recognized in 6 patients (4.2%). Three patients had a scrotal hematoma, 1 patient a wound infection, 1 patient developed chronic inguinal pain and one patient developed a chest infection. At 1 year follow-up, testicular volume was reduced in 3 abdominal testes (3/25, 12%), 2 canalicular testes (2/43, 4.7%) and 1 SIP testis (1/54, 1.9%).

Discussion

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The results of our study revealed that a majority of the children have orchiopexy at an appropriate age (before 2 years) with more than half of our patients having had an orchiopexy before their first birthday. This may reflect good screening practices at primary care level and tendency toward a timely referral. This is encouraging since there is overwhelming evidence in the literature which supports a surgical repair in early childhood mainly to achieve normal paternity, reduce risk of cancer, and prevent torsion.

The incidence of PPV and manifest hernia in association with an undescended testis has been well described before. The Patent processus vaginalis has been reported between 50% to 90% of patients with UDT which could harbor an occult inguinal hernia whereas 6% of clinical hernias are associated with undescended testes (28). The reason of this variation remains uncertain. In our review the incidence of PPV was higher in a distally located testis than the proximal one (Table 1). Furthermore, 15.4% of our study population had a clinical hernia associated with UDT which led to an early surgical repair (median age at surgery 2 months) in comparison to patients without clinical hernia (median age 11.3 months). However, the diagnosis of UDT could be overestimated in this group, due to the presence of clinical hernia which may position the testis in a higher location. Moreover, most of those patients had their surgery in the first few weeks where the incidence of UDT is the highest.   

Torsion of an UDT is a poorly addressed topic and a relatively rare phenomenon which can cause a diagnostic dilemma. Torsion was first described in 1840 in a child with UDT, since then historical articles estimated that testicular torsion is 10 times more common in an UDT (8) (29). During the 2 year study period, we identified 3 patients (2.1%) with a palpable UDT that presented with testicular torsion. Underestimation of the true incidence of torsion is possible and recognizing torsion in an intra-abdominally located testicular may not be clinically obvious. The salvage rate of UDT with torsion in the literature is quite poor (10%), in our very small series the salvage rate after one year followup was 67%. This may reflect an early diagnosis due to awareness of the risks of torsion by parents, GPs and Pediatricians. But this result could be biased because of a small sample size, 3 patients only, and probably reviewing our cases of torsion in an UDT would give us a more accurate estimation of the salvage rate.

The relationship between the location, hypotrophy and palpability of the undescended testis is important as it has surgical implications. In our study, the incidence of hypotrophy did not seem to be associated with the location of the testis. This appears to be different to traditional belief that the chance of the testis being smaller is higher if is intra-abdominal or close to the deep inguinal ring. A significant measurement error due to inaccuracy of reporting and missing data could have resulted in this difference. However, palpability of the testis preoperatively was a significant predictor of it being of a normal size.

In cryptorchidism, the reported incidence of intra-abdominal testis was estimated around 10% (50% of the nonpalpable testes) (30). In our review, 32% of the testes were impalpable during examination (55 testes). A high percentage (44%) of impalpable testes underwent 2 procedures i.e. diagnostic laparoscopy followed by inguinal orchiopexy. Sometimes it is quite difficult to accurately palpate the testis, either due to body habitus, testicular position or even compliance of the child during examination which can complicate the clinical evaluation and introduces a diagnostic error (31). The use of additional procedures did not result in additional complications in the study; however, they have added to the operative time and hence the cost. We wonder if this high incidence can be reduced by intra-operative ultrasonography.

The success rates for testes in abdominal, intracanalicular, and superficial inguinal pouch were 89%, 95.5% and 96.4%, respectively, which is quit comparable to the international literature. At one year followup, there was a reduction of testicular volume in 12% of abdominal testes, 4.7% in canalicular testes and 1.9% in superficial inguinal pouch. The median age for surgical intervention for testes that lost volume was 30 months, which was significantly higher than the overall group (p<0.01). This may suggest that early surgical intervention had a better chance of overall success. Kollin et al reached to almost the same conclusion in a prospective study where they documented an improved catch up growth of the testicular size following surgery at 9 months of age in comparison to surgery the age of 3 years (10).  

The overall success rates of orchiopexy (94.5%) and those for laparoscopic orchiopexy (88%) in this study compared favorably with those in the literature. This is possibly due to a shorter followup.

The reporting of the testicular sizes at surgery and at followup was found to be unsatisfactory in this study. As a result, longitudinal impact of testicular hypotrophy cannot be commented upon. This would reduce the ability of the clinician to offer prognostic counseling in many cases. This supports the need for highlighting the importance of accurate and objective measurements of testicular sizes in children born with undescended testes.

Conclusions

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The success rates for testes in abdominal, intracanalicular, and superficial inguinal pouch were 89%, 95.5% and 96.4%, respectively. Testicular retraction post orchiopexy was observed in 2.1% where they required a re-orchiopexy, and 2.7% had testicular atrophy during followup.

Acknowledgment

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I would like to acknowledge and extend my gratitude to the following persons who have made the completion of this manuscript possible: Sandeep Bidarkar, Aniruddh Deshpande, Andrew J. A. Holland, Ralph C. Cohen and Grahame H.H. Smith; from Department of Surgery, Children’s Hospital at Westmead, Sydney, Australia.

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Abbreviations

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FS: Fowler Stephens

PPV: Patent Processus Vaginalis

SIP: Superficial Inguinal Pouch

STD: Standard

UDT: Undescended Testis

Source(s) of Funding

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None

Competing Interests

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None

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