Surgical management of hypogonadic patients with hypotrophic testicles and small penis: a novel, combined technique with an infrapubic approach

by the Color Doppler ultrasound. The endocrinological testicular function was preserved. Unfortunately, both patients were diagnosed with complete azoospermia with histological tubular sclerohyalinosis. The postoperative stretched penile measurement demonstrated a real penile lengthening of 1.5 cm in both cases, which was found acceptable by both patients. As for subjective aesthetic outcomes, both patients said to be completely satisfied with surgery outcomes, reporting a gain in self-confidence. A psychiatric evaluation, conducted 4 months postoperatively, described an improvement in body self-perception thanks to the encouraging cosmetic results of the procedure. Testicular hypotrophy is a rare condition that typically affects young patients, with strong psychological repercussions. Main causes are genetic disorders, such as Klinefelter or Kallmann syndrome.1 BDD is a disorder which further impairs the quality of life of these already frail patients, and must not be underestimated.2 Therefore, surgeries aiming to restore an acceptable body image at the cost of minimal morbidity are very important in this category of patients. Ugarte y Romano and González Serrano3 recently reported a new surgical approach using chin implants for testicular augmentation. In their case report, a single inguinal approach was used to manage a monolateral testicular hypotrophy. According to this technique, our patients would have required a bilateral inguinal incision. Moreover, the concomitant presence of the testicle and chin prosthesis in the hemiscrotum might lead to an increased risk of infection and testicular damage. In addition, there is a risk of nontolerability of the prosthetic device.4 Finally, our patients, affected by bilateral hypotrophy, would have required two prostheses, with higher costs of the procedure. Ferro et al.5 suggested an innovative approach in two young patients affected by Kallmann syndrome, which involved testicular transposition through the septum with a single testicular prosthesis implantation in the hemiscrotum left empty. In our opinion, testicular transposition via a scrotal approach presents the risk of torsion or compression of the cord of the mobilized testis during the passage through the scrotal septum. Moreover, leaving a communication between the two hemiscrotums can increase the risk of infection and testicular damage. All these problems are overcome in our novel approach, performed through a V-inverted suprapubic incision, which leaves intact the scrotal septum and creates no communication between the two hemiscrotums. Moreover, our technique allows the Dear Editor, We have recently developed a novel surgical approach for the management of bilateral testicular hypotrophy, allowing both the preservation of gonadic function and some penile lengthening: aim of this letter is to describe our surgical technique, reporting the first two cases treated with this approach. Both patients were affected by nonmosaic Klinefelter syndrome, presenting with infertility, severe testicular hypotrophy and small penile size: the main patient characteristics are shown in Table 1. They severely complained about their scrotal appearance and small penile size: their discomfort was such that body dysmorphic disorder (BDD) was diagnosed after psychiatric evaluation. Both patients required a procedure able to restore a satisfying scrotal appearance and to achieve an acceptable penile length, while allowing a bilateral microdissection testicular sperm extraction (micro-TeSE), all through a single surgical incision. A V-shaped inverted suprapubic incision was performed, followed by an incision of the Scarpa’s fascia proximal to the penopubic junction. The suspensor ligament of the penis was than isolated transversally incised and detached from the periosteum of the pubis bone. The spermatic chords were isolated bilaterally. The gonads were bilaterally externalized from the scrotum after incision of the gubernaculum testis on both sides. A micro-TeSE was bilaterally performed, together with testicular biopsy for histological evaluation. The right gonad was then mobilized and transferred to the contralateral hemiscrotum through the infrapubic incision, leaving in place the scrotal septum. In the right hemiscrotum, left empty, we placed medium-sized testicular prosthesis (20 cc). Finally, a V-Y skin plasty with an aesthetic running intradermal suture was performed (Figure 1). Mean operative time was 95 min. No intraoperative or postoperative complications were recorded. At follow-up visits scheduled at 1 week, 6 months and 1 year after surgery, both patients were satisfied with the cosmetic appearance of the scrotum: the placement of both testicles in the left hemiscrotum did not impair their blood supply, as demonstrated Surgical management of hypogonadic patients with hypotrophic testicles and small penis: a novel, combined technique with an infrapubic approach