Surgical Management of Undescended Testis: A Two-Year Practice Audit

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 fo l lowing locat ions: 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 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 WebmedCentral > Audit Page 2 of 13 WMC004027 Downloaded from http://www.webmedcentral.com on 14-Feb-2013, 06:35:24 AM 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.