Orchiopexy for Cryptorchidism: What Surgeons Need to Know

Orchiopexy is a common surgical procedure primarily performed to correct cryptorchidism, a condition where one or both testes fail to descend into the scrotum. The procedure is crucial for improving fertility potential, reducing the risk of testicular cancer, and addressing associated complications. This guide provides an in-depth look at orchiopexy, covering everything from indications to postoperative care and recent advances.

Indications for Orchiopexy

Orchiopexy is indicated in several scenarios, the most common being the treatment of cryptorchidism. The condition is classified into palpable and non-palpable forms, each requiring different surgical approaches.

1. Cryptorchidism (Undescended Testis):
   • Palpable Testis: When the testis can be felt within the inguinal canal, the diagnosis is straightforward. Orchiopexy is recommended typically between 6 and 18 months of age to optimize fertility and reduce the risk of malignancy.
   • Non-Palpable Testis: When the testis cannot be palpated, it may be intra-abdominal, ectopic, or absent. Laparoscopy is often utilized to locate and treat the testis.
2. Testicular Torsion:
   • Emergency Indication: Orchiopexy is performed to untwist and fix the testis to prevent recurrence. In cases where the testis is non-viable, an orchiectomy may be performed.
3. Ectopic Testis:
   • Abnormal Position: In cases where the testis deviates from its normal path, such as in perineal or femoral ectopic locations, orchiopexy is necessary to relocate the testis to the scrotum.
4. Retractile Testis:
   • Risk of Becoming Ascended: Though retractile testes can usually be monitored, persistent cases may require orchiopexy.

Preoperative Evaluation

The preoperative evaluation for orchiopexy involves a detailed clinical assessment and appropriate imaging studies.

1. Clinical Examination:
   • Palpation: The primary step is to determine whether the testis is palpable. The inguinal and scrotal regions should be carefully examined.
   • Examination Under Anesthesia: In difficult cases, the examination may be repeated under anesthesia to confirm the presence and position of the testis.
2. Imaging Studies:
   • Ultrasonography: Often the first imaging modality used, especially in cases of non-palpable testes. It helps in differentiating between intra-abdominal and inguinal testes.
   • Magnetic Resonance Imaging (MRI): In cases where ultrasonography is inconclusive, MRI can provide detailed anatomical information.
   • Laparoscopy: Considered both a diagnostic and therapeutic tool, especially for intra-abdominal testes.
3. Laboratory Tests:
   • Hormonal Evaluation: In selected cases, particularly bilateral non-palpable testes, hormonal tests (hCG stimulation test) may help determine the presence of functional testicular tissue.
4. Anesthesia Evaluation:
   • Preoperative Anesthetic Assessment: Considering the young age of many patients, a thorough anesthesia evaluation is crucial to minimize perioperative risks.

Contraindications

Orchiopexy has few absolute contraindications, but certain conditions may necessitate delaying or avoiding the procedure.

1. Active Infection:
   • Scrotal or Inguinal Infection: Surgery should be postponed until the infection is fully treated to avoid complications.
2. Poor General Health:
   • Unfit for Surgery: Patients with severe systemic illness or uncontrolled medical conditions may not be suitable candidates for elective orchiopexy.
3. Intra-Abdominal Testis with Short Vascular Pedicle:
   • Risk of Testicular Atrophy: In cases where the testis has a very short vascular supply, a staged procedure or alternative surgical approach may be required.

Surgical Techniques and Steps

Orchiopexy can be performed through various approaches, depending on the testis's location. The primary goal is to position the testis within the scrotum without compromising its blood supply.

1. Inguinal Orchiopexy:
   • Step 1: Inguinal Incision: An incision is made along the inguinal canal. The spermatic cord is dissected free, and any associated hernia sac is addressed.
   • Step 2: Mobilization: The testis is mobilized to allow tension-free descent into the scrotum.
   • Step 3: Dartos Pouch Creation: A subcutaneous pouch is created within the scrotum to house the testis.
   • Step 4: Testicular Fixation: The testis is fixed within the dartos pouch to prevent retraction.
2. Laparoscopic Orchiopexy:
   • Step 1: Laparoscopic Entry: Ports are placed for the laparoscope and instruments. The intra-abdominal testis is located.
   • Step 2: Vascular Lengthening: The spermatic vessels are dissected to achieve adequate length, which may involve division of the testicular vessels (Fowler-Stephens procedure) in certain cases.
   • Step 3: Testicular Descent: The testis is either brought down through the inguinal canal or tunneled directly into the scrotum.
   • Step 4: Testicular Fixation: The testis is secured in the scrotum, typically using absorbable sutures.
3. Fowler-Stephens Orchiopexy:
   • Stage 1: Ligation of Testicular Vessels: This technique is used when the testis is located high in the abdomen with a short vascular pedicle. The vessels are divided to allow the testis to rely on collateral blood flow.
   • Stage 2: Orchiopexy (Delayed): After 6-12 months, the testis is mobilized and fixed in the scrotum.

Postoperative Care

Proper postoperative care is crucial for optimal recovery and minimizing complications.

1. Pain Management:
   • Analgesia: Non-opioid analgesics like acetaminophen or ibuprofen are usually sufficient. Opioids are rarely needed in pediatric patients.
   • Local Anesthesia: Some surgeons may use local anesthetic blocks during surgery to minimize postoperative pain.
2. Wound Care:
   • Incision Site: The surgical site should be kept clean and dry. Parents or caregivers should be instructed on how to care for the wound.
   • Sutures: Absorbable sutures are commonly used, so suture removal is generally not necessary.
3. Activity Restriction:
   • Rest: Limitation of physical activity for a few days to weeks, depending on the surgeon’s advice, helps prevent complications like testicular retraction.
4. Follow-Up:
   • Postoperative Visits: Follow-up visits are essential to monitor the position of the testis, assess healing, and identify any complications early.

Possible Complications

While orchiopexy is generally safe, complications can occur. Surgeons should be aware of the risks to counsel patients and manage any issues that arise.

1. Testicular Atrophy:
   • Vascular Compromise: If the blood supply to the testis is compromised during surgery, atrophy may occur, leading to loss of testicular function.
2. Testicular Reascension:
   • Inadequate Fixation: The testis may retract back into the inguinal canal if not properly secured, necessitating further surgery.
3. Infection:
   • Wound Infection: This is a rare but potential complication, managed with antibiotics and proper wound care.
4. Hematoma or Seroma:
   • Collection of Blood or Fluid: These may develop postoperatively and often resolve spontaneously but may occasionally require drainage.
5. Recurrence of Hernia:
   • Incomplete Hernia Repair: If an associated hernia sac is not adequately addressed during surgery, recurrence may occur.
6. Infertility:
   • Bilateral Cryptorchidism: Even after successful orchiopexy, patients with bilateral cryptorchidism may have reduced fertility potential.

Different Techniques

Several variations of orchiopexy exist, tailored to the individual patient’s needs and the surgeon’s preference.

1. Open Orchiopexy:
   • Traditional Approach: The standard inguinal incision approach is widely used, particularly for palpable testes.
2. Laparoscopic Orchiopexy:
   • Minimally Invasive: This approach is favored for non-palpable and intra-abdominal testes, offering a less invasive option with faster recovery.
3. Two-Stage Fowler-Stephens Orchiopexy:
   • For High Intra-Abdominal Testes: This staged procedure allows for the safe descent of a testis with a short vascular pedicle.
4. Microvascular Orchiopexy:
   • Advanced Technique: In selected cases, microvascular techniques are employed to reanastomose the testicular vessels, although this is not commonly used.

Prognosis and Outcome

The success rate of orchiopexy is high, with favorable outcomes in most cases.

1. Fertility:
   • Improved Potential: Early orchiopexy, particularly before 18 months of age, is associated with better fertility outcomes.
2. Cancer Risk Reduction:
   • Decreased Risk: Orchiopexy reduces but does not eliminate the risk of testicular cancer. Regular follow-up and self-examination are recommended.
3. Cosmetic and Psychological Outcomes:
   • Normal Appearance: Successful orchiopexy results in a normal scrotal appearance, which is important for the patient’s psychological well-being.

Alternative Options

While orchiopexy is the standard treatment, alternative options may be considered in specific situations.

1. Hormonal Therapy:
   • hCG or GnRH: In some cases, hormonal therapy is attempted to induce testicular descent, though success rates are variable and less reliable than surgery.
2. Observation:
   • Retractile Testis: For retractile testes, observation may be appropriate, with orchiopexy reserved for cases where the testis becomes ascended.
3. Orchiectomy:
   • Non-viable Testis: In cases where the testis is non-viable or poses a cancer risk, orchiectomy may be recommended.

Average Cost

The cost of orchiopexy varies widely depending on the region, healthcare system, and specific circumstances.

1. Hospital and Surgical Fees:
   • Cost Range: In the United States, the cost of orchiopexy ranges from $3,000 to $10,000, including hospital and surgeon fees.
2. Insurance Coverage:
   • Variable Coverage: In many cases, insurance covers orchiopexy, especially when performed for cryptorchidism.
3. Out-of-Pocket Costs:
   • Patient Responsibility: For those without insurance, out-of-pocket costs can be significant, highlighting the importance of financial planning and consultation.

Recent Advances

Research and innovation continue to improve the outcomes and techniques associated with orchiopexy.

1. Robotic-Assisted Surgery:
   • Precision and Control: Robotic systems are being explored for orchiopexy, offering enhanced precision, particularly in complex cases.
2. Stem Cell Therapy:
   • Fertility Preservation: Experimental approaches involving stem cell therapy are being investigated to preserve or restore fertility in patients with bilateral cryptorchidism.
3. Enhanced Recovery Protocols:
   • Faster Recovery: Protocols focusing on minimizing pain and optimizing recovery times are being increasingly adopted.
4. Long-Term Outcomes Studies:
   • Follow-Up Research: Ongoing studies are examining the long-term outcomes of orchiopexy, particularly concerning fertility and cancer risk.