Orchidopexy

Generality

Orchidopexy is the surgical procedure used to resolve cases of cryptorchidism.

Intervention by Orchidopessi.

From: www.betterhealth.vic.gov.au

Cryptorchidism, or "undescended testicle (s)", is a condition in which one or both testicles are still located between the abdomen and inguinal canal; in other words, they have not descended into the scrotum, as normally happens within the first few months of a baby's life.
The orchidopexy requires special preparation, such as, for example, the execution of some clinical tests (blood tests, urine tests, etc.) and the presentation, on the day of the operation, of a complete fast for at least 8 hours.
Doctors can perform the orchidopexy procedure in two distinct modalities: via a traditional surgical approach or laparoscopically.
Except in rare circumstances, the results at the end of the operation are more than satisfactory.
The risk of complications is low.

Anatomical and functional recall on the testicles

Two in number, the testes (or didymes) represent the male gonads.

The gonads are the reproductive organs that produce sex cells, also known as gametes. Male gametes are sperm, so the first task of the testes is to give rise to sperm (spermatogenesis).

The amount of sperm that a healthy male's testicles release over a lifetime is enormous.

Size and weight of the testicles in the adult male:

• 3.5-4 cm in length
• 2.5 cm wide
• 3 cm in anteroposterior diameter
• 20 grams of weight approximately

The second task of didymes - no less important than the first - is to produce male sex hormones (or androgens). The main representative of androgens is testosterone.

The testicles reside inside a sac, called the scrotum, which is located under the penis.
Their housing inside the scrotum usually takes place a month or two before birth. Before that, they are confined to a region of the abdomen.
Sometimes, it can happen that the process of "descending" of the testicles occurs after birth, during the first six months of life.

What is the orchidopexy?

Orchidopexy is a surgical procedure aimed at people suffering from cryptorchidism, for the placement of the testicles inside the scrotum.

WHAT IS CRYPTORCHIDISM?

Doctors speak of cryptorchidism (or undescended testicle (s)), when the testicles have not descended from the abdomen towards the scrotum, according to that natural process to which the introduction referred.
Therefore, an individual with cryptorchidism has one or both testicles at the abdominal level or in the inguinal canal (ie the duct that connects the abdomen to the scrotum and through which the didymes usually pass during the descent process).
Cryptorchidism is the most common abnormality of the urogenital system of male newborns and infants.
According to some statistical surveys, it would concern one male child in every 25, therefore 4% of male births.
Most cases of undescended testicle (s) heal spontaneously during the first months of life (spontaneous resolution). Those in whom the problem persists - estimates speak of one case out of 100 - need the help of a doctor and specific treatment, namely orchidopexy.
Doctors have not yet identified the precise causes of cryptorchidism, however they have ascertained the existence of a correlation between the failure of the testicles to descend into the scrotum and some situations such as:

• Premature birth. Particularly at risk are children who are born before the 37th week of pregnancy.
• Low birth weight
• Family history of cryptorchidism

60-65% of cryptorchidism cases involve only one testicle (unilateral cryptorchidism); the remaining percentage belongs to bilateral cryptorchidism, ie involving both testicles.

Origin of the term cryptorchidism

The term cryptorchidism derives from the "union of two Greek words:" crypto "(κρυπτος), which means" hidden "and" orchis "(όρχυς‚), which means testicle.
Hence, the literal meaning of cryptorchidism is hidden testicle.

Figure: various types of cryptorchidism.

When you do

The medical condition that makes orchidopexy surgery necessary has already been widely discussed. So, the point that remains to be clarified is: why is it important to resolve cryptorchidism?
Before dealing with this topic, it is good to remember that, according to doctors, the best time to operate on the testicle (s) is between 9 and 15 months.
However, there are particular cases, often the result of an "unexpected anatomical modification of the genitals, for which the intervention takes place much later, for example during childhood, adolescence or adulthood."

IMPORTANCE OF CURING CRYPTORCHIDISM

After various studies and the examination of numerous clinical cases, doctors argue that it is good to treat cryptorchidism early because:

• With its resolution, the involved testicle (s) function better.
• Cryptorchidism is the most important factor in testicular cancer. Based on the latest statistical research, it appears that those with an undescended testicle are 10 to 40 times more likely than normal males to develop testicular neoplasia.
  Furthermore, again from the same research, it emerged that 10% of seminomas (N.B: seminoma is the most common testicular cancer) is associated with a previous history of failure to descend one or both testicles.
• Failure to descend one or both testicles tends to favor the appearance of inguinal hernias.
• The permanence of the testicles in the abdomen, at an older age, represents a danger during sports where physical contact is required (football, rugby, etc.); it is also annoying when the person carrying the anomaly uses the seat belt and wears some particular clothing.
• The abnormal appearance of the scrotum of the carriers can affect the individual psychological sphere. Often, subjects treated at an older age than usual develop a sort of depression, due to the fact that they feel different from their healthy peers.

THE ORCHIDOPEXI IN A LATER AGE

Some men may suffer, suddenly and for no explanation, a retractable testicle. This particular condition - which can occur at any age, but especially during childhood - consists in the ascent of one or both testicles from the scrotum to the groin, through the inguinal canal.
Often, the retractable testicle heals spontaneously, without any treatment; however, when this is not the case, the only solution that can be adopted to solve the problem is the intervention of orchidopexy.

Preparation

Premise: since most of the orchidopexy interventions see very young children as protagonists, in this and in the next chapters the content of the texts will mainly concern the operation on subjects only a few months old.

Before the orchidopexy, the doctor must subject the little patient to various clinical tests (blood tests, urine tests, electrocardiograms, etc.), to ensure that there are no contraindications to surgical practice.
After that, he meets the parents and informs them about pre-operative measures.
Among these, the most important, which deserves a special mention, is the observance of a complete fast on the day of the procedure. In fact, since general anesthesia is required, the mother does not have to feed her baby before the operation takes place. for a certain number of hours The decision as to when the fast should begin (ie how long the patient should not eat food) rests solely with the treating physician.
Failure to comply with this pre-operative measure implies the cancellation of the procedure.

IF THE PATIENT IS A FEW YEARS OLD

When the patients are 5-6 year old children (or older individuals in general), doctors use the help of parents to find out if their children have suffered in the past from particular diseases, allergic reactions to drugs, etc.

Procedure

There are various ways (or approaches) to perform an "orchidopexy.
In general, the choice of approach depends on the position of the undescended testicle (s).

• Cryptorchidism located at the inguinal level.
  In these situations, the attending physician opts for a traditional surgical approach and makes two incisions: one in correspondence with the groin and the other in the scrotum. Through the inguinal incision, it mobilizes the retained testicle; while, through the scrotal incision, it provides for the correct housing of the testicle inside the scrotum.
  At the end of this phase, apply sutures on the incisions to promote skin healing. Typically, the sutures are resorbable.
• Abdominal cryptorchidism.
  In these situations, the treating physician opts for a minimally invasive surgical approach, known as laparoscopy, which involves making two or three mini-incisions on the abdomen. Through these small openings, he inserts various instruments (laparoscope, forceps, etc.), which are used to place the retained testicle or testicles inside the scrotum.
  As before, after placing the didymes in their right place, he closes the incisions with sutures.
  The advantage of laparoscopy is that the incisions are very small and heal in a much shorter time than traditional incisions.

From an operative point of view, the surgical treatment of cryptorchidism with an inguinal site is simpler than the surgical treatment of cryptorchidism with an abdominal site.
The reason is very simple: in the first condition, the testicles are located closer to the scrotum, so their arrangement is less complex.

WHAT DOES GENERAL ANESTHESIA IMPLY?

General anesthesia implies that the patient is asleep and completely unconscious during the entire procedure.
To administer the anesthetic drugs by venous route or by inhalation (N.B: the administration of these drugs lasts until the end of the operation), is a doctor specialized in anesthesia practices (ie an anesthetist).
Generally, the anesthetic works within 10-15 minutes. Only after falling asleep, the treating doctor has the green light to start treatment.
For the duration of the anesthesia, the patient remains connected to a series of instruments that measure his heart rate, his blood pressure, his body temperature and his oxygen level in the blood. In this way, there is a monitoring of its vital parameters and immediate and real-time feedback of any slightest variation.

WHO PERFORMS THE INTERVENTION?

The orchidopexy is usually performed by a pediatric surgeon or a pediatric urologist.

After the surgery

After the orchidopexy, a hospital stay of about 24 hours is expected.
During this time, the medical staff will monitor the patient's vital parameters (blood pressure, heart activity, etc.) and explain to the parents the various stages of recovery and the most important post-operative recommendations.

POST-OPERATIVE FEELINGS

It is quite normal that, after orchidopexy, patients experience:

• Pain in the operated area. Typically, this feeling resolves within a few days. In very young children, the alleviation of pain coincides with an improvement in their mood.
• Confusion and lightheadedness. These are effects due to general anesthesia. They resolve within 24 hours.
• Sense of tiredness. It gradually disappears in a few days.

POST-OPERATIVE RECOMMENDATIONS

The most important post-operative recommendations include:

• Make the child drink plenty of water, several times a day, to help eliminate the anesthetics administered for the operation.
• Prefer body washing in pieces over showering. Avoid using the bathtub. Failure to comply with this recommendation could result in problems for the sutures, which may come off earlier than expected.
• In the initial phase, give several small meals. The return to fewer but more substantial meals can take place a few days after the operation.
• Make the child wear comfortable undergarments. Some doctors also recommend the diaper, because it offers good protection.
• In the case of children aged 4-5 years and over, keep them at rest for a few weeks from any sporting activity and other dangerous pastimes (for example cycling).
  For the first few days, it is also good that they stay home from school.

Risks and complications

The "orchidopexy is a" now quite safe operation.
However, since it is still a major surgery, it presents a small margin of risk and the possibility of causing complications.

Possible complications of orchidopexy:

• Loss of blood, swelling and bruising at the level of the surgical incisions.
• Infections
• Ascent of the testicle in the same point where it was lodged before the operation
• Testicular atrophy
• Damage to the vas deferens, ie the tubular-shaped elements that unite the testicle to the urethra and through which the spermatozoa flow.

Results

The results largely depend on the location of the testicles.
If the didymes reside in the groin, the success rate of the orchidopexy exceeds 90%; if they are housed in the abdomen, it assumes lower values.