MAZARIS ET AL.
Surgery Illustrated – Focus on Details
BJUI
A novel method of scrotal orchidopexy: description
of the technique and short-term outcomes
BJU INTERNATIONAL
Evangelos Mazaris, Sergey Tadtayev, Taimur Shah and Gregory Boustead
Department of Urology, Lister Hospital, East and North Hertfordshire NHS Trust, UK
ILLUSTRATIONS by STEPHAN SPITZER, www.spitzer-illustration.com
KEYWORDS
testicular torsion, scrotal orchidopexy,
blood–testis barrier, surgery
INTRODUCTION
Testicular torsion is an urgent urological
condition requiring prompt surgical
intervention. The aim of surgery is
assessment of testicular viability, manual
detorsion of the testicle and scrotal
orchidopexy to prevent recurrence of the
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torsion in the future. The surgical approach
to this condition has developed over the
years, yet there is an on-going debate about
the technique of orchidopexy. Various
methods have been described, all of which
have certain disadvantages: a possibility of
recurrence, chronic scrotal discomfort,
negative effect on fertility and possibly an
increased risk of carcinogenesis. We are
proposing a new technique of scrotal
orchidopexy, which reliably secures the
testicle whilst avoiding breaching the tunica
albuginea and thus damage to testicular
parenchyma.
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DESCRIPTION OF THE TECHNIQUE
Step 1.
Vertical scrotal incision through the median
raphe followed by division of scrotal layers.
Parietal tunical vaginalis is opened
longitudinally.
Step 2.
Reduction of the spermatic cord torsion and
assessment of testicular viability.
2 0 1 2 B J U I N T E R N A T I O N A L | 11 0 , 1 8 3 8 – 1 8 4 2 | doi:10.1111/j.1464-410X.2012.11605.x
FOCUS ON DETAILS
Step 3.
Figure 1
After eversion of the edges of the parietal
layer of the tunica vaginalis in a ‘Jaboulay’
fashion and approximation with a
continuous 3/0 polyglactin absorbable
suture, one to three 4/0 polypropylene
non-absorbable sutures are placed through
the everted tunica.
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2012 BJU INTERNATIONAL
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MAZARIS ET AL.
Step 4.
Figure 2
One to three of the sutures are placed into
the dartos of the posterior scrotal wall. The
sutures are tied once the testicle is replaced
in its hemiscrotum.
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2012 BJU INTERNATIONAL
FOCUS ON DETAILS
Step 5.
The process is repeated on the contralateral
side. The dartos is closed with 3/0
polyglactin sutures in a continuous fashion
and the edges of scrotal skin approximated
with interrupted absorbable sutures.
SUMMARY
Despite the fact that urgent surgery for
testicular torsion is now considered the
‘gold standard’, many aspects of this
treatment, including the technique of
orchidopexy, the number of sutures required
and suture material of choice remain under
debate [1,2]. A significant number of
changes have been introduced over the
years: scrotal approach has replaced the
inguinal, non-absorbable sutures are now
favoured over absorbable and a three-point
fixation has largely replaced a single-point
fixation [3–10].
The data from animal research suggest that
antisperm antibodies may form in cases
where the blood–testis barrier is breached
with suture material [11,12]. Whilst it
remains controversial whether a similar
process leads to impaired spermatogenesis
in humans [13], men who underwent suture
fixation of the testicles for cryptorchidism in
childhood do have an increased risk of
infertility [14]. These concerns led to
introduction of sutureless techniques of
fixation; including dartos pouch orchidopexy
[15] and Jaboulay repair [16].
It has also been shown that testicular biopsy
increases the relative risk of testicular
cancer from two-fold [17] to 10-fold [18]. It
is assumed that this increased risk of cancer
is due to the breach in the tunica albuginea
and thus blood–testis barrier. In cases of
suture fixation of the testicles, the breach of
the blood–testis barrier occurs in a similar
fashion, but whether it increases the risk of
testicular cancer remains unknown.
Our technique of orchidopexy offers the
combined advantages of eversion of the
tunica vaginalis, which has been shown
previously to produce excellent fixation to
the scrotal wall [1,24] and avoidance of
injury to testicular parenchyma, whilst
offering an additional protection from
re-torsion in the form of non-absorbable
sutures through the tunica vaginalis into the
posterior scrotal wall. There is also an
additional benefit of perceived reduced
scrotal discomfort after surgery, as chronic
irritation of tunica albuginea by sutures is
avoided.
We have used this method of orchidopexy in
12 cases over the last 2 years. The results to
date have been encouraging. All patients
underwent uneventful recovery and had no
complaints of scrotal discomfort at the time
of outpatient review. We have seen no cases
of recurrence of testicular torsion during
this short follow-up period.
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1
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Absorbable sutures were used in the vast
majority of these cases of re-torsion [1].
However, recurrent torsion has also been
reported in cases where multiple nonabsorbable sutures [19,23] or orchidopexy in
a dartos pouch was used [1].
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2012 BJU INTERNATIONAL
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Correspondence: Sergiy Tadtayev,
Department of Urology, Lister Hospital,
Coreys Mill Lane, Stevenage SG1 4AB, UK.
e-mail: [email protected]
©
2012 BJU INTERNATIONAL