Year : 2011 | Volume
: 16 | Issue : 4 | Page : 142--144
Scrotal fixation in the management of low undescended testes
Paul A Sutton, Owen J Greene, Louise Adamson, Shailinder Jit Singh
Department of Paediatric Surgery, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, United Kingdom
Shailinder Jit Singh
Department of Paediatric Surgery, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH
Aims: Scrotal fixation (SF) is a known technique for the management of low undescended testes (UDT). SF assumes that most low UDT have no patent processus vaginalis (PPV) and can be managed via scrotal mobilization alone. We report our experience of the role of SF in the management of low UDT. Materials and Methods: A retrospective review of all palpable UDT operated on by the senior author between 1998 and 2008 was undertaken. Children diagnosed with palpable UDT were examined under general anesthesia; if the whole testis could be manipulated into the upper part of the scrotum, low UDT was assumed and SF was performed. Attempts to identify a PPV intraoperatively were made in all and, if found, the procedure was converted to standard inguinal incision orchidopexy. Results: One hundred and thirteen children with 134 UDT were identified. SF was performed in 55 testes; inguinal orchidopexy (IO) in 75 and four testes were excised. The median (IQR) age at SF was 5.5 [4.7-6.3] years. Three SF were converted to an IO when a PPV was discovered. The complications in SF were scrotal hematoma (n = 1) and superficial wound infection (n = 1). No post-operative herniae or atrophied testis were seen and none required a redo operation. The mean (SD) operative times for SF and IO were 29.5 (18.1) and 42.7 (16.6) min, respectively (P = 0.04). Conclusion: In our study, 52 of 55 (94.5%) patients with low UDT lacked a hernial sac and were successfully fixed by SF. SF is a viable, simple, quick and safe alternative to IO in the management of low UDT.
|How to cite this article:|
Sutton PA, Greene OJ, Adamson L, Singh SJ. Scrotal fixation in the management of low undescended testes.J Indian Assoc Pediatr Surg 2011;16:142-144
|How to cite this URL:|
Sutton PA, Greene OJ, Adamson L, Singh SJ. Scrotal fixation in the management of low undescended testes. J Indian Assoc Pediatr Surg [serial online] 2011 [cited 2019 Aug 19 ];16:142-144
Available from: http://www.jiaps.com/text.asp?2011/16/4/142/86871
The association of a patent processus vaginalis (PPV) with undescended testes (UDT) has been well reported. , This association may not however be as common as once thought, with some studies suggesting that a hernial sac may be absent in between 24% and 43% of all cases. ,, Some institutions advocate an inguinal approach for all UDT, on the belief that adequate mobilization and fixation is not possible using the scrotal approach alone. 
There have been numerous reports on scrotal orchidopexy for UDT since the publication of Bianchi and Squire in 1989. ,, In scrotal orchidopexy, the underlying technique is similar to inguinal orchidopexy (IO), the difference being that the ligation of the PPV if present is attempted through a scrotal incision.  Surgical exposure to achieve high ligation of the PPV is often suboptimal with this approach, and division of the lateral spermatic fascia at the internal ring is almost impossible. Scrotal fixation (SF) assumes that the majority of low UDT have no PPV and, based on the location of the testes, can be managed via scrotal mobilization alone. It is recommended only for low UDT lying below the external ring, whereas scrotal orchidopexy may be performed for canalicular testes too. In contrast to scrotal orchidopexy, a PPV discovered at SF is repaired through an inguinal approach.
In our institution, we adopted this approach based on the experience with SF, which was first reported in 1997.  The aim of our study was to establish the safety and utility of SF in the routine management of low UDT.
Materials and Methods
This is a retrospective review of all procedures for palpable UDT performed by the senior author between 1998 and 2008. Statistical analysis was performed using Microsoft Excel TM . The student's t-test was used to examine significant differences in the duration of the procedure.
The children identified had been diagnosed clinically with palpable UDT; those with a retractile testis were excluded by repeated and rigorous clinical examination. All children referred for orchidopexy were examined by the senior author in the outpatient clinic. The UDT were examined in a squatting position whenever feasible. Those testes that were palpable in the scrotum in a squatting position were labelled as retractile and were not listed for an operation. These children were actively followed-up to exclude an ascending testis. Those children in whom the testes were found to be absent from the scrotum in a squatting position were taken for operation and examined again under general anesthesia. In those patients where a squatting test was not feasible either due to age or non-compliance, testes were examined in the lying position with attempts made to milk them into the scrotum. Any testis that reached the middle of the scrotum or beyond was treated as a retractile testis. Those testes that reached only the upper part of the scrotum and retracted immediately back were treated as UDT.
All children were further examined under general anesthesia with attempts made to manipulate the testis down into the scrotum. Low UDT was diagnosed if the whole testis could be manipulated into the upper part of the scrotum, and high UDT diagnosed if this were not possible. In cases where the testis returned to the inguinal region following manipulation, these were also classified as low UDT.
The technique of SF is described fully elsewhere in the literature,  but in brief involves a single scrotal incision extending down to the tunica vaginalis. The cord is then mobilized from below only after which the testis is secured in an extra-dartos pouch. If a PPV is found, the procedure is converted to IO in order to ligate it through an inguinal incision near the internal ring.
This retrospective review identified 113 children, 92 (81.4%) with unilateral and 21 (18.6%) with bilateral cryptorchidism, giving a total of 134 UDT. None had a hernia/hydrocoele in addition to their UDT. On clinical examination in the outpatient department, five (3.7%) testes were low inguinal and the remainder were located in the superficial inguinal pouch. IO was performed in 75 testes (56.0%), SF in 55 testes (41.0%) and orchidectomy (due to small size) in four testes (3.0%). Of the 55 SF attempted, three (5.5%) were converted to an IO as in each case a PPV was discovered. In all three of these cases, the testis was located in the superficial inguinal pouch.
The age at operation for all ranged from 10 months to 13.5 years, with a median (IQR) age of 3 (2.1-5.5) years, whereas the median (IQR) age in the SF group was 5.5 (4.7-6.3) years. The mean (SD) operative times for IO and SF were 42.7 (16.6) and 29.5 (18.1) min, respectively (P = 0.04).
All patients were reviewed at first follow-up in the outpatient clinic 6 months following surgery, with none being lost to follow-up. Six of the 75 (8%) children who had IO suffered complications: re-ascent requiring subsequent repair (n = 1), reduced testicular volume requiring active surveillance only (n = 2), superficial wound infections requiring oral antibiotics (n = 2) and wound granuloma treated conservatively (n = 1). In contrast, only two of the 55 (3.6%) children who had SF suffered complications: scrotal hematoma treated conservatively (n = 1) and wound infection requiring oral antibiotics (n = 1). The testicular position and volume for all patients following SF was acceptable. The overall complication rate for IO was 8% compared with 3.6% for SF. No post-operative herniae or atrophied testis were seen and no SF operations required a subsequent procedure.
This paper follows a study from the same institution by Misra et al. on SF published in 1997.  In this study, SF was attempted in 67 children and was successfully completed through a scrotal approach in 58 (86.5%). The remaining nine children went on to have an IO during the same operation, as adequate mobilization was not possible. It is not clear from this paper whether or not these nine children had a PPV present at the time of operation. In our series, SF was attempted in 55 children and was successfully completed through a scrotal approach in 52 (94.5%). Three were converted to IO due to the discovery of a PPV intraoperatively, all of which had testes located in the area of the superficial inguinal pouch. In our series, no child required conversion of SF to IO due to inadequate mobilization of the testis. The data also suggests that in addition to providing good exposure, SF is significantly quicker than IO (P = 0.04).
The absence of a hernial sac for all positions of the testis during all forms of orchidopexy varies in the literature between 24% and 43% of cases. ,, The previous paper from our institution showed that no hernial sacs were discovered at SF compared with 5.5% in our study, confirming that a hernial sac is unlikely in low UDT.
A key factor to the success of SF is a rigorous examination, while the patient is under general anesthesia. If at this stage the testis cannot be manipulated down to the scrotum then a traditional inguinal approach should be undertaken. All SF were performed by a single senior surgeon (SJS), which is likely to have improved patient selection for SF.
There are four theoretical risks when performing SF: (1) missing a hernial sac, (2) inadequate mobilization, (3) damage to vas/vessels and (4) scrotal hematoma/wound infection. The results from our series showed no herniae at follow-up. There were no problems with inadequate mobilization intraoperatively, resulting in conversion to IO or a redo operation at a later date, and no cases of testicular atrophy resulting from presumed vascular damage. Our study does not allow us to comment on the theoretical risk of damaging the vas, and the incidence of scrotal hematoma/scrotal wound infection was low (3.6%).
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