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ORIGINAL ARTICLE |
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| Year : 2023 | Volume
: 28
| Issue : 2 | Page : 111-115 |
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Concurrent placement of the testicular prosthesis in children following orchiectomy/testicular loss
Ramesh Santhanakrishnan, Vinay Kumar Konamme, Murali Govindappa Saroja
Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| Date of Submission | 23-Jul-2022 |
| Date of Decision | 02-Sep-2022 |
| Date of Acceptance | 07-Oct-2022 |
| Date of Web Publication | 30-Nov-2022 |
Correspondence Address:
Vinay Kumar Konamme
Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, 271, 5th Cross, 5th Main, Canara Bank Layout, Vidyaranyapura Post, Bengaluru - 560 097, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jiaps.jiaps_100_22
 Abstract | | |
Introduction: Testis is essential for male sexual hormone production, fertility, and psychological well-being of a male. In the unfortunate event of testicular loss, placement of a testicular prosthesis perhaps will offer a sense of well-being, improved body image, and overall confidence in the growing child.
Aims: The aim is to evaluate the feasibility and assessment of outcomes following concurrent placement of testicular prosthesis in children following orchiectomy.
Materials and Methods: This is a cross-sectional study conducted by reviewing the reports of patients who underwent simultaneous insertion testicular prosthesis following orchiectomy for various indications between January 2014 and December 2020 at tertiary hospitals in Bengaluru. Children <18 years were included in this study. A transscrotal approach was preferred in cases where a transscrotal orchiectomy was done. Transinguinal approach was preferred in children undergoing prosthesis insertion as an isolated procedure. The size of the prosthesis was chosen based on the age of the child and the size of the scrotum. Outcomes were assessed on follow-up.
Results: A total of 29 children underwent prosthesis insertion (25 unilateral and four bilateral). The mean standard deviation age was 5.58 (3.92) years. The indications for prosthesis insertion were cryptorchidism with atrophic testis (22), torsion (3), Leydig cell tumor (2), and severely virilized Congenital adrenal hyperplasia (CAH) (2). Of these, three children (9%) had complications (wound gaping in two and wound infection in one) that needed removal of the implant. The mean duration of follow-up was 49.23 months. All the parents reported a good outcome, and none of the children who underwent prosthesis placement needed a change during this follow-up.
Conclusion: Concurrent placement of a testicular prosthesis is technically easy and a safe procedure, achieves satisfactory cosmetic appearance with minimal morbidity.
Keywords: Atrophic testis, infantile orchiectomy, infantile prosthesis, testicular prosthesis, testicular replacement, vanishing testis
How to cite this article:
Santhanakrishnan R, Konamme VK, Saroja MG. Concurrent placement of the testicular prosthesis in children following orchiectomy/testicular loss. J Indian Assoc Pediatr Surg 2023;28:111-5 |
How to cite this URL:
Santhanakrishnan R, Konamme VK, Saroja MG. Concurrent placement of the testicular prosthesis in children following orchiectomy/testicular loss. J Indian Assoc Pediatr Surg [serial online] 2023 [cited 2023 Jun 8];28:111-5. Available from: https://www.jiaps.com/text.asp?2023/28/2/111/362386 |
| Introduction | |  |
The presence of both the testes has a major role in psychological development in a male child and is a prerequisite for the identity of a male gender.[1] Testis plays a major role in male sexual hormone production and fertility, which in turn is essential for the psychological well-being of a male.
Various studies have reported the feelings of loss and uneasiness or shame following orchiectomy, both in children and adults.[2] Hence, the placement of a testicular prosthesis following orchiectomy can be attempted as an alternative to the native testis. Although it has no functional bearing, it offers a sense of well-being, improves body image, and overall confidence of the individual.[3]
Various conditions where testicular prosthesis can be placed are atrophic testis, noninfectious conditions requiring orchiectomy, tumors, and in emergency conditions like torsion of testicular rupture due to trauma.
A standardized protocol does not exist to counsel patients about testicular prosthesis placement at the time of orchiectomy. Few studies have reported that a patient's awareness can be improved by a proper counseling by the surgeons, which helps in addressing their concerns about complications such as extrusion, pain, hematoma, and infection.[4]
There is a very little literature on the testicular prosthesis placement in children. The indications for placement and route of insertion are unclear. The timing of implantation, especially whether to be done immediately following orchiectomy or to wait till the child attains puberty, is controversial.
Our study assesses the feasibility of placement of prosthesis in children of all age groups immediately following orchiectomy and in children found to have atrophic testis in inguinal exploration.
Aims and objectives
The aim is to evaluate the feasibility and assessment of outcomes following placement of testicular prosthesis in children following orchiectomy.
| Materials and Methods | | |
This was a cross-sectional study conducted by reviewing the records of patients who underwent simultaneous insertion of testicular prosthesis following orchiectomy for various reasons between January 2014 and December 2020 at tertiary care hospitals and later following up them.
Inclusion criteria
All children <18 years of age underwent placement of a testicular prosthesis in the same sitting following orchiectomy for any indication.
Exclusion criteria
- Children who had coexisting infective or inflammatory dermatological conditions in the operative area
- Children whose parents did not consent for prosthesis placement.
Parents of the children who were being operated for various surgical conditions involving the testis with a possibility of orchiectomy were explained regarding the option of concurrent testicular prosthesis placement. The possible complications like infection and the need for change of prosthesis as the child grows up in the future were also explained. After a written and informed consent was taken, the children were planned for surgery.
All the children received a single dose of intravenous ceftriaxone – 50 mg/kg as a prophylactic antibiotic.
Surgical technique
The incision was planned based on the diagnosis. In cases of torsion, atrophic testis, where a scrotal incision was already in place, the trans-scrotal approach was used to insert and fix the prosthesis as depicted in [Figure 1]. Transinguinal approach was used in cases of Leydig cell tumor and severely masculinized Congenital adrenal hyperplasia (CAH). | Figure 1: (a) Transverse scrotal incision for scrotal exploration showing right gangrenous testis and left normal testis, (b and c) placement of appropriate-size prosthesis, (d) photograph on follow-up
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In both the approaches, after an adequate exposure, the age-appropriate prosthesis [Table 1] was inserted into the scrotum and placed vertically. A purse-string suture using polyglactin/polypropylene was taken at the neck of scrotum also including the top end of the prosthesis containing the Dacron patch and fixed. The wound was closed in layers using polyglactin sutures. | Table 1: Normal testicular size and volume and the prosthesis used postorchiectomy
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No antibiotics were used postoperatively. Only analgesics were given as per the patient's requirement. A few cases were operated on day-care basis and were asked to report back 48 h after surgery to assess the wound status. The remaining cases were discharged 48 h after surgery after wound inspection. No dressing was used beyond 48 h after surgery. Patients were again followed up on the postoperative day 7, at 1 month, 3 months, 6 months, and 1 year and yearly thereafter up to 5 years.
Size and type of prosthesis
The size of the prosthesis was chosen based on the age of the child and the size of the scrotum.
The prosthesis used in our series was made of medical-grade silicone, manufactured by Surgiwear®, a company of implant manufacturers with an EN ISO 13485-2012 certification. They are available in three sizes – TE 101 (2.5 cm × 1.9 cm), TE 102 (3.0 cm × 2.0 cm), and TE 103 (3.5 cm × 2.5 cm).
Based on the age-appropriate normal testicular size and volume in the pediatric population,[5] children were divided into three categories and different-sized prostheses were inserted as mentioned in [Table 1].
Data collected
Preoperative data collected included the name, age, condition necessitating orchiectomy, and laterality. Intraoperative details included the findings at the time of orchiectomy and the route of insertion of the prosthesis. Postoperative data related to wound infection and the duration of hospital stay were collected. During the follow-up, data were collected about the wound complications such as wound infection, wound breakdown, implant rejection/extrusion of prosthesis without infection, abnormal sensation, or discomfort in the scrotum.
Statistical analysis
Statistical analysis of outcomes, complications, and satisfaction was performed using SPSS (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY, USA: IBM Corp.). Continuous variables were expressed as mean ± standard deviation (SD) and range. Chi-square (Fisher's exact test) was used to analyze categorical variables. P < 0.05 was considered statistically significant in this study.
| Results | | |
A total of 29 children underwent prosthesis insertion simultaneously following orchiectomy. The age group of these patients is outlined in [Table 2], and the indications are detailed in [Table 3]. The total number of prostheses inserted was 33, as four children had bilateral prostheses inserted. Among these children needing bilateral prosthesis insertion, they were inserted bilaterally at the same time in three of them. The other children had a small scrotal size, and hence, the second prosthesis was inserted 3 months following the first surgery. All the patients had uneventful postoperative recovery.
The mean (SD) age was 5.58 (3.92) years.
Cryptorchidism with atrophic testis was the most common indication for orchiectomy and prosthesis insertion.
Short-term results
The short-term outcome was defined as the outcome 1 month following surgery.
Among the 29 children with 33 prostheses, three children had complications (9%) that needed removal of the implant. All the three children who needed removal of the implant had undergone prosthesis insertion by scrotal approach (13%).
Two children out of the 14 children (14%) <5 years had wound dehiscence following placement of prosthesis. The details of the complications are described in [Table 4].
As mentioned in [Table 5], all the complications were seen in patients who had their prosthesis inserted through the scrotal approach. However, on statistical analysis, the difference between the complications was not statistically significant with P = 0.532.
Follow-up
The mean (SD) duration of follow-up was 49.23 months (21.51). The shortest duration of follow-up was 1 year, and the longest follow-up was 5 years.
No child complained of pain, abnormal sensation, or uneasiness at the site of surgery following the procedure. All parents reported a good outcome. Among the 13 children <5 years, none required a change of prosthesis to date.
| Discussion | | |
The appearance of the normal scrotum is important for the psychological development and well-being for a male child. Following testicular loss due to orchiectomy for any reason, children are at psychological stress and do experience ridicule among their normal peers. The insertion of the testicular prosthesis can be done as an alternative to the normal testis to simulate a normal-appearing scrotum and testis.
We report our experience on 29 children who underwent testicular prosthesis insertion simultaneously following orchiectomy.
Peycelon et al.[6] reported a retrospective study of 26 adolescent children with 38 prosthesis insertion. The assessment was based on the time of interval between orchiectomy and prosthesis insertion. Children were divided into (A) early-time intervals <1 year and (B) delayed prosthesis insertion beyond 1 year of orchiectomy. They reported a complication rate of 10.5% in children in the delayed group as against the early group. And hence concluded that the complication rate was significantly higher if the delay between the two surgeries exceeded 1 year (P = 0.01).
In our study, three children required prosthesis removal out of the total 33 prostheses that were placed, amounting to a complication rate of 9%. Two children (14.2%) <5 years developed skin necrosis. Skin necrosis was probably due to the placement of oversized implants, after which we did not opt for oversized prosthesis. The rest of the children had a smooth recovery and good outcomes.
Osemlak et al.,[7] in their study on 290 boys between the age of 4 and 16 years who underwent primary testicular prosthesis implantation, reported outcomes following different surgical accesses such as inguinal, transverse scrotal, suprascrotal, and transseptal scrotal. Early complications such as infection and delayed wound healing were significantly higher about 22% on scrotal access compared to 18% through inguinal access. In our study, 13% of children (three out of 23) following scrotal access developed complications in the initial part of our study. After we stopped using oversized prostheses, no child had the same problem. No complications were seen following insertion through the inguinal access.
Elder et al.,[8] in their study on placement of infant-sized testicular prosthesis based on 41 boys with cryptorchidism <5 years who underwent simultaneous insertion of the prosthesis, reported only one superficial wound complication. In the long term, 91% of the families rated the cosmetic appearance as “good” and 94% were content with the decision regarding the placement of prosthesis.
In our study, after excluding the three children who needed prosthesis removal, all the 26 children's families reported good cosmetic outcomes and were satisfied following the procedure. None of the children complained of any pain or discomfort after the procedure.
A few surgeons argue that if the prosthesis is placed at an early age, there may be a need for a change of the prosthesis as the child grows older. This is a valid point if monetary considerations are taken. However, we feel that the prosthesis should be placed before a boy's gender identity, and body image is established. In addition, there is a need to prevent the child from feeling low when exposed to outdoor activities like swimming. Furthermore, some boys may not opt for a revision in the size of the prosthesis. In addition, prosthesis placed concurrently following orchiectomy is beneficial as it prevents the contraction of the scrotum and thus from becoming asymmetrical. It acts as a “placeholder” prosthesis.[9]
Nerli et al.,[10] in their retrospective study on 27 adolescents/teens, testicular prosthesis placement performed at a later date postorchiectomy, reported that about 81.4% of the teens were satisfied with their prosthesis. Moreover, about 92.5% of teens expressed that they should have been offered the choice of prosthesis, preferably inserted at the initial orchidectomy.
In addition, the psychological impact and the advantage of a positive body image will be better if done in early childhood than after puberty, when the child might have already got an inferiority complex due to poor body image. A study with a longer follow-up is perhaps required to confirm this observation.
Testicular prosthesis placement only helps in simulating a normal-appearing scrotum and testis, even though there is no hormonal action. Many children and parents may not opt for the placement of the same. A detailed consent from both the parents and children must be taken before the procedure.
Delaying the insertion of testicular prosthesis till puberty to avoid two operations would perhaps negate the benefit of psychological well-being of a growing child. We believe that the insertion of the prosthesis in early childhood will ensure that the growing child will not develop a complex of a missing testis.
Limitations of our study were that it was a cross-sectional nonrandomized study with a small sample size. The duration of follow-up of children was not long enough to conclude that no change of prosthesis is required in smaller children as they grow older. Comparison of long-term satisfaction of the parents and body image in children with and without prosthesis was not assessed in our study.
| Conclusion | | |
Concurrent placement of a testicular prosthesis is technically easy and a safe procedure. It is associated with a good cosmetic outcome, patient and parent satisfaction, with acceptable morbidity. It may add to the psychological well-being of the growing child and also reduce parental anxiety.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Friedman RM. The role of the testicles in male psychological development. J Am Psychoanal Assoc 1996;44:201-53.  |
| 2. | Skoogh J, Steineck G, Cavallin-Ståhl E, Wilderäng U, Håkansson UK, Johansson B, et al. Feelings of loss and uneasiness or shame after removal of a testicle by orchidectomy: A population-based long-term follow-up of testicular cancer survivors. Int J Androl 2011;34:183-92. |
| 3. | Kogan S. The clinical utility of testicular prosthesis placement in children with genital and testicular disorders. Transl Androl Urol 2014;3:391-7. |
| 4. | Srivatsav A, Balasubramanian A, Butaney M, Thirumavalavan N, McBride JA, Gondokusumo J, et al. Patient attitudes toward testicular prosthesis placement after orchiectomy. Am J Mens Health 2019;13:1557988319861019. doi:10.1177/1557988319861019. |
| 5. | Seroukhov AY, Afoko AA, Mamaev IE. Global secular trend of gonadal size in men: Review and analysis of publications. Vestnik Urologii 2020;8:75-91. |
| 6. | Peycelon M, Rossignol G, Muller CO, Carricaburu E, Philippe-Chomette P, Paye-Jaouen A, et al. Testicular prostheses in children: Is earlier better? J Pediatr Urol 2016;12:6.e1-6. |
| 7. | Osemlak P, Jędrzejewski G, Cielecki C, Kalińska-Lipert A, Wieczorek A, Nachulewicz P. The use of testicular prostheses in boys. Medicine (Baltimore) 2018;97:e13911. |
| 8. | Elder JS, Keating MA, Duckett JW. Infant testicular prostheses. J Urol 1989;141:1413-5. |
| 9. | Hayon S, Michael J, Coward RM. The modern testicular prosthesis: Patient selection and counseling, surgical technique, and outcomes. Asian J Androl 2020;22:64-9. [ PUBMED] [Full text] |
| 10. | Nerli R, Sharma V, Ghagane S, Pingale N, Wagh A, Patil R. Testicular prosthesis in adolescents/teens – Our experience at tertiary hospital. Hum Androl 2017;7:32-35. |
[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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