An experimental study of the effect of two distinct surgical techniques of orchiopexy on spermatogenesis and testicular damage in cryptorchid testes

Outcomes following emergency fixation of torted and non-torted testes

INTRODUCTION

Scrotal exploration is a frequently performed emergency procedure in children. It is a subject of debate as to whether and how a non-torted testis should be fixed, with a wide variation in practice across the UK. This study aims to ascertain whether the method of testicular fixation (if any) impacts on patient outcomes.

METHODS

A review of all emergency scrotal explorations performed in children under the age of 18 between 2008 and 2018 in a tertiary Paediatric Surgery unit was undertaken. Patients were categorised by initial fixation method, chi squared analysis was used to compare complication and reoperation rates.

RESULTS

522 boys were taken to theatre, 424 had a unilateral procedure and 98 had bilateral; after 35 orchidectomies, 585 testes were left in situ. The most frequent diagnosis at operation was torted testicular appendage (n = 278, 53%), followed by testicular torsion (n = 79, 15%). The number of testes by category of fixation were: 72 no documented fixation, 130 dartos pouch only, 34 absorbable sutures, 346 non-absorbable sutures and 3 unspecified sutures. There was no difference in the reattendance rate between groups after outliers were removed (p = 0.72). Thirty-seven patients experienced complications, most commonly ongoing pain. Nine patients required an ipsilateral reoperation, 25 underwent a contralateral operation at a later date. The complication rate appeared to be higher in the no fixation group compared to the dartos (p = 0.02) and sutured groups (p = 0.048). Testes in the no fixation group had a higher reoperation rate compared to the sutured group (p = 0.002).

CONCLUSIONS

The present study is a detailed analysis of a wide variety of emergency testicular fixation methods in a large cohort, including the routine fixation of non-torted testes. Whilst there appears to be a benefit to using sutured or dartos fixation, this merits cautious interpretation. It is likely that influences on complications and reoperations are multifactorial and cannot be attributed solely to the method of testicular fixation. Adoption of a standardised approach to emergency fixation of testes within or across institutions may be a potential avenue for future studies.

Introducing a new scrotal orchiopexy technique: The fat anchor orchiopexy

Cryptorchidism is the most common congenital anomaly of the male genital tract. Cryptorchidism is associated with potentially serious consequences including reduced fertility, increases risk of cancer, susceptibility to torsion and traumatic injury, as well as future psychological problems related to an abnormal scrotal appearance. The mainstay of orchiopexy is to achieve an adequate tension-free and permanent scrotal fixation of the testis; one that prevents recurrent ascent. A number of suggestions have been made regarding keeping the testis in the scrotal position once it was brought down in the scrotum without tension. Several techniques for testicular fixation have been described to date; however, the optimal method remains controversial. We herein introduce a novel scrotal orchidopexy technique. This innovative fixation technique utilizes the sub-scrotal fat as a permanent anchor for fixing the low-lying cryptorchid testicle in the scrotum through a trans-scrotal incision. Therefore, the procedure was named "the fat anchor orchiopexy". We believe our method will give better options for scrotal fixation especially in cases of low-lying cryptorchid testes. This article provides a detailed description of this new fixation technique.

Comparative investigation of two surgical techniques of orchiopexy in the post-operative recurrence rate and testicular size in children in clinical trial study

Background:

Cryptorchidism is a common problem which is prevalent in 3% of male infants. This study aimed to determine the effect of both trans fixation and Dartos pouch fixation methods on the postoperative recurrence rate and testicular changes.

Materials and Methods:

In a clinical trial study, 70 children were randomly divided into two groups. In the first group, the correction of cryptorchidism was done by Dartos pouch without suture and in the second group; testis was sutured using common trans fixation. The size of testicles was measured before and 6 months after surgery, children were followed on postoperative complications, trauma to testicles and recurrence of disease in both groups. Data were analyzed using SPSS soft ware.

Results:

The mean size of testicles was 87.16 ± 20.6 mm² in the group with fixed testicle and 182.4 ± 37.9 mm² in the group with not-fixed testicle before operation and the difference between the two groups was significant (P = 0.013). After surgery, the mean size of testicles was 90.8 ± 19.9 mm² in the group with fixed testicle and 183.7 ± 41.2 mm² in the group with not-fixed testicle and the difference between them was significant (P = 0.026). The average of changes in testicular size was 3.62 ± 1.93 and 1.25 ± 5.35 mm² in both fixed and not-fixed groups, respectively and changes in testicular size had no significant difference between the two groups. (P = 0.68).

Conclusions:

Type of fixation had no effect on the size of testes or relevance to the level of retraction. The above management protocol did very well in our hands, and we recommend it for application in the management of undescended testis.

Testicular atrophy after attempted pediatric orchidopexy for true undescended testis

BACKGROUND/PURPOSE

A normal testis in the scrotum is the most important outcome of the attempted pediatric orchidopexy for a true undescended testis. The reports of post-orchidopexy testicular atrophy in the literature have ranged from non-existent to unclear. Our purpose in this study was to estimate the incidence of and associated risk factors for post-orchidopexy testicular atrophy.

METHODS

We performed a retrospective review of data from children who had an attempted orchidopexy for a true undescended testis from 1969 to 2003 inclusive. REB approval 1000011987.

RESULTS

There were 1400 attempted orchidopexies involving common (low) type (n=1135), ectopic type (n=174), and high type testes (n=91). There were a total of 111/1400 (8%) atrophic testes, mostly right-sided. 66/111 (59%) were MADE atrophic, and 45 (41%) were FOUND atrophic. Of the 1135 common type, 56 (5%) were MADE atrophic. In the ectopic and high types, the incidence of post-operative testicular atrophy was 1% and 9%, respectively. The most significant risk factors associated with testes MADE atrophic were high testicle, vas problems, and pre-operative torsion.

CONCLUSIONS

In this series, the incidence of post-operative testicular atrophy that was MADE was 5% in the common (low) type and 9% in the high type. These numbers and the above risk factors should be quoted to the caregiver during pre-operative informed consent.

The testis-specific double bromodomain-containing protein BRDT forms a complex with multiple spliceosome components and is required for mRNA splicing and 3'-UTR truncation in round spermatids

Members of the BET (bromodomain and extra terminal motif) family of proteins have been shown to be chromatin-interacting regulators of transcription. We previously generated a mutation in the testis-specific mammalian BET gene Brdt (bromodomain, testis-specific) that yields protein lacking the first bromodomain (BRDT(ΔBD1)) and observed disrupted spermiogenesis and male sterility. To determine whether BRDT(ΔBD1) protein results in altered transcription, we analyzed the transcriptomes of control versus Brdt(ΔBD1/ΔBD1) round spermatids. Over 400 genes showed statistically significant differential expression, and among the up-regulated genes, there was an enrichment of RNA splicing genes. Over 60% of these splicing genes had transcripts that lacked truncation of their 3'-untranslated region (UTR) typical of round spermatids. We selected four of these genes to characterize: Srsf2, Ddx5, Hnrnpk and Tardbp. The 3'-UTRs of Srsf2, Ddx5 and Hnrnpk mRNAs were longer in mutant round spermatids and resulted in reduced protein levels. Tardbp was transcriptionally up-regulated and a splicing shift toward the longer variant was observed. All four splicing proteins were found to complex with BRDT in control and mutant testes. We thus suggest that, along with modulating transcription, BRDT modulates gene expression as part of the splicing machinery. These modulations alter 3'-UTR processing in round spermatids; importantly, the BD1 is essential for these functions.

The return of the solitary testis

PURPOSE

To assess what is done and what is recommended concerning fixation of the solitary testis.

MATERIAL AND METHOD

We conducted an e-mail survey of current practices in 28 pediatric surgery departments in 28 university or general hospitals in France. We then reviewed what evidence could be found in the literature.

RESULTS

All surgeons fix the contralateral solitary testis following intravaginal torsion. Sixteen out of 28 fix the contralateral solitary testis following extravaginal torsion, 13/28 in cases of monorchia, and 8/28 following orchiectomy for trauma or tumour. Five surgeons have observed one case each of torsion of a solitary testis, and three have witnessed testicular necrosis following orchiopexy.

CONCLUSION

There is no consensus regarding fixation of the remaining testis in the literature. Scientific evidence does not show clearly whether fixation is necessary, regardless of the clinical situation. However, if fixation is performed it should be done using the dartos pouch sutureless technique.

Testicular histology after intestinal pedicle flap (cecum) apposition in rats

PURPOSE

Histological study of vascularization between a cecal pedicle flap and the testicle of Wistar rats.

METHODS

Fifty-three rats were studied. G1: submitted to celiotomy (a), mobilization of the right testicle (RT) to the abdomen (b), cecal flap suture to the RT (d) and cavity closure. G1: procedures a, b and d and fixation of RT into abdomen. G3: procedures a, b and d, exposition of RT to air and reposition into scrotum. G4: not operated. Euthanasia and histology was done after 20 days. Histometry and lesions score classification was done. Testicular vascularization was studied with comparison between G1 and G3. A p < .05 was considered significant.

RESULTS

The G1 RT diameters were not different to G2 RT and all have decreased size in comparison with RT of G3 and G4. The lesions score in the RT was 5.83 in G1 and 3.3 in G2 without statistical difference. The vascularization's average in G1 was 16.9 vessels in 400X field in the RT. In the G3 this average was 0.96 to the RT and 0.92 to left testicles. The weight's average in G1 was similar with G2 but different of G3 and G4.

CONCLUSION

A significant increase of vascularization was observed between the intestinal flap and the rat testicle.

Results of orchiopexy for the undescended testis

The undescended testis is one of the most common congenital abnormalities of the genitourinary system. Outcomes of orchiopexy include (1) having a viable, palpable testis in the scrotum, (2) fertility, as measured by paternity rates or semen analysis in adulthood and (3) risk of testicular cancer. Multiple operative techniques have been described and are associated with various success rates. In the past decade, success of orchiopexy for inguinal testes has been >95%. For abdominal testes, success for orchiopexy has been >85-90% in most series with single stage orchiopexy or two stage Fowler-Stephens orchiopexy, both with open surgical or laparoscopic technique. However, having a palpable testis in the scrotum does not assure fertility, as there are iatrogenic factors that may adversely affect the outcome. In adult men with a history of unilateral orchiopexy, fertility is nearly normal, but is significantly reduced following bilateral orchiopexy. The risk of testicular carcinoma is increased by a factor of 3.7 to 7.5 times. Tumor type is most commonly seminoma if the testis is undescended, whereas tumors that occur following orchiopexy are much more likely to be nonseminomatous.