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Orchiopexy
Orchiopexy
Orchiopexy
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Orchiopexy
Evolution of orchiopexy

Orchiopexy (or orchidopexy) is a surgery to move and/or permanently fix a testicle into the scrotum. While orchiopexy typically describes the operation to surgically correct an undescended testicle, it is also used to resolve testicular torsion.

Indications

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Undescended testicle

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Undescended testicles affect 1% of males and present bilaterally in 10% of those cases. The cause is unknown, with a small percentage associated with developmental abnormalities or chromosomal aberrations.[citation needed]

Early orchiopexy reduces the risks for cancer and sterility in males with cryptorchidism, or undescended testes.[citation needed]

Cryptorchidism is definitively diagnosed after 1 year of age, as testicular descent may occur after birth. Surgical placement into the scrotum is recommended by 18 months to decrease the likelihood of testicular cancer, testicular atrophy, and sterility.

Cryptorchidism is associated with tubular atrophy and sterility. In addition, cryptorchid testes carry a three to five times higher risk for testicular cancer (germ cell neoplasia in situ within the atrophic tubules). Patients are at increased risk for the development of cancer and atrophy in the contralateral, normally descended testes as well.

There are multiple different orchiopexy techniques used to correct an undescended testicle due to the large variation in location where the testes may present. The procedures have a high overall success rate.[1]

Testicular torsion

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Orchiopexy is performed in the event of testicular torsion, a urologic emergency presenting with intense pain and often without inciting injury.[citation needed]

While neonatal torsion occurs with no anatomic defect to account for its occurrence (occurring in utero or shortly after birth), adult torsion results from a bilateral congenital anomaly often called a "bell-clapper deformity", where the testis is abnormally anchored in the scrotal sac, leading to increased mobility.[1]

Twisting of the spermatic cord results in obstruction of the testicular venous drainage. Intense vascular engorgement and infarction may lead to testicular injury and sterility. If the cord is manually untwisted within approximately six hours the testis has a high chance of remaining viable. One in three cases results in dead testes, requiring orchiectomy.[2]

Surgical fixation in the form of orchiopexy is indicated to prevent the reoccurrence of torsion, and is usually performed bilaterally, even if only one testicle is affected by torsion. The procedure has a high success rate in preventing reoccurrence.[1]

Surgical techniques

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For fixation of the undescended testes

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For the management of palpable undescended testes (over 80% of undescended testes) the standard inguinal approach is the appropriate procedure.[3]

Approximately 50% of non-palpable testis are high in the inguinal canal or abdominal, while the other 50% are atrophic, and usually located in the scrotum. Diagnostic laparoscopy is often advised to determine the location of non-palpable testis.[4]

  • Prescrotal orchiopexy is often used for low inguinal testes, reducing surgical time and patient discomfort as compared to other methods,[4] while also reducing the risk of complications. Additionally, hernias and hydroceles can be successfully repaired during this procedure. This approach maintains the high success rate seen in other surgical methods.[5]
  • Standard open inguinal orchiopexy is most appropriate procedure for palpable testes.[4] With this technique, the spermatic cord and testicular vessels can be easily visualized and a patent processus vaginalis can be easily corrected. This approach requires a second incision to secure the testicle within the scrotum (as compared to the prescrotal approach).[5]
  • Laparoscopic orchiopexy is best used for abdominal testis, while mobile/peeping testis distal to the inguinal ring should be approached with the standard one-stage laparoscopic or open orchiopexy.[4] The major proposed benefits of laparoscopic orchiopexy are the possibility of high retroperitoneal dissection and/or rerouting the testes through a shorter pathway medial to the inferior epigastric vessels (called the “Prentiss maneuver”) for a more favorable scrotal position. The benefits of both techniques is debated, with neither showing a difference in success rates.[3] For palpable undescended testes, multi-study analysis has shown that there is no significant difference in safety or success rates between standard open inguinal and laparoscopic approaches, with the latter being more expensive and associated with a higher rate of complications (extensive high retroperitoneal dissection with scrotal hematomas and wound infection, Prentiss maneuvers with hemorrhage from epigastric vessels and wound infection).[3]
  • Fowler-Stephens orchiopexy is a two-stage procedure applied for high intra-abdominal testes (often with short vascular pedicle) or non-mobile testis.[4] This method makes use of collateral blood supply to maintain testicular blood flow, allowed the testis to be brought down further to reach the scrotum without tension. Stage 1 involved vessel ligation (spermatic arteries, as well as inferior epigastric, cremasteric, and vas deferens arteries), with a period of 6 months to allow for collateral blood supply to develop. Stage 2 involved testicular mobilization and fixation within the dartos pouch, which is often performed with laparoscopy. The two-staged Fowler-Stephens is now performed as routine management for intra-abdominal testes at many institutions.[6]
  • Microvascular autotransplantation is another option for patients with intra-abdominal testes, particularly in those with bilateral undescended testes. This technique uses microvascular anastomosis to maximize testicular blood supply after mobilization of the testicles (to get around the high variability in blood supply can complicate the Fowler-Stephens procedure). It takes a lot of microvascular surgical skill, specialized instrumentation, and is a much longer procedure.[7]

For fixation of testicular torsion

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Two distinct techniques used for surgical fixation are the sutured point-fixation and Jaboulay tunica plication. Multiple studies have shown that both are effective techniques for fixation with limited evidence favoring either in acute torsion.[2]

Sutured fixation may be performed using either absorbable or non-absorbable sutures, with 3 point fixation sites being preferred. There are concerns regarding potential complications arising from suture fixation (and required breach of the tunica albuginea) like infarction and abscess formation, however this is not supported by data.[citation needed]

The Jaboulay procedure was developed later as a non-suture fixation method that avoids trans-parenchymal sutures and instead utilizes eversion, loose plication, and adhesion formation. this technique is criticized for potential security inadequacy.[citation needed]

Overall, there is considerable variation in surgical practice for testicular fixation for testicular torsion, with no significant difference in effectiveness between sutured and Jaboulay fixation in emergency re-presentations, post-operative complications, or returns to operation.[8]

History

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The first attempts at surgical correction of cryptorchidism began in the early 1800s. Before this, inguinal testis were managed with the use of truss or castration, if at all.

The theory of orchiopexy is attributed to the observations of Baron Albrecht von Haller and John Hunter in the 1700s, who began to elucidate the anatomy and mechanism of testicular descent.

The first recorded attempt for surgical correction of an undescended testis was performed by James Adams in the London Hospital in 1871, although there are reports of attempts by several German doctors (J. F. Rosenmerkel in 1820 and M.J. von Chelius in 1837). The patient died due to infectious complications of the procedure.

Thomas Annandale completed the first successful orchiopexy in 1887 on a three-year-old boy. He discussed the care of this patient in The British Medical Journal, crediting Thomas Curling (who had worked with James Adams) with the idea of anchoring the testis to the bottom of the scrotum. Notably, Annandale was a close acquaintance of Joseph Lister, and practiced antiseptic techniques that had been absent from previous attempts by other physicians. The postoperative course was reported to be “satisfactory in every way”.

Max Schüller, Arthur Dean Bevan, and John K. Lattimer further contributed to the current techniques for orchiopexy between the late 1800s and early 1900s, with the steps for standard orchiopexy being established before the 1960s. At this point, the standard orchiopexy applied to most undescended testes had a high success rate ranging from 89% to 92%- Attention was then turned to the treatment of high undescended testes, which the standard orchiopexy did not adequately treat.

In 1979, Jones and Bagley suggested a high inguinal incision for high canalicular or intra-abdominal testes. Fowler and Stephens devised a means to preserve the blood supply of high undescended testes through collateral circulation. Their technique was modified into a two-staged operation. Later, one-stage laparoscopic orchiopexy was reported first to reveal the location of non-palpable testes and then as a therapeutic treatment.[9]

References

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Revisions and contributorsEdit on WikipediaRead on Wikipedia

Orchiopexy

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Orchiopexy is a surgical procedure used to treat by relocating an undescended from the , , or into the and securing it in place to promote normal development and function. , the most common congenital anomaly in male newborns, affects approximately 3% of full-term infants and up to 30% of premature infants, with about 80% of cases resolving spontaneously by of age. The condition increases risks of , , and torsion if untreated, prompting surgical intervention to mitigate these complications. According to American Urological Association (AUA) guidelines, orchiopexy is recommended between 6 and 18 months of age for persistent cases, as each six-month delay in surgery correlates with a 1% reduction in fertility potential. The procedure is typically performed under general anesthesia as an lasting about one hour, with approaches varying based on testicle palpability: inguinal or scrotal incisions for palpable testes, and laparoscopic techniques for nonpalpable ones, which may involve vessel division in some cases. The is mobilized, any adhesions are released, and it is anchored using nonabsorbable sutures in the dartos pouch to prevent retraction. Orchiopexy also serves as a treatment for in older patients by fixing the to avoid twisting. Postoperative recovery involves mild pain managed with analgesics, with most children resuming normal activities within 2 to 3 days and avoiding strenuous exercise for two weeks; swelling and bruising may persist for up to two weeks. Potential risks include , , , (up to 20% in some series), formation (about 1%), and rare damage to the , though overall success rates are high, significantly lowering long-term (up to 60% in untreated bilateral cases) and risks (40-fold increase if uncorrected). Long-term follow-up is advised to monitor for recurrence or associated conditions.

Definition and Background

Definition and Purpose

Orchiopexy is a surgical procedure that involves the fixation of a within the , primarily to correct (undescended ) by repositioning the or to prevent recurrent torsion following detorsion in cases of testicular twisting. The intervention addresses congenital maldescent, where the fails to descend into the during fetal development, or acute emergencies like torsion, where the twists and compromises blood supply. This procedure distinguishes itself from ( removal) by preserving testicular function when viable. The primary purposes of orchiopexy in are to facilitate proper testicular positioning in the , which helps mitigate long-term risks such as due to impaired and elevated potential for testicular , with an overall of approximately 3- to 8-fold higher and up to 40-fold in cases of intra-abdominal or bilateral if untreated. In the context of , the secures the testicle to the scrotal wall via plication after untwisting the cord, thereby reducing the likelihood of future episodes that could lead to ischemia and loss of the . Overall, these objectives prioritize preservation, oncologic risk reduction, and structural stability without eliminating all associated complications. For , common approaches include open inguinal or scrotal techniques for palpable testes and laparoscopic methods for non-palpable ones, while typically entails emergent detorsion combined with bilateral or ipsilateral fixation to prevent contralateral involvement. Age considerations emphasize early intervention for , ideally between 6 and 18 months to optimize outcomes before degenerative changes occur, whereas torsion requires immediate surgery regardless of age to salvage the .

Relevant Anatomy

The testis is an ovoid approximately 4-5 cm in length, encapsulated by the dense fibrous tunica albuginea, which divides the organ into lobules containing seminiferous tubules where occurs. These tubules, lined by Sertoli cells and germ cells, converge into the before connecting to the , a coiled tubular on the posterior testis responsible for maturation and storage. The extends from the deep inguinal ring to the testis, enclosing the (ductus deferens), , pampiniform venous plexus, lymphatic vessels, and autonomic nerves that provide sensory and vasomotor innervation. During fetal development, the testes originate near the kidneys in the and descend through the into the in a process governed by the and s like insulin-like hormone 3 and testosterone, typically completing between the 7th and 9th months of . This transabdominal phase occurs in the first trimester, followed by the inguinoscrotal phase driven by gubernacular swelling and regression. In , testicular descent arrests at various sites, including intra-abdominal (proximal to the internal inguinal ring), inguinal (within the canal), or ectopic locations such as the or femoral region due to anomalous gubernacular attachments. For , two primary types occur: intravaginal, where the testis and rotate together within the , allowing cord twisting in post-pubertal males; and extravaginal, involving rotation of the entire around the , more common in neonates before fixation develops. The scrotum consists of thin, pigmented skin overlying the dartos muscle, a layer of smooth muscle in the dartos fascia that contracts to regulate temperature by wrinkling the skin, while the overlying cremaster muscle, a skeletal muscle extension from the internal oblique, elevates the testes in response to cold or stimuli. Vascular supply to the testis arises primarily from the testicular artery, a direct branch from the abdominal aorta, which travels within the spermatic cord and anastomoses with the cremasteric and deferential arteries; venous drainage forms the pampiniform plexus, a countercurrent heat exchange system that cools arterial blood before reaching the testis to support spermatogenesis.

Indications and Diagnosis

Primary Indications

Orchiopexy is primarily indicated for the treatment of , also known as undescended testis, which affects approximately 3% of full-term male infants and up to 30% of preterm infants. Untreated carries significant risks, including rates of 10% to 30% in unilateral cases and over 90% in untreated bilateral cases, as well as a 3- to 5-fold increased risk of compared to the general population. Bilateral is associated with higher risks than unilateral cases, with paternity rates as low as 62% in affected men. Another primary indication is , an acute urological emergency caused by twisting of the , leading to testicular ischemia if not addressed promptly. This condition exhibits bimodal age peaks, occurring most frequently in neonates and during (ages 12 to 18 years). A key predisposing factor is the bell-clapper deformity, an anatomical abnormality allowing excessive testicular mobility, which is present bilaterally in up to 80% of cases. Rarer indications for orchiopexy include retractile testes that fail conservative observation, ectopic testes located outside the normal descent path (such as in the perineal or femoral regions), and preventive fixation following to avert recurrent torsion. Clinical guidelines from the American Urological Association recommend orchiopexy for by 18 months of age to mitigate long-term risks. For , emergent surgical intervention within 6 hours of symptom onset is advised to achieve testicular salvage rates of 90% to 100%.

Diagnostic Evaluation

The diagnostic evaluation for orchiopexy begins with a thorough to determine testicular position and assess for conditions necessitating surgical intervention, such as or . For suspected , the examination is performed in a warm environment to relax the , allowing of the testes along their descent path from the to the ; testes may be classified as palpable (e.g., inguinal or ectopic) or non-palpable (e.g., intra-abdominal or absent). In cases of acute scrotal pain suggestive of torsion, key findings include unilateral swelling, a high-riding testis in a horizontal lie, and absence of the ; Prehn's sign, where elevation of the testis relieves pain, may suggest rather than torsion, though it is unreliable with low sensitivity. Imaging modalities are selectively employed based on clinical suspicion, primarily to evaluate blood flow or localize non-palpable testes without delaying surgery. Color Doppler ultrasound is the initial imaging of choice for suspected , demonstrating reduced or absent intratesticular blood flow with high sensitivity (up to 93%) and specificity (100%), often compared to the contralateral side for viability assessment. For with non-palpable testes, routine imaging is not recommended prior to surgical referral due to limited utility, but ultrasound may identify position in select cases; MRI offers detailed localization of intra-abdominal testes with good accuracy, while diagnostic provides definitive intraoperative assessment during exploration. Hormonal evaluation is reserved for specific scenarios, particularly bilateral non-palpable testes in phenotypic males to confirm testicular presence and rule out anorchia. The (hCG) stimulation test involves a single intramuscular dose (typically 100 IU/kg), followed by serial serum testosterone measurements; a rise greater than 150 ng/dL indicates functional testicular tissue, guiding the need for orchiopexy, whereas absent response suggests bilateral absence and may preclude surgery. Additionally, baseline levels of müllerian inhibiting substance (MIS/AMH) can support evaluation for in ambiguous cases. Differential diagnosis is critical to distinguish conditions requiring orchiopexy from mimics, ensuring timely intervention. In , retractile testes (which descend with manipulation but may ascend secondarily) are differentiated by repeated exams, while associated inguinal hernias are assessed via for reducibility, and rare pediatric tumors (e.g., ) may present as scrotal masses warranting exclusion. For torsion, differentials include (fever, ), , , or trauma, often requiring Doppler to confirm ischemia; urgency is paramount, as testicular salvage rates exceed 90% if detorsion occurs within 6 hours but drop below 10% after 24 hours due to progressive ischemia.

Surgical Techniques

Techniques for Cryptorchidism

Orchiopexy for cryptorchidism is typically performed under general anesthesia to ensure patient comfort and immobility during the procedure. Preoperative preparation may include an examination under anesthesia to reassess testicular position, particularly for previously impalpable testes, and often involves antibiotic prophylaxis to reduce the risk of surgical site infection, especially in cases with risk factors such as young age or clean-contaminated procedures. The standard approach for palpable undescended testes is open inguinal orchiopexy, which begins with a transverse incision in the inguinal crease or over the external inguinal ring to access the and testis. The testis is mobilized by dissecting it from the , separating it from surrounding tissues while preserving the vascular pedicle, including the gonadal vessels and . Any patent processus vaginalis is identified and divided, with ligation of the sac to prevent formation. The mobilized testis is then transferred through the inguinal canal into a created dartos pouch in the , where it is fixed in place using nonabsorbable sutures to maintain its position without tension. For intra-abdominal or nonpalpable testes, is preferred, starting with diagnostic through small umbilical or supraumbilical incisions to visualize and confirm the testicular location. The testis is dissected from peritoneal attachments, mobilizing the and spermatic vessels while minimizing trauma to the vascular supply. A scrotal incision is made to form a neo-orchidopexy pouch, and the testis is guided into the via an route or direct passage, followed by secure fixation. This approach allows for intra-abdominal exploration and is particularly useful for peeping testes at the internal ring. In cases of high intra-abdominal testes with short spermatic vessels that prevent single-stage descent, two-stage techniques are employed. The single-stage method is ideal when the testis can reach the without vascular compromise, preserving the gonadal vessels intact. For more proximal testes, the two-stage Fowler-Stephens procedure—originally described in 1959—involves initial laparoscopic division of the gonadal vessels to promote collateral circulation from the vasal and , followed by a second-stage orchiopexy 3-6 months later to complete descent and fixation. Alternatively, the Shehata technique uses staged traction on the without vessel division to elongate the pedicle over multiple sessions, suitable for peeping or low intra-abdominal testes with long but looped vessels. Success rates for orchiopexy in correcting anatomical position range from 90-95% for open inguinal approaches and are comparable for laparoscopic methods in appropriately selected cases, with overall operative times typically lasting 30-60 minutes depending on and complexity.

Techniques for

requires emergent surgical intervention to restore blood flow and prevent testicular loss, typically performed under general within hours of symptom onset. The procedure begins with an attempt at manual detorsion in the if time permits, by externally rotating the testis laterally (counterclockwise for right-sided torsion or clockwise for left-sided) while stabilizing the ; with reported success rates varying from 26% to 95% across studies and is confirmed by symptom relief and Doppler showing restored flow. If manual detorsion fails or is not feasible, immediate scrotal exploration via a midline longitudinal or bilateral transverse incision is standard, allowing access to the affected hemiscrotum; an inguinal approach may be used if intra-abdominal pathology is suspected. Intraoperatively, the is opened to explore the testis, followed by detorsion in the direction opposite to the twist—typically counterclockwise for right-sided cases—until the is fully untwisted, often requiring multiple rotations. Viability is then assessed by observing testicular color, size, and turgor after wrapping in warm saline-soaked ; adjuncts include intraoperative to evaluate blood flow or, if equivocal, incising the tunica albuginea to check for punctate . If the testis appears non-viable (pale, cyanotic, or without flow), is performed to remove the necrotic tissue, with the decision guided by ischemia duration exceeding 24 hours as a poor prognostic indicator, though assessment remains surgeon-dependent. For viable testes, bilateral orchiopexy is conducted to prevent recurrence, given the high likelihood (up to 80%) of contralateral involvement due to anatomic predisposition like the bell-clapper deformity. Fixation involves securing the testis to the scrotal wall using non-absorbable sutures, such as 4-0 (), placed in three or four points through the tunica albuginea and anchored to the dartos pouch or ; a three-point method (medial, lateral, and inferior) is preferred for its balance of security and minimal tissue trauma. In adolescents, variations may include intravaginal techniques where the is plicated or everted (Jaboulay procedure) to create a more secure pouch, though standard dartos fixation remains most common. The contralateral testis undergoes identical orchiopexy regardless of appearance, as preventive measure. preservation is not typically emphasized in torsion cases, unlike in elective undescended testis repairs. Testicular salvage rates are highly time-dependent, achieving 90-100% if surgery occurs within 6 hours of symptom onset, dropping to approximately 50% between 12 and 24 hours, and less than 10% beyond 24 hours due to progressive ischemia. These outcomes underscore the urgency, with earlier intervention preserving fertility potential and avoiding in most cases.

Complications and Risks

Intraoperative Complications

Intraoperative complications during orchiopexy are uncommon, with overall adverse events reported in less than 5% of procedures. Vascular injury represents a key risk, involving to the , veins, or cremasteric vessels during testicular mobilization and . Such injuries are rare (typically <1-2% based on general intraoperative rates), but can compromise blood flow, leading to testicular ischemia and potential . to the occurs in approximately 1-2% of cases. Prevention strategies emphasize gentle, meticulous to avoid excessive skeletonization of the structures, thereby preserving vascular integrity. In orchiopexy performed for testicular torsion, iatrogenic torsion may arise from re-twisting of the testis during intraoperative manipulation or detorsion. This rare event underscores the need for precise handling and immediate bilateral fixation with nonabsorbable sutures to secure the testis and prevent recurrence. Hernia complications can occur due to incomplete closure of the processus vaginalis, particularly in cryptorchidism repairs where a patent processus is common. Failure to adequately ligate or resect this structure intraoperatively increases the risk of postoperative inguinal hernia development, with incidences up to 3% noted in prescrotal or laparoscopic approaches lacking formal internal ring closure. Thorough inspection and high ligation of the processus during surgery mitigate this risk. Anesthesia-related complications, though rare, include intraoperative that may impair testicular , especially under general or spinal . and have been observed in up to 14% of pediatric urological cases using spinal techniques (primarily at 14%, at ~2%), necessitating vigilant hemodynamic monitoring and prompt vasopressor support if needed.

Postoperative Risks

Following orchiopexy, wound represents a common short-term complication, occurring in approximately 1-3% of cases, and is typically managed with oral or intravenous antibiotics depending on severity. This risk is elevated in emergent procedures for , where rates can reach up to 6%, due to factors such as prolonged operative time and tissue ischemia. Hematoma formation or postoperative bleeding may lead to scrotal swelling and discomfort, often resolving conservatively but requiring surgical evacuation in cases of significant expansion or hemodynamic instability. Such collections arise from minor vessel oozing post-closure and are reported in up to 5% of procedures, particularly when is challenging. Testicular atrophy, affecting 1-20% of cases depending on testis location and surgical approach (e.g., ~3% for palpable unilateral testes, up to 20-25% for intra-abdominal), primarily stems from vascular compromise during or after surgery, and is monitored through serial to assess testicular volume and viability. Intraoperative vascular risks, such as inadvertent injury to the vessels, can contribute to this outcome if not fully mitigated. Complication rates vary by testis position and technique; for example, intra-abdominal testes have higher risk, while recent laparoscopic approaches show low overall complications (as of 2024). Less frequent postoperative issues include , which may necessitate re-closure, and , often transient and managed with catheterization in pediatric patients. Allergic reactions to suture materials, such as , are uncommon but possible, manifesting as local inflammation rather than true , which is extremely rare; occurring in under 5% of cases in some series and managed conservatively. Early detection of these risks is facilitated by routine follow-up examinations, typically within 1-2 weeks postoperatively, allowing for prompt intervention to prevent progression.

Recovery and Outcomes

Postoperative Care

Following orchiopexy for cryptorchidism, the procedure is typically performed on an outpatient basis, allowing discharge the same day once the effects of anesthesia have resolved. In contrast, orchiopexy for testicular torsion, being an emergent intervention, may involve a hospital stay of 1-2 days to monitor testicular viability and manage any acute postoperative pain or swelling. Pain is generally managed with over-the-counter medications such as acetaminophen or ibuprofen, administered as directed, often starting 4 hours post-surgery to preempt discomfort as anesthesia wears off; stronger analgesics like acetaminophen with codeine may be prescribed briefly for children over age 5 if needed, though most require them for only 1-3 days. Ice packs wrapped in cloth should be applied intermittently (10-30 minutes every 4 hours) for the first 24-48 hours to reduce swelling, while avoiding direct skin contact to prevent cold injury. Activity restrictions are essential to promote and prevent testicular displacement. Patients should avoid strenuous activities, rough play, contact sports, bicycle riding, or any straddle exercises for 2-4 weeks, resuming or light play within 1-3 days as tolerated; scrotal support, such as snug or a supportive garment, is recommended for the first week to minimize movement and discomfort. care involves keeping the incision dry for the first 48 hours, followed by gentle cleansing during showers (avoiding baths or soaking for 5-7 days to prevent ); antibiotic ointment may be applied 2-3 times daily if sutures are present, though many use absorbable stitches that dissolve within 2 weeks, eliminating the need for removal. Follow-up care includes a clinic visit at 1-2 weeks to assess wound healing and testicular position, with suture removal if non-absorbable materials were used; an ultrasound may be ordered if testicular atrophy is suspected based on exam findings, such as asymmetry or tenderness. Parents or caregivers should be educated on monitoring for complications, including fever above 101.4°F, increasing redness or swelling at the site, foul-smelling drainage, or persistent pain, prompting immediate contact with the healthcare provider to address potential infections or other issues.

Long-term Results

Orchiopexy for demonstrates high long-term success in maintaining testicular descent, with rates exceeding 90% in most cases, depending on the initial testicular position and surgical technique. For , bilateral orchiopexy achieves recurrence rates below 1%, effectively preventing further episodes in the vast majority of patients. Fertility outcomes are significantly improved by early intervention, particularly when orchiopexy is performed before 1 year of age, as it enhances and overall testicular function compared to later surgery. However, in bilateral cases, even with timely orchiopexy, approximately 20-25% of individuals face compromised potential based on hormonal and histological assessments. The procedure also reduces the risk of , particularly , by a factor of 2-6 times relative to untreated , with the greatest benefit observed when surgery occurs before age 10-12 years. Psychological benefits include improved through and adulthood. Reoperation rates for issues such as testicular ascent or range from 5-10%, often necessitating secondary procedures to address these late complications. As of the 2025 review of the American Urological Association guidelines, these outcomes remain consistent with current recommendations for orchiopexy between 6-18 months.

Historical Development

Early Attempts

The condition of undescended testes, known as , was first systematically described in 1786 by Scottish surgeon and anatomist John Hunter, who observed that testes failing to descend into the remained imperfect and suggested that surgical assistance might be beneficial if performed safely. Hunter's work, based on anatomical dissections of fetuses and adults, highlighted the gubernaculum's role in normal testicular descent and marked the pre-surgical recognition of the pathology, though no operative interventions were attempted at the time. Initial surgical efforts to correct emerged in the early but were largely unsuccessful, often limited to conceptual or experimental approaches. In 1820, German surgeon J.F. Rosenmerkel of advocated and reportedly attempted the first orchiopexy by mobilizing and placing the undescended testis into the , though the procedure failed due to postoperative complications. Throughout the mid-19th century, multiple trials by European surgeons, such as M.J. von Chelius in 1837 and James Adams in 1871, involved inguinal incisions to free and reposition the testis, but these were marred by high mortality rates—often exceeding 50% in reported cases—from wound infections and , as antisepsis was not yet standard. For instance, Adams's , an infant, succumbed to originating in the three days post-operation. A pivotal advancement occurred in 1877 when Scottish surgeon Thomas Annandale performed the first successful orchiopexy on a 3-year-old boy with an ectopic perineal testis, using a straightforward inguinal approach to mobilize the testis, elongate the , and fix it in the with sutures. Annandale's procedure benefited from Joseph Lister's emerging techniques, including carbolic acid sprays, which minimized risk and allowed the boy to recover fully without complications. This milestone shifted focus from purely traction-based methods—early non-surgical attempts using weights or elastic bands to gradually pull the testis downward, which proved unreliable and caused cord tension—to direct surgical fixation. These early endeavors were hindered by the absence of reliable in the initial decades (ether was introduced only in ), forcing operations under rudimentary pain control, and by inadequate antisepsis, resulting in frequent and death. Traction methods, while less invasive, often failed to achieve lasting descent due to insufficient cord lengthening and recurrent ascent, underscoring the era's limited understanding of testicular and vascular supply.

Modern Techniques

In the early , orchiopexy techniques evolved to address the challenges of mobilizing undescended testes while minimizing vascular compromise. Franz Torek introduced a two-stage traction method in , involving fixation of the testis to the for 3 to 6 months to gradually elongate the before scrotal placement; however, it was largely abandoned due to high rates of from prolonged tension and impaired blood supply. Concurrently, Arthur Bevan's two-stage approach, initially described in 1899 and refined in the , emphasized extensive retroperitoneal to lengthen spermatic vessels, division of the processus vaginalis to prevent reascent, and tension-free positioning with a purse-string suture, achieving success rates approaching 95% in over 400 cases by preserving testicular viability. Mid-century advancements simplified the procedure and improved safety. In the 1940s and 1950s, Robert E. Gross and Theodore C. Jewett popularized single-stage orchiopexy through inguinal incision, mobilizing the testis and placing it in a subdartos pouch without traction, reporting success in 90% of 1,222 operations by reducing operative time and risk. The widespread introduction of antibiotics, such as penicillin in the 1940s, dramatically lowered postoperative rates in pediatric surgeries, including orchiopexy, from historically high levels (often exceeding 20% pre-antibiotics) to under 5%, enabling broader adoption of these techniques. From the late onward, minimally invasive and specialized methods addressed intra-abdominal testes. , first applied diagnostically in 1976, was adapted for therapeutic orchiopexy in the early ; the Fowler-Stephens procedure, originally open in 1959, became laparoscopic as a two-stage approach involving initial vessel ligation to promote collateral circulation, followed by scrotal transposition, with success rates of 77% for two-stage variants. For high undescended testes with inadequate vessel length, microvascular auto-transplantation emerged in the 1970s—pioneered by Silber and Kelly in 1976—reimplanting the testis to the using microsurgical to inferior epigastric vessels, preserving direct arterial flow and achieving over 90% viability in reported series. Guidelines shifted in the toward early intervention, with organizations like the American Urological Association recommending orchiopexy before age 2 years (and ideally by 18 months) to mitigate loss and optimize fertility, based on histological evidence of progressive tubular after infancy. Contemporary practices since the 2010s emphasize precision and fertility preservation through robotic-assisted laparoscopy, which enhances visualization and dexterity for intra-abdominal cases, yielding success rates exceeding 95% in testis positioning and survival, comparable to traditional laparoscopy but with reduced operative trauma. This focus aligns with evidence that early orchiopexy (before 12 months) improves adult paternity rates to 75-90% in unilateral cases versus 50% if delayed, underscoring the priority of timely vascular preservation to support spermatogenesis.

References

  1. https://www.ncbi.nlm.nih.gov/books/NBK560904/
  2. https://my.clevelandclinic.org/health/treatments/17297-orchiopexy
  3. https://www.auanet.org/guidelines-and-quality/guidelines/cryptorchidism-guideline
  4. https://www.childrenscolorado.org/doctors-and-departments/departments/urology/tests-services/orchiopexy/
  5. https://pubmed.ncbi.nlm.nih.gov/32863201/
  6. https://medschool.cuanschutz.edu/surgery/divisions-centers-affiliates/pediatric/patient-care/orchidopexy
  7. https://pmc.ncbi.nlm.nih.gov/articles/PMC6219294/
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