Right Orchiopexy to Correct Undescended Testicle and Circumcision to Correct Phimosis

Case Overview

Cryptorchidism, or undescended testis, is a condition in which one or both testes fail to descend from the abdomen into the scrotum during fetal development. It is the most common congenital abnormality of the genitourinary tract,¹ occurring in approximately 3% of full-term and up to 30% of premature male infants.² The etiology of cryptorchidism is multifactorial, with genetic, environmental, maternal, and hormonal factors playing a role.³ Risk factors associated with cryptorchidism include prematurity, low birth weight, exposure to certain endocrine-disrupting chemicals during pregnancy, and genetic conditions such as Down syndrome.^4–6

If left untreated, cryptorchidism can lead to various long-term complications. One of the most significant concerns is an increased risk of testicular cancer, particularly seminoma and non-seminomatous germ cell tumors.⁷ Studies have shown that men with a history of cryptorchidism have a higher risk of developing testicular cancer compared to those without the condition.⁷ Additionally, cryptorchidism is associated with a higher risk of infertility, as the undescended testis may have impaired spermatogenesis due to the temperature difference between the abdomen and the scrotum.⁸ Other potential complications include testicular torsion, inguinal hernia, and an increased risk of trauma to the undescended testis.

The management of cryptorchidism aims to relocate the undescended testis into the scrotum, typically through surgical intervention known as orchiopexy. This procedure is recommended to be performed between 6–12 months of age, as early treatment has been shown to reduce the risk of complications and improve fertility outcomes.⁹ Delaying treatment beyond this age range can increase the likelihood of testicular damage and the need for more complex surgical interventions.

Phimosis, on the other hand, is a condition characterized by the inability to retract the foreskin over the glans penis. It can be physiological, occurring in infancy and resolving naturally as the child grows older, or pathological, resulting from scarring, infection, or inflammation.¹⁰ Untreated pathological phimosis can lead to various complications, such as urinary tract infections, balanitis, paraphimosis, and an increased risk of penile cancer.^11,12

The management of pathological phimosis may involve topical steroid creams or, in some cases, circumcision, which is the surgical removal of the foreskin. Circumcision is a relatively simple procedure that can effectively resolve phimosis and prevent potential complications.^13–16

This video serves as a step-by-step guide on orchiopexy to correct an undescended testicle and circumcision to correct phimosis. It highlights the importance of proper dissection, identification, and mobilization of the undescended testis, as well as the techniques for lengthening and mobilizing the spermatic cord. It emphasizes the significance of separating and ligating the hernia sac, if present, to prevent future complications. Additionally, the video illustrates the critical steps involved in repositioning the testis within the scrotum. Furthermore, the video addresses the management of phimosis through circumcision, a procedure that may be performed simultaneously with orchiopexy.

The surgical procedure begins with an oblique skin incision made in the inguinal region, parallel to the inguinal ligament. After dissecting the underlying subcutaneous tissue and Scarpa’s fascia, the external oblique aponeurosis is identified. Then, the external oblique aponeurosis is opened along the direction of the fibers, taking care to avoid injuring the ilioinguinal nerve. The undescended testicle and spermatic cord are identified and dissected off the walls of the inguinal canal. The testicle is examined for viability. The processus vaginalis is then identified and dissected off the contents of the spermatic cord, ligated at the level of the internal ring, and excised. To facilitate the descent of the testis into the scrotum, the spermatic cord, containing the blood vessels, nerves, and vas deferens, must be lengthened. The cremasteric muscles and restraining adventitial tissue are safely dissected free to gain length. This is achieved by dividing the cremasteric fibers surrounding the spermatic cord using electrocautery or scissors. A subcutaneous tunnel is created from the inguinal incision site to the scrotum, allowing for the passage of the spermatic cord and testis into the scrotum. Within the scrotum, a pouch is created in the dartos muscle layer to accommodate the testis in its new position. The testis is guided through the tunnel and positioned within the pouch in the scrotum, ensuring no tension on the spermatic cord. The testis is secured in its new position by suturing the surrounding dartos layer and gubernaculum to the testis, preventing retraction. The external oblique aponeurosis is then closed, followed by the closure of the subcutaneous layer and the skin.

Afterwards, the foreskin is retracted forward and held with Kelly clamps. The skin is divided to expose the glans, excised, and sutured with simple interrupted sutures, concluding the circumcision procedure.

In the postoperative period, the patient is monitored for any complications, such as bleeding, infection, or testicular ischemia. Proper follow-up care and instructions are provided to ensure the success of the procedure and prevent potential complications.

The importance of this surgical intervention lies in the preservation of testicular function, fertility potential, and the prevention of long-term complications associated with cryptorchidism. Early treatment is crucial, as it significantly reduces the risk of testicular damage and associated complications.

The video presented in this case is of significant importance for practitioners, particularly urologists and pediatric surgeons, as it provides a detailed and comprehensive demonstration of the surgical techniques involved in the management of cryptorchidism and phimosis. The step-by-step approach, coupled with the surgeon's commentary, offers valuable insights and practical guidance for those performing these procedures. By providing a detailed visual representation of these procedures, the video can enhance the understanding and skill sets of surgeons, ultimately leading to improved patient outcomes and a higher standard of care.

Statement of Consent

The parents of the patient referred to in this video have given their informed consent for surgery to be filmed and were aware that information and images will be published online.