Orch = pertaining to the testicle
Pexy = fixation or attachment
In the developing male fetus, the testicles grow in the baby’s abdomen and drop down into the scrotal sac near the end of pregnancy. In some boys (more frequently in premature births), one or both of the testicles will not fully come down to the scrotal sac, and this is referred to as cryptorchidism. The undescended testicle can remain in the abdominal cavity, or further along its intended course in the inguinal canal (groin area between the abdomen and the scrotal sac).Its position, and whether it is palpable (able to be felt during physical examination) will determine the recommended treatment.
If both testicles are undescended, we may have already recommended a trial of human chorionic gonadotropin (HCG) injections. This hormone therapy may cause the testicles to drop down further. HCG injections usually work better when both testicles are undescended.
Orchiopexy is not recommended for cosmetic reasons. Undescended testicles place your son at a much greater risk of developing testicular cancer in his lifetime compared to males with normally descended testicles. Cryptorchidism may also result in impaired spermatogenesis(ability to properly produce sperm) in the undescended and even the descended testicle. If left undescended, your child may be at risk for infertility. Also, torsion or twisting of the vascular spermatic cord on which the testicle dangles may result in loss of blood supply to and permanent damage to the testicle.
Orchiopexy is appropriately done as an “open” operation (involving small skin incisions) or as a “laparoscopic” operation (done through a scope with instruments inserted into the body through tiny incisions). Sometimes, laparoscopy is combined with an incision to maximize results. Rarely, with very high testicles, it is possible that the orchiopexy procedure is done in more than one operation (i.e. on two different dates). This is referred to as a “staged” operation.
As with any procedure in which anesthesia is administered, you will be asked not to feed your child anything (including any liquids) after midnight on the evening prior to the surgery. If your child is on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if your child is on, or has recently been taking any medication that may interfere with his ability to clot his blood. The most common of these medications are aspirin-like compounds and all related pain relievers, fever reducers, or anti-inflammatory compounds(whether prescription or over-the-counter). Please refer to the attached list and tell us if he has taken any of these within the past 10 days.
If his medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed any of the current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.
To review the basics of what we discussed in the office: The procedure can take up to two hours depending on an individual’s anatomy, the location of the testicle(s) and whether one or both sides require treatment.
As previously mentioned, undescended testicles are classified as palpable or non-palpable(depending on whether they can be felt on physical examination). Laparoscopy (putting the small telescope into the abdominal cavity) is often done to determine if a non-palpable testicle does indeed exist before any formal skin incisions are made to perform an orchiopexy. Many orchiopexy procedures may be done completely by laparoscopy depending on the location of the testicle and the surgeon’s experience in this area. In other instances, the laparoscopic portion may be used to move the testicle down to a point where it is easily approachable with an inguinal (lower abdomen near the groin) incision.
Laparoscopy: A camera (that is projected onto a television screen) and small instruments are placed through tiny holes in the abdomen. The abdomen is gently inflated with a type of gas to create a space that allows proper visualization. First, the testicle and the cord structures: the artery and vein (blood vessels) and the vas deferens (tube that transports the sperm) are identified. The remainder of the procedure is the same as in the open procedure. The cord is lengthened as much as possible to bring it down near, or into the scrotum. Once in position, it is fixed in place with sutures. Once the instruments are withdrawn, the small holes are all sutured closed and sterile bandages are applied.
Open Surgery: If the testicle is palpable, an open procedure or laparoscopy may be used. As mentioned, sometimes laparoscopy is employed first to locate and even partially bring the testicle down. Open surgery through a small incision may then be made to get the testicle into the scrotum. Sometimes, laparoscopy is not used regardless of the location of the testicle. The small incision is made across the inguinal region (groin area just above and off to the side of the penis or scrotal sac). Dissection is performed down to the testicle and cord. During the procedure, the testicle and cord structures are inspected to ensure that everything else appears within normal limits. Sometimes, the undescended testicle is smaller than the other testicle. In some instances, one of the arteries (vessels bringing blood to the testicle) must be sacrificed(purposely cut) to create a longer cord. The cord must be long enough to bring the testicle down to the scrotum without any tension. The testicle can usually survive because there are other small vessels bringing blood to the testicle. Once the testicle is in the scrotum, sutures are placed to fix the testicle in a pouch in the scrotum. To create the pouch, a small incision is made in the wall of the scrotal sac. The inguinal incision and the scrotal incision are then closed. The stitches may be buried underneath the skin and will therefore not require removal. A sterile bandage is then applied.
Your child will be in the recovery room for a short time before being sent home. He may have discomfort over the incision(s) and possibly in the groin and scrotum. If laparoscopy was performed, there may be small bandages directly over any incision(s). If an incision was made, it may also be covered.
Bandages are to remain on until follow up in the office unless you have been specifically instructed to remove them earlier. It is common to see small blood staining on the bandages. If the dressing becomes soaked, or you see active blood oozing, please contact us.
He may shower the day after surgery. Your surgeon may ask you not to place your child in a bath. Sometimes your surgeon may instruct you to place him in a warm bath a few days after surgery. We ask that he refrain from any strenuous activity or rough play (including gym or physical education) until after his follow up. Every patient has some degree of swelling and bruising, and it is not possible to predict in whom this might be minimal or significant. In the first 24 hours, it is important to minimize his activity and have him spend a lot of time sitting or lying down. Some patients have almost no discomfort while others are some what uncomfortable for a few days; longer is rare. For discomfort, he may have any pediatric-dose over-the-counter medicine to which he is not allergic (Tylenol®, Advil® or other ibuprofen product). Upon follow up in the office, we will examine him. The sutures we use are usually self-dissolving, and therefore just dissolve with time.
The tissues within the scrotum and over the incision(s) may swell and appear bruised. This may be more dramatic one or two days after than on the first day. This is expected.
If the testicle was easily palpable prior to the operation, it is usually found to be a normal testicle (one that will survive and function). It will, however, remain small if it was found to be shrunken during surgery. In that regard, it may always have decreased function compared with the other.
It is also possible for a testicle to shrink after the operation. It is possible that the testicle loses its blood supply during the effort to lengthen the cord. This is not always apparent during the actual surgery.
With very high testicles that cannot be brought down during the operation, one of two choices must be made:
*If the testicle looks normal and significant progress is made, we can stage the operation. This means that we can return to the operating room months later (after some healing has occurred)and make an attempt to bring it down the remainder of the way.
*If the testicle appears abnormal (fairly shrunken), or if we have little success in getting it near the scrotum on the first procedure, we may decide to remove the testicle as opposed to stage the operation. The operation is only successful if the testicle is successfully brought into the scrotum. Leaving the testicle in the inguinal canal is still putting your child at risk.
ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes which may include, but are not limited to:
We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).
The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.