An Evolution of Orchiopexy: Historical Aspect
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View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by PubMed Central www.kjurology.org DOI:10.4111/kju.2010.51.3.155 Review Article An Evolution of Orchiopexy: Historical Aspect Kwanjin Park, Hwang Choi Department of Urology, College of Medicine, Seoul National University, Seoul, Korea The history of treatment for cryptorchidism dates back more than 200 years. This re- Article History: view is intended to highlight some historical aspect that led us to our current surgical received 26 February, 2010 9 March, 2010 treatment of this condition. The medical and historical surgical literatures pertaining accepted to cryptorchidism were reviewed. Data sources were PubMed, Embase, conference pro- ceedings, and bibliographies. No language, date, or publication status restrictions were imposed. The study of cryptorchidism began with the anatomical descriptions of Baron Albrecht von Haller and John Hunter. Attempts at surgical correction of the un- Corresponding Author: descended testis began in the early 1800s, culminating in the first successful orchiopexy Kwanjin Park Department of Urology, College of by Thomas Annandale in 1877. Max Schüller, Arthur Dean Bevan and Lattimer con- Medicine, Seoul National University, tributed to the establishment of current techniques for standard orchiopexy. Later, lap- 101, Daehak-ro, Jongno-gu, Seoul aroscopy, high inguinal incision (Jones’ approach) and scrotal approach were added to 110-744, Korea the list of current orchiopexy. TEL: +82-2-2072-0695 FAX: +82-2-742-4665 Key Words: Cryptorchidism; Orchiopexy; History E-mail: urodori9@snu.ac.kr INTRODUCTION servations by two pioneers in the 18th century, Baron Albrecht von Haller and John Hunter. Over the ensuing Cryptorchidism (from the Greek kryptos, meaning years, theories on the mechanism of descent, and study of “hidden,” and orchis, meaning “testis”) refers to the ab- the histological and physiological alterations in the cryp- sence of a testis from the scrotum. Isolated cryptorchidism torchid testis came out, aiding the development of is the most common congenital anomaly of the male geni- orchiopexy. talia, affecting almost 1% of full-term infants at the age of Baron Albrecht von Haller, who became the Chairman 1 year [1]. During embryonic life, the testes form beside the in Anatomy and Surgery at Göttenger University in the mesonephric kidneys and descend via the inguinal canal 1730s, described the abdominal position of the fetal testis to the scrotum. If this process is faulty, a cryptorchid testis in his famous work ‘Opuscula Pathologica,’ published in may halt along the normal path of descent (undescended 1755. In the chapter regarding congenital hernia, he accu- or retractile testis), may travel off the normal path of decent rately indicated the presence of abdominal testis, though (ectopic testis), or may die or never develop (absent testis). he did not know the exact timing of testicular descent. Also, The history of the study of cryptorchidism and the first his explanation of the phenomenon responsible for the de- attempt to correct it began in the 18th century. Like other scent of the testis was wrong. However, it was important areas of medicine, which is a combined action of art and sci- that his description attracted the interest of John Hunter, ence, the progress of techniques in orchiopexy has been who later made some great observations that still hold true supported by an improved understanding of cryptor- today. chidism. In this context, this review aimed to describe the John Hunter is known as one of the fathers of modern sur- historical landmarks in the progress of orchiopexy in paral- gery and anatomy. He was born on a small farm near lel with the growing knowledge of cryptorchidism that had Glasgow, Scotland, in 1728, the youngest of 10 children. spurred the technical advances in orchiopexy. Among his 10 siblings, he and his older brother William made a significant contribution to medicine. They founded THE ERA OF PIONEERS the first independent anatomical school in London. John Hunter was a brilliant anatomist with unending curiosity, The theoretical bases that justify orchiopexy in patients a variety of interests, and a colorful character. Although with cryptorchidism originated from some critical ob- William wanted his younger brother to be a classic gentle- Korean Journal of Urology Ⓒ The Korean Urological Association, 2010 155 Korean J Urol 2010;51:155-160 156 Park and Choi man, his character made him a house-surgeon and later a current understandings, his observations surely gave a partner in the anatomy school. He was the leading expert theoretical basis on which later doctors attempted the first in the study of comparative anatomy, infectious diseases, orchiopexy. and gunshot wounds [2,3]. John Hunter began to study on the descent of fetal testis UNDERSTANDING AND CONTROVERSIES with an interest in Baron von Haller’s observations. In ABOUT GUBERNACULUM 1762, Hunter confirmed the abdominal position of the fetal testes as well as the neurovascular supply and the cre- The structure of the gubernaculum, or genitoinguinal liga- master or musculus testis (a more proper name, according ment, was first described and named by Hunter in 1762. to Hunter). Through postmortem dissection, he first ob- Although most authors believe that it contributes sig- served that the testis descends generally around the eighth nificantly to testicular descent, there is little consensus on month. He also described the retractile testes, undescend- the mechanism involved. Controversies around gubernac- ed testes, and testicular ectopia. He did not agree with the ulum were related to its tail structures and its role in the current suggestion that the testis was forced into the scro- development of ectopic testis. tum by the compressive force of respiration, or pulled by In 1840, Curling noted the gubernaculum to be a soft, sol- the cremaster muscle. Instead, he proposed the sig- id protruding body that varied in shape and size at different nificance of gubernaculum as a helm or rudder for tes- stages of testicular descent [6]. He also claimed that the gu- ticular descent [4]. bernaculum terminated in three muscular processes, Although the precise cause of failure to descend has not which he could trace before, during and after testicular been clearly understood at this time, his association of cryp- descent. He listed these as (i) external - connected to torchidism with faulty testis appears interesting, as he Poupart’s ligament; (ii) middle - through the external ring stated that: ‘‘when one or both testicles remain through life to the bottom of the scrotum; and (iii) internal - to the os in the belly, I believe that they are exceedingly imperfect pubis and the rectus muscle sheath. and probably incapable of performing their natural func- Since the gubernaculum contains muscle that is likely tions, and that this imperfection prevents the disposition to contract, this led Lockwood to propose the ‘traction theo- for descent from taking place.’’ ry’ of testicular descent. Following the examination of eight He believed in the necessity of treatment of undescended fetuses (7 weeks’ gestation to full term), he noted the testis after a period of patient observation. He wrote ‘‘As change of distal gubernaculum from a soft, jelly- like mass this progress is very slow, especially when the testicle is into a leash of fibers that spread out to several areas and creeping through the ring, a doubt often arises whether it pulled the testis into the scrotum [7]. Sometime later, his is better entirely to prevent its passage or to assist it by ex- description of the fibers became known as the ‘tails of ercise or other means; and it would certainly be the best Lockwood’ and the presumed cause of testicular ectopia practice to assist it, if that could be done effectually and (Fig. 1) [8]. Although Lockwood himself did not mention safely.” that abnormal development of the gubernacular tail could Hunter’s accurate description of fetal testicular descent be the cause of testicular ectopia, some authors referred to made great progress in the understanding of cryptor- Lockwood’s work as an explanation for testicular ectopia chidism. Although testicular decent and maldescent are [9-11]. now being explored on the molecular level, most of our In the early 20th century, the concept of gubernacular knowledge on cryptorchidism is still based on his obser- tails as a cause of testicular maldescent prevailed. Coley vations. Furthermore, even though many theories such as found many similarities between Curling’s and Lock- abdominal pressure, endocrine factors, cremasteric mus- wood’s theories and tried to amalgamate both theories [12]. cle contraction and gravity have been proposed to explain Some authors reported findings in conflict to the “tails testicular descent, none is more important than the gu- of Lockwood.” Sonneland could not find any corroborative bernaculum as Hunter claimed more than 2 centuries ago. evidence either embryological or anatomical for the ex- After the great discovery of Hunter, the discussion of the istence of multiple processes [9]. Instead of multiple gu- nature of the gubernaculum, the role of the cremaster, and bernacular tails, he claimed a singular gubernacular proc- the process of descent continued. ess and believed that the fibrous attachment of ectopic tes- In 1866 Thomas B. Curling summarized what was tis was just a result and not the cause of testicular known at that time regarding undescended testicles in his maldescent. McGregor also failed to find any subdivision book, A Practical Treatise on the Diseases of the Testis [5]. of the gubernaculum and concluded that Lockwood’s theo- Some of his observations hold true today, such as abnormal ry was unproved and proposed the ‘third inguinal ring’ or testicular function in undescended testis and proper evolu- congenital fascial packets or barriers as a cause of tes- tionary time limits to recovery of retained testicles. He also ticular ectopia [13,14].