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Single Scrotal Incision Orchiopexy - a Systematic Review ______Hugo Fabiano Fernandes Novaes, José Abraão Carneiro Neto, Antonio Macedo Jr, Ubirajara Barroso Júnior

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Single Scrotal Incision Orchiopexy - a Systematic Review ______Hugo Fabiano Fernandes Novaes, José Abraão Carneiro Neto, Antonio Macedo Jr, Ubirajara Barroso Júnior REVIEW Article Vol. 39 (3): 305-311, May - June, 2013 doi: 10.1590/S1677-5538.IBJU.2013.03.02 Single scrotal incision orchiopexy - a systematic review _______________________________________________ Hugo Fabiano Fernandes Novaes, José Abraão Carneiro Neto, Antonio Macedo Jr, Ubirajara Barroso Júnior Section of Pediatric Urology, Division of Urology Bahiana School of Medicine and Federal University of Bahia and Federal University of São Paulo ABSTRACT ARTICLE INFO _________________________________________________________ ___________________ Objective: To conduct a systematic review on single scrotal incision orchiopexy. Key words: Materials and Methods: A search was performed using Pubmed, through which 16 ar- Cryptorchidism; Orchiopexy; ticles were selected out of a total of 133. The following conditions were considered ex- Scrotum; Surgical Procedures, clusion criteria: other surgical methods such as an inguinal procedure or a laparoscopic Operative approach, retractile testes, or patients with previous testicular or inguinal surgery. Results: A total of 1558 orchiopexy surgeries initiated with a transcrotal incision were Int Braz J Urol. 2013; 39: 305-11 analyzed. Patients’ ages ranged between 5 months and 21 years. Thirteen studies used __________________ high scrotal incisions, and low scrotal incisions were performed in the remainder of the studies. In 55 cases (3.53%), there was a need for inguinal incision. Recurrence was ob- Submitted for publication: served in 9 cases, testicular atrophy in 3, testicular hypotrophy in 2, and surgical site in- December 18, 2012 fections in 13 cases. High efficacy rates were observed, varying between 88% and 100%. __________________ Conclusions: Single scrotal incision orchiopexy proved to be an effective technique and is associated with low rates of complications. Accepted after revision: May 27, 2013 INTRODUCTION of dissection, accelerated healing, less pain, good maintenance of testicular position and an excel- Cryptorchidism is the most common pa- lent cosmetic result (6). thology during childhood (1), affecting 2-4% of Despite the good results of transcrotal or- children at birth and decreasing to 1% in the first chiopexy found in the literature, its use is not wi- year of life (2,3). The majority of cryptorchidic despread. The objective of this study is to perform testes are in the superficial inguinal pouch of a systematic review on the subject. Denis Browne, making inguinal exploration the traditional surgical correction procedure (4). MATERIALS AND METHODS The inguinal procedure requires two in- cisions: one in the groin to release the testicle, Our Experience and another scrotal incision to make a pocket We retrospectively evaluated 18 patients to accommodate the testicle. In order to redu- (22 testes) who underwent scrotal orchiopexy be- ce the potential morbidity of this treatment, in tween August 2007 and August 2009. We reviewed 1989 Bianchi and Squire introduced a technique the charts concerning laterality of the surgery, age utilizing a single scrotal incision (5). It is sug- of the patients, inguinal conduit persistence and gested that this technique adds the advantages whether the patients had undergone a previous of a single incision, shorter operation time, ease surgery for undescended testis. 305 IBJU | SINGLE SCROTAL INCISION ORCHIOPEXY All patients were examined under anes- Figure 1a - The testis mobilized and delivered through the thesia and the decision of whether or not to per- incision. form a transcrotal approach was based on the ability to push the testis to the level of external inguinal ring. The incision was horizontal at the lowest part of the hemiscrotum for unilateral cases (Figures 1a and 1b), and longitudinal at the scrotal raphe for bilateral undescended testes (Figure-2). In the technique of scrotal orchiopexy we first manipulate the testis down toward the exter- nal inguinal ring. The testis is grasped with the thumb and the index finger. With the surgeon keeping traction on the testis the scrotal incision is performed and the testis and spermatic chord are freed from the cremasteric fascia (Figure-1a). When present, the inguinal conduit persistence is closed. Because the inguinal canal is short in children, the conduit can be closed at the level of Figure 1b - Final appearance for unilateral undescended testis. the internal inguinal ring. The dissection of the inguinal conduit elongates enough the spermatic chord, making it possible for the testes to reach the scrotum easily. The testes are fixated in the scrotum by means of a Dartos pouch. The patients are discharged the same day of the surgery. The patients were followed up regular- ly. They were directed to return to the office one week, one month and six months after surgery and then on a yearly basis. Systematic review A systematic review was performed throu- gh an electronic search on the Pubmed database using the following key words and combinations thereof: scrotal incision, cryptorchidism, orchio- Figure 2 - Final appearance for bilateral undescended testes. pexy and undescended testis. The search yielded 133 articles. Prospective and retrospective arti- cles were selected which evaluated children with primary cryptorchidism who were treated surgi- cally through single scrotal incision orchiopexy. Articles were excluded if they: evaluated secon- dary cryptorchidism from previous procedures or any other pathology; evaluated patients who underwent orchiopexy via another procedure (in- guinal or laparoscopic). The effectiveness of the technique was evaluated, defined as the presence of the testis in the scrotum after the procedure, without subsequent hypotrophy or atrophy, and without the need for an inguinal incision. 306 IBJU | SINGLE SCROTAL INCISION ORCHIOPEXY After evaluating the abstracts, 88 articles der anesthesia, excluding cases of retractile tes- were excluded that dealt with other issues, 23 that tis. The age range varied between 5 months and used laparoscopy as a means of access, and 4 whi- 21 years. All patients studied underwent single ch were review articles; 18 articles remained to scrotal incision orchiopexy; 13 studies used high be reviewed. After verifying the references of the scrotal incisions, and low scrotal incisions were selected articles, we included two articles (7,8), gi- performed in the remainder. Eleven studies recor- ving a total of 20 articles. After analyzing the full ded the incidence of patent processus vaginalis, articles, one study was excluded which studied the which was present in 324 of the 1090 cases eva- same group of patients as another study published luated (29.7%). later (9), one article which evaluated the technique In 55 cases (3.53%) an inguinal incision in patients with retractile and reoperated testicles was necessary. These patients had high testes (10), another which only evaluated patients with (1,2,11-14) requiring retroperitoneal dissection secondary or relapsed cryptorchidism and another (4,13,15) or the presence of the vaginal process article which did not evaluate the surgical results or hernia (1,11,16). of the orchiopexy separately from other inguinal Only one case presented intraoperative procedures (8). In the end, 16 articles were selected complications (injury to the vas deferens). Study for review. The present study was completed in 3 did not evaluate intraoperative complications. March 2011. In one article, the authors reported no intraope- rative or postoperative complications and 100% RESULTS efficacy. In this study, the follow-up was only 3 months (17). Our results The post-operative follow-up was hete- Eighteen patients (22 testes) underwent rogeneous, ranging from 3 months to 5 years, scrotal orchiopexy. The surgery could be perfor- with a lack of follow-up in some studies. Recur- med via scrotal approach in all cases and the tes- rence was observed in 9 cases (2-4,16,18), testi- tes could be brought down to the scrotum with cular atrophy in 3 (2,16), testicular hypotrophy no tension. No inguinal incision was necessary. in 2 patients (11) and surgical site infections in Persistence of inguinal conduit was 13 (2,11,12,16,19-21). Hematomas occurred in 22 found in 16 (72%) cases. In all, the conduit cases (2,3,12,15,16); in Study 2 alone 16 cases of could be closed at the level of inguinal internal hematoma were observed (15.09% of the patients ring. There were no intraoperative or postope- in the study). Study 2 also showed the highest ra- rative complications. tes of testicular atrophy (2 cases) and recurrence Two patients had unsuccessfully under- (5 cases), out of a total of 106 orchiopexies. gone previous inguinal surgery for undescen- Given the concept of efficacy that was ded testis. The testes remained in the superficial pre-established (the post-operative result after inguinal pouch of Denis Browne and could be single scrotal incision orchiopexy, with no sub- approached via scrotal approach with no com- sequent atrophy, hypotrophy or any other com- plication. plication that may result in orchiectomy), rates of In a mean follow up of 18 months (ran- success were found to be between 88 and 100%, ging from 3 to 37 months), no complication such as shown in Table-1. as infection, testicular atrophy, hydrocele or her- nia was observed. DISCUSSION Systematic review Orchiopexy is a necessary procedure for Results are shown in Table-1. A total the treatment of a common problem in the pe- of 1558 orchiopexy surgeries initiated with a diatric population. It is traditionally performed transscrotal incision were analyzed.
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