Introduction

Orchiopexy, alternatively referred to as orchidopexy, is a surgical intervention employed for the correction of undescended testicles (cryptorchidism) in children. When the natural descent of the testicles does not occur, this surgical procedure becomes necessary to lower and affix them in their typical position within the scrotum. Facilitating the early descent of the testicle into the scrotum may contribute to averting potential complications later in life, such as infertility, testicular cancer, and associated hernias.

Understanding cryptorchidism

During the development of an embryo, the testis is typically formed in the abdomen.  However, during the third trimester, the testicles start descending into the scrotum through a channel called the inguinal canal. In situations where one or both testicles fail to descend, it is called cryptorchidism. This condition stands out as the most prevalent birth defect concerning male genitalia. Studies revealed that approximately 3% of male newborns carried to full-term and a substantial 30% of premature male infants experience the condition of having one or both testicles undescended. Interestingly, around 80% of these resolve by their third month of life, resulting in a true incidence of about 1%.¹

Cryptorchidism can manifest on either one or both sides, but it often affects the right testicle. The whereabouts of the elusive testicle can be quite diverse, situated anywhere along the "path of descent". This includes high up in the abdomen to the inguinal ring (opening of the inguinal canal) within the inguinal canal. In rare cases, it can deviate from the expected path of descent by exhibiting hypoplasia (smaller than normal testes), dysgenesis (abnormal testes development), or even opting for the grand disappearing act, which is being absent.

Factors that increase the risk of cryptorchidism include prematurity, low birth weight, family history, having other abnormalities of the genitalia, or any drug that causes a negative effect on the male dominant (androgenic) hormones.

Significance of orchiopexy

The testicles are typically situated in the scrotum, a region with a lower temperature compared to the body, which is crucial for optimal sperm production during spermatogenesis. Cryptorchidism, a condition where the testicles fail to descend, disrupts this optimal environment, leading to poor sperm quality and a low sperm count, in turn bringing about infertility. Additionally, there is an increased risk of testicular cancer, particularly seminoma, though the exact connection between undescended testes and cancer remains unclear. Some studies suggest that the risk may be linked to underlying abnormalities in the testicle.²

Cryptorchidism also elevates the risk of testicular torsion, a condition where the spermatic cord twists, potentially cutting off blood supply and causing the loss of the affected testicle. If an undescended testicle is located in the pelvic region or inguinal canal, it becomes more susceptible to trauma as external forces can easily damage it. Cryptorchidism has also been associated with an increased risk of inguinal hernia.

The purposes of orchiopexy include:

• Effective sperm production
• Reduction in cancer risk
• Preventing complications such as trauma, inguinal hernia, or testicular torsion
• Improving psychosocial well-being.

The orchiopexy procedure

Existing guidelines advise orchiopexy to be performed between 6 to 12 months of age, with the recommendation not to delay beyond 18 months. Undergoing surgery within this specified timeframe is associated with favourable results in terms of fertility and protection against testicular cancer. Consequently, early intervention is linked to better outcomes.³

Preoperatively- Before the surgery, the healthcare providers will confirm the diagnosis. They will also take a comprehensive assessment of the patient,  becoming familiar with the patient’s biodata, medical and surgical history, and drug and allergy history through physical examination and laboratory or radiological examination in order to assess the general health of the patient and his fitness for surgery. A detailed explanation of the procedure, indications, and complications will also be given to the patient and caregiver. A consent form will also be given to the caregiver to sign.

Surgical process- the professionals needed for the surgery include- Paediatric surgeon, Anaesthesiologist, and Perioperative nurses. The patient is given general anaesthesia before the procedure occurs, this helps to put the patient to sleep and also prevents pain during the surgery.

Orchiopexy can be executed through various approaches based on the location of the undescended testicle. When the testicle cannot be felt manually, a laparoscopic method is employed. This involves using a minimally invasive technique with a camera and small incisions to locate and reposition the undescended testicle.

In cases where the testicle is found in the inguinal canal, surgeons opt for an inguinal orchiopexy. This approach involves accessing the testicle through the inguinal canal and securing it in the scrotum to facilitate optimal conditions for sperm production.

If the testicle is retractile or positioned at the upper part of the scrotum, a scrotal approach is preferred. This procedure directly addresses the scrotum, repositioning the testicle to create the necessary cooler environment for proper spermatogenesis.

In summary, the choice of the orchiopexy approach depends on the specific location of the undescended testicle. Laparoscopic methods are employed when the testicle is not palpable, inguinal orchiopexy is chosen for testicles in the inguinal canal, and a scrotal approach is preferred for retractile or upper scrotum positions. These tailored approaches aim to effectively correct cryptorchidism and optimize conditions for normal sperm development.

After the surgery, the health care provider explains some guidelines for post-operative care since the surgery occurs on an outpatient basis, eliminating the need for overnight hospital stays.

Patients are generally advised to progress from clear liquids to a regular diet after surgery, considering potential stomach discomfort and nausea from anaesthesia. Pain management involves the cautious use of Tylenol for one to three days, with a preference for Ibuprofen when possible.

Incision care includes allowing bathing 24 hours post-surgery, with the dressing naturally falling off. Normal postoperative effects like swelling and bruising are expected. Testicular position should be monitored, especially after inguinal incisions, to ensure they remain at the base of the scrotum.

Activity restrictions, from  two to three weeks, become necessary to prevent trauma in the surgical area. Younger children are cautioned against straddling toys. Return to normal activities, including school, is typically possible within a few days, with detailed instructions provided at the follow-up appointment one week post-surgery. 

Potential risks and complications

General surgical complications related to Orchiopexy include-

• Haemorrhage (bleeding)
• Infection
• Scarring
• Reaction to anaesthesia

Specific complications related to Orchiopexy include-

• Testicular atrophy is a severe complication that may arise, primarily attributed to excessive removal of tissue during dissection. This condition can have devastating consequences on the size and function of the testicles.
• Damage to or the constriction of the vas deferens is another potential complication. The vas deferens, responsible for transporting sperm, may undergo devascularization during dissection. Additionally, unintentional ligation or transection of the vas deferens can occur, posing challenges to reproductive processes.
• The ascent of the testis is a risk associated with the testicle becoming immobilised within the scrotum under undue tension. This typically results from insufficient liberation of the connective tissue surrounding the spermatic cord during the surgical procedure.
• Infection poses a significant risk, especially in cases of bilateral orchiopexy, where both testes are operated on simultaneously. This can lead to the infection spreading to both testicles, resulting in the loss of both.

To mitigate this risk, when dealing with bilateral undescended testicles, each corrective procedure is conducted separately and spaced several months apart. This precautionary measure aims to reduce the likelihood of simultaneous infection and subsequent loss of both testes.

Conclusion

 Orchiopexy stands as a vital intervention offering not only corrective measures for undescended testicles but also comprehensive care to enhance the overall well-being of individuals. As medical advancements continue, the procedure's efficacy and safety are expected to further improve, reinforcing its role as a crucial component in addressing cryptorchidism and safeguarding the future health of affected individuals.

Summary

Orchiopexy, a crucial surgical intervention for correcting undescended testicles in children, plays a pivotal role in averting potential complications that could manifest later in life. As explored in this article , cryptorchidism, the failure of testicles to descend naturally, is a prevalent birth defect affecting a significant percentage of newborn males. The risks associated with this condition, such as infertility, testicular cancer, and other related complications, emphasise the importance of timely and effective treatment.

Understanding the significance of orchiopexy reveals its multifaceted benefits. Beyond facilitating optimal sperm production and reducing the risk of cancer, orchiopexy acts as a preventive measure against complications like testicular torsion, trauma, and inguinal hernia. The psychosocial well-being of individuals undergoing the procedure is also addressed, emphasising the holistic impact of orchiopexy on patients' lives.

The orchiopexy procedure itself, when performed within the recommended time frame of 6 to 12 months of age, yields favourable outcomes in terms of fertility and protection against testicular cancer. The choice of approach, whether laparoscopic, inguinal, or scrotal, depends on the specific location of the undescended testicle, showcasing a tailored and effective strategy to correct cryptorchidism.

Postoperative care guidelines contribute to a smooth recovery, ensuring patients are equipped with the necessary information for a successful healing process. While potential risks and complications are inherent in any surgical procedure, the awareness of these factors, coupled with meticulous surgical techniques and precautionary measures, minimises the likelihood of adverse outcomes.