Journal of Pediatric Urology (2010) 6, 506e512

20 years of transcrotal orchidopexy forundescended testis: Results and outcomes

Morris Gordon a, Raimondo M. Cervellione a,*, Antonino Morabito b,Adrian Bianchi a

a Department of Paediatric Urology, Royal Manchester Children’s Hospital, Oxford Road, Manchester, UKb Department of Paediatric Surgery, Royal Manchester Children’s Hospital, Oxford Road, Manchester, UK

Received 16 September 2009; accepted 22 October 2009Available online 26 November 2009

KEYWORDSUndescended testis;Palpable testis;Orchidopexy;Transcrotalorchidopexy;Paediatric;High scrotalorchidopexy;Single incisionorchidopexy

* Corresponding author. Tel.: þ44 1E-mail address: cervellione@docto

1477-5131/$36 ª 2009 Journal of Peddoi:10.1016/j.jpurol.2009.10.016

Abstract Background: The role of the transcrotal approach to the undescended testisremains controversial despite its increasing popularity. The authors update their previouspublished series and review the literature on this subject, aiming to delineate the value of thistechnique.Methods: The authors performed a retrospective review of the transcrotal primary orchido-pexy carried out to treat palpable undescended testis at Royal Manchester Children’s Hospitalbetween 1993 and 2005. A structured review of literature published since the proposal of thistechnique was also performed.Results: 122 procedures were included. The transcrotal approach was successfully completedin 119 (97.5%). Additional groin incision was needed in three (2.5%) to further mobilize thespermatic cord. No immediate complications were recorded and 8.4% required a reoperativeprocedure. On review of the literature, a total of 16 articles were discovered spanning 1695transcrotal procedures, including the previously published authors’ experience. On combiningthe data, the transcrotal approach required an additional groin incision in 4.4% of cases, 1.6%experienced immediate and/or early complications, and the overall recurrence rate was 2.0%.Conclusions: Transcrotal orchidopexy for the treatment of palpable undescended testes isa safe procedure with a long-term success rate comparable to the two-incision approach.ª 2009 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Introduction

The majority of undescended testicles are palpable distalto the inguinal canal [1]. In 1989, Bianchi and Squire [2]

61 701 2177; fax: þ44 161 701 29rs.org.uk (R.M. Cervellione).

iatric Urology Company. Publishe

proposed that orchidopexy for the palpable undescendedtestis should commence with a scrotal incision, and that anadditional groin incision be reserved for the few high testesthat will not otherwise reach the scrotum, after maximal

28.

d by Elsevier Ltd. All rights reserved.

20 years of transcrotal orchidopexy for undescended testis 507

possible mobilization through the scrotum. The ‘TranscrotalOrchidopexy’ has the advantage of much less dissection,greater comfort for the patient, rapid healing, excellentcosmesis and a well maintained testicular position. In 1995,Bianchi and colleagues followed this up with a case series of367 orchidopexies [3] that confirmed low complicationrates and a success rate comparable to the two-incisionprocedure.

This paper presents the results of a further caserecord review of transcrotal orchidopexies for the palpableundescended testes performed at the Royal ManchesterChildren’s Hospital from 1993 to 2005 by Bianchi andcolleagues, which bring the published Manchester experi-ence up to 489 procedures. The authors have also reviewedthe literature published over the last 20 years relating tothis surgical technique.

Materials and methods

The authors retrospectively reviewed the case records ofall children who underwent orchidopexy from 1993 to2005 at Royal Manchester Children’s Hospital. The chil-dren were under the care of Bianchi and colleagues whocarry out the transcrotal approach [2] as the defaultprocedure for all children with a palpable undescendedtesticle. All patients who underwent primary transcrotalorchidopexy for the treatment of palpable undescendedtestis were included. Position of the testes wasconfirmed while under anaesthetic. Cases in whichconversion to a two-incision procedure took place werestill included in the study. Attention was given totesticular position before and immediately after theprocedure, complication rates, and overall outcome asdocumented at follow up. Follow ups initially took placebetween 6 months and 1 year after operation. Patientsexcluded from the study were those for whom caserecords were incomplete. Data were coded and enteredinto SPSS for Windows version 11.5 (SPSS Inc., Chicago,IL, USA) for descriptive analysis. It must be noted thatpaediatric surgery and paediatric urology have beenperformed in Manchester by Bianchi and colleagues atthree different sites during the study period. For prac-tical reasons, this review includes only the casesperformed at Royal Manchester Children’s Hospital.A literature search was carried out using the searchterms ‘transcrotal orchidopexy’ and all spelling deriva-tives, ‘single incision orchidopexy’, ‘single scrotalincision’, and ‘scrotal orchidopexy’ using the Medlinedatabase. Further articles were examined by searchingfor related articles on Medline and by referencesearching. Articles that presented data from case seriesor trials looking at outcomes of the transcrotal orchid-opexy were included.

Results

A total of 126 orchidopexies were identified for case reviewwithin the study period. Exclusion criteria led to fourprocedures being removed from the study. The remaininggroup consisted of 118 patients, of whom four had bilateralprocedures giving a total of 122 orchidopexies. The age

range at first operation was between 10 months and 8years. Before operation, the position of the testes was theneck of the scrotum in 11 patients (9.0%), the externalinguinal ring in 34 (27.9%), the inguinal canal in 25 (20.5%),near the internal inguinal ring in three (2.5%), ectopicposition in one patient (0.8%), and 48 (39.3%) were notclearly specified but simply noted to be ‘palpable’. Thetranscrotal approach was completed in 119 orchidopexies(97.5%). An additional groin incision was needed on threeoccasions (2.5%) to further mobilize the spermatic cord. Noshort-term complications were recorded in any procedures.

At follow up the testicular position was deemed unsat-isfactory in 12 of 122 testes (9.8%) and it was elected thata redo procedure be performed. Of these 12 redo proce-dures, two were from the group of three transcrotalorchidopexies that were converted to a two-incisionprocedure. Therefore, the long-term recurrence rate forthe group completed with a single transcrotal incisionwas 8.4% (10/119). The redo procedure was performedtranscrotally on 10 occasions. One required a conventionaltwo-incision procedure (groin and scrotum) and onea microvascular orchidopexy [4]. There were no immediatecomplications on reoperation and all testes at furtherfollow up were recorded to be in the scrotum. No testeswere recorded to have atrophied from any of the 122orchidopexies.

Including this report, a total of 489 transcrotal orchid-opexies have been reviewed at the Royal ManchesterChildren’s Hospital from 1984 to 2005 [2,3]. Of these cases,472 operations (96.5%) were completed transcrotally.Seventeen orchidopexies (3.5%) required an additionalgroin incision to mobilize further the spermatic cord in theretroperitoneum. Immediate or early complications, suchas scrotal haematoma or infection, were experienced onseven occasions (1.4%). Testicular position was deemedunsatisfactory and a redo procedure performed in 23 of the472 orchidopexies (4.9%) in which a transcrotal approachhad been carried out. A total of three testes atrophied(0.6%).

The review of the wider literature produced another 15articles [5e19] reporting case series for the transcrotalorchidopexy. These papers report a further 1209 transcrotalprocedures between 1996 and 2009. The rate of conversionto a conventional two-incision procedure at first operationis between 0% and 13%. Reported rates of immediate andearly complications varied from 0% to 5.4%. Overall recur-rence rate for the transcrotal cases varied from 0% to 5.4%.A summary of these studies and the Manchester experienceis shown in Table 1.

On combining data for the Royal Manchester Children’sHospital with the data that is available from the other 15case series to give an overall picture for the published dataon the transcrotal approach in the last 20 years, 4.4% ofprocedures (75/1698) required an additional groin incisionat first operation. Rates of immediate and early complica-tions are reported for all but three of these studies [6,7,15]and when combined the total rate is 1.6% (23/1394). Theoverall recurrence rate for all cases in which a transcrotalapproach was initially attempted was 2.0% (33/1665),although it must be noted that many papers did not specifyif these recurrence figures excluded those who were con-verted to a two-incision approach.

Table 1 Review of the published literature regarding transcrotal orchidopexy.

Authors Year No. ofcases

Preoperativelocation(as described ineach paper)

Inclusion criteria Exclusion criteria Conversiona two-incisprocedure

Immediateand earlycomplicationrate

No. ofrecurrences (%)[follow-up time]

Ref.

Bianchi A,

Squire B

1989 120 IC Z 12(10.0%) Not specified Not specified 5(4.2%) 3.3% 4 scrotal

haematomas

0 [6 monthse3

years]

[2]

EIR Z 36(30.0%)SIP Z 41(34.2%)NS Z 27(22.5%)

E Z 4(2.5%)Iyer KR et al. 1995 247 new

casesNK Z 247(100.0%) Not specified Not specified 9(3.6%) 1.2% 2 wound

infections1 unexplained

pyrexia

13(5.3%)[1e8 years]

[3]

Lais A,Ferro F

1996 50 IC Z 7(14.0%) Not specified Not specified 3(6%) 6% 3 scrotalhaematomas

1(2%)[3e5 years]

[5]EIR Z 28(56.0%))E Z 15(30.0%

Clarnette Tet al.

1997 33 NK Z 33 (100%) Undescendedtestes that wererecorded as

normal in infancy

Not specified 0 Not specified Not specified [6]

Misra D et al. 1997 67 EIR Z 67(100.0%) Testes that couldbe manipulatedinto the scrotum

with difficultyand on release ofpressure,returned into the

inguinal region

Not specified 9(13%) Allhernia sacconverted

two-incisioapproach

Not specified 0 [1e5 years] [7]

Jawad AJ 1997 106 IC Z 18(17.0%) All palpabletestes

Not specified 14(13%) 1.9% 2 woundinfections

5(5.4%)[8e36 months]

[8]EIR Z 29(27.3%)

SIP Z 35(33.0%)NS Z 21(19.8%)E Z 3(2.8%)

Caruso AP

et al.

2000 45 EIR Z 45(100%) All cases distal

to the externalring

Redo

procedures (15)

1(2.2%) 2.2% 1 scrotal

haematoma

1(2.2%)

[1 year]

[9]

Gokcora I,Yagmurlu A

2003 64 NK Z 64 (100%) Palpableundescended

testes

Acute scrotalinfection and

testicular torsionexcluded, as wellas having other

surgery

0 0 0 [1-6 years] [10]

508M

.G

ord

on

et

al.

toion

withwereto a

n

Russinko PJ,

Siddiq FMet al.

2003 83 IC Z 13% Testes that could

be drawn close toor into the scrotum

Retractile testes,

redo procedures(2)

1(1.2%) 2.4% 1 wound

cellulitis1 woundhaematoma

1(1.2%) [1e36

months]

[11]

EIR Z 20%NS Z 18%E Z 5%,SIP Z 44%

Based on 85 cases(two excluded)

Rajimwale A,Brant WO

et al.

2004 75 IC Z 2(3%) Testes that couldbe milked to the

level of themidpubic tubercleor beyond under

anaesthesia

Prior inguinalsurgery, retractile

testes

3(4.0%) 1.3% 1 scrotalhaematoma

1(1.3%) [6 weekse

1 year][12]

SIP Z 42(56%)

E Z 12(16%)G Z 19(25%)

Handa R,Kale Ret al.

2006 35 EIR Z 35(100%) Distal to theexternal ring

Retractile, ectopicand redo patients

0 2.8% 1 woundinfection

0 [2-6 months] [13]

Bassel Yet al.

2006 121 E Z 10(8.3%) All palpabletestes

Retractile testes 0 4 woundinfections (3.3%)

0 [6 monthse

1 year][14]

IC Z 14(11.6%)NS Z 17(14%)SIP Z 80(66.1%)

Dayanc Met al.Includes

previouscases [19]

2007 204 DEIR Z128(62.7%)

Palpable testesthat werenon-retractile

on exam underanaesthetic

Prior inguinalsurgery

12(5.9%) Not specified0[16-68 months]25 children lostto follow up

[15]

IC Z 76(37.3%)

Parsons Jet al.

2008 71 DG Z 71(100%) All cases ofectopic or

ascending testesbased onexamination

Nil e Includedfive cases with

prior surgery andthree congenitalabnormalities

14 (20%) 0 0 [1 weeke

3 months][16]

Samuel D,

Izzidien A

2008 206 NK Z 206(100%) All testes that

could be broughtinto the scrotumunder

manipulationwith tension

Retractile testis,

ectopic testisprevious inguinalsurgery

1(0.5%) 2 wound

infections (1%)

0 [6 weekse2

years]

[17]

Takahasi Met al.

2009 49 DEIR Z 49(100%) All palpabletested distal to

Inguinal ring onexam underanaesthesia

Prior surgery 0 0 1(2.7%)[12.1-68.8months]

[18]

Gordon Met al.

2009 119 IIR Z 3(2.5%) All palpabletestes Inadequate

note keeping(4)

3(2.5%) 0 10(8.4%)[6 monthse2years]

e

IC Z 25(20.5%)EIR Z 34(27.9%)NS Z 11(9.0%)

E Z 1(0.8%)NK Z 48(39.3%) (continued on next page)

20ye

ars

of

transcro

tal

orch

idopexy

for

undesce

nded

testis

509

Table

1(c

onti

nued).

Auth

ors

Year

No.

of

case

s

Pre

opera

tive

loca

tion

(as

desc

ribed

in

each

paper)

Incl

usi

on

crit

eri

aExc

lusi

on

crit

eri

a

Conve

rsio

nto

atw

o-i

nci

sion

pro

cedure

Imm

edia

teand

earl

yco

mplica

tion

rate

No.

of

recu

rrence

s(%

)

[follow

-up

tim

e]

Ref.

Tota

l19

89e

2009

1698

EIR

Z29

1e

e75

/169

8(4

.4%

)23

/139

1(1.

6%)

Exc

luded

thre

epapers

where

com

plica

tions

not

speci

fied

33/1

665

(2.0

%)

[2m

onth

se2

years

]

e

IIR

Z3

DEIR

Z17

7SI

PZ

235

DG

Z71

NS

Z91

EZ

49IC

Z89

GZ

19N

KZ

673

Abbre

viati

ons:

IIR

Zin

tern

al

ingu

inalri

ng,

ICZ

ingu

inalca

nal

,EIR

Zext

ern

alin

guin

alri

ng,

DEIC

Zdis

talto

ext

ern

alin

guin

alri

ng,

DG

Zdis

talgr

oin

,N

SZ

scro

tal

neck

,SI

PZ

superfi

cial

ingu

inal

pouch

,E

Zect

opic

,G

Zgl

idin

g,N

KZ

not

know

n.

Figure 1 Dissection of the processus vaginalis from a single

510 M. Gordon et al.

Discussion

Conventional orchidopexy today is still performed accord-ing to the concepts of Schuller [20] in 1881 and Bevan[21,22] in 1899 and 1903. The experiences of Bianchi andSquire [2] and Hazebroek et al. [23] confirmed that thetesticular vessels and the vas in the majority of palpableundescended testicles, after dissection of the cremasterand the processus vaginalis (Fig. 1), are long enough toallow the testes to reach the scrotum without tension.Based on these observations, the approach was reversedand it was found that in most instances it was unnecessaryto disrupt the inguinal canal, sufficient dissection beingpossible through the scrotal approach.

The details of the surgical technique have beendescribed previously [2], but some points have to beemphasized due to a few misinterpretations that can befound in the literature. Misra at al. [7] in 1997 illustrateda variation of the original technique described by Bianchiwith a lower transverse scrotal incision. The authorsbelieve that this does not help to find the testis and doesnot allow the creation of an adequate scrotal pouch.A curved, high, scrotal skin incision (Fig. 2) is, in ourexperience, the most convenient approach to the inguinalcanal through the scrotum. In the article, Misra et al. [7]also state that the inguinal approach is needed in the caseof a hernial sac discovered on scrotal exploration. In addi-tion, the editorial on the article by Parsons et al. [16] statesthat the transcrotal approach may need to be converted toa two-incision approach if high ligation of the sac is needed.In the authors’ experience over the last 20 years of usingthe procedure, the processus vaginalis can be successfullydissected and tied from a scrotal incision in the vastmajority of cases. Indeed, the scrotal approach is ourpreferred approach for the management of inguinal herniasand hydrocele [3].

scrotal incision.

Figure 2 Curved, high, scrotal skin incision used for thetreatment of the palpable undescended testis, shown in red.

20 years of transcrotal orchidopexy for undescended testis 511

But are the results of transcrotal orchidopexy compa-rable to those reported in the literature for the traditionaltwo-incision procedure? In 1995, Docimo [24] reviewed theliterature for conventional orchidopexy techniques. From64 articles pertaining to 8425 testicles, a preoperativelocation was reported for 2491 testicles. Of these, 842 wereintra-abdominal, leaving a total of 1649 palpable testes.The location for these 1649 testes was at the internal ring in294 (17.8%), 681 were cannicular (41.3%) and 674 beyondthe external ring (40.9%), most ectopically in the superficialinguinal pouch. The overall recurrence rate for procedureswhich had a 6-month follow up was 12.5% (176/1405). Whenthe series was divided by date of publication and only thosepublished after 1985 were included, the overall recurrencerate was 4.1% (15/371). Our own Manchester data combinedwith all the transcrotal data in the literature showed anoverall recurrence rate of 2.0% (30/1665).

If we look at the preoperative position of the testes,where it was recorded, there are no series that look at veryproximal testes, near the internal inguinal ring. Themajority of authors have excluded these high undescendedtestes from their transcrotal series; however, we haveincluded all palpable testes as this is our routine practice.The general view from the Docimo [24] paper is that moreproximal testes tend to have a poorer outcome on opera-tion and this is widely accepted. In the authors’ view,transcrotal orchidopexy can be attempted for proximalundescended testes, bearing in mind that if the dissectionof the cord is not enough to bring the testis into thescrotum, a second groin incision can be safely made. Wewould maintain that whether the procedure is eventuallycompleted through a single- or two-incision approach, thiswill have no impact on the chance of recurrence.

Comparing the calculated recurrence rate of 2.0% for allpublished transcrotal cases with 4.1% (15/364) from theDocimo [24] review for testes at or beyond the inguinal

canal in papers after 1985, the authors find that thetranscrotal approach seems to offer at least comparable ifnot better results.

There are very few further contemporary papers withresults for the two-incision approach [25,26], and so a moreappropriate, similarly sized control group is not available atthis time. Prospective studies with appropriate controlgroups are still needed. Despite this paucity of contempo-rary comparative data, as the body of published evidenceon the transcrotal approach increases, the merits of thistechnique are leading to its more widely accepted usewithin the urological community. A recent editorial byCanning [27] on the paper by Samuel et al. [17] stated that,given the large amount of favourable data on this tech-nique, perhaps the time has come for paediatric urologiststo consider it, the advantages of a single incision and rapidoperative time providing an attractive alternative for thiscommon surgical condition.

The authors recognise the limitations of this study. Thisreview only covered procedures performed at the RoyalManchester Children’s Hospital, one of three paediatricsurgical sites within the region at the time where theauthors would perform this procedure. Therefore, thenumber of procedures performed within the study period isless than with previous published data from Bianchi andcolleagues [2,3], and the study group does contain a muchwider age range than the previous Manchester experience,as older children will tend to be operated on at this sitewithin the hospital trust. A number of testes did not havea specific preoperative position noted under anaesthetic.It is the author’s view that a number of proximal testeshave been included in this group of 48 patients. As hasalready been noted, it is well recognised that this group ofpatients have significantly higher recurrence rates [24], andthe authors feel this has contributed to a higher recurrencerate in this Manchester series than previously found.Further research to allow comparison of results specificallyfor proximal testes and a prospective study design tominimize these limitations are needed in the future.

Conclusions

Published data from the last 20 years confirm that trans-crotal orchidopexy is followed by uncomplicated healingand a well-placed scrotal testis. In comparison with theconventional two-incision operation, transcrotal orchid-opexy offers the advantage of an aesthetic single scrotalcrease incision, less dissection and greater comfort for theday-case child. Moreover, the literature suggests that thetranscrotal orchidopexy offers at least a comparablerecurrence rate to the two-incision approach for thetreatment of the testes preoperatively located in the distalportion of the inguinal canal. Further studies are necessaryto evaluate the role of transcrotal orchidopexy for thetreatment of more proximal undescended testes incomparison to the two-incision approach.

Conflict of interests

There are no conflicting interests for any of the authors.

512 M. Gordon et al.

Funding

None.

References

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