Surgery for Undescended testes

Undescended testes

In most boys both testes are down in the normal position of the scrotum by the time of birth with their descent having already occurred in utero.  In about 2% of boys however the testis remains in a position that is too high.  If a testis has not made it down to the scrotum by 3 months of age it is extremely unlikely to do so, and plans can be made for surgical correction.  The ideal time to perform a surgical correction of an undescended testis is around 12 months of age.  The scrotum sits at a slightly lower temperature then body temperature and there is some evidence that maturation of the testis is adversely affected if it sits in a position that is too high.  The testis is either a “palpable testis” or an “impalpable testis”.  It is very important whether or not the surgeon can feel the testis in the groin.  If the surgeon can feel the testis, then it is very likely to be able to be brought down into the scrotum at the one operation.  This is called an orchidopexy.

Retractile testis

Retractile testes are testes that are pulled up into the superficial inguinal pouch but do spend some of their time down in the scrotum.  Classically it was noted in the blue book that these testes were normally descended at birth and the family often gives the history that they see the testes down when the child is having a warm bath, however they are often not there when they are changing their nappy.  It is important to differentiate retractile testes from truly undescended testes.  A retractile testis can be manipulated down into the scrotum and then after a 20 sec stretch of the cremaster muscle it remains there for the rest of the examination.  Testes in this situation can be observed and as long as the examination remains the same no operative intervention is necessary.  The cremaster muscle is most active between about 2 and 6 years of age.  These children need to be carefully monitored because a small number of them may develop a situation known as the “ascending“ testis.  These testes are normally placed when the child is young but then take on a higher and higher position as the child grows.  The same rules apply as for undescended testis.  If the testis cannot be bought down into the scrotum then surgical correction is indicated.  

Impalpable Testis

It is very important whether or not the surgeon can feel the testis in the groin.  If the surgeon cannot feel a testis (impalpable testis), one of two things may have occurred.  One is that the testis may be very high, i.e inside the inguinal canal or inside the abdomen.  The other is that the testis may have “disappeared”.  The approach to the impalpable testis has multiple steps and takes the form of a decision-making tree. The initial treatment is a laparoscopy to look for the high testis.  If the testis is inside the abdomen then an assessment is made about the length of the blood vessels.   If they are long enough, then the testis can be brought down at the same operation. This is called an orchidopexy. If the blood vessels are very short, and tethering the testis in place, a 2-Stage method is used.  At the first operation the blood vessels are divided.  Over the next 6 months the other blood supplies to the testis are given a chance to increase and then a second operation is performed to bring the testis down.

If at laparoscopy the testis is not in the abdomen then a groin incision is made to explore the inguinal canal.  If the testis is found here then it is brought down into the scrotum. This is called an orchidopexy.  More commonly however, the vas and blood vessels come to an abrupt halt and no testicular tissue is left.  The small amount of scar tissue that remains where the testis used to be is then excised.

Post op care - Orchidopexy

We recommend no baths or showers for 2 days after the operation and then return to normal baths and showers.  There is a clear, waterproof dressing over the groin incision and usually some tissue glue on the scrotal incision.  These will fall off of their own accord and do not need to be replaced.  The stitches are dissolving stiches.  They are under the skin and do not need to be removed. It is quite normal for the scrotum to become quite bruised in the days after surgery.  This is expected but will settle down over the next 7 – 10 days.  Return to all normal activities e.g swimming and sports after 10 days.