Abstract

Objective: Several factors can affect post orchiopexy testicular position & atrophy. Our interventional study aimed at examining the effect of such factors on the outcome of open orchiopexy.

Methodology: The age, weight, site & side of the operated testis, surgical duration, feasibility of hernia sac ligation and retroperitoneal dissection were reported. Post-operative follow up of testicular position & atrophy were recorded by clinical examination and by ultrasound scan at the end of the 1st post-operative week and every three months for one post-operative year.

Results: Our study included 357 patients with 400 palpable maldescended testes (43 patients presented bilaterally). About 306 patients (76.5%) had a postoperative normal testis and only 7 patients (1.8%) had an atrophic testis on follow up. A normal position was affected significantly by low body weight, pre-operative inguinal location of testis as well as intra-operative feasible hernia sac ligation (p< 0.001, MCp=0.003 & MCp=0.006 respectively). Post-operative testicular atrophy was affected significantly by preoperative extrainguinal site of testis (FEp= 0.043).

Conclusion: Low body weight, pre-operative inguinal position & feasible herniotomy can result into normal post-operative testicular scrotal position. Also a pre-operative inguinal testicular position have a lower incidence of having post-operative testicular atrophy

Keywords: Palpable maldescended; Testicular position; Atrophy.

Citation: Elrouby A, Abdelaziz D. Factors affecting the post-operative testicular position & atrophy after open orchiopexy done for cases with palpable maldescended testis in the pediatric age group. Japanese J Gastroenterol Res. 2022; 2(6): 1078.

Introduction

Palpable variety of maldescended testis is present in 80% of those patients in whom the testis is found clinically along the inguino-scrotal way. However, the remaining 20% have an impalpable presentation [1]. The optimum treatment of maldescended testis is surgery (orchiopexy) which is characterized usually by a high success rate (95%) and minimal complication rate (1%), this procedure is better done 12 to 18 months old. Hormonal therapy in such condition is not recommended with a low success rate (only 15-20%) and a higher long term complication rate as regard its effect on spermatogenesis [2].

Orchiopexy was described successfully for the first time in 1879 by Annandale T [3], after that the procedure was recommended as a routine one in 1950s and early 1960s [4]. The classical approach of orchiopexy is the inguinal one with insertion of the testis in the subdartos pouch. The fibrosis developed between the everted tunica vagialis and the surrounding tissues is the main fixing power of the operated testis. An important point is the retroperitoneal dissection which adds a lot for the success of this operation [4]. A modification was described in 1989 by Bianchi A et al. using a single high scrotal approach for those testes located distal to the external inguinal ring [5].

The success of orchiopexy is measured by allocation of the testis in the bottom of the scrotum relaxed without any tension together with absence of testicular atrophy [6]. However, factors affecting this success was not assessed in the literature so the aim of our work was to assess these factors.

Aim of the work

The aim of our work is to evaluate the factors affecting the post-operative position and/or atrophy of the testis following open inguinal orchiopexy for the treatment of palpable maldescended testis in the pediatric age group.

Material & methods

Our interventional study included all patients admitted to Elshatby University Hospital during two year duration from January 2019 to January 2021 presented with palpable maldescended testis. The age and weight of the studied patients were recorded. The pre-operative side and site of the operated testis whether inguinal, peeping or extra-inguinal were also recorded by clinical examination. All of the studied patients had been subjected to one stage conventional open orchiopexy through an inguinal incision. Patients with bilateral maldescended testis have been operated on two sessions with three months interval. Intra-operative observations including the operative duration, feasibility of herniotomy and retroperitoneal dissection were reported.

Post-operative follow up including the position of the operated testis (pubic tubercle, high scrotal or normal low- scrotal position) as well as testicular atrophy were recorded by clinical examination and by ultrasound scan at the end of the 1st postoperative week and every three months for one post-operative year. Testicular atrophy was reported when testicular volume was less than 12 mL as defined by the European Society of Urogenital Radiology [7].

Statistical analysis

Data were coded, reviewed and analyzed using the SPSS version 25.0 (Armonk, NY: IBM Corp). Quantitative data were expressed as median and range. Qualitative data were expressed as frequency and percentage. One-way ANOVA test was used to detect any statistically significant differences between three or more independent normally distributed groups. Pairwise comparison was conducted among significant groups. Monte Carlo and Fischer exact probability were used to test the association between two or more categorical variables or to detect difference between two or more proportions. Logistic regression was used to predict the relationship between one dependent binary variable and independent variables by estimating probabilities.

Results

Our study included 357 patients with 400 palpable maldescended testes as there were 43 patients presented bilaterally (86 testes) and 314 patients presented unilaterally. The mean age of the studied patients was 21.0 ± 10.38 months, while the mean weight of them was 16.78 ± 8.56 Kg (Table 1). Preoperative clinical examination of the studied patients revealed that most of them had unilateral palpable maldescended testis (88%) and most of their testes were in the inguinal region (94.7%). The surgical duration varied between 15 min to 35 min (median = 20) with a mean of 20.43 ± 5.62 min. Operative records revealed that dissection and transfixion-ligation of the associated hernia sac was done easily in 355 patients (99.4%) with retroperitoneal dissection in all patients (Table 2). The postoperative follow up of the operated testes showed that more than three quarters of them had a normal postoperative low scrotal position (76.5%) and only 1.8% developed postoperative testicular atrophy (Table 3).

Table 1: Demographic data of the studied patients.

Table 2: Pre-operative clinical examination of the studied patients.

Table 3: Postoperative follow up of the operated testes.

Statistical analysis of the factors affecting the post-operative testicular position revealed that the body weight (p< 0.001), the pre-operative presence of the testis in inguinal region (MCp= 0.003) as well as an easily done herniotomy (MCp= 0.006) affected significantly the surgical outcome. Patients with lower body weight, a pre-operative inguinal testis and an easily done intraoperative herniotomy have a significantly higher incidence of having a normal low post-operative testicular position (Table 4 & 5).

Neither the age at operation nor the body weight affected the development of post-operative testicular atrophy significantly as seen in table 6. The median of surgical duration (20 min) was the same in those who developed testicular atrophy and in those who did not show this complication (Table 6).

Table 7 illustrates that the postoperative atrophy had no significant difference as regards side of orchiopexy and sac ligation. On the other hand; development of such complication had a significant difference as regard the pre-operative site of the maldescended testis (FEp= 0.043) as atrophic testis had a higher percentage of being pre-operatively in the extra-inguinal location.

Logistic regression analysis of the variables predicting the postoperative site outcome (abnormal site= 1, low scrotal= 0) of the study sample as a dependent variable. Four variables were used to build the logistic regression model namely age, weight, preoperative site of mal-descended testis (inguinal versus extra-inguinal) and sac ligation. The final model revealed that two variables significantly affect postoperative site outcome. The first factor is weight of the child as patients with postoperative abnormal site were 1.1 times more likely to be overweight compared to patients with postoperative low scrotal site (OR= 1.074, CI= 1.045 – 1.104). The second factor is preoperative site of mal-descended testis as patients with postoperative abnormal site were three times more likely to have extra inguinal testis preoperatively compared to patients with postoperative low scrotal site (OR= 3.084, CI= 1.181 – 8.295). The overall model percentage 76.8%, R2 = 0.111, p< 0.001 (Table 8).

Table 4: Effect of demographic factors on the postoperative testicular position.