Testicular surgery
Testicular surgery encompasses various procedures aimed at addressing conditions affecting the testicles, including testicular torsion, undescended testicles, and varicoceles. Surgical intervention is critical for conditions like testicular torsion, which is characterized by severe pain and requires prompt treatment to avoid testicular necrosis. The standard procedure for torsion is orchiopexy, where the twisted testicle is untwisted and secured to the scrotum to prevent recurrence. Undescended testicles are typically corrected in early childhood to preserve function, while varicoceles, which can impact fertility, may also necessitate surgical repair if associated with significant symptoms or complications.
Orchiectomy, the removal of a testicle, is performed in cases of abscesses, tumors, or trauma, with careful consideration of surgical technique to minimize the risk of tumor spread. While testicular surgery is generally safe, potential complications include infection, bleeding, and scrotal swelling. The surgical landscape for these conditions has evolved, with advancements in techniques such as laparoscopic surgery and microsurgery. Overall, testicular surgery remains a vital component of urologic care, addressing a range of issues that can affect male reproductive health and well-being.
Testicular surgery
Anatomy or system affected: Endocrine system, genitals, glands, reproductive system
Definition: The fixation of a testicle to the scrotum or the removal of a testicle or the veins surrounding a testicle.
Indications and Procedures
Fixation of a testicle may be performed as a treatment for torsion (twisting) of the testicle and undescended testicle (cryptorchidism). Removal of a testicle may be required because of infection, traumatic rupture, pain, necrosis (death of the testicle), or the presence of a testicular tumor.
Testicular torsion occurs most commonly in males under twenty-five years of age. Torsion is usually associated with acute testicular pain that is intense enough to produce nausea, vomiting, and severe discomfort. The testicle is usually firm, tender, and displaced upward in the scrotum. It is frequently difficult to examine the gland because of the severe pain. Manual elevation of the testicle may relieve discomfort in some patients with infections of the epididymis, but it has no effect on patients with torsion. Testicular torsion is considered a surgical emergency. Information regarding this condition can be obtained using scrotal ultrasound or radionuclide scans, but most patients require surgical exploration to identify this condition. It is important to relieve the torsion as quickly as possible to restore blood supply to the testicle. Prolonged delay before surgical intervention can result in a nonviable, necrotic testicle.
Treatment of testicular torsion is by a surgical procedure called orchiopexy. After an incision in the scrotum, the testicle is untwisted under direct vision. If more than six hours have elapsed before surgery, a necrotic testicle may result, and an orchiectomy may be required. If the testicle appears viable, orchiopexy is carried out. In orchiopexy, the testis is anchored in the scrotum with a row of three or more absorbable sutures through the lining of the testicle and the dartos muscle layer of the scrotal wall. These sutures fix the testicle to the scrotum to eliminate further torsion. A small plastic drain may be placed to limit swelling and enhance drainage during recovery. The skin is closed with absorbable sutures. Because testicular torsion frequently occurs on both sides, the opposite testicle is similarly fixed with orchiopexy.
Undescended testes are located outside the scrotum, usually in the inguinal canal, but they may also be found in the abdomen. Orchiopexy should be performed at one to two years of age to preserve future testicular function. While rare cases require microsurgery, most orchiopexies are performed using a scrotal incision with testicular fixation similar to that described for torsion.
Varicoceles occur in approximately 15 percent of adult males, usually following puberty. Their importance is the association with infertility in some men with low sperm counts. Varicoceles occur primarily on the left side and result from abnormalities in the veins draining the left testicle. While tying off the veins of the varicocele is important in adolescent males with an associated decrease in testicular size, most varicoceles do not require surgery. If low sperm count, persistent infertility, decreased testicular volume, or prolonged pain occurs from the varicocele, surgical intervention may be appropriate.
Varicocele surgery can be performed through the abdomen, groin, or scrotum. Most surgeons prefer a high ligation, which involves a small incision just above the groin (internal inguinal ring). The vein draining the testicle is identified beneath the abdominal muscles. It is separated from the vas deferens (sperm tube) and arteries supplying the testicle, is ligated with several sutures, and is divided. This method of treatment is the most direct, least complicated, and most effective for varicocele ligation. The procedure is performed on an outpatient basis. Most patients are able to return to normal activity within seven days. Under certain circumstances, with previous failed high ligations or with very large scrotal varices, a scrotal incision may be selected by the surgeon to remove all dilated veins from around the testicle. This technique is most useful in patients with decreased testicular volume or pain caused by a varicocele.
Orchiectomy, or removal of a testicle, is used to treat an abscess, infection, traumatic rupture, loss of testicular function, prostate cancer, and testicular tumors. Removal of the testicle for testicular tumors is especially important since these tumors are curable if identified and treated early. This procedure is carried out through an incision in the groin and not in the scrotum, a technique that decreases the chance of testicular tumor spread to the scrotum. A small incision in the groin above the scrotum is made, the spermatic cord is clamped, and the testicle is delivered into the incision and inspected. If a testicular tumor is identified, the spermatic cord is tied, and the testis removed. The incision is then closed using standard suture techniques. If a testicle is to be removed for other indications, such as infection, prostate cancer, pain, or trauma, a scrotal incision is appropriate. The incision, which is similar to that described for testicular torsion, exposes the testicle and spermatic cord and allows for clamping and ligation of the spermatic cord prior to testicular removal. A drain is not usually necessary for orchiectomy. Should cancer be involved, routine follow-up is required through the use of CT scans and MRI in the years following the initial surgery.
Uses and Complications
Rapid identification of testicular torsion is paramount before compromise of the blood supply results in the death of the testicle. Diagnosis of testicular torsion should be within six to eight hours of onset. Episodic torsion can also occur and is associated with the preservation of testicular function and anatomy. Varicocele ligation is carried out for associated decreased testicular volume, pain, and, most commonly, infertility with diminished sperm count or sperm activity.
The complications associated with testicular surgery include infection in the scrotum, bleeding into the scrotum, and scrotal swelling. Pain, which is usually short-lived and localized, may occur with the inguinal incisions used for the removal of testicular tumors. Bleeding is the most common significant complication of testicular surgery and results in enlargement of the scrotum, significant discoloration, and pain. Bleeding is most often identified within six to twelve hours after testicular surgery. Testicular surgery is usually performed using absorbable sutures in the scrotal skin, and suture removal after surgery is unnecessary.
Perspective and Prospects
Surgical procedures for scrotal abnormalities have been common urologic procedures for centuries. Technologies, such as radiographic embolization of testicular veins for varicoceles, have been tried, but they are not generally accepted as superior to simple surgical procedures. These procedures, which are expensive and have unique complications, are less likely to be effective than more common, simple surgical interventions. Laparoscopy has been widely used for varicocele ligation, but it has little advantage over high ligation and is more expensive and time-consuming. Orchiopexy for abdominal or other high-lying testes can be performed using microsurgical techniques in the twenty-first century. The testis can be removed and transplanted to a scrotal location, or the spermatic cord can be rerouted to permit scrotal placement and to avoid orchiectomy.
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