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Original Article

Scrotal fixation in the management of low undescended testes

Paul A. Sutton, Owen J. Greene, Louise Adamson, Shailinder Jit Singh
Department of Paediatric Surgery, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham,
United Kingdom

Address for correspondence: Mr. Shailinder Jit Singh, Department of Paediatric Surgery, Nottingham University Hospitals NHS
Trust, Derby Road, Nottingham (UK), NG7 2UH. E-mail: shialindersingh@ntlworld.com

ABSTRACT Access this article online

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Aims: Scrotal fixation (SF) is a known technique for the management of low undescended DOI: 10.4103/0971-9261.86871
DOI
testes (UDT). SF assumes that most low UDT have no patent processus vaginalis (PPV) Quick Response Code:
Code

and can be managed via scrotal mobilization alone. We report our experience of the role of
SF in the management of low UDT. Materials and Methods: A retrospective review of all
palpable UDT operated on by the senior author between 1998 and 2008 was undertaken.
Children diagnosed with palpable UDT were examined under general anesthesia; if
the whole testis could be manipulated into the upper part of the scrotum, low UDT
was assumed and SF was performed. Attempts to identify a PPV intraoperatively were
made in all and, if found, the procedure was converted to standard inguinal incision
orchidopexy. Results: One hundred and thirteen children with 134 UDT were identified.
SF was performed in 55 testes; inguinal orchidopexy (IO) in 75 and four testes were
excised. The median (IQR) age at SF was 5.5 [4.7–6.3] years. Three SF were converted
to an IO when a PPV was discovered. The complications in SF were scrotal hematoma
(n = 1) and superficial wound infection (n = 1). No post-operative herniae or atrophied
testis were seen and none required a redo operation. The mean (SD) operative times for
SF and IO were 29.5 (18.1) and 42.7 (16.6) min, respectively (P = 0.04). Conclusion:
In our study, 52 of 55 (94.5%) patients with low UDT lacked a hernial sac and were
successfully fixed by SF. SF is a viable, simple, quick and safe alternative to IO in the
management of low UDT.

KEY WORDS: Cryptorchidism, patent processus vaginalis, scrotal fixation, undescended

testes

INTRODUCTION underlying technique is similar to inguinal orchidopexy

The association of a patent processus vaginalis
(PPV) with undescended testes (UDT) has been well
reported.[1,2] This association may not however be as
common as once thought, with some studies suggesting
that a hernial sac may be absent in between 24%
and 43% of all cases.[3-5] Some institutions advocate
an inguinal approach for all UDT, on the belief that
adequate mobilization and fixation is not possible using
the scrotal approach alone.[6]
There have been numerous reports on scrotal
orchidopexy for UDT since the publication of Bianchi
and Squire in 1989.[7-9] In scrotal orchidopexy, the
142
(IO), the difference being that the ligation of the PPV
if present is attempted through a scrotal incision.[10]
Surgical exposure to achieve high ligation of the PPV
is often suboptimal with this approach, and division
of the lateral spermatic fascia at the internal ring is
almost impossible. Scrotal fixation (SF) assumes that
the majority of low UDT have no PPV and, based on
the location of the testes, can be managed via scrotal
mobilization alone. It is recommended only for low
UDT lying below the external ring, whereas scrotal
orchidopexy may be performed for canalicular testes
too. In contrast to scrotal orchidopexy, a PPV discovered
at SF is repaired through an inguinal approach.
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Sutton, et al.: Scrotal fixation of low undescended testes
In our institution, we adopted this approach based on
the experience with SF, which was first reported in
1997.[5] The aim of our study was to establish the safety
and utility of SF in the routine management of low UDT.
MATERIALS AND METHODS
This is a retrospective review of all procedures for
palpable UDT performed by the senior author between
1998 and 2008. Statistical analysis was performed
using Microsoft ExcelTM. The student’s t-test was used
to examine significant differences in the duration of
the procedure.
The children identified had been diagnosed clinically
with palpable UDT; those with a retractile testis were
excluded by repeated and rigorous clinical examination.
All children referred for orchidopexy were examined
by the senior author in the outpatient clinic. The
UDT were examined in a squatting position whenever
feasible. Those testes that were palpable in the scrotum
in a squatting position were labelled as retractile and
were not listed for an operation. These children were
actively followed-up to exclude an ascending testis.
Those children in whom the testes were found to be
absent from the scrotum in a squatting position were
taken for operation and examined again under general
anesthesia. In those patients where a squatting test was
not feasible either due to age or non-compliance, testes
were examined in the lying position with attempts made
to milk them into the scrotum. Any testis that reached
the middle of the scrotum or beyond was treated as
a retractile testis. Those testes that reached only the
upper part of the scrotum and retracted immediately
back were treated as UDT.
All children were further examined under general
anesthesia with attempts made to manipulate the testis
down into the scrotum. Low UDT was diagnosed if the
whole testis could be manipulated into the upper part
of the scrotum, and high UDT diagnosed if this were
not possible. In cases where the testis returned to the
inguinal region following manipulation, these were also
classified as low UDT.
The technique of SF is described fully elsewhere in
the literature,[5] but in brief involves a single scrotal
incision extending down to the tunica vaginalis. The
cord is then mobilized from below only after which the
testis is secured in an extra-dartos pouch. If a PPV is
found, the procedure is converted to IO in order to ligate
it through an inguinal incision near the internal ring.
RESULTS
This retrospective review identified 113 children, 92
Journal of Indian Association of Pediatric Surgeons / Oct-Dec 2011 / Vol 16 / Issue 4
(81.4%) with unilateral and 21 (18.6%) with bilateral
cryptorchidism, giving a total of 134 UDT. None had a
hernia/hydrocoele in addition to their UDT. On clinical
examination in the outpatient department, five (3.7%)
testes were low inguinal and the remainder were located
in the superficial inguinal pouch. IO was performed
in 75 testes (56.0%), SF in 55 testes (41.0%) and
orchidectomy (due to small size) in four testes (3.0%).
Of the 55 SF attempted, three (5.5%) were converted to
an IO as in each case a PPV was discovered. In all three
of these cases, the testis was located in the superficial
inguinal pouch.
The age at operation for all ranged from 10 months
to 13.5 years, with a median (IQR) age of 3 (2.1–5.5)
years, whereas the median (IQR) age in the SF group
was 5.5 (4.7–6.3) years. The mean (SD) operative times
for IO and SF were 42.7 (16.6) and 29.5 (18.1) min,
respectively (P = 0.04).
All patients were reviewed at first follow-up in the
outpatient clinic 6 months following surgery, with none
being lost to follow-up. Six of the 75 (8%) children
who had IO suffered complications: re-ascent requiring
subsequent repair (n = 1), reduced testicular volume
requiring active surveillance only (n = 2), superficial
wound infections requiring oral antibiotics (n = 2) and
wound granuloma treated conservatively (n = 1). In
contrast, only two of the 55 (3.6%) children who had
SF suffered complications: scrotal hematoma treated
conservatively (n = 1) and wound infection requiring
oral antibiotics (n = 1). The testicular position and
volume for all patients following SF was acceptable.
The overall complication rate for IO was 8% compared
with 3.6% for SF. No post-operative herniae or atrophied
testis were seen and no SF operations required a
subsequent procedure.
DISCUSSION
This paper follows a study from the same institution
by Misra et al. on SF published in 1997.[5] In this study,
SF was attempted in 67 children and was successfully
completed through a scrotal approach in 58 (86.5%).
The remaining nine children went on to have an IO
during the same operation, as adequate mobilization
was not possible. It is not clear from this paper whether
or not these nine children had a PPV present at the
time of operation. In our series, SF was attempted in
55 children and was successfully completed through a
scrotal approach in 52 (94.5%). Three were converted
to IO due to the discovery of a PPV intraoperatively, all
of which had testes located in the area of the superficial
inguinal pouch. In our series, no child required
conversion of SF to IO due to inadequate mobilization
of the testis. The data also suggests that in addition to
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Sutton, et al.: Scrotal fixation of low undescended testes

providing good exposure, SF is significantly quicker REFERENCES

than IO (P = 0.04).
The absence of a hernial sac for all positions of the testis
during all forms of orchidopexy varies in the literature
between 24% and 43% of cases.[3-5] The previous paper
from our institution showed that no hernial sacs were
discovered at SF compared with 5.5% in our study,
confirming that a hernial sac is unlikely in low UDT.
A key factor to the success of SF is a rigorous examination,
while the patient is under general anesthesia. If at this
stage the testis cannot be manipulated down to the
scrotum then a traditional inguinal approach should be
undertaken. All SF were performed by a single senior
surgeon (SJS), which is likely to have improved patient
selection for SF.
There are four theoretical risks when performing SF: (1)
missing a hernial sac, (2) inadequate mobilization, (3)
damage to vas/vessels and (4) scrotal hematoma/wound
infection. The results from our series showed no herniae
at follow-up. There were no problems with inadequate
mobilization intraoperatively, resulting in conversion
to IO or a redo operation at a later date, and no cases
of testicular atrophy resulting from presumed vascular
damage. Our study does not allow us to comment on the
theoretical risk of damaging the vas, and the incidence
of scrotal hematoma/scrotal wound infection was low
(3.6%).
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Cite this article as: Sutton PA, Greene OJ, Adamson L, Singh SJ.
Scrotal fixation in the management of low undescended testes. J Indian
Assoc Pediatr Surg 2011;16:142-4.
Source of Support: Nil, Conflict of Interest: Nil.

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