Journal of Pediatric Urology (2008) 4, 330e332

REVIEW ARTICLE

An old technique for surgery of ‘high’ undescended

testis revisited
Levent Elemen*, Selami Sozubir, Melih Bulut

Department of Pediatric Surgery, Yeditepe University, Medical Faculty, Devlet Yolu, Ankara cad. 102-104 Kozyatagi,
Istanbul, Turkey

Received 30 October 2007; accepted 25 February 2008

Available online 1 May 2008

KEYWORDS Abstract Introduction: Most undescended testes resolve spontaneously in the first year of
Prentiss’ maneuver; life. If the testis remains undescended by the second year, the most probable means of scrotal
Undescended testis; placement is orchiopexy. After the first successful operation for orchiopexy, many surgical
Orchiopexy modifications were described. This study presents our limited experience with Prentiss’
maneuver in six boys with high undescended testes.
Patients and methods: Two left, two right and two bilateral testes, in six patients, were oper-
ated. Five patients were admitted with the complaint of unilaterally or bilaterally ‘empty scro-
tum’. The sixth patient previously had a right high undescended testis which had been placed
in a high scrotal position. Following the standard steps of inguinal orchiopexy Prentiss’ maneu-
ver were performed and yielded adequate distance to place the testes mid scrotum.
Results: On follow-up, Doppler ultrasound examination revealed normal sized testes with
normal blood flow in all patients with dimensions correlated with age.
Conclusion: Although perhaps only useful in orchiopexy for high undescended testis, incision of
the transversalis fascia preserves testicular blood flow by relieving tension on the testicular
vessels.
ª 2008 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Introduction 21e23% [1]. Most undescended testes resolve spontane-

Cryptorchidism is present in 3e4% of all newborns and more
prevalent among premature newborns with an incidence of
* Corresponding author. Present address: Department of Pediatric
Surgery, Kocaeli University, Medical Faculty, Eski Istanbul Yolu,
41380 Umuttepe, Kocaeli, Turkey. Tel.: þ90 542 534 35 51.
E-mail address: elemenlevent@hotmail.com (L. Elemen).
ously in the first year of life [1]. If the testis remains unde-
scended beyond this time, the most probable means of
scrotal placement is orchiopexy [1].
The age at which orchiopexy is performed may affect
fertility [2]. It is supposed by many authors that near
normal histology of the testis may be achieved by orchio-
pexy performed between 6 and 24 months of life [3e6].
The main goal of early orchiopexy is preservation and

1477-5131/$34 ª 2008 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jpurol.2008.02.006
Surgery for ‘high’ undescended testis
maximization of potential for future fertility, prevention of
torsion and trauma, and improvement in body image
[2,4,5]. Besides, although it has not been shown to reduce
the risk of testicular tumors, orchiopexy may facilitate
detection through self-examination of the testes [2,5].
After the first successful operation for undescended
testis, performed by Max Schüller more than 100 years
ago, many different surgical procedures with modifications
were described [1]. One such, Prentiss’ maneuver, was de-
fined as the incision of transversalis fascia with or without
ligation of deep epigastric vessels following the standard
steps of inguinal orchiopexy [7e9].
Our standard practice is to perform orchiopexy at 6e12
months of age. The aim of this study was to present our
experience and follow-up in six older boys who underwent
the standard steps of orchiopexy followed by Prentiss’
maneuver.
Patients and methods
Six patients with an age distribution of 13e84 months
(27.1  23.7 months) were included in the study. Five of
the patients were admitted with the complaint of unilater-
ally or bilaterally ‘empty scrotum’. The sixth patient previ-
ously had a right high undescended testis which had been
placed in a high scrotal position 1 year before. Orchiopexy
was performed in two left, two right and two bilateral testes.
All of the operations were performed under general
anesthesia via inferior skin crease incisions according to the
side of the undescended testis. Testes were found just
distal to the internal inguinal ring, gubernacular attach-
ments were divided, and mobilization along the posterior
aspect of the spermatic cord was performed with gentle
traction on the testis. Cremasteric fibers were divided for
additional mobilization. Spermatic cord mobilization was
continued into the external inguinal ring until the deep
epigastric vessels were visualized. The processus vaginalis
was separated from the spermatic cord and dissected high
into the inguinal canal where it was ligated in native cases,
while en bloc liberation of spermatic cord and vessels was
achieved in the redo case to prevent vascular injury. All
of the testes were found to be still so far from mid scrotum,
that tension-free placement within the scrotum was impos-
sible. A hernia sac ligature was held to help expose the
retroperitoneal space. Peritoneum was bluntly elevated
from the testicular vessels. The lateral spermatic fascia
was divided at the level of the inguinal canal in order to
gain additional length by allowing the vessels a straighter
course to the scrotum. Transversalis fascia was incised
Table 1 Length gained using Prentiss’ maneuver, postoperative testicular volumes and normal values according to age
Patient Age Side Gained
no. (months) length (mm)
I 13 Right 28
II 14 Bilateral 31.4/32
III 15 Left 31.5
IV 25 Right 36
V 26 Bilateral 35.4/35
VI 84 Left 44
331
while preserving the deep epigastric vessels. The length
of the course before and after Prentiss’ maneuver was
measured by a ruler and net length gain was calculated.
Thus, the testes were brought to a mid-scrotal position
via a new route under the transversalis fascia and fixed
into the Dartos pouches already prepared. No tension on
the spermatic cord and vessels was encountered. The trans-
versalis fascia was closed tightly enough to prevent hernia-
tion and not to constrict cord and vessels, and the incision
was closed. Normal inguinal canal lengths according to the
age of the children were calculated by the formulae
suggested by Tanyel et al. [10].
Patients were discharged at the 2nd postoperative hour
and were called for routine office visits on the 7th post-
operative day and then on a monthly basis. At the 6th
postoperative month a testicular Doppler ultrasound (US)
examination was performed by an experienced radiologist
using high-frequency linear phased-array probes with a vari-
able frequency on an US machine (GE Logic 9, General
Electric Co., USA). Testicular US was performed with the
patient in the supine position and a large amount of warm
gel was used to minimize pressure on the skin. Gray-scale
US was first used to localize the testis, and then color
Doppler US examination was added for evaluating intra-
testicular vascular flow. Technical parameters were opti-
mized for detection of slow flow. All the Doppler signal
waveforms were measured.
Results
With the use of Prentiss’ maneuver 28e44 mm
(34.16  4.77 mm) of extra course were achieved. No prob-
lems were encountered during the postoperative office visits.
Doppler US examinations revealed normal blood flow for all
eight testes with dimensions correlating with age (Table 1)
[11]. All the patients are doing well without complications.
Discussion
Cryptorchidism is still a pathology that requires surgical
correction before the age of 24 months [3e5,12]. After the
first successful results of orchiopexy achieved by Max Schül-
ler 120 years ago [1,7], many technical modifications, one
of which is Prentiss’ maneuver, were described [8,9]. Pren-
tiss originally described his technique in older boys in whom
the anatomy of the region is much different from that in
infants [8,9]. The position of the deep inguinal ring changes
during the development of the inguinal canal. In infants the
Normal inguinal Testicular Normal testicular
canal length (mm) [10] volume (cc) volume (cc) [11]
23.93 0.7 0.7e0.9
24.21 0.7/0.8 0.7e0.9
24.50 0.7 0.7e0.9
27.10 0.9 0.7e0.9
27.22 0.8/0.9 0.7e0.9
34 1.7 1e2
332
deep and superficial inguinal rings are superimposed upon
one another and therefore the deep inguinal ring is located
primarily medial to the femoral artery [13]. More recent
studies in prepubescent children have confirmed the posi-
tion of the deep inguinal ring to be more medial than the
midpoint of the inguinal ligament throughout childhood
[13]. As the external inguinal ring remains relatively more
lateral (or deep inguinal ring more medial) in older boys,
the distance which the testis should travel during orchio-
pexy increases. The limiting factor in moving the testis
into the scrotum is the length of the testicular artery and
vein [14,15]. Transecting the hernia sac and separating it
from the cord structures often allows significant testicular
mobilization. Division of the longitudinal cremasteric fibers
running along the spermatic cord, as well as dividing the
external spermatic fibers, generally frees up the spermatic
cord sufficiently to allow the testis to reach the scrotum
[14,15]. If the testicular vessels are still found to be too
short after these steps then a Prentiss’ maneuver may be
necessary [15]. This technique significantly shortens the
distance that the testis must travel to reach the scrotum
by medial displacement of the testis [15], and changing an
angulated route to a much more direct route to the scrotum
[8,9]. Generally, the maneuver is accomplished by taking
down the floor of the inguinal canal, moving the spermatic
cord to the medial aspect of the canal, and reclosing the
floor of the inguinal canal [8,9,15]. Its use is under debate
as it is considered a highly invasive surgical technique [7].
As the preservation of blood flow by relieving tension on
the testicular artery is the main factor limiting the surgeon
in carrying the testis to a proper position [2,15], high unde-
scended testes are frequently brought to a high scrotal
position, and mid-scrotal placement is delayed for a second
operation [15]. When Prentiss first described his technique,
he suggested that the increase in length was four times that
obtained by the routine classical dissections confined to the
inguinal canal in boys older than 6 years [8,9]. Thus, he
proposed the proper mid-scrotal placement of testes in
a single operation. In our experience with the Prentiss’
maneuver length gain was limited to 1.3e1.4 times that
of the classical inguinal dissection, which was sufficient in
boys operated later than the usual age at orchiopexy.
The technique has some limitations. Prentiss’ original
description of the maneuver includes incision of trans-
versalis fascia up to the renal lodge for re-routing of intra-
abdominal testes [8,9], which seems unnecessary with the
current use of laparoscopic techniques for non-palpable
testicles [2,5,16]. Also, we were not able to find an article
in the literature regarding the fate of failed orchiopexies
with Prentiss’ maneuver. It is evident that dissection of
the inguinal canal for a redo orchiopexy following the
maneuver would be of great difficulty. As in previous stud-
ies [17], a follow-up period of 6 months was thought to be
L. Elemen et al.
adequate. Although we did not observe any atrophy in this
time, longer follow-up studies are needed.
In conclusion, it should be kept in mind that Prentiss’
maneuver, particularly in older boys, provides adequate
length created by straightening the angulation of the
testicular artery, and preserves testicular blood flow by
relieving tension on the testicular vessels.
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