Journal of Pediatric Urology (2021) 17, 835.e1e835.

e6

Testicular blood supply and growth in

children with high cryptorchidism
treated with gubernaculum preserving
a
Pediatric Surgery, Inner
vs. cutting laparoscopic orchiopexy: A
Mongolia Maternal and Child
Health Care Hospital,
pilot trial
Huhehaote, Inner Mongolia,
010020, China
Jianguo Zhang a,1, Xia Yang b,1, Chao Zhang b, Haowei Li b,
b
Pediatric Surgery, The Fourth Yongxiang Zhao b, Chaosheng Ku a, Lin Qi a, Yu Bai a, Lin Yang a,
Hospital of Baotou, Baotou, Hailong Zhang a, Dongqing Yue c, Wenfeng Wei a, Haibin Yu a,*
Inner Mongolia, 014030, China

c
Medical Imaging Department,
The Fourth Hospital of Baotou,
Baotou, Inner Mongolia,
014030, China
* Correspondence to: Haibin Yu,
Pediatric Surgery, Inner
Mongolia Maternal and Child
Health Care Hospital,
Huhehaote, Inner Mongolia,
010020, China Tel.: þ86
15848169023
1424494668@qq.com (H. Yu)
Keywords
Gubernaculum testis; Laparos-
copy; High cryptorchidism;
Testicular blood supply;
Comparative observation
Summary
Introduction
It is still controversial whether the frenum of testis
should be retained in laparoscopic testicular
fixation.
Materials and methods
It is a prospective experiment to study testicular
preservation on testicular growth in children with
high cryptorchidism.
Results
From January 2018 to June 2020, 120 children with
high cryptorchidism in Inner Mongolia Maternal and
Child Health Care Hospital and The Fourth Hospital
of Baotou were randomly divided into retention
group (60 cases in group P, aged 1e3 years, average
1.85  0.58) and cutting group (60 cases in group C,
aged 1e3 years, average 1.75  0.66) (P Z 0.52).
PSV, EDV, RI and testicular volume were measured
by color Doppler ultrasound before operation and
1,3,6,12 months after operation. No, there was sig-
nificant difference between the two groups
(P > 0.05).
Conclusions
There is no significant difference in testicular blood
supply and growth between laparoscopic testicular
fixation and frenulum amputation in children with
high cryptorchidism.

Received 1 July 2021

Revised 4 October 2021
Accepted 7 October 2021
Available online 12 October
2021

1
These authors contributed equally to this work.

https://doi.org/10.1016/j.jpurol.2021.10.002
1477-5131/ª 2021 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
835.e2
Introduction
Cryptorchidism (retained testis) is a common congenital
disease of the genito-urinary system in children and is
related to the abnormal growth of the gubernaculum testis
[1e4]. It occurs in 1%e4% of full-term male infants and 15%e
30% of premature male infants [4,5]. It can be subtyped into
high cryptorchidism and low cryptorchidism, according to
the position of the testis [3,4]. Patients with high cryptor-
chidism have their testes above the inguinal canal ring and
account for approximately 25% of all patients with cryptor-
chidism [3,4]. Most retained testes descend without external
force in the first 3 months after birth but are less likely to
continue to descend after 6 months of age [3,4].
Laparoscopic treatment is widely used for high cryptor-
chidism in clinical practice [4,6], but it remains contro-
versial whether the gubernaculum should be spared or not
[5,7e12]. Indeed, some authors believe that conventional
surgeries for cryptorchidism would damage the testicular
bed and blood supply to some ramus communicans, and
would lead to abnormal testicular growth as blood flow
would be affected by the elongation of the reserved blood
vessels after the testes are descended [5,7,9,10]. On the
other hand, some authors suggest that the vascularization
of the gubernaculum will help maintain a proper blood
supply to the testis and avoid atrophy [8,11e13]. Robertson
et al. [11] reported a testes survival rate of >90%, while a
retrospective study by Braga et al. [12] reported rates of
testicular atrophy of 6.6% and 28.3% with gubernaculum-
sparring laparoscopic orchiopexy and conventional laparo-
scopic orchiopexy, respectively.
Therefore, this prospective trial aimed to explore the
impact of preserving or not the gubernaculum testis on
postoperative testicular growth in children by comparing
the postoperative blood supply and testicular growth. This
trial could provide a higher level of evidence for laparo-
scopic orchiopexy.
Material and methods
Study design and participants
In this pilot prospective trial, patients with high cryptor-
chidism admitted to the pediatric surgery departments of
Inner Mongolia Maternal and Child Health Care
Hospital and The Fourth Hospital of Baotou from January
2018 to June 2020 were enrolled. The study was approved
by the ethics committees of Inner Mongolia Maternal and
Child Health Care Hospital and The Fourth Hospital of
Baotou. The informed consent form was signed by the legal
guardians of the enrolled children.
The inclusion criteria were 1) no history of testicular
descent, 2) testes were not palpable in the inguinal canal
during a physical examination, and 3) testis-like tissues
observed at the inner ring mouth or in the abdomen in color
Doppler ultrasonography. The exclusion criteria were 1)
<12 months or >3 years of age, 2) testicular absence, 3)
orchitis, epididymitis, or testicular torsion, 4) cryptorchi-
dism relapse, 5) underwent other scrotal operations or
history of laparotomy operation as abdominal adhesions
may affect the surgery, 6) severe cardiac, pulmonary,
J. Zhang et al.
hepatic, or renal dysfunction; or 7) not tolerant to CO2
pneumoperitoneum.
Randomization and blinding
The children were randomized to the preservation and
cutting groups using a random number table prepared by a
biostatistician. Randomization was stratified to ensure a
uniform distribution between the two hospitals. The
outcome assessors were blind to grouping.
Surgery
All patients underwent laparoscopic descent and fixation
for high cryptorchidism [3,4]. All surgeries were performed
by an associate chief physician with >15 years of experi-
ence (ZJ).
Surgery in the preservation group
First, a 5-mm incision was made at the umbilicus for
pneumoperitoneum at 8e10 mmHg pressure. A laparoscope
was placed in, and one 5-mm operational trocar (puncture
device 30160M1, Karl Storz Endoskope, Tuttlingen, Ger-
many) was inserted into the left and right abdomen,
separately. Under the laparoscope, the testis of the
affected side was observed at the inner ring mouth or in the
abdomen, with the free spermatic vessel and the vas def-
erens of sufficient length. A sharp circular separation was
performed at the inner ring mouth to enable an aspirator
rod to be inserted into the scrotum along the inguinal
canal. An incision was made on the scrotum, and the tunnel
was enlarged under the dartos toward the bottom of the
scrotum. After that, the periorchium was lifted, and the
incision was enlarged in the non-vascular zone to find the
gubernaculum testis. The testis was then gradually drawn
out, and the adhesive tissues were debonded. The sper-
matic cord was checked for torsion, and the testis was
checked for tensionlessness and then fixed in the tunnel
under the dartos toward the bottom of the scrotum. Finally,
the incision was sutured conventionally.
Surgery in the cutting group
A 5-mm incision was made at the umbilicus for pneumo-
peritoneum at 8e10 mmHg pressure. A laparoscope was
placed in, and one 5-mm operational trocar (puncture device
30160M1, Karl Storz Endoskope, Tuttlingen, Germany) was
inserted into the left and right abdomen, separately. Under
the laparoscope, the testis of the affected side was observed
at the inner ring mouth or in the abdomen, with the free
spermatic vessel and the vas deferens of sufficient length. A
sharp circular separation was performed at the inner ring
mouth, the gubernaculum testis was lifted (without
damaging the vas deferens) and cut off with electrocautery
at the lowest position, and the testis was lifted under the
laparoscope to the contralateral inner ring month (i.e.,
drawn into the scrotum). After that, an aspirator rod was
inserted into the scrotum along the inguinal canal. An inci-
sion was made on the scrotum, and the tunnel was enlarged
under the dartos toward the bottom of the scrotum. Next,
Gubernaculum-preserving laparoscopic orchiopexy
the periorchium was cut open, and hemostatic forceps were
inserted into the abdomen along the aspirator to gently
clamp the joint at the epididymis, gradually drawing out the
testis and debonding the adhesive tissues. The spermatic
cord was checked for torsion, and the testis was checked for
tensionlessness and then fixed in the tunnel under the dartos
toward the bottom of the scrotum. Finally, the incision was
sutured conventionally.
Observation indicators
Color Doppler ultrasonography (HITACHI Ascendus, Japan,
PHILIPS EPIQ7, Dutch) was used to measure the peak sys-
tolic velocity (PSV), maximum end-diastolic velocity (EDV),
mean blood flow resistance index (RI), and testicular vol-
ume (length  width  height) [14,15] of the patients
before and at 1, 3, 6, and 12 months after surgery.
Statistical analysis
All data were analyzed using SPSS 19.0 (IBM Corp., Armonk,
NY, USA). The continuous data were tested for normal
distribution using the KolmogoroveSmirnov test. They are
presented as means  standard deviations and were
analyzed using Student’s t-test. The categorical data are
presented as n (%) and were analyzed using the chi-square
test or Fisher’s exact test. Two-sided P-values P < 0.05
were deemed to be statistically significant.
Results
Characteristics of the participants
A total of 135 patients were randomized: 72 in the pres-
ervation group and 63 in the cutting group. Twelve patients
in the preservation group and three in the cutting group
dropped out and were excluded. Finally, 60 patients were
retained in the preservation group and 60 patients were
retained in the cutting group.
All 120 patients underwent successful laparoscopic phase
I testicular descent and fixation. The 60 patients in the
preservation group were 1e3 years of age (mean, 1.85  0.58
years). The 60 patients in the cutting group were 1e3 years
of age (mean, 1.75  0.66 years) (P Z 0.52).There was no
secondary operation, and there was no testicular atrophy in
both operations.
Testicular Doppler ultrasound
The patients were examined at 1, 3, 6, and 12 months after
surgery. There were no differences in PSV, EDV, RI, and
testicular volume between the two groups over the 12-
month follow-up (all P > 0.05) (Table 1 and Fig. 1).
Discussion
It remains controversial whether the gubernaculum testis
should be preserved or not during laparoscopic orchiopexy
[5,7e12]. This pilot trial aimed to explore the impact of
preserving or not the gubernaculum testis on postoperative
835.e3
testicular growth in children with high cryptorchidism. The
results suggest no differences in testicular blood supply or
growth between children with high cryptorchidism who
underwent laparoscopic orchiopexy with preservation vs.
cutting of the gubernaculum testis.
Cryptorchidism is a common urinary system disease in
children that may cause declined semen quality and a
higher risk of testicular germ cell tumor [1e4,16]. Hutson
et al. [17,18] studied the regulation process of testicular
descent, the potential mechanism of testicular descent to
cause infertility and tumor, and its impact on germ cells
through animal experiments. Hormone therapy is the
conventional treatment for patients under 1 year of age,
and patients failing to respond to hormone therapy and
over 1 year of age should receive surgical treatment as
early as possible [3,4,19], with the purpose to not only
restore the testis to its normal anatomical position but
also enable the testis to grow and function properly.
Therefore, the key to surgery for normal testicular growth
is to reduce the surgical trauma as much as possible, with
testicular growth in child patients to be regularly exam-
ined after surgery.
Braga et al. [12] reported laparoscopic gubernaculum
testis preserving surgery as a feasible and alternative sur-
gery to the conventional FowlereStephens testicular sur-
gery, suggesting that the preservation of extra testicular
blood supply (via testicular vessels and compliant arteries)
might improve the survival of the testes after laparoscopic
testicular surgeries, with a 6.6% rate of atrophy, compared
with 28.3% with conventional laparoscopic orchiopexy. This
is supported by other studies [8,11,13,20,21]. Ellis et al.
[22] also reported robust collateral circulation when pre-
serving the gubernaculum testis.
In this study, the testicular blood flow and growth were
followed for 12 months after surgery, and the results
showed no differences between the two groups. Some
reasons could explain this lack of difference. First, the
gubernaculum testis provided a small blood flow and did not
substantially affect testicular growth in children. Second,
child patients underwent surgery at an early age, and their
reproductive system could recover quickly. The reserved
vessels, including the vas deferens and the cremaster
vessel, could increase blood flow and rebuild the collateral
circulation as the patients grew, to ensure normal testicular
growth in child patients. Third, the postoperative follow-up
lasted for only 12 months and could be insufficient to
reflect the impact of blood flow on testicular growth.
Therefore, whether to reserve the gubernaculum testis
should be decided based on the actual patient’s situation
[23], and unnecessary damage caused by separation should
be avoided, and the gubernaculum should not be cut off
only for easy operation. Furthermore, laparoscopy is ad-
vantageous in finding the testes and preserving the original
anatomical structure in child patients with high cryptor-
chidism. It facilitates secondary operations on child pa-
tients with a short spermatic cord, so it should be the most
preferred surgical method.
Despite that this was a two-center pilot randomized
trial, this study has biases and limitations. As it was a pilot
trial, no power analysis was performed, and the sample size
might be too small to observe a difference. Besides, the
835.e4 J. Zhang et al.

Table 1 Comparison of the indicators between the two groups.

Variables Preservation Cutting group t P
group (60 patients)
(60 patients)
Age 1.851  0.583 1.753  0.662 0.713 0.520
PSV (cm/s) Before surgery 3.491  1.185 3.547  0.655 0.335 0.738
1 month after surgery 4.483  1.549 5.154  1.715 2.316 0.209
3 months after surgery 3.972  1.527 3.793  0.881 0.827 0.410
6 months after surgery 3.589  1.095 3.690  0.901 0.574 0.567
12 months after surgery 3.125  1.320 3.540  0.807 2.199 0.221
EDV (cm/s) Before surgery 1.169  0.561 1.304  0.322 1.708 0.090
1 month after surgery 1.585  0.609 1.822  0.673 2.085 0.390
3 months after surgery 1.607  1.117 1.663  0.440 0.388 0.699
6 months after surgery 1.315  0.581 1.483  0.485 1.788 0.892
12 months after surgery 1.156  0.517 1.252  0.358 1.245 0.216
RI Before surgery 0.679  0.153 0.683  0.205 0.154 0.878
1 month after surgery 0.669  0.189 0.671  0.195 0.460 0.964
3 months after surgery 0.680  0.213 0.665  0.176 0.417 0.677
6 months after surgery 0.624  0.132 0.614  0.260 0.246 0.806
12 months after surgery 0.582  0.111 0.565  0.238 0.528 0.598
Testicular Before surgery 0.480  0.193 0.448  0.180 0.995 0.322
volume (cm3) 1 month after surgery 0.519  0.226 0.524  0.191 1.430 0.886
3 months after surgery 0.572  0.291 0.558  0.187 0.327 0.744
6 months after surgery 0.572  0.256 0.597  0.197 0.622 0.535
12 months after surgery 0.584  0.267 0.571  0.200 0.330 0.742
PSV: peak systolic velocity; EDV: maximum end-diastolic velocity; RI: mean blood flow resistance index.

Fig. 1 PSV, EDV, RI, and testicular volume between the two groups over the 12-month follow-up. (A) Comparison of PSV between
the two groups; (B) Comparison of EDV between the two groups; (C) Comparison of RI between the two groups; (D) Comparison of
testicular volume between the two groups.

follow-up was only 12 months. Children have fine internal insufficient testicular descent made it challenging to
testicular arteries with slow blood flow that are difficult to monitor one specific artery before and after surgery.
detect [24,25], reduced blood flow signals under color All cases have been followed up for more than 12
Doppler ultrasonography on the affected side due to months, and some cases have been followed up for more
Gubernaculum-preserving laparoscopic orchiopexy
than 36 months. It is planned to follow up until adoles-
cence. In addition to observing the testicular growth and
development of cases, we should also compare the changes
of testosterone level in adolescence. Therefore, some
cases may be lost to follow-up.
Because the study was set as the comparison of the two
methods of primary surgery, patients with secondary repair
surgery were excluded. In future studies, patients with high
cryptorchidism who need secondary repair surgery can be
included in the study. It should also be considered that the
number of patients who need secondary surgery is small
and the study and follow-up time are longer. The author has
been engaged in pediatric surgery for more than 10 years.
Only 2 patients underwent secondary repair surgery. All of
them occurred before this study. The testis of patients
after secondary repair surgery developed well. In recent 3
years, patients with secondary repair surgery are rare,
which may be related to the increased experience of
laparoscopic surgery, or they may not meet patients with
higher cryptorchidism.
Conclusions
In conclusion, there were no differences in testicular blood
supply or growth between children with high cryptorchi-
dism who underwent laparoscopic orchiopexy with preser-
vation vs. cutting the gubernaculum testis.
Ethical approval
The study was approved by the ethics committees of Inner
Mongolia Maternal and Child Health Hospital and the Fourth
Hospital of Baotou. The informed consent form was signed
by the legal guardians of the enrolled children.
Funding
This work was supported by the Baotou Municipal Health
Fund Program [grant number 2018C2007-4-2]. The funder
had no role in study design, data collection and analysis,
decision to publish, or preparation of the manuscript.
Conflicts of interest
None.
Acknowledgements
We want to express our thanks to our data collectors at
Inner Mongolia Maternal and Child Health Hospital and the
Fourth Hospital of Baotou.
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