Methods of fixing the testes in the scrotum
A number of different approaches have been used to fix testicles in the scrotum. All the methods have been developed to
- Fix the testicle securely so it can’t reascend
- Prevent the testicle from twisting (testicular torsion)
The two major approaches (and their benefits/drawbacks are):
classic transfixion orchiopexy (transparenchymal suture fixation)
- transfixation sutures are used for testicular fixation
involves one, two or three stitches in the dartos fascia and through the testicular wall, either close together, or at different points
- results in inflammatory reactions to suturing
- numerous reports of torsion after stitching in place
- Uncomfortable as child and adult – tension on stitches, dependence on surgeon’s skill in positioning in scrotum
Creating a dartos / subdartos pouch (eversion of the parietal tunica vaginalis)
- a pouch in the scrotal layers is made, the testicle is put in it, and the neck of the pouch tightened
- no stitches are placed into the testicle, preventing damage
- it has excellent scarification (scarring to hold the testicle in place), resulting in fantastic fixation to the scrotal wall, all round the testicle (so it cannot rotate)
Read on to find out which is best for your child!
Why does how the testicle’s fixed matter?
Research has shown that whether the testis is stitched in place with absorbable or non-absorbable sutures, putting stitches into the testicle (the tunica albuginea):
- causes significant testicular inflammation
- increases the risk of infertility
- may damage the testicle’s vessels
Normally the sperm-making parts of the testicle are separated from the bloodstream (technically we say there’s a blood-testis barrier). Blood vessels, lymphatics and nerves do not penetrate the seminiferous tubule where sperm is made. Specialised cells restrict the ‘flow’ of substances.
By putting a stitch into the testicle during orchidopexy and breaching the blood-testis barrier, there is the possibility of forming anti-sperm antibodies that may affect botht he descended and undescended testicles, increasing potential subfertility. (source)
Experiments on rats have shown that suture fixation of the testis through the tunica albuginea results in elevated anti-sperm antibodies and significant histological changes, including lower Johnsen scores and reduced seminiferous tubular diameter of the contralateral testis (the normal one).
In 1989 an experiment was presented to the American Academy of Pediatrics. The authors performed an orchidopexy on 34 rats divided into three groups.
In one group the testes were fixed with absorbable sutures, in another with nonabsorbable sutures and in the third with the classical dartos-pouch technique with eversion of the tunica vaginalis but no suture fixation.
They found that 76% of the testes that had been fixed with catgut sutures had abscess formation, 88% had evidence of tubular necrosis and 82% had no spermatogonia.
Testes fixed with Nylon sutures were adherent only at the site of the fixation, with no spermatogenesis in 29% and tubular atrophy in 58%.
By contrast testes fixed using a dartos pouch had complete circumferential adherence of the testis, normal spermatogenesis in 94% and minimal tubular atrophy in 23%.
The potential for sperm antibodies
Some studies – and there is contradictory evidence for this – have shown that if a testicle is pierced and blood and semen mix, the body’s white blood cels may
There may be a sympathetic orchidopathia as a consequence of the immunological phenomenon. One study strongly associated a scrotal suture with infertility.
The theory is that the body learns to attack the sperm-making cells, and this affects both the now-descended testicle and the other, naturally descended one.
Placement of sutures in the tunica albuginea for fixation is generally discouraged because it causes significant testicular inflammation, increases infertility risk, and may damage intratesticular vessels.
Ask your son’s surgeon how he will fix the testicle(s) in the scrotum. If he doesn’t say “dartos pouch”, “sub-dartos pouch”, “extra-dartos pouch” or another variation, I recommend you choose a different surgeon.