Orchidopexy Bilateral

Bilateral orchidopexy surgery

Bilateral orchidopexy is an operation where both undescended testicles (one in each side) are pulled into the scrotum and attached. It is a standard operation in pediatric urology normally carried out in infants or young boys but sometimes in older children or adults, in cases where the condition carries on. When bilateral orchidopexy is indicated, the testes are undescent and lie between the scrotum and the epididymis.

Bilateral orchidopexy is advised to cases of:

• Bilateral undescended testes (cryptorchidism) - the testicles can't be dropped into the scrotal sac.
• Retractile or ectopic testes - testicles are moved or located in an unusual place. 
• Torsion of testis- emergency orchidopexy can be performed bilaterally to eliminate the possibility of a twisting in the future.
• Testicular exploration - testicles of both sides are examined in order to detect anatomical anomalies.

Advantages of Bilateral Orchidopexy

• Recovers normal testicular position, look.
• Helps retain fertility potential.
• Less risk of testicular torsion and cancer.
• Self-examination and monitoring are easier during adulthood.

Bilateral orchidopexy procedure

Bilateral orchidopexy is a surgery done to have both undescended testicles suspended in the scrotum and fixed. The procedure may be performed by means of open procedure or laparoscopic procedure as the testes can or cannot be palpated.

Preoperative Preparation

• Diagnosis is made by physical examination, and occasionally by ultrasound and/or laparoscopy.
• Anaesthesia: The child is under general anaesthesia (unconscious and pain free) during the procedure.
• Positioning: Position the patient supine (laying on their back).    
• Sterilization: Before the procedure, the scrotum and groin are washed and disinfected.

Surgical Interventions (Open Bilateral Orchidopexy)

Step 1: Incision

• Each inguinal (groin) area is incised in a small incision or in some cases the testis is low and thus directly in the scrotum.

Step 2: Identification and Mobilization

• The testis and the spermatic cord structures (vas deferens and blood vessels) are well-located.
• The testis is released of any tissues around it and fibrous bands that limit its movements.
• In case of need, patent processus vaginalis (little peritoneal expansion) is ligated and partitioned to avoid the formation of hernias.

Step 3: Preparation of the Dartos Pouch

• This is a subdartos pouch (small pocket) made in each side of the scrotum.
• The testicle will be securely held in the natural position in this pouch.

Step 4: Translocation of Testis

• The testis is pulled down through the inguinal canal into the scrotum. 
• The spermatic cord is sufficiently long to prevent the testis from being under tension in the scrotum. 

Step 5: Fixation

• In order to avoid the testes returning to the groin, the testis is produced to the bottom of the scrotum by use of absorbable stitches.

Step 6: Closure

• The scrotal and groin incisions are closed with absorbable sutures. 
• Sterile dressing would be applied.

Duration of Surgery

• Takes an average of 60-90 minutes on both sides.
• Majority of the patients will be able to go home the same day or subsequent to a stay over.

Postoperative Care

• Pain, swelling or bruising are mild and are treated with painkillers.
• Ice packs, scrotal support can be recommended.
• The normal functioning is expected to resume in approximately 1 week.
• Do not play sport or roughly in 3 to 4 weeks.
• The appointment of a follow-up visit occurs after 1-2 weeks to evaluate healing and testicular position.

Success Rate

• Over 95 percent success in permanent implantation of both testes in the scrotum.
• The sooner the surgery is performed (before the age of 1 year), the more favorable the results on fertility and testicular functioning.

Orchidopexy for bilateral undescended testicles

Orchidopexy bilateral undescended testicles (bilateral cryptorchidism) is an operation done to relocate both the testes which have not descended on their own to be in the scrotum to their correct location and hold them firmly. It is a highly frequent urological surgery in children and plays a significant role in the preservation of fertility, hormonal activity, and the minimization of the cancer risk.

Indications

Orchidopexy should be done to:

• Bilateral undescended testes - the testicles are not enclosed by the scrotum at an age beyond 6 months.
• Retractile testes - failure to remain down in groin or scrotum but manage to move to and fro.
• Ectopic testes - are found out of the normal descent path.
• Non-palpable testis cannot be felt on examination (generally require laparoscopy to investigate).

Bilateral laparoscopic orchidopexy

Bilateral laparoscopic orchidopexy is a procedure performed through minimally invasive surgery that brings each undescended testicle (one per side) into the scrotum and secures them there. It is especially done when the testes are not palpable or is within the abdomen and thus can hardly be repaired using the open surgery. This method enables accurate visualization, reduced tissue damage as well as accelerated recovery as opposed to conventional open surgery.

Surgical Procedure Steps

Step 1: Port Insertion and Visualization

• Three small openings (5 mm or less) are cut in the abdomen:
• One to take laparoscopic (camera)
• Two for working instruments
• The ability to clearly view the abdomen is achieved by the use of gas (carbon dioxide) in order to inflate the abdomen (pneumoperitoneum).

Step 2: Testis identification

• To locate the testicles and trace the spermatic vessels and vas deferens, the surgeon searches the left and right sides of the abdomen. 
• If the testes reside in the abdomen in both cases, the distance between them and the internal inguinal ring determines the next step.

Step 3: Mobilization of Vessels in testicles

• It is done very delicately to allow sufficient length of testicular arteries and veins which then are able to go down into the scrotum.
• The peritoneal attachment is severed in such a way that the testes are not strained.

Step 4: Making of Scrotal Pouch

• There are two incisions done on the scrotum that are small.
• A hole is made on the abdomen to the scrotum (along the inguinal canal or an additional opening).

Step 5: Descent and Fixation

• The laparoscopic graspers are used to bring down each testis towards its corresponding scrotal pouch.
• Testes are attached (sutured) to the pouch dartos in order to stop retreating.

Step 6: Closure

• The abdomen will be deflated and the small holes will be sealed using absorbent sutures.
• One uses sterile dressings.

Duration of Surgery

• Time: each side - 90 to 120 minutes.
• Hospital Stay: Generally day-care or overnight staring.

Benefits of Laparoscopic Approach

• Direct visualization of retroperitoneal and intraperitoneal organs. 
• Capability to treat both sides within the same procedure.
• Reduced incisions and scarring.
• Fewer pain and quicker healing.
• Easily transformed to Fowler-Stephens procedure in case of high intra abdominal testes.
• Treatment and examination within a single appointment.

Factors Affecting Bilateral orchidopexy surgery cost India

The critical factors influencing cost are as below:

Type of surgery / complexity

• The added equipment, the added time on the OR, and the additional expertise will generally make a typical open orchidopexy (both sides) less expensive than a laparoscopy. 
• The testes can be intra-abdominal, non-palpable or two-stage (e.g. Fowler-Stephens orchidopexy) which complicates the procedure and increases the cost. 
• Bilateral vs unilateral: Parts should be operating on both sides which is generally more expensive as twice the work. As an illustrative case, bilateral cases can be more expensive than unilateral. 

Type and infrastructure of hospital

It could be an expensive or specialized private hospital with state of the art facilities, or it can be a smaller or a simpler facility. The high-end hospitals are priced higher. 
The type of room selected: general ward or semi-private or private or luxury suite. The category of a room influences the stay cost. 

Location / city

• In big cities, the cost is usually higher. The increased living expenses in urban areas also mean increased overheads in the hospitals. 
• Travel, accommodation (in case the patient has been admitted in a different city or country) are also a burden to the total cost.

Surgeon / team expertise

• There may be a surgeon who is very experienced, with recognised qualifications or specialisation (paediatric urology, laparoscopic specialist) so their fees may be higher. 
• Further manpower (anaesthetist, specialised nursing, monitoring) that is needed when conducting complex laparoscopic bilateral surgery will cost more.

Pre-operative investigations and diagnostics

• Additional imaging (ultrasound, MRI, laparoscopy for diagnosis) and examination may be necessary in cases of bilateral or non-palpable testis, which increase the cost. 
• It includes all preoperative workup (blood tests, ECG etc.). 

Intra-operative supplies / equipment

• Special instruments, ports, camera systems, additional OT time, CO2 insufflation etc. are needed in laparoscopic surgeries. These are an expense to a less complex open process.
• When special methods (microsurgery, special sutures) are employed, there is a rise in costs. 

Inpatient care / postoperative care

• Length of hospital stay, ICU or long-term monitoring, complications, room type, and the like all affect cost. The hospitals may levy charges on a day-to-day basis and the longer the stay, the greater the cost. 
• Postoperative drugs, dressings, follow-ups, counselling- all this helps.

International patient package / medical tourism

• It is possible that with international patients the hospital can package these meals such as surgery+stay+transport+translation etc and this could add to the quoted cost, which could be higher than local patient cost.

Conclusion

Open or laparoscopic bilateral undescended testicles are successfully and safely treated by bilateral orchidopexy to establish normal testicular position and development with reproductive health in the long term. Early (6-18 months) performance of this procedure has been shown to greatly enhance fertility potential, hormonal activity and lowers the chances of testicular cancer, and torsion. All in all, bilateral orchidopexy is a curative, preventive, and restorative operation with a high success rate, few complications, and positive results in cases of experienced pediatric or urologic surgeons in accredited hospitals.

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FAQ

Will the child be in pain after surgery?

• One would expect mild discomfort or swelling over a few days and this can easily be handled by pain relievers given by the doctor.

Do the testicles lift up once more after operation?

• In rare cases, testes re-ascend due to loosening of fixation or scar tissue. In case this occurs, a revision orchidopexy can be needed.

Would there be any effect of the operation on fertility in the future?

• The testicles will produce sperm normally and fertility can be maintained if performed at an early age (<1yr). 

Is this a day-care surgery?

• Yes, the majority of the cases are performed in the form of day-care procedures, when discharge is made on the same day or following an overnight observation.

Is bilateral orchidopexy possible for adults?

• Yes, but preoperative surgery is desirable. In adults, it can result in appearance improvement and simplified examination but may not completely regain fertility when performed late on.