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Tandilava Rene, MD., Ph D., Associate Professor, of the Batumi Shota Rustaveli State University, JSC "EVEXMedical Corporation" M. Iashvili Batumi Maternal and Child Central Hospital.
E-mail: dr.rene-geo@mail.ru.
Tandilava Zurab, student of The Faculty of Medicine, Friedrich-Alexander University Erlangen-Nurnberg, Germany
OUR EXPERIENCE IN THE SURGICAL TREATMENT OF CRYPTORCHIDISM IN CHILDREN
Abstract. The remote results of surgical treatment of cryptorchidism at 355 children in the age of 2-15 years are investigated. The efficiency is analysed. Orchiopexy was used. It is established, that optimal method of surgical correction of cryptorchidism at children is the modified Petriwalsky-Shoemaker. Despite of good clinical results achieved, ultrasonic research data of gonads demonstrate the preservation of morphological changes of germinative epithelium. The appropriate conclusions are made.
Keywords: cryptorchidism, undescended testis, orchidopexy, operation of Petriwalsky-Shoemaker, operation of Sokolov.
Introduction
Cryptorchidism is a common pathology of sexual development. Its incidence rate is 1-4%. The disease is also causes morpho-functional disorders of the sex glands, hypogonadism, infertility and impotence [1,2]. Most surgeons advice to peform surgery on the children under the age of 3 years, until the occurence of significant degenerative changes in the testicles [1, 2, 3].
Over time, the principles of surgical procedure has changed significantly. The traumatic surgeries [4] were replaced by new, more preserving methods [3, 5, 6, 7, 8]. Gonad fixation and its various method is considered the main stage of the surgical treatment of cryptorchidism. However, in case of orchiopexy, traction for the elements of the spermatic cord is unacceptable. This causes reflex spasm of the artery and veins of the gonad, leads to irreversible changes in the germinative epithelium and atrophy of the testicle and disruption of its reproductive function [7, 8, 9].
Materials and methods
To achieve optimal conditions for the testicle function after it is lowered into the scrotum and to improve the results of surgical treatment of cryptorchidism, we have divided the course of the applied methods in two stages — spermatic cord mobilization and gonad fixation after it is lowered into the scrotum. The first stage is identical for all types of surgery and provides maximal mobilization of the neurovascular bundle and vas deferens by wide dissection in the retroperitoneal space in the direction of the kidney and the posterior wall of the bladder. If necessary, the transverse fascia is dissected, and
the lower epigastric vessels are tied. This does significantly shortens the path to the scrotum and lower the testicle without tensioning the spermatic cord.
It is the second stage that distinguishes the cryptorchism correcting methods currently used. The Petriwalsky-Shoemaker method is the most preserving, but we used the modified surgery method [1, 10], that is used in our department since 1992. According to this method, the testicle is lowered into the scrotum in the prepared bed between the skin and fascia dartos through a small incision in the dartos behind the remnants of the adductor canal. If the neurovascular bundle and the vas deferens are sufficiently mobilized, not stretched, the testicular membranes are simply fixed with a suture on the adductor canal to the scrotal septum. With a relatively short spermatic cord, tension of the neurovascular bundle, or vas deferens, two additional interrupted sutures are made, the membranes of the proximal areas of testicle are fixed to the dartos itself.
From 1990 to 2017, in the Department of Pediatric Surgery at the M. Iashvili Batumi Maternal and Child Central Hospital, 1256 surgeries were performed in 1198 patients aged from 2 to 15 years. 148 patients underwent surgery by Sokolov method [4] (prior to 1993), 296 — by classical method Petriwalsky-Shoemaker [3, 5], the modified Petriwalsky-Shoemaker [1, 10] method was used to perform surgery on 754 patients.
Results and discussion
Long-term results of cryptorchidism surgical treatment in 355 children were studied. 105 of them underwent surgery by
OUR EXPERIENCE IN THE SURGICAL TREATMENTOF CRYPTORCHIDISM IN CHILDREN
the Petriwalsky-Shoemaker method, 160 underwent surgery by the modified method, 90 boys underwent surgery by the Sokolov method (prior to 1993). The results of treatment in the compared groups were evaluated in 3-10 years after the surgical operation. Universally accepted anatomical criteria were used in their evaluation: gonad size, consistency, mobility, position to the scrotum. The structure of the operated testicle tissue was evaluated on the basis of ultrasound data, compared with the echogenicity of the contralateral gonad tissue.
58 of the 90 boys operated by the Sokolov method had right-sided cryptorchidism, 19 — left-sided, and 13 — bilateral. 82 of the 160 patients operated on using the modified method were diagnosed right-sided cryptorchidism, 64 — left-sided, and 14 — bilateral. 69 children operated by the Petriwalsky-Shoemaker method had right-sided cryptorchidism, 24 — left-sided, and 12 had bilateral cryptorchidism.
After the surgery that used the Sokolov method, out of 11 (12.22%) patients with unsatisfactory clinical results, 10 showed gonad atrophy and 1 had a relapse of the disease. The number of children with satisfactory clinical results clearly prevails over the number of patients with good clinical effect. The long-term results of Sokolov surgery method show that prolonged traction of testicular vessels causes their mechanical narrowing and reflex spasm, leading to atrophy of the genital.
The orchiopexy method of Petriwalsky-Shoemaker is more preserving. However, after suturing aimed at narrowing the hole in the dartos, relatively short spermatic cord leads to either an effect of mechanical compression of the testicular vessels (gonad atrophy in 7 patients out of 11 with an unsatisfactory result) or a recurrence if the gonad slips out of the bed (4 cases). Also, a small difference in the parameters of clinically good and satisfactory results of the surgery most likely indicates that the moment of narrowing of the opening in the datos is not always justified and is possibly dangerous.
Analysis of the long-term results of the modified Petriwalsky-Shoemaker method confirms our assumptions. Replace-
ment of the narrowing suture with interrupted ones that fixate their own membranes to the dartos, has sharply decreased the unsatisfactory results leading to reduction gonadal atrophy rate to 0 (with 1 case of disease relapse in one patient). The increase in the number of patients with good clinical outcome should also be noted.
32 children aged 5-15 years underwent testicular ultrasound in 3-6 years after the surgery. Among them, 11 underwent surgery by a modified method, Petriwalsky-Shoemaker was used in 21 patients. All children with unsatisfactory results were examined (12 boys), as well as 5 patients with satisfactory and good clinical effect (total of 20). All patients with unsatisfactory and satisfactory results had a structural damage of the testicular tissue (increased echolocation) was found at the surgical region in comparisson to the contralateral. Ultrasound data of the children with a good clinical effect is more promising, because echolocation changes was detected in 1 boy out of five that underwent surgery using a modified method and in 2 children out of five that underwent surgery using the Petriwalsky-Shoemaker method. The results indicate that morphological changes in testicular tissue persist for many years after the surgical correction of cryptorchidism.
Conclusion
The method of choice in the surgical treatment of cryptorchidism in children is the modified Petriwalsky-Shoemaker method. However, the most extensive and wide dissection of the elements of the spermatic cord in the retroperitoneal space minimizes the significance of any method of orchiopexy. Children with cryptorchidism should be treated holisticaly. Surgical correction is one of the stage of the disease treatment. To make the effect of surgical operation permanent, stimulation and maintenance of reproductive function of the genital organ, all operated children need a comprehensive examination of the pediatric andrologist, as well as the observation of an endocrinologist in order to decide the necessity of hormonal therapy.
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