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656 CHAPTER 16 Urological surgery and equipment
Scrotal exploration for torsion and orchiopexy
Indications
Scrotal exploration is used for suspected testicular torsion.
Technique
A midline incision is used, since this allows access to both sides so that they may both be fixed within the scrotum. Untwist the testis and place in a warm, saline-soaked swab for 10 minutes.
If it remains black, remove it, having ligated the spermatic cord with a transfixion stitch of absorbable material. If it pinks up, fix it. If uncertain about its viability, make a small cut with the tip of a scalpel. If the testis bleeds actively, it should be salvaged (close the small wound with an absorbable suture). If not, it is dead and should be removed. Whatever you do, fix the other side, since the predisposing “bell clapper” deformity tends to be bilateral.
Fixation technique
Some surgeons fix the testis within the scrotum with suture material, inserted at 3 points (3-point fixation). Some use absorbable sutures and others, nonabsorbable sutures. Those who use the latter argue that absorbable sutures may disappear, exposing the patient to the risk of retorsion.1
Those who use absorbable sutures argue that the fibrous reaction around the absorbable sutures prevents retorsion and argue that the patient may be able to feel nonabsorbable sutures, which can be uncomfortable. The sutures should pass through the tunica albuginea of the testis, and then through the parietal layer of the tunica vaginalis lining the inner surface of the scrotum.
Others say the testis should be fixed within a dartos pouch,2 arguing that suture fixation breaches the blood–testis barrier, exposing both testes to the risk of sympathetic orchiopathia (an autoimmune reaction caused by development of antibodies against the testis).
For dartos pouch fixation, open the tunica vaginalis, bring the testis out and untwist it. Develop a dartos pouch in the scrotum by holding the skin with forceps and dissecting with scissors between the skin and the underlying dartos muscle. Enlarge this space by inserting your two index fingers and pulling them apart. Place the testis in this pouch.
Use a few absorbable sutures to attach the cord near the testis to the inside of the dartos pouch to prevent retorsion of the testes. The dartos may then be closed over the testis and the skin can be closed in a separate layer.
SCROTAL EXPLORATION FOR TORSION AND ORCHIOPEXY 657
Postoperative care and potential complications and their management
As with all procedures involving scrotal exploration, a scrotal hematoma may result that may have to be surgically drained.
Procedure-specific consent form—recommended discussion of adverse events
Serious or frequently occurring complications of scrotal exploration
Common
• The testis may have to be removed if nonviable.
Occasional
•You may be able to feel the stitch used to fix the testis.
•Blood collection around the testes, which slowly resolves or requires surgical removal
•Possible infection of incision or testis requiring further treatment
Rare
•Loss of testicular size or atrophy in future if testis is saved
•No guarantee of fertility
Alternative therapy includes observation for risks of loss of testis and autoimmune reaction.
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