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Treatment ofScrotal andTesticular
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Trauma: I—Minor andIntermediate
46
Interventions
Penetrating scrotal injury poses no question about its surgical management as the wound
has to be explored, debrided, and closed. In addition, common sense obliges one to question deep organ (testicles) damage during the exploration. However, the interventional
approach has not always been prioritized for blunt scrotal trauma in the past. Indeed, up
to half a century back, blunt testicular trauma was mainly managed conservatively. An
unacceptably higher number of testicles were lost because of this approach as the intervention was decided only late after the occurrence of complications: aggravation of the
hematoma and worsening of the pain, abscess, testicular ischemic necrosis, stula, and
so on. A late complication is testicular atrophy and the loss of spermatogenesis.
The 1970s marked a paradigm shift from conservative to early scrotal exploration and testicular repair in blunt trauma. This shift has been greatly supported by
modern imaging techniques. Nowadays, testicular rupture is readily diagnosed with
the aid of ultrasonography (US), prompting urgent repair and enhancing the testis
salvage rate [1]. Early comparative studies showed a failure rate, i.e., an orchidectomy rate of 45% and 9% for delayed and early exploration, respectively [2, 3]. As
per many authors, a maximum interval of 3days from the time of trauma is the limit
between an early intervention and a delayed one [1–3].
Today, all the expert panels (i.e., European association of urology (EAU), American
urological association (AUA), British association of urological surgeons (BAUS), and
société internationale d’urologie (SIU)) recommend prompt exploration of the injured
testis whenever there is a large hematoma, obvious physical ndings of testicular rupture, sonographic evidence of testicular rupture, or inconclusive US ndings [4–7].
Data from the NTDB for the period 2007–2015 showed that nearly half (48.3%)
of scrotal or testicular trauma victims underwent a subsequent scrotal or testicular
operation, the most common procedure being either a repair of scrotal laceration or
testicular rupture (37.3%), followed by unilateral orchiectomy (23.4%) [8].
Despite the progress in testicle preservation, the surgeon should always get
signed consent from the patient for possible orchidectomy before taking him to the
operating theater.
© The Author(s), under exclusive license to Springer Nature Singapore Pte
Ltd. 2023
S. A. AL-Mamari, Urogenital Trauma: A Practical Guide,
https://doi.org/10.1007/978-981-99-6171-9_46
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46 Treatment ofScrotal andTesticular Trauma: I—Minor andIntermediate…
The intervention is performed under general or regional (spine) anesthesia with
the patient in a supine position. He should be catheterized and a broad-spectrum IV
antibiotic (Tazocin) be given before the scrotal incision which is centered on the
injury side and preferably transverse. Once the tunica vaginalis is opened, clots are
rapidly removed, the testis is delivered, and the tunica albuginea is meticulously
inspected for any tear, and care is taken to delicately manipulate eventually extruded
seminiferous tubules. Assessment of the testis vitality is carried out including ruling
out possible cord injury. After debridement of necrotic tissues, the viable tunica
albuginea is repaired with a continuous 4/0 resorbable suture taking care to progressively reintroduce all the viable seminiferous tubules. Once the repair is over, the
testis is replaced in the scrotal cavity and the scrotal wall is closed with resorbable
sutures after leaving a drain in situ [1, 9] (Fig.46.1a, b).
A follow-up with ultrasound is performed at 3 months to evaluate the testis
viability.
In the pediatric population, a study has also conrmed that early exploration
(dened by the authors as less than 35h from the trauma time) results in a high rate
of testicular salvage, with no post-operative complications, shorter hospital stays
(2days), and no late sequels after a mean follow-up of nearly 5years: sustained
viability of the testis, no atrophy on Doppler ultrasound, normospermia after
6months, and no abnormal anti-sperm antibodies [10].
When there is a signicant loss of tunica albuginea and the quantity of extruded
and viable seminiferous tubules is too large to be reintegrated within the capsule, a
neo-capsule can be created by wrapping the tunica vaginalis around the defect and
suturing its free edges to the albuginea with 3/0 resorbable materials (polyglactin)
or by using a free graft of the tunica vaginalis. On the one hand, this prevents the
creation of a mini-compartment syndrome, and on the other hand, it avoids unnecessary excision and loss of viable testicular tissues. This technique was proven to be
superior to the use of synthetic material (polytetrauoroethylene Gore-Tex patch
graft) which is associated with a high rate of secondary infection and the need for
orchidectomy [11–15] (Figs.46.2, 46.3, and 46.4).
Fig. 46.1 (a) Intraoperative view of testicular rupture with extruded seminiferous tubules. (b)
Testicular repair consisting of débridement and primary tunical closure. (From Buckley and
McAninck [1], with permission from Wolters Kluwer Health)
cd
46 Treatment of Scrotal and Testicular Trauma: I—Minor and Intermediate…
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Fig. 46.2 Repair of
ruptured testis using tunica
vaginalis. Free edges of
tunica vaginalis were
wrapped around the
extruding seminiferous
tubules and secured with
3.0 polyglactin 910
sutures. (From Molokwu
etal. [13], with permission
from Elsevier)
393
a
b
Fig. 46.3 Testicular repair using tunica vaginalis: (a) Ruptured tunica albuginea and prolapsed
testicular contents. (b) Suture between the layers of the tunica albuginea. (c) Tunica vaginalis ap.
(d) Suture of the tunica albuginea and testicular serosal ap. (From Yokokawa etal. [14]. Creative
Commons License)
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Fig. 46.4 (a, b) Post-repair using a tunica vaginalis ap: Right testicle in sagittal and transverse
planes. Thin tunica albuginea uniformly surrounding testicle (yellow arrows), homogeneous testicular parenchyma echogenicity, and absent hematocele. (From Blok et al. [15]. Creative
Commons attribution license)
46 Treatment ofScrotal andTesticular Trauma: I—Minor andIntermediate…
Nevertheless, a study has reported the successful use of biosynthetic material in
a small series of extensive testicular ruptures with excellent results even with penetrating wounds (gunshot) [16]. This technique might prove useful in cases where
the tunica vaginalis itself has been extensively damaged by the trauma but implies
strict asepsis, thorough wound debridement and wash, and the continuation of antibiotics after discharge. Extracellular matrix graft materials were also successfully
tried for the reconstruction of tunica albuginea using bovine pericardium and cadaveric dermis [17].
As mentioned in the introduction, the decision to explore the scrotum should be
straightforward for penetrating trauma. In a large single institutional series of 97
patients who sustained scrotal gunshot injuries, 91 (94%) of them were explored,
and in almost half of these (44 patients or 48%), a testicular injury was found. In the
group with testicular injury, half were repaired and half underwent orchidectomy
[18]. A 30-year monocentric review mentioned an overall testicular salvage rate of
46% after penetrating trauma, and a particular 77%, 11%, and 0% salvage rate for
gunshot wounds (GSWs), stab wounds, and bites, respectively [19–21] (Figs.46.5
and 46.6).
In GSWs, the clinician should also have a low suspicion threshold for associated
urethral and/or penile injury and request additional studies to rule them out [21].
An inguinal testicular dislocation can be achieved manually with a fully sedated
patient or under general anesthesia. If this non-invasive approach is not successful,
an inguinal exploration is indicated to gently push the testis back to the scrotal cavity, and a combined small transverse scrotal incision will be needed for testicular
xation [22]. The extremely rare case of testicular dislocation into the penis is managed with complete penile degloving and testicular relocation inside the scrotum
[23] (Fig.46.7).
ab
46 Treatment of Scrotal and Testicular Trauma: I—Minor and Intermediate…
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Fig. 46.5 Bilateral
testicular gunshot injury:
Tunica albuginea defects
and bullet hole. (From
Abidoğlu etal. [20], with
permission from Springer)
395
Figs. 46.6 (a) Repair of the right testis with tunica vaginalis ap. (b) Repair of the left testis with
tunica vaginalis ap. (From Abidoğlu etal. [20], with permission from Springer)
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46 Treatment ofScrotal andTesticular Trauma: I—Minor andIntermediate…
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Fig. 46.7 (a) Operative photograph showing the exposure of a dislocated right testis into the penis
through a degloving circumcoronal incision. (b) Operative photograph showing completed relocation of testis in the right hemiscrotum (same patient discussed in Fig. 44.1). (From Raykar etal.
[23], with permission from Springer Nature)
References
1. Buckley JC, McAninch JW. Use of ultrasonography for the diagnosis of testicular
injuries in blunt scrotal trauma. J Urol. 2006;175(1):175–8. https://doi.org/10.1016/
S0022- 5347(05)00048- 0. PMID: 16406902.
2. Gross M. Rupture of the testicle: the importance of early surgical treatment. J Urol.
1969;101(2):196–7. https://doi.org/10.1016/s0022- 5347(17)62310- 3. PMID: 5765482.
3. Cass AS. Testicular trauma. J Urol. 1983;129(2):299–300. https://doi.org/10.1016/
s0022- 5347(17)52062- 5. PMID: 6834494.
4. EAU Guidelines. Edn. Presented at the EAU Annual Congress Amsterdam, March 2022.
ISBN 978-94-92671-16-5. https://uroweb.org/guidelines/urological- trauma/chapter/
urogenital- trauma- guidelines.
5. Morey AF, Broghammer JA, Hollowell CMP, McKibben MJ, Souter L. Urotrauma
guideline 2020: AUA guideline. J Urol. 2021;205(1):30–5. https://doi.org/10.1097/
JU.0000000000001408. Epub 2020 Oct 14. PMID: 33053308.
6. Lucky M, Brown G, Dorkin T, Pearcy R, Shabbir M, Shukla CJ, Rees RW, Summerton
DJ, Muneer A, BAUS Section of Andrology and Genitourethral Surgery (AGUS). British
Association of Urological Surgeons (BAUS) consensus document for the management of male
genital emergencies—testicular trauma. BJU Int. 2018;121(6):840–4. https://doi.org/10.1111/
bju.14163. Epub 2018 Apr 10. PMID: 29635819.
7. Morey AF, Metro MJ, Carney KJ, Miller KS, McAninch JW. Consensus on genitourinary trauma: external genitalia. BJU Int. 2004;94(4):507–15. https://doi.org/10.1111/
j.1464- 410X.2004.04993.x. PMID: 15329102.
References
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8. Grigorian A, Livingston JK, Schubl SD, Hasjim BJ, Mayers D, Kuncir E, Barrios C,
Joe V, Nahmias J. National analysis of testicular and scrotal trauma in the USA. Res Rep
Urol. 2018;10:51–6. https://doi.org/10.2147/RRU.S172848. PMID: 30128306; PMCID:
PMC6089605.
9. Buckley JC, McAninch JW. Diagnosis and management of testicular ruptures. Urol Clin
North Am. 2006;33(1):111–6, vii. https://doi.org/10.1016/j.ucl.2005.11.002. PMID:
16488285.
10. Pogorelić Z, Jurić I, Biočić M, Furlan D, Budimir D, Todorić J, Milunović KP.Management
of testicular rupture after blunt trauma in children. Pediatr Surg Int. 2011;27(8):885–9. https://
doi.org/10.1007/s00383- 011- 2873- 9. Epub 2011 Mar 9. PMID: 21387107.
11. Kapoor D, Leech J, Yap W.Use of tunica vaginalis patch graft for repair of traumatic testicular
rupture. Urology. 1992;40(4):374–5. https://doi.org/10.1016/0090- 4295(92)90394- c. PMID:
1413362.
12. Ferguson GG, Brandes SB.Gunshot wound injury of the testis: the use of tunica vaginalis
and polytetrauoroethylene grafts for reconstruction. J Urol. 2007;178(6):2462–5. https://doi.
org/10.1016/j.juro.2007.08.021. Epub 2007 Oct 15. PMID: 17937945.
13. Molokwu CN, Doull RI, Townell NH.A novel technique for repair of testicular rupture after
blunt trauma. Urology. 2010;76(4):1002–3. https://doi.org/10.1016/j.urology.2010.06.011.
PMID: 20932424.
14. Yokokawa S, Tabei T, Kobayashi K. Testicular rupture successfully treated with a tunica
vaginalis ap. IJU Case Rep. 2020;4(2):82–5. https://doi.org/10.1002/iju5.12246. PMID:
33718811; PMCID: PMC7924093.
15. Blok D, Flannigan M, Jones J.Testicular rupture following blunt scrotal trauma. Case Rep
Emerg Med. 2019;2019:7058728. https://doi.org/10.1155/2019/7058728. PMID: 31934468;
PMCID: PMC6942712.
16. Doan PN, Yip J, Wang H, Chia D, Kim LHC, Wang A.Case—Repair of extensive testicular
rupture: a unique use for biosynthetic grafts. Can Urol Assoc J. 2020;14(1):E42–4. https://doi.
org/10.5489/cuaj.6052. Epub 2019 Jun 17. PMID: 31670646; PMCID: PMC6955173
17. Marchalik D, Triest JA, Wright HC, Bandi G.Use of “off the shelf” extracellular matrix graft
materials for repair of testicular rupture: a novel technique. Urology. 2014;84(3):719–21.
https://doi.org/10.1016/j.urology.2014.05.026. PMID: 25168558.
18. Simhan J, Rothman J, Canter D, Reyes JM, Jaffe WI, Pontari MA, Doumanian LR, Mydlo
JH.Gunshot wounds to the scrotum: a large single-institutional 20-year experience. BJU Int.
2012;109(11):1704–7. https://doi.org/10.1111/j.1464- 410X.2011.10631.x. Epub 2011 Oct 12.
PMID: 21992688.
19. Phonsombat S, Master VA, McAninch JW.Penetrating external genital trauma: a 30-year single
institution experience. J Urol. 2008;180(1):192–5; discussion 195–6. https://doi.org/10.1016/j.
juro.2008.03.041. Epub 2008 May 21. PMID: 18499189.
20. Abidoğlu S, Karagözlü Akgül A. Close range gun shot injury bilateral ruptured testis
repair using tunica vaginalis ap. Indian J Surg. 2022;84:824–7. https://doi.org/10.1007/
s12262- 021- 03043- 2.
21. Goldman C, Shaw N, du Plessis D, Myers JB, van der Merwe A, Venkatesan K. Gunshot
wounds to the penis and scrotum: a narrative review of management in civilian and military
settings. Transl Androl Urol. 2021;10(6):2596–608. https://doi.org/10.21037/tau- 20- 1175.
PMID: 34295746; PMCID: PMC8261456.
22. Zavras N, Siatelis A, Misiakos E, Bagias G, Papachristos V, Machairas A.Testicular dislocation
after scrotal trauma: a case report and brief literature review. Urol Case Rep. 2014;2(3):101–4.
https://doi.org/10.1016/j.eucr.2014.02.004. PMID: 26955557; PMCID: PMC4733017.
23. Raykar R, Ratkal JM, Jadhav R, etal. Traumatic dislocation of testis into penis, what and how?
Case report and review of literature. Indian J Surg. 2019;81:175–7. https://doi.org/10.1007/
s12262- 018- 1846- 9.
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Treatment ofTesticular Trauma: II—
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Complex Interventions
47.1 Replantation ofanAmputated Testis
Many cases of testicular amputations occur as a consequence of self-mutilation, and
this aspect will be developed in a special section at the end of this book. Many others are reported following an assault, road trafc accident (RTA), or industrial accident. A shattered or badly crushed testis is generally nonviable and should be
discarded. However, when a sharp instrument (e.g., knife, scissors, razor, etc.) has
penetrated the upper scrotum and severed the spermatic cord, the testis can still be
viable if the patient presents within 4–6h. It should be mentioned that unilateral
injury exceptionally justies a fastidious microsurgical replantation taking into
account the very small diameters of involved vessels, the necessity for specialized
centers, and the uncertainty of success. But when dealing with a solitary testis or
bilateral testes amputation in a young patient victim of accident or assault, all local
and regional competencies should be solicited to optimize the future chances of the
unfortunate patient to live a normal marital life and prevent psychological drama.
Evins etal. reported the rst attempt to replant testes in 1977in a paranoic patient
who had self-emasculated. They lleted and positioned them into bilateral subcutaneous thigh pockets. However, subsequent follow-up with biopsy showed nonfunctional gonadal tissues [1]. Nonetheless, the idea of locating a testis into a thigh
pocket is meaningful when the testis has kept its pedicle, i.e., an intact spermatic
cord and vessels. Indeed, this technique is frequently performed after creating a tunnel from the inguinal area and is indicated when there is a traumatic avulsion of the
scrotum or after debridement of an extensive Fournier’s gangrene [2–4].
The rst successful testicular microvascular replantation was reported by
Rodríguez Costa etal. from Spain in 1978 on a 3-year-old boy [5]. Then a successful
microvascular testicular autotransplantation was reported by Giuliani etal. on two
patients with cryptorchidism in Genoa (Italy) in 1981 [6]. Shioshvili from Tbilisi
(Georgia, old Union Of Soviet Socialist Republics (USSR)) successfully performed
a microvascular testicular replantation in 1987 on a 19-year schizophrenic patient
47
© The Author(s), under exclusive license to Springer Nature Singapore Pte
Ltd. 2023
S. A. AL-Mamari, Urogenital Trauma: A Practical Guide,
https://doi.org/10.1007/978-981-99-6171-9_47
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47 Treatment ofTesticular Trauma: II—Complex Interventions
who self-amputated the right testis [7]. And just a year later, Xu etal. reported a similar technique showing normal follicle-stimulating hormone levels, normal seminiferous tubules, germ cells, and Leydig cells on biopsy at 4months [8]. Since then, a
handful of encouraging cases have been reported in the literature [9, 10].
A very recent review published in 2022 has listed a total of 13 cases of testis
replantation in the English literature, most of them being subsequent to selfmutilation in psychiatric patients [11]. In one situation, testis replantation was the
ultimate and forced solution to correct a horrible medical error consisting of a
wrong side orchidectomy for a right testicular tumor in a 25-year-old man. After
noticing the error, the tumor-bearing (right) testis was also totally removed as a
partial approach was not an option and the left testis was salvaged with microsurgical replantation after an urgent referral to a specialized center [11].
Technique ofTesticular Reimplantation
The amputated testis must be kept in moist gaze, covered with ice, and thoroughly
washed and debrided on arrival. The intervention is performed under general anesthesia. The vessels are ushed with diluted heparin and anastomosed directly to the
corresponding proximal vessels in an end-to-end fashion using 10/0 Prolene on the
artery and the veins with interrupted sutures. Obviously, this procedure requires an
operating microscope taking into account the very small diameter of the vessels,
artery 1mm, and vein 2–3mm. The vas deferens is also ushed with diluted heparin
and anastomosed in an end-to-end fashion using interrupted 7/0 Prolene [9].
If, for any reason, the proximal cord vessels cannot be utilized, being too small,
damaged by a crushing injury, or retracted, branches of the femoral vessels can be
used and the supercial inferior epigastric artery and vein offer a solution for revascularizing the severed testis [11, 12].
When the amputated testis is intact but does not have sufcient pedicle length to
be replanted orthotopically or when the perineum was also seriously damaged by a
dramatically mutilating trauma, it has been proposed to temporarily implant the
healthy gonad in an ectopic site (e.g., the non-dominant forearm) where it will
continue its endocrine function. Here, the testis vessels can be anastomosed to the
radial artery and to one of its venae comitantes just proximal to the wrist. Later on,
after stabilization of the hormonal function, which takes several months, the testis is
harvested from its temporary site along with the underlying skin and a good length
of the vessels (radial artery and one vena comitans) and replanted into the perineum
with vascular anastomosis to the deep inferior epigastric vessels and end-to-end
possible anastomosis of the proximal and distal vas deferens [13] (Figs.47.1 and
47.2). It is important to remember that the viability of the forearm will hence-
forth rely on the integrity of the ulnar artery and the Allen test is necessary to
assess the patency of the palmar arch before this procedure.
In view of the uncertainty of the results in testicular replantation, it is advisable
to take a sample of seminiferous tubules and proceed to testicular sperm extraction
(TESE) for cryopreservation before the surgery [10]. Indeed, sperm
47.1 Replantation of an Amputated Testis
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Fig. 47.1 Replanted testis
in its ectopic position.
(From Ramdas etal. [13],
with permission from
Elsevier)
Fig. 47.2 Refabricated
testicular pedicle prior to
transfer. (From Ramdas
etal. [13], with permission
from Elsevier)
401
cryopreservation from an ejaculate is recommended in all other fertility-threatening
conditions such as a testicular tumor, severe infection, surgery, or gonadotoxic therapy (e.g., chemotherapy and radiation therapy). However, TESE and sperm cryo-
preservation are possible only in post-puberty and adult boys. They are useless
in pre-pubertal boys, who have only spermatogonial stem cells (SSCs) and not
mature spermatozoa. Ongoing research is aiming at the cryopreservation of tes-
ticular tissues (rather than sperms alone) to allow a chance for the spermatogonial
stem cells (SSCs) to mature and produce sperms through the new concept of “in-
vitro spermatogenesis” [14, 15].
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