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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_32_библиотеки_им_акад_М_И_Перельмана
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252 Testis, Hydrocoele and Varicocoele
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Figure 18.12 Grade III varicocoele. Visibly dis-
tended cremasteric veins (‘bag of worms’).
●
ʻ20/38 harbingerʼ – combination of dierence
in testicular volume of > 20% and peak retro-
grade ow on Doppler ultrasound.
Of these, impaired testicular growth and signicant dierential in testicular volumes are indications for possible intervention which are also
applicable to boys and adolescents. However,
semen quality and infertility are far less relevant – particularly in younger adolescents with
asymptomatic varicoceles. In these patients the
issues surrounding ‘prophylactic’ treatment
remain controversial. e arguments in favour
of surgical intervention in adolescents can be
summarised as follows:
●
Persistence of an untreated varicocoele into
adult life leads to a demonstrable reduction in
testicular volume and there is evidence that
surgical correction may partly reverse this
process, leading to some degree of subsequent
‘catch-up growth’.
●
e incidence of varicocoele among men
investigated for infertility is higher than in
the male population at large.
●
Some studies have found an improvement in
semen quality and pregnancy rates follow-
ing treatment of varicocoele in subfertile
men.
a Valsalva manoeuvre. In addition to clinical
examination a scrotal ultrasound scan should be
performed assess the varicocoele and measure
testicular volume. is should be combined with
an abdominal scan to exclude a renal tumour.
Indications for Treatment
e criteria which warrant consideration of surgical intervention in adults include.
●
Persistently abnormal semen quality
●
Altered sperm function tests
●
Infertility
●
Pain or signicant discomfort
●
Dierences in testicular volume between the
two testes exceeding 15–20%
●
Peak retrograde ow on Doppler ultrasound
>38 cm /s
Arguments against prophylactic surgical intervention in adolescents are:
●
Varicocoeles exist in some 15% of adult males,
most of whom, as judged by paternity, have
normal fertility.
●
Although a link exists between varicocoele
and infertility or subfertility there is no
consistent correlation between the presence
or size of the lesion and semen quality or
ferti lit y.
Opinion remains divided but the present tendency is to advise ‘prophylactic’ intervention for
larger, grade III lesions, particularly if there is testicular asymmetry with a discrepancy in testicular volume of >20%. From the mid teens onwards
the decision on whether to proceed to surgical
correction of grade III varicoceles can also be
guided by semen analysis.
Varicocoele / Treatment Options 253
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Treatment Options (Figure 18.13)
Embolisation
Embolisation may be carried out under sedation,
although a general anaesthetic is usually used in
prepubertal boys. A catheter introduced via the
right femoral or internal jugular vein is screened
into the le renal vein and thence into the spermatic vein. Venography is performed to identify
collaterals. Embolisation is undertaken using
coils inserted into the testicular vein or, less oen,
by the injection of a sclerosant.
Surgical ligation
Using the inguinal approach (Ivanissevich), the
internal inguinal ring is exposed via the inguinal
canal; the spermatic veins are exposed deep to the
transversalis fascia and divided at this level.
In the high approach (Palomo), a short transverse incision is performed lateral to the internal
inguinal ring. e testicular vessels are identied
extraperitoneally above the point they diverge
from the vas deferens. In Palomo’s original
description, the testicular artery, vein and lymphatics are all ligated and divided together but
many surgeons ligate only the veins.
Microvascular ligation of the veins can be
performed beyond the external inguinal ring or
within it. Magnication is employed and intraoperative ultrasound may be helpful in identifying
and preserving the arteries. Care is taken to preserve the testicular and cremasteric arteries, the
vas deferens and its artery. e lymphatics should
also be preserved as this is believed to minimise
the incidence of postoperative hydrocoele.
With laparoscopic ligation, three ports are
placed and the testicular vessels identied. e
veins can either be dissected and divided alone or
clipped and ligated en bloc, along with the artery as in the Palomo technique. is approach also
allows easy identication and division of any
abnormal veins and is also especially applicable
to the rare case of bilateral varicocoele. As with
open techniques, lymphatic vessels should be preserved as far as possible in order to reduce the risk
of postoperative hydrocele. is can be facilitated
by injecting methylene blue into the scrotum preoperatively to demonstrate the lymphatics more
clearly at operation.
Figure 18.13 Varicocoele treatment options.
(1) Surgical ligation of individual veins, ingui-
nal approach. (2) Surgical ligation of veins and
artery, high approach. (3) Laparoscopic clipping, all vessels or selective ‘artery sparing’.
(4) Embolisation.
Complications and Outcome
e fact that several surgical techniques continue
to be employed for treating varicocoeles indicates
that no single technique gives consistently satisfactory results. High success rates have been claimed
for laparoscopic ligation and the Paloma technique (100% and 93%, respectively). Recent data
254 Testis, Hydrocoele and Varicocoele
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in adults suggest that the best surgical results are
typically obtained with the inguinal or subinguinal microscopic techniques – with low recurrence
rates (2%) and low incidence of hydrocele formation (0.75%). However, these results in adults have
not yet been replicated in the paediatric age group.
Improvement in fertility has been reported
in subfertile men following varicocoele ligation,
although subfertile men represent only a minority of all men with varicocoeles. Whether prophylactic treatment of asymptomatic varicocoeles in
adolescents is benecial for fertility has yet to be
ascertained.
KEY POINTS
●
e optimal age for orchidopexy
remains uncertain. Paediatric urologists and paediatric surgeons favour the
rst year of life any time aer 6 months
ofage.
●
e risk of testicular atrophy should
be specically discussed with parents when obtaining consent for
orchidopexy.
●
Laparoscopy is the investigation of
choice for impalpable testes.
●
In infants a clear diagnostic distinction must be made between an inguinal
hernia (which requires prompt surgical intervention in this age group) and
a communicating hydrocoele (which
generally resolves as a result of spontaneous closure of the patent processus
vaginalis within the rst 2 years of life).
●
e available evidence suggests that
treatment of varicocoeles in adolescence
should be limited to boys with grade III
varicocoeles, symptoms and/or evidence of impaired testicular growth.
FURTHER READING
Balawender K, Orkisz S, Wisz P. Testicular
microlithiasis: what urologists should know.
A review of the current literature. Cent
European J Urol. 2018;71(3):310 –314.
Esposito C, Escolino M, Turrà F, et al. Current
concepts in the management of inguinal
hernia and hydrocele in paediatric patients
in laparoscopic era. Semin Pediatr Surg.
2016;25(4):232–240.
Macey MR, Owen RC, Ross SS, Coward RM.
Best practice in the diagnosis and treatment
of varicocele in children and adolescents.
Ther Adv Urol. 2018;10(9):273–282.
Niedzielski JK, Oszukowska E, Słowikowska-
Hilczer J. Undescended testis – current
trends and guidelines: a review of the literature. Arch Med Sci. 2016;12(3):667– 677.
Hutson JM. Journal of paediatric surgery-
sponsored Fred McLoed lecture.
Undescended testis: the underlying mechanisms and the effects on germ cells that
cause infertility and cancer. J Pediatr Surg.
2013;48(5):903–908.
The Acute Scrotum
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DAVID F M THOMAS
Topics covered
19
Overview of clinical aspects and investigation
Torsion of the testis
Torsion of testicular appendage
OVERVIEW OF CLINICAL
ASPECTS
Acute scrotal pathology constitutes one of the
few real emergencies in paediatric urology
because of the risk to the testis posed by testicular torsion.
Testicular torsion accounts for 80–90% of
cases of acute scrotal symptoms in pubertal boys
and adolescents. Urgent surgical exploration is
mandatory unless there is compelling evidence of
an alternative diagnosis. e dierential diagnosis is more varied in prepubertal boys. Although
torsion of a testicular appendage (hydatid of
Morgagni) is the commonest diagnosis in this
age range testicular torsion nevertheless accounts
for approximately one-third of cases. Other
causes of acute scrotal symptoms in prepubertal boys include; epididymo-orchitis, idiopathic
scrotal oedema, acute hydrocoele and Henoch–
Schonlein vasculitis (Figure 19.1).
Epididymo-orchitis
Idiopathic scrotal oedema
Other acute scrotal pathology
INVESTIGATION
e denitive “investigation” in children and
adolescents presenting with acute scrotal symptoms is urgent surgical exploration. A negative
exploration is preferable to the loss of a potentially viable testis because of the failure to explore
the scrotum.
e role of diagnostic imaging, notably colour
Doppler ultrasonography, is largely conned to prepubertal boys in whom testicular torsion has been
eectively excluded on clinical grounds. Doppler
ultrasonography provides information on blood
ow in addition to real-time anatomical imaging of
the scrotal contents (Figure 19.2). Drawbacks include
operator dependency, limited out-of-hours availability, false negative or false positive results and additional delay in restoring blood supply to the testis in
cases of torsion.
Radionuclide testicular scanning (RTS) is now of
largely historical interest.
255
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Figure 19.1 The relative
frequency of different causes
of acute scrotal pathology at
different ages in childhood and
early adult life. (From BenChaim J, Leibovitch I, Ramon J,
et al. Etiology of acute scrotum
at surgical exploration in children, adolescents and adults.
Eur Urol. 1992;21:45–47.)
TESTICULAR TORSION
occur into late adulthood. Sporting activity and
trauma may be implicated as precipitating fac-
e reported incidence is around 1:3,000–1:4,000
with the estimated incidence of neonatal torsion
being 1:17,000. Testicular torsion occurs most
frequently between the ages of 14 and 16 but can
Figure 19.2 Scrotal ultrasound. Colour Doppler signals denote blood ow in the tissues surrounding
the testis but absence of perfusion (ischemia) in the testis itself.
tors but most cases occur without any obvious
reason and, indeed, torsion can occur during
sleep. Torsion in maldescended testes accounts
for 2–5% of cases.
Testicular torsion / Pathophysiology 257
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Aetiology
In the majority of cases, the testis twists within
its coverings in the scrotum (Figure 19.3). is
is described as intravaginal torsion – as opposed
to extravaginal torsion in which the testis and its
coverings twist in their entirety. e extravaginal
form is virtually conned to neonatal torsion.
Intravaginal torsion is conventionally attributed
to a predisposing abnormality (“bell-clapper
testis”) in which the testis is suspended within
the tunica by an abnormally long leash of spermatic vessels. However, autopsy studies suggest
that “bell clapper testis” simply represents one
end of the normal anatomical spectrum, rather
than being a distinct entity.
Pathophysiology
In experimentally induced torsion in animal
models, 720° torsion consistently leads to complete cessation of blood ow to and from the
testis. is is rapidly followed by the onset of
irreversible ischaemic damage to the seminiferous tissue. e correlation between duration
of torsion and the timescale of ischaemic damage in experimentally induced 360° torsion is
less precise. e majority of published clinical
studies are retrospective and are of poor scientic quality. In particular, assessment of potential viability of the testis is oen based solely on
the subjective judgement of the surgeon (oen a
relatively junior surgeon) at the time of surgery.
Without the inclusion of longer term follow-up
data, the “viability” or “salvage” rates reported
in such studies are largely meaningless. Where
clinical and ultrasound follow-up studies have
been undertaken these have consistently found
that a high proportion of testes which had been
judged to be potentially viable at the time of surgery nevertheless underwent total (or severe partial) atrophy.
e weight of published evidence indicates
that the best prospect of conserving a viable testis
of normal size lies in restoring its blood supply
within 4–6 hours. Complete or partial atrophy
Figure 19.3 (a) Intravaginal torsion. “Bell-clapper” testis suspended on an abnormally long leash
of vessels (mesorchium) within the tunica vaginalis. (b) Undue mobility of the testis predisposes to
torsion around the axis of the spermatic cord.
258 The Acute Scrotum
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is virtually inevitable if the blood supply is not
restored within 6–8 hours and atrophy is the rule
aer 8–10 hours. e “6-hour rule” cited in the
context of litigation is broadly supported by the
scientic evidence.
Presentation
Testicular torsion is characterised by an acute
onset of unilateral scrotal pain and swelling
which is accompanied by vomiting in around
40% of cases. However, the clinical presentation
can be variable and the “full house” of classic
features is probably present in less than 50%
of cases. Testicular torsion is oen accompanied by referred pain in the groin and/or lower
abdominal quadrant which may be perceived as
being more severe than the pain arising in the
testis itself. In such cases there is a risk of right
sided torsion being misdiagnosed as appendicitis and le sided torsion being misdiagnosed as
gastroenteritis. Testicular torsion in infants and
small children is oen relatively painless in the
early stages – only coming to light when obvious scrotal swelling and discolouration become
apparent (Figure 19.4). Clinical examination
may reveal that the aected testis is located in
an elevated position within the scrotum as a
consequence of contraction of the cremasteric
muscle. e testis is usually acutely tender on
direct palpation – although this is not always
the case in prepubertal boys.
When the torsion has been established for a
few hours, oedema and inammatory changes
develop in the overlying scrotal tissues. e features of a more advanced torsion may be misinterpreted as epididymo orchitis – which is a much
rarer condition in this age group.
Management
Urgent surgical exploration is the keystone of
management. To avoid unnecessary delay (and
increased risk to the potential viability of the testis) urgent surgical exploration should usually
be performed in the hospital where the child or
young person rst presents. e Royal College
Figure 19.4 (a) Deceptively painless pre-
sentation of testicular torsion in an infant
with a 3-day history of minimal symptoms.
Discolouration of the scrotum prompted his
parents to seek medical advice. (b) Prompt
surgical exploration nevertheless revealed a
necrotic testis.
Testicular torsion / Technical Aspects of Fixation 259
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of Surgeons of England states that “Transfer of a
boy with a suspicion of torsion from a secondary
institution to a tertiary care centre should be an
exceptional occurrence (e.g. medical comorbidities”.) Following exposure of the testis via a scro-
tal incision, the spermatic cord is untwisted and
testicular viability assessed. Factors inuencing
the decision to conserve or remove the testis
include the duration of the history, the appearance of the testis and arterial bleeding on incising the tunica albuginea (Fig ure 19.5). Unless
the testis is clearly viable it is preferable to err
in favour of orchidectomy. If the history is short
and the testis is judged to be viable it should be
xed to prevent recurrent torsion. Regardless of
the procedure on the aected side, prophylactic
xation of the contralateral testis should always
be performed because of the bilateral nature of
the predisposing anatomy.
Technical Aspects of Fixation
is is probably best achieved by inserting three
non-absorbable sutures (e.g. 4/0 prolene) between
the scrotal wall and tunica albuginea of the upper
and lower poles and mid zone of the testis. Concerns
that puncture of the tunica albuginea by xation
sutures might provoke the production of anti-sperm
antibodies have been shown to be unfounded.
No xation technique oers a total guarantee
against further torsion, but three point xation
with a non-absorbable suture material is widely
regarded as being the most reliable.
Figure 19.5 (a) Characteristic appearances of early torsion (3-hour history). The right testis is
tender, mildly swollen, and lies in an elevated position within the scrotum. (b) This testis was judged
to be viable in view of the short history and operative ndings indicating good return of perfusion
following detorsion.
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Prognosis
Fertility
Men with a history of testicular torsion in adolescence or early adulthood are at increased risk of
impaired semen quality. e percentage of men
whose semen quality is reduced varies considerably between dierent studies but is typically
in the range 20–50%. Most studies do not differentiate between men in whom the testis was
removed and those in whom it was conserved. A
number of possible mechanisms have been suggested to account for the reduction in sperm density (sperm count) but the simplest explanation is
the quantitative reduction in seminiferous tissue
arising from the loss of one testis.
By contrast to the literature on semen quality, there is surprisingly little published evidence
on paternity (the actual ability to father children) in men with a previous history of torsion.
However, two recent studies have reported that
their paternity rates are no dierent to those in
normal age matched controls. In addition, these
studies found no dierence in the time taken to
achieve conception and no dierence in paternity
between those men who had undergone detorsion
and preservation of the testis and those in whom
the testis had been removed. One of these studies
also looked at quality of life and sexual function
and found no dierences in self-reported parameters between men with a history of torsion and
age matched controls.
Endocrine function: Published studies have
consistently reported that plasma testosterone levels are within the normal range in men with a history of torsion – regardless of whether the aected
testis was conserved or removed. Levels of gonadotrophin hormones- (Follicle Stimulating Hormone
(FSH) and Luteinizing Hormone (LH) are also
unaected – although levels of Inhibin B (a marker
of Sertoli cell function) are sometimes reduced.
Testicular prosthesis: e elective implantation of a testicular prosthesis should be oered
to young patients who have previously undergone orchidectomy or in whom the testis has
undergone severe atrophy. e decision should be
deferred until the mid-teens (or later) to ensure
that the patient is competent to make a fully
informed decision and to enable the surgeon to
implant an adult-sized prosthesis of comparable
size to the contralateral testis (Figure 19.6).
Figure 19.6 (a) Silicone gel testicular prosthesis.
This is inserted via an inguinal incision and
positioned in the most dependent part of the
scrotum by inverting the scrotum and placing
an anchoring suture in the reinforced disc at the
lower pole of the prosthesis. (b) Postoperative
appearances.
Neonatal torsion / Presentation 261
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RECURRENT TESTICULAR PAIN
e possible risk of impending torsion should
always be considered in any boy who is referred
with a history of unexplained symptoms of
intermittent testicular discomfort or swelling.
In practice it is very dicult to assess whether
such a history is genuinely indicative of episodes
of mild, self-limiting torsion or, alternatively,
unrelated symptoms of testicular discomfort,
which are not uncommon in this age group.
e parents and (depending on his age) the boy
himself should be counselled appropriately and
oered prophylactic xation. If they decline this
course of action they should nevertheless be
strongly advised of the importance of attending the nearest emergency department without
delay in the event of a sudden onset of more
severe testicular pain.
PREPUBERTAL TORSION
Although testicular torsion is a less frequent
cause of acute scrotal symptoms in this age group
it nevertheless accounts for around one-third of
cases of acute scrotal pathology. e presentation is less distinctive than in older boys and
adolescents. e torsion may be relatively (or
completely) painless in the early stages and the
parents may be unaware of its occurrence until
scrotal swelling, erythema and discolouration
have supervened. For this reason the opportunities to operate in time to conserve a viable testis
are far more limited in this age group.
NEONATAL TORSION
With very rare exceptions, testicular torsion
which is diagnosed in the rst few days aer birth
has occurred during intrauterine life rather than
the early neonatal period. Indeed, cases of intrauterine testicular torsion have been documented
on prenatal ultrasound. “Neonatal” torsion is usually of the extra vaginal rather than intravaginal
pattern.
Presentation
Clinical examination typically reveals marked
scrotal discolouration and a hard, indurated
testis. On ultrasonography the testis and epididymis are enlarged and surrounded by
haemorrhagic uid and oedema of the scrotal
tissues. Perfusion is absent on colour Doppler
ultrasonography.
Unsurprisingly, the prospects of salvaging a
viable testis in these circumstances are eectively
zero.
Historically “neonatal” torsion was managed
by urgent surgical exploration and xation of
the contralateral testis. In the 1990s, however, a
more conservative approach was adopted, which
was based on the use of ultrasound to conrm the
diagnosis and then monitor the subsequent involution and atrophy of the testis.
However, the rationale for the conservative
approach is now being questioned by a growing number of case reports of bilateral synchronous and asynchronous “neonatal” torsion. is
appears to occur more frequently than would be
expected by chance – indicating that extra vaginal torsion may be associated with higher risk of
torsion in the contralateral testis than was previously believed. In addition, there are rare case
reports of torsion which appears to have genuinely occurred in the neonatal period. Opinion
remains divided: whilst some paediatric urologists continue to favour conservative management of neonatal torsion others favour surgical
exploration and prophylactic xation of the contralateral testis.
No studies have been reported which have
looked specically at long-term outcomes in men
with a history of unilateral “neonatal” torsion.
However, it can be reasonably assumed that their
endocrine function is normal and despite some
possible reduction in semen quality (notably
sperm density) their overall prospects of achieving paternity are likely to be normal or only marginally reduced.
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