Blackwell Science, LtdOxford, UKBJUBJU International1464-410XBJU InternationalMay 2005 957 Point of Tech INSERTING TESTICULAR PROSTHESES LAWRENTSCHUK and WEBB
Inserting testicular prostheses: a new surgical technique for difficult cases NATHAN LAWRENTSCHUK and DAVID R. WEBB Surgery and Urology, University of Melbourne, Austin Hospital, Heidelberg, Victoria, Australia Accepted for publication 21 November 2004
INDICATIONS Testicular prostheses are inserted for cosmetic reasons, e.g. after inguinal orchidectomy for testicular cancer, or scrotal orchidectomy for benign conditions (torsion, trauma, infarction), previous failed insertion of a prosthesis, and in congenital conditions such as Klinefelter syndrome, where the testes are small and the scrotum poorly developed.
contracted and often fibrotic scrotum, or the thickened capsule that surrounded a preexisting prosthesis, using a tissue expander that causes minimal trauma, whilst keeping the scrotal neck intact. This allows the prosthesis to reside in a physiological position and prevents proximal migration of the prosthesis in cooler weather.
METHOD When placed at the time of inguinal orchidectomy the positioning of the prosthesis is not an issue, as it falls naturally in the position of the removed testicle, or it may be sutured to the gubernacular remnant and drawn down with the prosthesis. However, if there is a delay after inguinal orchidectomy or other scrotal surgery, then significant scarring and contraction of the scrotum hinders placing the prosthesis. In rarer cases of congenital absence or poor development of normal testes, the scrotum is naturally contracted, never having been stretched. It is in these difficult situations where anatomical placement is crucial to cosmesis. A common complication of inserting a testicular prosthesis is failure to adequately distend the scrotum, with secondary displacement of the prosthesis to a higher position in the scrotum or inguinal canal, where it is unsightly and may be uncomfortable [1]. Not surprisingly, when surveyed, about a quarter of men (27%) were unhappy with the position of their prosthesis [2]. In the difficult situations outlined, the challenge is to dilate the
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We were presented with a challenging group of patients who had had previous inguinoscrotal surgery or congenital abnormalities. In the past 5 years we treated 10 such patients (median age 30 years), placing 12 prostheses (Table 1). Patients with Klinefelter syndrome present not only with a poorly developed scrotum, but also small testes that must be protected from injury during surgery. A further two patients in the series had had previous orchidectomy and then implantation with high-riding prostheses enveloped in fibrous pseudocapsules. A further patient had two orchidopexies before a prosthesis was inserted. The remaining five patients had one inguinoscrotal operation before requesting a prosthesis. SURGICAL TECHNIQUE The patient is prepared and draped while supine, with the scrotum exposed and prophylactic antibiotics administered. An incision is made in the groin through the old orchidectomy incision if present and a self1111
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retaining retractor inserted. The external oblique is then exposed and incised, identifying the neck and previous tunnel to the scrotum that usually commences at the external ring, or the spermatic cord if this is still present. A finger identifies the scrotal neck, beginning the entry tunnel into the scrotum (Fig. 1). A pair of standard Rampley sponge-holding forceps (Fig. 2) are then gently advanced through the identified neck or passed alongside the cord, into the scrotum. The fulcrum of the forceps is positioned to align with the scrotal neck so the neck is not stretched (Fig. 3a). The dense adhesions or existing prosthesis capsule are divided and fractured, by opening and closing the forceps in a gentle spreading motion that may be directed to all parts of the scrotum (Fig. 3b). The length of the forceps enables adhesions to be broken all the way to the most dependent region of the hemiscrotum. When closed, the forceps tips approximate the position of the prosthesis, indicating if further dissection is necessary. An anatomical pouch has now been created about which a pseudocapsule will eventually develop as healing occurs. The wound is then irrigated with iodine-based antiseptic. After a glove replacement, the chosen prosthesis is placed into the scrotum where, if necessary, it is gently ‘milked down’ from the outside of the scrotal skin, to confirm satisfactory placement in the pouch created. The wound is closed in layers. If prostheses are sutured, narrow tissue forceps may be used to invert the scrotal skin into the inguinal canal, then a suture is placed in the scrotum and tied to the prosthesis before placement. After surgery the patients are encouraged to ‘milk down’ the prosthesis to maintain it in the pouch region until healed and a peri-prosthetic fibrous pseudo-capsule has developed.
COMPARISON WITH OTHER METHODS All 10 patients in the series have had satisfactory cosmetic results from the present surgical technique. In particular, the prosthesis inserted whilst leaving the congenitally small testes in situ in the patients with Klinefelter syndrome was successful, and has not been previously described. There were no wound infections or prosthetic extrusions. 111 2
TABLE 1 Previous diagnoses and surgery before inserting an inguinal testicular prosthesis Patient category Klinefelter syndrome Testicular cancer
Torsion Prosthesis malpositioned (high-riding)
Previous surgery None, but congenital poorly developed scrotum and hypogonadism Inguinal orchidectomy Scrotal orchidectomy Inguinal orchidopexy (undescended testis) Scrotal orchidectomy Scrotal orchidopexy (twice on same side) Scrotal orchidectomy (torsion) later transcrotal prosthesis Scrotal orchidectomy (torsion) later inguinal prosthesis
N, age (years) 2, 29, 29
N prostheses 4*
2, 36, 30 1, 40 1, 30
2 1 1
1, 22 1, 19 1, 51
1 1 1
1, 34
1
*Bilateral surgery for both patients with their small testes left in situ.
FIG. 1. A high-riding right testicle (A) after orchidopexy, that subsequently developed cancer. The patient had a previous left orchidectomy for cancer. A finger identifies the scrotal neck, beginning the entry tunnel into the scrotum before inserting forceps (B), but the limitation of the finger as a dissector is apparent. A
Bruising in the scrotum after surgery is reported by all patients with this technique, but there were no haematomas requiring drainage. All patients were followed extensively (mean 2.2 years) with satisfaction surveys. Most importantly, there have been no high-riding prostheses or requests for replacement. Several approaches to inserting a difficult testicular prosthesis have been proposed, including, in children, the use of tissue expanders that are serially dilated and involve multiple anaesthetics [3], whilst scrotal approaches [4,5] have essentially been
B
abandoned because of extrusion of the implants [1]. Originally we used an index finger to dilate the scrotum; invariably, the tunnel created by the finger was too short (Fig. 1b), the scrotal neck was stretched, and without counter-traction an anatomical pouch in the scrotum was not created. Also, previous fibrous prosthetic pseudo-capsules could not be expanded. Other techniques attempting to allow correct positioning of the testicular prosthesis have been described, e.g. the use of a vaginal speculum [6], Hegar dilator [7], and a Foley catheter [8]. The aim of using such devices is to dilate the scrotal space to allow positioning of the prosthesis.
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INSERTING TESTICULAR PROSTHESES
FIG. 2. Rampley’s sponge-holding forceps (24 cm long) with rounded tips (A). The forceps have a wide arc of action (B) but the fulcrum is fixed at 1–2 cm (C), allowing expansion of the scrotum without stretching the scrotal neck. A
B
forceps are long enough for this dissection, but the balloon being set back from the catheter tip limits the depth to which it may be placed. The balloon also tends to ride back toward the scrotal neck during dilatation, further limiting the inferior expansion of the scrotum. Also, because the Foley catheter is not rigid, dense capsular and surgical adhesions dictate the catheter position, whereas sponge-holding forceps are easily controlled and directed to the desired site. Forceps achieve accurate spreading and dissection, enabling a true subcutaneous pouch by expanding the dartos muscle.
C
DIFFICULTIES AND COMPLICATIONS As outlined, the only real disadvantage of this technique is minor bruising immediately after surgery, caused by stretching the scrotal pouch and dividing adhesions. There were no instances of having to drain a haematoma or wound infection, which are both theoretically possible with any technique of insertion.
FIG. 3. The sponge-holding forceps with the fulcrum positioned to align with the scrotal neck, so the neck is not stretched (A). The forceps may be opened and directed to all parts of the scrotum, ensuring adequate dissection (B). A
B
We think that creating a pouch of adequate size and site in the scrotum, with the subsequent development of a pseudocapsule, is the key determinant of the position of a testicular prosthesis, as it is with breast implants [9], and not suture fixation of the implant to the base of the scrotum, as stated elsewhere [2]. Although there may still be a place for suturing prostheses, we have abandoned suturing as we have found it unnecessary. The present technique is cheap and simple, requiring no new or unusual instruments or devices. It has been used for 5 years in all of the difficult situations outlined above. We have found it to be quick and easy to master, giving excellent cosmetic results. CONFLICT OF INTEREST None declared. REFERENCES 1
ADVANTAGES AND DISADVANTAGES The present technique has advantages over using a speculum or dilator, in that overstretching of the scrotal neck, allowing prosthesis migration, is not an issue (Fig. 2). Furthermore, the round tips of the spongeholding forceps approximate a testicle in size,
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and unlike the other instruments, depict from outside the scrotum the exact site where the implant will reside. The advantage of forceps over using a balloon catheter as a tissue expander is that the last ª 2 cm of dissection, critical to the position of the prosthesis, is reached. Sponge-holding
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Marshall S. Potential problems with testicular prostheses. Urology 1986; 28: 388–90 Adshead J, Khoubehi B, Wood J, Rustin G. Testicular implants and patient satisfaction: a questionnairebased study of men after orchidectomy for testicular cancer. BJU Int 2001; 88: 559–62 111 3
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Lattimer JK, Stalnecker MC. Tissue expansion of underdeveloped scrotum to accommodate large testicular prosthesis. A technique. Urology 1989; 33: 6–9 Solomon AA. Testicular prosthesis: a new insertion operation. J Urol 1972; 108: 436–8 Abbassian A. A new surgical technique for testicular implantation. J Urol 1972; 107: 618
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Zaontz MR, Ritchie EL, Maizels M, Firlit CF. Insertion of testicular prosthesis: use of vaginal speculum. Urology 1990; 35: 130–2 Elkabir JJ, Smith GL, Dinneen MD. Testicular prosthesis placement: a new technique. BJU Int 1999; 84: 867–8 Simms MS, Huq S, Mellon JK. Testicular prostheses: a new technique for insertion. BJU Int 2004; 93: 179
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McArthur PA, Green AR, Hancock K. Histological examination of the capsules surrounding Trilucent breast implants. Br J Plast Surg 2001; 54: 684–6
Correspondence: Nathan Lawrentschuk, University of Melbourne Surgery and Urology, Austin Hospital, Heidelberg, Victoria Australia. e-mail:
[email protected]
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