Hasan Rıza AYDIN, ŞENOL ADANUR, YILMAZ AKSOY

Başarısız primer orşiopeksiden sonra inguinal reoperasyon: İnternal oblik kas inzsizyonu yoluyla yaklaşım

Amaç: Geçmişte orşiopeksiye maruz kalmış ancak testis pozisyonu tatmin edici olmayan inmemiş testisli olgularda, uyguladığımız inguinal reoperasyon deneyimlerimizi ve uzun dönem sonuçlarını sunmayı amaçladık. Gereç ve Yöntem: Ocak 2000- Mayıs 2014 tarihleri arasında 29 anormal testis pozisyonlu(1 bilateral) 28 hasta değerlendirildi. Bütün hastaların geçmişte inguinal cerrahi hikayesi mevcuttu. Uzun dönem takipte prepubertal hastalarda sadece klinik muayene yapılırken postpubertal hastalara, semen analizi ve testiküler volüm muayenesi de yapıldı. Bulgular: Reoperasyon uygulanan 28 hastanın reoperasyon zamanında ortalama yaşları 12±5.7 yıl (2-27) idi. Toplam 18 hastada 19 testise başarılı reorşiopeksi uygulandı. Reorşiopeksi uygulanan 19 hastanın preoperatif testis lokalizasyonu sırasıyla internal inguinal ring, inguinal kanal, eksternal inguinal ring; 2,13,4 idi. 19 testisin 10’unda (%52.6) spermatik damarlar ve vas deferensin gergin olmayacak şekilde yeterli mobilizasyonunu sağlamak için internal oblik kas kesisi yapıldı. Reorşiopeksi esnasında vakaların 6’sında (%31.5) patent processus vajinalis, 3’ünde ise (%15.7) başarısız herni onarımı belirlendi. 10 testise ise atrofik testis veya spermatik kord kısalığından dolayı orşiektomi uygulandı. Reorşiopeksi yapılan 19 hastanın 11’i (%57.8) uzun dönem takip için başvurdu. Ortalama takip süresi 37.4±27.9 ay (4-95) idi. Tüm testisler atrofi olmaksızın skrotum içinde idi. Sonuç: Başarısız primer orşiopeksiden sonra inguinal reoperasyonlarda, deneyimli pediatrik cerrahlar tarafından uygun diseksiyonla internal abdominal kas kesisi yapılarak, daha iyi internal inguinal ring vizüalizasyonu sağlanıp, yeterli kord ve spermatik damar uzunluğu elde edilerek operasyonun başarı oranları anlamlı şekilde artırılabilir

Anahtar Kelimeler:

Kriptorşidizm, İnguinal kanal, Reoperasyon

Inguinal re-operation after an unsuccessful primary orchiopexy: Approach through internal oblique muscle incision

Objective: We aimed to present our experiences with inguinal re-operations and resulting long term outcomes in cryptorchidism cases who had previously underwent unsatisfactory orchiopexy procedures where proper testis position had not been achieved. Materials and Methods: Between January 2000 and May 2014, twenty eight patients with abnormal testis position (bilateral in one) were evaluated. All patients had a history of previous inguinal operation. Results: The mean age at re-operation time was 12±5.7 years(2-27). A successful orchiopexy was performed in 19 testes of 18 patients. Internal oblique muscle incision was performed in order to provide adequate mobilization so that the spermatic vessels and vas deferens would not be too tight in 10 of the 19 testes(52.6%). During re-orchiopexy, a patent processus vaginalis was deteced in 6 cases(31.5%) and unsuccessful hernia repair was detected in 3 cases (15.7%). Orchiectomy was performed for 10 testes either due to testicular atrophy or the presence of a short spermatic cord. Conclusion: İn inguinal re-operatıon after an unsuccessful primary orchiopexy, the success rate of surgery may be improved in the hands of experienced pediatric surgeons where better visualisation of the internal inguinal ring is achieved with internal abdominal muscle incision which provides a proper dissection and a sufficient lenght of cord and spermatic vessel.

Keywords:

Cryptorchidism, İnguinal canal, Reoperation,

PDF

___

1. Smolko MJ, Kaplan GW, Brock WA. Location and fate of the nonpalpable testis in children. J Urol 1983;129:1204-6.
2. Docimo SG. The results of surgical therapy for cryptorchidism: a literature review and analysis. J Urol 1995; 154:1148-52.
3. Cartwright PC, Velagapudi S, Snyder III HM, Keating MA. A surgical approach to reoperative orchiopexy. J Urol 1993; 149:817-8.
4. Dudley AG, Sweeney DD, Docimo SG. Orchiopexy after prior inguinal surgery: a distal approach. J Urol 2011; 185:2340-3.
5. Leung MW, Chao NS, Wong BP, Chung KW, Kwok WK, Liu KK. Laparoscopic mobilization of testicular vessels: an adjunctive step in orchidopexy for impalpable and redo undescended testis in children. Pediatr Surg Int 2005; 21:767-9.
6. Palacio MM, Sferco A, Garcia Fernanndez AE, Vilarrodona HO. Inguinal cordopexy: a simple and effective new technique for securing the testes in reoperative orchiopexy. J Pediatr Surg 1999; 34:424-5.
7. Cartwright PC, Snyder HM 3rd. Obstacles in reoperative orchiopexy—and a method to master them. Contemp Urol 1993; 5:56-64.
8. Cartwright, P. C. Reoperative orchiopexy. Dial Pediatr Urol 1993; vol.16, No.7, p. 1.
9. Adamsen S, Borjesson B. Factors affecting the outcome of orchiopexy for undescended testis. Acta Chir Scand 1988; 154:529–533.
10. Maizels M, Gomez F, Firlit CF. Surgical correction of the failed orchiopexy. J Urol 1983; 130:955–957.
11. Pesce C, d’Agostino S, Costa L, Musi L, Manzi M. Reoperative orchiopexy: Surgical aspects and functional outcome. Pediatr Surg Int 2001; 17:62–64.
12. Palacio MM, Sferco A, García Fernanndez AE, Vilarrodona HO. Inguinal cordopexy: a simple and effective new technique for securing the testes in reoperative orchiopexy. J Pediatr Surg 1999; 34:424-5.
13. Bianchi A, Squire BR. Transscrotal orchidopexy: orchidopexy revised. Pediatr Surg Int 1989: 4:189–192
14. Jawad AJ. High scrotal orchidopexy for palpable maldescended testes. Br J Urol 1997; 80:331–333.
15. Livne PM, Savir A, Servadio C. Re-orchiopexy: advantages and disadvantages. Eur Urol 1990;18:137-139.
16. Cohen TD, Kay R, Knipper N. Reoperation for cryptorchid testis in prepubertal child. Urology 1993;42: 437-439.
17. Redman JF. Reoperative orchidopexy: approach through the cremasteric fascia. Dial Pediatr Urol 1993;16:5-7.
18. Noseworthy J. Recurrent undescended testes. Semin Pediatr Surg 2003;12:90–93.
19. Ziylan O, Oktar T, Korgali E, Nane I, Ander H. Failed orchiopexy. Urol Int 2004: 73:313-5.
20. Mesrobian H G. Evaluation and management of the undescended testes and failed orchiopexy. Prob Urol 1988; 2: 87.
21. Redman JF. Inguinal reoperation for undescended testis and hernia: approach to the spermatic cord through the cremaster fascia. J Urol 2000; 164:1705-7.
22. Kennedy WA, Snyder HM. The undescended testis: anupdate. The potential for fertility in patients with undescended testis. Dial Pediatr Urol 1997; 20: 6-7.
23. Mandat KM, Wieczorkiewicz B, Gubala-Kacala M. Semen analysis of patients who had orchidopexy in childhood. Eur J Pediatr Surg 1994; 4: 94-97.