Journal of Pediatric Urology (2021) 17, 835.e1e835.

e6

Testicular blood supply and growth in

children with high cryptorchidism
treated with gubernaculum preserving
a
Pediatric Surgery, Inner
vs. cutting laparoscopic orchiopexy: A
Mongolia Maternal and Child
Health Care Hospital,
pilot trial
Huhehaote, Inner Mongolia,
010020, China
Jianguo Zhang a,1, Xia Yang b,1, Chao Zhang b, Haowei Li b,
b
Pediatric Surgery, The Fourth Yongxiang Zhao b, Chaosheng Ku a, Lin Qi a, Yu Bai a, Lin Yang a,
Hospital of Baotou, Baotou, Hailong Zhang a, Dongqing Yue c, Wenfeng Wei a, Haibin Yu a,*
Inner Mongolia, 014030, China

c
Medical Imaging Department, Summary of Baotou were randomly divided into retention
The Fourth Hospital of Baotou, group (60 cases in group P, aged 1e3 years, average
Baotou, Inner Mongolia, Introduction 1.85  0.58) and cutting group (60 cases in group C,
014030, China It is still controversial whether the frenum of testis aged 1e3 years, average 1.75  0.66) (P Z 0.52).
should be retained in laparoscopic testicular PSV, EDV, RI and testicular volume were measured
* Correspondence to: Haibin Yu, fixation. by color Doppler ultrasound before operation and
Pediatric Surgery, Inner 1,3,6,12 months after operation. No, there was sig-
Mongolia Maternal and Child Materials and methods nificant difference between the two groups
Health Care Hospital, It is a prospective experiment to study testicular (P > 0.05).
Huhehaote, Inner Mongolia,
preservation on testicular growth in children with
010020, China Tel.: þ86
15848169023
high cryptorchidism.
[email protected] (H. Yu) Conclusions
Results There is no significant difference in testicular blood
Keywords From January 2018 to June 2020, 120 children with supply and growth between laparoscopic testicular
Gubernaculum testis; Laparos- high cryptorchidism in Inner Mongolia Maternal and fixation and frenulum amputation in children with
copy; High cryptorchidism; Child Health Care Hospital and The Fourth Hospital high cryptorchidism.
Testicular blood supply;
Comparative observation

Received 1 July 2021

Revised 4 October 2021
Accepted 7 October 2021
Available online 12 October
2021

1
These authors contributed equally to this work.

https://doi.org/10.1016/j.jpurol.2021.10.002
1477-5131/ª 2021 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
835.e2 J. Zhang et al.

Introduction hepatic, or renal dysfunction; or 7) not tolerant to CO2

pneumoperitoneum.
Cryptorchidism (retained testis) is a common congenital
disease of the genito-urinary system in children and is Randomization and blinding
related to the abnormal growth of the gubernaculum testis
[1e4]. It occurs in 1%e4% of full-term male infants and 15%e The children were randomized to the preservation and
30% of premature male infants [4,5]. It can be subtyped into cutting groups using a random number table prepared by a
high cryptorchidism and low cryptorchidism, according to biostatistician. Randomization was stratified to ensure a
the position of the testis [3,4]. Patients with high cryptor- uniform distribution between the two hospitals. The
chidism have their testes above the inguinal canal ring and outcome assessors were blind to grouping.
account for approximately 25% of all patients with cryptor-
chidism [3,4]. Most retained testes descend without external Surgery
force in the first 3 months after birth but are less likely to
continue to descend after 6 months of age [3,4]. All patients underwent laparoscopic descent and fixation
Laparoscopic treatment is widely used for high cryptor- for high cryptorchidism [3,4]. All surgeries were performed
chidism in clinical practice [4,6], but it remains contro- by an associate chief physician with >15 years of experi-
versial whether the gubernaculum should be spared or not ence (ZJ).
[5,7e12]. Indeed, some authors believe that conventional
surgeries for cryptorchidism would damage the testicular Surgery in the preservation group
bed and blood supply to some ramus communicans, and
would lead to abnormal testicular growth as blood flow
First, a 5-mm incision was made at the umbilicus for
would be affected by the elongation of the reserved blood
pneumoperitoneum at 8e10 mmHg pressure. A laparoscope
vessels after the testes are descended [5,7,9,10]. On the
was placed in, and one 5-mm operational trocar (puncture
other hand, some authors suggest that the vascularization
device 30160M1, Karl Storz Endoskope, Tuttlingen, Ger-
of the gubernaculum will help maintain a proper blood
many) was inserted into the left and right abdomen,
supply to the testis and avoid atrophy [8,11e13]. Robertson
separately. Under the laparoscope, the testis of the
et al. [11] reported a testes survival rate of >90%, while a
affected side was observed at the inner ring mouth or in the
retrospective study by Braga et al. [12] reported rates of
abdomen, with the free spermatic vessel and the vas def-
testicular atrophy of 6.6% and 28.3% with gubernaculum-
erens of sufficient length. A sharp circular separation was
sparring laparoscopic orchiopexy and conventional laparo-
performed at the inner ring mouth to enable an aspirator
scopic orchiopexy, respectively.
rod to be inserted into the scrotum along the inguinal
Therefore, this prospective trial aimed to explore the
canal. An incision was made on the scrotum, and the tunnel
impact of preserving or not the gubernaculum testis on
was enlarged under the dartos toward the bottom of the
postoperative testicular growth in children by comparing
scrotum. After that, the periorchium was lifted, and the
the postoperative blood supply and testicular growth. This
incision was enlarged in the non-vascular zone to find the
trial could provide a higher level of evidence for laparo-
gubernaculum testis. The testis was then gradually drawn
scopic orchiopexy.
out, and the adhesive tissues were debonded. The sper-
matic cord was checked for torsion, and the testis was
Material and methods checked for tensionlessness and then fixed in the tunnel
under the dartos toward the bottom of the scrotum. Finally,
Study design and participants the incision was sutured conventionally.

In this pilot prospective trial, patients with high cryptor- Surgery in the cutting group
chidism admitted to the pediatric surgery departments of
Inner Mongolia Maternal and Child Health Care A 5-mm incision was made at the umbilicus for pneumo-
Hospital and The Fourth Hospital of Baotou from January peritoneum at 8e10 mmHg pressure. A laparoscope was
2018 to June 2020 were enrolled. The study was approved placed in, and one 5-mm operational trocar (puncture device
by the ethics committees of Inner Mongolia Maternal and 30160M1, Karl Storz Endoskope, Tuttlingen, Germany) was
Child Health Care Hospital and The Fourth Hospital of inserted into the left and right abdomen, separately. Under
Baotou. The informed consent form was signed by the legal the laparoscope, the testis of the affected side was observed
guardians of the enrolled children. at the inner ring mouth or in the abdomen, with the free
The inclusion criteria were 1) no history of testicular spermatic vessel and the vas deferens of sufficient length. A
descent, 2) testes were not palpable in the inguinal canal sharp circular separation was performed at the inner ring
during a physical examination, and 3) testis-like tissues mouth, the gubernaculum testis was lifted (without
observed at the inner ring mouth or in the abdomen in color damaging the vas deferens) and cut off with electrocautery
Doppler ultrasonography. The exclusion criteria were 1) at the lowest position, and the testis was lifted under the
<12 months or >3 years of age, 2) testicular absence, 3) laparoscope to the contralateral inner ring month (i.e.,
orchitis, epididymitis, or testicular torsion, 4) cryptorchi- drawn into the scrotum). After that, an aspirator rod was
dism relapse, 5) underwent other scrotal operations or inserted into the scrotum along the inguinal canal. An inci-
history of laparotomy operation as abdominal adhesions sion was made on the scrotum, and the tunnel was enlarged
may affect the surgery, 6) severe cardiac, pulmonary, under the dartos toward the bottom of the scrotum. Next,
Gubernaculum-preserving laparoscopic orchiopexy 835.e3

the periorchium was cut open, and hemostatic forceps were testicular growth in children with high cryptorchidism. The
inserted into the abdomen along the aspirator to gently results suggest no differences in testicular blood supply or
clamp the joint at the epididymis, gradually drawing out the growth between children with high cryptorchidism who
testis and debonding the adhesive tissues. The spermatic underwent laparoscopic orchiopexy with preservation vs.
cord was checked for torsion, and the testis was checked for cutting of the gubernaculum testis.
tensionlessness and then fixed in the tunnel under the dartos Cryptorchidism is a common urinary system disease in
toward the bottom of the scrotum. Finally, the incision was children that may cause declined semen quality and a
sutured conventionally. higher risk of testicular germ cell tumor [1e4,16]. Hutson
et al. [17,18] studied the regulation process of testicular
Observation indicators descent, the potential mechanism of testicular descent to
cause infertility and tumor, and its impact on germ cells
Color Doppler ultrasonography (HITACHI Ascendus, Japan, through animal experiments. Hormone therapy is the
PHILIPS EPIQ7, Dutch) was used to measure the peak sys- conventional treatment for patients under 1 year of age,
tolic velocity (PSV), maximum end-diastolic velocity (EDV), and patients failing to respond to hormone therapy and
mean blood flow resistance index (RI), and testicular vol- over 1 year of age should receive surgical treatment as
ume (length  width  height) [14,15] of the patients early as possible [3,4,19], with the purpose to not only
before and at 1, 3, 6, and 12 months after surgery. restore the testis to its normal anatomical position but
also enable the testis to grow and function properly.
Statistical analysis Therefore, the key to surgery for normal testicular growth
is to reduce the surgical trauma as much as possible, with
All data were analyzed using SPSS 19.0 (IBM Corp., Armonk, testicular growth in child patients to be regularly exam-
NY, USA). The continuous data were tested for normal ined after surgery.
distribution using the KolmogoroveSmirnov test. They are Braga et al. [12] reported laparoscopic gubernaculum
presented as means  standard deviations and were testis preserving surgery as a feasible and alternative sur-
analyzed using Student’s t-test. The categorical data are gery to the conventional FowlereStephens testicular sur-
presented as n (%) and were analyzed using the chi-square gery, suggesting that the preservation of extra testicular
test or Fisher’s exact test. Two-sided P-values P < 0.05 blood supply (via testicular vessels and compliant arteries)
were deemed to be statistically significant. might improve the survival of the testes after laparoscopic
testicular surgeries, with a 6.6% rate of atrophy, compared
Results with 28.3% with conventional laparoscopic orchiopexy. This
is supported by other studies [8,11,13,20,21]. Ellis et al.
[22] also reported robust collateral circulation when pre-
Characteristics of the participants serving the gubernaculum testis.
In this study, the testicular blood flow and growth were
A total of 135 patients were randomized: 72 in the pres- followed for 12 months after surgery, and the results
ervation group and 63 in the cutting group. Twelve patients showed no differences between the two groups. Some
in the preservation group and three in the cutting group reasons could explain this lack of difference. First, the
dropped out and were excluded. Finally, 60 patients were gubernaculum testis provided a small blood flow and did not
retained in the preservation group and 60 patients were substantially affect testicular growth in children. Second,
retained in the cutting group. child patients underwent surgery at an early age, and their
All 120 patients underwent successful laparoscopic phase reproductive system could recover quickly. The reserved
I testicular descent and fixation. The 60 patients in the vessels, including the vas deferens and the cremaster
preservation group were 1e3 years of age (mean, 1.85  0.58 vessel, could increase blood flow and rebuild the collateral
years). The 60 patients in the cutting group were 1e3 years circulation as the patients grew, to ensure normal testicular
of age (mean, 1.75  0.66 years) (P Z 0.52).There was no growth in child patients. Third, the postoperative follow-up
secondary operation, and there was no testicular atrophy in lasted for only 12 months and could be insufficient to
both operations. reflect the impact of blood flow on testicular growth.
Therefore, whether to reserve the gubernaculum testis
Testicular Doppler ultrasound should be decided based on the actual patient’s situation
[23], and unnecessary damage caused by separation should
The patients were examined at 1, 3, 6, and 12 months after be avoided, and the gubernaculum should not be cut off
surgery. There were no differences in PSV, EDV, RI, and only for easy operation. Furthermore, laparoscopy is ad-
testicular volume between the two groups over the 12- vantageous in finding the testes and preserving the original
month follow-up (all P > 0.05) (Table 1 and Fig. 1). anatomical structure in child patients with high cryptor-
chidism. It facilitates secondary operations on child pa-
Discussion tients with a short spermatic cord, so it should be the most
preferred surgical method.
It remains controversial whether the gubernaculum testis Despite that this was a two-center pilot randomized
should be preserved or not during laparoscopic orchiopexy trial, this study has biases and limitations. As it was a pilot
[5,7e12]. This pilot trial aimed to explore the impact of trial, no power analysis was performed, and the sample size
preserving or not the gubernaculum testis on postoperative might be too small to observe a difference. Besides, the
835.e4 J. Zhang et al.

Table 1 Comparison of the indicators between the two groups.

Variables Preservation Cutting group t P
group (60 patients)
(60 patients)
Age 1.851  0.583 1.753  0.662 0.713 0.520
PSV (cm/s) Before surgery 3.491  1.185 3.547  0.655 0.335 0.738
1 month after surgery 4.483  1.549 5.154  1.715 2.316 0.209
3 months after surgery 3.972  1.527 3.793  0.881 0.827 0.410
6 months after surgery 3.589  1.095 3.690  0.901 0.574 0.567
12 months after surgery 3.125  1.320 3.540  0.807 2.199 0.221
EDV (cm/s) Before surgery 1.169  0.561 1.304  0.322 1.708 0.090
1 month after surgery 1.585  0.609 1.822  0.673 2.085 0.390
3 months after surgery 1.607  1.117 1.663  0.440 0.388 0.699
6 months after surgery 1.315  0.581 1.483  0.485 1.788 0.892
12 months after surgery 1.156  0.517 1.252  0.358 1.245 0.216
RI Before surgery 0.679  0.153 0.683  0.205 0.154 0.878
1 month after surgery 0.669  0.189 0.671  0.195 0.460 0.964
3 months after surgery 0.680  0.213 0.665  0.176 0.417 0.677
6 months after surgery 0.624  0.132 0.614  0.260 0.246 0.806
12 months after surgery 0.582  0.111 0.565  0.238 0.528 0.598
Testicular Before surgery 0.480  0.193 0.448  0.180 0.995 0.322
volume (cm3) 1 month after surgery 0.519  0.226 0.524  0.191 1.430 0.886
3 months after surgery 0.572  0.291 0.558  0.187 0.327 0.744
6 months after surgery 0.572  0.256 0.597  0.197 0.622 0.535
12 months after surgery 0.584  0.267 0.571  0.200 0.330 0.742
PSV: peak systolic velocity; EDV: maximum end-diastolic velocity; RI: mean blood flow resistance index.

Fig. 1 PSV, EDV, RI, and testicular volume between the two groups over the 12-month follow-up. (A) Comparison of PSV between
the two groups; (B) Comparison of EDV between the two groups; (C) Comparison of RI between the two groups; (D) Comparison of
testicular volume between the two groups.

follow-up was only 12 months. Children have fine internal insufficient testicular descent made it challenging to
testicular arteries with slow blood flow that are difficult to monitor one specific artery before and after surgery.
detect [24,25], reduced blood flow signals under color All cases have been followed up for more than 12
Doppler ultrasonography on the affected side due to months, and some cases have been followed up for more
Gubernaculum-preserving laparoscopic orchiopexy 835.e5

than 36 months. It is planned to follow up until adoles- [2] Acer T, Hicsonmez A. The separation of the epididymis and the
cence. In addition to observing the testicular growth and abnormal attachment of the gubernaculum cause undes-
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methods of primary surgery, patients with secondary repair [4] Kolon TF, Herndon CD, Baker LA, Baskin LS, Baxter CG,
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