腹腔镜下睾丸切除术及常见问题【视频+英文讲义】

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What is Orchiectomy?

Orchiectomy which is also spelled orchidectomy is a surgical procedure to get rid of a testicle and also the full spermatic cord through an incision within the abdomen or by laparoscopy. Orchiectomy is a form of castration. The procedure is generally performed by a urologist or general surgeon. Often it is conducted as same-day surgery, using the patient returning home within hours of the procedure. Some patients want to possess a prosthetic testicle inserted into their scrotum.

Who gets the testes to be removed?

Undescended testis is really a relatively common condition in boys. The conventional treatment methods are orchiopexy. In grown-ups, orchiopexy is done only when sufficient length could be mobilized. Otherwise, orchiectomy is ideal as undescended testis predisposes to carcinoma. The incidence of carcinoma increases as patient grow older. It is not uncommon in developing country to see a man of age 30 years or more presenting with unilateral absence of testis/empty hemiscrotum. Ultrasonography of the abdomen should be done to localize the exact position of the testis. A computed tomography (CT) scan is also good investigation to find out this condition. Undescended testes is also called as cryptorchidism.

Overall, 3% of full-term male newborns have undescended testis, decreasing to 1% in male infants aged six months to 1 year. The prevalence of cryptorchidism is 30% in premature male neonates. Factors that Predispose to cryptorchidism include prematurity, low birth weight, small size for gestational age, twinning, and maternal contact with estrogen throughout the first trimester. Seven percent of siblings of boys with undescended testes have cryptorchidism. Spontaneous descent following the first year of life is uncommon.

What is cryptorchidism?

Cryptorchidism is easily the most common genital problem encountered in pediatric patient. Cryptorchidism literally means hidden or obscure testis and usually describes an undescended or maldescended testis. Despite a lot more than A century of research, many facets of cryptorchidism aren't well defined and remain controversial. Untreated cryptorchidism clearly has deleterious effects around the testis with time. Understanding the abnormalities of morphogenesis and also the molecular and hormonal milieu associated with cryptorchidism is crucial to contemporary diagnosis and management of this extremely common entity.

This problem was initially described in 1786 by Hunter and has been recognized for centuries. The very first surgical orchiopexy was attempted in 1820 by Rosenmerkal. However, it wasn't until 1877 that Annandale performed the very first successful orchiopexy.

What is Orcheopexy?

Orcheopexy is a surgical procedure to bring the testes back in to the scrotum. Successful surgical keeping the testis within the scrotum is based on the principles originally explained Bevan in 1899. Included in this are adequate mobilization of the testis and spermatic vessels, ligation of the associated hernia sac, and adequate fixation of the testis inside a dependent area of the scrotum. A variety of techniques have been described and are highlighted in the following Intraoperative details section.

How is oecheopexy done?

Options for the treatment of an intra-abdominal testis vary depending on the patient's age, testis size, contralateral testis, and the surgeon's skills. Jordan et al (1992) first described the strategy of laparoscopic orchiopexy, and all sorts of modern techniques are similar. It is necessary to decide early if your staged laparoscopic Fowler-Stephens orchiopexy is essential. When the testis is farther than 4 cm in the internal ring, this should be considered. However, observe that more than 90% of intra-abdominal testes could be brought down successfully without such extreme maneuvers. When the staged procedure is used, the first and second operations are separated by 6-9 months to permit collateralization from the deferential artery.

The peritoneum should be incised around the internal ring and continued superiorly lateral to the vessels and medial to the vas deferens. A triangle of peritoneum should be left between your vas and vessels distally. The vessels are carefully mobilized, and optical magnification with the laparoscopic approach is quite helpful in this regard. The testis should be brought down after a subdartos pouch is made by passing a 12-mm radially dilating trocar into the peritoneum just lateral towards the lateral umbilical ligament. Afterward, additional dissection of the vessels is essential in some cases. Surgeon should be sure that the cord is torsion-free as the testis is brought down. Standard scrotal fixation should be performed. The 2-mm ports don't require closure, however the 5-mm umbilical port should be closed to prevent omental herniation.

Is Laparoscopic Orchiectomy safe?

The use of laparoscopic surgery has proven to be a safe and effective means of treatment for the intra-abdominal testis. In countries where the majority of the population is poor and illiterate. By the time a boy or young man with an undescended testis arrives at the hospital, it is already for them too late to do orchiopexy. It is common that most of these patients have no symptoms, orchiectomy had to be done because of the risk of torsion and malignant transformation. Doing orchiectomy in these patients effectively, the advantages of minimally invasive surgery can be utilized.

How's undescended testes diagnosed?

The only way to diagnose is physical exmination by a good surgeon followed by ultrasound or CT scan. Physical examination will show empty scrotum. Laparoscopic diagnosis is also a surgery of choice followed by orchiectomy is the removal of testicles using laparoscope where the surgery will be performed through small incisions and specially designed instruments. Laparoscopic procedure is more comfortable than the conventional surgery and helps the patients restore to their normal functions quicker.

What To Expect After Surgery?

Orchiectomy can be done as an outpatient procedure or with a short hospital stay. Regular activities are usually resumed within 1 to 2 weeks, and a full recovery can be expected within 2 to 4 weeks.

What are the risk of orchiectomy?

Orchiectomy causes sudden hormone changes in the body. Side effects from hormone changes include:

• Sterility.
• Loss of sexual interest.
• Erection problems.
• Hot flashes.
• Larger breasts (gynecomastia).
• Weight gain.
• Loss of muscle mass.
• Thin or brittle bones (osteoporosis).
  

What is radical orchiectomy?

A radical orchiectomy is one aspect of the definitive treatment of testicular cancer. Testicular cancer generally affects young men between puberty and age 35 years. Successful treatment incorporates a number of modalities, including radical orchiectomy, retroperitoneal lymph node dissection, chemotherapy, and radiation.

A radical orchiectomy is suggested for the control over a suspected testicular tumor. A testicular tumor should be suspected in almost any patient using the physical findings of a painless, firm, and irregular mass as a result of the testicle. Confirm this with Doppler ultrasonography of the scrotum. Most cases of testicular tumors demonstrate hypoechoic hypervascular intratesticular lesions. Elevated levels of alpha-fetoprotein and/or human chorionic gonadotropin should also advise a testicular tumor of germ cell type.

CONCLUSIONS: Laparoscopic orchiectomy seems to be advantageous and well accepted by patient, less pain and reduced hospital stay. It should be accepted by the repotoire of surgeons and we preferred the laparoscopic approach for the obvious benefits of less pain, better cosmesis, and early discharge.