Low-Lying Testicle: Who Is a Candidate for Scrotal Orchiopexy?

Some undescended testicles have passed through the inguinal canal and sit at its exit, or at the upper part of the scrotum. This testicle is easily palpable on examination, descends into the upper half of the scrotum when pulled down, but retracts upward when released.

The surgery is performed under general anesthesia, usually with a regional block added, and is completed through a single incision.

• Re-examination under anesthesia: Once the muscles are relaxed, how far the testicle descends into the scrotum is assessed one final time; the final decision is made at this point.
• Scrotal incision: A small incision is made in the upper scrotum, placed along one of the natural skin creases.
• Delivery of the testicle: The testicle and its coverings are brought out through this incision; the gubernaculum (guiding ligament) attachments are divided.
• Mobilization of the cord: The cremaster fibers and adhesions are divided through the same incision, upward as far as the external ring; the cord is given length without tension.
• Checking for a hernia sac: If an open peritoneal extension is present, it is separated through the same incision and ligated as high as possible.
• Placement in the subdartos pocket: A pocket is created between the skin and the dartos muscle, the testicle is placed into it, and the incision is closed with dissolvable stitches.

• In unilateral cases, the surgery usually takes 30–45 minutes and is performed as day surgery. In our practice, this operation is also performed jointly by two pediatric urology specialists; when the sac needs to be ligated higher up, having a second surgeon is valuable.

The most visible benefit of scrotal orchiopexy is that it is completed through a single, small incision. Because the anterior wall of the inguinal canal is not opened, postoperative pain and swelling are less, and recovery is faster.

• The literature reports success rates in appropriately selected cases similar to the inguinal approach, with a shorter operative time and a better cosmetic outcome. This approach can also be considered for re-ascended testicles, because it avoids operating through scar tissue in the groin.

The scrotal approach is not suitable for every testicle. If the cord does not lengthen sufficiently, if the hernia sac is wide and sits high, or if the testicle turns out to be higher than expected, a second incision is added in the groin during the same session. This is not a failure but a backup step planned from the outset.

Mild swelling and bruising in the scrotum last a few days; pain resolves with simple pain relievers. Bathing begins after the period specified by the physician; activities that put pressure on the area are avoided for a few weeks.

• At the first follow-up visit, the testicle’s position, size, and the wound are assessed; checkups continue within the first year and then yearly until adolescence. Fever, increasing redness, discharge, or noticeable and increasing swelling in the scrotum should be reported to the physician.