A New Technique of Expanding the Underdeveloped Scrotum

Abstract

Sir: Absence of testis often leads to underdevelopment of the scrotum. Tissue expanders1 stretch the underdeveloped scrotum to accommodate a testicular prosthesis. Disadvantages are the need for a second operation, the use of an implant with the risk of infection, the inflation time, repeated visits, and punctures to inflate the expander. A self-inflatable device overcomes these disadvantages. In 1982,2 a self-inflating model was introduced based on a silicone balloon filled with a hyperosmotic fluid, later replaced by hydrogel in 2000,3 commercialized as the OSMED expander (OSMED GmbH, Hartheim, Germany). The expander absorbs body fluids, leading to gradual swelling, providing a predetermined volume and size. The use of an osmotic expander for this indication has never been described before. A 17-year-old boy with bilateral cryptorchidism was treated earlier with bilateral orchidopexy and later with orchidectomy on the right side and scrotal fixation on the left side. The left testis atrophied. Placement of a testicular prosthesis failed. At examination, the testicular implant was fixed in the right inguinal region, with an underdeveloped scrotum without palpable testis (Fig. 1).Fig. 1.: Preoperative situation: migrated testicular prosthesis on the right side and shriveled underdeveloped empty scrotum.A large pocket was created under general anesthesia by an incision high on the scrotal sac. The OSMED rectangular expander with a final volume of 200 ml was inserted. The pocket was closed using a purse-string suture to prevent migration. Drains were not used. The migrated testicular prosthesis was removed. The patient was discharged to home on the first postoperative day. No infection or wound dehiscence, discomfort, or pain was observed at follow-up. Maximum expansion was achieved after 4 weeks, with explantation after 40 days. Two 5-cm testicular implants were fixed at the bottom of the pouch. A 4-month follow-up showed no adverse effects, with a satisfactory result (Fig. 2).Fig. 2.: Satisfactory result after 4 months.By expanding the scrotal tissue, additional scarring from multiple procedures in the past was overcome, providing adequate scrotal soft-tissue coverage. Tissue expansion does not alter the contractility or expansion of the scrotal wall in response to ejaculation, cold, or warmth. Disadvantages of traditional expanders are implant leakage, because of the great mobility of the scrotum, and the need for fillings, risking iatrogenic infections.4 The position of the valve can be troublesome because of the great mobility and limited space. Osmotic expanders overcome many of these disadvantages. The small size of the device reduces operative time, requiring a short incision.5 The final volume of the osmotic expander is defined accurately, facilitating surgical planning. The inflation process is uncontrollable, which can be troublesome in causing, for example, skin ischemia or pain. In our patient, the inflation progress was gradual, without pain or discomfort even at full expansion. At 4-month follow-up, no adverse effects were observed. The testicular prosthesis did not migrate or override and had an aesthetically pleasing result. Scrotal tissues responded well with contraction to cold and relaxation after warm stimuli. In conclusion, we can say that the use of an osmotic expander for expanding the underdeveloped scrotum is a safe, reliable, and easy technique that brings important advantages over the use of traditional expanders. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Gregory P. A. Van Eeckhout, M.D. Bert Vanmierlo, M.D. Marc Kioe A. Sen, M.D. Paul Wylock, M.D. Department of Plastic, Reconstructive, and Aesthetic Surgery Johan Braeckman, M.D. Department of Urology Universitair Ziekenhuis Brussel Brussels, Belgium