First Clinical Use of an Omental Pedicle Flap for the Surgical Correction of a High Intra-Abdominal Testicle

Abstract

Sir: Intra-abdominal testes are five times as likely to undergo malignant degeneration as testicles within the inguinal canal.1 High intra-abdominal testes are the most difficult to correct, with the results of testicular viability and function frequently being disappointing. The high failure rate (26 percent)2 is likely due to the fact that testicular blood flow is reduced up to 80 percent with spermatic vessel ligation, leading to insufficient germ cell perfusion.3 Another procedure used in this situation is microvascular autotransplantation, but this operation requires vessels of adequate size and expertise in microsurgical technique. Therefore, especially when the contralateral testicle is normal, an orchiectomy is preferred due to the high risk of testicular atrophy associated with most of the salvage procedures. However, if the chances of postoperative viability of the testicle could be increased, perhaps more salvage orchiopexies would be performed. In situations where the testicular vessels are not adequate for microvascular autotransplantation and the collateral circulation from the vas deferens is not sufficient to maintain testicular viability, a different technique is needed. Our solution was to perform an orchiopexy in two stages with the use of an omental pedicle flap. Our patient had a single left intra-abdominal hypoplastic testicle superior to the left common iliac artery. There was no vas deferens attached to the gonad due to previous operations. His vascular pedicle was too small (0.5 mm in diameter) to permit safe microvascular transfer. Therefore, the testicle was marsupialized in an omental flap to allow external neovascularization of the testicle (Fig. 1, above). The patient returned to the operating room 6 months later. The testicular pedicle was divided and the omental flap was lengthened (Fig. 1, below). It was transferred down through the midline between the rectus muscles, just above the pubic bone, into the left hemiscrotum. The testicle remains viable and the patient continues to demonstrate normal testosterone levels, maintaining his secondary male sexual characteristics.Fig. 1.: (Above) Left high intra-abdominal hypoplastic testicle and omental flap. (Below) Neovascularized testicle within the omental flap, demonstrating adequate length for scrotal placement.There are several indications for use of the omentum in reconstructive surgery,4 thanks to its plasticity, volume, and ability to neovascularize adjacent tissue through the induction of angiogenesis.5 Clinical use of the omentum to perform a two-stage orchiopexy has not previously been described. In summary, a two-stage transposition to the scrotum of a high intra-abdominal testicle was performed successfully via an omental pedicle flap. The omental pedicle flap for orchiopexy has several advantages, including the ease of lengthening the flap, so that the testicle can be transferred into the scrotum, and neovascularization of the testicle, decreasing its probability of atrophy. This procedure should be performed in two stages, to allow angiogenesis and neovascularization of the testicle to occur. Due to the high rate of atrophy associated with the standard orchiopexy of intra-abdominal testes, we propose that our procedure be added as a surgical option to increase the likelihood of preserving testicular viability and function. This is especially important in patients who have only a single functional testicle, to prevent their need for life-long treatment with exogenous testosterone. Steven A. Earle, M.D. University of Miami School of Medicine Jackson Memorial Hospital Deirdre M. Marshall, M.D. Division of Plastic and Reconstructive Surgery Andrew S. Labbie, M.D. Division of Urology Miami Children’s Hospital Miami, Fla.