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Undescended testes occur in 1-3% of newborns; the prevalence is even higher in premature babies. Traditionally the surgical approach has been inguinal orchidopexy, involving two incisions – inguinal and scrotal. In 1989, Bianchi and Squire proposed single scrotal incision orchidopexy as an alternative. However, which is best? Scrotal orchidopexy (SO) has not been definitively shown to be superior to inguinal orchidopexy (IO); a number of randomised controlled trials (RCTs) have shown equivalent success rates and complication rates. Perhaps there has been a failure to show superiority through varying definitions of surgical success, indication bias, age differences and position of the testes at time of surgery. Here, McGrath et al. have aimed to determine whether SO is better than IO in terms of postoperative pain and decreased operative time. One hundred and sixty-five patients were recruited into an RCT (January 2015 to June 2019) and 161 patients completed follow-up. Mean operative time was similar on an intention to treat basis. Although those undergoing IO received more paracetamol and ibuprofen in hospital, there were no differences between the two groups at home. Likewise, pain scores were initially higher in the IO group, but the results of pain assessment at 24 hours (i.e., at home) showed no differences. Overall complication rate was 4% (6/161) – one testicular atrophy, three re-ascents into the upper scrotum and two wound infections. Of these, five underwent SO. Interestingly, the overall conversion rate was 23% with 18 of 80 patients undergoing SO requiring an additional inguinal incision. Of these 18, 13 had canicular testes (which represents a conversion rate of 72% for canicular testes). Therefore, as per my surgical training, SO may provide a safe and effective alternative to IO in selective cases. Scrotal orchidopexy is probably suited for testes that are located with the inguinal canal and unable to be brought down through manipulation to the scrotum. The technique may also provide some initial benefit in lowering pain scores and analgesic requirements, but this difference is not seen in the longer term.

Randomized controlled trial of scrotal versus inguinal orchidopexy on postoperative pain.
McGrath M, Kim J, Farrokhyar F, Braga LH
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Neil Featherstone

Cambridge University Hospitals NHS Foundation Trust (Addenbrookes Hospital).

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