Is infant scrotum surgery considered high risk?

From the Guidelines

Infant scrotum surgery is generally not considered high risk when performed by experienced pediatric surgeons. The most common procedures, such as hydrocele repair or orchiopexy for undescended testicles, are routine operations with low complication rates, as indicated by the American Urological Association (AUA) guidelines 1. However, as with any surgery involving anesthesia in infants, there are inherent risks that must be considered. These include potential anesthesia complications, bleeding, infection, and specific risks related to the procedure itself such as damage to the testicle or its blood supply. The risk profile increases with certain factors like prematurity, underlying health conditions, or complex anatomical issues.

According to the AUA guidelines, imaging for cryptorchidism is not recommended prior to referral, which should occur by 6 months of age 1. Orchidopexy is the most successful therapy to relocate the testis into the scrotum, while hormonal therapy is not recommended. Successful scrotal repositioning of the testis may reduce but does not prevent the potential long-term issues of infertility and testis cancer.

Surgeons typically use specialized techniques and equipment designed for infants, and procedures are often performed on an outpatient basis with minimal incisions. Parents should expect detailed pre-operative discussions about specific risks, post-operative care instructions including pain management (typically acetaminophen or ibuprofen at age-appropriate doses), and signs of complications to watch for. The benefits of addressing scrotal conditions early often outweigh the relatively low surgical risks, as untreated conditions may lead to fertility issues or other complications later in life.

Key considerations for infant scrotum surgery include:

• Referral to a surgical specialist by six months (corrected for gestational age) for timely evaluation and treatment of cryptorchidism 1
• The use of specialized techniques and equipment designed for infants to minimize risks and complications
• Detailed pre-operative and post-operative discussions with parents to ensure informed decision-making and proper care
• The potential long-term benefits of early intervention, including reduced risk of infertility and testis cancer.

From the Research

Infant Scrotum Surgery Risk

The risk associated with infant scrotum surgery can be considered in the context of the underlying conditions that necessitate such surgical interventions.

• Testicular torsion, a condition where the spermatic cord becomes twisted, cutting off the blood supply to the testicle, is a rare event in infancy but often leads to testicular loss if not promptly addressed 2.
• The management of neonatal testicular torsion involves not only the salvage of the affected testicle, which is rarely achieved, but also the preservation of the contralateral gonad through scrotal fixation to prevent future torsion 3.
• Historical studies have shown that clinical differentiation between torsion of the testis, torsion of the appendices, and epididymo-orchitis is challenging, even with specialized investigations like Doppler ultrasound and radionuclide scanning, suggesting that expedient surgical exploration may be necessary in cases of acute scrotum 4.
• Advances in diagnostic techniques, such as scrotal scanning and color Doppler ultrasound, have improved the precision of diagnosing testicular torsion and other scrotal pathologies, potentially reducing the need for unnecessary surgical explorations 5, 6.
• The decision to operate is influenced by the urgency of the condition, the potential for testicular salvage, and the risks associated with surgery itself, including the risk of complications and the impact on future fertility.

Surgical Risks and Considerations

• The risk of complications from infant scrotum surgery, such as infection, bleeding, and damage to surrounding structures, must be weighed against the potential benefits of prompt intervention.
• Studies have demonstrated that with appropriate surgical technique and post-operative care, the risk of significant complications can be minimized 2, 3.
• The long-term outcomes of infant scrotum surgery, including effects on fertility and testicular function, are areas of ongoing research and consideration in the management of these conditions.

Diagnostic Approaches

• The use of diagnostic imaging, such as color Doppler ultrasound, can help identify which children with an acute scrotum require surgical exploration, potentially sparing others from unnecessary surgery 6.
• Clinical assessment and history remain crucial in the initial evaluation of infants presenting with scrotal symptoms, guiding the decision for further diagnostic testing or surgical intervention.