In children undergoing orchidopexy for undescended testes, does two‑point fixation versus three‑point fixation affect rates of testicular atrophy, postoperative pain, wound infection, or re‑ascent?

Orchidopexy Fixation Technique: Two-Point vs. Three-Point

The available evidence does not address two-point versus three-point testicular fixation techniques in orchidopexy, and current guidelines do not specify the number of fixation points required. The literature focuses instead on comparing scrotal versus inguinal surgical approaches rather than the specific number of suture fixation points used to secure the testis within the scrotum.

What the Evidence Actually Addresses

The guideline literature emphasizes that standard orchidopexy achieves success rates exceeding 96% with testicular atrophy occurring in fewer than 2% of cases, but does not specify fixation point methodology 1, 2. The critical surgical goals are:

• Tension-free placement of the testis deep within the scrotum 3
• Prevention of testicular re-ascent, which occurs in approximately 4–5% of cases 1
• Preservation of testicular blood supply to minimize atrophy risk (<2%) 1, 2

Relevant Fixation Technique Comparisons

The research literature compares different anatomical fixation methods rather than the number of suture points:

Dartos Pouch Technique

• The Petrivalsky/Schoemaker technique (Dartos pouch fixation) demonstrated a 4.2% re-ascent rate in 353 patients with follow-up 3
• This approach showed significantly lower relapse rates (p < 0.025) compared to transscrotal fixation alone 3

Transscrotal Fixation

• The Gross technique (transscrotal fixation) showed a 9.2% re-ascent rate in 469 patients with follow-up 3
• Scrotal fixation without inguinal exploration successfully managed 94.5% of low undescended testes when no patent processus vaginalis was present 4

Clinical Implications for Practice

In the absence of specific evidence comparing two-point versus three-point fixation, the surgeon should prioritize:

• Secure fixation within a Dartos pouch, which demonstrates lower re-ascent rates than simple transscrotal fixation 3
• Adequate mobilization of the spermatic cord to achieve tension-free placement 1
• Concurrent hernia repair when a patent processus vaginalis is identified 1

Complications to Monitor Regardless of Fixation Points

• Testicular atrophy: occurs in <2% of cases across all techniques 1, 2
• Wound infection: no significant difference between scrotal and inguinal approaches 5, 6, 7
• Re-ascent: ranges from 4.2% to 9.2% depending on fixation technique used 3
• Postoperative pain: generally less with scrotal approaches 6

Common Pitfalls

• Inadequate cord mobilization leading to tension on the testis increases re-ascent risk 1
• Failure to identify and ligate a patent processus vaginalis during orchidopexy 1
• Excessive tension on testicular vessels during fixation can compromise blood supply and cause atrophy 3