Surgical Implant Techniques
Of historical interest, intracapsular insertion of a testicular prosthesis following subscapsular orchidectomy using a scrotal incision in patients with advanced prostate cancer was first described by Tolson in 1944 and endorsed as recently as 1984.16
In 1972, Abbassian17 described the insertion of a testicular prosthesis in a subcuticular pouch which was said to be useful in patients with extensive atrophy and scarring of the scrotal area. A skin incision is made in the opposite hemi-scrotum ensuring not to cross the midline raphe. Through this incision, a subcuticular pouch is created for the prosthesis in the empty hemi-scrotum. However, this procedure is associated with a high incidence of prosthesis extrusion.
To minimise the risk of extrusion of the prosthesis, Latimmer6 advocated a high scrotal or low inguinal incision, anchoring the prosthesis to the bottom of the scrotum and narrowing the upper scrotum with additional sutures. This technique is difficult to perform in the presence of a contracted or scarred hemi-scrotum. In such circumstances, an appropriate space may be created using a sponge-holding forceps18 or by using the balloon of a Foley catheter.15,19
Currently, most surgeons use a low groin incision whenever possible to implant a testicular prosthesis in the belief that this is associated with a lower risk of infection and extrusion. A finger is then placed into the scrotal sac and the potential space created by inflation of a Foley catheter balloon. The most pendant part of the scrotum is subsequently inverted and the prosthesis secured with a PDS suture placed through its suture loop. During transfixation of the dartos, particular care must be taken to avoid skin penetration and, thereby, promote infection and possible extrusion of the prosthesis.
Congenital or acquired bilateral anorchia often requires testicular implants and testosterone administration. A group in Boston, MA, USA explored the possibility of creating hormone-releasing testicular prostheses. In animal models, they produced implants that released physiological levels of testosterone over a prolonged period of time; however, no studies have been carried out to date in humans.
Studies have shown that a certain proportion of men who have testicular prostheses inserted are unhappy about the size or shape of their implant.22 One possible reason for this is that as the size of the implant increases, the length-to-width ratio decreases producing a less elliptical implant. The manufacturing companies might address this issue by producing more natural looking implants in the larger sizes required by adults.