NEW YORK (Reuters) – After doctors removed the wrong testis from a young man, the search was on for a surgeon who might be willing to try to replant it.
A new case report details the experience of a 25-year-old patient who had developed testicular pain and a palpable mass in his right testis; he went to a local hospital for a radical orchiectomy only to have the surgical team remove the left – wrong – testis.
Once the team recognized their error, they began searching for a center with microsurgical capacity to replant the testis.
“The take-home message is that microsurgery can be used to reattach an organ, in the case of a wrong-site surgery,” lead author Dr. Fatma Tuncer, a microsurgery fellow at the Cleveland Clinic, in Ohio, at the time of the surgery, told Reuters Health by email. She is now an assistant professor of plastic surgery at the University of Utah.
“The vast majority of surgeries, including urologic procedures will never have such an event, but there are helpful groups of physicians that are available to reduce the morbidity of such an event,” said coauthor Dr. Brian Gastman, a professor of surgery at the Case Western School of Medicine and a surgeon at the Cleveland Clinic.
“We were, I believe, the third one contacted, each one causing a greater time of ischemia,” Dr. Gastman told Reuters Health by email. “I accepted the patient and in doing so had the buy-in of my urology and anesthesia colleagues.”
Once Dr. Gastman and his team agreed to take on the task, the patient, and his testis, were flown to Cleveland. Once the patient arrived, he was counseled on the risks and benefits of the surgery. After agreeing to the surgery, the patient was taken to the OR immediately by the plastic surgery and urology teams.
Prior to initiating anesthesia, the testicle was examined and the urology team performed testicular sperm extraction as the patient did not have any biological children. The sperm were transported to a CLIA-certified andrology lab and were cryopreserved.
Next, the team examined the testis and spermatic cord under the microscope. The team identified the testicular artery, veins and vas deferens and marked them with prolene sutures. They next placed the testis in a moist gauze over ice until the recipient vessels were prepared.
After the team reconnected vessels, they observed strong arterial and venous Doppler flow on both testicular vessels and the testis itself. Five days after the replantation surgery, the team performed a radical orchiectomy on the correct side.
Dr. Gastman isn’t sure how well the testis will perform over time. “I cannot speak too much on this as it is ongoing,” he said. “But he will likely need some level of hormonal supplementation. I can state that the testis is alive and palpable.”
This is a “very interesting paper,” said Dr. Miroslav Djordjevic, a professor of urology at the Icahn School of Medicine at Mount Sinai, New York. “Congratulations to colleagues for a great idea for solving this wrong-site surgery with very precise microsurgical technique and new insight in the fight to save the organs.”
Still, Dr. Djordjevic told Reuters Health by email, “postoperatively, the authors confirmed there was not complete testicular function based on testosterone levels and hypotrophy of the reimplanted testis. The main reason is the time between removal and reimplanation. Based on experiences with testicular torsion, four to six hours is the maximum that will offer restoration of volume and function. Here, a longer period (10 hours) resulted in poor outcomes.”
“Our experience with testicular implantation in monozygotic twins showed great success (Belgrade University, Serbia, December 2019, personal report) because the cold ischemia was only one hour,” Dr. Djordjevic said.
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