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Testicular Reimplantation — Operative Atlas

This is the operative atlas for testicular reimplantation across both major clinical scenarios. For the clinical-conditions framework (indications, outcomes synthesis, experimental cryopreserved-tissue context), see Testicular Reimplantation (clinical conditions). Related: Testicular Prosthesis, Testicular Torsion, Genital / Scrotal Trauma.

Two distinct operative scenarios:

  1. Testicular autotransplantation — for high intra-abdominal testes (cryptorchidism).
  2. Traumatic testicular replantation — after complete amputation / avulsion.

Both depend on microsurgical expertise and minimisation of ischemia time.

A. Testicular Autotransplantation for Intra-Abdominal Testes​

Preoperative planning and patient selection​

Indicated for high intra-abdominal testes where spermatic vessels are too short for conventional orchiopexy. Testis localised preoperatively by laparoscopy or known to be intra-abdominal and grossly normal in appearance.[1] Per the AUA Cryptorchidism Guideline — primary orchiopexy / one-stage Fowler–Stephens / two-stage Fowler–Stephens / autotransplantation as alternative when these are not feasible or have failed.[2]

Phase 1 — Abdominal dissection and testicular mobilisation​

  1. Access — traditionally via laparotomy; increasingly via laparoscopy or robotic-assisted (da Vinci system, four trocars oriented toward the ipsilateral lower quadrant).[3]
  2. Testicular dissection — testis identified intraperitoneally; gubernaculum divided; peritoneum overlying spermatic cord incised; testicular artery, testicular vein(s), and vas deferens individually identified and mobilised.
  3. Vas deferens preservation — vas with its blood supply (deferential artery) carefully preserved intact and mobilised with sufficient length to reach the scrotum without tension. The vas is never divided.[4]
  4. Vessel preparation — gonadal (testicular) vessels isolated and mobilised as high as possible in the retroperitoneum to maximise proximal stump length; once adequate length achieved, vessels clipped and transected.[3]
  5. Recipient vessel preparation — deep inferior epigastric artery and vein identified in the rectus sheath / preperitoneal space and mobilised. Standard recipients due to reliable caliber, accessibility, and proximity to the inguinal canal.[5][6][7]

Phase 2 — Delivery and ischemia management​

  1. Testicular delivery — testis (now on vas-deferens pedicle only) and prepared inferior epigastric vessels delivered through an inguinal or lower-abdominal incision. If robotic, robot undocked at this point.[3]
  2. Hypothermia — testis cooled (cold saline-soaked gauze or ice slush, ~ 4–20 °C) to extend ischemia tolerance during anastomotic phase. Animal data: hypothermia preserves 90% of germinal epithelium at 4 h and 85% at 6 h, vs only 25% and 8% under normothermic conditions.[4][8]

Phase 3 — Microsurgical vascular anastomosis (critical phase)​

Requires an experienced microvascular surgeon.

  1. Microscope setup — typically 25–40× magnification.[5][1]
  2. Arterial anastomosis (testicular artery → inferior epigastric artery):
    • End-to-end using interrupted mattress sutures with 9-0 or 10-0 monofilament nylon.[3][6][1]
    • Mattress stitches specifically accommodate the caliber mismatch between smaller testicular artery and larger inferior epigastric artery.[6]
    • Minimal adventitial stripping — only enough to prevent intimal flap formation.[9]
    • Typically 6–8 interrupted sutures circumferentially.
    • Boeckx series (n = 25, 96% success) specifically emphasised the end-to-end mattress technique for diameter discrepancy.[6]
  3. Venous anastomosis (testicular vein → inferior epigastric vein):
    • Also end-to-end.
    • May use running 9-0 nylon (as in robotic-assisted technique) or interrupted sutures.[3][10]
    • Generally technically easier due to larger caliber but equally critical — venous congestion / infarction was the cause of failure in the Wacksman series.[10]
  4. Patency confirmation — clamps released; visual confirmation (pulsatile arterial flow, venous filling) + intraoperative Doppler. Some series have used postoperative radionuclide scanning or selective arteriography to verify anastomotic patency.[3][7]

Phase 4 — Orchiopexy and closure​

  1. Scrotal fixation — revascularised testis passed through the inguinal canal (or a neo-hiatus) into the ipsilateral hemiscrotum and fixed inferiorly and laterally within a dartos pouch using standard orchiopexy technique.[3]
  2. Closure — all incisions closed in layers.

Operative times (autotransplantation)​

ParameterTypical value
Total operative time~ 4.25 h
Vascular anastomosis phase40–90 min
Total ischemia time (with hypothermia)60–120 min

Anchor: Giuliani / Carmignani review.[5]

B. Traumatic Testicular Replantation​

Emergent procedure after complete testicular amputation.

Specimen preservation (prehospital / transit)​

  • Amputated testis wrapped in saline-moistened gauze, sealed bag, on ice (not directly on ice to avoid freezing injury).
  • Cold ischemia dramatically extends the window — successful replantation reported with total ischemia 4 h 20 min (3 h warm + 1 h 20 min cold; Altarac) up to 6 h total (Xu).[11][12]

Surgical technique​

  1. Wound exploration and debridement — spermatic-cord stump identified, debrided of nonviable tissue; testicular artery, pampiniform plexus veins, vas deferens individually identified under the microscope.
  2. Specimen preparation — severed ends of testicular artery, veins, and vas identified and freshened.
  3. Microsurgical reanastomosis:
    • Arterial — end-to-end anastomosis of testicular-artery stumps using 9-0 or 10-0 nylon under the operating microscope.
    • Venous — anastomosis of the pampiniform-plexus veins — at least one or two veins must be reanastomosed to prevent venous congestion.
    • Vas deferens — standard vasovasostomy technique (two-layer or modified one-layer with 9-0 or 10-0 nylon for mucosal layer).
  4. Confirmation of perfusion — visual testicular colour change (dusky / pale → pink); Doppler confirmation of arterial inflow.
  5. Orchiopexy — replanted testis fixed in the scrotum.

Xu 1988 illustrative case — bilateral funiculus completely severed (one 0.8 cm proximal to upper pole, the other at funiculus-testis junction). Right-sided testis successfully replanted with total ischemia 6 h; biopsy at 120 d showed germ cells in various stages of development and normal Leydig cells.[12]

Ischemia Tolerance — Key Data​

ConditionGerminal-epithelium preservation
2 h normothermicNo significant destruction
4 h normothermic25%
6 h normothermic8%
4 h hypothermic (4 °C)90%
6 h hypothermic (4 °C)85%
Rabbit model — optimal cold ischemia4 h recommended[13]

Anchors: Harrison[1], Miller hypothermia[8], Qian cold-ischemia I/R model[13].

Technical Pearls and Pitfalls​

  • Vessel size mismatch — testicular artery 0.5–1.0 mm; inferior epigastric artery larger. Mattress sutures or fish-mouth incisions at the smaller-vessel end accommodate the discrepancy.[6]
  • Arterial thrombosis — primary cause of graft failure; almost always technical error at the anastomosis.[6]
  • Venous congestion — second most common cause of failure; ensure adequate venous outflow (at least one good-caliber vein).[10]
  • Antispasmodics — topical papaverine or lidocaine applied to vessels to prevent vasospasm during anastomosis.
  • Anticoagulation — systemic heparinisation (typically 100 IU/kg IV) before vessel clamping; some surgeons also irrigate the vessel lumen with heparinised saline.
  • Avoid tension — anastomosis must be completely tension-free; any tension dramatically increases thrombosis risk.
  • Postoperative management — bed rest 2 d minimum (up to 7 d in some protocols); serial Doppler ultrasound monitoring of testicular perfusion.[3]
  • Modified-interrupted suturing technique (Huang 2020) — needle rested on vessel wall between suture passes improves stability and precision for small-caliber vessels — applicable to testicular autotransplantation.[14]

Robotic-Assisted Approach (Chao 2022)​

da Vinci system for intra-abdominal dissection and vessel mobilisation; undocked for microsurgical anastomosis under operating microscope. At > 1 yr follow-up, transplanted testis remained palpable, stable in size, serum testosterone unchanged.[3]

Outcomes Summary​

Autotransplantation success rates by series​

SeriesnSuccessFollow-up
Bukowski 17-yr review[15]2796%Variable
Boeckx[6]2596%Mean 24 mo
Harrison[1]12100% of follow-up6–30 mo
Wacksman[10]786% (6/7)Variable
Upton[16]1060%Variable

Traumatic replantation​

Starmer 2018 SR — only 8 reported cases of testicular replantation after trauma; viable sperm in ~ 50%. Most common failure causes: prolonged ischemia time and extensive crush injury to vascular supply.[17]

Evidence Limitations​

  • All series are small and retrospective; no RCTs.
  • Autotransplantation outcomes dominated by single-centre series with experienced microvascular teams; generalisability to lower-volume centres uncertain.
  • Robotic-assisted Chao 2022 series is technical proof-of-concept — long-term comparative outcomes vs open microsurgery not yet established.[3]
  • Traumatic replantation evidence is limited to ~ 8 published cases; standardised reporting and PROMs absent.[17]
  • Long-term fertility outcomes post-autotransplantation are sparsely reported.

References​

1. Harrison CB, Kaplan GW, Scherz HC, Packer MG, Jones J. Microvascular autotransplantation of the intra-abdominal testis. J Urol. 1990;144(2 Pt 2):506–507; discussion 512–513. doi:10.1016/s0022-5347(17)39504-6

2. Kolon TF, Herndon CD, Baker LA, et al. Evaluation and treatment of cryptorchidism: AUA Guideline. J Urol. 2014;192(2):337–345. doi:10.1016/j.juro.2014.05.005

3. Chao BW, Shakir NA, Hyun GS, Levine JP, Zhao LC. Robotic-assisted testicular autotransplantation. Urology. 2022;159:255. doi:10.1016/j.urology.2021.09.020

4. Shioshvili TI. Bilateral abdominal cryptorchidism in males: autotransplantation of the testis. Eur Urol. 1985;11(6):386–387. doi:10.1159/000472546

5. Giuliani L, Carmignani G. Microsurgical testis autotransplantation. A critical review. Eur Urol. 1983;9(3):129–132. doi:10.1159/000474066

6. Boeckx W, Vereecken R, Depuydt K. Microsurgery for intra-abdominal testicular retention. Eur J Obstet Gynecol Reprod Biol. 1998;81(2):191–196. doi:10.1016/s0301-2115(98)00190-0

7. Martin DC, Salibian AH. Orchiopexy using microvascular surgical technique. J Urol. 1980;123(3):435–436. doi:10.1016/s0022-5347(17)55972-8

8. Miller DC, Peron SE, Keck RW, Kropp KA. Effects of hypothermia on testicular ischemia. J Urol. 1990;143(5):1046–1048. doi:10.1016/s0022-5347(17)40180-7

9. Urbaniak JR, Soucacos PN, Adelaar RS, Bright DS, Whitehurst LA. Experimental evaluation of microsurgical techniques in small artery anastomoses. Orthop Clin North Am. 1977;8(2):249–263.

10. Wacksman J, Dinner M, Handler M. Results of testicular autotransplantation using the microvascular technique: experience with 8 intra-abdominal testes. J Urol. 1982;128(6):1319–1321. doi:10.1016/s0022-5347(17)53481-3

11. Altarac S. A case of testicle replantation. J Urol. 1993;150(5 Pt 1):1507–1508. doi:10.1016/s0022-5347(17)35828-7

12. Xu YM, Wu P, Cai PC, Cheng ZC. Replantation of the testis: report of a case. J Urol. 1988;139(3):596–598. doi:10.1016/s0022-5347(17)42539-0

13. Qian HJ, Du XJ, Zhang C, et al. Cold ischemia time influences spermatogenesis in a testicular ischemia/reperfusion injury model. Transplant Proc. 2010;42(5):1610–1613. doi:10.1016/j.transproceed.2009.12.058

14. Huang HK, Wang JP, Tu YK. A modified "interrupted" method with resting of the suture needle on the vessel wall for microvascular anastomosis. Microsurgery. 2020;40(1):89–90. doi:10.1002/micr.30522

15. Bukowski TP, Wacksman J, Billmire DA, Lewis AG, Sheldon CA. Testicular autotransplantation: a 17-year review of an effective approach to the management of the intra-abdominal testis. J Urol. 1995;154(2 Pt 1):558–561.

16. Upton J, Schuster SR, Colodny AH, Murray JE. Testicular autotransplantation in children. Am J Surg. 1983;145(4):514–519. doi:10.1016/0002-9610(83)90050-8

17. Starmer BZ, Baird A, Lucky MA. Considerations in fertility preservation in cases of testicular trauma. BJU Int. 2018;121(3):466–471. doi:10.1111/bju.14084