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One stage rotation flap scrotoplasty and orchidopexy for the correction of
ectopic scrotum: A case report

Article  in  Urology Case Reports · April 2019

DOI: 10.1016/j.eucr.2019.100886

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 Urology Case Reports 25 (2019) 100886

Contents lists available at ScienceDirect

Urology Case Reports

journal homepage: www.elsevier.com/locate/eucr

Trauma and reconstruction

One stage rotation flap scrotoplasty and orchidopexy for the correction of T
ectopic scrotum: A case report
Irfan Wahyudi, Isaac Ardianson Deswanto∗, Gerhard Reinaldi Situmorang, Arry Rodjani
Department of Urology, Faculty of Medicine of University of Indonesia, Indonesia

ARTICLE INFO ABSTRACT

Keywords: Ectopic scrotum (ES) is a particularly rare congenital malformation of the scrotum and commonly associated
Ectopic scrotum with other congenital malformations. A 2-year-old boy was presented with ectopic scrotum, low lesion im-
One stage rotation flap perforate anus, spina bifida and pubic diastasis since birth. There are various surgical methods available to be
Scrotoplasty discussed in the management of ES. We performed correction of the ectopic scrotum and concomitant bilateral
Orchidopexy
orchidopexy in one stage of surgery. This procedure is relatively simpler to perform and gives out favorable
cosmetic result.

Introduction diatric orthopedics to be left alone due to the risk of surgery out-
weighing the benefits. We performed correction of the ectopic scrotum
Ectopic scrotum (ES) is a particularly rare congenital malformation and bilateral orchidopexy in one stage of surgery.
of the scrotum and commonly associated with other congenital mal- An inguinal incision was first performed on the left side to mobilize
formations. The ectopic scrotal location is variable, and the testicles the funiculus until the left testis was able to be moved down to the
may be present or absent in the abnormal scrotum. ES can occur in anatomical position of the scrotum. This was followed by correction of
various locations, starting from the perineum and inguinal canal to the the ectopic scrotum that was initiated with a Y incision that extends
medial thigh, majority of which are usually found in the inguinal, su- from the right hemiscrotum until it reached the ectopic scrotal sac
prainguinal, infrainguinal, or perineal area. A defect in the guberna- (Fig. 1). An inguinal rotational scrotal skin flap was used to relocate the
culum formation during the conception period is hypothesized to be scrotal sac (Fig. 2). The median raphe and two hemiscrotum sacs were
strongly associated with the development of ES.1 constructed inferiorly to the penis, where the scrotal sac should have
formed. Bilateral orchidopexy was performed afterwards, started with
Case presentation positioning the left testis in the left hemiscrotum sac with the fixation of
tunica vaginalis using Vicryl® 4.0 with anchoring suture in the 6 0′clock
A 2-year-old boy was presented with ectopic scrotum, anal atresia, direction. The fixation of the right testis to the right hemiscrotal sac was
spina bifida and pubic diastasis since birth. The child underwent pos- also performed afterwards followed by adequate skin closure.
terior sagittal anorectoplasty in June 2016, followed by spina bifida
closure in February 2017. Upon clinical examination, right hemi- Discussion
scrotum was normal in size and location with normal testicle located in
the high scrotal position. The left hemiscrotum was present in the left Congenital abnormalities of the scrotum are rare medical conditions
inguinal region, with the left testicle located below the superficial in- which usually include 4 distinct groups of anomalies starting from pe-
guinal ring. Scrotal raphe and the phallus developed normally. The noscrotal transposition, bifid scrotum, accessory scrotum and finally
sizes of both testicles were approximately 30 × 20 mm. Pelvic X-ray ectopic scrotum. The beginning of scrotum development starts at 4
revealed pubic diatheses which were decided in a conference with pe- weeks of gestation that was initiated by the formation of labio-scrotal

∗
Corresponding author. Department of Urology, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunksuumo General Hospital, Jl. Pangeran Diponegoro
No.71, RW.5, Kenari, Senen, Kota Jakarta Pusat, Daerah Khusus Ibukota Jakarta, 10430, Indonesia.
E-mail address: isaacdeswanto@yahoo.com (I.A. Deswanto).

https://doi.org/10.1016/j.eucr.2019.100886
Received 17 January 2019; Received in revised form 8 April 2019; Accepted 9 April 2019
Available online 10 April 2019
2214-4420/ © 2019 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
I. Wahyudi, et al. Urology Case Reports 25 (2019) 100886

compressions. Rather, this may because by a single dysmorphogenic

event during the late blastogenesis period.2,3
There are various surgical methods available to be discussed in the
management of ES. Daniel et al. shared their experience of performing
rotation flap scrotoplasty followed by subsequent orchidopexy in the
following 6 months after the first surgery.4 On the other hand, Filho
et al. used perineal scrotal skin flaps to prepare the scrotal sac.5 A single
staged rotation flap scrotoplasty with immediate orchidopexy formed
the basis of reconstructive repair in our patient. This procedure is re-
latively simpler to perform and gives out favorable cosmetic result.
Despite the various reparative techniques available in the literature,
there is no definite rule as to which surgical approach is more superior
to another. Choosing which procedures to perform depends on the
competency as well as the preference of the surgeon.

Conclusion

To conclude, ectopic scrotum is speculated to be caused by defective

gubernaculum formation and is very well oriented with other con-
genital malformations such as anorectal malformation, spina bifida or
pubic diastasis as presented in this case. We performed a single stage
rotational flap scrotoplasty and bilateral orchidopexy with favorable
cosmetic results and adequate testicular descent.
Fig. 1. A. Clinical Features; B. Marked Flap Incisions; C. Pelvic X-ray showing
Pubic Diastasis. Consent

Written informed consent was obtained from the patient for pub-
lication of this case report and accompanying images. A copy of the
swellings. These labio-scrotal swellings are located laterally to the written consent is available for review by the Editor-in-Chief of this
cloacal membrane and posteriorly to the genital tubercle. In the 12 journal.
weeks of gestation, they start to move inferomedially and fuse together,
thus forming the scrotum. The descent of testes into the scrotum occurs Conflicts of interest
with the insertion of gubernaculum into the labio-scrotal swellings. Any
defects in the formation of gubernaculum can impair or even prevent The authors declare that they have no competing interests.
the migration and fusion of labio-scrotal swellings, therefore resulting
in ectopic scrotum and concurrent malposition of the testes. The causes Authors’ contributions
of defective gubenarculum formation can be mechanical, genetic,
chromosomal or teratogenic. A mechanical pressure effect on the de- I.W, I.A.D, G.R.S and A.R all performed the review of literature,
veloping fetus usually occurs in pregnancies complicated by oligohy- performed patient care, and were major contributors in writing the
dramnios and breech presentation. These conditions together with manuscript. All authors read and approved the final manuscript.
disproportionate size of the fetus may lead to an abnormally flexed limb
posture. This causes the contralateral heel to directly press on the re- Funding
gion of developing scrotum. On the other hand, association of lower
spine agenesis with pubic diastasis as in this case, may be attributed to This research did not receive any specific grant from funding
more than just a defect that is caused by direct mechanical agencies in the public, commercial, or not-for-profit sectors.

Fig. 2. A. Marked flap before beginning incision; B. Raised Flaps and 6 months post Op Follow Up.

2
I. Wahyudi, et al. Urology Case Reports 25 (2019) 100886

Acknowledgements ectopic scrotum in a neonate : case report and literature review. Pediatr Int.
2012;54:575–576.
2. Bawa M, Garge S, Sekhon V, Rao K. Inguinal ectopic scrotum, anorectal malformation
The authors would like to thank the staff of Urology of Cipto with sacral agenesis and limb defects: an unusual presentation. J Korean Pediatr Surg.
Mangunkusumo Hospital that took part in the care of these patients. 2015;21(2):32.
3. Hoar RM, Calvano CJ, Reddy PP, Bauer SB, Mandell J. Unilateral suprainguinal ec-
topic scrotum: the role of the gubernaculum in the formation of an ectopic scrotum.
Appendix A. Supplementary data Teratology. 1998;57(2):64–69.
4. Daniel G, Coleman R. Staged rotation flap scrotoplasty and orchidopexy in a patient
Supplementary data to this article can be found online at https:// with inguinal ectopic scrotum. J Surg Case Rep. 2015(10):1–3.
5. Sobral Filho DSR, da Silva HD, Damazio E. Surgical correction of ectopic penis and
doi.org/10.1016/j.eucr.2019.100886. scrotum associated with bilateral orchidopexy. Einstein. 2017;15(2):223–225.

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