There are doctors who are there to save mankind, to say the least. A surgeon called Alain Lironi is known beyond Switzerland – he is a pediatric surgeon who operates on children from all over the world. We came to interview him about pediatric cardiology but suddenly we moved to another important topic that doctor Lironi specializes in: operations on testes in boys.
The significance of the problem can hardly be overstated: about one boy out of one hundred has improperly developed testes! And this can influence whether or not he can have children of his own in future, if his kind can reproduce and so if mankind itself can…
Precision is one of the most important factors in this delicate sphere and it must be observed. Parents must notice the defect in time and the operation must be performed in time – no sooner, no later. And, of course, the, most important factor is the surgeon’s hands. a six-month-old baby is the future of man and what he will become depends on a balance between all three factors. Our conversation concerns what the Hospital La Tour Geneve clinic does for boys in order for them to grow healthy.
– One of the most common problems in boys is when the testes are located improperly, are not visible during external inspection and cannot even be touched. The thing is, in the prenatal stage, they are developed in the abdominal cavity next to the kidneys and gradually come down to the groin, and then they shift to scrotum, usually on the eve of the birth. But sometimes it doesn’t happen and then you must consult a doctor.
It happens quite often, about 1 case in every 100 boys. If they are not operated on in time, cancer can develop 20 years later. When the testes are not lowered they are either excised or relocated to the proper place. It is a very common operation and foreign patients often come to us to have it.
– Can you avoid surgery?
– Surgical intervention is not always necessary. Sometimes you can resolve the problem without an operation. It all depends on the age of the boy and on the circumstances. We observe babies younger than one year and the final diagnosis is made 6 months later because there is a chance that the testes will fall into place by themselves. But if it doesn’t happen then we have to perform the operation in a year because there is a risk to the reproductive function: the boy loses the capacity to develop spermatozoid cells every month.
– Are there age restrictions for the operation?
– In some countries surgery is done when it is too late – 5–6 years. And the result is worse. We think the boys should be operated on when they are younger than 2 years old. It is too hard to do it at a younger age – the baby’s organs are still too small, and the anesthesia is too much for the body to bear (this question is discussed with the anesthesiologist separately). We prefer waiting until the baby turns one year old: medicine has already proved that the best time for surgery is from 1 to 2 years. Of course, there are cases when we have to operate earlier (in the case of a strangulated hernia). But usually the problem doesn’t require immediate action, doesn’t bother the baby and disturbs only the mother and father who want their baby to be 100% healthy.
– So, it’s really important that the parents notice the defect and bring the baby to the doctor, isn’t it?
– Yes, if you have the slightest suspicion that there is something wrong with the testes you have to have a clinical examination – it is very important.
– Does the surgery take place under general anesthetic?
– Yes, we use general anesthetic. We can also use spinal anesthesia or combine the two methods of anesthesia.
– Is it major surgery?
– No, it’s not. Of course, it is delicate as we are speaking about the testes. If the testis is not found with a clinical or radiological examination, we have to use laparoscopy. First, we insert a 5 mm camera. We see vessels that go from the kidneys, we see the deferens channel. Then we insert tools through the abdominal cavity and place the testis in proper place during one operation. When the testis is palpable in the inguinal area (or detected by US), we can use an inguinal approach without using laparoscopy. In some cases, reoperation may be necessary. If the testicle is too small we have to excise it as there is risk of oncogenesis.
– This is, for sure, the saddest scenario…
– Indeed. When necessary, we can do a testicular implant later (in adolescence) though I usually try to talk the patient out of it as it gives only an aesthetic effect. But sometimes young people of 1617 years come to me and say: «I cannot start sexual relationships with a girl with only one testis». That is, they had surgery in childhood and now it is time to communicate physically with girls and a new problem emerges. Then we make a prosthesis.
– Do we know the reasons why developmental defects of the testes appear?
– Medicine doesn’t know. Perhaps it lies in genetic factors, in 10–15% of cases. The environment surely has an adverse impact on it. We have more and more urogenital malformations because of it and this concerns not only people but animals as well.
– Are such problems of the testes growing?
– Yes, every year. When I started my surgical practice in the university, such cases would be seen once a month and we craved the operation, as every young doctor needs practice. Now I operate every week, more than 50 times a year. Of course, it’s not an official statistic. But it is thus for my practice. And at every conference, medics say that these diagnoses are getting more and more common.
– In which cases do you refuse to operate?
– Even if parents bring patients in too late – when they are more than 7 years old – we will still take on the operation. As a rule, the biopsy shows that there is no sperm in the testes. But it is possible and, moreover, necessary to perform surgery, as even though the testicle doesn’t produce sperm, it is necessary for testosterone production. And we need to control the situation in the future: we must watch to see the testis grows or not. If the child is in adolescence already (11–12 years old) and the testis doesn’t grow, it must be excised as it is too risky to keep it. But even if it develops properly, we still need to observe it from time to time, and you must consult the doctor if there are any abnormal feelings or changes because the risk of oncogenesis is too high.
– But if the surgery was done in time and it was successful, there will not be consequences in future, will there? The boy can forget about the problem, right?
– It all depends on how the testes are developing. Sometimes, we perform the operation, relocate them to the proper place but then observe a congenital abnormality – the size is not normal or the anatomy is not normal. In such cases, we discuss the following question with parents: should we keep the testis or not? – and then we discuss options. Usually we give the testicles time to bounce back. But if they don’t grow and don’t develop as they are supposed to, then reoperation for removal will follow. If the size is normal and the development is ok, then the chances of the boy having no problems in the future are good.
Usually, the size of the testes directly correlates to the functionality: if the size is good then the testes function well.
– Do you use robotics during surgery?
– I see no sense in using robots – laparoscopy itself is much more effective. Of course, you have more freedom with a robot, you see everything clearly. However, you don’t feel what you’re doing. And it is really important for the pediatric surgeon to feel everything with his hands, as the organs of the baby are so small. For me, the main argument lies in the question, «Are there advantages for the patient?» This is usually expensive surgery, as sophisticated technologies are used. The tool that must be inserted into the body must be really small. And I use tools that are 3–4 mm in diameter. Why do I need a robot? I don’t want to close the doors on new technologies but for now I don’t see robots as useful to my patients.
– Now, much emphasis is placed on men’s health and the fact that it leaves much to be desired – do the problems really begin in childhood?
– Of course, many dysfunctions have their roots in childhood. And more often than not they can be avoided by a timely consultation with a doctor. Different countries deal with this topic differently. I also research children’s development in other parts of the world because I take part in a mission (I was in Africa, South Sudan and other countries). We examine, we operate. They have many other problems, though – when disturbances and civil war began, people (including children) with gunshot wounds were brought into our hospital, so any other problems receded into the background.
– Why did you decide to go into pediatrics? Many doctors find this sphere too complicated.
– First, I was a general surgeon. I fell into pediatrics: I was acquainted with the chief of the pediatric department, they had a free place and they called me. I thought, «Why not»? And now I really like this sphere – here I create, here I mould a child’s health for many years to come and I do not only remove something. In pediatrics, I give a child a different future.
Alain Lironi
A member of the Swiss Medical Association, and an expert in the sphere of surgery and children’s surgery in the Hopital de la Tour. He studied medicine in Switzerland, in the University of Geneva; he qualified in 1983.
He practiced in the leading clinics of Switzerland in different spheres of surgery. He was the chief resident in the ambulatory surgery unit (HUG, 1988–1989); in visceral surgery (HUG, 1989–1990, 1992–1993); in general surgery (Hopital des Cadolles, 1990–1992); in pediatric surgery (HUG, 1993–1995), in pediatric surgery (Necker, Enfants Malades, 1995), one of the heads of pediatric surgery (HUG, 1996–2001), and is an external consultant (HUG) to this day.
A participant of medical associations: a member of the AMG (Association of Medics of Geneva) board of directors since 2005; a member of the Swiss unit of «Medecins du Monde» (Doctors of the World), 2011–2014.
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