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Testicular Reimplantation (Replantation, Autotransplantation, Experimental Tissue Transplantation)

Testicular reimplantation encompasses two distinct clinical scenarios:

  1. Replantation of a traumatically amputated testis — microsurgical reanastomosis after complete avulsion or amputation (penetrating trauma, self-mutilation, assault).[1][2]
  2. Autotransplantation of a high intra-abdominal testis to the scrotum for cryptorchidism — first described by Silber and Kelly 1976.[5]

A third emerging area is transplantation of cryopreserved testicular tissue for fertility restoration, which remains experimental.[13]

For the operative atlas, see Testicular Reimplantation (atlas page). Related: Genital / Scrotal Trauma, Testicular Prosthesis.

1. Testicular Replantation After Traumatic Amputation​

Rare microsurgical procedure after complete testicular avulsion. Only a handful of cases have been reported, so the evidence is case reports and small series, and no denominator of attempted replantations exists.[2][3]

Etiology. Reported mechanisms are crush-avulsion injuries (for example a tractor accident), penetrating or assault injuries, psychotic self-mutilation and, rarely, wrong-site surgery.[21][22][23] Self-inflicted cases often involve concurrent penile amputation, so evaluate the penis and the rest of the genitalia together, and involve psychiatry alongside the surgical plan.[23]

Amputated part and evaluation. Resuscitate first. Wash the testis with sterile saline, wrap it, double-bag it and keep it cool; cooling and precise microanastomosis are the main determinants of success.[23] Assess the recipient cord stump (artery, pampiniform veins, vas), the degree of crush to the vascular pedicle and the scrotal wound. Postoperative duplex ultrasonography documents perfusion of the replanted testis.[1]

Viability window. No validated ischemia limit exists. The best-documented success had 4 h 20 min total ischemia (3 h warm); reported failures cluster with longer ischemia and extensive crush of the pedicle.[1][3] A 2025 case of bilateral crush-avulsion amputation replanted one testis, whereas the other, with severe vascular damage, could not be replanted; the replanted testis was functional at 15 years.[21] A replantation after a 15-hour delay failed on postoperative day 9.[23]

Alternatives. If replantation is not feasible (delayed presentation, crushed pedicle, no microsurgical service), options are debridement with orchiectomy of the nonviable testis, delayed testicular prosthesis, and testicular sperm extraction or cryopreservation when both testes or nearly all parenchyma are lost.[3]

  • Technique — testicular artery and veins reanastomosed to the spermatic-cord stump using microsurgical technique under the operating microscope; local hypothermia to extend ischemia tolerance.[1][2]
  • Landmark Altarac 1993 case — successful replantation with total ischemia 4 h 20 min (3 h warm), a single case; at 6 months: homogeneous parenchyma on ultrasound, normal Doppler flow, normal semen and testosterone, biopsy with active spermatogenesis and normal Leydig cells.[1]
  • Starmer 2018 SR identified only 8 reported cases of testicular replantation after trauma; viable sperm found after surgery in 5/11 patients across all fertility-preservation approaches (2 TESE, 8 replantations, 1 cryopreservation), not in five of the eight replantations; both TESE cases and the single cryopreservation case obtained sperm. Most common failure causes were prolonged ischemia time and extensive crush injury.[3]
  • Hormonal and fertility outcomes are known only from individual reports: normal testosterone, semen analysis and spermatogenesis on biopsy at 6 months,[1] and endocrine and reproductive function at up to 15 years in one case.[21] These are not rates.
  • ACS Best Practice Guidelines 2025 emphasize testicular preservation where feasible. Complete avulsion requires individualized assessment of ischemia, tissue/vessel damage and microsurgical capability; replantation evidence is limited to rare cases.[4]

2. Testicular Autotransplantation for Cryptorchidism​

For high intra-abdominal testes (~ 5% of cryptorchid cases) where conventional orchiopexy cannot achieve adequate scrotal positioning.[6] Primary orchiopexy and one- or two-stage Fowler–Stephens procedures are established approaches. Autotransplantation is a specialized alternative described in selected series, not a routine replacement for them.[6][8]

Surgical technique (summary): testicular vessels divided high in abdomen; testis mobilised on its vas deferens; microvascular reanastomosis of testicular vessels to inferior epigastric vessels under the operating microscope (25–40× magnification; 9-0 or 10-0 nylon); orchiopexy in dartos pouch. Average operative time ~ 4.25 h; vascular anastomoses 40–90 min.[5][6][7][8] See the 04e operative atlas for full step-by-step.

Success rates​

Seriesn (testes)SuccessFollow-up
Bukowski 17-year review[8]27 (23 patients)96%Variable
Boeckx[9]2596%Mean 24 mo
Harrison[10]12 (10 boys); 8 with follow-up8/8 palpably normal in scrotum6–30 mo
Wacksman[7]7 (of 8 intra-abdominal testes)86% (6/7); 1 venous infarctionVariable
Upton[11]1060% viableVariable

Complications and modern outcomes​

  • Arterial thrombosis — a cause of graft failure; anastomotic technique and vessel condition matter.[9]
  • Venous congestion / infarction — reported in early series.[7]
  • Selected 1990s series reported success above 95%; these are historical specialist results, not contemporary multicenter estimates.[8][9][12]

Robotic-assisted approach (Chao 2022)​

da Vinci robotic system for intra-abdominal dissection and vessel mobilisation; robot undocked for the microsurgical anastomosis under operating microscope. In this single 18-year-old with a solitary intra-abdominal testis, at > 1 yr the transplanted testis remained palpable, stable in size; serum testosterone unchanged.[5]

Advantages vs Fowler–Stephens orchiopexy​

  • Does not rely on collateral blood supply (variable, may be inadequate).
  • Provides a more physiological blood supply to the testis.
  • Particularly valuable for bilateral intra-abdominal testes and cases where prior Fowler–Stephens has failed.[6][8]

3. Experimental — Cryopreserved Testicular Tissue Transplantation​

Emerging area focused on fertility preservation in prepubertal boys undergoing gonadotoxic cancer therapy.[13][14][15][16]

  • 3,000 testicular tissue samples cryopreserved globally.[13]

  • ITTT (immature testicular tissue transplantation) and SSCT (spermatogonial stem cell transplantation) feasibility demonstrated in animal models including non-human primates.[14][13][15]
  • Critical safety concern: risk of reintroducing malignant cells during autotransplantation.[14][13][16]
  • PanCareLIFE Consortium + International Late Effects of Childhood Cancer Guideline Harmonization Group recommend that transplantation of cryopreserved testicular tissue should only be offered in the context of a research protocol given its experimental nature; ASCO 2025 likewise restricts prepubertal testicular tissue cryopreservation to clinical trials.[16][20]
  • Preclinical studies describe graft revascularization and substantial spermatogonial loss; these experimental timelines and survival estimates are not established human fertility outcomes.[17]

While not "reimplantation" per se, the tunica albuginea incision with tunica vaginalis flap (TVF) technique is a related salvage approach for torsed testes that appear ischemic after detorsion:

  • Figueroa 2012 (retrospective, 11 TVF patients) — TVF reduced orchiectomy rates from 35.9% to 15% and achieved a 54.6% salvage rate even in testes with prolonged ischemia (mean 31.2 h).[18]
  • Kim 2025 SR (8 studies; n = 293) — most studies had high risk of bias; comparative pooling did not establish superior salvage with TVF. Consider it selectively rather than as proven protection against atrophy.[19]

See Testicular Torsion.

Key Takeaways​

  • Testicular autotransplantation is an uncommon specialist option; selected historical series report >95% anatomical success, which does not establish normal lifetime fertility.[8][9][12]
  • Traumatic testicular replantation is rare but feasible; ischemia time is the critical determinant of success.[3][1]
  • Cryopreserved testicular tissue transplantation remains experimental and should only be performed under research protocols.[13][16]
  • Microsurgical expertise and minimisation of ischemia time are the two most important factors across all reimplantation contexts.

See Also​

References​

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

2. Flores RL, Hazen A, Galiano RD, Klapper AM, Levine JP. Nonextremity replantation: the management of amputations of the facial parts and testicle. Clin Plast Surg. 2007;34(2):197–210, viii. doi:10.1016/j.cps.2006.10.002

3. 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

4. Johnsen N, Wessells H, Archer-Arroyo K, et al. Best Practices Guidelines: Management of Genitourinary Injuries. American College of Surgeons; 2025. Guideline

5. 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

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

7. 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

8. 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.

9. 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

10. 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

11. 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

12. Bukowski TP, Wacksman J, Billmire DA, Sheldon CA. Testicular autotransplantation for the intra-abdominal testis. Microsurgery. 1995;16(5):290–295. doi:10.1002/micr.1920160503

13. Safrai M, Goossens E, Mitchell RT, et al. Is the time right for transplanting immature testicular tissue or cells to restore male fertility? Expert perspectives on clinical implementation of autotransplantation of cryopreserved testicular tissue or cells for fertility restoration. Best Pract Res Clin Obstet Gynaecol. 2025;102:102638. doi:10.1016/j.bpobgyn.2025.102638

14. Kilcoyne KR, Mitchell RT. Fertility preservation: testicular transplantation for fertility preservation — clinical potential and current challenges. Reproduction. 2019;158(5):F1–F14. doi:10.1530/REP-18-0533

15. Pelzman DL, Orwig KE, Hwang K. Progress in translational reproductive science: testicular tissue transplantation and in vitro spermatogenesis. Fertil Steril. 2020;113(3):500–509. doi:10.1016/j.fertnstert.2020.01.038

16. Mulder RL, Font-Gonzalez A, Green DM, et al. Fertility preservation for male patients with childhood, adolescent, and young adult cancer: recommendations from the PanCareLIFE Consortium and the International Late Effects of Childhood Cancer Guideline Harmonization Group. Lancet Oncol. 2021;22(2):e57–e67. doi:10.1016/S1470-2045(20)30582-9

17. Li JT, Zhang L, Liu JJ, et al. Testicular damage during cryopreservation and transplantation. Andrologia. 2021;53(10):e14191. doi:10.1111/and.14191

18. Figueroa V, Pippi Salle JL, Braga LH, et al. Comparative analysis of detorsion alone versus detorsion and tunica albuginea decompression (fasciotomy) with tunica vaginalis flap coverage in the surgical management of prolonged testicular ischemia. J Urol. 2012;188(4 Suppl):1417–1422. doi:10.1016/j.juro.2012.02.017

19. Kim J, Lorenzo A, Rivera KC, et al. Effectiveness of tunica albuginea incision and tunica vaginalis flap for testicular torsion: a systematic review. World J Urol. 2025;43(1):246. doi:10.1007/s00345-025-05638-w

20. Su HI, Lacchetti C, Letourneau J, et al. Fertility Preservation in People With Cancer: ASCO Guideline Update. J Clin Oncol. 2025;43:1488–1515. doi:10.1200/JCO-24-02782

21. Erçöçen AR, Zereyak U. Successful Testis Replantation After Bilateral Traumatic Testis Amputation With a 15-Year Follow-Up of Functional Testis: A Case Report. Microsurgery. 2025;45(5):e70074. doi:10.1002/micr.70074

22. Tuncer FB, Frautschi RS, Lundy SD, Haber GP, Gastman B. First Report of Testicular Replantation Following Wrong-Site Surgery. Urology. 2022;164:267–272. doi:10.1016/j.urology.2021.11.044

23. Abdella MK, Gebreselassie KH, Kurabachew HA. Self-inflicted penile and testicular amputation: a very rare case report and treatment dilemma in the absence of microsurgical service. Int J Surg Case Rep. 2024;122:110043. doi:10.1016/j.ijscr.2024.110043