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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.

  • 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); 6-mo follow-up: 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 in ~ 50%; most common failure causes were prolonged ischemia time and extensive crush injury.[3]
  • ACS Best Practice Guidelines 2025 emphasise that surgeons should make every effort to salvage affected testicles in trauma; microsurgical replantation is the current reconstructive solution.[4]

2. Testicular Autotransplantation for Cryptorchidism​

For high intra-abdominal testes (~ 5% of cryptorchid cases) where conventional orchiopexy cannot achieve adequate scrotal positioning.[6] AUA Cryptorchidism Guideline lists 3 options for intra-abdominal testes: primary orchiopexy, one-stage Fowler–Stephens, two-stage Fowler–Stephens — autotransplantation is an alternative when these are not feasible or have failed.

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]2796%Variable
Boeckx[9]2596%Mean 24 mo
Harrison[10]12100% of follow-up6–30 mo
Wacksman[7]786% (6/7)Variable
Upton[11]1060%Variable

Complications and modern outcomes​

  • Arterial thrombosis — primary cause of graft failure; almost always technical at the anastomosis.[9]
  • Venous congestion / infarction — reported in early series.[7]
  • Failure rates have decreased with improved microsurgical technique; modern series report > 95% success.[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. At > 1 yr follow-up, 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.[16]
  • Neoangiogenesis in transplanted grafts initiates around day 3 and is generally complete by day 7; spermatogonia survival ~ 37–41% of fresh controls.[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 — 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 (n = 293) — TVF may preserve testicular volume and prevent orchiectomy; outcomes depend heavily on ischemic duration.[19]

See Testicular Torsion.

Key Takeaways​

  • Testicular autotransplantation for high intra-abdominal testes is a well-established microsurgical procedure with > 95% success in experienced hands.[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.

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.

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