History of Orchiopexy for Cryptorchidism 157 taching the testis to the inguinal region and then to the floor of the scrotum. His theory was that the gubernacular mes- enchyme could be disrupted by surrounding fibrous tissues to cause undescended or maldescended testis. He proposed that ‘a fibrous band is formed (a ‘‘tail of Lockwood’’) which anchors the gubernaculum and later the testicular appara- tus to the surrounding tissues, and, by virtue of the proc- essus vaginalis having being formed normally elsewhere, the descending testis is diverted from its course in the direc- tion of the band. This then is the aetiology of an ectopic tes- tis and also the formation of the tails of Lockwood, which are a pathological feature rather than a normal component of the gubernaculum.’ According to his theory, the tail of Lockwood indicated either a gubernacular process or an ab- normal fibrous attachment, causing great confusion [15,16]. 　By the mid 1980s most investigators completely rejected the theory of multiple gubernacular tails providing trac- tion to cause testicular descent. In 1987, Heyns published a landmark paper describing testicular descent in 178 hu- man fetuses, the largest number of fetuses examined at the time. What he found was no inclusion of muscle in the gu- bernaculum and singular rather than multiple processes of distal gubernaculum [17]. 　At present, many studies have now shown conclusively that multiple gubernacular processes (or tails) do not exist and that the distal gubernaculum is unattached to sur- rounding tissues during inguinoscrotal migration in both rodents and humans. Attachment to the scrotum (or else- where) occurs only after normal (or abnormal) testicular descent is complete. Although some recent papers still re- ferred to tails of Lockwood as a cause of ectopic testis and even transverse testicular ectopia, it is certainly time to dispel the myth of the tails of Lockwood as a cause for ec- FIG. 1. Theories of testicular ectopia [8]. (A) Old theory: Mythical ‘tails of Lockwood’ was used to explain the location of ectopic testis because the gubernaculum pulled the testis into position. (B) Current theory: The testis migrates to the scrotum (or elsewhere) attached to the guber- naculum, with subsequent regression of the gubernaculum and formation of a secondary fibrous attachment (known as the gubernacular ligament). topic testis. THE FIRST ATTEMPT AT SURGICAL CORRECTION OF CRYPTORCHIDISM Before the periods when orchiopexy was widely accepted, an inguinal ascended testis was managed primarily with the use of truss or castration. 　It was said the surgery for correction of undescended tes- tis was attempted by several German doctors such as J.F. Rosenmerkel of Munich in 1820 and M.J. von Chelius in 1837 [4]. However, the first recorded attempt was per- formed by James Adams in the London Hospital in 1871 on an outpatient. His reason for correction was shown in the Lancet published at that time [18]. He proposed 3 rea- sons to operate on an undescended testis: poor scrotal de- velopment due to cryptorchidism, the risk of atrophy of the abdominal testis, and the likelihood of injury or pain asso- ciated with the abnormal location. He reported on one 11-week-old patient who was referred for an empty left scrotum, normal right testicle and an “oval swelling in the perineum, to the left of the middle line.. in front of the anus.” Adams performed the orchiopexy with Curling through a 1.5 inch incision over the external ring. The spermatic cord and testicle were freed from attachments. The tunica vagi- nalis was uninjured and a catgut suture was used to affix the testicle into the scrotal pouch, after which the wound was closed. Owing to the high prevalence of erysipelas in the hospital, the operation was performed on an outpatient basis and the child was sent home. Nevertheless, the pa- tient developed a wound infection on postoperative day 3 that progressed to fatal erysipelas. Adams personally per- formed the autopsy and concluded that ‘‘death was caused by peritonitis commencing in the tunica vaginalis and ex- Korean J Urol 2010;51:155-160