Tabei, S.S., Raheem, O.A.

Testosterone pellet, V-technique, testopel, Testosterone replacement therapy

Long-acting testosterone pellets, granted FDA approval in 1972, became commercially accessible in 2008 under the brand name Testopel ©. These pellets are composed of 75 mg of crystalline testosterone and are inserted into the hypovascular subcutaneous tissue (1, 2). According to FDA recommendations, the administration of 2 to 6 pellets is advised every 3 to 6 months. Testosterone levels are evaluated 1 to 4 weeks after insertion, with the guidance to add 2 pellets if the total testosterone level is below 500 ng/dl and reduce by 2 pellets if it exceeds 1000 ng/dl. Reimplantation is recommended if the total testosterone level falls below 400 ng/dl (3).

Convenience and compliance, along with a reduced risk of secondary exposure compared to gels, make this option favorable. Physician recommendations support its use. However, the high cost is often cited as a significant factor leading to patient dropout (4).

The Standard Technique (ST), also known as the "stacking method," involves stacking all pellets and inserting them into a single tract. On the other hand, the Modified V-Technique (VT) entails inserting pellets along two tracts with a 15-degree angle from the incision site.

Comparing the two techniques, the rates of pellet extrusion are significantly lower with VT at 0.8%, as opposed to ST at 7.5%. Similarly, the incidence of infection is lower with VT at 1.2%, compared to ST at 5% (5).

In this video, we demonstrated the V-technique Testopel insertion from a physician’s point of view.

1. McCullough A. A Review of Testosterone Pellets in the Treatment of Hypogonadism. Curr Sex Health Rep. 2014;6(4):265-9.

2. Kresch E, LTFN, MM, DNA, RR, PM, et al. Efficacy and safety outcomes of a compounded testosterone pellet versus a branded testosterone pellet in men with testosterone deficiency: a single-center, open-label, randomized trial. Sex Med. 2023;11(2):qfad007.

3. Kaminetsky JC, MB, HM, SM. A phase IV prospective evaluation of the safety and efficacy of extended release testosterone pellets for the treatment of male hypogonadism. J Sex Med. 2011;8(4):1186-96.

4. Smith RP, KA, CRM, RS, KJR, MA, et al. Factors influencing patient decisions to initiate and discontinue subcutaneous testosterone pellets (Testopel) for treatment of hypogonadism. J Sex Med. 2013;10(9):2326-33.

5. Conners W, FK, MA. Outcomes with the “V” Implantation Technique vs. Standard Technique for Testosterone Pellet Therapy. The Journal of Sexual Medicine. 2011;8(12):3465-70.