Laparoscopy in the Management of Impalpable Testicle

Purpose : In paediatric urology, one of the main applications of laparoscopy is the evaluation and treatment of impalpable testis. Herein we present our initial experience with laparoscopy in patients with impalpable testis. Material and Methods : Laparoscopy was performed under general anaesthesia on 13 patients. If the internal spermatic vessels and vas deferens made their way into the internal inguinal ring, the inguinal canal was dissected. Laparoscopic orchiopexy or orchiectomy was performed in cases with intra-abdominal testis. If the internal spermatic vessels found terminated intraperitoneally with a blind-end, the case was considered as a vanishing testis.

Results : Thirteen boys, aged from 18 months to 25 years (median 9.8 years) were identified with 21 impalpable testes. 14 of the 21 impalpable testes, the vas and the vessels were through the internal ring, and the inguinal region needed dissection. Orchiopexy was performed on 12 testes and orchiectomy was performed on two atrophic testes. Four of 21 testes were intra-abdominally localized. Laparoscopic orchiopexy was performed in two testes and laparoscopic orchiectomy was performed in two testes. Two boys were diagnosed as vanishing testes; the absence was unilateral on the left side in one case and bilateral in the other.

Conclusion : Diagnostic laparoscopy is a very helpful, minimally invasive technique in the diagnosis of impalpable testes especially when ultrasonography and/or computed tomography are not informative enough. In addition, orchiectomy and orchiopexy can be done as laparoscopically in the patients with intra-abdominal testes. Therefore, the laparoscopy has an important role in the diagnosis and treatment of impalpable testes.     

Management of an impalpable testis: the role of laparoscopy.

The use of laparoscopy through a small infraumbilical incision permits noninvasive exploration of the pelvic fossae. The vas deferens as well as the spermatic vessels can be identified either with the testicle or as a blind ending. Twenty-six laparoscopies were performed on 19 patients with unilateral impalpable testis and 7 with bilateral impalpable testis. In this small series, laparoscopy was found to be the best method of locating the impalpable testis, and, depending on the laparoscopic findings, no further surgery or a simple inguinal exploration or abdominal incision is needed for the management of this condition.     

Scrotal nubbins associated with blind-ending spermatic vessels and a normal vas deferens on laparoscopy

Objectives:   To determine whether a scrotal nubbin is present in children with unilateral non-palpable testis when diagnostic laparoscopy demonstrates blind-ending vessels and a normal vas deferens entering a closed internal ring.
Methods:   Eighty consecutive patients with a unilateral nonpalpable testis were retrospectively reviewed. Patients underwent initial diagnostic laparoscopy, and, if needed, subsequent inguinal exploration was performed. On inguinal exploration, any testicular remnant or nubbin-like tissue was removed and evaluated histologically. Patients with a patent processus vaginalis were excluded from this analysis.
Results:   Overall, 60 of the 80 patients had neither an abdominal testis nor a patent processus vaginalis. Of these 60, 34 patients had both a vas deferens and spermatic vessels entering a closed internal ring, and all of these underwent inguinal exploration. A total of 17 patients had both a blind-ending vas deferens and blind-ending spermatic vessels; no inguinal exploration was attempted. In nine patients, laparoscopy revealed blind-ending vessels with a normal vas deferens entering the closed internal ring. Of these nine, six underwent inguinal exploration, and a scrotal nubbins was found in three. At histological examination, hemosiderin deposit and calcification were seen in the nubbin tissue. No viable germ cell was detected in these specimens.
Conclusions:   A laparoscopic finding of blind-ending vessels above the closed internal ring does not mean intra-abdominal vanished testis, regardless of the appearance of the vas deferens.     

Intra-abdominal testis with loop-like epididymis and intra-canalicular vas and vessels

A case of intra-abdominal testis with loop-like epididymis and intra-canalicular vas and vessels is presented. A 3-year-old male with left impalpable testis since birth was admitted to our department. Physical examination and ultrasonography were inconclusive. Laparoscopy revealed a small left abdominal testis with surrounding adhesions close to the left-obliterated umbilical artery. The vas deferens and spermatic vessels were entering into the internal inguinal ring. The processus vaginalis was patent. At inguinal exploration the testis was atrophic and the epididymis was loop-like, joining the vas deferens in the inguinal canal. The spermatic vessels continued to the atrophic testis in a loop-like manner. The testis, epididymis and the vas deferens were removed. Histopathological examination of the testis revealed Sertoli cells only. If inguinal exploration had been performed without laparoscopy, the presence of the vas deferens and spermatic vessels in the inguinal canal with the absence of the testis could have been misdiagnosed as vanishing testis. Abdominal testis would thus have been missed, with increased risk of complications, particularly malignancy.     

Indications, technique and outcomes of the one-time laparoscopic orchidopexy

The investigation of a male with impalpable testes is one of the most frequent diagnostic indications of laparoscopy and it is accepted as a therapeutic tool for the treatment of the intra-abdominal testis. We have studied thirteen patients being surgically operated by a video-assisted orchidopexy without spermatic vessels section. The technique consists of wide mobilization of the spermatic vessels and the vas deferens from the posterior peritoneum, sectioning the gubernaculum and descending of the testis to the scrotum. In all the cases, the internal groin ring was later closed by means of a laparoscopy. There were no intraoperative complications. In 100% of the cases, the testis was descended to the scrotum. The surgical time oscillated between 40 and 80 minutes (60 minutes mean). At follow-up from 6 months to 4 years, the outcome was satisfactory in 11 patients, whereas in 2 cases the operated testis ascended.     

Avoidance of inguinal incision in laparoscopically confirmed vanishing testis syndrome

PURPOSE: Nonpalpable testicles may be due to the vanishing testis syndrome, intra-abdominal position, examination obscured by obesity or scar tissue and rarely testicular agenesis. Laparoscopy is an excellent means of distinguishing these entities without the need for open abdominal exploration. We investigated whether laparoscopy affects the need for an inguinal incision and exploration when no testicle is palpable and the vas and vas deferens are visualized exiting the internal inguinal ring on laparoscopy. MATERIALS AND METHODS: In 34 boys 6 to 18 months old (mean age 41) physical examination demonstrated a nonpalpable testicle, including on the right side in 12, on the left side in 17 and bilaterally in 5. The vanishing testis syndrome was diagnosed after laparoscopy when no testicle was palpable despite physical examination done with the patient under anesthesia, spermatic vessels were visualized exiting the internal inguinal ring or spermatic vessels were visualized in the abdomen with or without an identifiable intra-abdominal testicular nubbin. RESULTS: Laparoscopy confirmed the vanishing testis syndrome in 16 patients, intra-abdominal testicles in 13 and peeping testes in 1. Adequate examination using anesthesia was not possible in 4 patients with obesity, or previous inguinal or lower abdominal surgery. These boys underwent inguinal exploration after laparoscopy showed the vas and vessels exiting a closed internal inguinal ring. Of the 16 cases of the vanishing testis syndrome orchiectomy with contralateral scrotal orchiopexy was performed in 14 through a median raphe scrotal incision and in 1 through an inguinal incision for an associated inguinal hernia. In the remaining patient who underwent laparoscopy only a blind ending vas and vessels were visualized in the abdomen without an identifiable nubbin. The infraumbilical and median raphe incisions healed without obvious scars. Followup was at least 1 year. CONCLUSIONS: When spermatic vessels are visualized exiting the internal inguinal ring on laparoscopy in the setting of a nonpalpable testicle, a median raphe scrotal incision can be made to remove the testicular nubbin associated with the vanishing testicle syndrome. Orchiectomy is possible through this median raphe incision even when the testicle is in the inguinal canal because this distance in young children is small. Cosmesis is excellent since 1 incision is within the umbilicus and the other is on the median scrotal raphe.     

腹腔镜下手术治疗腹股沟型隐睾

目的 探讨腹腔镜下睾丸固定术治疗腹股沟型隐睾的可行性及微创优势. 方法 腹股沟型隐睾患儿90例.年龄8个月～6岁,平均17个月.左侧24例、右侧53例、双侧13例,共103个睾丸.腹腔镜下离断鞘状突或疝囊,松解腹膜后精索,将睾丸拉入腹腔,离断引带;将睾丸拉入阴囊固定. 结果 90例103个睾丸手术均顺利,无中转开放手术者.平均手术时间(32.7±5.2)min.103个睾丸患侧鞘状突未闭93侧(90.3%);77例单侧隐睾对侧鞘状突未闭12例(15.6%).术中发生皮下气肿3例(3.3%),拔出套管后,经切口排出气体,气肿消失.术后随访6～12个月,103个睾丸均在阴囊内,无萎缩及睾丸回缩. 结论 腹腔镜下腹股沟型隐睾固定手术安全、有效,弥补了开放术式破坏腹股沟管解剖完整性、腹膜后高位松解困难等缺陷.     

Laparoscopy for the impalpable testes: experience with 53 testes.

Impalpable testes constitute approximately 20% of most series of undescended testes. From January 1986 to March 1991, we performed laparoscopies on 53 patients with impalpable testes. Thirty-two of them were found to have normal vasa and vessels entering each internal ring on the side in question. Of these, 14 were found to have "vanishing testes" at exploration, 12 others underwent successful orchiopexy, and the remaining 6 had excisional biopsies of fibrotic testicular remnants. Five patients had no visible vessels and a sixth had a blind-ending vas and vessels adjacent to the internal ring; in these cases no further investigations were deemed necessary. Fifteen patients were found to have abdominal testes and underwent high testicular vessel ligation and division at the time of the laparoscopy; 14 of them have undergone staged orchiopexy 6 months after laparoscopy and one is scheduled for this procedure. A 3-month follow-up of those who had orchiopexy showed excellent results in 10 patients and poor results in 3, all of whom had small testes that were unimproved or worse following vessel ligation. Four boys were spared operations as a result of findings at laparoscopy. Early in the series there was one failed laparoscopy, but it was successfully completed later. the procedure, but it was successfully treated with antibiotics. There were no other complications. Laparoscopy is a safe procedure that allows accurate diagnosis and may prevent additional intervention in the treatment of the absent testes. It facilitates the locating of the impalpable testis and the planning and timing of subsequent orchiopexy. We believe that laparoscopy is the preferred procedure in the management of impalpable testes.     

Laparoscopic examination of the nonpalpable testis

We evaluated the results and advantages of laparoscopic examination in 28 patients with 32 nonpalpable testes. Between April 1991 and May 2006, 28 patients, 12 months to 12 years old, with 32 nonpalpable testes underwent diagnostic laparoscopy under general anesthesia before surgical management of the testes. If the blind end of the vas deferens and/or spermatic vessels was observed, the diagnosis of vanishing testis was made, and no further examination or treatment was performed. If intra-abdominal testis was observed, laparoscopic orchiectomy or open orchiopexy was performed. If the internal spermatic vessels and vas deferens entered into the internal inguinal ring, the diagnosis of intra-canalicular testis was made so that the inguinal canal was opened for surgical interventions. Of the 32 nonpalpable testes 10 were on the right side and 22 were on the left side (4 patients had bilateral undescended testes). There were 7 (21.8%) vanishing, 5 (15.6%) intra-abdominal and 20 (62.5%) intra-canalicular testes. There were no complications related to laparoscopy. Laparoscopy can be safely performed to assess the location of the non-palpable testes. Another advantage of the laparoscopic examination is that orchiopexy or orchiectomy can be immediately performed after the examination to avoid a second surgery.     

LAPAROSCOPY FOR THE NON-PALPABLE TESTIS: A REVIEW OF TWENTY-EIGHT PATIENTS (1988–90)

The applications of laparoscopy as a diagnostic and therapeutic tool are being continually expanded and applied to the younger patient. In this study, 28 boys with 32 non-palpable testes underwent laparoscopy as part of their management. The patients' ages ranged from 10 months to 13 years. There was one failed laparoscopy and one minor complication. Blind ending vas deferens and vessels proximal to the deep inguinal ring were noted in six patients and no viable testes were found in these boys. Five abdominal testes were noted; three underwent scrotal fixation, one was excised after failed Fowler-Stephens orchidopexy and one had a staged procedure. Twenty-one non-palpable testes were noted on laparoscopy to have the vas deferens and vessels entering the inguinal canal; of these, 12 were atrophic on inguinal exploration. The remaining nine testes were successfully fixed in the scrotum. This study concludes that laparoscopy is a safe and effective part of the management of the non-palpable testis. The advantages of laparoscopy in the localization of the testis and its potential uses in treatment are highlighted.     

The vanishing testis: diagnosis and histological findings

PURPOSE: Controversy exists on how to diagnose the vanishing testis and the degree of investigation required. In this series, we reviewed anatomical and histological findings in vanishing testes and investigated the effectiveness of diagnostic laparoscopy and imaging studies. MATERIALS AND METHODS: Between 1974 and March 1999, 107 boys with nonpalpable testis underwent surgery. Of the total, 52 had spermatic vessels, vas deferens, and/or nubbin, and as a result the diagnosis of vanishing testis was made. RESULTS: The affected side of vanishing testis was left 41, right 9 and bilateral 2.35 nubbins were found and the lengths of 24 nubbins were 5 mm or less. Histological examinations were performed in 43 cases including 27 nubbins. From that total, 31 had vas deferens and 11 had epididymis. Only two nubbins had seminiferous tubules but they included no germ cells. The two nubbins were greater than 5 mm long. Laparoscopic surgery was undertaken in 12 separate cases of the vanishing testis and as a result hypoplastic spermatic vessels were present in 7 of the 12 cases. CONCLUSION: The incidence of viable testicular tissue in vanishing testes was 4.7% in our series and it ranges from 0-16% in other series. We submit that one can diagnose the inguinal vanishing testis with preoperative imaging and laparoscopy, and that the nubbin seldom contains testicular tissue. Our results do not support the necessity to remove nubbins.     

Collateral circulation after spermatic vessel ligation for abdominal testis and its impact on staged laparoscopically assisted orchiopexy

PURPOSE: Staged laparoscopically assisted orchiopexy for abdominal testis entails initial spermatic vessels ligation followed by mobilization of the testis, preserving the vas and its vessels as a sole source of testicular blood supply. This mobilization includes all peritoneal attachments of the testis, including the gubernaculum, which may carry collateral circulation to the testis. This study considers the anatomy of the gubernaculum and the collateral circulation after spermatic vessels ligation and its possible effects on the viability of the testis. MATERIALS AND METHODS: The anatomy of the gubernaculum and the effect of spermatic vessels ligation on the collateral circulation were studied in 90 boys with 100 abdominal testes with a short pedicle. Patients with vanishing testis or those not needing ligation of the spermatic vessels were excluded from the study. The anatomy and the vascularity of the testis, gubernaculum, and vas were studied at initial laparoscopy and 6 weeks later after spermatic vessel ligation. Based on these findings, the technique for laparoscopically assisted orchiopexy were modified, preserving the gubernaculum whenever possible in cases having prominent collaterals. RESULTS: Based on the attachment and blood vessel configuration of the gubernaculum, the patients were divided into two groups: in group 1 (open internal ring), there were 46 testes in which the gubernaculum passed through an open internal ring having an inguinal attachment. In group 2 (closed internal ring), there were 54 testes with a soft gubernaculum attached to a closed internal ring without inguinal attachment. In group 1 the gubernaculum was short and tough in 32 of 46 testes, with no visible blood vessels in all cases. In group 2 the gubernaculum was long and soft in 43 of 54 testes and showing evident blood supply before clipping of the spermatic vessels in 30 testes. Subsequent laparoscopy done after 6 weeks showed prominent collateral circulation around the gubernaculum in 26 testes and around the vas in 20 testes in the group 1 patients, and around the vas in 20 and the gubernaculum in 34 testes in group 2. Preservation of the gubernaculum was possible in 43/54 (80%) of group 2 patients and in 14/46 (30%) of group 1 patients. CONCLUSION: Routine cutting of the gubernaculum is not necessary for proper mobilization of the abdominal testis: collateral circulation varies from patient to patient, and once the gubernaculum shows prominent blood supply, its preservation is mandatory. The decision to cut the gubernaculum should be taken while the performing initial spermatic vessel ligation and not during the second stage to avoid compromise of the settled collateral circulation.     

Laparoscopic-Assisted Management of Impalpable Testis in Patients Older than 10 Years

Objective:

Cryptorchidism affects 1% of male births. The majority of patients with undescended testis are identified and treated in childhood, but a significant proportion of them especially in third-world countries are neglected and present late. Herein, we present our initial experience of managing impalpable testis in older children and adults with laparoscopic assistance.

Patients and Methods:

This study was conducted from 2003 through 2008 at LUMHS Jamshoro. Thirty-two patients with 40 impalpable testes were included in this study. Diagnostic laparoscopy was performed in 32 anesthetized patients. Laparoscopic-assisted orchiopexy or orchiectomy was performed in patients with intraabdominal testis. Testicular vessels and vas deferens were mobilized and after obtaining sufficient length were brought through the posterior wall of the inguinal canal by creating a neo-inguinal ring medial to the epigastric vessels after a small inguinal incision.

Results:

Of 40 impalpable testis, ultrasound localized 16 (40%) of them, and on laparoscopy, 36 (90%) were localized, 30 (75%) as intraabdominal and in 6 (15%) cases vas and vessels were entering into the internal inguinal ring (intracanalicular). The remaining 4 patients were diagnosed as having vanishing testis (anorchia). Laparoscopic orchiectomy was performed in 14 (35%) of these testes, while single-stage laparoscopic-assisted orchiopexy using Prentiss'' maneuver was performed in 16 (40%) testis. No major complications occurred. Seven testes were associated with ipsilateral hernias and were simultaneously repaired laparoscopically.

Conclusion:

Laparoscopic-assisted single-stage orchiopexy is a safe and successful procedure for intraabdominal testis in adolescents and older patients. The additional benefit of shortening the usual course of spermatic cord was beneficial to fix the testis in the scrotum without tension.     

Adult nonpalpable testis: is laparoscopy always required?

Laparoscopy is widely used in the diagnosis and treatment of nonpalpable testes. Some nonpalpable testes are vanishing testes. In such cases, unnecessary laparoscopic interventions can be avoided by a careful selection of cases. Between 1996 and 2001, laparoscopic intervention was applied to 107 patients with nonpalpable testes. Of the cases, 23 were bilateral and 84 were unilateral. Patients were between 19 and 27 years of age (average age, 23 years). Diagnostic ultrasonography was performed in 44 of the 84 patients with nonpalpable testes. Dimensions of the scrotal testis were determined by the Prader orchiometer method. The dimensions of the opposite scrotal testis (of the scrotal nubbin) and the abdominal testis were compared with the dimensions of 20 normal, healthy individuals' scrotal testis (control group). Results were evaluated by the Mann-Whitney U test. During laparoscopy, 24 (28.5%) of the patients were found to have a vanishing testis. The vas deferens and the testicular blood vessels ended bluntly at the anterior edge of the interior inguinal ring in one patient, inside the inguinal canal in five patients, and in the scrotum in 18 patients. Among the 84 patients with nonpalpable testes, no testis was found in any of the 18 patients with palpable scrotal nubbins. The opposite scrotal testes were hypertrophic in 17 (70.8%) of 24 patients who had vanishing testis (P < .05), and they were hypertrophic in 22 (36%) of the 60 patients (P > .05) who had laparoscopically identified intraabdominal testes. We conclude that clinical and radiologic diagnosis is sufficient for adult patients with nonpalpable testicles and palpable scrotal nubbins and hypertrophic contralateral scrotal testes. Laparoscopic intervention should be applied to patients who do not have palpable scrotal nubbins.     

小儿腹股沟不可触及睾丸的隐睾症诊治

目的:总结腹股沟不可触及睾丸的小儿隐睾症诊治经验。方法:回顾性分析收治腹股沟不能触及睾丸的隐睾患儿36例临床诊治资料。分析腹腔镜手术指征,腹股沟探查指征,术前超声检查的作用和术式的选择。结果:腹股沟不能触及的隐睾共36例(41侧),占总数的10.0%(36/361),经腹腔镜和腹股沟探查确定睾丸缺如18例(侧),腹内型隐睾16例(21侧),阴囊内睾丸残余2例(侧)。将腹腔镜下所见分4型,I型9例(侧),II型9例(侧)(其中IA型7例,IB型2例),III型11例(13侧),IV型7例(10侧)[其中IVA型5例(7侧),IVB型2例(3侧)]。分别采用经腹股沟睾丸下降固定,腹腔镜辅助睾丸下降固定术,分期Fowler-Stephen术。术前超声结果阳性诊断率为75%(27/36),睾丸缺如患儿对侧睾丸体积明显大于腹内型隐睾及睾丸残余患儿对侧睾丸体积。术后随访睾丸萎缩1例。结论:对于腹股沟未能查到睾丸的小儿隐睾症应行腹腔镜检查,腹腔镜下II型者,无需再行腹股沟探查,I型需探查腹股沟及阴囊。III型和IVB型可经腹股沟或腹腔镜辅助下行睾丸下降固定术,IVA型隐睾需在腹腔镜辅助下行睾丸下降固定或行分期Fowler-Stephen术。术前超声检查对侧睾丸大小有利于判断是否有睾丸缺如。     

Laparoscopic diagnosis and treatment of nonpalpable testis

OBJECTIVE: Laparoscopy has become one of the important diagnostic modalities of nonpalpable testis and has been developed and applied in the treatment of this disease. In the present study, we investigated the usefulness of laparoscopy in the diagnosis and treatment of nonpalpable testis. METHODS: Laparoscopy was carried out under general anesthesia on 21 patients (23 testes) from October 1991 to October 1999. If the internal spermatic vessels and vas deferens made their way into the internal inguinal ring, the inguinal canal was dissected with an incision in the inguinal region to look for the testis. Patients with intra-abdominal testis underwent laparoscopic orchiopexy or orchiectomy. If the internal spermatic vessels terminated with a blind end intraperitoneally, making it impossible to identify the testis, the case was judged to be vanishing testis and the operation was finalized without any further examination. RESULTS: In eight of 23 testes (35%), the internal spermatic vessels and vas deferens made their way into the internal inguinal ring. The inguinal region was examined in all the eight testes. Orchiopexy was carried out on two testes and orchiectomy was carried out on six testes. An intra-abdominal testis was detected in eight of 23 testes (35%). Laparoscopic orchiopexy was carried out on seven testes. One-stage orchiopexy was carried out on two of the seven testes and two-stage Fowler-Stephens orchiopexy was carried out on five of the seven testes. Orchiectomy was carried out on the remaining testis. Blocking or lack of the internal spermatic vessels and vas deferens was seen in seven of the 23 testes (30%) and this condition was diagnosed as vanishing testis. CONCLUSION: Laparoscopy for nonpalpable testis is considered to be the most effective technique for diagnosing the presence or absence of the testis and the location of the testis.     

SURGICAL MANAGEMENT OF THE NONPALPABLE TESTIS: THE CHILDREN'S HOSPITAL OF PHILADELPHIA EXPERIENCE

Purpose

The management of the nonpalpable testis permits an individualized operative approach. We analyze the results of surgical management of a large series of patients with a nonpalpable testis.

Materials and Methods

Between January 1986 and June 1994 we treated 1,866 boys with undescended testes. There were 447 testes (24%) that were not palpable at presentation. Intraoperative data on these patients were collected for age at presentation, bilateral testes position, testicular size, associated inguinal anomalies (vas, epididymis and processus vaginalis) and surgical approach. For intra-abdominal testes postoperative results of 2 surgical techniques, the Fowler-Stephens procedure and Koop orchiopexy (retroperitoneal mobilization of spermatic vessels and vas) were compared in 76 patients with at least 18 months of followup.

Results

Average patient age at presentation was 34 months with 63% presenting before age 48 months. Of the impalpable testes 58% were on the left side, 35% were on the right side and 7% were bilateral. At operation 181 testes (41%) were atrophic or absent, 91 (20%) were intraabdominal with 14 (3.1%) bilateral, 136 (30%) were in the inguinal canal and 39 (9%) were in other locations, including 22 at the pubic tubercle, 2 in the upper scrotum, 13 in the superficial inguinal pouch and 2 in the perineum. Of the intra-abdominal group associated extratesticular malformations were identified in 36 cases (39%). Attachment of the vas deferens to the testis was abnormal in 23 of 64 cases (36%), including 10 that were completely detached and 13 with head or tail attachment only.Of the 91 evaluable cases in the intra-abdominal group 38 (42%) had been treated with the Fowler-Stephens repair (5 in 2 stages), 33 (36%) with inguinal orchiopexy and intraperitoneal dissection without dividing the spermatic vessels, 5 with 2-stage procedures and vessel preservation and 14 (15%) with orchiectomy. One testis was left in situ. The inguinal approach with intraperitoneal extension was successful in defining the testis location or blind-ending vas and vessels in 100% of the cases. A single operation to perform orchiopexy was successful in 92% of the cases. Overall, results were considered excellent or acceptable in 32 of 33 cases (97%) after Koop orchiopexy and 28 of 38 (74%) after the Fowler-Stephens orchiopexy.

Conclusions

Nonpalpable testes accounted for 24% of the patients presenting with undescended testes. At surgical exploration 39% of impalpable testes were distal to the external inguinal ring, 41% were atrophic or absent and 20% were intra-abdominal. All cases were treated through a standard inguinal incision. These data provide evidence that the inguinal approach to orchiopexy with transperitoneal mobilization of the vas and vessels without transection is highly successful for the intra-abdominal cryptorchid testis and, to date, is the preferred technique for the management of the intra-abdominal undescended testis.     

Emerging trends in the management of the impalpable testis.

BACKGROUND: The management of the impalpable undescended testis is controversial. The study examines emerging trends in the management of this problem. METHODS: Two groups of boys were treated consecutively and recorded prospectively from 1974 to 1984 and from 1990 to 1998 inclusive. A consistent policy of using the preperitoneal approach for impalpable testis was adopted during both time intervals but during the second study period examination under anaesthesia and diagnostic laparoscopy were introduced to ascertain testicular presence and location. RESULTS: Some 919 boys were treated for cryptorchidism during the study period. Ninety boys in the first group (23 per cent) underwent preperitoneal explorations for impalpable testes. Anorchia was present in 18 and orchidectomy was performed in two boys. Thirty boys in the later group (5 per cent) were diagnosed as having impalpable testes. Fifteen boys underwent successful preperitoneal orchidopexy, anorchia was present in 11 and four underwent orchidectomy, carried out for high intra-abdominal testes. CONCLUSION: Examination under anaesthesia and subsequent laparoscopic assessment for all impalpable testes has reduced the need for preperitoneal exploration for the impalpable undescended testis. In this large series, division of the testicular vessels in order to secure scrotal placement of the testis was required in one instance only.     

THE ROLE OF LAPAROSCOPY IN EVALUATION OF THE IMPALPABLE UNDESCENDED TESTIS

Background : The evaluation and management of the impalpable testis remains controversial. The authors' experience with laparoscopy for the treatment of this condition is reported here. Methods : All children with impalpable testes underwent an examination under anaesthetic and if negative, a laparoscopy was performed to locate the testis. A prospective evaluation was undertaken to determine the success and morbidity of this approach. Results : Thirty-six children (median age 2.5 years) underwent laparoscopy to localize 40 impalpable testes. In 32 patients with unilateral impalpable testis, 10 were intra-abdominal, nine were absent. In 13 patients, the vas and vessels entered the groin, and in 12 of these a small testis remnant was excised and in the other a normal-looking testis was brought down. In four patients with bilateral impalpable testes, one testis was absent, three testes were intra-abdominal and four were small testis remnants in the groin. The average laparoscopy time was 15 min, and 34 of 36 children were operated on as day-stay cases. One child had an omental hernia via a port site. Conclusion : Laparoscopy is safe and effective at localizing impalpable testes in children and can be performed as day-stay procedures in the majority of cases.     

Transinguinal Laparoscopy for Nonpalpable Testis

Background: About 20% of all undescended testes are nonpalpable. Although surgical exploration was previously the method of choice for management, laparoscopy from the inferior edge of the umbilicus has been established as a useful method of examining a testis that is nonpalpable. However, conventional subumbilical laparoscopy is unnecessary when the testis or its remnant is located below the internal inguinal ring. We evaluated the efficacy of transinguinal laparoscopy after inguinal exploration performed for nonpalpable testis.
Methods: Twelve children with 14 nonpalpable testes (2 children had bilateral nonpalpable testes) were considered for a novel method of laparoscopy. We performed laparoscopy through the internal inguinal ring after opening the inguinal canal.
Results: Inguinal exploration revealed the testis or its remnant in 5 patients, and thus prevented unnecessary laparoscopy in these individuals. Transinguinal laparoscopy identified the anatomy in 7 patients. Four of the latter were found to have blind-ending vas deferens and spermatic vessels, while in 3 patients, the testes were located in the peritoneal cavity.
Conclusion: Transinguinal laparoscopy may become the accepted method for managing nonpalpable testes, as inguinal exploration can eliminate the need for laparoscopy in some cases, and the visualization achieved with transinguinal laparoscopy is just as good as that with conventional laparoscopy.