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.     

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.     

Preoperative magnetic resonance imaging in the management of the nonpalpable testis

We evaluated the efficacy of magnetic resonance imaging (MRI) as the preoperative study in the management of the nonpalpable testis. From 1997 to 2005, a total of 41 MRI was performed for the patients with nonpalpable testis and 42 testes were evaluated. The MRI showed 19 testes from 18 patients in the inguinal region. Eighteen testes were found in the inguinal region and one was intraabdominal during groin exploration. Six testes were pointed out to be intra-abdominal by MRI. Five testes were identified in the abdomen and one was disclosed to be vanishing testis. Seventeen testes could not be detected by MRI and they underwent laparoscopic or groin exploration. Four abdominal testes were identified. Thirteen patients had a diagnosis of vanishing testis. The sensitivity and the specificity of our MRI studies in predicting the presence of nonpalpable testis were 85.7% and 92.9%, respectively. Enlarged lymph node could be misdiagnosed as abdominal testis. Inguinal undescended testes can be diagnosed accurately with MRI. MRI is informative regarding the testis location and useful for limiting the area of surgical exploration.     

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.     

腹腔镜下腹腔内高位隐睾下降固定术的疗效观察

目的：探讨腹腔镜下腹腔内高位隐睾下降固定术的疗效。方法：应用腹腔镜技术进行诊断并行隐睾下降固定术治疗不可触及的高位腹腔内型隐睾患儿21例（24侧）,年龄2～12岁,平均4岁。结果：21例患儿均得到明确诊断。14例（17侧）行一期睾丸下降固定术,3例行Fowler Stephens一期睾丸下降固定术,3例睾丸缺如,1例行睾丸萎缩切除术。随访6～30个月,平均16个月,下降固定的睾丸位置良好,睾丸均无萎缩和回缩。结论：采用腹腔镜技术可以准确诊断高位不可触及的腹腔内型隐睾,并可同时行睾丸下降固定术,安全、有效、微创,值得推广。     

Routine laparoscopy for nonpalpable testes?

There are still no accepted criteria for the selection of patients with nonpalpable testes for laparoscopy versus a primary surgical exploration. We here report our experience using routine laparoscopy in such patients. The aim was to determine whether laparoscopy should be the first operative intervention or follow an inguinal exploration. Included in the study were 61 boys with 69 nonpalpable testes. Thirty-three testes were found in the abdomen, and 36 testes were extra-abdominal or nonexistent. If an exploration of the inguinal region had been the initial surgical intervention, six testes would have been found, making laparoscopy unnecessary. On the other hand, in the search for 63 missing testes, laparoscopy saved the patients from laparotomy or an extensive inguinal exploration. We conclude that an accurate knowledge of testis, vas, and vessel location gained by laparoscopy facilitates the selection of an appropriate surgical strategy, saving at least 51% of patients from laparotomy or an extensive inguinal exploration.     

Comparison of ultrasonographic and laparoscopic findings in adult nonpalpable testes cases

OBJECTIVE: There is a small number of studies in adult nonpalpable testes cases, and there is no published paper on the diagnostic value of their ultrasonographic examination. In this prospective study, we compared the sonographic and laparoscopic findings in adult cases with nonpalpable testes to assess the necessity and the profits of ultrasound. MATERIALS AND METHODS: 50 cases, 38 unilateral and 12 bilateral, with nonpalpable testes were investigated. Patients' ages ranged from 20 to 25 years with a mean of 22. Sonographic examinations were performed with a high-resolution ultrasonography device. RESULTS: Laparoscopic evaluation of the patients with unilateral nonpalpable testis yielded 27 testes out of a total 38. In one case, the testis was detected in the inguinal canal with inguinal exploration. The remaining 10 cases were regarded as vanishing testes. All 24 testes of 12 patients with bilateral nonpalpable testes were found. The pre-laparoscopic ultrasonographic examination detected 20 of 24 testes in bilateral cases (83% sensitivity), and 17 of 26 testes in unilateral cases (65% sensitivity). CONCLUSION: Our results suggest that ultrasonography does not exclude the necessity for laparoscopy, and it is not superior to physical examination in detection of the inguinal atrophic testes or testicular nubbin.     

The Utility of Ultrasonography in the Management of Undescended Testis in a Developing Country

Background

The use of ultrasonography to localize the testis in children with undescended testis is still controversial. This study was designed to determine the value of ultrasound in the preoperative assessment of children with undescended testis in a resource-limited setting.

Methods

A retrospective evaluation of all boys undergoing operation for undescended testes at the University of Nigeria Teaching hospital Enugu from June 2005 to December 2009 was performed. The operative findings were compared with the preoperative findings on clinical and ultrasound examinations.

Results

Overall, 49 boys with 60 undescended testes (unilateral in 38, and bilateral in 11 cases) were operated on during the study period. The median age of the patients was 5 (range, 1–14) years. At operation, 39 (65%) testes were located at the inguinal region, 17 (28.3%) were intra-abdominal, and 4 (6.7%) were vanishing testes. Of the inguinal testes, 30 (77%) were clinically palpable, and 38 (97.4%) accurately localized by ultrasound (p = 0.006). The intra-abdominal testes, the vanishing testes, and one inguinal testis were not identified with ultrasound. However, two testes identified as inguinal by ultrasound were found intraabdominal at operation, and two of the vanishing testes were recognized as viable testes by ultrasound.

Conclusions

Ultrasound may identify some otherwise nonpalpable inguinal testes and hence affect therapeutic approach. It may, however, be unhelpful in truly abdominal and vanishing testes.     

Laparoscopic assessment and orchidectomy for the adult undescended testis

The aim of this study was assessment of the usefulness of laparoscopy in the diagnosis and treatment of the adult nonpalpable testicle. We reviewed retrospectively the case notes of five adult patients with cases of impalpable testis that were evaluated and treated laparoscopically in our institutions. All five patients had unilateral nonpalpable testicles. The mean age of the patients was 36.5 years (+/- 5 years). Laparoscopy defined the intraabdominal anatomy accurately in all cases, and there were no laparoscopic complications. Two testes were found intra-abdominally, another testicle was found lying in the inguinal canal, and the last two testes were absent. Laparoscopy is a safe and reliable method in diagnosing adults with nonpalpable testis and also allows the completion of the operative procedure during a 1-day hospital stay.     

Laparoscopic management of the adult nonpalpable testicle

OBJECTIVES: This report describes own experiences with laparoscopic management of adult men with cryptorchidism. PATIENTS AND METHODS: 8 men with nonpalpable testes were referred to our department. Laparoscopy was used to assess the presence and location of the gonad and perform an orchiectomy or orchidopexy, respectively. RESULTS: A uni-/bilateral atrophic testicle was palpable in 2 patients under general anesthesia and removed after inguinal exploration. In 4 individuals the testicular vessels and vas deferens were found laparoscopically entering the internal inguinal ring. Two vanishing testicles and 2 atrophic gonads were removed during subsequent inguinal exploration. In 1 patient with a solitary testis, a morphologically intact abdominal testicle was presented. In this patient, endocrine function was lost completely after stage 1 of a Fowler-Stephens orchidopexy. In 1 patient an atrophic abdominal testicle was removed laparoscopically. CONCLUSIONS: These results demonstrate the suitability of laparoscopy for the treatment of cryptorchidism in the adult population. In most cases, atrophic inguinal gonads or vanishing testicles are found and should be removed. Our results suggest that in cases of intact abdominal testicles, Fowler-Stephens orchidopexy with transection of the spermatic vessels should be avoided to preserve endocrine function of the gonad.     

Laparoscopy for nonpalpable testes

Purpose

Laparoscopy is now considered integral to the management of nonpalpable testes, although its benefits are not clearly documented. The authors prospectively determined the value of laparoscopy in patients with nonpalpable testes.

Methods

Between December 1997 and October 2001, 37 patients with 40 nonpalpable testes were scheduled for laparoscopy followed by definitive treatment. Laparoscopy was cancelled in 4 patients (5 testes) because their testes became palpable under anesthesia. In the remaining 33 patients (35 testes), it was determined at the time of surgery whether, as a consequence of laparoscopy: (1) retroperitoneal exploration was avoided (2) definitive treatment was facilitated.

Results

Laparoscopy did not alter the management of 27 testes (77%) that were treated through an inguinal incision with orchiopexy for 17 testes (6 intraabdominal and 9 at the deep ring) and removal of 10 atrophic nubbins. It was only useful in avoiding retroperitoneal dissection for 5 (14%) vanishing testes, and it may have been of benefit for 3 testes treated with a 2-stage Fowler-Stephens orchiopexy.

Conclusions

The majority of our patients with nonpalpable testes could have been treated through an inguinal incision with laparoscopy being reserved for situations in which the testis was not identified on inguinal exploration.     

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.     

Laparoscopic orchidopexy in children

BACKGROUND: Cryptorchidism is a common condition in boys. Approximately 20% of undescended testes are nonpalpable and may be located within the abdominal cavity. Given the potential of these gonads for malignant transformation and infertility, it is essential to determine the presence or absence of a nonpalpable testis. METHODS: Radiologic imaging and open surgical exploration have proved to be unreliable. In the hands of experienced surgeons, laparoscopy has become the method of choice for evaluating the nonpalpable testis. RESULTS AND CONCLUSION: An increasing number of surgeons are applying laparoscopy in the treatment of nonpalpable testes, and early results are encouraging. Both diagnostic and therapeutic laparoscopy necessitate operative skills. The exact advantages of laparoscopy over conventional surgery in orchidectomy and single- or two-stage orchidopexy need to be determined.     

Is human chorionic gonadotropin useful for identifying and treating nonpalpable testis?

PURPOSE: We evaluated the efficacy of human chorionic gonadotropin (HCG) for identifying and treating nonpalpable testis. We then compared the cost-effectiveness of this approach to that of laparoscopy. MATERIALS AND METHODS: We reviewed patient charts during a 15-month period and identified 51 boys (64 testes) who underwent surgery to correct cryptorchidism. There were nonpalpable testes in 17 cases and bilateral cryptorchidism in 2 for a total of 19 impalpable testes. All patients were offered a full course of HCG. Those electing hormonal treatment received intramuscular injection of 2,000 IU/m.2 HCG (maximum 1,500 IU/injection) 3 times weekly for 3 weeks. RESULTS: A full course of HCG was given in 8 patients (10 testes). Of the 10 testes 8 became palpable after HCG treatment, including 1 atrophic nubbin located in the inguinal canal. Of the 2 testes that remained impalpable 1 discovered at the level of the renal vessels had complete epididymal nonunion and 1 was located closer to the inguinal ring. All 9 untreated patients underwent laparoscopy, which identified 3 intra-abdominal, 3 vanished and 2 peeping testes, and 1 atrophic testis in the inguinal canal. CONCLUSIONS: HCG therapy is valuable for identifying and treating nonpalpable testis. Using this agent enabled the testicle to be detected while avoiding the risks and cost associated with the laparoscopic procedure.     

Magnetic resonance angiography for the nonpalpable testis: a cost and cancer risk analysis

PURPOSE: For the unilateral nonpalpable testis standard management is open surgical or laparoscopic exploration. An ideal imaging technique would reliably identify testicular nubbins and safely allow children to forgo surgical exploration without compromising future health or fertility. Our goal was to perform a cost and risk analysis of magnetic resonance angiography (MRA) for unilateral nonpalpable cryptorchid testes. MATERIALS AND METHODS: A search of the English medical literature revealed 3 studies addressing the usefulness of MRA for the nonpalpable testicle. We performed a meta-analysis and applied the results to a hypothetical set of patients using historical testicular localization data. Analysis was then performed using 3 different management protocols-MRA with removal of testicular nubbin tissue, MRA with observation of testicular nubbin tissue and diagnostic laparoscopy. A cancer risk and cost analysis was then performed. RESULTS: MRA with observation of testicular nubbin tissue results in 29% of patients avoiding surgery without any increased cost of care. Among the 29% of boys with testicular nubbins left in situ and observed the highest estimated risk was 1 in 300 of cancer developing, and 1 in 5,300 of dying of cancer. CONCLUSIONS: A protocol using MRA with observation of inguinal nubbins results in nearly a third of boys avoiding surgical intervention at a similar cost to standard care without any significant increased risk of development of testis cancer.     

Laparoscopic diagnosis and therapy of cryptorchism]

Between May 1987 and December 1991, laparoscopy was performed in 33 selected children with 40 nonpalpable testes, to localize the testes. Of 40 testes sought, 16 were present (14 intra-abdominal and 2 inguinal), and in 24 cases testicular aplasia was verified. The authors describe the technique of laparoscopy for unilateral and bilateral undescended testes. Exact anatomical localization of the testes by laparoscopy facilitated accurate planning of operative repair. The advantages of laparoscopy compared with ultrasound and MR imaging in 14 selected patients are described. In 3 patients with an intra-abdominal hypoplastic testis we performed laparoscopic orchiectomy. This new operative procedure is described. Laparoscopic orchiectomy is minimally invasive, offering a practicable alternative to orchiectomy in the case of an atrophic or hypoplastic abdominal testis. No complications were noted.     

Impalpable testis: laparoscopy or inguinal canal exploration?

OBJECTIVE: There is great controversy regarding the best approach to impalpable testis. In this retrospective study we evaluated the accuracy of intraperitoneal laparoscopy, inguinal canal exploration and ultrasound in the diagnosis of impalpable testis. MATERIAL AND METHODS: Over a 2-year period (2004-06), 76 patients with a diagnosis of uni- or bilateral clinically impalpable testis were referred to our center. A preoperative ultrasound evaluation was done and all patients underwent intraperitoneal laparoscopy. An inguinal canal incision and exploration was done in all cases except for patients with high intra-abdominal testes (> 2 cm above the internal ring), for whom laparoscopic dissection, mobilization and orchidopexy were necessary. RESULTS: The mean age of the patients was 15.36 years (range 1-39 years). The undescended testis (UDT) was right-sided in 25% of patients, left-sided in 41% and bilateral in 34%. Intraperitoneal laparoscopy, inguinal canal exploration and ultrasound detected 70.6%, 78.4% and 15.6% of testes, respectively. CONCLUSIONS: Laparoscopy changed the management protocol of impalpable UDT in only 21% of cases. Inguinal canal exploration alone was sufficient in the majority of our cases. We recommend laparoscopy for those patients with impalpable UDT in whom an initial inguinal canal exploration proves negative.     

Magnetic resonance imaging for localizing the nonpalpable undescended testis.

A prospective evaluation of the value of magnetic resonance imaging (MRI) for localizing the nonpalpable undescended testis was performed in 17 boys aged 1 year to 5 years 4 months who had a clinical diagnosis of nonpalpable testes. The results were compared between the MRI, ultrasonographic, clinical, and definitive surgical diagnosis in all patients. Nine nonpalpable undescended testes were identified in the inguinal canal or just proximal to the inguinal ring by MRI, and these were confirmed by surgical findings. Six nonpalpable testes were not observed by MRI, and the absence of these testes was surgically confirmed. Like scrotal testes, all the undescended testes showed a low intensity on sequences with a short repetition time (TR) and echo time (TE), and a high intensity on long TR/TE sequences. Undescended testes were observed better on coronal images than on axial images. MRI promises to become an important diagnostic tool in the detection of nonpalpable undescended testes.     

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.     

Laparoscopic orchiopexy for palpable undescended testes: a five-year experience

BACKGROUND: Most recent reports of laparoscopic orchiopexy concern nonpalpable testes. We report the results of this approach in patients with undescended palpable testes. MATERIALS AND METHODS: Between January 1999 and September 2004, 28 patients with 30 undescended palpable testes were treated by laparoscopic orchiopexy performed by the same surgeon. Patients with palpable cryptorchidism were included. Patients with nonpalpable testes, retractable, or vanishing testes were excluded. The mean age of the patients was 25 months (range, 8 months-5 years) and the mean weight was 16 kg (range, 8-24 kg). We used a 4-port technique (one 10-mm, two 2-3 mm, and one 5-mm), a 4-mm scope, and 2-3 mm instruments. RESULTS: The mean operative time was 50 minutes. The complication rate was 13.3% (4/28), all in the first two years, at the beginning of the learning curve. The remaining testes were descended by laparoscopy; 5 (16.6%) were peeping testes. We had 10 (33.3%) left and 16 (53.3%) right palpable cryptorchidia cases, plus 4 testes (13.3%) that were bilateral undescended and palpable. No hernia was found in 8 (28.6%) cases; a homolateral hernia was found in 18 (64.3%) cases, and we did not close the processus vaginalis, we only resected the membranes. We found 2 (7.1%) with contralateral hernia in which we did close the processus vaginalis. On follow-up ranging 5 months-5 years, 29 of these testes maintain good size and a correct position, with no recurrent inguinal hernia. CONCLUSION: The laparoscopic approach is a safe way to descend the palpable testicle. Although this is not a large series, it shows that laparoscopic orchiopexy of palpable undescended testes can be done without a higher complication rate than the open procedure (13.3% vs. 12.2%), with several of the advantages of the laparoscopic approach.