Laparoscopic Management for Non-Palpable Testis

doi:10.4236/oju.2013.37052

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Open Journal of Urology, 2013, 3, 276-280

Published Online November 2013 (http://www.scirp.org/journal/oju)

http://dx.doi.org/10.4236/oju.2013.37052

Open Access OJU

Laparoscopic Management for Non-Palpable Testis

Abdel-Aziz Ali Emara1,2

1Department of Urology, Al-Azhar University, Cairo, Egypt

2Department of Urology, Ghodran Hospital, Baljurashi, KSA

Email: abdelazi[email protected]

Received October 10, 2013; revised November 5, 2013; accepted November 12, 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Purpose: To present our experience with laparoscopic management of the non-palpable undescended testis. Patients

and Methods: Between Nov. 2010 and Oct. 2012, 47 non-palpable testes in 41 patients were evaluated prospectively

by laparoscopy. The age of the patients at the time of surgery varied from 1 to 9 years with a mean age of 2.85 years.

Testicular viability and location were evaluated by physical examination and Doppler ultrasonography after 1 and 3

months. Results: Out of 49 testicular units, 47 (95.9%) were successfully treated by laparoscopic orchiopexy. 45 tes-

ticular units (91.8%) were treated by one-stage laparoscopic orchiopexy, 2 (4.1%) were treated by two-stage laparo-

scopic orchiopexy and 2 (4.1%) diagnosed as vanishing testis with detection of blind end spermatic vessels and vas def-

erens during laparoscopy. Physical examination and Doppler study demonstrated that 46 of 47 testes (97.9%) were vi-

able and 45 of 47 (95.7 %) were located in the low er scrotum and 2 of 47 (4.3%) in the upp er scrotum at the end of fol-

low-up. Conclusion: The laparoscopy is a reliable technique for diagnosis and treatment of the non-palpable in-

tra-abdominal testis with high success and survival rates of the testes.

Keywords: Laparoscopy; Orchiopexy; Undesc ended Testis

1. Introduction

An undescended testis is one of the most common clini-

cal disorders of childhood, occurring in approximately

3% of full-term newborns, 21% of premature newborns,

and 0.8% - 1.8% of 1-year-old boys [ 1]. In the boys w ith

undescended testis, the testis is palpable in the groin in

80% [2] and non-palpable in 20% and 20% - 50% of

those with non-palpable testis, the testis is absent [3]. A

non-palpable testis is defined as, a testis not palpated by

any examination technique, including pre-operatively un-

der anaesthesia [4]. Non-palpable testes have an in-

creased risk of malignant transformation, infertility and

epididymal malformation [5].

Many diagnostic methods have been described of whi c h

the most promising method is the use of diagnostic lapa-

roscopy. Non-palpable undescended testis management

basically includes four surgical techniques: 1) Open or-

chidopexy in stages; 2) Fowler-Stephens orchidopexy in

which spermatic vessels are sectioned and the deferential

artery is preserved in 1 or 2 stages by open or laparo-

scopic approach; 3) Testicular autotransplant with sper-

matic vessel section and microsurgical anastomosis to the

epigastric ve ssels and 4) laparosco pic orchid o pexy.

Of the above mentioned techniques, laparoscopic or-

chidopexy is gaining in popularity, and has an 88% -

100% cure rate [4]. Its advantages are greater dissection

of spermatic vessels and vas defer ens and the creation of

a medial neohiatus that consequently shortens the dis-

tance between the abdominal cavity and the scrotum

during testicular descent. This technique was originally

described for intra-abdominal undescended testis man-

agement but it has also been employed in high palpable

undescended testis with good results [6]. We aimed to

present our experience with laparoscopic management of

the non-palpable, intra-abdominal, undescended testis.

2. Patients and Methods

Study design, patient selection and assessment: This

prospective study was conducted between Nov. 2010 and

Oct. 2012, Patients were consecutively enrolled from

patients referred to the urology and pediatric clinics at

Ghodran Hospital, Baljurashi, Kingdom of Saudi Arabia

(KSA) for treatment of undescended testis. All patients

underwent thorough history-taking, physical examination

and abdominal ultrasonography. A testis was considered

non-palpable if it was not palpable clinically or detected

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by abdominal ultrasonography. The intra-abdominal van-

ishing testis syndrome (unilateral anorchia) was diag-

nosed if the spermatic vessels and vas deferens were

noted to end blindly during laparoscopy. Accordingly,

surgical exploration was not performed in these cases. If

an intraabdominal testis was identified laparoscopically,

orchiopexy was done. The study protocol was approved

by the Ethics Committee of Ghodran Hospital, KSA and

parents of all patients enrolled in this study provided

written informed consent.

Laparoscopic technique: Diagnostic laparoscopy was

performed in 41 patients with non-palpable testis. A clear

diet was started on the day before surgery and a fasting

of 4 - 8 hours according to their age was applied before

laparoscopy. A single dose of cefazolin sodium 40 mg/kg

was given by IM route for prophylaxis. Before laparo-

scopy, physical examination was repeated under general

anaesthesia in order to palpate the testes. A urethral

catheter was inserted into the bladder. A patient was

placed supine in the frog-leg position and in the 30 de-

grees Trendelenburg position. A U-shaped incision of 1

cm length was made just below the umbilicus. The ante-

rior wall of the abdomen was pulled upwards and then a

10 mm trocar was inserted into the abdominal cavity by

open technique. CO2 was insufflated to achieve pneu-

moperitoneum at a pressure of 10 mm Hg. A zero degree

10 mm laparoscope was inserted and the abdominal or-

gans were inspected. During the diagnostic laparoscopy,

intraperitoneal examination for a unilateral non-palpable

undescended testis began with examination of the normal

contralateral internal inguinal ring, vas deferens and

spermatic vessels. Followed by determination and evalu-

ation of the median (urachus), medial (obliterated um-

bilical artery) and lateral (inferior epigastric artery) um-

bilical ligaments, external iliac vessels, any potential

intra-abdominal testis, the vas deferens, spermatic ves-

sels and the patency of internal ring of the affected side

were determined. Anatomic orientation of the localiza-

tion and volume, mobility of the testis, the distance be-

tween the testes and the inguinal canal, paratesticular

anomalies, lengths of vas deferens and spermatic vessels

and presence of inguinal hernia were assessed to proceed

with either orchiectomy or orchiopexy and either one or

two stage orchiopexy. Blind-ended vas deferens and sper-

matic vessels were considered as vanishing testis.

Mobilization of the testis was performed by incisin g of

the peritoneum over the superior border of the internal

ring. The gubernaculum was identified and mobilized

circumferentially to provide traction by grasping its tes-

ticular end. Dissection was continued distally along the

gubernaculum until the scrotum began to invaginate. The

gubernaculum was transected using electrocautery as far

as possible. Dissection was continued cranially toward

the renal hilum as far as possible to gain enough length

on the spermatic cord to allow tension free orchiopexy.

The peritoneum over the vas may also be incised to gain

additional length. If the spermatic vessels remained too

short, we performed a first stage Fowler Stephens pro-

cedure by placing 2 endoscopy clips as far proximal as

possible on the cord vessels, the vessels were transected

between clips. If adequate leng th was obtained, the tip of

the endoscopy dissector was placed medial to the inferior

epigastric vessels and lateral to the medial umbilical

ligaments on the anterior abdominal wall. Then the dis-

sector tip was directed toward the ipsilateral hemiscro-

tum. A 5 mm trocar cannula was passed over the dissec-

tor through the scrotal incision into the abdominal cavity

and the free end of gubernaculum was grasped and the

testis was brought into approximation with the end of the

trocar. The testis, grasping forceps and trocar were with-

drawn through the scrotum. The cord structures were

inspected to verify that were not twisted. Two 3-zero

polydioxanone sutures were used to complete the or-

chiopexy distally as possible in created sub-dartos pouch.

Finally, the pneumoperitoneum was deflated and the fas-

cia and skin were closed.

The patients underwent the hospital care and medica-

tions (cefazolin sodium 40 mg/kg) and discharged on ou t-

patient medications (amoxicillin 45 mg/kg). They were

invited to visit the outpatient clinic for follow-up.

Follow up: Patien ts wer e follo wed af ter on e week , one

month and 3 months from laparoscopic orchiopexy op-

eration. Detailed medical history and physical examina-

tion were done at each follow-up visit. Scrotal Doppler

ultrasound was performed at 1, 3-month visits.

The time of the procedure, intra-operative complica-

tions, hospital stay, recovery from operation, defined as

the time at which the child returned to his normal pre-

operative activities, and testicular location and viability

were estimated.

3. Results

Forty one patients with non-palp able testis were enrolled

in this study. The mean age of studied patients was 2.85

± 0.85 years (range, one year to 9 years). The non-pal-

pable testis was bilateral in 16 (32.7%), right un ilateral in

23 (46.9%) and left unilateral in 10 (20.4%) (Table 1).

Out of 49 testicular units, diagno stic laparoscop y showed

that 45 were located within 3 cm of the internal inguinal

ring, 2 were more than 3 cm from the internal inguinal

ring and 2 diagnosed as vanishing testis with detection of

blind end spermatic vessels and vas deferens, one at right

side and other at left. None of the patients associated

with oblique inguinal hernia. Of 49 testicular units, 45

(91.8%) were treated by one-stage laparoscopic orchio-

pexy in which the non-palpable testis was located within

3 cm from the internal inguinal ring and two-stage lap ar o-

scopic orchiopexy was performed in 2 (4.1%) in which

the non-palpable testis was located more than 3 cm from

the internal inguin al ring side (Table 2).

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278

Table 1. Patients’ criteria.

No. of patients 41

No. of testicular units 49

Age, year (mean ± SD) 2.85 ± 0.85

Laterality of intra-abdominal testis No. of testicular units (%)

Unilateral 33 67.3

Right 23 46.9

Left 10 20.4

Bilateral 16 32.7

Table 2. Location of non-palpable testis and its management.

Location No. % Procedure

Within 3 cm of internal ring 45 91.8% One stage laparoscopic orchiopexy

Beyond 3 cm from internal ring 2 4.1% Two stages laparoscopic orchiopexy

Vanishing testis 2 4.1% None

The mean operation time was 22.3 ± 7.8 minutes,

(range, 15 to 30 minutes) for diagnostic laparoscopy;

88.9 ± 20.2 minutes (range, 79 to 110 minutes), for

laparoscopic one stage unilateral orchiopexy; 117.7 ±

11.66 minutes, (range, 95 to138 minutes), for laparo-

scopic one stage bilateral orchiopexy and 177.4 ± 12.6

minutes (range, 153 to 192 minutes), for laparoscopic

two stages unilateral orchiopexy.

All patients who underwent diagnostic laparoscopy

were discharged from the hospital within 6 hours after

the operation. The patients who underwent unilateral or

bilateral laparoscopic orchiopex y were discharged within

24 hours. The mean time for recovery was 3 ± 0.83 days

for diagnostic laparoscopy, 7 ± 2.09 days for laparo-

scopic one stage unilateral orchiopexy, 10 ± 2.8 days for

laparoscopic one stage bilateral orchiopexy and 7 ± 1.9

days for laparoscopic two stages unilateral orchiopexy

for each stage.

Subcutaneous emphysema was reported in only one

case, most probably due to improper placement of first

trocar. None of the patients had late postoperative com-

plications.

The mean operation time, hospital stay, complications

of the operations and recovery periods are summarized in

Table 3.

One month after the laparoscopic orchiopexy, physical

examination and Doppler ultrasonography showed that

46 of 47 testicular units had average size and normal

vascularity, giving a testicular survival rate (TSR) within

1 month of 97.9%. Only one testicular unit (3.1%) was

atrophied and avascular. 45 of 47 (95.6%) were located

in the lower scrotum and 2 of 47 (4.3%) in the upper

scrotum. No changes in testicular size and viability were

found at 3-month follow-up (Table 4).

4. Discussion

The current series represent our experience with laparo-

scopic management of non-palpable testis over 2 years.

Our results were in accordance with previous global re-

sult patterns demonstrating that laparoscopy is an excel-

lent technique not only for diagnosis but also for treat-

ment of non-palpable undescended testis.

Early recognition and surgery for undescended testis,

before 1 year of age, remain the most important interven -

tions to reduce the negative impact of both unilateral and

bilateral cryptorchidism [7]. Since 1976, when Cortesi et

al. [8] first reported a case of abdominal testis identified

by laparoscopy, the laparoscopy founded by many au-

thors a valuable adjunct to clinical examination in the

search of the non-p alpable undescended testes. The treat-

ment of non-palpable testes by laparoscopy was used

only after 1990 as the urologists gained experience with

the method and since then laparoscopic orchiopexy and

orchiectomy have been increasingly used [9,10]. During

the diagnostic laparoscopy, we looking at the internal

inguinal rings for vas deferens (medially) and the tes-

ticular vessels (laterally), in unilateral cases, it is prudent

to inspect the contralateral side especially in the inter-

pretation of findings in relation to the diameter of the

vessels. Laparoscopic detection of the distance of the

testes from the internal ring, the length of the vas defer-

ens and the vessels will give an indication to the ease of

the subsequent orchidopexy. Laparoscopic identification

of blind-ending testicular vessels prior to entering the

internal ring is sufficient to diagnose a vanishing testis,

which does not require further surgical exploration [11,

12].

In the literature, the laparoscopic accuracy rate of in

determination of the location of th e testes was more than

95% [12-14]. Laparoscopy allows the visualization of the

testis, to assess its presence, position, size and the rela-

tive lengths of the vas deferens and the gonadal vessels

which permits the planning of further management (or-

chidopexy or orchidectomy), or indeed avoids extensive

exploration for an absent testis when blind ending vessels

A. A. EMARA 279

Table 3. The mean operation time, hospital stay, complications of the operations and recovery.

Operation time,

minute (mean ± S D) Hospital stay, hour

(mean ± SD) Complications No. (%) Recovery, da y (mean ± SD)

Peri-operative Post-operative

Diagnostic laparoscopy 22.3 ± 7.8 6 ± 2.1 1 (%) (subcutaneous emphysema)0 3 ± 0.83

Laparoscopic

unilateral orchiopexy 88.9 ± 20.2 23.4 ± 12.1 0 0 7 ± 2.09

Laparoscopic

bilateral orchiopexy 117.7 ± 11 .66 23.8 ± 15.6 0 0 10 ± 2.8

Laparoscopic

two stages orchiopexy 177.4 ± 12.6 24 ± 11.7 0 0 7 ± 1.9 (for each stage)

Table 4. Testicular survival outcomes of laparoscopic orchiopexy and post operative location of the testis according to the

laparoscopic technique and the loc a tion of the nonpalpable intra-abdominal te stis.

Laparoscopic procedure No. of testicular units Preoperative location of the testisPostoperative location of the testis Testicular survival

One stage laparoscopic

orchiopexy 45 Within 3 cm of inter na l ring Bottom of scrotum 45/45

Two stages laparoscopic

orchiopexy 2 Beyond 3 cm from internal ring High/mid scrotum 1/2

are noted [3]. By lapar oscopy it possible to avoid unne c-

essary surgical interventions in the cases of impalpable

undescended testis. In fact, unnecessary surgical opera-

tions can be avoided in 42% of the cases [15].

Jongwon et al. [3] reported that of 86 testicular units,

17 testicular units (19.8%) were treated by Fowler-Ste-

phens laparoscopic orchiopexy (FSLO). One-stage FSLO

was performed in 14 testicular units (16.3%) and two-

stage FSLO in 3 testicular units (3.5%).

In our study, 47 ou t of 4 9 testicu lar un its (95.9 %) were

treated by laparoscopic orchiopexy. 45 testes (91.8%)

located within 3 cm of the internal inguinal ring were

treated successfully by one-stage laparoscopic orchio-

pexy and 2 testes (4.1%) located more than 3 cm from

the internal inguinal ring were treated by two-stage la-

paroscopic orchiopexy. So, the choice of laparoscopic

technique mostly depended on the distance from the in-

ternal inguinal ring to the non-palpable intra-abdominal

testis.

Riquelme-Heras et al. [4], reporting that twenty-five

patients were released 24 hours after surgery and 2 pa-

tients with a history of bronchial hyperactivity who de-

veloped respiratory symptoms were released 48 hours

after surgery.

In our study, one of most advantages of laparoscopy

are early discharge, rapid recovery, minimal intra-opera-

tive and none postoperative complications.

Samadi et al. [16] conducted PLO in 70.5% and FSLO

in 29.5% of a total of 203 testicular units and reported a

success rate of 95%, which was higher than the 76%

success rate of open surgery. Lindgren et al. [17] did a 6

month clinical follow-up after laparoscopic orchiopexy

and reported a success rate of 93%. Lintula et al. [18]

reported a success rate of 88% for 19 testicular units un-

dergoing laparoscopic orchiopexy and a success rate of

82% for 18 testicular units receiving open surgery, high-

lighting the excellent surgical outcomes of the laparo-

scopic orchiopexy.

Jongwon et al. [3] performed PLO in 80.2% and FSLO

in 19.2% of 86 testicular units. In examination that took

place 3 months after the laparoscopic orchiopexy, the

TSR was 93.7% and the rate of fixation in the lower

scrotum was 76.2%. If classified on the basis of laparo-

scopic techniques, the PLO showed a fixation rate in the

lower scrotum of 79.6%, one-stage FSLO showed a rate

of 63.6% and two stages FSLO showed a r a te of 66.7%.

In our study, the testicular survival rate was 97.9%.

The location of the viable testis after the laparoscopic

orchiopexy was 95.6% in the lower scrotum. Therefore,

the success rate of the laparoscopic orchiopexy for a non-

palpable intra-ab dominal testis was 95.6%. The testicular

survival rate (TSR) not only affected by the size, viabil-

ity of the testis, length and caliber of the spermatic ves-

sels and vas but also by the distance between the testis

and internal ring and subs equently the number of laparo-

scopic orchiopexy stages.

5. Conclusion

The laparoscopy is a reliable technique for diagnosis and

treatment of the non-palpable intra-abdominal testis with

high success and survival rates of the testes. In our study,

the non-palpable testis was properly managed by laparo-

scopy with short hospital stay, rapid recovery and mini-

mal complications.

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