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Boehm K, Fischer ND, Qwaider M, Haferkamp A, Schröder A. Contralateral testicular hypertrophy is associated with a higher incidence of absent testis in children with non-palpable testis. J Pediatr Urol 2022; 19:214.e1-214.e6. [PMID: 36460587 DOI: 10.1016/j.jpurol.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVE The objective of our study is to examine the impact of monorchism on contralateral testicular size in children with non-palpable testis (NPT). Enhanced contralateral testicular volume or longitudinal diameter (length) serves as a predictor of monorchism. In the present study, we assessed the ability of ultrasound measured enlarged contralateral testicular length for predicting monorchism (and hence a testicular nubbin) in children with NPT. Furthermore, we evaluated the general prevalence of viable versus non-viable testes in patients referred to our institution with unilateral undescended testis between 2005 and 2020. STUDY DESIGN We analysed the records of 54 patients who underwent diagnostic laparoscopy for NPT between 2005 and 2020 in a European tertiary care centre. Testicular lengths (longitudinal diameter) and testicular volume of the contralateral testis, as well as surgeon (surgeon 1 vs surgeon 2 vs others) and age at surgery (months) were assessed and stratified according to intraoperative findings (presence or absence of a testicular nubbin). Testicular length and volume were evaluated by ultrasound examination in office prior to surgery. Chi-square and t-test for descriptive analyses as well as uni- and multivariable logistic regression analyses were performed using R Version 3.1.0 (R Project for Statistical Computing, www.R-project.org). RESULTS A total of 15 children presented with viable testes and 39 patients with testicular nubbin. Mean age was 20.5 months in the overall cohort and 22.6 vs 19.7 months in children with viable testis vs testicular nubbin (p = 0.4). In patients with presence of a testicular nubbin, the contralateral testis was larger (median length 17 mm (16-19.2)) as compared to patients with a viable testis (median length 15 mm (14-17), p = 0.001). Similarly, contralateral testicular volume was lower in patients with a present viable testis (0.6 ccm vs 0.8 ccm; p < 0-001). This effect remained statistically significant when logistic regression analyses were adjusted for age and weight at surgery, year of surgery, surgeon, and laterality. OR (odds ratio) for presence of a testicular nubbin was 1.6 (per mm) [95% CI (confidence interval) 1.13-2.17; p = 0.007]. CONCLUSION Patients with preoperative increased length and volume of the contralateral testis in the ultrasound examination are at significantly higher risk of monorchism than their counterparts with lower testicular length. This should be emphasized during counselling of the parents prior to surgery. In our experience parents cope more easily with the diagnosis of monorchism, once this has already been discussed and explained thoroughly prior to surgery.
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Affiliation(s)
- Katharina Boehm
- Department of Urology, University Medical Center, Carl-Gustav-Carus University, Dresden.
| | - Nikita Dhruva Fischer
- Department of Urology and Pediatric Urology, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Mohammad Qwaider
- Department of Urology and Pediatric Urology, University Medical Center, Johannes Gutenberg University, Mainz, Germany; Department of Urology, Klinikum Darmstadt, Darmstadt, Germany
| | - Axel Haferkamp
- Department of Urology and Pediatric Urology, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Annette Schröder
- Department of Urology and Pediatric Urology, University Medical Center, Johannes Gutenberg University, Mainz, Germany
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Gates RL, Shelton J, Diefenbach KA, Arnold M, St Peter SD, Renaud EJ, Slidell MB, Sømme S, Valusek P, Villalona GA, McAteer JP, Beres AL, Baerg J, Rentea RM, Kelley-Quon L, Kawaguchi AL, Hu YY, Miniati D, Ricca R, Baird R. Management of the undescended testis in children: An American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee Systematic Review. J Pediatr Surg 2022; 57:1293-1308. [PMID: 35151498 DOI: 10.1016/j.jpedsurg.2022.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 12/31/2021] [Accepted: 01/08/2022] [Indexed: 01/03/2023]
Abstract
PURPOSE Management of undescended testes (UDT) has evolved over the last decade. While urologic societies in the United States and Europe have established some guidelines for care, management by North American pediatric surgeons remains variable. The aim of this systematic review is to evaluate the published evidence regarding the treatment of (UDT) in children. METHODS A comprehensive search strategy and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were utilized to identify, review, and report salient articles. Five principal questions were asked regarding imaging standards, medical treatment, surgical technique, timing of operation, and outcomes. A literature search was performed from 2005 to 2020. RESULTS A total of 825 articles were identified in the initial search, and 260 were included in the final review. CONCLUSIONS Pre-operative imaging and hormonal therapy are generally not recommended except in specific circumstances. Testicular growth and potential for fertility improves when orchiopexy is performed before one year of age. For a palpable testis, a single incision approach is preferred over a two-incision orchiopexy. Laparoscopic orchiopexy is associated with a slightly lower testicular atrophy rate but a higher rate of long-term testicular retraction. One and two-stage Fowler-Stephens orchiopexy have similar rates of testicular atrophy and retraction. There is a higher relative risk of testicular cancer in UDT which may be lessened by pre-pubertal orchiopexy.
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Affiliation(s)
- Robert L Gates
- University of South Carolina School of Medicine - Greenville, Greenville, SC, United States
| | - Julia Shelton
- University of Iowa, Stead Family Children's Hospital, Iowa City, IA, United States
| | - Karen A Diefenbach
- Ohio State University, Nationwide Children's Hospital, Columbus, OH, United States
| | - Meghan Arnold
- University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, MI, United States
| | | | - Elizabeth J Renaud
- Alpert Medical School of Brown University, Hasbro Children's Hospital, Providence, RI, United States
| | - Mark B Slidell
- Comer Children's Hospital, The University of Chicago Medicine, Chicago, IL, United States
| | - Stig Sømme
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, United States
| | - Patricia Valusek
- Pediatric Surgical Associates, Children's Minnesota, Minneapolis, MN, United States
| | | | - Jarod P McAteer
- Providence Pediatric Surgery, Sacred Heart Children's Hospital, Spokane, WA, United States
| | - Alana L Beres
- University of California, Davis, Sacramento CA, United States
| | - Joanne Baerg
- Loma Linda University Children's Hospital, Loma Linda, CA, United States
| | | | - Lorraine Kelley-Quon
- Children's Hospital Los Angeles, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | - Akemi L Kawaguchi
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Yue-Yung Hu
- Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Doug Miniati
- Division of Pediatric Surgery, Kaiser Permanente Roseville Women and Children's Center, Roseville, CA, United States
| | - Robert Ricca
- University of South Carolina School of Medicine - Greenville, Greenville, SC, United States.
| | - Robert Baird
- Division of Pediatric Surgery, BC Children's Hospital, University of British Columbia, Vancouver, BC, United States
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Bawazir OA, Maghrabi AM. A comparative study between two techniques of laparoscopic orchiopexy for intra-abdominal testis. Indian J Urol 2021; 37:261-266. [PMID: 34465956 PMCID: PMC8388342 DOI: 10.4103/iju.iju_507_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 03/25/2021] [Accepted: 05/08/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction: Several techniques have been described for laparoscopic orchidopexy in patients with intra-abdominal testes. We aimed to report our experience with the staged laparoscopic traction orchiopexy (Shehata technique) and to compare it to the Fowler-Stephens orchidopexy (FSLO). Methods: We conducted a retrospective cohort study at two pediatric surgery departments from 2017 to 2020. Fifty-six patients underwent laparoscopic exploration and the testis was intra-abdominal in 41 of them. Patients with vanished testis or those who underwent open orchidopexy or vessel-intact laparoscopic orchidopexy were excluded. Those who underwent FSLO (n = 18), or Shehata laparoscopic orchidopexy (n = 11) were compared. Results: Preoperative data were comparable between both the groups. FSLO had a significantly shorter first-stage operative time (34.61 ± 6.43 vs. 58 ± 9.39 min, P < 0.001), with no difference in the second stage. There was no difference in the initial position of the testes between both the techniques. The testis dropped from the fixation position in three patients in the Shehata group (27.27%), and consequently, the cord did not increase in length by the second stage, and these testes barely reached the scrotum. At 12 months’ follow-up, the testes’ size, position, and consistency were comparable between the two groups. Conclusion: Staged laparoscopic traction orchidopexy is feasible for the management of intra-abdominal testes, especially in the low-lying testes.
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Affiliation(s)
- Osama Abdullah Bawazir
- Department of Surgery, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
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Undescended Testes and Laparoscopy: Experience from the Developing World. Adv Urol 2018; 2018:1620470. [PMID: 30473708 PMCID: PMC6220417 DOI: 10.1155/2018/1620470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 09/23/2018] [Indexed: 02/02/2023] Open
Abstract
Background Cryptorchidism or undescended testes is the most common disorder of the male endocrine glands in children. With the advancements in laparoscopic techniques and instruments, laparoscopic orchidopexy has become the standard procedure in the management of nonpalpable undescended testes. Aim To evaluate and determine the therapeutic role, sensitivity, and specificity of laparoscopy in localizing nonpalpable testes and the mean operative time, the conversion rate (and reasons thereof), postoperative wound infection, postoperative stay, and time taken for return to daily activities following laparoscopic orchidopexy or orchidectomy. Materials and Methods This was a prospective study carried out in the Postgraduate Department of Surgery, Government Medical College, Srinagar, J&K, India, from May 2008 to August 2011. All patients who presented to the outpatient department with complaints of absent testes were examined, and the ones with nonpalpable testes were included in the study. Results The mean operative time for bilateral and unilateral nonpalpable testis was 102.76 and 53.67 minutes, respectively. Minor postoperative wound infections were noted in 4 of our patients. Mean duration of hospital stay was 14.23 hrs for unilateral cases and 16.27 hrs for bilateral cases. Patients who underwent laparoscopic orchidopexy resumed their normal activities within 4 ± 1 days. Conclusion Laparoscopy clearly demonstrates the anatomy and provides visual information upon which a definitive decision can be made for further management of the undescended nonpalpable testis.
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Anwar AZM, Fathelbab TK, Abdelhamid AM, Galal EM, Ali MM, Tawfiek ER. Initial laparoscopy and optimized approach for unilateral nonpalpable testis: review of 8-year single-center experience. Int Urol Nephrol 2018; 50:2139-2144. [PMID: 30311046 DOI: 10.1007/s11255-018-2006-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 10/05/2018] [Indexed: 01/16/2023]
Abstract
PURPOSE We evaluated the role of initial laparoscopy and optimized approach in cases of unilateral nonpalpable testis. METHODS Seventy-four patients with nonpalpable testes were presented. We excluded 9 patients, with palpable testes under anesthesia. Laparoscopy was offered to 65 patients. Contralateral testis hypertrophy with length ≥ 1.8 cm was confirmed in 47 patients. Ultrasound results were available for 35 patients. RESULTS Age ranged from 1 to 10 years. Of 65 nonpalpable testes, right side comprised 23 (35.4%) and the left 42 (64.6%). Laparoscopy revealed intra-abdominal testis in 18 patients (27.7%), blind-ending vessels and vas in 8 (12.3%), and vas and vessels traversing the internal ring in 39 (60%). Treatment of intra-abdominal testes included Fowler-Stephens orchiopexy in 7 patients, laparoscopic orchiopexy in 9, and laparoscopic orchiectomy in 2. In 8 patients with blind-ending vas and vessels, laparoscopy was terminated. In 39 patients with vas and vessels traversing the internal ring, scrotal exploration was performed in 36 patients with closed internal ring and inguinal exploration in 3 with open internal ring. Vanished testes were present in 43/47(91.5%) of patients with contralateral testis hypertrophy ≥ 1.8 cm. Ultrasound detected the presence of a testis in only 4/11 (36.3%) of patients, although it could not identify vanished testis. CONCLUSIONS Initial laparoscopy should be retained as one of the standard treatment for nonpalpable testis. It was the only required modality in 26 patients (40%) and optimized further treatment in 39 patients (60%) by evaluation of the condition of the internal ring.
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Affiliation(s)
| | | | | | - Ehab Mohmed Galal
- Urology Department, School of Medicine, University Hospital, 61111, Minia, Egypt
| | - Mostafa Magdi Ali
- Urology Department, School of Medicine, University Hospital, 61111, Minia, Egypt
| | - Ehab Rifat Tawfiek
- Urology Department, School of Medicine, University Hospital, 61111, Minia, Egypt
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Elsherbeny M, Abdallah A, Abouzeid A, Ghanem W, Zaki A. Staged laparoscopic traction orchiopexy for intra-abdominal testis: Is it always feasible? J Pediatr Urol 2018; 14:267.e1-267.e4. [PMID: 29567012 DOI: 10.1016/j.jpurol.2018.01.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 01/30/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND AND OBJECTIVES Laparoscopic orchiopexy for intra-abdominal testis is a well-known and commonly practiced technique. The traction technique is based on elongation of the testicular vessels without cutting them, in contrast with the two-stage Fowler-Stephens technique in which the testicular vessels are divided. The current study evaluated the feasibility of the traction technique according to the type of intra-abdominal testis. PATIENTS AND METHODS The study included 20 boys with 22 intra-abdominal testes and who underwent staged laparoscopic traction orchiopexy between October 2013 and October 2015. Eighteen testes were proximal to the internal ring by <2 cm (type III), while the remaining four were high and away from the internal ring by >2 cm (type IVa). The patients' ages ranged between 6 months and 5 years (mean 2.2 years; median 2 years). Patients were followed up for 1 year for testicular atrophy and satisfactory scrotal site relocation. RESULTS This study did not detect any cases of testicular atrophy among the participants (0/22), while failure to achieve satisfactory scrotal site was found in two out of the four cases with type IVa intra-abdominal testes. DISCUSSION Traction techniques for elongating the testicular vessels were employed years ago, but this was revisited by Shehata in 2008. It has the advantage of preserving the main testicular blood supply, which can be reflected by the decreasing rate of testicular atrophy when compared with the Fowler-Stephens orchiopexy. The results of the traction technique may be less satisfactory regarding the testicular location for higher types of intra-abdominal testes (type IVa). CONCLUSION Staged laparoscopic traction orchiopexy was a feasible technique for intra-abdominal testes (within 2 cm of the internal ring), but the results were less satisfactory when applied for higher intra-abdominal testes (type IVa).
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Affiliation(s)
| | | | - Amr Abouzeid
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Wael Ghanem
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ahmed Zaki
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
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7
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Lee SR. Laparoscopic one-stage orchiopexy for transverse testicular ectopia. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2017. [DOI: 10.1016/j.epsc.2017.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Abstract
PURPOSE While the nonpalpable testis represents a small portion of all cryptorchid testes, it remains a clinical challenge for pediatric urologists. Controversy exists surrounding the best evaluation and management of this entity. In this review we update what is known about the nonpalpable testis, including the etiology, preoperative evaluation and best surgical management as well as novel techniques and ongoing controversies. MATERIALS AND METHODS We searched PubMed® and MEDLINE® from January 2000 to January 2017 using relevant key terms. Of 367 articles 115 were considered for inclusion based on a priori design. Using a narrative review format, an update on the evaluation and management of the nonpalpable testis including novel concepts and techniques was synthesized. RESULTS The nonpalpable testis should be evaluated by physical examination only. Imaging is not indicated for routine cases. The optimal surgical approach and technique remain debatable but several novel techniques have been described. Due to the rarity of the nonpalpable testis, randomized controlled trials and other quality comparisons are difficult. Therefore, management remains controversial. CONCLUSIONS Evaluation and management of the nonpalpable testis remain difficult, and some aspects are still debated. Future research should focus on multi-institutional collaborative trials to determine the optimal operative management.
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Affiliation(s)
| | - Kate H Kraft
- Department of Urology, University of Michigan, Ann Arbor, Michigan
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Alam A, Delto JC, Blachman-Braun R, Wayne G, Mittal AG, Castellan M, Kozakowski K, Labbie A, Gosalbez R. Staged Fowler-Stephens and Single-stage Laparoscopic Orchiopexy for Intra-abdominal Testes: Is There a Difference? A Single Institution Experience. Urology 2016; 101:104-110. [PMID: 27845220 DOI: 10.1016/j.urology.2016.09.060] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 09/22/2016] [Accepted: 09/26/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare single-stage laparoscopic orchiopexy (SSLO) and staged Fowler-Stephens (SFS) procedures in the management of intra-abdominal undescended testes, and to analyze postoperative atrophy and malpositioning as end points. MATERIALS AND METHODS A retrospective chart review identified laparoscopic orchiopexy patients with intra-abdominal testes between November 2006 and November 2014. Of 167 patients who had laparoscopic orchiopexy, 73 (85 testes) were identified as having laparoscopic orchiopexy. Baseline characteristics, as well as testicular scrotal position and size at follow-up, were recorded. Regression analysis was performed to compare outcomes between patients who underwent SFS and SSLO. RESULTS Of the 85 laparoscopic orchiopexies, 35 underwent SFS and 50 had SSLO. Patient demographics were comparable in both groups. The median age at surgery was 12 months (5-151 months), and the average follow-up was 17.3 months. On follow-up, there were 0 recorded cases of SFS patients with abnormally positioned testes postoperatively, whereas there were 10 (20.0%) SSLO patients who had abnormally positioned testes (odds ratio: 0.05, 95% confidence interval: 0.01-0.44). Differences in atrophy rates were not significant. CONCLUSION These results suggest that there may be no difference between the 2 approaches in terms of postoperative atrophy. However, the SFS appears to be more successful in securing a favorable scrotal position. Atrophy does not seem to be associated with other patient factors. Prospective, randomized studies are indicated to further explore outcome differences between the 2 approaches.
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Affiliation(s)
- Alireza Alam
- Division of Pediatric Urology, Nicklaus Children's Hospital, Miami, FL.
| | - Joan C Delto
- Urology Department, Mount Sinai Medical Center, Miami Beach, FL
| | | | - George Wayne
- Urology Department, Mount Sinai Medical Center, Miami Beach, FL
| | - Angela G Mittal
- Division of Pediatric Urology, Nicklaus Children's Hospital, Miami, FL; Department of Pediatric Urology, Texas Children's Hospital and Baylor School of Medicine, Houston, TX
| | - Miguel Castellan
- Division of Pediatric Urology, Nicklaus Children's Hospital, Miami, FL
| | | | - Andrew Labbie
- Division of Pediatric Urology, Nicklaus Children's Hospital, Miami, FL
| | - Rafael Gosalbez
- Division of Pediatric Urology, Nicklaus Children's Hospital, Miami, FL
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Mehendale VG, Shenoy SN, Shah RS, Chaudhari NC, Mehendale AV. Laparoscopic management of impalpable undescended testes: 20 years' experience. J Minim Access Surg 2013; 9:149-53. [PMID: 24250059 PMCID: PMC3830132 DOI: 10.4103/0972-9941.118822] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 01/28/2013] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Laparoscopy is the best available method to manage impalpable undescended testes. We performed our first laparoscopic orchiopexy in June 1992 and found good results in consecutive cases with laparoscopic orchiopexy over last 20 years. MATERIALS AND METHODS From June 1992 to May 2012, 241 patients with 296 impalpable testes were operated upon by laparoscopic approach. One-stage laparoscopic orchiopexy was performed in 152 cases, while two-stage Fowler - Stephens laparoscopic orchiopexy was performed in 55 cases. Laparoscopic orchiectomy was required in 20, and in 21 patients testes were absent. One-sided laparoscopic orchiopexy was performed in a male pseudo hermaphrodite. RESULTS None of the testis atrophied after two-stage Fowler - Stephens laparoscopic orchiopexy, while in 152 cases of single-stage orchiopexies one testes atrophied. One patient developed malignant change in the testis, 6 years after orchiopexy. CONCLUSIONS Laparoscopy is the best way to diagnose impalpable undescended testes. No other imaging investigation was required. Single-stage laparoscopic orchiopexy for low level undescended testis has very good results. For high-level undescended testis and when one-stage mobilisation is difficult, two-stage Fowler - Stephens orchiopexy has excellent results. Minimum 4 months should separate first and second stage of laparoscopic Fowler - Stephens procedure. Even when open orchiopexy is being done for intra-canalicular testes in a child, it is advisable to be ready with laparoscopy if necessary, at the same time, in case open surgery fails to mobilise the testicular vessels adequately.
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Affiliation(s)
- Vinay G Mehendale
- Medico Surgical Clinic and Hospital, Seth VC Gandhi and MA Vora Municipal General Hospital, Rajawadi, Ghatkopar, Mumbai, Maharashtra, India
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Shehata SM, Shehata SMK, A Baky Fahmy M. The intra-abdominal testis: lessons from the past, and ideas for the future. Pediatr Surg Int 2013; 29:1039-45. [PMID: 23995239 DOI: 10.1007/s00383-013-3406-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The intra-abdominal testis (IAT) has been always an enigma for both diagnosis and treatment. Imaging techniques are known for low sensitivity for localizing the IAT. It has been universally accepted that the gold standard for localizing the IAT is diagnostic laparoscopy. Orchiopexy techniques for IAT are complicated and attended with a higher rate of failure and complication than those for the palpable testis. For the low-lying abdominal testis, a one-stage procedure without interruption of the vessels has a high success rate. The Prentiss maneuver bridges the borders of normal pathway to gain a straighter course to the scrotum. The interruption of the main vascular supply of the testis, depending on collateral circulation, has been used for many years but with questionable effects on the microscopic delicate structure of the testis. Microvascular autotransplantation was intended to avoid this effect, but it is technically demanding and requires special expertise. The principle of traction has been used in the past but was abandoned due to high rate of atrophy. Recently, traction has been revisited with a new approach with very encouraging results. The key to success in any technique for orchiopexy is the complete absence of tension.
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Affiliation(s)
- Sameh M Shehata
- Pediatric Surgery, Alexandria University, Alexandria, Egypt,
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12
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Neissner C, Ebert AK, Rösch WH. [Analysis of laparoscopic orchidopexy in intra-abdominal testis]. Urologe A 2011; 50:573-8. [PMID: 21503664 DOI: 10.1007/s00120-011-2528-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Laparoscopy is an established diagnostic procedure but is less frequently used as a therapeutic method for impalpable testes. To compare the results of the classic two-stage orchidopexy described by Fowler-Stephens with a testicular vessel-sparing single-stage approach in the management of intra-abdominal testes we retrospectively analyzed our data.From January 2005 to September 2010, 105 patients (mean age 32 months) underwent laparoscopy for impalpable testes. In cases of intra-abdominal testes, laparoscopic orchidopexy was performed either in a two-stage procedure including initial ligation of the testicular vessels or as a direct single-stage procedure without ligation of the vessels. The results of both approaches were evaluated postoperatively clinically and by ultrasonography. Among the 122 impalpable testes 63 were located intra-abdominally; single-stage orchidopexy was performed in 29 testes whereas a two-stage approach was conducted in 14 testes. Fourteen gonads had to be removed due to atrophy and in six cases no testis was found at all. In the other 59 cases inguinal exploration followed resulting in 22 orchidopexies, 34 removals and 3 blind-ending vessels. During a mean follow-up of 17 months none of the 29 testes treated by single-stage orchidopexy atrophied or reascended. By contrast, two cases of atrophy, one reascent and one subumbilical wound infection occurred after the two-stage procedure. Considering our excellent experiences with single-stage management, we conclude that the single-stage approach is a reliable, safe and efficacious treatment modality of intra-abdominal testes. However, the two-stage procedure including testicular vessel ligation should be restricted to high abdominal testes with very short vessels.
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Affiliation(s)
- C Neissner
- Klinik für Kinderurologie in Kooperation mit dem Lehrstuhl für Urologie der Universität Regensburg, Klinik St. Hedwig, Steinmetzstraße 1-3, 93049 Regensburg, Deutschland.
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Sultan RC, Johnson KC, Ankem MK, Barone JG. Laparoendoscopic single site orchiopexy. J Pediatr Surg 2011; 46:421-3. [PMID: 21292103 DOI: 10.1016/j.jpedsurg.2010.06.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2010] [Revised: 06/24/2010] [Accepted: 06/25/2010] [Indexed: 11/27/2022]
Abstract
We report a laparoendoscopic single site orchiopexy in a 2-year-old boy with a right nonpalpable testis. Diagnostic laparoscopy using a 5-mm port revealed a right intraabdominal testis. The 5-mm port site was extended to accommodate the smallest commercially available triport, and orchiopexy was performed. The operative time was 55 minutes, and the estimated blood loss was minimal. There were no complications, and surgical and cosmetic results were excellent. Laparoendoscopic single site surgery is a feasible technique for orchiopexy of the nonpalpable testis.
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Affiliation(s)
- Raymond C Sultan
- Section of Pediatric Urology, Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA.
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Tasian GE, Copp HL. Diagnostic performance of ultrasound in nonpalpable cryptorchidism: a systematic review and meta-analysis. Pediatrics 2011; 127:119-28. [PMID: 21149435 PMCID: PMC3010084 DOI: 10.1542/peds.2010-1800] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
CONTEXT Ultrasound is frequently obtained during the presurgical evaluation of boys with nonpalpable undescended testes, but its clinical utility is uncertain. OBJECTIVE To determine the diagnostic performance of ultrasound in localizing nonpalpable testes in pediatric patients. METHODS English-language articles were identified by searching Medline, Embase, and the Cochrane Library. We included studies of subjects younger than 18 years who had preoperative ultrasound evaluation for nonpalpable testes and whose testis position was determined by surgery. Data on testis location determined by ultrasound and surgery were extracted by 2 independent reviewers, from which ultrasound performance characteristics (true-positives, false-positives, false-negatives, and true-negatives) were derived. Meta-analysis of 12 studies (591 testes) was performed by using a random-effects regression model; composite estimates of sensitivity, specificity, and likelihood ratios were calculated. RESULTS Ultrasound has a sensitivity of 45% (95% confidence interval [CI]: 29-61) and a specificity of 78% (95% CI: 43-94). The positive and negative likelihood ratios are 1.48 (95% CI: 0.54-4.03) and 0.79 (95% CI: 0.46-1.35), respectively. A positive ultrasound result increases and negative ultrasound result decreases the probability that a nonpalpable testis is located within the abdomen from 55% to 64% and 49%, respectively. Significant heterogeneity limited the precision of these estimates, which was attributable to variability in the reporting of selection criteria, ultrasound methodology, and differences in the proportion of intraabdominal testes. CONCLUSIONS Ultrasound does not reliably localize nonpalpable testes and does not rule out an intraabdominal testis. Eliminating the use of ultrasound will not change management of nonpalpable cryptorchidism but will decrease health care expenditures.
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Affiliation(s)
- Gregory E. Tasian
- Department of Urology, University of California, San Francisco, California
| | - Hillary L. Copp
- Department of Urology, University of California, San Francisco, California
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