Scrotal Exploration for Unilateral Nonpalpable Testis

Does the presence of blind-ended vas deferens and spermatic vessels in laparoscopic exploration of non-palpable testes conclusively indicate testicular absence?

Objective

The purpose of this study was to determine whether the presence of blind-ended vas deferens and spermatic vessels (VDSV) during laparoscopic exploration of non-palpable testes (NPT) indicates testicular absence or atrophy.

Materials and methods

A retrospective analysis was conducted on clinical data of patients diagnosed with NPT and treated with surgical intervention at our center from April 2013-April 2023. The dataset encompassed information such as the children's age, affected side, size of the contralateral testis, surgical procedures employed, outcomes, and histopathological examination results. All patients underwent physical examination and ultrasonography preoperatively, followed by a combination of laparoscopic exploration and exploration through inguinal or scrotal incisions during surgery. Long-term follow-up was conducted postoperatively.

Results

A total of 476 cases comprising 504 NPT were included in this study: 302 cases on the left side, 146 cases on the right side, and 28 cases bilaterally. All patients underwent surgical treatment within 6-126 months (median 13 months). During laparoscopic exploration, blind-ended VDSV were found in 90 testes (72 on the left side, 18 on the right side), while exploration through inguinal or scrotal incisions revealed 52 (57.8%) testicular nodules with atrophy, which were excised, leaving 38 (42.2%) without any findings. Histopathological examination of atrophic nodules revealed fibrosis as the most common finding in 41 cases (78.8%), followed by involvement of the vas deferens in 33 cases (63.5%), calcification in 24 cases (46.2%), epididymis in 23 cases (44.2%), and hemosiderin deposition in 7 cases (13.6%). Fibrosis, calcification, hemosiderin deposition, involvement of the vas deferens, and epididymis were found in combination in 47 specimens (90.4%). Seminiferous tubules (SNT) were found in 3 specimens (5.7%), and germ cells (GC) were found in 1 specimen (1.9%).

Conclusion

The presence of blind-ended VDSV during laparoscopic exploration of NPT does not necessarily indicate testicular absence or disappearance. It is possible that atrophic testicular nodules are located within the inguinal canal or scrotum. This understanding contributes to the management of non-palpable testes. Considering their unpredictable malignant potential, we recommend excision.

Management of pediatric vanishing testes syndrome based on pathological diagnosis: a single-center retrospective study

This study aims to explore the optimal management strategy for pediatric vanishing testes syndrome (VTS) based on pathological characteristics. We retrospectively analyzed clinical data and pathological results of children with unilateral VTS who underwent surgical treatment at our center from July 2012 to July 2023. The children were categorized into the testicular excision group and testicular preservation group based on the surgical approach. Clinical characteristics and outcomes were compared between the two groups. Pathological examination results of excised testicular tissues were collected and analyzed, and long-term follow-up was conducted. A total of 368 children were included in this study. The age of the children at the time of surgery was 27 months (range, 6-156). Among them, 267 cases (72.6%) had VTS on the left side, and 101 cases (27.4%) on the right side. There were no statistically significant differences (P > 0.05) in age, affected side, contralateral testicular hypertrophy (CTH), testicular location, and preferred surgical incision between the testicular excision group (n = 336) and the testicular preservation group (n = 32). In the preservation group, two children experienced scrotal incision infections, showing a statistically significant difference compared to the excision group (P < 0.05). Pathological examination of excised tissues revealed fibrosis as the most common finding (79.5%), followed by vas deferens involvement (67%), epididymis involvement (40.5%), calcification (38.4%), and hemosiderin deposition (17.9%). Seminiferous tubules (SNT) was present in 24 cases (7.1%), germ cells (GC)in 15 cases (4.5%), and ectopic adrenal cortical tissue(EACT) in 1 case (0.3%). VTS belongs to a type of non-palpable testes (NPT) and requires surgical exploration. Considering the risk of scrotal incision infection after preserving atrophic testicular remnants and the unpredictable malignant potential, we recommend excision.

The optimum cut-off value of contralateral testis size in the prediction of monorchidism in children with nonpalpable testis: A systematic review

BACKGROUND

Contralateral Testis Hypertrophy (CTH) is a clinical marker that could be used to guide the choice of the main surgical strategy. In patients with a Non-palpable Testis (NPT), the degree of CTH as measured by testicular length or volume has been shown to be able to predict whether the undescended testis will survive.

OBJECTIVE

The purpose of this study was to establish the proper cut-off for identifying non-viable testes based on the current literature.

DESIGN

We systematically searched several medical databases as well as Google Scholar search engines for references and citations. All the studies that reported CTH as a result of NPT in prepubertal boys were included. Data from the included articles was gathered by two independent reviewers. The checklist developed by the Joanna Briggs Institute (JBI) was used to evaluate the methodological quality of the studies that were included. Due to the incredibly high degree of heterogeneity among the studies, no meta-analysis was done.

RESULTS

The current systematic review included 17 studies that assessed the cut-off point to detect non-viable testis. The size and length of the testes were taken into consideration based on our findings. We found that different studies reported various ideal cut-off values for predicting non-viable testes, which can be brought on by various measuring techniques, evaluation ages, and patient groupings. The difference in testis volume was greater than the difference in its length, which can be attributable to the fact that some studies used an orchidometer to measure the testis's length directly or indirectly.

CONCLUSION

According to the results of our study, it seems that defining a cut point for diagnosis of CTH based on the size of the testis, cannot demonstrate the absence of a non-palpable testis.

Abdominal Cryptorchidism with Complete Dissociation between the Testis and Deferent Duct Mimicking Testicular Regression Syndrome

Complete separation of the deferent duct from the epididymis in cryptorchid testes residing in the abdomen is an extremely rare variant of developmental disorders of the testis and epididymis. Available sources mention only three clinical cases similar to our observations. The unique anatomic aspects of this disorder hamper the correct diagnosis of an intra-abdominal cryptorchid testis. Two boys with nonpalpable left-sided cryptorchidism underwent diagnostic laparoscopy, revealing an intra-abdominally located testis. The epididymis was completely separated from the deferent duct, and the epididymis and testis were supplied by testicular vessels. Exploration of the inguinal canal revealed blind-ending deferent ducts. The testis was brought down through the inguinal canal and fixed in the scrotum in both boys. The follow-up examination at 6 months revealed no signs of testicular atrophy or malposition of the testis in either patient. With our observations in mind, the exclusive use of a transscrotal or transinguinal approach as the initial surgical exploration in the treatment of patients with nonpalpable forms of cryptorchidism may be inappropriate. Careful laparoscopic examination of the abdominal cavity is indispensable in children with suspected testicular regression syndrome or nonpalpable forms of cryptorchidism.

Contralateral testicular hypertrophy is associated with a higher incidence of absent testis in children with non-palpable testis

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.

Management of the undescended testis in children: An American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee Systematic Review

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.

Serial Inhibin B Measurements in Boys with Congenital Monorchism Indicate Compensatory Testicular Hypertrophy in Early Infancy

AIM

 Congenital monorchism is considered a condition in which an initially normal testis has existed but subsequently atrophied and disappeared due to a third trimester catastrophe (presumably torsion). Since inhibin B concentrations appear related to Sertoli and germ cells number, we evaluated pre- and postoperative inhibin B of boys with congenital monorchism to determine whether the well-known hypertrophy of the contralateral testis was reflected in inhibin B concentrations.

MATERIALS AND METHODS

 Twenty-seven boys consecutively diagnosed with congenital monorchism (median age 12 months) underwent follow-up with reproductive hormones 1 year postoperatively (median age 25 months). The results were compared with inhibin B of 225 boys with congenital nonsyndromic unilateral cryptorchidism, by converting values to multiple of the median (MoM) for age in normal boys.

RESULTS

 Ten boys (37%) had blind-ending vessels and ductus deferens (vanished testis) and the remaining (63%) had testicular remnants. At the time of diagnostic procedure, monorchid boys did not have significantly lower inhibin B (median 114, range 20-208) than unilateral cryptorchid boys (136, 47-393) (p = 0.27). During follow-up, MoM values of inhibin B increased in monorchid boys (median 0.59 to 0.98) and in unilateral cryptorchid boys (0.69 to 0.89) (both p < 0.0001). Compared with the concentration at surgery, an additional 44% monorchid boys had inhibin B MoM values higher than 1.0, whereas only additional 23% of unilateral cryptorchid boys exhibited such values (p = 0.04).

CONCLUSION

 Generally, inhibin B MoM values were normalized during follow-up in boys with congenital monorchism, reflecting compensatory hypertrophy within the first 2.5 years of life. The compensatory capacity to increase was better in monorchism than in unilateral cryptorchidism.

Histopathological Features of Vanishing Testes in 332 Boys: What Is Its Significance? A Retrospective Study From a Tertiary Hospital

The purpose of this study is to analyze the histopathological features of resected testicular remnant specimens, ascertain the incidence of the presence of either germ cells (GCs) or seminiferous tubules (SNTs), and assess whether surgical excision of the remnant is necessary. A total of 332 boys with vanishing testis underwent surgical removal of unilateral testicular remnants, with age 7-164 months (median age 25 months). Among the total 332 cases, 212 (63.8%) were younger than 36 months and 143 (66.5%) were found to have hypertrophied contralateral testes larger than 1.6 cm in longitudinal diameter under sonography. SNTs were only present in 21 (6.3%) cases and GCs were present in 7 (2.1%) cases. Compared to the review studies, the very low incidence of SNTs and GCs in which implies extremely low chances of potential malignancy. We propose that surgical removal of vanishing testis remnants in an inguinal or scrotal position may not be necessary.

Safety and Efficacy of Laparoscopic Management of Intracanalicular Testes in Pediatrics

Introduction: Undescended testis is a relatively common congenital anomaly in male children with a prevalence of 1%-2% in live births. Upon discovering an empty scrotum, it is important to determine whether the testis is palpable, ectopic, retractile, or nonpalpable. A canalicular or "emergent" testis is a peeping one that freely slides to and fro between the abdominal cavity and inguinal canal. It may be impalpable initially, but at a time, it emerges from the internal ring to be palpable when it is "milked" down (where it was concealed from detection). It is reported that 15%-40% of cryptorchidism are viable peeping/canalicular testis. The laparoscopic approach for treating intracanalicular undescended testes offers many advantages over open inguinal orchiopexy. It maintains the integrity of the inguinal canal and eliminates the need to divide the epigastric vessels during dissection. The ability to dissect the testicular vessels at a higher level would increase the vessel length available to bring the testis down to the scrotum without strain. The aim of this study is to present our experience and evaluate laparoscopic approach for management of intracanalicular testes regarding operative safety, efficacy, and postoperative outcomes. Patients and Methods: This is a prospective study conducted at Department of Pediatric Surgery, MCH Hospital, Bisha, Saudi Arabia and Pediatric Surgery Department, Al-Azhar University Hospitals, Cairo, Egypt, in the period from October 2018 to August 2020 to evaluate the safety and efficacy of laparoscopic orchiopexy for intracanalicular testis. Patients with retractile testes, ectopic testes, testes located distal to the external inguinal ring, and nonpalpable testes were excluded from the study. Results: The study was conducted on 62 male children with 70 intracanalicular (peeping) testes, with age range from 8 months to 48 months (mean age: 24 months). Among them, 26 cases (∼42%) were left-sided, 28 (∼45%) were right-sided, and 8 (∼13%) cases were affected bilaterally. Postoperatively, all testes maintained good size without postoperative hydrocele or inguinal hernia. One case (1.4%) required open redo-orchiopexy because of testicular re-ascent to the level of scrotal neck. Moreover, there was no evidence of testicular atrophy confirmed by postoperative ultrasonography. All patients had good satisfied cosmetic results obtained by parent's questionnaire at postoperative follow-up visits. Conclusion: Laparoscopic orchiopexy for management of (intracanalicular) undescended testes is safe, effective, less invasive, without disturbance of inguinal canal anatomy, and with better cosmetic results.

Assessment of referral patterns for boys with suspected undescended testes and identification of risk factors to aid diagnosis

INTRODUCTION

Undescended testis (UDT) is a clinical diagnosis and a common reason for referral to paediatric urology outpatients. Our aim was to assess current referral patterns at our unit and to identify predictive factors that may better aid primary care physicians (PCP) in diagnosing UDT based on history and physical exam.

METHODS

A retrospective analysis of referrals to outpatients from 2014 to 2016 was performed to assess current referral patterns including referral source, age, reason for referral and outcome following assessment by a single consultant paediatric urologist.A prospective analysis of new referrals was performed to identify predictive factors which may aid in the diagnosis of UDT including gestational age, presence of scrotal asymmetry and previously obtained imaging.

RESULTS

From 2014 to 2016, 259 boys were referred with suspected UDT. The majority of referrals were received from PCPs (62%) followed by Neonatology (29%), Paediatrics (8%) and general surgery (1%). Median age at time of assessment was 29 (5-180) months. One hundred and eight (41.7%) boys were diagnosed with UDT.There were 74 boys assessed prospectively. Median age at assessment was 24.5 (6-171) months. We identified 3 predictors of a diagnosis of UDT; history of prematurity (p = 0.001), UDT mentioned to the parents at birth (p = 0.027) and scrotal asymmetry on examination (p < 0.001). Greatest diagnostic inaccuracy was found in boys referred beyond one year of age (27.7%). In this cohort, the absence of all three risk factors was associated with a negative predictive value of 94.1%.

CONCLUSION

The majority of boys with suspected UDT are referred beyond the age recommended for orchidopexy (6-12 months). The majority of boys referred for assessment did not have UDT. We have identified three predictive factors that may aid referring physicians when assessing boys, particularly those older than 1 year.

Sentinel nubbin: A potential pitfall in the management of undescended testis secondary to epididymo-testicular nonunion

INTRODUCTION

Epididymal anomalies are common in boys with undescended testis. Epididymo-testicular non-union with a nubbin in the scrotum is a rare anomaly and may be confusing during management of cryptorchidism. The non-fused epididymis and vas deferens which are descended to the scrotum, may be regarded as nubbin tissue secondary to testicular atrophy and proximal testis may be overlooked.

OBJECTIVE

To evaluate a relatively rare anomaly of epididymo-testicular non-union in which vas deferens and epididymis are descended to the scrotum resembling a nubbin tissue, while a separate testis remains in a proximal peritoneal fold (hernia or processus vaginalis)which could potentially be missed during the management of patients with undescended testis.

STUDY DESIGN

The charts of the fourteen patients with epididymo-testicular non-union and a scrotal nubbin are retrospectively evaluated.

RESULTS

Median age of the patiens was 1.5 years (0.5-12), 11 were left and 3 were right. No connection could be demonstrated between the testis and vaso-epididymal unit in any of the patients. Orchidopexy was performed in 13 patients while orchidectomy in1 patient. The scrotal nubbin tissue is excised in 4 patients and histological examination revealed sections of vas deferens and epididymis. One of the patients underwent inguinal exploration and orchidectomy for assumed testicular atrophy elsewhere but histological examination revealed vas deferens and epididymis without any sign suggesting an atrophic testis. An intrabdominal testis was found incidentally in this patient and he underwent 2 additional procedures for orchidopexy.

DISCUSSION

Although epididymo-testicular anomalies are common in boys with undescended testis, nonunion is the rarest type of this anomaly. Similar cases are reported in the literature as simple fusion anomalies with indefinite clinical significance or even polyorchidism although no accessory testis could be demonstrated. However, the scrotal nubbin tissue which actually contains epididymis and vas is a potential decoy and may result in missing of the proximal testis if regarded as a sign of testicular atrophy and further evaluation is obviated. As this is retrospective study, actual incidence of the condition is yet to be determined.

CONCLUSION

A scrotal nubbin tissue may be secondary to epididymo-testicular nonunion as well as testicular atrophy. As feasibility of radiological imaging studies are limited, a laparoscopic exploration may be considered to confirm or to exclude a separate testis in patients with scrotal nubbin. Prospective studies are needed to evaluate the actual incidence of the condition and gain-loss analysis of laparoscopic exploration.

Testicular hypertrophy as predictor of contralateral nonpalpable testis among Chinese boys: An 18-year retrospective study

OBJECTIVE

To assess the accuracy of contralateral testis hypertrophy for predicting the fate of nonpalpable testis in Chinese boys at different ages.

METHODS

The data of patients who presented with unilateral impalpable testis and who underwent laparoscopy at the Children's Hospital of Chongqing Medical University between January 1, 2000 and January 1, 2018 were reviewed. The boys were divided into four groups: age-matched volunteers with no testicular abnormalities represented the control group (group I), boys with palpable undescended testis (group II), boys with nonpalpable testis (NPT)/viable testis (VT) (group III), and boys with NPT/non-viable testis (NVT) group (group IV). Scrotal testes were prospectively measured by ultrasonography for volume and size, and diagnostic laparoscopy was performed to determine the state of the cryptorchid testis.

RESULTS

The mean contralateral testicular volume and length in the boys with an absent testis was 0.78mL and 17mm compared with 0.67mL and 15mm in the boys with a testis present and 0.63mL and 15mm in the controls, respectively (P<0.05). The predictive accuracy, sensitivity, and specificity for an absent testis were 64.9%, 75%, and 49%, respectively, for volume and 64.2%, 56.3%, and 76.4%, respectively for length at the optimal cutoff value of 0.65mL volume and 16.55mm length. Contralateral testis volume was the most accurate in predicting monorchism in 0-2-year-olds (sensitivity: 75%, specificity: 70%, accuracy: 73.1%) and the contralateral testicular length was most accurate for 4-6-years-old (sensitivity: 68.6%; specificity: 77.8%; accuracy: 72.2%). We also included 29 patients with bilateral undescended testis (UDT) and with unilateral nonpalpable. Cutoff values for testicular volume and length were 0.6mL (sensitivity: 81.8%, specificity: 88.9%, accuracy: 86.2%) and 13.5mm (sensitivity: 63.6%, specificity: 77.8%, accuracy: 77.8%).

CONCLUSION

The present results exclusively obtained from laparoscopic exploration suggest that a testis volume of>0.65mL or a testis length of>16.55mm could predict monarchism with an accuracy of about 65%. In younger patients aged 0-2 years and 4-6 years, the overall predictive accuracy increases to about 73% but laparoscopic exploration is still required.

Detection of monorchidism in boys with unilateral undescended testes: clinical benefits and limitations of contralateral testicular size

INTRODUCTION

Contralateral testicular size was recommended as an effective measurement in prediction of monorchidism in some previous studies but a few argued it as invalid. Further investigation was demanded.

OBJECTIVES

To investigate the effectiveness of contralateral testicular size in prediction of monorchidism in patients with unilateral non-palpable undescended testes (NPT) aged between 9 and 48 months.

MATERIALS AND METHODS

Total of 707 patients aged between 9 and 48 months and diagnosed with unilateral undescended testes (UDT) between January 2016 and December 2018 at the study department were enrolled. In accordance with physical examinations and surgical findings, patients were divided into three groups: palpable UDT (group A, n = 609), non-palpable but viable testes (group B, n = 57) and monorchidism (group C, n = 41). Contralateral testicular length and volume were evaluated with ultrasonography. Comparison of contralateral testicular size between three groups and calculation of optimal cut-off value and diagnostic performance of it among NPT were performed.

RESULTS

The length and volume of contralateral testes of group C were larger than of group A (P < 0.01) and group B (P < 0.01), whereas these differences between groups were small. Among patients with NPT, a receiver operating characteristic curve was used to determine the optimal cut-off value. It revealed that both a testicular length of 17.5 mm and a volume of 1.05 ml provided the highest Youden's index for prediction of monorchidism. The sensitivity and specificity for testicular length were 34.1% and 94.7%, and volume were 34.1% and 93%, respectively. The predictive accuracy for testicular length and volume were 69.4% and 65.7%, respectively. Even though the negative predictive value was merely 66.6% (54/81) and 66.2% (53/80), the positive predictive value (PPV) reaches to 82.3% (14/17) and 77.7% (14/18) for testicular length and volume.

DISCUSSION

Several factors including choosing of measurement tools, age range, ethnicity, and selection bias of cohorts may be accounted for the huge differences among cut-off values and predictive accuracy. The diagnostic performance of contralateral testicular size in prediction of monorchidism in patients with NPT was poor. But the PPV was relatively promising. Contralateral testicular hypertrophy can provide information for surgical planning.

CONCLUSION

The overall diagnostic performance of contralateral testicular size in prediction of monorchidism in poatients with UDT aged between 9 and 48 months was poor. But the efficiency of cut-off value predicting absence of viable testes was relatively higher. This value should be objectively applied but only as a reference which would not be a complete replacement of laparoscopy exploration.

Non-palpable testis: is management consistent and objective?

INTRODUCTION

Diagnostic laparoscopy is recommended for boys with non-palpable testis (NPT) by American and European guidelines with the decision to pursue inguinal exploration based upon testicular vessel appearance. We hypothesized that management decisions are not consistent with the guidelines, and that assessment of vessels is subjective.

MATERIALS AND METHODS

Pediatric urologist management decisions were evaluated via an electronic survey to determine impact of contralateral testicle size, sonographic findings, surgeon region, and years in practice. In a digital image survey, surgeons were asked to interpret gonadal vessel status of 32 consecutive cases of NPT with absent abdominal testis as normal, atretic, or blind-ending to determine intra- and inter-rater reliability.

RESULTS

Of the 339 participants, more Europeans (49%) chose sonography as the first management step for NPT compared to US surgeons (12%). Regardless of sonographic findings, over 80% chose laparoscopy as the first step. In the presence of normal, atretic, and blind-ending vessels, the decisions to proceed with inguinal/scrotal exploration were 88%, 68%, and 17%, respectively. Contralateral hypertrophy and sonography findings had no significant impact on the decision to proceed with inguinal/scrotal exploration. The visual gonadal vessel survey showed surgeon interpretation of normal or blind-ending vessels had moderate inter-rater reliability. Surgeons did not agree on normal status 37% of the time and did not agree on atretic status 66% of the time. There was no statistical difference between European and US respondents (P = 0.23). Intra-rater reliability was fair for blind-ending vessels. When the first interpretation was blind-ending, the same surgeon changed interpretation of the same image 39% of the time. There was no statistical difference by years of practice.

CONCLUSIONS

Non-visualization of NPT on sonography and contralateral testis size had no significant impact upon management decisions. Surgeons chose to pursue inguinal/scrotal exploration based upon laparoscopic gonadal vessel status. However, these interpretations were subjective with low inter- and intra-rater reliability.

Initial laparoscopy and optimized approach for unilateral nonpalpable testis: review of 8-year single-center experience

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.

Surgical exploration for impalpable testis: Which should be first, inguinal exploration or laparoscopic abdominal exploration?

PURPOSE

To discuss an optimal surgical approach for impalpable testis in children, our own treatment results and those reported in the literature were reviewed.

MATERIALS AND METHODS

Seventy-two impalpable testes were diagnosed in 68 patients: unilateral in 64 patients and bilateral in 4 patients. All patients underwent surgical exploration at the ages of 6 to 140months (median, 15months). The inguinal canal was initially explored, and abdominal exploration was performed with laparoscopy when an extra-abdominal testis was not identified. In addition, articles regarding surgical exploration for impalpable testis, published over the last 20years, were retrieved and the results were examined.

RESULTS

Testes were detected by inguinal exploration in 28 of 72 (39%) impalpable testes: intracanalicular in 22 testes and at the internal inguinal ring (peeping or low abdominal testis) in 6 testes. All these testes were treated by conventional inguinal orchidopexy. Laparoscopic exploration was performed in 44 (61%) impalpable testes, and 4 (5.6%) high abdominal testes were detected and treated by two-stage Fowler-Stephens orchidopexy. Vanishing or absent testis was the final diagnosis in the remaining 40 testes (55.6%). The literature review showed that the ratios of intra- and extra-abdominal testes were lower in the articles that reported the results of inguinal or scrotal exploration than in those of laparoscopic exploration, although the difference was not significant.

CONCLUSIONS

Considering the relatively low incidence of high abdominal testis, we recommend to start with inguinal exploration for impalpable testis. When an extra-abdominal testis is not detected, transinguinal laparoscopic exploration should be indicated.

LEVEL OF EVIDENCE

Treatment study, Level IV.

Impact of Preoperative Ultrasonographic Evaluation for Detection of a Viable Testis in Patients With a Unilateral Nonpalpable Testis

OBJECTIVES

To investigate the impact of preoperative ultrasonography (US) for detecting a viable testis in patients with a unilateral nonpalpable testis.

METHODS

Patients with a unilateral nonpalpable testis or unilateral palpable undescended testis who underwent preoperative US were enrolled. Patients were divided into 3 groups as follows: nonpalpable testis/no testis (n = 27), which included patients who had a unilateral nonpalpable testis with no viable testis detected at surgery; nonpalpable testis/viable testis (n = 10), which included patients who had a unilateral nonpalpable testis with a viable testis identified at surgery; and palpable undescended testis (n = 63), which included patients who had a unilateral palpable undescended testis. Preoperative US findings were compared among each group.

RESULTS

The testicular volume on the contralateral descended side in the nonpalpable testis/no testis group was significantly greater than that in the nonpalpable testis/viable testis and palpable undescended testis groups. When a testicular volume of 0.54 mL was used as the cutoff value, the sensitivity, specificity, positive predictive value, and negative predictive value for the presence of the affected testis were 75.3%, 100%, 100%, and 60.0%, respectively. The testis on the affected side was detected in none of the nonpalpable testis/no testis group, 7 of the nonpalpable testis/viable testis group, and all of the palpable undescended testis group. When a visible testis on the affected side and a testicular volume of 0.54 mL or less were defined as positive, all patients in the nonpalpable testis/viable testis and palpable undescended testis groups had positive findings versus none in the nonpalpable testis/no testis group.

CONCLUSIONS

Preoperative US provides valuable information for predicting the presence of a viable testis in patients with a unilateral nonpalpable testis by estimating both the unaffected testis and the affected side.

Presence of viable germ cells in testicular regression syndrome remnants: Is routine excision indicated? A systematic review

There is no consensus in the literature about the necessity for excision of testicular remnants in the context of surgery for an impalpable testis and testicular regression syndrome (TRS). The incidence of germ cells (GCs) within these nubbins varies between 0 and 16% in previously published series. There is a hypothetical potential future malignancy risk, although there has been only one previously described isolated report of intratubular germ-cell neoplasia. Our aim was to ascertain an accurate incidence of GCs and seminiferous tubules (SNTs) within excised nubbins and hence guide evidence-based practice. The systematic review protocol was designed according to the PRISMA guidelines, and subsequently published by the PROSPERO database after review (CRD42013006034). The primary outcome measure was the incidence of GCs and the secondary outcome was the incidence of SNTs. The comprehensive systematic review included articles published between 1980 and 2016 in all the relevant databases using specific search parameters and terms. Strict inclusion and exclusion criteria were ultilised to identify articles relevant to the review questions. Twenty-nine paediatric studies with a total of 1455 specimens were included in the systematic review. The mean age of the patients undergoing nubbin resection was 33 months and the TRS specimen was more commonly excised from the left (68%). The incidence of SNTs was 10.7% (156/1455) and the incidence of GCs, 5.3% (77/1455). Histological analysis excluding the presence of either SNTs or GCs was consistent with TRS, fibrosis, calcification or haemosiderin deposits. There is limited evidence on subset analysis that GCs and SNTs may persist with increasing patient age. This systematic review has identified that 1 in 20 of resected testicular remnants has viable GCs and 1 in 10 has SNTs present. There is insufficiently strong evidence for the persistence of GCs and SNTs with time or future malignant potential. Intra-abdominal TRS specimens may contain more elements and, therefore, require excision, although this is based on limited evidence. However, there is no available strong evidence to determine that a TRS specimen requires routine excision in an inguinal or scrotal position.

Blind ending vessels on diagnostic laparoscopy for nonpalpable testis: Is a nubbin present?

INTRODUCTION

The traditional management paradigm for nonpalpable testis (NPT) has been that inguinal or scrotal exploration for a nubbin may be omitted when blind ending vessels are observed during diagnostic laparoscopy. Our aim was to examine whether blind ending vessels excluded the presence of a nubbin in a series of boys who underwent exploration in this setting.

MATERIALS AND METHODS

Using a surgical database and chart review, pre-pubertal boys (≤12 years) with the diagnosis of undescended or atrophic testis who underwent a diagnostic laparoscopy for unilateral NPT between 2000 and 2015 were retrospectively identified. Physical exam, procedural and pathologic findings were confirmed by chart review.

RESULTS

595 boys underwent diagnostic laparoscopy for NPT by 11 surgeons. Of these, 318 had an intra-abdominal testis and 18 underwent diagnostic laparoscopy alone. Of the remaining 259, 32 had an open internal ring and inguinal or scrotal exploration was performed. The remaining 227 with a closed ring comprised the cohort for our analysis, of whom 188 had vessels entering the ring, 36 had blind ending vessels, and in three the vessel status was unavailable. In the 188 boys with vessels entering the ring, 164 (87%) had a nubbin excised during inguinal or scrotal exploration, of which 93% were grossly identified as an atrophic testis. Pathology confirmed the presence of hemosiderin in 44% and calcifications in 54%. In the 36 boys with blind ending vessels, 26 (72%) had a nubbin excised during inguinal or scrotal exploration, of which 96% were grossly identified as an atrophic testis. Pathology confirmed hemosiderin in 54% and calcifications in 58%. All seven cases with both blind ending vas and vessels had an atrophic testis grossly identified. Of all 207 excised remnants in this series, nubbins with viable testicular elements (seminiferous tubules in 11, germ cells in two) were only excised during cases that reported a non-atretic vas or any vessels entering the internal ring.

CONCLUSION

In this large multi-institutional series, blind ending vessels were associated with a nubbin noted during inguinal or scrotal exploration in the majority of cases. Based on this series if the surgeon's goal is to remove all nubbins, exploration is necessary regardless of vessel appearance. However, viable testicular elements were rarely identified and only when either a non-atretic vas or any vessels were observed to enter the ring.

Canadian Urological Association-Pediatric Urologists of Canada (CUA-PUC) guideline for the diagnosis, management, and followup of cryptorchidism

Cryptorchidism is one of the most common congenital anomalies in males, characterized by inability to palpate the testicle in the expected normal anatomical position (i.e., within its respective hemi-scrotum). It represents an abnormality of testicular descent and development associated with long-term concerns, including infertility, hypogonadism, and development of neoplasms.

Laparoscopic management and its outcomes in cases with nonpalpable testis

OBJECTIVE

Diagnostic laparoscopy is the gold standard in the algorithm of nonpalpable testis. Testicular tissue is examined and treatment is planned accordingly. In this study we reviewed the place of diagnostic laparoscopy, and evaluated the results and effectiveness of laparoscopy in the diagnosis and management of nonpalpable testis.

MATERIAL AND METHODS

Children who had diagnostic laparoscopy for nonpalpable testes were included in the study. Physical examination results, ultrasonography (USG) reports, age at surgery, laparoscopic and inguinal exploration findings, surgical procedures, orchiopexy results, early and late-term complications were evaluated. Follow-up visits were performed at 3-month intervals for the first, at 6-month intervals for the 2. year, then at yearly intervals. Testicular size and location was evaluated by during control examination.

RESULTS

Overall 58 boys, and 68 testes (26 left: 44.8%; 22 right: 37.9%, and 10 bilateral: 17.2%) were included in the study. Mean age at surgery was 5.5 years (10 months-17 years). Diagnostic value of USG was 15.7%. Diagnostic laparoscopy findings were as follows: Group 1: blind-ended vessels, n=7 (10.2%); Group 2: intraabdominal testes, n=8 (11.7%); Group 3: vas and vessels entering internal ring, n=53 (77.9%). Overall 43 testes underwent orchiopexy, which were normal (n=8) or hypoplastic (n=35). Mean follow-up period was 19 months (1-12 years), and on an average 7 visits were performed (5-14). On follow-up, 5 testes were normal-sized and located in the scrotum, while 4 testes were atrophic and underwent orchiectomy. Two testes were found in the inguinal canal and redo orchiopexy was performed. Control USG revealed reduced testicular blood supply and volume.

CONCLUSION

Laparoscopic surgery is safe and effective in the management of nonpalpable testes. In the majority, routine use of diagnostic laparoscopy in the algorithma does not confer any additional contributions in many patients.

Scrotal testis size in unilateral non-palpable cryptorchidism, what it can and cannot tell: Study of a Middle Eastern population

BACKGROUND

Predicting the fate of a unilateral non-palpable testis based on its scrotal counterpart has been recommended by some, yet disputed by others, and the question remains open.

OBJECTIVE

To investigate the accuracy of contralateral testis hypertrophy in predicting the absence of a unilateral non-palpable testis in a Middle Eastern population.

STUDY DESIGN

This retrospective study included all patients referred to the present institution with unilateral non-palpable testis between June 2010 and August 2014, who had undergone laparoscopy. The scrotal testis was examined by sonography for size and volume, and diagnostic laparoscopy was utilized to determine the state of the cryptorchid testis.

RESULTS

Of the 135 referred patients, 64 were aged ≤8 years, 29 were 9-18 years, and 42 were >18 years old. Diagnostic laparoscopy revealed 63 intra-abdominal testes, 20 small intra-inguinal testes, 32 vanished testes, and 20 nubbins or aplasia (Summary fig.). Scrotal testis volume was only a modest predictor for absence of the contralateral gonad in adult patients in whom a 22 ml cut-off yielded 64.3% sensitivity and 92.9% specificity. For those aged <18 years, overall accuracy was poor and dropped below 60%. Relative enlargement of contralateral testis in decreasing order of size was observed in patients with primary monorchism, followed by those with secondarily atrophic or nubbin testis, and then those with normal sized inguinal or abdominal testis.

DISCUSSION

Unlike some previous series, which based their conclusions upon open exploration and mostly studied pre-pubertal subjects, the present results exclusively from laparoscopic exploration suggested that contralateral testis volume is a poor and inconsistent predictor of monorchism in children, and marginally predictive for young adults with unilateral non-palpable testis. This study comprised a reasonably large overall sample size compared with preceding reports; however, the number of patients within in each age group was limited. Greater numbers could allow for statistical comparison stratified by age group, for which this study was not powered.

CONCLUSION

Contralateral testis volume predicts, with modest accuracy, monorchism in adults with unilateral non-palpable testis. In younger patients, the overall predictive accuracy of scrotal testis size is poor and not consistently dependable.

The Nonpalpable Testis: A Narrative Review

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.

Management of undescended testes: European Association of Urology/European Society for Paediatric Urology Guidelines

CONTEXT

Undescended testis is the most common endocrinological disease in the male newborn period. Incidence varies between 1.0% and 4.6% in full-term neonates, with rates as high as 45% in preterm neonates. Failure or delay of treatment can result in reduced fertility and/or increased testicular cancer risk in adulthood.

OBJECTIVE

To provide recommendations for the diagnosis and treatment of boys with undescended testes which reduce the risk of impaired fertility and testicular cancer in adulthood.

EVIDENCE ACQUISITION

Embase and Pubmed were searched for all relevant publications, from 1990 to 2015 limited to English language. Data were narratively synthesized in light of methodological and clinical heterogeneity. The risk of bias of each included study was assessed.

EVIDENCE SYNTHESIS

There is consensus that early treatment, by 18 months at the latest, for undescended testes is mandatory to avoid possible sequelae regarding fertility potential and cancer risk. The current standard therapy is orchidopexy, while hormonal therapy is still under debate. However, in some individuals the successful scrotal placement of previously undescended testes may not prevent potential negative long-term outcomes regarding fertility and testicular malignancy.

CONCLUSIONS

There is good evidence for early placement of undescended testes in the scrotal position to prevent potential impairment of fertility and reduce the risk of testicular malignancy. No consensus exists on the various forms of hormonal treatment, which are assessed on an individual basis.

Can Hypertrophy of the Contralateral Testis Predict the Absence of a Viable Testis in Infancy with Cryptorchidism: A Prospective Analysis

This prospective study aimed to evaluate whether Contralateral compensatory testicular hypertrophy (CTH) is valid as a predictive tool for a non-viable testis in children aged between 6 and 18 months, and whether CTH is affected by mini-puberty. Seventy-two testes from 60 boys aged between 6 and 18 months were categorized into three groups: 24 testes contralateral to surgically removed non-viable testes (NVTs), 24 testes contralateral to surgically corrected undescended testes (UDTs), and 24 testes from a normal controls. Contralateral testicular length and volume were measured with ultrasonography and compared among the groups. Group 1 (NVT) had a significantly longer length and larger volume than group 2 (UDT). The length and volume of each group among three developmental periods (6-10, 10-14, and 14-18 months) were also analyzed. In the controls, the length was significantly larger at 6-10 months than at 10-14 months in accordance with previously reported changes in testicular size due to the effect of "mini-puberty." The volume of controls showed a similar pattern, though without statistical significance. However, this pattern was not observed in the NVT and UDT groups. A receiver operating curve revealed that a testicular length of 16.1 mm or a volume of 0.59 ml had the highest sensitivity and specificity for predicting NVTs. The CTH was also found to be valid as a predictive tool for a NVT in children of ages 6 to 18 months, as the effect of mini-puberty appeared to be absent in the NVT and UDT groups. However, the cut-off values were less than those of previous reports. The proper cut-off level according to the age and measurement method should be applied in this developmental period.

Testicular hypertrophy as a predictor for contralateral monorchism: Retrospective review of prospectively recorded data

OBJECTIVES

Testicular hypertrophy has previously been evaluated as a predictor of monorchism. However, its implication in clinical practice is not well evaluated. The aim of the present study was to examine its value in planning the operative time.

PATIENTS AND METHODS

Medical charts of prospectively recorded data of 76 consecutive patients with unilateral impalpable testis from 2011 to 2014 were reviewed at the present institute. Inclusion criteria included prepubertal patients with non-palpable testes by examination under anesthesia. Contralateral testes were prospectively measured using a Takihara orchidometer. Orchiectomy or orchiopexy was performed according to the viability of the undescended testis (UDT). Collected data included age of surgery, contralateral testicular size, surgical time and laparoscopic findings. A ROC curve was used to define the best cut-off volume of the contralateral testis that can predict ipsilateral testicular viability. The Student's t-test was used to examine if this cut-off volume would be useful in allocating the operative time.

RESULTS

Of 76 patients, four palpable testes by examination under anesthesia were excluded. The remaining 72 patients were included in the study. Ipsilateral normal viable testes were found in 26 (36.1%) patients, while 46 (63.9%) had non-viable testes (testicular nubbins or vanishing testes) (Figure). A contralateral testicular volume > 2 ml was significantly predictive for monorchism with 71.7% sensitivity and 100% specificity (P < 0.001). The mean operative time for management of UDT with a contralateral size >2 ml was 50 min, which was significantly shorter than that for UDT with a contralateral size ≤ 2 ml, which was 88 min (P < 0.001).

DISCUSSION

In previously published reports, the cut-off value for testicular hypertrophy that predicts monorchism greatly varied. This is likely due to the different methods used for testicular measurements that make it impractical to make a direct comparison. The usefulness of predicting monorchism before surgery has not previously been used as a guide for allocating operative time in the management of a unilateral non-palpable testicle. This study had some limitations, including a relatively small sample size and involvement of different surgeons, which may have affected the operative time.

CONCLUSION

Using the cut-off volume of a contralateral testis >2 ml as a predictor for monorchism can reduce the allocated operative time by approximately one third.

Unnecessary diagnostic imaging: a review of the literature on preoperative imaging for boys with undescended testes

Cryptorchidism or undescended testis is one of the most common pediatric disorders of the male endocrine glands and the most common genital disorder identified at birth. Ultrasound is commonly ordered for boys with undescended testes prior to referral to a surgical specialist, but its sensitivity and specificity is insufficient to reliably localize non-palpable testes and thus confers unnecessary costs to the patient and the healthcare system. We review the ability of ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) to reliably locate undescended testes and emphasize whether diagnostic imaging should change the decision to operate or the surgical approach for boys with cryptorchidism.

Reliance of preoperative scrotal examination versus final operative findings in the evaluation of non-palpable testes

OBJECTIVE

The current study evaluates whether the preoperative scrotal examination in children with non-palpable testes is sufficient in all cases or if laparoscopy is necessary to confirm the examination findings. Are the findings different amongst physicians depending on their level of experience?

MATERIALS AND METHODS

This retrospective study was done between October 2009 and May 2013. Children with non-palpable testes underwent an examination under anesthesia prior to surgery to feel for a testis or nubbin, followed by a diagnostic laparoscopy to validate the scrotal examination. The test was considered correct if the laparoscopic findings supported the scrotal examination. It was considered incorrect if laparoscopy revealed a different finding.

RESULTS

A total of 74 testes were evaluated. All patients underwent examination under anesthesia by the surgeon and senior resident. The findings were recorded separately. Despite careful examination by experienced surgeons under anesthesia, the scrotal examination was incorrect in 14 patients. Four viable testes would have been missed if laparoscopy had not been performed.

CONCLUSION

Laparoscopy should be considered in case of palpable scrotal nubbins to ensure no testis is left within the abdominal cavity.

Groin exploration for the nonpalpable testes: a single center experience

BACKGROUND

Management of non-palpable testes in Nigeria can be difficult due to late presentation and poor resources. Surgical exploration is often required for diagnosis and treatment.

AIM

This study reviews the management outcome of clinically non-palpable testeis in a tertiary center in Nigeria.

MATERIALS AND METHODS

Ten years retrospective review of all clinically non-palpable testes in children aged 2-15years managed at the Obafemi Awolowo University Teaching Hospitals Complex Ile-Ife Nigeria.

RESULTS

Thirty two children with 44 testicular units were managed. The right side was involved in 12 (37.5%); left in 8 (25.0%) and bilateral in 12 (37.5%) patients. Pre-operative ultrasound was done in 12 patients with localization in just 4 patients (33.3% success rate). At groin exploration, 34 (77.32%) testicular units were located in the inguinal canal. Eight patients with 10 The remaining 10 (22.7%) testicular units required additional mini-laparotomy for which six (13.6%) and 4 (9.1%) testicular units respectively were either in the retroperitoneum or not found. Of the testes in the groin, twenty two (64.7%) testicular units were normal while 12 (35.3%) were atrophic. Four of the retroperitoneal testes were normal while 2 were atrophic. Eight (22.5%) testicular units among the inguinal group had multi-staged orchidopexy; while 2 each of the retroperitoneal group had orchidectomy, one stage orchidopexy, two staged Fowler Stephens (F-S) procedure or lost to follow up after first stage of F-S procedure. Mean follow up period was 2 months. 2 testicular units each had retracted or vanished respectively during follow up.

CONCLUSION

Groin exploration still offers a viable approach Surgical exploration is still useful in to the management of non-palpable testes in low resource environment despite the lack of laparoscopy.

Is there an optimal contralateral testicular cut-off size that predicts monorchism in boys with nonpalpable testicles?

OBJECTIVE

To identify a contralateral testicular cut-off size that would predict monorchism (intra-abdominal vanishing testis or inguinal/scrotal nubbin) in boys with unilateral nonpalpable testis (NPT).

MATERIALS AND METHODS

Boys with cryptorchidism, treated by a single surgeon at a tertiary care center from 2009 to 2013, were grouped based on intra-operative findings: boys with a solitary gonad (monorchism group, M) and two control groups: intra-abdominal testis (IAT) and palpable undescended testis (pUDT). Immediately before the procedures, the contralateral descended testes were measured using callipers. Boys with NPT underwent diagnostic laparoscopy. Sensitivity, specificity, positive and negative predictive values, likelihood ratios and receiver operating characteristic (ROC) curves were calculated.

RESULTS

Out of the 324 boys with cryptorchidism, 58 were found to have pUDT and 85 had NPT. Of these 85 boys with NPT, 50 had an IAT and 35 had monorchism. Mean ages at surgery for groups M, IAT and pUDT were similar (28.0, 31.3 and 30.4 months, respectively; P = 0.4). Mean length of the contralateral descended testes in groups M, IAT and pUDT was 24.3, 16.5 and 18.8 mm, respectively. Contralateral testicular cut-off lengths of 18, 19 and 20 mm had positive likelihood ratios (LR+) of 6.5, 7.4 and 10.1, respectively. The area under the ROC curve was 95% (95% CI: 91-100%).

CONCLUSION

A contralateral testicular cut-off length of 19-20 mm had the best accuracy in predicting monorchism in boys aged 11-30 months with unilateral NPT.

Laparoscopic versus open orchiopexy in the management of peeping testis: a multi-institutional prospective randomized study

OBJECTIVE

Peeping testis is an inconsistently palpable/seen undescended testis that migrates back and forth at the internal inguinal ring. Both open and laparoscopic orchiopexy are effective forms of management. The present study aimed to evaluate the efficacy and safety of both approaches.

PATIENTS AND METHODS

Between September 2007 and January 2012, 46 peeping inguinal testes were randomly treated with either open (25 cases) or laparoscopic (21 cases) orchiopexy procedures. Spermatic vessels were preserved for all cases. Operative details, postoperative morbidity and final testicular site and size were recorded.

RESULTS

The median age of the children was 2.5 years (range 0.5-12.0). The follow-up period ranged from 1.0 to 5.5 years. Of these testes, 20 in the open surgery group and 19 in the laparoscopic group maintained correct intrascrotal position (P = 0.428). Re-do orchiopexy was indicated for two cases in the surgical group (P = 0.493). No cases of testicular atrophy or hernia were encountered.

CONCLUSION

Open and laparoscopic orchiopexy procedures for peeping testes are fairly comparable. However, laparoscopy is relatively more effective, as two re-do orchiopexies were required in the open surgical group.

The value of ultrasonography in boys with a non-palpable testis

BACKGROUND

In patients with a non-palpable testis (NPT) on physical examination, the testis is assumed either to be situated intra-abdominally or to be hypoplastic or absent. Diagnostic laparoscopy in these boys is considered the preferable first step. In this study the diagnostic value of pre-operative ultrasound for NPT is assessed in comparison with laparoscopy.

METHODS

All boys aged under the age of 17 years who were diagnosed with an NPT by a pediatric surgeon from 2000 till 2012 were evaluated. All patients of whom clinical, ultrasonographic, and operative findings were available were included.

RESULTS

Ninety-six boys with 117 NPTs were included. With ultrasound 67 testes were detected in the inguinal canal, which was confirmed peroperatively for 61 testes. Of the 15 testes with an intra-abdominal position on ultrasound, 10 were found intra-abdominally during surgery. The positive predictive value of the ultrasonography is 91% for inguinally located testes and 67% for intra-abdominally located testes.

CONCLUSION

Ultrasonography has a high positive predictive value for inguinally located testes. When ultrasound locates a testis in an inguinal location, a primary inguinal exploration can be considered, preventing an unnecessary diagnostic laparoscopy.

Testicular atrophy after attempted pediatric orchidopexy for true undescended testis

BACKGROUND/PURPOSE

A normal testis in the scrotum is the most important outcome of the attempted pediatric orchidopexy for a true undescended testis. The reports of post-orchidopexy testicular atrophy in the literature have ranged from non-existent to unclear. Our purpose in this study was to estimate the incidence of and associated risk factors for post-orchidopexy testicular atrophy.

METHODS

We performed a retrospective review of data from children who had an attempted orchidopexy for a true undescended testis from 1969 to 2003 inclusive. REB approval 1000011987.

RESULTS

There were 1400 attempted orchidopexies involving common (low) type (n=1135), ectopic type (n=174), and high type testes (n=91). There were a total of 111/1400 (8%) atrophic testes, mostly right-sided. 66/111 (59%) were MADE atrophic, and 45 (41%) were FOUND atrophic. Of the 1135 common type, 56 (5%) were MADE atrophic. In the ectopic and high types, the incidence of post-operative testicular atrophy was 1% and 9%, respectively. The most significant risk factors associated with testes MADE atrophic were high testicle, vas problems, and pre-operative torsion.

CONCLUSIONS

In this series, the incidence of post-operative testicular atrophy that was MADE was 5% in the common (low) type and 9% in the high type. These numbers and the above risk factors should be quoted to the caregiver during pre-operative informed consent.

Laparoscopy in the surgical management of the non-palpable testis

INTRODUCTION

To demonstrate that laparoscopic intervention should be considered as the initial surgical approach in the management of the non-palpable testis (NPT).

METHODS

From 2007 to 2011, 100 testicular units underwent same surgeon laparoscopic management for NPT. Diagnostic laparoscopy was performed in all NPT and intra-abdominal testes (IAT) were managed by laparoscopic orchiopexy if low, laparoscopic Fowler-Stephens technique if high, and laparoscopic orchiectomy if atrophic. Percutaneous access to the abdomen was performed in most cases and laparoscopic management was performed with three 5 mm ports. We compared patient's age, race, pre/post-operative exam, pre-operative work up, and IAT location upon laparoscopic intervention with surgical outcome. Fisher's exact test for two independent proportions was used for statistical analysis and reported our results.

RESULTS

One hundred testicular units underwent diagnostic laparoscopy for NPT. All patients were from Puerto Rican descent. 55.0% were found to be intra-abdominal and were subdivided into groups according to surgical intervention. Mean post-operative follow-up was 24 months. Patients 24 months of age or younger undergoing diagnostic laparoscopy for NPT had a statistically significant probability of resulting in successful laparoscopic orchiopexy as opposed to laparoscopic orchiectomy due to an atrophied IAT (n = 55 testicular units, p < 0.05). No laparoscopic related complications were reported.

CONCLUSION

Our findings support the use of an initial laparoscopic approach in the NPT as the majority of these patients will have IAT, avoiding unnecessary inguinal and scrotal explorations. We also recommend that patients with IAT should undergo laparoscopic orchiopexy prior to 2 years of age to increase probability of successful management. Further studies focusing in patients with NPT are needed in the future to confirm our findings.

Comparison of the inguinal and scrotal approaches for the treatment of communicating hydrocele in children

The inguinal approach is used for the treatment of hydrocele in the pediatric population. Although studies on scrotal orchiopexy have mentioned hernia or hydrocele repair through the same scrotal incision as a part of an orchiopexy procedure, there are a few studies reporting the treatment of isolated communicating hydrocele through a scrotal incision. We retrospectively evaluated and compared the outcomes of inguinal and scrotal approaches for the treatment of communicating hydrocele in boys. The classical inguinal and scrotal approaches to the treatment of communicating hydrocele were performed on 46 and 30 testicular units (in 43 boys and 27 boys, respectively). The patients' charts were reviewed to assess the operative times as well as the immediate and long-term complications during follow-up periods. The patients' ages ranged from 1 year to 8 years (3.6 ± 2.0 years) in the inguinal group and from 1 year to 10 years (mean 4.6 ± 2.8 years) in the scrotal group. Operative time was significantly lower in the scrotal group (p < 0.0001). The early minor complication rate did not differ between the two groups. Furthermore, there were no major complications noted. None of the patients had hydrocele recurrence after a mean follow-up of 6 months. The advantages of the scrotal approach for the treatment of communicating hydrocele are as follows: it is well tolerated, simple, and cosmetically appealing, and it has a short operative time in comparison with the standard inguinal approach. The scrotal incision technique is an effective alternative in communicating hydrocele treatment.

The intra-abdominal testis: lessons from the past, and ideas for the future

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.

The value of finding a closed internal ring on laparoscopy in unilateral nonpalpable testis

PURPOSE

There is an ongoing debate about whether initial laparoscopy is as efficient as initial extra-abdominal exploration for unilateral nonpalpable testis. The aim of this study was to clarify whether the finding of a closed internal ring on laparoscopy accurately predicts extra-abdominal findings in unilateral nonpalpable testis.

METHODS

Both laparoscopy and subsequent extra-abdominal exploration were prospectively performed in consecutive patients with unilateral nonpalpable testis. Laparoscopic findings were reviewed with respect to the status of the vas deferens, spermatic vessels, and the appearance of the internal ring. Except for patients with an abdominal testis, all patients underwent subsequent open exploration regardless of the laparoscopic findings. Open explorations were primarily performed by scrotal incision. During open exploration, any testicular remnants were removed and evaluated histologically.

RESULTS

A total of 100 patients with unilateral nonpalpable testis were evaluated, of whom 15 had an abdominal testis. Of the 85 patients without an abdominal testis, an open internal ring was recognized in only 8. Of the remaining 77 with a closed internal ring, subsequent open exploration revealed testicular nubbins in all patients (100%), regardless of the laparoscopic findings of the vessels and vas. Nine nubbins were associated with intra-abdominal vanishing vessels above the closed internal ring. All nubbins were confirmed by histological findings, and the incidence of viable germ cell elements was 7.4%.

CONCLUSIONS

When laparoscopy demonstrates no abdominal testis in patients with unilateral nonpalpable testis, the finding of a closed internal ring on laparoscopy is always associated with the presence of an extra-abdominal nubbin, regardless of the status of the vessels and the vas at the internal ring. Subsequent extra-abdominal exploration can be obviated in this circumstance if nubbin excisions are skipped. Initial diagnostic laparoscopy for unilateral nonpalpable testis provides not only the intra-abdominal findings, but also exact prediction of the extra-abdominal findings in patients with a closed internal ring.

An unusual case of intra-abdominal testicular torsion: role of laparoscopy

The authors report a case of intra-abdominal testicular torsion, where laparoscopy has been useful for diagnosis and surgical management. A boy was presented with a left impalpable testis. Laparoscopy revealed a twisted spermatic cord at the inlet pelvis, which ended in a testicular remnant located in the sub-umbilical area. After orchiectomy, the pathologist confirmed testicular atrophy. Diagnosis of intra-abdominal testicular torsion should be considered in patients with impalpable testis and abdominal pain, but could not be excluded in those with no symptoms.

Imaging studies for non-palpable testis: Are they at all required?

Undescended testis is one of the common surgical disorders in childhood and twenty percent of the undescended testes are nonpalpable. Surgical management is required in almost all cases for the repositioning or removal of the undescended testes and early intervention is preferred for optimal outcome. Use of imaging studies for accurate preoperative localisation of the nonpalpable testis is a wide prevalent practice. However, available evidences have questioned the need of such studies.

Diagnostic imaging in cryptorchidism: utility, indications, and effectiveness

BACKGROUND

Cryptorchidism (undescended testis) is the most common genitourinary anomaly in male infants.

METHODS

We reviewed the available literature on the diagnostic performance of ultrasound, computed tomography, and magnetic resonance imaging (MRI) in localizing undescended testes.

RESULTS

Ultrasound is the most heavily used imaging modality to evaluate undescended testes. Ultrasound has variable ability to detect palpable testes and has an estimated sensitivity and specificity of 45% and 78%, respectively, to accurately localize nonpalpable testes. Given the poor ability to localize nonpalpable testes, ultrasound has no role in the routine evaluation of boys with cryptorchidism. Magnetic resonance imaging has greater sensitivity and specificity but is expensive, not universally available, and often requires sedation for effective studies of pediatric patients. Diagnostic laparoscopy has nearly 100% sensitivity and specificity for localizing nonpalpable testes and allows for concurrent surgical correction.

CONCLUSIONS

Although diagnostic imaging does not have a role in the routine evaluation of boys with cryptorchidism, there are clinical scenarios in which imaging is necessary. Children with ambiguous genitalia or hypospadias and undescended testes should have ultrasound evaluation to detect the presence of müllerian structures.

Diagnostic laparoscopy for the management of impalpable testes

PURPOSE

Controversy exists regarding the best approach to impalpable testes. We determined the usefulness of diagnostic laparoscopy for the management of impalpable testes.

MATERIALS AND METHODS

Between 2000 and 2008, 86 patients with a mean age of 34 months underwent diagnostic laparoscopy. An inguinal canal exploration was performed in all cases, except in patients in whom the internal spermatic vessels terminated intraperitoneally with a blind end.

RESULTS

The undescended testis was right-sided in 24 patients (27.9%), left-sided in 47 patients (54.7%), and bilateral in 15 patients (17.4%). Three patients (3.5%) had bilateral impalpable testes. The vas and vessels traversed the internal ring in 51 of 89 impalpable testes (57.3%); 20 (22.5%) were localized intraperitoneally, and 18 (20.2%) were diagnosed as vanishing testes. Open orchiopexies were performed on 24 testes (27.0%) and orchiectomies were performed on 43 nubbin testes (48.3%). After a mean follow-up period of 30 months, 12 of the 14 testes (85.7%) were viable following open conventional orchiopexy, compared with 6 of the 10 testes (60%) following a 1-stage Fowler-Stephens orchiopexy.

CONCLUSIONS

Diagnostic laparoscopy is a very helpful and minimally invasive technique in the diagnosis of impalpable testes, especially when preoperative ultrasonography is not sufficiently informative.

Imaging use and cryptorchidism: determinants of practice patterns

PURPOSE

We determined the rate of diagnostic imaging use for the preoperative evaluation of boys with cryptorchidism and the factors that influence referring providers to obtain imaging.

MATERIALS AND METHODS

We conducted a national cross-sectional survey of pediatricians randomly sampled from the American Medical Association Physician Masterfile. The primary outcome was whether the respondent obtained imaging at the initial evaluation of boys with cryptorchidism. Participants were queried regarding practice location and type, length of time in practice, frequency of reading academic journals and the accessibility of surgical subspecialists. For those who ordered imaging, respondents were asked how frequently they ordered imaging, and were asked to select patient factors and professional beliefs that influenced their decision to obtain imaging. Factors associated with imaging use were identified using multivariate logistic regression.

RESULTS

Of the pediatricians who acknowledged contact by surveyors 47% completed the survey and 34% of respondents reported always or usually ordering imaging. Of those who obtained imaging 96.4% used ultrasound. Pediatricians in practice fewer than 20 years (OR 3.43, 95% CI 1.92-6.16) and those in nonacademic practices (OR 3.00, 95% CI 1.34-6.71) were more likely to order imaging. Pediatricians obtained imaging because of beliefs that imaging reliably identifies a nonpalpable testis, reassures the family and assists the surgeon with operative planning.

CONCLUSIONS

Ultrasound is heavily used by pediatricians for the preoperative evaluation of cryptorchidism, especially when the testis is nonpalpable. Given the poor diagnostic performance of ultrasound in this setting, we recommend developing strategies to reduce imaging use in cryptorchidism.

Diagnostic performance of ultrasound in nonpalpable cryptorchidism: a systematic review and meta-analysis

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.