Laparoscopy in the management of the impalpable undescended testis

Comparative Outcomes of Single-Stage versus Two-Stage Laparoscopic Fowler-Stephens Orchidopexy: A Systematic Review snd Meta-Analysis

INTRODUCTION

 Intra-abdominal testis (IAT) remains a challenging and controversial subset within the management of cryptorchidism. While Fowler-Stephens orchidopexy (FSO) is still being advocated as the gold standard for the treatment of this entity, there is new and conflicting evidence on the comparative outcomes between single- or two-stage laparoscopic FSO (LFSO). The aim of the study is to investigate whether staging has benefits in children receiving LFSO.

METHODS

 We searched the PubMed, Medline, Embase, and Cochrane Trials databases for studies comparing single- with two-stage LFSO in children from January 1, 1995 to December 31, 2023. We assessed the identified studies for quality and performed a systematic review and meta-analysis in accordance with the Preferred Reporting of Systematic Reviews and Meta-Analyses. The main outcome measures examined were success rate (in terms of the scrotal position of the testis) and testicular atrophy, which were analyzed using fixed effect models.

RESULTS

 We included 17 eligible studies that involved a total of 499 operated testes. The overall success rates of single- and two-stage LFSO were 79.4 and 90.3%, respectively. The overall testicular atrophy rates of single- and two-stage LFSO were 17.3 and 11%, respectively. Fixed effect model analysis showed that two-stage LFSO is significantly superior to single-stage LFSO in overall success rate (odds ratio [OR: 2.57]; 95% confidence interval [CI]: 1.50-4.39, p = 0.0006) and testicular atrophy rate (OR: 0.48; 95% CI: 0.28-0.79, p = 0.004). There is no heterogeneity in the reports, and the funnel plot showed no publication bias.

CONCLUSIONS

 Two-stage LFSO remains the first choice of operation for children with a high IAT, with a significantly higher success rate and a lower testicular atrophy rate.

Reference value of testicular temperature measured by finite element analysis after first staged inguinal orchidopexy in children with abdominal testis and short spermatic cord

PURPOSE

This study aims to build a 3D reconstruction computed simulation model and to establish a regression equation for detecting the testis's temperature by its location after first staged open orchidopexy in children with abdominal undescended testis (UDT) and short spermatic cords.

METHODS

In this cross-sectional study, we enrolled 31 children with abdominal UDT and short spermatic cords who underwent first staged orchiopexy between 2017 and 2020. Using ultrasonography to obtain the testis's location distance from the skin surface (X1), external iliac vessel (X2), and internal inguinal ring (X3), we input the data into a 3D reconstruction computed simulation along with COMSOL to calculate the testicular temperature. We also used multivariate regression to establish the testicular temperature regression equation from the gathered data.

RESULT

The mean age of the participants was 4.47 ± 1.21 years. The mean size of the operated testis was 0.39 ± 0.13 cc. The mean distance of the testis from X1, X2, and X3 was 3.27 ± 1.25 mm, 21.06 ± 6.42 mm, and 27.19 ± 10.09 mm, respectively. The testicular temperature regression equation derived from testis location was calculated by the formula: 34.57 + 0.0236 X12 - 0.0105 X2 - 0.0018 X3. The concordance for testis temperature calculated via the computational method and regression equation was 83%.

CONCLUSIONS

The current study provided a reference value for the testicular temperature of children with abdominal UDT and short spermatic cords after the first stage of orchiopexy. A testicular temperature regression equation can be established based on the testis location, which will provide relevant information for the testicular development assessment, disease diagnosis, and follow-up, and possibly determination of the time of the second stage of orchiopexy.

Laparoscopic Percutaneous Endoscopic Gastrostomy Is Useful for Elderly

Background:

In recent years, enteral nutrition has become relatively easy to perform through the penetration of percutaneous endoscopic gastrostomy (PEG). However, there have been reports of complications, such as mispuncture of other organs at the time of performing PEG. Previously, we had constructed a gastrostomy under the laparotomy for difficult PEG cases, and 2 years ago, we introduced laparoscopically assisted PEG. This study aimed to clarify the feasibility and safety of LAPEG for elderly people over 65 years old.

Methods:

We evaluated the perioperative outcomes in 7 elderly patients who underwent LAPEG during these 2 years. In these subjects, the safety of LAPEG was evaluated retrospectively based on the surgical outcomes, perioperative complications, and postoperative course using the clinical archives.

Results:

The subjects' mean age was 81.1 ± 8.03 years. LAPEG was successful in all 7 patients. The median operation time was 38 minutes (range, 31–71 minutes). Intraoperative and postoperative early or late complications from LAPEG were not observed in our cases. Enteral nutrition was commenced 2 days after PEG placement in all cases without complications.

Conclusion:

We summarized the LAPEG cases performed at our institution for the elderly, and have reported its feasibility and safety. The strongest advantage of LAPEG was that it allowed placement of the PEG without any complication under direct observation of the intraperitoneal cavity to confirm the safety of each organ.

Replacement of Male Mini-Puberty

Context

Clinical management of congenital hypogonadotropic hypogonadism (CHH) remains a challenge in pediatric endocrinology.

Objective

To investigate whether daily subcutaneous injections of the recombinant human LH/FSH preparation could mimic the physiological male mini-puberty.

Design and Setting

The REMAP (REplacement of MAle mini-Puberty) study with up to 10 years of follow-up.

Patients and Intervention

Ten neonates or infants, all with bilateral cryptorchidism in intra-abdominal/inguinal position and micropenis with the absence of neonatal male mini-puberty, received daily subcutaneous injections of Pergoveris^® (LH/FSH 75/150 IU) for 3 months.

Main Outcome Measures

Restoration of bilateral cryptorchidism/micropenis and the Leydig/Sertoli cells function.

Results

At the end of treatment, median LH and FSH, both undetectable before treatment, reached high normal levels of 4.45 IU/L and supranormal levels 83 IU/L, respectively; median inhibin-b and anti-Mullerian hormone levels increased from subnormal (27.8 and 1.54 ng/mL, respectively) to normal levels (365 and 150 ng/mL, respectively); median testosterone increased from just detectable (0.02 ng/mL) to normal levels (3.3 ng/mL). Stretched penile length increased from a median of 2 to 3.8 cm. During therapy, all testes descended to the scrotal position (by the end of the first month in three patients, the second month in four patients, and the third month in three patients), measuring 1.5 mL and appearing normal in ultrasonography. Three infants received additional treatment with testosterone enanthate. In two infants, one of two testes regressed in the low inguinal area; both infants were successfully treated surgically. After 1 to 10 years of follow-up, all testes are still in scrotal position and have slightly regressed in size.

Conclusions

The proposed regimen mimics neonatal male mini-puberty and successfully treats infants with micropenis and cryptorchidism in CHH.

Undescended Testes and Laparoscopy: Experience from the Developing World

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.

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.

Laparoscopic treatment of nonpalpable testicle. Factors predictive for diminished size

PURPOSE

The purposes of this study were to demonstrate the usefulness of laparoscopy in intraabdominal testicle (IAT) and to determine factors associated with diminished size during the final outcome after laparoscopic orchidopexy.

METHODS

This is a retrospective analysis of consecutive patients from 1999 to 2013 with a minimum follow-up of 1year. Patient and testicular factors were related to diminished size.

RESULTS

Sixty one patients, and 92 testicles were included. Median age at operation was 42months. Initially we found 66 normal sized testes (71.7%), 22 hypotrophic (23.9%) and four atrophic (4.3%). Eighty seven testes were brought down laparoscopically, 50 in one surgical stage and 37 in two stages. Mean follow-up was 40.2months and the final outcome was success: 73.5% and diminished size: 26.5%. Variables associated with diminished size were hypotrophy during initial evaluation, short spermatic vessels, section of spermatic vessels, two-stage surgery and tension to reach contralateral inguinal ring. Multivariate analysis showed that initial hypotrophy (odds ratio [OR] 4.96, confidence interval 95% [CI] 1.36-18.10) and tension to reach contralateral ring (OR 4.11, 95% CI 1.18-14.34) were associated with diminished size.

CONCLUSIONS

Laparoscopy is useful in treating IAT. Initial size and tension to reach contralateral ring are factors associated with diminished size.

Evaluation and treatment of cryptorchidism: AUA guideline

PURPOSE

Cryptorchidism is one of the most common pediatric disorders of the male endocrine glands and the most common genital disorder identified at birth. This guideline is intended to provide physicians and non-physician providers (primary care and specialists) with a consensus of principles and treatment plans for the management of cryptorchidism (typically isolated non-syndromic).

MATERIALS AND METHODS

A systematic review and meta-analysis of the published literature was conducted using controlled vocabulary supplemented with key words relating to the relevant concepts of cryptorchidism. The search strategy was developed and executed by reference librarians and methodologists to create an evidence report limited to English-language, published peer-reviewed literature. This review yielded 704 articles published from 1980 through 2013 that were used to form a majority of the guideline statements. Clinical Principles and Expert Opinions were used for guideline statements lacking sufficient evidence-based data.

RESULTS

Guideline statements were created to inform clinicians on the proper methods of history-taking, physical exam, and evaluation of the boy with cryptorchidism, as well as the various hormonal and surgical treatment options.

CONCLUSIONS

Imaging for cryptorchidism is not recommended prior to referral, which should occur by 6 months of age. Orchidopexy (orchiopexy is the preferred term) is the most successful therapy to relocate the testis into the scrotum, while hormonal therapy is not recommended. Successful scrotal repositioning of the testis may reduce but does not prevent the potential long-term issues of infertility and testis cancer. Appropriate counseling and follow-up of the patient is essential.

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.

Predictive factors for successful vessel-intact laparoscopic orchiopexy for intra-abdominal testes

OBJECTIVE

To identify the predictive factors for successful vessel-intact laparoscopic orchiopexy (VILO) for nonpalpable intra-abdominal testes (NPIT).

MATERIALS AND METHODS

25 boys with 28 NPITs within 2 cm of the internal ring underwent VILO. They were divided into two groups based upon outcome, for statistical comparison. Group A (successful VILO): patients with testes pexed in scrotum during surgery, and maintained viability and scrotal position of testes at 3-month & 6-month postoperative follow up. Group B: failed VILO.

RESULTS

Intrascrotal fixation at VILO was achievable for 17/28 NPITs. Postoperative follow up and final outcome data were available for 25/28 NPITs, of which 14 were successful (A) while 11 had failed VILO (B). The mean age of patients in group A differed significantly from that of patients in group B (4.16 years versus 6.64 years; p = 0.035). The mean testis-to-internal ring distance was 0.50 cm for group A and 1.05 cm for group B, but this was not statistically significant (p = 0.141). There was statistically a highly significant difference (p = 0.002) with respect to the mean internal ring-to-midscrotum distances in groups A and B: 5.56 cm and 7.05 cm, respectively. A scatter-plot of age or height against internal ring-to-midscrotum distance showed a fairly linear relationship.

CONCLUSIONS

Age or height of the patient at surgery is an independent factor predicting the success of VILO for intra-abdominal testis. The internal ring-to-midscrotum distance increases with age/height, resulting in increased testis-to-midscrotum distance and higher failure rate of VILO in older children.

Effectiveness of hormonal and surgical therapies for cryptorchidism: a systematic review

BACKGROUND AND OBJECTIVE

Controversy remains concerning the optimal treatment approach for cryptorchidism. The objective of this study was to assess effectiveness of hormone therapy or surgery for cryptorchidism.

METHODS

We searched Medline and other databases from 1980 to February 2012. Two reviewers independently assessed studies against predetermined criteria. Two reviewers independently extracted data and assigned overall quality and strength of evidence ratings using predetermined criteria.

RESULTS

Fourteen studies addressed effectiveness of hormonal treatments, and 26 studies addressed surgical intervention outcomes. Hormonal treatment is associated with testicular descent in some children, but rates generally do not exceed those seen with placebo by >10%. Surgical treatment is associated with success rates of testicular descent ranging from 33% to 100%, depending on surgery. Weighted success averages were 78.7% for 1-stage Fowler-Stephens (FS), 86% for 2-stage FS, and 96.4% for primary orchiopexy. Descent rates were similar among studies comparing laparoscopic and open surgeries. Reported harms of hormonal treatments were mild and transient. Adverse effects specifically associated with surgical repair were rare.

CONCLUSIONS

The body of the reviewed literature comprises primarily fair- and poor-quality studies, limiting our ability to draw definitive conclusions. Hormonal treatment is marginally effective relative to placebo but is successful in some children and with minimal harms, suggesting that it may be an appropriate trial of care for some patients. Surgical options are effective, with high rates of testicular descent (moderate strength of evidence for FS procedures, high for primary orchiopexy). Comparable outcomes occur with laparoscopic and open approaches.

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.

Open versus laparoscopic staged Fowler-Stephens orchiopexy: impact of long loop vas

PURPOSE

There is a paucity of literature on factors associated with testicular atrophy following second stage laparoscopic Fowler-Stephens orchiopexy. We hypothesized that dissection of a long looping vas during this procedure could compromise testicular blood supply, leading to testicular atrophy.

MATERIALS AND METHODS

Following an initial laparoscopic testicular vessel ligation, a second stage Fowler-Stephens orchiopexy was performed in 73 testes (laparoscopic in 61, open in 12). The presence of a long looping vas was noted from the first stage operative notes. Doppler ultrasound was performed postoperatively to confirm testicular atrophy.

RESULTS

Atrophy rate at a mean followup of 13.5 months was 20.5% (15 of 61 in laparoscopic and 0 of 12 in open orchiopexy). None of the 5 long looping vas testes atrophied following open orchiopexy, compared to 5 of 6 (83%) following laparoscopic orchiopexy (p = 0.03). Analyzing the laparoscopic group alone, a long looping vas was significantly associated with risk of atrophy (p <0.01).

CONCLUSIONS

The presence of a long looping vas was associated with a higher atrophy rate following laparoscopic second stage Fowler-Stephens orchiopexy. Laparoscopic management of the long looping vas may be more challenging and, therefore, in such cases open Fowler-Stephens orchiopexy may result in better success rates by preserving the integrity of the collateral vessels.

Management of boys with nonpalpable undescended testis

Cryptorchidism is one of the most common genitourinary disorders in young boys. Although the management of boys with palpable testis is standardized, there are no formal guidelines for the management of boys with nonpalpable testis. In this Review we look at the current trends in the diagnosis and treatment of this disorder, as well as the indications for therapy and surgical procedures. On the basis of current evidence, we find that there is no optimum orchidopexy technique for the treatment of intra-abdominal testis, although it is preferable to adopt techniques that preserve the spermatic vessels. We also briefly examine the follow-up of patients with this disorder and its common complications. As yet, there are no data that assess the potential of laparoscopic orchidopexy being a risk factor for impaired fertility later in life.

Decision Making During Laparoscopic Orchiopexy for Intra-Abdominal Testes Near the Internal Ring

PURPOSE

We studied whether testicular proximity to the ipsilateral internal ring or ability to reach the contralateral ring predicted the likelihood that laparoscopic orchiopexy would deliver an intra-abdominal testis to the dependent scrotum.

MATERIALS AND METHODS

Records of patients undergoing laparoscopic orchiopexy for testes within 2 cm of the internal ring were reviewed. Factors considered included patient age, mobility of the testis to the contralateral ring, intraoperative positioning in the upper vs lower scrotum, and postoperative findings of testicular viability and location.

RESULTS

Of 46 testes treated with laparoscopic orchiopexy 20 reached the low scrotum. The remaining 26 testes only reached the upper scrotum. Of these testes 14 were fixed to the most distal aspect of the scrotum that they would reach, while 12 were managed by vessel transection with 1-stage orchiopexy to the low scrotum in 10 and the upper scrotum in 2. Patient age at surgery, location within 2 cm of the internal ring and mobility to the contralateral ring did not predict ability of laparoscopic orchiopexy to bring the testis to the low scrotum. Followup was available in 42 testes at a mean of 6.8 months (range 1 to 25), with 25 (60%) in the low scrotum, 6 (14%) in the upper scrotum, 6 (14%) showing atrophy and 5 (12%) reoperated on for a position at or above the upper margin of the scrotum.

CONCLUSIONS

Factors evaluated did not indicate the likelihood that laparoscopic orchiopexy would result in a testis in the dependent scrotum. It is unclear whether a testis only reaching the upper scrotum should be fixed with vessels intact, or undergo 1-stage Fowler-Stephens orchiopexy to attempt to reach the low scrotum.

The use of laparoscopy in the management of nonpalpable undescended testes

PURPOSE OF REVIEW

The stable incidence of undescended nonpalpable testes and the ever-progressing utilization of laparoscopy has led to the commonplace utilization of laparoscopy in the diagnosis and treatment of these nonpalpable testes. The historical published literature is ambiguous with regard to recommendations regarding the use of laparoscopy in the setting of nonpalpable testes. As a result, this review is timely and necessary in that it is important for the practicing physician and surgeon to review and have available to them the current recommendations for the management of patients with nonpalpable testes.

RECENT FINDINGS

With ongoing advances of minimally invasive surgery in the face of the limitations of both ultrasound and magnetic resonance imaging, the use of laparoscopy in the diagnosis and treatment of nonpalpable testes is now commonplace. Several reports recommend laparoscopy as the gold standard for the evaluation and treatment of nonpalpable testes, allowing for localization of the testis, characterization of the testis and associated structures (vas deferens, testicular vessels) and subsequent treatment options.

SUMMARY

Because of the superior diagnostic capabilities and the ability to provide therapeutic interventions, laparoscopy should be used in the evaluation and treatment of all patients with nonpalpable testes.

Persistent mesonephric duct found at laparoscopy for impalpable testis

Laparoscopy is an increasingly popular choice for treatment of the impalpable testis. There are many anatomical variants that may be found at operation. We present a case of a 1-year-old boy who presented with an impalpable right testis and absent right kidney, and at laparoscopy was found to have a persistent mesonephric duct. Awareness of this variation allowed for adequate excision and subsequent investigations.

Collateral Circulation after Spermatic Vessel Ligation for Abdominal Testis And Its Impact on Staged Laparoscopically Assisted Orchiopexy

PURPOSE

Staged laparoscopically assisted orchiopexy for abdominal testis entails initial spermatic vessels ligation followed by mobilization of the testis, preserving the vas and its vessels as a sole source of testicular blood supply. This mobilization includes all peritoneal attachments of the testis, including the gubernaculum, which may carry collateral circulation to the testis. This study considers the anatomy of the gubernaculum and the collateral circulation after spermatic vessels ligation and its possible effects on the viability of the testis.

MATERIALS AND METHODS

The anatomy of the gubernaculum and the effect of spermatic vessels ligation on the collateral circulation were studied in 90 boys with 100 abdominal testes with a short pedicle. Patients with vanishing testis or those not needing ligation of the spermatic vessels were excluded from the study. The anatomy and the vascularity of the testis, gubernaculum, and vas were studied at initial laparoscopy and 6 weeks later after spermatic vessel ligation. Based on these findings, the technique for laparoscopically assisted orchiopexy were modified, preserving the gubernaculum whenever possible in cases having prominent collaterals.

RESULTS

Based on the attachment and blood vessel configuration of the gubernaculum, the patients were divided into two groups: in group 1 (open internal ring), there were 46 testes in which the gubernaculum passed through an open internal ring having an inguinal attachment. In group 2 (closed internal ring), there were 54 testes with a soft gubernaculum attached to a closed internal ring without inguinal attachment. In group 1 the gubernaculum was short and tough in 32 of 46 testes, with no visible blood vessels in all cases. In group 2 the gubernaculum was long and soft in 43 of 54 testes and showing evident blood supply before clipping of the spermatic vessels in 30 testes. Subsequent laparoscopy done after 6 weeks showed prominent collateral circulation around the gubernaculum in 26 testes and around the vas in 20 testes in the group 1 patients, and around the vas in 20 and the gubernaculum in 34 testes in group 2. Preservation of the gubernaculum was possible in 43/54 (80%) of group 2 patients and in 14/46 (30%) of group 1 patients.

CONCLUSION

Routine cutting of the gubernaculum is not necessary for proper mobilization of the abdominal testis: collateral circulation varies from patient to patient, and once the gubernaculum shows prominent blood supply, its preservation is mandatory. The decision to cut the gubernaculum should be taken while the performing initial spermatic vessel ligation and not during the second stage to avoid compromise of the settled collateral circulation.

Two-Stage Fowler-Stephens Orchidopexy Preserving The Gubernacular Vessels And A Purely Laparoscopic Second Stage

PURPOSE

We describe a modification of the two-stage laparoscopic Fowler-Stephens technique in which the gubernacular vessels are preserved and the testis is brought down the canal via the internal ring. A purely laparoscopic second stage is performed. We report our outcomes with this technique.

MATERIALS AND METHODS

All laparoscopic Fowler-Stephens orchidopexies undertaken at our hospital from 1996 to July 2004 were identified from a prospectively collected database of all surgical procedures undertaken in the unit. A retrospective case-note review was undertaken.

RESULTS

We identified 21 patients, 4 bilateral and 17 unilateral, giving a total of 25 intra-abdominal testes. Mean age at presentation was 21 months (range, 0-56 months). Mean age at the first stage was 36 months (range, 11-68 months). The testis position at initial laparoscopy was high in 5, close to the internal inguinal ring in 9, peeping in 6, and pelvic in 5. The testis size at this stage was either normal, good sized, or reasonable sized in 15, small or dysplastic in 5, and in 5 the size was not commented upon. The testicular vessels were mainly divided by diathermy at the first stage, but in 6 the vessels were clipped. The second stage was undertaken 6 months after the first, in order to allow the collateral blood supply to adapt. Twelve testes had changed position category during this interval, 2 having ascended to a higher position and 10 descended to a lower position; 12 were in the same position at both stages; and in 1 case the position was not commented upon at the second stage. A purely laparoscopic second stage technique was used in 21 cases; an assisted-open second stage was undertaken in 1 case. In 3 cases the testis was palpable in the groin at examination under anesthesia and so an open second stage orchidopexy was performed. Follow-up was at 6 and 18 months after the second stage. Eighteen of the 21 testes that underwent a purely laparoscopic second stage survived at 6 months, giving a success rate with this technique of 86%. The overall testis survival rate in the entire group at 6 months was 88% (22/25). Findings in those patients reviewed at 18 months were unchanged.

CONCLUSION

The two-stage laparoscopic Fowler-Stephens orchidopexy, with preservation of the gubernacular vessels and predominantly using a purely laparoscopic second stage, provided a very good testis survival rate, approaching 90%.

Results of orchiopexy for the undescended testis

The undescended testis is one of the most common congenital abnormalities of the genitourinary system. Outcomes of orchiopexy include (1) having a viable, palpable testis in the scrotum, (2) fertility, as measured by paternity rates or semen analysis in adulthood and (3) risk of testicular cancer. Multiple operative techniques have been described and are associated with various success rates. In the past decade, success of orchiopexy for inguinal testes has been >95%. For abdominal testes, success for orchiopexy has been >85-90% in most series with single stage orchiopexy or two stage Fowler-Stephens orchiopexy, both with open surgical or laparoscopic technique. However, having a palpable testis in the scrotum does not assure fertility, as there are iatrogenic factors that may adversely affect the outcome. In adult men with a history of unilateral orchiopexy, fertility is nearly normal, but is significantly reduced following bilateral orchiopexy. The risk of testicular carcinoma is increased by a factor of 3.7 to 7.5 times. Tumor type is most commonly seminoma if the testis is undescended, whereas tumors that occur following orchiopexy are much more likely to be nonseminomatous.

Laparoscopic Management of the Adult Nonpalpable Testicle

OBJECTIVES

This report describes own experiences with laparoscopic management of adult men with cryptorchidism.

PATIENTS AND METHODS

8 men with nonpalpable testes were referred to our department. Laparoscopy was used to assess the presence and location of the gonad and perform an orchiectomy or orchidopexy, respectively.

RESULTS

A uni-/bilateral atrophic testicle was palpable in 2 patients under general anesthesia and removed after inguinal exploration. In 4 individuals the testicular vessels and vas deferens were found laparoscopically entering the internal inguinal ring. Two vanishing testicles and 2 atrophic gonads were removed during subsequent inguinal exploration. In 1 patient with a solitary testis, a morphologically intact abdominal testicle was presented. In this patient, endocrine function was lost completely after stage 1 of a Fowler-Stephens orchidopexy. In 1 patient an atrophic abdominal testicle was removed laparoscopically.

CONCLUSIONS

These results demonstrate the suitability of laparoscopy for the treatment of cryptorchidism in the adult population. In most cases, atrophic inguinal gonads or vanishing testicles are found and should be removed. Our results suggest that in cases of intact abdominal testicles, Fowler-Stephens orchidopexy with transection of the spermatic vessels should be avoided to preserve endocrine function of the gonad.

The role of videolaparoscopy in the diagnostic and therapeutic approach of nonpalpable testis

OBJECTIVE

Evaluate the results from the first 5 years of experience with laparoscopy for diagnosis and treatment of nonpalpable testes.

MATERIALS AND METHODS

Medical records of 51 patients submitted to laparoscopic testicular exploration, during a 5-year period, were retrospectively analyzed. Patients' mean age was 65.7 months (median = 48) on the first procedure. The youngest patient was 10 months and the oldest was 14 years old on the first surgery. Twenty-four (47%) patients presented nonpalpable testes bilaterally, 7 (14%) only at the right side and 20 (39%) at the left, totaling 75 testicular units assessed. Patients who had their testes palpated after anesthetic induction were excluded from the study, and in all other cases, surgical management was based on the testicular position and viability. During the post-operative follow-up, surgical success was classified as palpable testis in scrotal sac, with adequate consistency and volume.

RESULTS

Nine (12%) testes were not localized, but their vessels and deferent duct were atrophic. Two (3%) testes were intra-abdominal and atrophic, and 2 (3%) gonads, in the same patient, had a dysmorphic aspect. Nineteen (25%) testicular units were located close to the internal inguinal ring (peeping testes) and, in 22 (29%) units, the spermatic vessels and deferent duct penetrated the internal inguinal ring. Eight (10%) testes were located at a distance of less than 2 cm from the internal inguinal ring and 13 (17%) at a distance greater than 2 cm. The 2 intra-abdominal atrophic testes were removed. Inguinotomy was performed in a total of 41 (54%) cases, reaching a surgical success of 89%. Laparoscopic orchiopexy in one stage, without vascular ligation, was performed in 9 (12%) testes, which presented a distance of less than 2 cm from the internal inguinal ring, also with a surgical success index of 89%. Orchiopexy in 2 stages, with ligation of the spermatic vessels, was performed in 13 (17%) testicular units located at a distance greater than 2 cm from the internal inguinal ring, reaching 77% of good results.

CONCLUSION

Videolaparoscopy is a safe and effective method for diagnosis and treatment of nonpalpable testis.

SUCCESSFUL OUTPATIENT MANAGEMENT OF THE NONPALPABLE INTRA-ABDOMINAL TESTIS WITH STAGED FOWLER-STEPHENS ORCHIOPEXY

PURPOSE

Previous reports of orchiopexies have shown an 85.9% success rate for staged Fowler-Stephens orchiopexy (FSO). We review our experience with nonpalpable testes (NPTs).

MATERIALS AND METHODS

A total of 119 patients with 128 NPTs were treated at our institution between 1994 and 2001. Atrophic testes or "nubbins" were removed. Once an intra-abdominal testis was identified the peritoneum was opened and firm traction was placed on the gonad. If feasible, primary orchiopexy was completed. Otherwise, staged Fowler-Stephens orchiopexy was performed.

RESULTS

Primary orchiopexy was performed in 28 testes in 27 patients without division of the spermatic vessels. An atrophic nubbin was removed in 45 patients. All children with bilateral NPTs had at least 1 viable intra-abdominal testis found at surgery. Staged FSO was performed in 55 testes in 47 children. The second stage was performed at a median of 3.5 months after initial ligation of the spermatic vessels. Median followup was 1 year and mean followup was 9 months. Five patients were lost to followup. Successful surgery was defined as a dependent scrotal location and testis size equivalent to the contralateral mate. The overall success rate for the primary orchiopexy group was 100%. In the staged FSO group 1 patient had an atrophic testis at 1-year followup, yielding an overall success rate of 98%.

CONCLUSIONS

A high degree of success can be obtained for children with intra-abdominal testes. Mobility of the testis on exploration is a good indicator that the testis can be managed with primary orchiopexy without division of the vessels. If primary orchiopexy cannot be performed, excellent results are achieved with a staged FSO.

Lost and found testes: the importance of the hCG stimulation test and other testicular markers to confirm a surgical declaration of anorchia

BACKGROUND

In patients with impalpable testes,laparoscopy or open surgery is considered conclusive in establishing the absence of testicular tissue.

METHODS

Retrospective chart review.

RESULTS

Over a 22-year period, 4 out of 82 patients with a diagnosis of bilateral anorchia by laparoscopy or laparotomy had persistent testicular tissue suggested by endocrine evaluations. The clue to the presence of testicular tissue was: (1) a pubertal rise in plasma testosterone (2 patients); (2) the presence of possible Müllerian structures and of a detectable plasma anti-Müllerian hormone (1 patient), and (3) the fact that one of the gonads had not been seen at surgery (1 patient who still had a testosterone response to hCG postoperatively). Testes were localized by venography (3 patients) and laparotomy (1 patient).

CONCLUSION

A surgical diagnosis of bilateral anorchia needs to be confirmed by hCG stimulation, gonadotropin levels, or other markers of testicular function.

Groin exploration for nonpalpable testes: laparoscopic approach

PURPOSE

Diagnostic laparoscopy (DL) is the technique of choice for exploration of nonpalpable testes (NPT). Nevertheless, groin exploration is necessary to evaluate the cord and gonadal structures entering the internal ring. This retrospective analysis evaluates our hypothesis that hypoplastic cord structures entering the internal ring predicts absence of a viable testicle and a laparoscopic groin exploration in these cases can reduce the number of unnecessarily performed open groin exploration (OGE).

MATERIALS

A retrospective review was performed of 23 boys with 26 NPTs who were operated on from June 1998 to October 2000 to evaluate our protocol for NPT using DL and OGE.

RESULTS

Of 26 NPTs in 23 boys, 3 bilateral intraabdominal testis were detected (2 Fowler Stephens; 1 standard orchidopexy). Twenty cord structures entered the internal ring. Three appeared normal at DL with a viable testis followed by an orchidopexy. Seventeen were hypoplastic without patent processus. During LGE no viable testis was detected: blind-ending cords, no biopsy (n = 4); testicular regression syndromes (n = 3), early fetal regression (n = 6), no residual testicular structures (n = 4).

CONCLUSIONS

This experience confirms the authors' hypothesis and criteria for LGE in all cases. The authors conclude that LGE is a helpful tool in the diagnostic workup of NPT to avoid unnecessary OGE and is a further step in the minimally invasive approach to all kinds of findings of NPT.

Laparoscopy-assisted orchidopexy: an ideal treatment for children with intra-abdominal testes

BACKGROUND AND PURPOSE

The investigation of a child with a nonpalpable testis is probably the most frequent indication for laparoscopy in pediatric patients. The objective of this study was to evaluate the results and advantages of laparoscopy-assisted orchidopexy performed without dividing the spermatic vessels.

PATIENTS AND METHODS

During a 3-year period, 85 boys with nonpalpable testes (NPT) (91 testes overall) underwent laparoscopic diagnostic exploration. Twenty-five patients (27.4%) showed an intra-abdominal testis (IAT): 24 underwent a laparoscopy-assisted orchidopexy (LAO) without sectioning of the spermatic vessels, and one, whose inner spermatic vessels were not adequately long for LAO without tension, underwent a two-step Fowler-Stephens (FS) procedure. The technique consists of dissection and mobilization of the inner spermatic vessels and the vas deferens from the posterior peritoneum, sectioning of the gubernaculum attachments, and bringing down of the testis into the scrotum through the internal inguinal ring, if open, or through a neo-inguinal ring created medial to the epigastric vessels.

RESULTS

Surgery lasted between 40 and 80 minutes (median 60 minutes). All the testes were brought down into the scrotum. There was only 1 (4%) intraoperative complication, which occurred in the second patient operated on with this procedure. He experienced an iatrogenic rupture of the spermatic vessels secondary to excessive traction.

CONCLUSION

Laparoscopic orchidopexy is the logical extension of diagnostic laparoscopy for the evaluation of NPT. Concerning the technique, we believe that LAO with intact spermatic vessels could be considered the treatment of choice in the patient with IAT, as it does not affect normal testicular vascularization. Alternatively, in the case of very high IAT (more than 3 cm from IIR), an FS procedure may be considered.

Avoidance of inguinal incision in laparoscopically confirmed vanishing testis syndrome

PURPOSE

Nonpalpable testicles may be due to the vanishing testis syndrome, intra-abdominal position, examination obscured by obesity or scar tissue and rarely testicular agenesis. Laparoscopy is an excellent means of distinguishing these entities without the need for open abdominal exploration. We investigated whether laparoscopy affects the need for an inguinal incision and exploration when no testicle is palpable and the vas and vas deferens are visualized exiting the internal inguinal ring on laparoscopy.

MATERIALS AND METHODS

In 34 boys 6 to 18 months old (mean age 41) physical examination demonstrated a nonpalpable testicle, including on the right side in 12, on the left side in 17 and bilaterally in 5. The vanishing testis syndrome was diagnosed after laparoscopy when no testicle was palpable despite physical examination done with the patient under anesthesia, spermatic vessels were visualized exiting the internal inguinal ring or spermatic vessels were visualized in the abdomen with or without an identifiable intra-abdominal testicular nubbin.

RESULTS

Laparoscopy confirmed the vanishing testis syndrome in 16 patients, intra-abdominal testicles in 13 and peeping testes in 1. Adequate examination using anesthesia was not possible in 4 patients with obesity, or previous inguinal or lower abdominal surgery. These boys underwent inguinal exploration after laparoscopy showed the vas and vessels exiting a closed internal inguinal ring. Of the 16 cases of the vanishing testis syndrome orchiectomy with contralateral scrotal orchiopexy was performed in 14 through a median raphe scrotal incision and in 1 through an inguinal incision for an associated inguinal hernia. In the remaining patient who underwent laparoscopy only a blind ending vas and vessels were visualized in the abdomen without an identifiable nubbin. The infraumbilical and median raphe incisions healed without obvious scars. Followup was at least 1 year.

CONCLUSIONS

When spermatic vessels are visualized exiting the internal inguinal ring on laparoscopy in the setting of a nonpalpable testicle, a median raphe scrotal incision can be made to remove the testicular nubbin associated with the vanishing testicle syndrome. Orchiectomy is possible through this median raphe incision even when the testicle is in the inguinal canal because this distance in young children is small. Cosmesis is excellent since 1 incision is within the umbilicus and the other is on the median scrotal raphe.

Laparoscopic orchidopexy in children

BACKGROUND

Cryptorchidism is a common condition in boys. Approximately 20% of undescended testes are nonpalpable and may be located within the abdominal cavity. Given the potential of these gonads for malignant transformation and infertility, it is essential to determine the presence or absence of a nonpalpable testis.

METHODS

Radiologic imaging and open surgical exploration have proved to be unreliable. In the hands of experienced surgeons, laparoscopy has become the method of choice for evaluating the nonpalpable testis.

RESULTS AND CONCLUSION

An increasing number of surgeons are applying laparoscopy in the treatment of nonpalpable testes, and early results are encouraging. Both diagnostic and therapeutic laparoscopy necessitate operative skills. The exact advantages of laparoscopy over conventional surgery in orchidectomy and single- or two-stage orchidopexy need to be determined.

Laparoscopic management of the undescended testicle

The role of laparoscopy with regards to the undescended testicle has been hotly debated since the late 1970s and early 1980s when it was realized that the abdominal testicle could be visualized with the laparoscope. Many enthusiastically embraced the laparoscope for diagnosis and localization of the impalpable undescended testicle, whereas others staunchly maintained that laparoscopy was overly invasive and really facilitated little with regards to orchidopexy. Diagnostic laparoscopy, when compared with the other modalities, holds its own well with regards to accuracy and efficacy. In the early 1990s, the role of laparoscopy expanded to include performance of orchidopexy. It would be naive to believe that the debate cooled with the evolution of laparoscopic orchidopexy. Over the years, since introduction of the operation, there have been many institutions that have examined the role of laparoscopic orchidopexy quite critically. In many people's minds, laparoscopic orchidopexy is a clear competitor to open orchidopexy for the impalpable undescended abdominal testicle; in a few people's minds, it has become the gold standard.