Laparoscopic orchidopexy: a review of a large clinical series

The Safety and Effectiveness of Single-Stage, Vessel-Preserving, Laparoscopic Orchiopexy for Intra-Abdominal Testes in Pediatric Patients: A 10-Year Single-Center Experience

Objectives: Intra-abdominal testes are located in a variety of intra-abdominal positions, most less than 2 cm from the internal ring. Various surgical techniques of laparoscopic orchiopexy have been described to date. The aim of this study was to evaluate the safety and long-term efficacy of a single-stage, vessel-preserving, laparoscopic orchiopexy for intra-abdominal testes in pediatric patients. Methods: A retrospective search of the medical records of 32 children (34 testes) who underwent single-stage, vessel preserving, laparoscopic orchiopexy for intra-abdominal testes between 1 January 2014 and 31 December 2023 was performed. Single-stage laparoscopic orchiopexies were performed in all patients for whom sufficient length of the spermatic cord was achieved during the procedure. The volume of each patient's testes was measured using ultrasound before and 6 months after laparoscopic orchiopexy. The main outcome of this study was testicular volume before and after the procedure. The secondary outcomes were the occurrence of early and late complications, the duration of surgery, and the length of hospital stay. Results: The median age at the time of surgery was 10 months (interquartile range-IQR 9, 13). The majority of the children (n = 24; 75%) were less than 12 months old at the time of surgery. A normal testis was found in 24 patients (70.6%), while a hypotrophic testis was visible in 10 cases (29.4%). The majority of the testes were located near the internal ring (n = 19; 55.9%), while in the remaining cases, the testes were located near the iliac blood vessels. The median duration of the surgical procedure was 37.5 min (IQR 33, 42.5). The duration of hospitalization was one day for all the children. No intraoperative complications were observed. One child had a wound infection at the site of the umbilical trocar, which was treated conservatively. In two cases (5.5%), testicular atrophy was detected during long-term follow-up. In three cases, the testis was found in a higher position in the scrotum during the follow-up period, but in two cases, the position was normal during the follow-up period, while in one case, the position in the scrotum remained unchanged. At long-term follow-up with a median of 35 months (IQR 19, 60.5), the overall success rate was 94.5%. The median testicular volume at 6-month follow-up increased from 0.31 mL (IQR 0.28, 0.43) to 0.40 mL (IQR 0.33, 0.53) (p = 0.017). Conclusions: Single-stage, vessel-preserving, laparoscopic orchiopexies for intra-abdominal testes are safe and effective in pediatric patients in whom adequate spermatic cord length can be achieved during the procedure.

Laparoscopy in the Evaluation of Impalpable Testes and Its Short-term Outcomes: A 7 Years' Experience

Aims:

The aim of this study is to report and analyze results of laparoscopy in impalpable testes performed between 2009 and 2016 and its short-term outcomes.

Materials and Methods:

Demographic data, laterality, laparoscopic findings, operative time, procedure, hospital stay, complications, and follow-up data of 76 patients with 79 impalpable testes from 2009 to 2016 were retrospectively collected and analyzed. Successful outcome was defined as maintenance of intrascrotal position with no atrophy at a follow-up of at least 6 months.

Results:

Impalpable testes constituted 24% of undescended testes in our series. Mean age was 3.9 years. Forty-two patients had left-sided, 31 right-sided, and three bilateral impalpable testes. Of the 79 clinically impalpable testes, on laparoscopy, 3 were vanishing testes, 52 were intra-abdominal (6 high-lying and 46 low-lying), 18 canalicular and 6 nubbin testes. Ultimately, 52 underwent laparoscopic orchiopexy: 46 single-staged orchiopexy and 6 two-staged Fowler–Stephens procedure. Mean operating time was 77 min. Complications were few and mostly minor. Eleven patients were lost in follow-up. On a mean follow-up of 23 months, one testis that underwent single-staged laparoscopic orchiopexy atrophied whereas good size and intrascrotal position were maintained in the rest.

Conclusions:

Laparoscopy in impalpable testes was safe, feasible, and effective. Overall outcome was good which was obtained by minimal use of electrocautery, dissection with wide strip of peritoneum and extensive retroperitoneal dissection for mobilization. There is a need for wide reporting of cases from high-volume pediatric surgery centers in India.

Laparoscopy in the management of impalpable testis (Series of 64 Cases)

BACKGROUND

The undescended testis represents one of the most common disorders of childhood. Laparoscopy has been widely used both in the diagnosis and treatment of non-palpable testis. In this study, we investigated and evaluated the usefulness of laparoscopy in the diagnosis and treatment of no palpable testis.

PATIENTS AND METHODS

From January 2003 to January 2008, we used laparoscopy in the management of 64 patients with 75 impalpable testes. Their ages varied from 1 to 15 years (median age = 4.6 years). The site and the size of the testes were localised by abdominopelvic ultrasonography in all 64 children for accurate diagnosis. One stage laparoscopic orchiopexy was performed in 26 testes, staged Fowler-Stephens orchiopexy was underwent in 17 testes, while laparoscopic orchidectomy was done in 5 testes. Follow-up by clinical examination and colour Doppler ultrasound was performed in every patient who underwent orchiopexy.

RESULTS

There were 11 patients with bilateral non-palpable testes. The overall diagnostic agreement of ultrasound with laparoscopy was seen in only 16 out of 75 testes (21.3%). The results of diagnostic laparoscopy were varied and showed various pathological. Conditions and positioned of the testes, such as 20 low intra-abdominal testes (26.6%), 17 testes were high intra-abdominal (22.7%), and 18 testes (24%) entered the inguinal canal. Associated inguinal hernia was present in 4 patients. After a mean follow-up period of 26 months (6 months - 5 years), all testes were in the bottom of the scrotum except 3 testes were retracted to the neck of the scrotum and atrophy of the testis occurred in 2 patients (2.7%).

CONCLUSION

Laparoscopy has proven to be the only diagnostic modality where the findings provide a clear dependable direction for the definitive management of impalpable testes, so it allows an accurate diagnosis and definitive treatment in the same sitting.

The role of laparoscopy in children with groin problems

The use of laparoscopic surgery has grown dramatically in recent years in most all types of surgery. Historically, the early use of laparoscopic surgery was for pelvic and groin problems. In this article we review the current technique, indications, benefits and complications of laparoscopy in diagnosis and management of various groin problems in children including undescended testes (non-palpable and palpable) and inguinal hernia.

A modified technique of laparoscopic mobilisation and transfer of intra-abdominal testis via inguinal canal

Several techniques have been described for mobilising intra-abdominal testis (IAT) into the scrotum. Many are associated with significant morbidity. We hereby introduce our modification of the technique that is safe and reproducible. Surgical technique using a nylon tape to railroad instruments into the peritoneal cavity to minimise false passage and trauma is described in detail. Once the testis is delivered out of the scrotal wound, further division of restrictive bands to mobilise the testis is carried out laparoscopically. These steps are not previously described in the literature. A retrospective study of consecutive patients with IAT undergoing surgical intervention by a single surgeon over a period of 15 years has been included to demonstrate outcome. Twenty-five patients with unilateral IAT (10R, 15L) and 2 patients with bilateral IAT, a total of 29 IAT, underwent laparoscopic orchidopexy over the period 1997-2012. Median age of the patients was 3.0 years. One-stage testicular vessel preserving (VP) orchidopexy was performed in 20 testes, Fowler-Stephen (FS), vessel sacrificing orchidopexy (3 one-stage and 6 two-stage) was required in 9 testes. At follow-up, atrophy was detected in 1 (5.0 %) and 2 (22.2 %) patients of the VP and FS groups respectively. The railroading technique of transferring IAT into the scrotum via the inguinal canal under laparoscopic guidance minimises tissue trauma. It negates the need to create new tissue opening. It is reproducible with a testicular atrophy rate comparable to published literature.

Laparoscopic orchiopexy and varicocelectomy: is there really an advantage?

The role of laparoscopy in the case of nonpalpable cryptorchidism is both diagnostic and therapeutic. Laparoscopic orchiopexy for nonpalpable testes in the pediatric population has become the preferred surgical approach among pediatric urologists over the last 20 years. In contrast, laparoscopic varicocelectomy is considered one of several possible approaches to the treatment of a varicocele in an adolescent; however, it has many challengers and it has not gained universal acceptance as the gold standard. This article reviews the published evidence regarding these surgical techniques.

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.

Management of undescended testis: a decision analysis

BACKGROUND

Undescended testis (UDT) or cryptorchidism is the most common genital anomaly seen in boys and can be treated surgically by orchidopexy. The age at which orchidopexy should be performed is controversial for both congenital and acquired UDT.

METHODS

A decision analysis is performed in which all available knowledge is combined to assess the outcomes of orchidopexy at different ages.

RESULTS

Without surgery, unilateral congenital UDT and bilateral congenital UDT are associated with average losses in quality-adjusted life-years (QALYs) of 1.53 QALYs (3% discounting 0.66 QALYs) and 5.23 QALYs (1.91 QALYs), respectively. Surgery reduces this QALY loss to on average 0.84 QALYs (0.21 QALYs) for unilateral UDT and 1.66 QALYs (0.40 QALYs) for bilateral UDT. Surgery at detection will lead to the lowest QALY loss of 0.91 (0.34) and 1.73 (0.60) QALYs, respectively, for unilateral and bilateral acquired UDT compared with surgery during puberty and no surgery. No sensitivity analysis is able to change the preferences for these strategies.

CONCLUSIONS

Based on our decision analytic model using societal valuations of health outcomes, surgery for unilateral UDT (both congenital and acquired) yielded the lowest loss in QALYs. Given the modest differences in outcomes, there is room for patient (or parent) preference with respect to the performance and timing of surgery in case of unilateral UDT. For bilateral UDT (both congenital and acquired), orchidopexy at any age provides considerable benefit, in particular through improved fertility. As there is no strong effect of timing, the age at which orchidopexy is performed should be discussed with the parents and the patient. More clinical evidence on issues related to timing may in the future modify these results and hence this advice.

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.

Is it necessary to close the peritoneum over the deep inguinal ring during laparoscopic orchidopexy?

BACKGROUND

During laparoscopic orchidopexy, some authors routinely close the peritoneum over the area of the deep inguinal ring (DIR). We report our experience, to determine whether leaving the peritoneum over the DIR without closure is associated with an increase in the occurrence of postoperative inguinal hernia.

PATIENTS & METHODS

This is a retrospective review of patients who underwent laparoscopy for impalpable testes in 2004-2010. The patients were divided into two groups: I) cases in whom the peritoneum over the DIR was routinely closed, and II) cases in whom the DIR was left without closure. The patients were followed up in the outpatient clinic.

RESULTS

During the study period, 442 boys underwent laparoscopy for 570 impalpable testes. The testis was found to be 'vanishing' or 'atrophic' in 182 (32%). The mobilized testis passed through the anatomical DIR in 198 (51%), and through a new deep ring in 190 (49%). The DIR was closed (I) in 178 (46%) and left open (II) in 210 (54%) cases. On follow up (mean 50 months for I and 41 months for II), there were no cases of inguinal hernia.

CONCLUSION

Closing the peritoneum over the area of the DIR may not be necessary, even in cases where the testis has to be passed through a medially created new deep ring, because of a short cord.

Transumbilical multiport laparoscopic orchiopexy in children: comparison with standard laparoscopic orchiopexy

OBJECTIVE

To compare the clinical outcomes of transumbilical multiport laparoscopic orchiopexy (TMLO) vs standard laparoscopic orchiopexy (SLO) for 1-stage management of impalpable testes in children.

MATERIALS AND METHODS

A total of 30 patients underwent primary TMLO from January 2010 to December 2011. An additional 25 patients underwent SLO during the same period. These 2 procedures were performed with 3 ports and the usual laparoscopic instruments. The demographic, intraoperative, postoperative, and follow-up data were analyzed and compared between the patients.

RESULTS

The patients' demographic data were similar between the 2 groups. The mean operative time was slightly longer in the TMLO than in the SLO group (54.2 vs 47.3 minutes, P <.05), without intraoperative complications in either group. However, no significant difference was noted between the TMLO and SLO groups in the length of hospital stay (4.0 vs 4.1 days, P >.05), interval to resume feeding (5.2 vs 5.4 hours, P >.05) or full activity (2.1 vs 2.2 days, P >.05), viable testis rate (33 of 34 vs 27 of 28, P >.05), or testicular atrophy (1 of 34 vs 1 of 28, P >.05).

CONCLUSION

TMLO is a feasible and safe procedure for the management of impalpable testes in children, with clinical outcomes similar to those of SLO. Future randomized studies with a larger number of patients and longer follow-up are warranted to elucidate the benefits and limitations of TMLO in children.

Advances in the surgical pediatric urologic armamentarium

The surgical armamentarium of the pediatric urologist has changed greatly in the past 2 decades on account of new technology and careful adaptation of minimally invasive techniques in children. Conventional laparoscopy, robotic-assisted laparoscopy, laparoendoscopic single-site surgery, and endourologic surgery have, to varying degrees, provided new approaches to urologic surgery in the pediatric population. This article reviews the technology and adaptations behind these recent advances as well as their current applications in management of urologic disease in children.

The evolving role of laparoscopic surgery in paediatric urology

OBJECTIVES

We review the various applications of laparoscopic and robotic-assisted laparoscopy in paediatric urology, as the laparoscopic and robotic approach in this population is gradually being recognised.

METHODS

We searched PubMed for human studies in English that were published between 1990 and the present, focusing on laparoscopic nephrectomies and partial nephrectomies, laparoscopic and robotic pyeloplasties and ureteric reimplantation, laparoscopic orchidopexy and varicocelectomy. We also reviewed robotic-assisted laparoscopic urological major reconstructions. Key articles were reviewed, extracting the indications, techniques, and the advantages and disadvantages.

RESULTS AND CONCLUSIONS

Laparoscopy has a defined place in modern paediatric urological surgery. Laparoscopic nephrectomies, pyeloplasties and abdominal exploration for the evaluation and management of impalpable undescended testicles have become the standard of care. Robotic-assisted laparoscopic surgery is developing as a safe and effective option even for infant patients.

Pediatric laparoscopic and robot-assisted laparoscopic surgery: technical considerations

Laparoscopy has become an effective modality for the treatment of many pediatric urologic conditions that need both extirpative and reconstructive techniques. Laparoscopic procedures for urologic diseases in children, such as pyeloplasty, orchiopexy, nephrectomy, and bladder augmentation, have proven to be safe and effective with outcomes comparable to those of open techniques. Given the steep learning curve and technical difficulty of laparoscopic surgery, robot-assisted laparoscopic surgery (RAS) is increasingly being adopted in pediatric patients worldwide. Anything that can be performed laparoscopically in adults can be extended into pediatric practice with minor technical refinements. We review the role of laparoscopic and RAS in pediatric urology and provide technical considerations necessary to perform minimally invasive surgery successfully.

Laparoscopic versus open orchiopexy for non-palpable undescended testes in children: a systemic review and meta-analysis

BACKGROUND

Laparoscopic orchidopexy (LO) has been widespread used in the management of non-palpable testis (NPT) in children. However, the real advantages of LO over traditional open orchidopexy (OO) still remain exclusive.

METHODS

Published studies until August 31, 2010 were searched from Medline, Embase, Ovid, Web of Science, and Cochrane databases. Randomized controlled trials (RCTs) and observational clinical studies (OCSs) with a comparison of LO and OO were included for a systemic review and meta-analysis.

RESULTS

Out of 226 studies, 2 RCTs and 5 OCSs were eligible for inclusion criteria, comprising 176 cases of LO and 263 cases of OO. The hospital stay of LO was significantly shorter than that of OO (WMD = -0.66; 95% confidence interval [CI] = -0.95 to -0.37; P < 0.00001). However, no significant difference was observed between LO and OO in operative time (WMD = 4.02; 95% CI = -9.89 to 17.93; P = 0.57), time to resume feeding (WMD = -2.29; 95% CI = -6.78 to 2.20; P = 0.32) or full activity (WMD = -9.71; 95% CI = -27.84 to 8.42; P = 0.29), recurrence (OR = 0.60; 95% CI = 0.13 to 2.72; P = 0.51), viable testis rate (OR = 1.61; 95% CI = 0.30 to 8.52; P = 0.58), success rate (OR = 1.41; 95% CI = 0.44 to 4.46; P = 0.56), and testicular atrophy (OR = 1.70; 95% CI = 0.49 to 5.98; P = 0.40).

CONCLUSION

Although shorter hospital stay is noted in LO, it does not provide significant advantage over open surgery for treating NPT. However, due to the publishing bias, a series of RCTs are necessary to explore the efficiencies of LO in the management of NPT in children.

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.

Evolution of laparoscopy in pediatric urology

The use of laparoscopy has evolved over the last 30 years, particularly in the last decade, from merely extirpative or diagnostic procedures to intricate reconstructive procedures on the major genitourinary organs. The development of laparoscopy as a method of treating urological problems has progressed more slowly in children compared with adults; perhaps due to the availability of miniaturized technology, the steep learning curve and the high success of traditional open surgery. This article seeks to provide a comprehensive review of the evolution of laparoscopy from its inception to its present-day applications in the field of pediatric urology, including the current indications and results of various laparoscopic procedures.

Laparoscopy in the management of impalpable testis: series of 64 cases

BACKGROUND

The undescended testis represents one of the most common disorders of childhood. Laparoscopy has been widely used for the diagnosis and treatment of non-palpable testis. In this study, we investigated and evaluated the usefulness of laparoscopy in the diagnosis and treatment of the non-palpable testis.

METHODS

From January 2003 to January 2008, we used laparoscopy in the management of 64 patients with 75 impalpable testes. The patients' ages varied from 1 to 15 years (median 4.6 years). The sites and sizes of the testes were localized by abdominopelvic ultrasonography (US) in all 64 children. One-stage laparoscopic orchiopexy was performed for 26 testes, staged Fowler Stephens orchiopexy for 17 testes, and laparoscopic orchidectomy for five testes. Follow-up by clinical examination and color Doppler US was performed in every patient who underwent orchiopexy.

RESULTS

There were 11 patients with bilateral non-palpable testes. The overall diagnostic agreement of US with laparoscopy was seen for only 16 of 75 testes (21.3%). The results of diagnostic laparoscopy were varied and showed various pathologic conditions and positions of the testes, such as 20 low intraabdominal testes (26.6%), 17 high intraabdominal testes (22.7%), and 18 testes (24%) that had entered the inguinal canal. Associated inguinal hernia was present in four patients. After a mean follow-up period of 26 months (6 months-5 years) all testes were seen to be located in the bottom of the scrotum, with the exception of three testes that had retracted to the neck of the scrotum and two testes that had atrophied (2.7%).

CONCLUSIONS

Laparoscopy has proven to be the only diagnostic modality where the findings provide a clear, dependable direction for definitive management of impalpable testes. It allows an accurate diagnosis and simultaneous definitive treatment.

The undescended testis: diagnosis, treatment and long-term consequences

BACKGROUND

The late descent of a testicle into the scrotum may impair its development. Reduced fertility is the main risk of primary cryptorchidism even after timely treatment, as histopathological changes (Leydig cell hypoplasia) already become apparent in the first few months of life. There is evidence, however, that treatment is often delayed. Hormonal and surgical treatments complement each other and should be provided before the child's first birthday.

METHODS

Selective literature search in PubMed (January 2008) based on the following keywords: "cryptorchidism", "maldescensus testis", "etiology", "therapy", "semen quality", "testicular cancer". Particular attention was paid to the current S2 guidelines on cryptorchidism.

RESULTS/DISCUSSION

Hormone therapy is the best initial treatment in most cases, with a few exceptions. If this is unsuccessful, surgery should be performed without delay. The success of treatment depends on the initial position of the testicle. Treatment does not lessen the risk of malignancy. Parents must be informed about this risk. The undescended testicle is the most common genital malformation in boys. When diagnosed, it should be treated hormonally and/or surgically before the child's first birthday to minimize the risk of impaired fertility. Successful treatment before age 13 appears not to lessen the risk of testicular cancer, but it does facilitate early detection by enabling physical examination of the testicle.

Bladder injuries during laparoscopic orchiopexy: incidence and lessons learned

PURPOSE

Laparoscopic orchiopexy is a safe operation. However, the bladder can be injured during creation of the transperitoneal tunnel for the cryptorchid testis. We reviewed our experience with this complication.

MATERIALS AND METHODS

We searched the operative notes of patients who had undergone laparoscopic orchiopexy between August 15, 2002 and October 1, 2008, and identified bladder injuries and their treatment.

RESULTS

A total of 93 patients underwent laparoscopic orchiopexies for 101 undescended testes during the study interval, with 3 procedures resulting in bladder injuries. The 3 operations varied with regard to whether the injury was recognized intraoperatively or postoperatively, and repaired in an open or laparoscopic fashion.

CONCLUSIONS

Bladder injury during laparoscopic orchiopexy is a rare but serious complication that can be managed by an open or laparoscopic approach. We recommend placement of a urethral catheter and syringe assisted drainage of all urine from the bladder at the beginning of the operation, careful perivesical dissection particularly in children with prior inguinal surgery, filling and emptying of the bladder during the procedure, and maintaining a high index of suspicion especially when hematuria is observed.

Diagnostic laparoscopy and management of the impalpable testis--a review of 10 years' practice at a non-paediatric specialist centre

BACKGROUND

Laparoscopy is used for the diagnosis and treatment of impalpable testes. We reviewed practice and outcomes in our unit over the last 10 years.

METHODS

Retrospective case-note review of patients undergoing laparoscopy with or without orchidopexy for impalpable testes.

RESULTS

Eighty-three patients underwent laparoscopy. Twelve patients had bilateral impalpable testes; 25.3% of testes were identified intra-abdominally, 21% in the internal ring, and 29.5% of cases had vas and vessels entering the deep ring. A 76.5% success rate was achieved following diagnostic laparoscopy and standard open orchidopexy for testes in the region of the internal ring, compared to a 40.0% success rate following one-stage laparoscopic orchidopexy for 'low' intra-abdominal testes.

CONCLUSION

Laparoscopy is useful in managing patients with an impalpable testis from both a diagnostic and therapeutic standpoint. The success rate following laparoscopic orchidopexy in our non-paediatric specialist centre is lower than in most reports from paediatric specialist centres. This suggests the importance of centralization of such complicated, less frequently performed surgical procedures to a specialist centre.

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.

Incidence and management of the inguinal hernia during laparoscopic orchiopexy in palpable cryptoorchidism: preliminary report

During the laparoscopic approach of undescended testis, an associated inguinal hernia is a frequent finding that must be treated at the same time. The objective of this presentation is to show the incidence and management of the inguinal hernia that were found during laparoscopic orchidopexy, reporting how the scar tissue will join the edges of the canal and the parietal peritoneum will grow above. Between January 1999 and December 2002, 31 patients with 33 palpable and nonpalpable undescended testes were treated by laparoscopic orchidopexy. Patients were between 6 months and 9 years. We used four ports, and 2 mm instrument. When an associated inguinal hernia were found we only removed the membranes of the processus vaginalis and did not close the defect. All cases were treated by the same surgeon. The average surgical time was 50 min that included the orchiopexy and the treatment of the associated inguinal hernia. We found inguinal hernia in 23 cases (69.9%). We did not find any inguinal hernia in the opposite side of the undescended testis. In two patients with bilateral undescended testis that were approached in two stages 3 months later we confirmed the closure of the hernia defect. These 23 patients have 21.5 months average follow up and confirm no recurrence. With an average follow up of 21.5 months, we found no inguinal hernia in any of the patients. A larger volume study with longer follow up is needed to confirm that there is no need for closure of the internal inguinal ring during laparoscopic orchidopexy.

Current management of the undescended testicle

Cryptorchidism, where either one or both testes fails to migrate to the base of the scrotum, affects 4% to 5% of full-term and 9% to 30% of premature males at birth. The testis can be found in any position along its usual line of descent; however, approximately 80% will be located in the inguinal region, just outside the inguinal canal. Early correction, from 3 to 6 months of age, is currently advised. The preferred means of investigation and subsequent surgical intervention are dependent on the position of the cryptorchid testis. Risks associated with cryptorchidism include infertility and malignancy. The aim of appropriate management is to minimize these, and any other, associated complications.

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%.

Testicular torsion: a complication of laparoscopic orchidopexy

A 19-month-old boy presented with an impalpable right testis. At second-stage Fowler-Stephens laparoscopic orchidopexy, the testicle was found to be torted, a complication that has not been described previously. The procedure, known complications, possible reasons for torsion and possible techniques to avoid torsion occurring are reviewed.

[The position of laparoscopic surgery in pediatric urology]

With growing experience in laparoscopic techniques there is a switch in pediatrics from ablative surgery to reconstructive procedures. Besides the established procedures such as laparoscopic nephrectomy and orchidopexy, procedures like heminephrectomy and pyeloplasty have proven practicable and become standard therapies in children and infants. Due to technical advances, as shown for our own patients, the number of treated infants is still increasing. However, laparoscopic reconstructive procedures presuppose a good deal of experience in preparation and suture techniques, and remain reserved for centers with daily experience in laparoscopy. Daily experience with difficult urological laparoscopic procedures in adults will remain more common than in pediatric centres.

Laparoscopy vs inguinal exploration for nonpalpable undescended testis

OBJECTIVE

The optimal initial surgical approach for nonpalpable undescended testis (UDT) is debated. The aim of the present study is to compare the results of initial laparoscopy and inguinal exploration in the management of unilateral nonpalpable undescended testes.

METHODS

The results of 20 children with unilateral nonpalpable UDT managed by initial laparoscopy (group I) were compared with 20 age-matched children managed by inguinal exploration (group II). The location of testes and results of orchiopexy were compared in both groups. A single surgeon performed all the operative procedures.

RESULTS

The majority of testes (16/20 group I, 17/20 group II) in both groups were canalicular or low abdominal. Vanishing testes accounted for one-third (13/40) of the testes, the majority (85%) of which were located in the inguinal canal. All children were discharged within 24 hours of the operation. The success of orchiopexy at 4-6 weeks post-operatively was 85% and 86% in the two groups respectively. Retrospectively, only 7/40 (18%) of the testes would benefit from laparoscopy.

CONCLUSIONS

Initial laparoscopic and inguinal approaches to nonpalpable UDT give comparable results. This report failed to demonstrate any specific advantage of initial laparoscopy in the majority of children with unilateral nonpalpable UDT.

Cryptorchidism: an indicator of testicular dysgenesis?

Cryptorchidism is a common ailment of new-born boys, affecting 1-9% of full term boys at birth. Cryptorchidism has been associated with an increased risk of testicular cancer and reduced fertility. Aetiology of cryptorchidism remains obscure in most cases. Familial occurrence suggests a heritable susceptibility to cryptorchidism; however, seasonal variation in the incidence of cryptorchidism suggests that environmental factors also contribute. Testicular descent is characterised by androgen-dependent regression of cranial suspensory ligament and androgen + insulin-like hormone 3 (Ins l3)-dependent gubernacular outgrowth. Even though hormonal defects are rarely detected in patients, both hypo-and hypergonadotropic hormonal patterns have been associated with cryptorchidism. Moreover, cryptorchid boys have significantly reduced serum androgen bioactivity at 3 months of age when normal boys have a strong surge of reproductive hormones. Defects in Ins l3 action cause cryptorchidism in male mice, and over-expression in female mice causes ovarian descent. Defects in leucine-rich repeat-containing G-protein-coupled receptor 8/G-protein-coupled receptor affecting testis descent (LGR8/GREAT), the receptor for Ins l3, manifest the same phenotype as Ins l3 knockout mutants. Even though mutations found in Ins l3 and LGR8/GREAT genes are not a common cause of cryptorchidism in patients, it remains to be resolved whether low Ins l3 levels during development are associated with cryptorchidism. Cryptorchidism may reflect foetal testicular dysgenesis that may later manifest as subfertility or testicular cancer.

Prepubertal unilateral spermatic vessel ligation decreases haploid cell population of ipsilateral testis postpubertally in rats

DNA flow cytometry is a sensitive and rapid technique to evaluate the germ cell maturation of testis. The haploid cell population of testis specifically denotes testicular maturation. High ligation of spermatic vessels (HLSV) and low ligation of spermatic vessels (LLSV) have been described in the surgical treatment of high undescended testis. Estimation of germ cell population of testis after these maneuvers has not been performed so far by DNA flow cytometry; hence this study was designed. Thirty male rats, aged 30 days, were randomized into three groups. Group I underwent sham surgery; group II underwent unilateral HLSV-ligation and division of main spermatic vessels, similar to the Fowler-Stephens technique; and group III underwent unilateral LLSV-ligation and division of main spermatic vessels close to the testis, similar to the Koff and Sethi technique. Thirty days later, the ipsilateral testes were harvested, and haploid, diploid, and tetraploid cells were counted by DNA flow cytometry. The mean (+/-SD) percentage of the haploid cell population was 68.7+/-4.8, 49.3+/-6.5, and 50.8+/-6.4 in groups I, II, and III, respectively. There was a significant (p<0.05) decrease in haploid cell population between groups I and II and between groups I and III. However, there was no significant difference between groups II and III. In conclusion, prepubertal HLSV as well as LLSV decreases the haploid cell population of ipsilateral testis in rats. LLSV has no advantage over HLSV.

Laparoscopic assessment and treatment of non-palpable testis in an 18-year-old male

Laparoscopy, both diagnostic and therapeutic, has been used in the management of pediatric non-palpable testes. We report a case of left non-palpable testis at the unusual age of 18 years. Laparoscopic exploration revealed an intra-abdominal testis lying between the internal inguinal ring and external iliac vessels. The testis was visually in good condition and, in contrast to the accepted procedure of orchiectomy performed in late adolescent cryptorchidism, we decided to preserve this intra-abdominal testis, which was located too far from the scrotum for a primary orchidopexy. The first stage of the Fowler-Stephens procedure was performed laparoscopically. The second-stage orchidopexy was performed successfully through an inguinal approach 3 months later, after sonographic ascertainment of non-decreased testicular volume. Laparoscopy allows thorough exploration for an intra-abdominal testis, with simultaneous therapeutic options. Our experience highlights the feasibility of laparoscopic assessment and treatment of cryptorchidism in adolescents and young adults.

Laparoscopic and robotic approach to genitourinary anomalies in children

The evolution of laparoscopic surgery in pediatric urology has been long and slow, but is emerging steadily and seems to be here to stay. This article reviews the basic applications of laparoscopic methods in pediatric urology, including diagnostic and operative procedures. The new horizons of robotic assistance for laparoscopic surgery make highly accurate and efficient reconstructive procedures possible.

Bimanual digital rectal examination for the evaluation of the nonpalpable testis

PURPOSE

In the evaluation and treatment of the nonpalpable testis open surgical exploration and laparoscopy are methods used to differentiate abdominal, infrainguinal (below the internal ring) and atrophic or absent testes. We sought to evaluate the use of bimanual digital rectal examination as an additional tool to localize the nonpalpable testis.

MATERIALS AND METHODS

Forty-one consecutive patients with 45 nonpalpable testes were evaluated in a prospective fashion. Bimanual digital rectal examination was performed with the patients under general anesthesia just before diagnostic laparoscopy or open inguinal exploration. Palpability, location, length and contralateral testicular length were recorded.

RESULTS

Twenty-five gonads or spermatic cords (56%) were palpable using the bimanual technique. All positive examinations were confirmed laparoscopically or by open exploration, and the majority of gonads were intra-abdominal (17 of 25, 68%). Seventeen normal appearing gonads underwent orchiopexy and 8 were removed secondary to atrophy, dysgenesis or poor position. Twenty testes (44%) were not palpated using this method. Of these gonads 10 normal appearing testes were found at exploration and underwent orchiopexy. Of the 10 remaining gonads 6 atrophic testes were removed, and 4 hemosiderin laden remnants were thought to represent "vanished testes." Overall, 26 gonads or remnants were intra-abdominal, 10 were "peeping" or canalicular and 9 were infrainguinal. The overall specificity was 100%, with a sensitivity of 60%. The positive predictive value was 100%.

CONCLUSIONS

Bimanual digital rectal examination is a valuable tool in the evaluation of the nonpalpable testis, and identified the presence and position of the testis in the majority of our cases. Although sensitivity is low, when the testis is palpated by this method, diagnostic laparoscopy to localize the testis may be avoided.