The management of nonpalpable testis with combined groin exploration and subsequent transinguinal laparoscopy

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

PURPOSE

We evaluated the role of initial laparoscopy and optimized approach in cases of unilateral nonpalpable testis.

METHODS

Seventy-four patients with nonpalpable testes were presented. We excluded 9 patients, with palpable testes under anesthesia. Laparoscopy was offered to 65 patients. Contralateral testis hypertrophy with length ≥ 1.8 cm was confirmed in 47 patients. Ultrasound results were available for 35 patients.

RESULTS

Age ranged from 1 to 10 years. Of 65 nonpalpable testes, right side comprised 23 (35.4%) and the left 42 (64.6%). Laparoscopy revealed intra-abdominal testis in 18 patients (27.7%), blind-ending vessels and vas in 8 (12.3%), and vas and vessels traversing the internal ring in 39 (60%). Treatment of intra-abdominal testes included Fowler-Stephens orchiopexy in 7 patients, laparoscopic orchiopexy in 9, and laparoscopic orchiectomy in 2. In 8 patients with blind-ending vas and vessels, laparoscopy was terminated. In 39 patients with vas and vessels traversing the internal ring, scrotal exploration was performed in 36 patients with closed internal ring and inguinal exploration in 3 with open internal ring. Vanished testes were present in 43/47(91.5%) of patients with contralateral testis hypertrophy ≥ 1.8 cm. Ultrasound detected the presence of a testis in only 4/11 (36.3%) of patients, although it could not identify vanished testis.

CONCLUSIONS

Initial laparoscopy should be retained as one of the standard treatment for nonpalpable testis. It was the only required modality in 26 patients (40%) and optimized further treatment in 39 patients (60%) by evaluation of the condition of the internal ring.

The Nonpalpable Testis: A Narrative Review

PURPOSE

While the nonpalpable testis represents a small portion of all cryptorchid testes, it remains a clinical challenge for pediatric urologists. Controversy exists surrounding the best evaluation and management of this entity. In this review we update what is known about the nonpalpable testis, including the etiology, preoperative evaluation and best surgical management as well as novel techniques and ongoing controversies.

MATERIALS AND METHODS

We searched PubMed® and MEDLINE® from January 2000 to January 2017 using relevant key terms. Of 367 articles 115 were considered for inclusion based on a priori design. Using a narrative review format, an update on the evaluation and management of the nonpalpable testis including novel concepts and techniques was synthesized.

RESULTS

The nonpalpable testis should be evaluated by physical examination only. Imaging is not indicated for routine cases. The optimal surgical approach and technique remain debatable but several novel techniques have been described. Due to the rarity of the nonpalpable testis, randomized controlled trials and other quality comparisons are difficult. Therefore, management remains controversial.

CONCLUSIONS

Evaluation and management of the nonpalpable testis remain difficult, and some aspects are still debated. Future research should focus on multi-institutional collaborative trials to determine the optimal operative management.

High single scrotal-incision orchidopexy as the standard technique in infants aged 6-24 months

OBJECTIVE

To prospectively investigate the effectiveness of high single scrotal-incision orchidopexy (HSSIO) for palpable undescended testis (PUDT) in infants aged 6-24 months.

PATIENTS AND METHODS

From March 2012 to July 2014, 46 age range-restricted (6-24 months) infants with 57 PUDT underwent HSSIO after obtaining written consent from their parents. The exclusion criteria were ectopic, retractile testes and recurrent cases. All infants were examined before surgery in the outpatient department and after anaesthesia induction immediately before surgery. All infants had general anaesthesia with a caudal block. The operative time, intraoperative and postoperative complications, and follow-up of the infants at 0.5, 3 and 6 months were recorded and analysed.

RESULTS

The mean (SD; range) operative time was 23.45 (3.28; 18-29) min. A hernia sac was found in 39 (68.4%) UDTs. For postoperative complications, only one infant developed a scrotal haematoma that was managed conservatively. The procedure was successful in 56/57 PUDT (98%). An auxiliary procedure was needed in one case, to obtain more length of the cord by extension of the incision to the external ring.

CONCLUSION

HSSIO is a safe and feasible technique, with many benefits, and as such should be considered as the standard technique for orchidopexy in infants aged 6-24 months.

Orchiopexy through a single high transverse scrotal incision

BACKGROUND

Palpable Undescended Testis (PUT) represents a common paediatric problem in many premature and some mature infants. There are several surgical techniques to correct PUT either through combined inguinal and scrotal incision or single transverse scrotal incision. This study assessed single high transverse scrotal incision for the management of PUT as regards to feasibility, postoperative success and final cosmetic results.

MATERIALS AND METHODS

One hundred twenty patients were managed at the Paediatric Surgery Department of Tanta University Hospital with PUT during the period from March 2010 to March 2014. They were all operated at the age of 6-12 months. We excluded recurrent cases, and cases older than 12 months. Through high transverse scrotal incision, the layers were divided, and the canal entered through the external ring, dissecting the PUT and bringing it through the incision. Hernia sac, if present, was ligated at the neck. Creation of the dartos pouch was then made through the same incision. All infants were followed-up at 1 month, 2 months and 6 months to detect any re-ascended cases, testicular atrophy and the final cosmetic appearance.

RESULTS

A total of 140 PUTs were operated upon in 120 patients. PUT was bilateral in 20 patients, right-sided in 65 cases and left-sided in 35 cases. Thirty testes were located at the external ring; the others were located within the inguinal canal. No cases needed a redo operation, and there was no case of postoperative testicular atrophy.

CONCLUSION

Single high transverse incision was sufficient to deal with PUT especially, in young infants (age 6 months) with no need for conversion in most cases to the traditional two incisions technique, and good long term follow-up and a better cosmetic results.

Single scrotal-incision orchidopexy for palpable undescended testis in children

OBJECTIVE

To evaluate the single scrotal-incision orchidopexy (SSIO) technique in patients with an undescended testis palpable in the inguinal canal or below the external inguinal ring.

PATIENTS AND METHODS

Between January 2011 and December 2013 we performed 100 SSIOs in 89 patients. The mean (range) follow-up was 9 (3-36) months.

RESULTS

In 88 testes the SSIO was performed with no difficulties. In four patients an additional dissection by opening the external ring and canal was necessary; none of these patients developed an inguinal hernia after surgery. In eight patients conversion to an inguinal approach was necessary because of difficulty in controlling the hernial sacs and inadequate mobilisation. At the follow-up assessment, of the 89 patients, none developed testicular atrophy, one (1%) had wound dehiscence and four (5%) had a scrotal haematoma. There was no statistically significant difference between the testicular size at baseline and that during the follow-up. At 3 months after surgery the overall cosmetic result was excellent.

CONCLUSION

The SSIO is minimal-access surgery allowing less dissection, less discomfort for the patient, rapid healing, excellent cosmetic results and a good success rate. This technique is safe and effective for undescended testes palpable in the inguinal canal or below the external inguinal ring.