Laparoscopy in 100 consecutive patients with 128 impalpable testes

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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.

Post-orchidectomy retroperitoneal seminoma: A case report

Between 2 and 5% of malignant germ cell tumors in males arise at extragonadal sites. The origin of extragonadal retroperitoneal germ cell tumors remains controversial. Whether these develop primarily in the retroperitoneum or are metastases of a primary testicular tumor has long been debated. We report a 38-year-old male who presented with abdominal pain and was diagnosed with retroperitoneal seminoma. The patient gave a history of having undergone a right orchidectomy for an undescended testis via the inguinal route 10 years previously with a reported histology of benign inflammatory mass.

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.

Surgical treatment of undescended testes

The mainstay of therapy for undescended testes is operative treatment within the first years of life in order to avoid ongoing testicular degenerative changes. The surgical therapy for the palpable undescended testis is orchiopexy and when the testis is non-palpable, a supplementary laparoscopic approach. Success of orchiopexy for inguinal testes has been >95% and for abdominal testes >85-90% in most series.

CONCLUSION

Operation within the first year of life is a safe therapy for undescended testes.

Seminoma de testículo abdominal en un paciente adulto: reporte de un caso

OBJECTIVE

To present a new case of an Intra-abdominal Testicular Seminoma in an adult.

METHODS/RESULTS

We report a 30 year old patient with cryptochidism, that after consulting to the emergency service due to abdominal pain, was diagnosed an Intra-abdominal Testicular Seminoma.

DISCUSSION

The incidence of testicular cancer in cryptorchidic testis is 3 to 48 times higher than in general population. The existence of maldescended testis in adult population is rare in developed countries, due to the normal practice of elective orchidopexia in children under 2 years old and orchiectomy in maldecended testis in postpuberal pacients. In spite these measures of prevention, there are still isolated cases of Intra-abdominal testicular tumors in adults.

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.

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.

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.

LONG-TERM OUTCOME OF FOWLER-STEPHENS ORCHIOPEXY IN BOYS WITH PRUNE-BELLY SYNDROME

PURPOSE

Intra-abdominal testes in boys with prune-belly syndrome have been conventionally managed by 1 or 2-stage orchiopexy with division of the gonadal vessels. We reviewed a series of adults with prune-belly syndrome to assess the morphological and functional outcome of orchiopexy in childhood with specific reference to the spontaneous onset of puberty, hormonal profiles and sexual function.

MATERIALS AND METHODS

A total of 41 boys were divided into 3 groups depending on the type of orchiopexy performed, namely group 1-20 with bilateral 1-stage orchiopexy, group 2-10 with unilateral 1-stage and contralateral 2-stage orchiopexy, and group 3-11 with bilateral 2-stage orchiopexy.

RESULTS

In group 1 9 of 20 patients had good scrotal testes bilaterally, 6 had a good scrotal testis on 1 side and 3 had small testes on each side. Two boys required testosterone supplementation but 18 had normal hormonal and sexual function. In group 2 6 of 10 patients had good scrotal testes bilaterally and 4 had a good scrotal testis on 1 side. All patients underwent spontaneous puberty with good sexual function. In group 3 7 of 11 boys had good scrotal testes bilaterally and 3 had 1 good testis with normal puberty and sexual function. These 10 patients underwent spontaneous puberty with good sexual function.

CONCLUSIONS

The majority of boys with prune-belly syndrome had a satisfactory outcome after orchiopexy with division of the gonadal vessels with testicular function sufficient to induce puberty and maintain satisfactory sexual function in adult life.

Role of laparoscopy in patients with previous negative exploration for impalpable testis

OBJECTIVES

To evaluate the impact of laparoscopy in the treatment of patients with previous negative inguinal exploration for impalpable undescended testes.

METHODS

A retrospective review was performed of patients who underwent laparoscopy after prior incomplete or "questionable" negative inguinal explorations for nonpalpable undescended testes.

RESULTS

Twenty-seven males aged 1 to 22 years old, with 30 impalpable testes, underwent laparoscopy after prior negative open exploration. The operative notes were available for all patients. In 9 patients (33%), blind-ending spermatic vessels, vas deferens, and a closed ring were found. However, in the remaining 18 patients (67%), viable intra-abdominal or inguinal gonads (9 patients) and intra-abdominal remnants (9 patients) were identified. In 1 patient, seminoma of an intra-abdominal testis was present.

CONCLUSIONS

When a patient is referred with an inconclusive previous open exploration for an impalpable gonad, laparoscopy has an important role in establishing or refuting the diagnosis of an absent testis. Moreover, therapeutic laparoscopy provides definitive options to standard open techniques when a viable testis or remnant is encountered. In this study, laparoscopy proved more accurate than open exploration with operative notes available defining the nature of the exploration.

The role of laparoscopy in the management of the impalpable testicle

BACKGROUND

Laparoscopy can identify patients who would benefit from further surgical intervention. Most importantly it is 100% sensitive in identifying the vanishing testicle.

AIMS

To review the role of laparoscopy in the management of the undescended testis.

METHODS

Thirty-one patients underwent a laparoscopy for an impalpable testicle over a nine-year period at this institution.

RESULTS

There were 30 successful laparoscopies completed for 31 impalpable testes,13 of which were normal. All underwent groin exploration of which 11 were located. Seventeen had an abnormal laparoscopy. Of these, 11 were located in the abdomen and four were diagnosed as vanishing testes.

DISCUSSION

Sixteen per cent of patients had an absent testicle at laparoscopy and were spared any further surgical intervention. In the remaining 84%, over half had their surgical procedure altered as a result of the laparoscopic findings. This experience, has led us to believe that laparoscopy is a safe, reliable and sensitive procedure crucial to the management of the impalpable testis.

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

PURPOSE

About 20% of all cryptorchid testes are nonpalpable. Although surgical exploration was previously the method of choice for management, laparoscopy from the inferior edge of the umbilicus has been established as a useful method of finding a testis that is nonpalpable. However, conventional subumbilical laparoscopy is unnecessary when the testis or its remnant is located below the internal inguinal ring. We evaluated the efficacy of transinguinal laparoscopy after inguinal exploration for a nonpalpable testis.

MATERIALS AND METHODS

While 30 patients each had a unilateral nonpalpable and a contralateral descended palpable testis, 3 had a unilateral nonpalpable and a contralateral undescended palpable testis. When we identified neither a normal testis nor a spermatic cord at exploration of the inguinal canal, we subsequently performed laparoscopic observation through the internal inguinal ring.

RESULTS

Of the 30 patients with a unilateral nonpalpable and a contralateral descended testis 8 required transinguinal laparoscopy. However, the procedure was avoided in 22 patients because the testis, its remnant or testicular vessels and vas deferens were detected by inspecting the inguinal region.

CONCLUSIONS

Further extended incision into a Pfannenstiel incision was unnecessary in cases of blind ending vas and vessels in the peritoneum with transinguinal laparoscopy. In addition, laparoscopy was avoided in 22 of the 30 children (73.3%) with a unilateral nonpalpable and a contralateral scrotal testis. Our strategy of initial inguinal exploration followed by transinguinal laparoscopy for nonpalpable testis may become a reasonable alternative.

Germ cells may survive clipping and division of the spermatic vessels in surgery for intra-abdominal testes

PURPOSE

Laparoscopy is a well described modality that provides an accurate visual diagnosis upon which further management of intra-abdominal testes may be based. Laparoscopic ligation of spermatic vessels as stage 1 of the procedure is a natural extension of laparoscopy. A staged approach provides adequate viability of the intra-abdominal testis. However, it is uncertain whether the more sensitive germ cells survive this procedure in addition to the Sertoli and interstitial cells of the human testis. Survival of germ cells is a prerequisite of later fertility potential.

MATERIALS AND METHODS

We studied 17 nonpalpable testes in 10 patients 1 year and 7 months to 13(1/2) years old. Results of testicular biopsies of 13 intra-abdominal testes taken at stages 1 and 2 of surgery were available for histological comparison.

RESULTS

Median number of spermatogonia per tubular cross section of the biopsies taken at stage 2 was slightly lower (0.03) compared to the median number at stage 1 (0.06) of the operation but this difference was not significant (p = 0.2031).

CONCLUSIONS

Our study shows that the spermatogonia may survive clipping and division of the spermatic vessels, although the number of spermatogonia per tubular transverse section decreases slightly.

Routine laparoscopy for nonpalpable testes?

There are still no accepted criteria for the selection of patients with nonpalpable testes for laparoscopy versus a primary surgical exploration. We here report our experience using routine laparoscopy in such patients. The aim was to determine whether laparoscopy should be the first operative intervention or follow an inguinal exploration. Included in the study were 61 boys with 69 nonpalpable testes. Thirty-three testes were found in the abdomen, and 36 testes were extra-abdominal or nonexistent. If an exploration of the inguinal region had been the initial surgical intervention, six testes would have been found, making laparoscopy unnecessary. On the other hand, in the search for 63 missing testes, laparoscopy saved the patients from laparotomy or an extensive inguinal exploration. We conclude that an accurate knowledge of testis, vas, and vessel location gained by laparoscopy facilitates the selection of an appropriate surgical strategy, saving at least 51% of patients from laparotomy or an extensive inguinal exploration.

The difficult orchidopexy: the value of the abdominal pre-peritoneal approach

OBJECTIVE

To analyse the outcome of using the abdominal pre-peritoneal (APP) approach to orchidopexy.

PATIENTS AND METHODS

During an 8-year period, the experience of one surgeon in the management of 553 boys (median age 4.5 years, range 1-13) with undescended testes (596 testes) was assessed. The analysis emphasized those patients who had an orchidopexy performed using the APP approach detailing; the original position of the testis at exploration, whether successful placement within the scrotum was possible, and whether atrophy or ascent of the gonad occurred subsequently.

RESULTS

In 98 boys (110 testes) the testes were impalpable or high within the inguinal canal and they were explored using the APP approach. Of the 34 testes (31%) which were found abdominally, 12 were high intra-abdominal and the remaining 22 just deep to the internal inguinal ring. These included seven bilateral and 20 unilateral intra-abdominal testes. The remaining 76 undescended testes included five with bilateral high testes, 29 high unilateral testes, 13 repeat orchidopexies, 17 'vanishing testis syndrome' and seven atrophic testes. The remaining 486 undescended testes were treated using a standard orchidopexy and were therefore excluded from analysis.

CONCLUSION

The value and advantages of this operative approach and its place in the management strategy of the difficult orchidopexy are discussed.

Pediatric laparoscopy for nonpalpable testes with new miniaturized instruments

New miniaturized pediatric telescopes (1.9 or 3.5 mm) and reusable instruments (3.5-mm trocars, scissors, graspers) were used for the first time in a prospective study to evaluate handling safety and efficacy in laparoscopic diagnosis of unilateral nonpalpable testes. The results were confirmed during the same anesthesia by open operation for either orchiopexy or removal of rudimentary spermatic cord structures. Laparoscopy in 13 boys revealed one abdominal testis, 5 vanishing testes, and 7 cases of inguinal retention associated with an open inner inguinal ring. The illumination and detail resolution of the minitelescope were excellent. The 3.5-mm instruments were fully functioning with regard to tissue dissection. No complications occurred. Without technical disadvantages but with increased safety for the patient, the new miniaturized pediatric laparocopic instruments indeed realize a step forward to minimal invasion in infants and children.

Laparoscopy in the management of the impalpable undescended testis

BACKGROUND

This study evaluates the role of laparoscopy for managing the intra-abdominal testis.

METHODS

Over 30 months, 48 children (six with previous groin explorations) underwent laparoscopy for a unilateral impalpable undescended testis. The patients' age ranged from 1 to 9 years.

RESULTS

Eleven children required insertion of 'working ports' for mobilization of obscuring colon before the diagnosis could be established. Twenty-eight children had an absent testis. In nine, vas and vessels entered the internal ring. In 19, vas and vessels ended blindly above the internal ring. Twenty children had an intra-abdominal testis. Ten underwent a laparoscopic single-stage orchidopexy (eight without and two with ligation of vessels); at a minimum follow-up of 2 years, one testis in this group had atrophied, three were located in the lower half of the scrotum and six in the upper half. The remaining ten children underwent a laparoscopic two-stage Fowler-Stephens operation. At a minimum follow-up of 6 months, eight of these testes were palpable in the lower half and two in the upper half of the scrotum. CONCLUSION In the majority of cases, laparoscopy obviates the need for groin exploration. Technically a first-stage Fowler-Stephens procedure can be performed easily and effectively via the laparoscope. However, the second-stage Fowler-Stephens procedure or single-stage orchidopexy requires laparoscopic skills and may not necessarily provide sufficient length to the testicular attachment.

Laparoscopic resection of intra-abdominal testicular tumor

Intra-abdominal testicular neoplasms are difficult to diagnose, with open surgical exploration and excision the traditional mode of therapy. We report a patient with an intra-abdominal seminoma resected laparoscopically. In patients who present without evidence of retroperitoneal adenopathy, laparoscopy can be used for diagnosis, and with minimally invasive surgical techniques, to resect these tumors.

Management of impalpable testes: indications for abdominal exploration

Various approaches to the management of the impalpable testis in cases of cryptorchidism have been advocated. The authors' experience over the past 13 years was reviewed to try to determine an optimal approach. Of 1,305 patients with undescended testicles seen between February 1982 and December 1995, 157 boys (12.03%) had impalpable testes with 17 having bilateral impalpable testes for a total of 174 impalpable testes. A hernia sac was present in 155 impalpable testes with a testicle present in all cases. No hernia sac was found in 19 impalpable testes, five of which had no testicle present. This was confirmed by either open exploration or laparoscopy. One hundred forty-eight boys underwent groin exploration as initial treatment, 13 of these had bilateral impalpable testes. In addition to the five absent testicles with no hernia sac, one patient with a hernia sac and no testicle evident benefited from subsequent laparoscopy to identify an intraabdominal testicle. All other patients underwent routine orchidopexy or orchidectomy (one case with grossly malformed testicle). Nine boys underwent laparoscopy as initial treatment, four of these had bilateral impalpable testes. Two abnormal testicles were found and removed. Groin exploration and subsequent orchidopexy was definitive treatment in all other cases. The association of a hernia sac with an impalpable undescended testicle is very significant (P < .00001 Fisher's Exact test). The absence of a sac therefore may reflect an alternate diagnosis. When no sac is found with a testicle in the groin, this may represent an ectopic testicle. When no sac is found with no testicle, this may represent a vanishing testicle. From this experience the authors conclude that groin exploration should be the initial approach to impalpable testes. The presence of a hernia sac with an absent testicle demands further exploration; the absence of a hernia sac with an absent testicle suggests a vanishing testicle and may need no further exploration.