Laparoscopy for impalpable testes

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

BACKGROUND AND OBJECTIVE

The objective of our study is to examine the impact of monorchism on contralateral testicular size in children with non-palpable testis (NPT). Enhanced contralateral testicular volume or longitudinal diameter (length) serves as a predictor of monorchism. In the present study, we assessed the ability of ultrasound measured enlarged contralateral testicular length for predicting monorchism (and hence a testicular nubbin) in children with NPT. Furthermore, we evaluated the general prevalence of viable versus non-viable testes in patients referred to our institution with unilateral undescended testis between 2005 and 2020.

STUDY DESIGN

We analysed the records of 54 patients who underwent diagnostic laparoscopy for NPT between 2005 and 2020 in a European tertiary care centre. Testicular lengths (longitudinal diameter) and testicular volume of the contralateral testis, as well as surgeon (surgeon 1 vs surgeon 2 vs others) and age at surgery (months) were assessed and stratified according to intraoperative findings (presence or absence of a testicular nubbin). Testicular length and volume were evaluated by ultrasound examination in office prior to surgery. Chi-square and t-test for descriptive analyses as well as uni- and multivariable logistic regression analyses were performed using R Version 3.1.0 (R Project for Statistical Computing, www.R-project.org).

RESULTS

A total of 15 children presented with viable testes and 39 patients with testicular nubbin. Mean age was 20.5 months in the overall cohort and 22.6 vs 19.7 months in children with viable testis vs testicular nubbin (p = 0.4). In patients with presence of a testicular nubbin, the contralateral testis was larger (median length 17 mm (16-19.2)) as compared to patients with a viable testis (median length 15 mm (14-17), p = 0.001). Similarly, contralateral testicular volume was lower in patients with a present viable testis (0.6 ccm vs 0.8 ccm; p < 0-001). This effect remained statistically significant when logistic regression analyses were adjusted for age and weight at surgery, year of surgery, surgeon, and laterality. OR (odds ratio) for presence of a testicular nubbin was 1.6 (per mm) [95% CI (confidence interval) 1.13-2.17; p = 0.007].

CONCLUSION

Patients with preoperative increased length and volume of the contralateral testis in the ultrasound examination are at significantly higher risk of monorchism than their counterparts with lower testicular length. This should be emphasized during counselling of the parents prior to surgery. In our experience parents cope more easily with the diagnosis of monorchism, once this has already been discussed and explained thoroughly prior to surgery.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Staged laparoscopic traction orchiopexy for intra-abdominal testis: Is it always feasible?

BACKGROUND AND OBJECTIVES

Laparoscopic orchiopexy for intra-abdominal testis is a well-known and commonly practiced technique. The traction technique is based on elongation of the testicular vessels without cutting them, in contrast with the two-stage Fowler-Stephens technique in which the testicular vessels are divided. The current study evaluated the feasibility of the traction technique according to the type of intra-abdominal testis.

PATIENTS AND METHODS

The study included 20 boys with 22 intra-abdominal testes and who underwent staged laparoscopic traction orchiopexy between October 2013 and October 2015. Eighteen testes were proximal to the internal ring by <2 cm (type III), while the remaining four were high and away from the internal ring by >2 cm (type IVa). The patients' ages ranged between 6 months and 5 years (mean 2.2 years; median 2 years). Patients were followed up for 1 year for testicular atrophy and satisfactory scrotal site relocation.

RESULTS

This study did not detect any cases of testicular atrophy among the participants (0/22), while failure to achieve satisfactory scrotal site was found in two out of the four cases with type IVa intra-abdominal testes.

DISCUSSION

Traction techniques for elongating the testicular vessels were employed years ago, but this was revisited by Shehata in 2008. It has the advantage of preserving the main testicular blood supply, which can be reflected by the decreasing rate of testicular atrophy when compared with the Fowler-Stephens orchiopexy. The results of the traction technique may be less satisfactory regarding the testicular location for higher types of intra-abdominal testes (type IVa).

CONCLUSION

Staged laparoscopic traction orchiopexy was a feasible technique for intra-abdominal testes (within 2 cm of the internal ring), but the results were less satisfactory when applied for higher intra-abdominal testes (type IVa).

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

CONTEXT

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

OBJECTIVE

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

[Minimally invasive surgery in childhood]

Similar to surgery in adults, minimally invasive techniques have also become established in pediatric surgery for a wide variety of indications and partially replaced the corresponding conventional open surgical procedures. This applies not only to laparoscopy for abdominal surgical interventions but also to thoracoscopic procedures. The therapy spectrum in pediatric surgery includes all congenital and acquired diseases of the growing organism, from neonates to adolescents and for this reason the indications that are suitable for minimally invasive surgical procedures are corresponding versatile. According to the literature almost every operation in pediatric surgery was performed via a minimally invasive access route. Of course, not every generally feasible minimally invasive technique can be considered as being suitable to replace proven and established open conventional procedures in pediatric surgery.

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

OBJECTIVES

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

PATIENTS AND METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

Role of laparoscopy and ultrasound in the management of "impalpable testis" in children

BACKGROUND

Undescended testes is one of the most common congenital abnormalities in boys. In cases of impalpable testes, ultrasound is often used to find the testis, which frequently provides false-negative results. Recently, laparoscopy has become popular in the management of impalpable testes.

METHODS

Retrospective study of all children with impalpable testes presenting for laparoscopy between August 2007 and July 2011 who had undergone ultrasound examinations without localizing the testes was conducted and the role of laparoscopy in diagnosing impalpable testes was evaluated.

RESULTS

Twenty-three patients presented with impalpable testes for laparoscopy. All patients underwent ultrasound examinations in which the testes could not be identified. Of the 23 patients, Five patients were found to have palpable testes in the superficial inguinal pouch under anesthesia and proceeded to conventional open exploration during which the testes were brought into the scrotum. Eighteen patients were found to have impalpable testes in an evaluation under anesthesia (EUA) and proceeded to laparoscopy. Twelve patients were found to have intra-abdominal testes and underwent laparoscopic-assisted orchidopexy. Three patients underwent a two-stage Fowler-Stephens procedure, and two patients with "vanishing" testes with the vas and atrophic vessels entering a closed internal ring proceeded to open exploration and orchidectomy for atrophic testes. In addition, a teenager with atrophic testes underwent laparoscopic orchidectomy.

CONCLUSIONS

Laparoscopy is superior to ultrasound in the management of impalpable testes when high-resolution ultrasound is not available during the diagnostic process, with respect to both the sensitivity of localizing the testis and being more time and cost effective.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Diagnostic performance of diffusion-weighted MRI in the detection of nonpalpable undescended testes: comparison with conventional MRI and surgical findings

OBJECTIVE

The aim of this feasibility study was to evaluate the role of diffusion-weighted MRI in the evaluation of nonpalpable undescended testes.

MATERIALS AND METHODS

Thirty-six boys with undescended testes underwent preoperative abdominal and pelvic MRI to identify the location of the testes. MRI included free-breathing diffusion-weighted imaging (DWI) with b values of 50, 400, and 800 s/mm(2), a T1-weighted turbo spin-echo sequence, and a T2-weighted fat-suppressed turbo spin-echo sequence. After laparoscopic examinations, two observers independently reviewed the preoperative images. The DW images alone were reviewed first, followed by the conventional MR images alone and the conventional MR and the DW images together. The laparoscopic and MRI findings were compared. Sensitivity, specificity, and accuracy in the identification of nonpalpable undescended testes were calculated for DWI, conventional MRI, and the combination of DWI and conventional MRI.

RESULTS

The combination of DWI and conventional MRI was the most sensitive and most accurate technique. Observer 1 found 31 undescended testes, and observer 2, 30 testes with this technique. Sensitivity was 0.91 and 0.88 for observers 1 and 2, and accuracy was 0.92 and 0.86. With DWI alone, observer 1 located 30 testes, and observer 2, 28 testes (sensitivity, 0.88 and 0.82; accuracy, 0.86 and 0.81). Using conventional MRI alone, both observers located 29 testes (sensitivity, 0.85; accuracy, 0.86 and 0.84). The accuracy of locating testes was superior with the combination of DWI and conventional MRI for both observers (accuracy, 0.92 and 0.86). An intraabdominal atrophic testis managed by laparoscopic orchiectomy was found by neither observer with DWI or with conventional MRI.

CONCLUSION

Use of DWI with a high b value yields information that complements conventional MRI findings, improving identification and location of nonpalpable undescended testes. We recommend the use of conventional MRI in addition to DWI to increase the preoperative sensitivity and accuracy of identifying and locating nonpalpable testes.

Cryptorchidism: pathogenesis, diagnosis, treatment and prognosis

Cryptorchidism is a common genital anomaly diagnosed at birth or during childhood. Genetic and/or environmental factors that alter expression or function of hormones crucial for testicular descent, insulin-like 3, and testosterone, may contribute to cryptorchidism. When identified at birth, surgical treatment is indicated by 6 months of age if testes fail to descend, or at the time of diagnosis in older children. A laparoscopic approach is preferred for abdominal testes. Early surgical therapy may reduce the risk of subfertility and/or malignancy.

Laparoscopy-assisted orchiopexy for recurrent undescended testes in children

OBJECTIVE

Reoperative orchidopexy is a technical challenge to pediatric surgeons. The laparoscopy-assisted procedure is described for securing the testis in the scrotum in patients with a past history of open orchidopexy and testes in an unsatisfactory position.

PATIENTS AND METHODS

Thirty-one patients with 35 abnormally positioned testes (4 bilateral) were evaluated. All patients had a past history of inguinal surgery, and ages ranged between 2.5 and 13 years (mean, 5.5 years). Previous surgical procedures included 32 orchiopexies and 3 testicular detorsion of undescended testis. If needed, inguinal dissection was performed to loose the adherence between the cord and inguinal canal. Laparoscopic orchidopexy was applied to allow the testis to remain in the scrotum without tension. Patients underwent follow-up every 3 months after the operation with physical and ultrasound examinations.

RESULTS

Ten low inguinal testes were treated directly with open inguinal redo orchidopexy, whereas laparoscopy-assisted orchidopexy was possible in 23 (92%) of the remaining 25 reoperations. In 2 (8%) of these cases, severe scarring was present between the cord and the inguinal canal impeding the laparoscopy-assisted orchidopexy. For laparoscopy-assisted procedure, the operation time was 42 to 67 minutes (mean = 52 min). After the laparoscopy-assisted reoperations, 23 (92%) testes remain within the scrotum after a mean follow-up of 22 months (range, 6-32 months).

CONCLUSION

When feasible, laparoscopy-assisted orchiopexy is a simple and effective technique for securing testicles in reoperative orchiopexy procedures.

Total laparoscopic correction of transverse testicular ectopia

Transverse testicular ectopia is a well-described, rare congenital abnormality of testicular maldescent, in which both testes descend through one inguinal canal. There have been few reports on the laparoscopic diagnosis and laparoscopy-assisted management of this condition. We present a case of a 5-year-old boy who underwent laparoscopy for a right impalpable testis. During the procedure, the right testis was identified at the left internal ring. The common investing meso-orchium was divided and the right testis was brought down through the right inguinal canal laparoscopically. As far as we are aware, this is the first case of transverse testicular ectopia managed entirely laparoscopically.

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.

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.

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.