Journal of Indian Association of Pediatric Surgeons Medknow Publications on behalf of the Indian Association of Pediatric Surgeons ISSN: 0971-9261 EISSN: 1998-3891 Vol. 11, Num. 4, 2006, pp. 207-210

Journal of Indian Association of Pediatric Surgeons, Vol. 11, No. 4, October-December, 2006, pp. 207-210

Review Article

Role of laparoscopy in the management of impalpable testes

El-Gohary MAmin

Department of Pediatric Surgery, Mafraq Hospital, Abu Dhabi
Correspondence Address:Mafraq Hospital, P.O Box 2951, Abu Dhabi, magmagae@yahoo.com

Code Number: ip06042

Abstract

Both diagnostic and operative laparoscopy was used in the management of 189 impalpable testes. 66 were either vanishing or atrophied, 17 were found in the inguinal canal, 19 in the groin, and 87 intra-abdominal. Four of the latter group were associated with persistent Mullerian duct syndrome and one with splenogonad fusion. Four atrophied abdominal testes were excised laparoscopically, 47 were treated with one stage laparoscopic orchidopexy and 34 with laparoscopic Fowler Stephen (FS) procedure. A good scrotal position was achieved in 63% of the one stage procedure and 69% with the two stage FS approach.

Keywords: Laparoscopy, undescended testis

INTRODUCTION

MATERIALS AND METHODS

From November 1995 to December 2005, we used diagnostic and/or operative laparoscopy in the management of 159 children with 189 impalpable testes. Their age varied from 1-13 years (mean 3.8 years). Our protocol consisted of examination under anesthesia followed by diagnostic laparoscopy and definitive treatment. In 19 patients the testes were noted to be in the superficial inguinal pouch despite repeated clinical examination. About 17 testes were seen entering the upper part of the inguinal canal and 87 were found at a variable distance proximal to the internal ring. Of the latter group we encountered one case of splenogonada fusion, four cases with Mullerian duct remnant and eight in sub-renal position.

The epididymis was partially dissociated from the testes and looped into the inguinal canal in 13 cases and in one case it was completely dissociated [Figure - 1]. We encountered 25 vanishing, 4 atrophied abdominal and 37 atrophied scrotal testes.

Open orchidopexy was carried out in 19 patient in whom testes were found to be at superficial inguinal ring and in 10 patients with canlicular position. Excision of atrophied remnants of testes was carried out in 25 atrophied scrotal testes via inguinal incision. Histopathology did not identify scrotal tissues in 22 and in three; there were immature testicular tissues.

One stage laparoscopic-assisted orchidopexy (LAO) was performed in 40 abdominal and seven high canalicular testes. The testicular vessels are dissected free from peritoneal attachment as high as possible and the testes are brought into scrotal sac via a direct rout medial to the internal ring.

Laparoscopic Fowler Stephen procedure (FS) was performed in 34 high abdominal testes. In the first stage 2 metal clips are applied to the testicular vessels 3 cm above the testis without any testicular mobilization [Figure - 2][Figure - 3]. In the second stage (3-6 months later) the vessels are severed between the two clips and the testes are brought down on the artery to the vas with wide base of peritoneal attachment to the scrotal sac via the direct rout.

RESULT

DISCUSSION

Laparoscopy has been established as the most reliable diagnostic modality for the management of impalpable testes.[1],[2],[3],[4],[5],[6],[7],[8] It clearly demonstrates the anatomy and provides visual information upon which a definitive decision can be made.

Both internal rings can be inspected; the location and size of the testes, their blood supply and the nature, course and termination of the vas, and epididymis can be determined. All of these anatomical landmarks individually or collectively have bearing on the operative management of the impalpable testes.

All other diagnostic modalities (ultrasound, computerized tomography, magnetic resonance imaging and venography) have never attained such accuracy and are unreliable especially in the event of a negative result.[9]

19 patients after repeated clinical examination including examination under general anesthesia were found to have their testes in the superficial inguinal pouch. 11 of those were obese boys and six had emerging testes with complete hernial sac allowing the testes to pop in and out of the abdominal cavity.

Our criteria for diagnosing vanishing testes [Figure - 4] are to see the vas and vessels ending blindly at or above closed internal ring.[10] Seeing the vas alone entering the canal and ending into what looks like a nubbin of cord remnants does not diagnose absent testis. We have encountered one case in which the vas enters closed internal ring and a normal testis lying completely dissociated from the vas in the pelvis. This particular case would have been labeled as an atrophied testis, but for the diagnostic accuracy of laparoscopy. The explanation to these phenomena is related to the embryological development of the wollfian system separately from the testis with the gubernaculums attached to the epididymis rather than the testis.[11]

One stage LAO,[5],[6],[7],[8] was attempted in 47 case cases seven of which were high abdominal testes. The testicular vessels are first mobilized retro peritonealy and testes are brought down to the scrotal sac via a direct rout created by a 3 mm incision into the scrotum through which a forceps is introduced to grasp and transfer the testis into scrotum. We have achieved a good scrotal position in 63% of the cases, mid scrotal in 25% and high scrotal in 15%. The latter poor outcome was associated with testes lying high above the internal ring. For this reason, we now restrict our LAO the testes lying just above the internal ring. The key to successful outcome is to be able to bring the testis to the contra lateral internal ring with no tension. A second stage redo orchidopexy was attempted in 10 of the mid and seven high scrotal testes 6-8 months after initial laparoscopy and we managed to bring seven to a normal scrotal position. The overall good result was 34 out of 45 (75%) [Table - 1][Table - 2][Table - 3][Table - 4][Table - 5].

Laparoscopic second stage (FS)[12],[13],[14] orchidopexy was performed for high abdominal testes. In the first stage we used two clips on the testicular vessels about 3 cm from the testes (30 cases) and recently we used diathermy (4 cases). During the second stage, we sever the vessels and bring the testes with a wide mesentery through a direct route medial to the internal ring. We achieved good scrotal position in 22 cases (70%) and mid scrotal position in six (18%). We lost the testes in four (12%). Follow up between 6 months and 4 years showed that two of the mid-scrotal cases settled in a good scrotal positing, but atrophied testes were noted in three cases. Two cases are at present waiting for a second stage laparoscopic orchidopexy.

In eight of the abdominal cases the testes were found to be in sub renal position, in which the vas was seen looping in the upward direction and ending in none descended testes. The initial findings of the first case diagnosed was that of a leach of flimsy vessels entering an opened inguinal canal, which would have been labeled as an absent testis, but for the careful abdominal inspection showing the upward direction of the vas deferens.

We strongly recommend careful exploration of the abdomen tracing the vas and vessels before labeling impalpable testes as absent. Canlicular testes can be managed either by one stage (LAO) or open technique. We have used open orchidopexy in seven and LAO in 10. Testes were in mid-scrotal position in 2 of the 7 and 3 of the 10. We do recommend using the open technique in inguinal testes, as the results are comparable to the laparoscopic technique.

We prefer to wrap the testes in a Silastic sheath if we fail to bring it into a satisfactory position. This helps to identify the testis during the second exploration and helps to avoid injuring vital structures.

CONCLUSION

References

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