Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 48, Num. 1, 2002, pp. 25-26

Journal of Postgraduate Medicine, Vol. 48, Issue 1, 2002 pp. 25-26

Laparoscopic Orchidectomy for Undescended Testis in Adults

Desai CS, Prabhu RY, Supe AN

Department of Surgery, Seth G. S. Medical College and K. E. M. Hospital, Parel, Mumbai - 400 012, India.
Address for Correspondence: A. N. Supe, MS, Dept. of Surgery, Seth G.S. Medical College and K.E.M. Hospital, Parel, Mumbai - 400 012, India. E-mail: avisupe@vsnl.com

Code Number: jp02006

Abstract:

BACKGROUND: Impalpable testis is a significant diagnostic and therapeutic challenge in adults, for both radiologist and surgeons, with few reports in literature addressing this problem in adults. Laparoscopy is a reliable and definitive procedure obviating the necessity of advance investigation and subsequent inguinal exploration in adults. AIMS: To study the utility of laparoscopy as combined diagnostic and therapeutic modality for undescended testis in adults. SETTINGS AND DESIGN: Prospective study from a single surgical unit of a large tertiary referral centre during August 2000 to January 2002. METHODS AND MATERIAL: Nine patients of unilateral undescended testis with average age 22.7 years (range 13-31 years) underwent diagnostic laparoscopy and orchidectomy subsequent to detailed clinical, ultrasound and examination under anaesthesia (EUA) procedure. All patients were operated with one 10 mm umbilical camera port, one suprapubic port and 1 lateral port. RESULTS: None of the patients had palpable testis or an inguinal cough impulse on clinical examination and during EUA. In only 3 (33.3%) patients, the ultrasound could locate the testis situated at the deep ring. On laparoscopy all testes were identified, 4 were present at the deep ring, 3 were intra-abdominal and 2 had blind ending vas entering the deep ring. Mesh plug was inserted in the internal ring in these 2 patients, after dissecting the peritoneum. None of the patients had intra or post-operative complications and all were discharged on the next day. CONCLUSION: Laparoscopy is one of the most satisfactory methods for the diagnosis and management of non-palpable testis in adult cryptorchid patients. (J Postgrad Med 2002; 48:25-26)

Key Words: Laparoscopy, Undescended testis, Cryptorchidism.

Impalpable testis is a significant diagnostic and therapeutic challenge in adults for both radiologists and surgeons. There are many reports in literature addressing such problem in paediatric age group,^1-4 but few for adult patients.^5-8 The higher success rate of laparoscopic orchidopexy over the open procedure in paediatric age group has been firmly established in recent large multi-institutional analysis and has become the modality of choice for cryptorchid children.⁹ Due to well developed musculature with subsequent clinical difficulty in localizing testis and due to higher chances of malignancy in testis of undescended nature in adults, frequently multiple pre-operative investigations are advised to these patients. We studied the utility of laparoscopy in adult patients presenting to a large tertiary centre as a single combined modality for diagnosis and management.

Patients and Methods

Nine adult patients with an average age of 22.7 years (range 13-31) presenting with undescended testis during the period August 2000 to January 2002, to a single large tertiary referral centre were prospectively studied. Clinical examination for any palpable testis in scrotum, inguinal canal or at the site of the deep ring was done. Patients were also evaluated by real time ultrasonography of abdomen and inguinal canal to locate missing testis.

Under general anaesthesia, palpation of inguinal canal and abdomen was done. Patients were kept in supine position, with arm opposite to the side of undescended testis fully adducted where the surgeon and camera assistant were standing. Pneumoperitoneum was established by Veeres needle and 10-mm cannula and laparoscope was inserted immediately below umbilicus. Position of testis and it's size were noted. Two more operating ports were inserted, one of 5-mm size in corresponding iliac fossa and other suprapubically. In cases of visible atrophied testis suprapubic port was of 10-mm and in those, where testis couldn't be seen and only vas was visualised entering the inguinal canal, 5-mm port was inserted. The testis was than mobilised and gonadal vessels were dissected and clipped and than vas was clipped and divided and testis was removed from 10-mm port. In those cases of blind ending vas entering the internal ring, where peritoneum over deep ring was opened, mesh plug was inserted in the deep ring and peritoneum was closed with clips. All testes were sent for histopathological examination. Position of testis, average size of testis, complication of procedure and stay in hospital were evaluated.

Results

All patients had unilateral undescended testis with normally descended opposite testis. None of these could be palpated during clinical examination and during examination under anaesthesia. None of them had impulse on cough. In only 3 (33.3%) patients testis could be localised at the deep ring by real time ultrasonography. On laparoscopy 4 (44.4%) had testis at the deep ring, 3 (33.3%) had high intra-abdominal testis and 2 (22.2%) had blind ending vas entering deep ring. All were subjected to orchidectomy. Average size of testis was 1.5 cm (range 1-1.8 cm). Average operative time was 55 minutes (range 45-80 minutes). Histopathology of all these testes showed uniform atrophy of seminiferous tubules. None had evidence of malignancy. There was no intra-operative complications, no major blood loss during surgery. Mesh plug was needed to be inserted in 2 patients of blind ending vas. All patients were discharged on next day. None developed inguinal hernia on follow up.

Discussion

Impalpable testis is a significant problem in paediatric age group with well-established role of laparoscopic orchidopexy in its management.^1-4,9 Clinically it is often possible to locate missing testis in children, whereas these testes are always difficult to be located due to well developed musculature in adult patients and atrophy of testis. None of them could be located in present series. Ultrasonography could locate them in only 3 patients. Sexton et al reported 8 of 14 (57.1%) patients could be located by combined clinical and ultrasonographic examination.⁶ Recently the application of magnetic resonance imaging for the preoperative localisation of non-palpable testis in obese children as an alternative to laparoscopy has been discussed,¹⁰ but considering most of the adult patients will require orchidectomy, which is feasible laparoscopically, this investigation is not cost-effective. Also yield of MRI in this report was only 37.2%.¹⁰

In majority of adult patients cryptorchid testis is intra-abdominal either at the deep ring or high intra-abdominally. Seven of nine (77.7%) patients had such location in present group. Lojanapiwat et al also reported intra-abdominal testis in 95% of adult patients.⁴ Large percentage of this position further emphasis the need of laparoscopy obviating the need of unnecessary inguinal exploration and disrupting normal inguinal canal mechanism. Orchidectomies were done in all cases in view or age of patients and atrophy of testis. Dean et al had suggested that if attenuated testicular vessels are noted entering inguinal canal,¹¹ then inguinal exploration is indicated and Sexton et al also did this.⁶ However, in cases of blind ending vas, when there is no inguinal hernia, laparoscopy can be safely used with the deep ring occluding mesh plug as done in present series.

There was no major intraoperative or post-operative complication. Most of the reports in literature are also without any complications. Merguerian et al reported 3 cases (3.2%) of complications of which one was major bowel injury.² All our patients were discharged on next post-operative day.

Conclusion

Laparoscopy remains the modality of choice in the diagnosis and surgical management of adult cryptorchidism. Its minimal invasiveness combined with excellent imaging obviates the need for costly investigations like MRI and CT scan and prevents unnecessary inguinal exploration and laparotomy.

References

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