Laparoscopic Management of Cryptorchidism in Adults

European Urology European Urology 48 (2005) 453 457 Laparoscopy Laparoscopic Management of Cryptorchidism in Adults R. Kucheria, A. Sahai, T.A. Sami, B. Challacombe, H. Godbole, M.S. Khan, P. Dasgupta* Department of Robotics and Laparoscopic Urology, Guy s & St. Thomas Hospitals & GKT School of Medicine, London, UK Accepted 7 April 2005 Available online 25 April 2005 Abstract Objectives: Little is reported on the management of impalpable testis in adults. We present the impact of laparoscopy in this patient group. Patients and methods: Twelve adult patients have been referred to our centre over the last year, with impalpable testis. Pre-operative assessment was by either ultrasound or magnetic resonance imaging (MRI) or both. Quality of life and patient satisfaction were assessed by validated SF8 TM and client satisfaction (CSQ-8) questionnaires. Patients were also administered a self constructed questionnaire specifically looking at the impact of a laparoscopic service on their condition. Results: The mean age was 29 yrs (range: 19 36). Two patients declined treatment. Of ten patients undergoing transperitoneal laparoscopy, five had intra-abdominal testes treated by laparoscopic orchidectomy (none malignant), two had the vas going into the deep ring and needed inguinal orchidectomy for an impalpable nubbin while in three cases there were blind ending vessels and vas. SF8 scores for physical HRQoL were unchanged but mental scores were significantly improved (p < 0.03). All patients were completely satisfied with a mean CSQ-8 score of 30.6 out of a possible 32. The majority of patients indicated that the availability of a laparoscopic service had prompted them to seek medical advice. Conclusions: Laparoscopic examination and orchidectomy is a safe and reliable procedure. Excellent patient satisfaction and quality of life are achievable. In particular mental health scores improve as previous uncertainty is removed. The advent of laparoscopy has encouraged adult patients to seek advice regarding a condition that has been present since childhood. We advocate the use of laparoscopy in evaluating and treating adult patients with maldescended testes. # 2005 Elsevier B.V. All rights reserved. Keywords: Laparoscopy; Impalpable testis; Cryptorchidism; Health related quality of life; Patient satisfaction 1. Introduction With an incidence of 1% at one year of age, cryptorchidism is usually diagnosed and treated in early life [1]. Only a few cases escape early detection by the school health program and come to light in adulthood. With an increasing immigrant population from less developed countries there has been an associated rise in the number of cryptorchid adults. Though the increase * Corresponding author. Present address: Urology Department, 1st Floor, Thomas Guy House, Guy s Hospital, London Bridge, London, SE1 9RT, UK. Tel. +207 188 6788; Fax: +207 188 4675. E-mail address: prokarurol@aol.com (P. Dasgupta). in incidence of testis cancer has been well demonstrated the only evident risk factor is cryptorchidism [2]. Late detection can be a problem in countries with underdeveloped health programs [3]. Risks associated with cryptorchidism include trauma, torsion and development of malignancy [4]. An undescended testis may be palpable or impalpable. An impalpable testis may be intra-abdominal, atrophic or absent [5]. Ultrasonography and magnetic resonance imaging (MRI) are the non-invasive investigations used to evaluate these patients, however the literature suggests their sensitivity is limited (32 67%) [6]. Laparoscopy is both diagnostic and therapeutic with the main benefit of initiating treatment as soon as diagnosis is made. It is 0302-2838/$ see front matter # 2005 Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2005.04.008

454 R. Kucheria et al. / European Urology 48 (2005) 453 457 now regarded as the gold standard for the management of cryptorchidsm in children [7], but few reports address its role in the adult population. In this paper we report our experience of laparoscopy in the management of cryptorchidism in 12 adults. questionnaire assessed not only overall satisfaction but also patient attitudes towards informed consent using a procedure specific video and laparoscopic information leaflet. An independent member of staff separate from the laparoscopy team collected both the HRQoL and patient satisfaction data to minimise clinician bias. 2. Patients and methods Twelve adult males with impalpable testis were referred to our department over one year. Of these, 11 had unilateral and 1 bilateral undescended testes (one impalpable and the other in the groin). The mean age of the patients was 29 years (range 19 36 years). All patients were investigated for testicular tumour markers [a fetoprotein (AFP), b HCG & LDH] and underwent either an ultrasound scan of the abdomen, pelvis and inguinal regions or magnetic resonance imaging (MRI) of abdomen, pelvis and inguinal regions or both in addition to a plain chest radiograph. After the initial assessment, patients were counselled and informed consent was obtained for a laparoscopic procedure. Two of the twelve patients declined any form of surgery (both had unilateral maldescent). They are being monitored regularly by ultrasound. 2.1. Operative technique The patients were positioned supine in the Trendelenburg position. A pneumoperitoneum was created using the open Hasson technique. A 10 mm umbilical camera port and two additional ports were introduced one 10 mm port on the ipsilateral side fingerbreadth below the umbilical port in the mid clavicular line, the other a 5 mm port at a point corresponding to the McBurney s point on the contralateral side. After the first five operations we changed port positioning to have the camera at the umbilicus and the two working ports (10 mm, 5 mm) contralateral to the side of the maldescended testis. This seems to make the operating easier as the surgeon does not have to lean over the patient. The gonadal vessels and vas deferens were identified. The peritoneum above the vessels was then opened and the vas deferens dissected to locate the testis. Three outcomes were noted: (a) intra-abdominal testis, (b) blind ending vessels and vas and (c) the vas and vessels entering the deep inguinal ring (i.e. impalpable inguinal testicular nubbin) (Fig. 1a, b, and c). Intraabdominal testes were treated laparoscopically by orchidectomy. Patients who had vessels and vas going into the inguinal canal had open inguinal exploration and orchidectomy of an inguinal testicular nubbin. In two patients who appeared to have blind ended vas, an atrophied testis was located at the deep inguinal ring and excised. Only one patient had insertion of a testicular prosthesis as requested, although it was offered to all patients. Basic demographic data was collected on all patients. In addition operative time, intra-operative blood loss, post-operative analgesia requirements, length of hospital stay, time to full recovery and complications were recorded. 2.2. Health related quality of life (HRQoL) and Patient Satisfaction (PS) Quality of life of the patients was assessed by administration of the SF8 TM questionnaire [8], a validated health related quality of life questionnaire, pre-operatively and four weeks post procedure. The SF8 questionnaire has two components, physical (PCS8) and mental (MCS8). Patient satisfaction was assessed using the client satisfaction short form-8 (CSQ-8) questionnaire and a specific selfformulated questionnaire in the 4th post-operative week. This 3. Results Tumour markers (one AFP, one b HCG) were found to be raised in two out of twelve patients. The levels reverted to normal after laparoscopic orchidectomyneither had malignancy in the excised testis or any other abnormality to explain their abnormal blood tests. The imaging modalities included ultrasound which gave an accurate diagnosis in 3 out of 8 patients (37.5%) and MRI was accurate in 4 out of 6 patients (66.7%). Laparoscopy on the other hand was 100% accurate. One patient with bilateral maldescent (left inguinal, right absent testis) was also found to have micropenis, hypospadias, and azoospermia and was referred to the genetics department for karyotype analysis. He had biopsies taken from his inguinal testis for infertility diagnosis and showed absence of sperms and no evidence of intra tubular germ cell neoplasia. The cord and vessels were too short to allow sufficient mobilisation to bring the inguinal testis into the scrotum. The patient is on testosterone supplement. He and his partner are being counselled for artificial insemination by a donor. Of the ten patients who underwent transperitoneal laparoscopy, five had intra-abdominal testes and underwent orchidectomy, two had a testicular nubbin in the inguinal canal necessitating groin exploration and excision of the nubbin and in three there were blind ending vessels and vas which needed no further treatment. Histology did not show any carcinoma in situ or malignancy in any patient. The operative times were between 40 and 100 minutes (mean 60 minutes). Blood loss was less than 10 ml in all cases. The mean dose of morphine or equivalent administered post-operatively was 3.5 mg. The mean post-operative hospital stay was 1.5 days (range 1 2 days). The mean time to return to normal activity was 10.4 days (range 4 28 days). One patient had a minor complication in the form of superficial wound infection which delayed his full recovery to 28 days. Quality of life data assessed by SF8 HRQoL form pre-op and at 4 weeks post-op resulted in mean PCS8 of 54.35 and 54.48 (p < 0.45) respectively. Mean MCS8 pre- and post-operatively were 39.88 and 55.82 (p < 0.03) respectively. Mean CSQ-8 score was 30.6 (of a possible maximum score of 32) assessed at 4 weeks post-operatively. 83.3%

R. Kucheria et al. / European Urology 48 (2005) 453 457 455 Fig. 1. of patients read the laparoscopic information leaflet given to them before the operation and 80% of patients understood the material. 50% of patients thought we should offer patients the choice of watching a preoperative video of the procedure, whilst 50% declined on grounds of increasing anxiety. 66.7% of patients wished to take home a copy of their own operative video. 4. Discussion Abdominal cryptorchidism if left untreated beyond the age of 11 years of age carries a 32 times higher risk of malignancy [9] as well as an increased risk of torsion. In addition spermatogenesis is virtually absent. As a result this warrants an aggressive diagnostic and therapeutic approach [4,10]. There has been a significant shift in attitude towards managing adult cryptorchidsm. Based on an analysis of a database of 34,135 orchiectomies and incorporating age, ASA (American Society of Anaesthesia) score, specific mortality data, as well as the relative risk of death from germ cell tumour, Farrer et al. recommended limiting surgical intervention to patients aged 32 years or younger [11]. Motivated by advances in combination chemotherapy, Oh et al. analysed data on germ cell mortality and peri-operative mortality of orchidectomy in the United States from the National Centre for Health Statistics. They concluded that the anaesthetic and operative risk of surgery for an intra-abdominal testis

456 R. Kucheria et al. / European Urology 48 (2005) 453 457 in a healthy adult population up to the age of 50 years is so negligible, that such a procedure should be offered to this group, and may be considered in healthy patients in ASA class I, up to the age of 60 years [10]. Traditionally patients presenting with cryptorchidism required either a groin exploration or laparotomy with associated morbidity, increased post-operative analgesia requirements, significantly long convalescence and chronically painful and disfiguring scars. Our results with laparoscopy clearly show a minimal use of analgesia, a short hospital stay and notable patient satisfaction. Laparoscopy has been shown to be very effective in diagnosing and treating maldescended testes with little morbidity. Therapeutic options depend upon the position of the testes and whether it is unilateral or bilateral. Unilateral maldescended testis, in adults with normal contralateral testis, diagnosed at the time of laparoscopy can be treated with orchidectomy. No patient in our series had his single testis removed. For bilateral intraabdominal testes one can mobilise at least one testis to the scrotum and perform an orchidopexy either as a one stage or two stage Fowler Stephens procedure. In single stage orchidopexy the testis can be mobilised into the scrotum sometimes by using a 5 mm scrotal port. It may be ideal to biopsy this testis to rule out intratubular germ cell tumour. In our series there were no patients with bilateral intra-abdominal testes however, one had bilateral maldescent whose left testis was inguinal and right absent on laparoscopy. A Fowler Stephens procedure was obviously not applicable in his case. Mobilisation of the inguinal testis proved difficult due to very short vessels and cord. Biopsies were taken from the testis and intratubular germ cell tumour was ruled out. Although there have been significant advances in imaging modalities, the last decade has seen the inclusion of laparoscopy, not only as a useful diagnostic tool but also providing the patient a therapeutic option at the same time. Thus laparoscopy is a rapid, minimally invasive option with little morbidity that challenges the role of imaging and open surgery in cryptorchidism. In our experience, laparoscopy was better than MRI and ultrasound for confirming the diagnosis and had the added advantage of executing orchidectomy when a testis was discovered. In their series Agarwal et al, could localise 7 of 19 undescended testes pre-operatively using ultrasonography. However amongst these 7, subsequent laparoscopy showed erroneous findings in 3 cases [13]. Basekim et al found a sensitivity of only 65% with pre-operative ultrasound in unilateral undescended testes and 83% sensitivity with bilateral undescended testes [14]. They once again reiterate the superiority of laparoscopy over ultrasonography in diagnosis of the undescended testis. Laparoscopy has the advantage of viewing intracorporeally and with magnification whereby it may detect testis when not seen on an ultrasound or even an MRI scan. It also allows a detailed search of the absent testis all along its path of embryological descent by inspecting the retroperitoneum. Increasing experience in children has questioned the need for any imaging and most recent literature would support laparoscopy as the definitive method of diagnosis thus removing the need for expensive imaging in children and adults [12]. 5. Conclusion Laparoscopy with or without orchidectomy is a safe and reliable procedure in adult impalpable testis. It is associated with minimal blood loss, short hospital stay, reduced analgesic requirement and high patient satisfaction. Laparoscopy not only provides an accurate diagnosis but also allows definitive treatment. The HRQoL data indicates significant improvement in mental heath as the anxiety of a missing organ and potential malignancy is removed in one procedure with little morbidity. Based on the current literature and our own results we wish to recommend laparoscopic evaluation and treatment as the gold standard for maldescended testis in the adult population. We also recommend that a database should be set up for reporting laparoscopic orchidectomies for generating further research and evaluating results. Acknowledgements The authors thank Abhay Rane, Geoff Koffman and the Charitable Foundation of Guy s and St. Thomas. Health related Quality of Life questionnaire: SF8 TM. License no. F1-121304-20845. References [1] Berkowitz GS, Lapinski RH, Dolgin SE, et al. Prevalence and natural history of cryptorchidism. Paediatrics 1993;92:44 9. [2] Hughye E, Matsuda T, Thonneau P. Increasing incidence of testicular cancer worldwide: a review. J Urol 2003;170:5 11.

R. Kucheria et al. / European Urology 48 (2005) 453 457 457 [3] Raina V, Shukla NK, Gupta NP, et al. Germ cell tumours in uncorrected cryptorchid testis at Institute Rotary Cancer Hospital, New Delhi. Br J Cancer 1995;71:380 2. [4] Rogers E, Teahan S, Gallagher H, et al. The role of orchiectomy in the management of postpubertal cryptorchidism. J Urol 1998;159:851 4. [5] Kaplan GW. Nomenclature of cryptorchidism. Eur J Pediatr 1993;152(Suppl 2):S17 9. [6] Maghnie M, Vanzulli A, Paesano P, et al. The accuracy of magnetic resonance imaging and ultrasonography compared with surgical findings in the localisation of the undescended testis. Arch Paediatr Adolesc Med 1994;148:699 703. [7] Peters CA. Laparoscopy in paediatric urology. Curr Opin Urol 2004;14:67 73. [8] The Medical Outcomes Trust (MOT), Health Assessment Lab (HAL) and QualityMetric Incorporated, co-copyright holders of all SF-36 1, SF-12 1 and SF-8 TM Health Surveys. [9] Herrinton LJ, Zhao W, Husson G. Management of cryptorchidism and risk of testicular cancer. Am J Epidemiol 2003;157:602 5. [10] Farrer JF, Walker AH, Rajfer J. Management of the postpubertal cryptorchid testis: a statistical review. J Urol 1985;134:1071. [11] Oh J, Landman J, Evers A, Yan Y, Kibel AS. Management of the postpubertal patient with cryptorchidism: an updated analysis. J Urol 2002;167:1329 33. [12] Jordan GH. Laparoscopic management of the undescended testicle. Urologic Clinics of North America 2001;28(1):23 9, vii viii. [13] Vijjan VK, Malik VK, Agarwal PN. The role of laparoscopy in the localization and management of adult impalpable testes. JSLS 2004;8:43 6. [14] Pekkafali MZ, Sahin C, Basekim CC. Comparison of ultrasonographic and laparoscopic findings in adult nonpalpable testes cases. Eur Urol 2003;44:124 7. Editorial Comment Craig A. Peters, Boston, MA, USA craig.peters@childrens.harvard.edu This report presents an argument for the utility of diagnostic laparoscopy in adults and there is clearly a role for this modality. Laparoscopy has been well established in pediatric applications to be the ideal means of diagnostic evaluation for a non-palpable testis. The integration with surgical management of the testes can be argued, in that any testis may be brought into the scrotum, albeit occasionally with a Fowler-Stephens staged orchiopexy (even inguinal testes). Laparoscopic surgical management is also an option, as used for orchiectomy in this series, and would seem to be preferable to open surgery. The assessment of QOL associated with these patients and their laparoscopic experience is an interesting method to evaluate a surgical procedure. Yet, without a control group can only serve to encourage the use of these tools in later studies of the impact of our surgical manipulations of patients. These data in no way can be perceived to prove that this is better than open surgery. None-the-less, diagnostic laparoscopy is well suited for the adult with a non-palpable testis, just as it is with children.