Laparoscopy in the Management of Impalpable Testicle

Acta chir belg, 2005, 105, 662-666 Laparoscopy in the Management of Impalpable Testicle N. Satar, Y. Bayazıt, Ş. Doran Çukurova University, Faculty of Medicine, Department of Urology, Balcalı Hospital, Adana, Turkey. Key words. Cryptorchidy ; laparoscopy ; orchiopexy ; orchiectomy. Abstract. Purpose : In paediatric urology, one of the main applications of laparoscopy is the evaluation and treatment of impalpable testis. Herein we present our initial experience with laparoscopy in patients with impalpable testis. Material and Methods : Laparoscopy was performed under general anaesthesia on 13 patients. If the internal spermatic vessels and vas deferens made their way into the internal inguinal ring, the inguinal canal was dissected. Laparoscopic orchiopexy or orchiectomy was performed in cases with intra-abdominal testis. If the internal spermatic vessels found terminated intraperitoneally with a blind-end, the case was considered as a vanishing testis. Results : Thirteen boys, aged from 18 months to 25 years (median 9.8 years) were identified with 21 impalpable testes. 14 of the 21 impalpable testes, the vas and the vessels were through the internal ring, and the inguinal region needed dissection. Orchiopexy was performed on 12 testes and orchiectomy was performed on two atrophic testes. Four of 21 testes were intra-abdominally localized. Laparoscopic orchiopexy was performed in two testes and laparoscopic orchiectomy was performed in two testes. Two boys were diagnosed as vanishing testes ; the absence was unilateral on the left side in one case and bilateral in the other. Conclusion : Diagnostic laparoscopy is a very helpful, minimally invasive technique in the diagnosis of impalpable testes especially when ultrasonography and/or computed tomography are not informative enough. In addition, orchiectomy and orchiopexy can be done as laparoscopically in the patients with intra-abdominal testes. Therefore, the laparoscopy has an important role in the diagnosis and treatment of impalpable testes. Introduction Isolated cryptorchidism is one of the most frequent congenital anomalies of the male genital system (1). The testes arise in the abdominal cavity in the eighth week of intrauterine life. In the last month of the third trimester, they descend through the inguinal canal and in the 38 th week they descend to the scrotum. The rate of undescended testis varies from 9.2% to 30% in premature babies and from 3.4% to 5.8% in the babies born at term (2). Descent of the testes may continue till the ninth month of life. The rate of undescended testis in one yearold babies is about 1% and the rate remains unchanged until puberty (1). The testis cannot be palpated in approximately 20% of all cases of undescended testis. Most of the impalpable testes are intra-abdominal although an impalpable testis does not exclude an intracanalicular or absent testis. Thirty percent of impalpable testes are atrophic and 20% of them are absent (1). Ultrasonography (USG) and computerized tomography (CT) mostly fail to show impalpable testes. Before the advent of laparoscopy, surgical exploration was often used to show the testes. In the past 25 years, a laparoscopic technique, reported by CORTESI, has been widely used in the diagnosis of undescended testis (3). With the advent of improved laparoscopic techniques, therapeutic laparoscopy has started to become a viable option in the treatment of impalpable testis (4, 5). We evaluated thirteen patient with undescended testis in which we performed laparoscopy. Materials and methods We performed laparoscopy on 21 impalpable testes in thirteen cases. The problem was bilateral in eight cases and unilateral in five cases. We tried to palpate undescended testes both in supine and frog-legs positions ; and in the older children either in the supine or standing positions. Being cost-effective and non-invasive, abdominopelvic ultrasonography (USG) was preferred for initial evaluations. Computerized tomography (CT) in six cases and magnetic resonance imaging (MRI) in one case were performed due to inconclusive USG results. Laparoscopy was based on the findings of USG, CT and MRI (Fig. 1). A clear diet was started on the day before surgery and a fasting of 4-8 hours according to their age was applied before laparoscopy. A single dose of cefazolin sodium 40 mg/kg was given by IM route for prophylaxis. Before laparoscopy, physical examination was repeated under general anaesthesia in order to palpate

Laparoscopy of Impalpable Testicle 663 Impalpable Testis USG (CT or MRI) Laparoscopy Intra-abdominal Intra-abdominal Vas and vessels Blind-ending vessels testis entering the internal ring No further Laparoscopic Laparoscopic Inguinal investigation orchiectomy orchiopexy exploration (vanishing testis) Fig. 1 Surgical algorithm in the impalpable testis the testes. A urethral catheter was inserted into the bladder and the patients were placed in Trendelenburg position for laparoscopy. A U-shaped incision of 1 cm length was made just below the umbilicus. A Veress needle was inserted into the abdomen and CO 2 was insufflated to achieve pneumoperitoneum at a pressure of 20 mm Hg. The anterior wall of the abdomen was pulled upwards and then a 10 mm trocar was inserted into the abdominal cavity. The pressure of pneumoperitoneum decreased to 15 mm Hg. A zero degree 10 mm laparoscope was inserted and the abdominal organs were inspected. Median (urachus), medial (obliterated umbilical artery) and lateral (inferior epigastric artery) umbilical ligaments, vas deferens, external iliac vessels and the opening of inguinal canal were determined. In laparoscopy of unilateral impalpable testis, firstly vas deferens and spermatic vessels on the unaffected side were examined. When internal inguinal ring was not seen, the normal testis was tracted downwards externally to facilitate visualizing the inner side of the inguinal ring. When a testis was detected in the abdomen during diagnostic laparoscopy, the localization and volume of the testis, paratesticular anomalies, lengths of vas deferens and spermatic vessels and presence of inguinal hernia were determined. When there was an atrophied testis or gonadal remains at the end of vas deferens and spermatic vessels, laparoscopic orchiectomy was preferred. At the side of undescended testis, vas deferens and spermatic vessels and the testis (if present) were visualized. In order to find the possible intra-abdominal testis, vas deferens and spermatic vessels were traced till the internal inguinal ring. Descent of vas deferens and spermatic vessels through the internal ring excluded the diagnosis of intra-abdominal testis. In such cases, laparoscopy was terminated and inguinal canal was opened and the testes were explored. Blind-ended vas deferens and spermatic vessels were considered as vanishing testis. When the testes were in the abdomen, their size, appearance and mobility ; the distance between the testes and the inguinal canal ; the length of spermatic vessels and vas deferens were assessed to proceed with either orchiectomy or orchiopexy. Following diagnostic laparoscopy, CO 2 was emptied and the fascia and the skin were closed with an absorbable suture. In two cases of bilateral intra-abdominal testes, an additional 10 mm trocar was inserted just below the costal margin on the midclavicular line. On the opposite side, a 5 mm trocar was inserted on the midclavicular line below the level of umbilicus. For orchiectomy, the testis was freed from the surrounding tissues. Vas deferens and spermatic vessels were clipped and cut with laparoscopic scissors. For laparoscopic orchiopexy, a 5 mm trocar was inserted through the scrotum to pull down the testis. The operation was performed as described by DOCIMO and PETERS (6). Results Laparoscopy was performed for 21 impalpable testes in 13 patients. The patients were between 18 months and 25 years old with a mean age of 9.8 years. Nine patients were in the prepubertal stage and four patients were in the postpubertal stage (Table I). In fourteen impalpable testes (66.6%), vas deferens and spermatic vessels were through the internal inguinal ring and in all these cases, inguinal region was explored. Following a surgical exploration, orchiopexy was performed in twelve testes (57.1%), and orchiectomy in two testes (9.5%), in which the testes were extremely atrophied (Table II). Inguinal hernia repair was performed besides orchiopexy in two cases (15.4%).

664 N. Satar et al. Table I Age distribution of the patients with impalpable testes Age Patient Number (%) 0-2 2 15.38 3-5 3 23.07 6-9 2 15.38 10-14 3 23.07 > 14 3 23.07 Total 13 100 One of the two patients found to have bilateral intraabdominal testes was 25 years old and refused orchiectomy. Then, a biopsy and bilateral laparoscopic orchiopexy were performed according to his will. The other patient was 14 years old and had atrophied testes with very short vas deferenses and spermatic vessels. He underwent laparoscopic orchiectomy. Vas deferenses and spermatic vessels could not be visualized in one case of bilateral impalpable testes and two 5 mm trocars were inserted to search the testes up to the level of kidneys. Bilateral blind-ending spermatic vessels were found and the case was considered as bilateral vanishing testis. Another boy with unilateral impalpable testis was also diagnosed as vanishing testis. The mean operation time was 20 min. (15-30 min.) for diagnostic laparoscopy, 180 min. for laparoscopic orchiopexy and 120 min. for laparoscopic orchiectomy. In one case, subcutaneous emphysema occurred due to improper placement of Veress needle. All patients who underwent diagnostic laparoscopy were discharged from the hospital within six hours after the operation. The patients who underwent laparoscopic orchiopexy or orchiectomy were discharged within 24 hours. None of the patients had late postoperative complications (Table III). Discussion Laparoscopy was first used by CORTESI to diagnose impalpable undescended testes in 1976 and later Lowe reported a large series of diagnostic laparoscopy in cases of impalpable testes (3, 7). Only after 1990, laparoscopy was used for the treatment of impalpable testes as the urologists gained experience with the method and since then laparoscopic orchiopexy and orchiectomy have been increasingly used (8, 9). A complementary human chorionic gonadotropine (hcg) stimulation test may be performed in impalpable testes patients. It is possible to detect whether there is functioning testicular tissue present or not by measuring Table II Procedures and clinical outcomes in the impalpable testis Diagnostic Laparoscopic Laparoscopic Inguinal Inguinal Intra-abdominally laparoscopy orchiopexy orchiectomy orchiopexy orchiectomy absent testis N (%) N (%) N (%) N (%) N (%) N (%) Intra-abdominal Testis 4 (19) 2 (9.5) 2 (9.5) Vas and vessels entering the internal ring 14 (66.6) 12 (57) 2 (9.5) Intra-abdominal blind ending vessels 3 (14.3) 3 (14.3) Total 21 (100) 2 (9.5) 2 (9.5) 12 (57) 2 (9.5) 3 (14.3) Table III Surgery time, hospitalization time and complications of the operations Mean Operation time Hospitalization time Complications (minutes) (hours) Peroperative Postoperative Diagnostic laparoscopy 20 6 1 (subcutaneous emphysema) Laparoscopic orchiopexy* 180 24 Laparoscopic orchiectomy 120 24 Inguinal orchiopexy 60 24 Inguinal orchiectomy 45 24 * : Bilateral.

Laparoscopy of Impalpable Testicle 665 serum testosterone levels (10). On the other hand, the negative result of this test does not necessarily indicate the anatomical absence of a testicle. We think that, regardless of the results of this test, laparoscopic exploration is an extremely important step in the diagnosis and treatment of the patients with impalpable testes. In the literature, it was reported that the accuracy rate of laparoscopy in determination of the location of the testes was more than 95% (11, 12). Laparoscopy helps to localize testes and guide the operation and can be used safely in all age groups. Blind-ending spermatic vessels obviate other investigational techniques and can be considered absence of testes. Absence of testes is usually due to prenatal or perinatal torsion. When spermatic vessels are through the internal inguinal ring, it is obligatory to assess the inguinal canal. These vessels may extend to a testis, which can be small, and the testis may contain remains of seminiferous tubules, which must be removed. During an inguinal exploration, we found that two of 14 undescended testes (14,3%) were extremely atrophied. These patients underwent orchiectomy. MOORE et al. performed diagnostic laparoscopy in 96 patients with 117 impalpable testes and found intraabdominal testis and vanishing intra-abdominal testis in 24% and 7% of the patients respectively. There were descended vas deferens and spermatic vessels through the internal ring in 66% of the patients, but there were not vas deferens and spermatic vessels in 3% of the patients. They reported that all patients underwent exploration through a high inguinal or Pfannenstiel s incision and 31.6%, 30.7% and 1.7% of the cases in which vas deferens and spermatic vessels descended through the internal ring had canalicular vanishing testis, canalicular testis and ectopic testis respectively. They also noted that 1.7% of the cases in which intraabdominal vas deferens and spermatic vessels were not found on laparoscopy turned out to have testes on exploration (13). Two of our cases had bilateral intraabdominal testes. One of them underwent laparoscopic orchiopexy and the other bilateral laparoscopic orchiectomy since the bilateral testes were atrophied and the pedicles were very short. Diagnostic laparoscopy rarely causes complications in cases of impalpable testis. The anterior wall of the abdomen is thinner in children than in adults and therefore laparoscopy may have a higher risk of complications in children. When an appropriate Veress needle is not used, the vessels and the intestines may be damaged during peritoneal insufflations or during the insertion of the needle, though the complication rarely occurs. We did not observe any organ damage. However, there was preperitoneal CO 2 leakage in one case, and when we recognized the leakage, we changed the direction of the needle and formed an appropriate pneumoperitoneum. In order to prevent the complications, trocars can be placed with the open method described by HASSON (14). This method is safer in patients with abdominal surgery history. We did not prefer Hasson s technique in cases without an abdominal scar, as the risk of complications is low. Undescended testes in adults should be treated with orchiectomy. When bilateral undescended testes are treated with orchiectomy, testosterone supplements should be given and prosthesis of testes should be placed to avoid negative effects of an empty scrotum on the patient. A bilateral orchiopexy was performed in a 25 year-old patient after obtaining biopsy from the testes. The patient was informed about the risk of testis cancer, and he has been followed regularly since the operation. Laparoscopy makes it possible to avoid unnecessary surgical interventions in the cases of impalpable undescended testis and helps localize the testes, determine paratesticular pathologies, select an appropriate surgical procedure and perform orchiopexy safely. In fact, unnecessary surgical operations can be avoided in 42% of the cases (15). Although the mean operation time is usually longer in laparoscopy compared to open operations, with experience the duration can be shortened. Laparoscopy is an important alternative in the diagnosis and treatment of impalpable testes because it has the advantages of an acceptable rate of complication, less severe postoperative pain, smaller scar, shorter hospital stay and early return to daily activities. References 1. SCHNECK F. X., BELLINGER M. F. Abnormalities of the testes and scrotum and their surgical management. In : Campbell s Urology. WALSH P. C., RETIK A. B., VAUGHAN E. D., WEIN A. J. 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