|Year : 2000 | Volume
| Issue : 1 | Page : 13-15
Role of laparoscopy in the management of impalpable testis
SK Chowdhary, RK Chaudhury, PP Singh, Y Paljor, SC Joseph
Department of Paediatric Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh and St. Stephens Hospital, Delhi, India
S K Chowdhary
Assistant Professor in Pediatric Surgery, Advanced Pediatric Centre, PGIMER, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: A study to evaluate the safety and efficacy of laparoscopy using conventional laparoscopy equipment in children presenting with impalpable testis.
Patients and Methods: Prospective study to include all boys referred with impalpable testis between 2 yrs-12 yrs. Examination under sedation (Chloral hydrate 50-75 mg/ kg oral) by a consultant pediatric surgeon. Period of study included all consecutive boys referred between October 97-October 98. A database was created to enter clinical details, imaging studies, laparoscopic findings, surgery and outcome.
Results: 13 consecutive boys included in the study with 15 impalpable testes. 2 testes could not be located on laparoscopy. 6 testes were located on laparoscopy, 4 near the internal ring and 1 each at the bifurcation of iliac vessels and paravesical region. All 6 underwentfirst-stage Fowler Stephens orchidopexy followed by second-stage in 5 of them. The other 7 underwent conventional orchidopexy for canalicular testes.
Conclusions: Laparoscopy is a safe and effective method of evaluating and treating a child with impalpable testis. Conventional adult equipment used in trained hands is safe for use in normal children older than 2 years.
Keywords: Laparoscopy; Impalpable Testis.
|How to cite this article:|
Chowdhary S K, Chaudhury R K, Singh P P, Paljor Y, Joseph S C. Role of laparoscopy in the management of impalpable testis. Indian J Urol 2000;17:13-5
|How to cite this URL:|
Chowdhary S K, Chaudhury R K, Singh P P, Paljor Y, Joseph S C. Role of laparoscopy in the management of impalpable testis. Indian J Urol [serial online] 2000 [cited 2019 May 22];17:13-5. Available from: http://www.indianjurol.com/text.asp?2000/17/1/13/41005
| Introduction|| |
Up to 30% premature babies are born with undescended testes and around 4% boys delivered at term have an empty scrotum. At the end of 1 year, 75% of these testes have descended.  In cases where the scrotum remains empty at the end of 1 year, testes may either be palpable or impalpable-Clinical evaluation of an impalpable testes remains controversial and inaccurate.  Laparoscopy is appearing as the single most reliable technique to investigate this problem. There is as yet no published data on the use of laparoscopic technique for impalpable testes from our country. Literature on results of orchidopexy have been reviewed and found to be accurate and complete in description only in a minority of cases. ,
| Patients and Methods|| |
All children coming to our Hospital with undescended testes between October 1997-October 1999 where examined and referred for evaluation by the pediatric surgeon. In the pediatric surgery OPD, all such children were administered Chloral hydrate (50 mg/kg-75 mg/kg) orally ˝ hour prior to examination. If the testis could not be palpated the boys were offered laparoscopy as the first mode of investigation.
After induction with general anaesthesia, nasogastric tube was inserted and bladder was emptied with a catheter. A supraumbilical transperitoneal port was made for 10 mm reusable trocar. A purse string suture was used including all layers of anterior abdominal wall. The trocar was introduced by the open technique and stabilised with the purse string suture. The gas insufflator was used to inflate the peritoneal cavity up to 8-10 mm Hg. A 10 mm telescope was then used for visualisation of the internal ring by using the lateral ligament as guide. If necessary a second trocar (5 mm) was inserted under visualisation for mobilising the bowel or using the clip applicator. Those who underwent first stage of Fowler Stephens Orchidopexy, underwent the second-stage open surgery 6 weeks later. The clinical details and postoperative outcome were recorded on a clinical database.
| Results|| |
Fifteen children were thought to have impalpable testes and referred to the pediatric surgery outpatient. After examination under sedation, 2 testes were palpable in 2 children and thus excluded from the study. In 13 other children there were 15 impalpable testes. After anaesthesia, in none of them definite testes could be palpated. 2 children had bilaterally impalpable testes. The age range varied between 2-11 years with a mean age of 4-5 years. In 2 children the vas and vessels both were ending at the internal ring. No further exploration was done in them, as the finding was confirmatory of absent testis. In 1 further boy, only the vas was found to be entering the internal ring; inguinal exploration revealed an atrophic testis. 6 testes were intra-abdominal; 4 near the internal ring without a mesorchium, 1 paravesical and 1 at the bifurcation of iliac vessels. While locating the other 6 testes, vas and vessels were seen leaving the inguinal canal. Conventional orchidopexy was used to bring these canalicular testes down. One canalicular testis was atrophic and had to be removed. In the 6 intra-abdominal testes, clipping of gonadal vessels were done in 5. In the remaining case diathermy was used. 6 weeks later these boys underwent second-stage Fowler Stephens orchidopexy, excepting 1 who failed to follow-up. One of these testes underwent an ischaemic atrophy at 3 months. The other 4 testes are palpable without any appreciable change at 3 months-12 months follow-up. No complication was noted in any boy during or after the procedures.
| Discussion|| |
The management of impalpable testis entails a clinical examination in a co-operative child or under sedation for confirming the diagnosis. Subsequently, most clinicians do some investigation to locate the testis. Ultrasonography, CT Scan and MRI are able to locate the testis in only 76% cases.  Among our 13 children 100% of them came with some imaging done outside. A few surgeons have elected to explore the groin primarily in such a situation. Their argument is that in at least 50% cases the impalpable testes are present in the inguinal canal.  This has been the observation in our study too. However the problem arises when the canal is empty. One is often led into a frustrating attempt at retroperitoneal dissection. Secondly, if the testis was not in a position to bring down by cord mobilisation technique, the chance to use collateral blood to the testis along the vas is already lost. In 2 of our children, laparoscopic findings helped in preventing a laparotomy and retroperitoneal dissection for an absent testis. However in those children where laparoscopy confirmed that vas and vessels were entering the internal ring and testes were located in the inguinal canal, laparoscopy may be argued as unnecessary intervention.
The clinical evaluation of an impalpable testis is dependant on the clinician, co-operation of the child and the size of testis. In a study, physical examination of children with undescended testes demonstrated an accuracy of 53% for the physician and 83% for the paediatric urologist. In the same study CT and MRI were only accurate in less than 33%.  The child is ideally examined in a relaxed atmosphere and sedation may be a better technique. The final test is examining the testis under anaesthesia before proceeding for any operative procedure. We did not find any difference in our findings in a child examined under sedation in the sedation versus examination under anaesthesia.
Laparoscopy for the impalpable testis was an extension of the preliminary work by Duckett of primary ligation of spermatic vessels and the use of vasal collaterals for orchidopexy.  Ransley reported favourable experience with this approach in 1984.  Laparoscopic technique was reported for this problem by Bloom et al in 1988.  Paediatric laparoscopy in India lagged behind, among other reasons, because of the limited role of laparoscopy in children and the expensive paediatric instrumentation.
Jordan et al reported the use of 10 mm telescope in children older than 5 years.  We have used the 10 mm trocar by an open technique, 10 mm telescope 0 degree, and 5 mm clip applicator on a 5 mm disposable port without any problem. Authors are aware that paediatric range of laparoscopic equipment is available. However, in our charitable institution cost constraint in optimum health care delivery encouraged us to use the most versatile and rugged telescope. The authors have had previous training and experience in laparoscopic surgery. We believe that the use of standard equipment will keep the cost of procedure low and is safe in experienced hands.
In 65 patients who underwent laparoscopy, 16 patients were found to have 17 intra-abdominal testes.  In another study of 44 non-palpable testes 36 were intra-abdominal.  In our study the 2 cases where the vessels and vas were ending at the internal ring probably represent antenatal torsion and is well recognised and reported by other authors.  The 6 intra-abdominal testes did not represent "peeping testes" as they were not mobile.
Although in the classical description, an interval of 6 months between the 2 stages was advised the experimental evidence for this time gap between the 2 stages of Fowler Stephens operation is not available in literature. Pascaul et al have shown that spermatic vessel ligation in rats produce an initial decrease in blood flow to 80% of the testes at 1 hr but was restored to normal flow within 30 days. There was preservation of testicular integrity without any change in the weight of the gonad up to 54 days.  Subsequent experimental evidence has also shown that the contralateral testis remains unaffected in terms of spermatogenesis.  The operative finding confirmed that in the 5 boys within 6 weeks after spermatic vessel clipping, there were good collateral vessels along the vas.
In the follow-up, 1 of the 5 boys who underwent a second-stage Fowler Stephens orchidopexy had ischaemic atrophy within 3 months. In 4 others, there is no appreciable change in the position, size or consistency of the testis within 3-12 months. These are early results and chronic ischaemia may lead to further loss. In a collective review, successful results of conventional orchidopexy in intraabdominal testes at the internal ring or above have been analysed and reported to be around 76.1% versus 89.8% for testes at or below the canal with a highly significant p value of <.001.  For the Fowler Stephens technique, the success rates have been variously quoted between 67-81%.  At this stage it appears that laparoscopy remains the single most effective method of localising the testis. The choice of bringing down this testis will remain in the hands of the surgeon and his own experience of both the procedures.
| Conclusions|| |
Laparoscopy was successful in providing accurate information on each impalpable testis investigated. Conventional laparoscopic equipment is safe in trained hands for normal children above 2 years. It can help in preventing abdominal exploration in children with absent testes. Second-stage Fowler Stephens orchidopexy at 6 weeks needs further investigation to confirm our encouraging result.
| References|| |
|1.||Rajfer J, Walsh PC. Testicular descent: Normal & Abnormal. Urol Clin North Am 1978; 5: 223-235. |
|2.||Whitaker RH. Undescended testis - the need for a standard classification. Br J Urol 1992; 70: 1-6. |
|3.||Cortes D, Thorup JM, Lenz K, Beck BL, Neilson OH. Laparoscopy in 100 consecutive patients with 128 impalpable testes. Br J Urol 1995: 75: 281-287. |
|4.||Docimo SG. The results of surgical therapy for cryptorchidism: a literature review and analysis. J Urol 1995: 154: 1148-1152. |
|5.||Nasaar AH. Laparoscopic assisted orchidopexy: a new approach to the impalpable testes. J Pediatr Surg 1995; 30: 39-41. |
|6.||Wojeichowski K, Rueld T, Walczak M. Sye AK. Long-term results of undescended testicle operative treatment. Proc paediatr Surg 1977; 10: 2977-3004. |
|7.||Hrebinko RL. Bellinger ME The limited role of imaging techniques in managing children with undescended testes. J Urol 1993; 150: 458-460. |
|8.||Stephens FD. Fowler Stephens Orchidopexy. Sent Urol 1988: 6: 103. |
|9.||Ransley PG. Vodermark JS, Caldamone AA, Bellinger ME Preliminary ligation of the gonadal vessels prior to orchidopexy for the intra-abdominal testicle. A staged Fowler Stephens Procedure. World J Urol 1984; 2: 266. |
|10.||Bloom DA, Ayers JWT, McGuire EJ. The role of laparoscopy in management of nonpalpable testes. J Urol (Paris) 1988; 9: 465. |
|11.||Jordan GH, Winslow BH. Laparoscopic single stage and staged orchidopexy. J Urol 1994; 152: 1249-1252. |
|12.||Bloom DA. Two step Orchiopexy with pelviscopic clip ligation of the spermatic vessels. J Urol 1991: 145: 1030-1033. |
|13.||Lindgren B W, Darby EC, Faiella L. Laparoscopic orchidopexy: procedure of choice for the nonpalpable testis. J Urol 1998; 159: 2132-2135. |
|14.||Al Salem AH. Intrauterine testicular torsion: early diagnosis and treatment. Br J Urol 1999; 83: 1023-1025. |
|15.||Pascual JA. Villanueva Meyer J, Salido E et al. Recovery of testicular blood flow following ligation of testicular vessels. J Urol 1989; 142: 549-552. |
|16.||Ortolano V, Nasrallah PF. Spermatic vessel Ligation (Fowler Stephens Maneuver): Experimental results with regard to Fertility. J Urol 1986; 136: 211-213. |