Early Clinical Experience With Monti Procedure and Managing the Nonpalpable Testis in Children

Fashioning bowel segments into a catheterizable stoma for patients who require reconstruction of the lower urinary tract is an alternative to the Mitrofanoff procedure, as described by Gerharz and Gosalbez. Two children’s hospitals offer different perspectives on the management of the nonpalpable testis.

Transverse Retubularized Ileum: Early Clinical Experience With a New Second Line Mitrofanoff Tube

Gerharz EW, Tassadaq T, Pickard RS, et al. : J Urol 15:525–528, 1998

Refashioned Short Bowel Segments for the Construction of Catheterizable Channels (the Monti Procedure): Early Clinical Experience

Gosalbez R, Wei D, Gousse A, et al. : J Urol 160:1099–1102,1999

In some children undergoing urinary tract reconstruction, the appendix is absent or unusable. In such patients, the Monti procedure using a 2 to 2.5 cm ileal segment is an alternative to the classic Mitrofanoff procedure using appendix or ureter. The technique involves incising the ileal segment longitudinally approximately l cm from the mesentery. The resulting rectangular pedicle (2 cm × 6–7 cm) is retubularized over a 14F catheter in a transverse direction. Interrupted 4-0 chromic catgut or 5-0 polydioxanone sutures are placed. The mesentery divides the small caliber tube into a short and long segment. The tunnel flap valve is created using the longer portion of the tube for reimplantation submucosally into either the native, augmented bladder or into an intestinal reservoir. The shorter segment is brought to the right lower quadrant or to the umbilicus. Spatulation of the distal end of the ileal tube is important to avoid stenosis of the stoma. In patients with thick abdominal walls, 2 end-to-end retubularized ileal segments can be joined. The long segments are positioned on either side of the mesenteric pedicles, which allows bridging a thick abdominal wall.

Gerharz et al report on 9 children and 7 adults with the diagnosis of exstrophy, meningomyelocele, imperforate anus, and detrusor instability who required the formation of a continent catheterizable channel with or without augmentation cystoplasty. In this series, 81% of the patients were completely continent without any difficulty catheterizing the stoma. In 2 patients, revision was required for leakage, and reimplantation was performed.

Gosalbez et al also reported on their experience with the Monti technique in 8 patients. Two patients in their series required additional procedures due to stoma leakage.

Both Gerharz and Gosalbez describe this new technique for creating a catheterizable stoma for lower urinary tract reconstruction. Although most pediatric urologists prefer to use the appendix for the Mitrofanoff stoma, the appendix is not always available, and only a small subset of patients have ureters that can be used for this purpose. The refashioned ileal bowel segment is an ideal tube for intermittent catheterization and creates an excellent tunnel flap valve for continence. Long ileal segments that have been tapered and reimplanted are often difficult to catheterize due to mucosal folds and redundancy that occur long term.¹ Also, the position of the mesentery makes it difficult to reimplant this type of long tube. The Monti procedure circumvents most of these difficulties. If augmentation is performed, the ileal segments can be taken in continuity. Also, the double tubularized segments to bridge a thick abdominal wall are extremely useful in select patients.

Current Findings in Diagnostic Laparoscopic Evaluation of the Nonpalpable Testis

Cisek LJ, Peters CA, Atala A, et al. : J Urol 160:1145–1149, 1998

Surgical Management of the Nonpalpable Testis: The Children’s Hospital of Philadelphia Experience

Kirsch AJ, Escala J, Duckett JW, et al. : J Urol 159:1340–1343, 1998

Both the Cisek et al and Kirsch et al reports are from well-known children’s hospitals with very different perspectives on the treatment of the nonpalpable testis. The report by Cisek et al from Children’s Hospital in Boston identified 263 nonpalpable testes in 225 patients evaluated between 1992 and 1996. In 40 patients, 46 testes (18%) became palpable following the administration of anesthesia. The remainder of patients underwent laparoscopy. Approximately 13% of patients undergoing laparoscopy were found to have a viable testis distal to the internal inguinal ring, which would have been found with a standard inguinal approach. Approximately 49% of the testes were in a precanalicular region, of which 12% were nonviable, obviating the need for inguinal exploration. A conventional inguinal incision would have provided optimal operative exposure in only one-third of patients. In the other two-thirds of patients, the laparoscopic localization of the testis optimized the incision chosen for exploration. The authors advocate laparoscopy as a valuable diagnostic tool for localizing the nonpalpable testis. Diagnostic laparoscopy is a safe and rapid technique that can aid in optimal placement of a small abdominal incision for orchidopexy or accurately diagnose “vanishing” or remnant testes.

Kirsch et al reported the surgical management of the nonpalpable testis over the past decade at the Children’s Hospital of Philadelphia. Of 1866 boys with cryptorchidism, 447 (24%) had a nonpalpable testis. Their report focused on 2 surgical techniques used for managing the intra-abdominal testis: the Fowler-Stephens procedure and the Koop orchidopexy involving retroperitoneal mobilization of the spermatic vessels and vas. The report provided 18 months of follow-up in 76 of these patients.

At surgery, 181 (41%) of testes were atrophic or vanishing. Ninety-one (20%) were intra-abdominal, 136 (30%) were in the inguinal canal, and 39 (9%) were distal to the external ring in an upper scrotal or ectopic position. Of the nonpalpable testes, 14 (3.l%) were bilateral and intra-abdominal.

Of those patients with intra-abdominal testes, 91 were examined further. The Fowler-Stephens repair was performed in 38 (42%). Five of these procedures were performed in 2 stages. Thirty-three patients (36%) underwent inguinal orchidopexy and intraperitoneal dissection without dividing the spermatic vessels. Five of these procedures were performed in 2 stages with vessel preservation. Fourteen patients (15%) underwent orchiectomy. One testis was left in situ. The Koop repair using an inguinal approach with retroperitoneal dissection and mobilization was successful in 92% of patients. Results were excellent in 97% following the Koop orchidopexy, but only 74% after the Fowler-Stephens orchidopexy. The authors conclude that the inguinal incision with retroperitoneal mobilization of the vessels and vas via a transperitoneal approach without vascular transection is the preferred technique for managing the intra-abdominal testis.

The authors state that they do not treat patients who have unilateral or bilateral undescended testes with human chorionic gonadotropin (hCG). Also, they commented that they do not perform laparoscopy for a unilateral nonpalpable testis, although they note that laparoscopy would have been helpful in planning the surgical incision of 3.1% of their patients with bilateral nonpalpable, intra-abdominal testes. Of their cases, 40% had an absent or atrophic testis, which would also have been diagnosed through an inguinal approach. Most atrophic remnants are located beyond the internal ring and, therefore, despite visualizing the vas and vessels entering the internal ring using laparoscopy, an inguinal exploration would still be indicated.

These two studies illustrate that the use of laparoscopy for the nonpalpable testis remains controversial. When there is hypertrophy of the descended testis on physical examination, this suggests that the nonpalpable testis is absent.¹ When the testis is absent, it is thought to be secondary to in utero torsion. It is my practice to perform a scrotal-inguinal sonogram to localize the nonpalpable testis, even though the sensitivity as reported by Cain et al is poor for the true intra-abdominal testis.² It is a sensitive technique for identifying inguinal testes that are nonpalpable during the physical examination. Therefore, one-third of patients presenting with an nonpalpable testis in Cisek’s series would not need laparoscopy if a sonogram and examination under anesthesia were performed. Also, Polascik et al reported the use of hCG stimulation preoperatively to improve the ability to palpate the nonpalpable testis.³ Nonresponders often had an absent or atrophic testis. Of 99 nonpalpable testes, approximately 40% became palpable and 2 completely descended. Sixty percent remained nonpalpable, and two-thirds of these were absent or atrophic. Therefore, sonography and hCG may together increase the number of nonpalpable testes that can be localized or become palpable preoperatively. In boys who undergo only an inguinal exploration in which a vas is identified in the canal, entering into the scrotum, it is important to open the peritoneal cavity to check for an abdominal testis and a long looping vas, unless it is obvious that there is an atrophic testis in the scrotum.

Although laparoscopy may impact on the surgical approach, in the 1-year-old male, the skin can be moblized sufficiently using a standard inguinal incision and a high retroperitoneal exposure obtained for high dissection of the vessels. In older children, a suprainguinal approach or Jones’ approach is beneficial.⁴ There were no data in Cisek’s report on the number of patients with intra-abdominal testes who required division of the vessels and their long-term success.

It is probably prudent at this time to employ the laparoscopic approach for the nonpalpable testis that is not localized on sonography, since one cannot predict those testes that would best be approached with testicular microsurgical autotransplant.⁵ For those uncommon cases, we have employed the assistance of our plastic surgeons. High testes that are not viable long term (26%) following the Fowler-Stephens procedure may have been placed intrascrotally on some tension. Accurate laparoscopic assessment of these testes may assist in choosing autotransplant rather than a Fowler-Stephens procedure. Other cases that have vasal agenesis and a normal-appearing high intra-abdominal testis must also be microsurgically autotransplanted. Since we now have the armamentarium to make the best decision for the surgical approach to the intra-abdominal testis, there should be no excuse for unplanned removal of a testis. A second anesthesia will permit a microsurgical team approach when indicated for high intra-abdominal testes in patients for whom there is more likely to be failure following the Fowler-Stephens procedure.