Laparoscopy in the Evaluation of Impalpable Testes and Its Short-term Outcomes: A 7 Years' Experience

Abstract

Aims:

The aim of this study is to report and analyze results of laparoscopy in impalpable testes performed between 2009 and 2016 and its short-term outcomes.

Materials and Methods:

Demographic data, laterality, laparoscopic findings, operative time, procedure, hospital stay, complications, and follow-up data of 76 patients with 79 impalpable testes from 2009 to 2016 were retrospectively collected and analyzed. Successful outcome was defined as maintenance of intrascrotal position with no atrophy at a follow-up of at least 6 months.

Results:

Impalpable testes constituted 24% of undescended testes in our series. Mean age was 3.9 years. Forty-two patients had left-sided, 31 right-sided, and three bilateral impalpable testes. Of the 79 clinically impalpable testes, on laparoscopy, 3 were vanishing testes, 52 were intra-abdominal (6 high-lying and 46 low-lying), 18 canalicular and 6 nubbin testes. Ultimately, 52 underwent laparoscopic orchiopexy: 46 single-staged orchiopexy and 6 two-staged Fowler–Stephens procedure. Mean operating time was 77 min. Complications were few and mostly minor. Eleven patients were lost in follow-up. On a mean follow-up of 23 months, one testis that underwent single-staged laparoscopic orchiopexy atrophied whereas good size and intrascrotal position were maintained in the rest.

Conclusions:

Laparoscopy in impalpable testes was safe, feasible, and effective. Overall outcome was good which was obtained by minimal use of electrocautery, dissection with wide strip of peritoneum and extensive retroperitoneal dissection for mobilization. There is a need for wide reporting of cases from high-volume pediatric surgery centers in India.

INTRODUCTION

Undescended testis is one of the most common congenital anomalies in boys, affecting 1%–3% of full-term and up to 30% of preterm neonates. Nearly 10%–20% of undescended testes are considered as impalpable.

Laparoscopy in impalpable testes is considered as the gold standard procedure for diagnosis and in therapeutic planning. It was also the most commonly performed laparoscopic procedure by us. In India, there is a relative lack of well-designed large series on pediatric laparoscopy. In this article, we report and retrospectively analyze our data of laparoscopy in impalpable testes from 2009 to 2016 and review its short-term outcomes.

MATERIALS AND METHODS

The records of the patients undergoing laparoscopy for impalpable testes from 2009 to 2016 were retrospectively collected and reviewed. The various variables noted were: demographic data, laterality, clinical assessment, laparoscopic findings, operating time, subsequent therapeutic operative procedure, hospital stay, follow-up, and complications.

For inclusion in the review, an impalpable testis was defined as one which could not be clinically palpated at any time. Patients with palpable testes were excluded from the study and such testes which were palpable at birth but later became impalpable.

The laparoscopic technique practiced was as per standard literature with an umbilical port for camera and two working ports depending on the side. Location, size of the testes and its distance from the deep ring, and the iliac vessels were noted and accordingly operative planning done:

1. In case of blind ending vessels: no intervention was required

2. In case of intra-abdominal testes [Figure 1]:

   1. Testis low-lying or <2 cm from deep ring: single-stage laparoscopic orchiopexy
   2. Testis high-lying or >2 cm from deep ring: two-stage Fowler–Stephens procedure.

3. When deep ring open and vessels found entering the ring: inguinal exploration followed by orchiopexy if adequate in size and orchiectomy if nubbin testis is found.

Figure 1.

Laparoscopic view of intraabdominal testes – low-lying (left side) and high-lying intra-abdominal testis (right side)

After the procedure, the patients were followed up at regular intervals and the testes assessed for its location, size, and sensation. For outcome analysis, success was defined as a testis that remained intrascrotal with no atrophy or decrease in size at a follow-up of at least 6 months.

Complications were noted down from the follow-up data as:

1. Early: e.g., hemorrhage/hematoma, infection

2. Late: e.g., port site hernia

RESULTS

Seventy-six consecutive patients admitted with 79 impalpable testes underwent laparoscopy from 2009 to 2016 [Tables 1 and 2]. Three hundred and thirty patients with undescended testes were admitted for surgical intervention during this period. Thus impalpable testes constituted 23.9% of undescended testes.

Table 1.

Results of laparoscopy in 79 impalpable testes

Table 2.

Different case series (including ours) documenting the results and outcome of laparoscopy in impalpable testes

Mean age of the patients with impalpable testes was 3.9 years (range 1 year–12 years). Forty-two patients had left-sided impalpable testes, 31 right-sided and only three bilateral impalpable testes.

Results of laparoscopy are summarized in Table 1. Hence, ultimately 52 underwent laparoscopic orchiopexy: 46 single-staged orchiopexy and 6 two-staged Fowler–Stephens procedure.

Mean operating time was 77 min (range 20 min–130 min). Fifty-nine patients were discharged the next day after an overnight stay whereas 17 patients had a 2 days stay. Two patients had scrotal hematoma and five had minor wound infection in the immediate postoperative period which resolved on conservative management.

During a mean period of 23 months (range 7 months–6.5 years), 11 patients were lost to follow-up. One patient developed port site hernia as late complication. One testis that underwent single-stage laparoscopic orchiopexy atrophied whereas good size and intrascrotal position were maintained in the rest of the patients who followed up regularly [Table 2].

DISCUSSION

Undescended testis remains one of the most common congenital anomalies in boys with an incidence of 1%–3% in full-term going up to 30% in preterm neonates but coming down to <1% by 1 year of age. Unilateral cryptorchidism accounts for about 85% of cases.[7]

Of the two stages of testicular descent, failure of first stage or transabdominal stage (between 8 and 15 weeks gestation) is rare and results in intra-abdominal testis. Failure of second stage of descent is more common resulting in testis lying anywhere between deep ring and neck of scrotum.[8]

Many series have showed that up to 20% of undescended testes remain impalpable even in completely relaxed or anaesthetized children.[9,10]

Weiss et al. in a prospective study comparing ultrasonography (USG) with clinical examination concluded that USG was not a satisfactory screening modality.[11] Hutson and Clarke are of the view that USG is not superior to good clinical examination except in obese patients.[8]

Cortesi et al. introduced laparoscopy as a diagnostic procedure for impalpable testis in 1976 and now it has become a gold standard procedure for diagnosis as well as therapeutic planning.[12] Scott reported first series on pediatric laparoscopy in impalpable testis in 1982.[13]

Current recommendation for surgical intervention is anytime after 3–6 months of age if a testis remains undescended. A Scandinavian consensus report recommends orchiopexy before 1 year to preserve spermatogenesis.[14] MacKinnon showed that orchiopexy if done before 2 years, the predicted fertility is around 87% whereas if delayed up to puberty, chances of fertility fall to 14%.[15] Further proof that orchiopexy at earlier age improves fertility is shown in animal model. Postorchiopexy, the risk of infertility, is 78%–100% in bilateral and 33% in unilateral orchiopexy.[16]

Different management options depend on diagnostic laparoscopic findings. If there is blind ending vessel, diagnosis is vanishing testis and no further intervention is required.[17] In case, intra-abdominal testis is seen in low-lying position, single-stage orchiopexy can be performed whereas in high-lying intra-abdominal testis, single- or two-stage Fowler–Stephens technique can be performed.[18] Although originally described as an open procedure, Fowler–Stephens technique can be done laparoscopically.[19] We prefer to do it as a two-stage procedure as postulated by Hutson and Clarke, the tension on vas and in turn vasal artery is more in single-stage technique which may increase risk of testicular ischemia and atrophy.[8]

If vas and vessels are seen entering the deep ring, the testis is canalicular which can be the case in 10%–30% of impalpable testis.[17] Inguinal exploration is performed and orchiopexy done. Orchiectomy will be required if there is only a fibrous remnant or nubbin testis. Careful exploration of the abdomen and tracing of vas and vessel are recommended before impalpable testis is pronounced as being absent. One should be aware of possibility of a testis being in an abnormal position (retro colic or separated from vas) even in case of blind vas with no apparent vessel seen.

With time, the role of laparoscopy has progressed from diagnostic to therapeutic procedure in impalpable testes. Most of the series have reported success rate >90% with minimal complications.

Different large published important series over the years documenting the results and the outcome of laparoscopy in impalpable testes are summarized in Table 2 and the results of our series have been reviewed in their light.

As seen in our series, the mean age was higher than the recommended age at 3.9 years (range 1 year–12 years) which may be due to late referral, decreased awareness, and sometimes long-waiting periods.

Seventy-nine had 79 impalpable testes, which is ~24% of the 330 patients admitted with UDT between 2009 and 2016 as compared to 10%–20% quoted in literature.

Although right side is the more frequently undescended side overall, in our series as in most series of impalpable testes; unilateral impalpable testis was more common in the left side. Though there were 23 patients out of 330 having bilateral UDT (7%), only 3 patients had bilateral impalpable testes which are 0.9% of UDT and 3.9% of impalpable testes.

Mean operating time was similar to some of the earlier series but slightly higher than recent series at 77 min (20 min–2 h 10 min). Forty-six out of 79 testes were low-lying intra-abdominal, of which 19 were peeping testes, for which single-stage laparoscopic orchiopexy was employed. Only 6 out of 79 were high lying for which laparoscopic two-stage Fowler–Stephens' technique was employed.

Complications were far and few, mostly early (scrotal hematoma, wound infection) which resolved with conservative treatment. Only one patient developed port site hernia. Eleven patients were lost to follow-up.

Testicular atrophy was seen in one patient whereas intrascrotal position and size was maintained in the rest who followed up regularly. Overall results were good. We adhered to certain principles in laparoscopic orchiopexy for superior results: minimal use of electrocautery, dissection with a wide strip of peritoneum between the cut edge and vas, extensive retroperitoneal dissection for mobilization, [Figure 2] gentle handling of testis and particularly for Fowler–Stephens technique, high clipping of testicular vessels, and completing the procedure in two stages at 6 months.

Figure 2.

Laparoscopic orchiopexy being performed with minimal use of diathermy, mobilization with a wide strip of peritoneum (left side) and extensive retroperitoneal dissection (right side)

CONCLUSIONS

Laparoscopy in impalpable testis appears to be safe, feasible, and effective and gives overall good results. There is a need for wide reporting of cases and laparoscopic training for residents in all high-volume pediatric surgical units doing laparoscopic surgery as laparoscopy is a gold standard procedure in impalpable testis helping in therapeutic planning as per findings. It also prevents unnecessary intervention in case of vanishing testes.

When seen in the light of other important series on laparoscopy in impalpable testes, overall success rate in maintenance of intra-scrotal position was good which we have obtained by adhering to certain principles such as minimal use of electrocautery, dissection with a wide strip of peritoneum, and extensive retroperitoneal dissection for mobilization.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.