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Shadpour P, Kashi AH, Arvin A. Scrotal testis size in unilateral non-palpable cryptorchidism, what it can and cannot tell: Study of a Middle Eastern population. J Pediatr Urol 2017; 13:268.e1-268.e6. [PMID: 28254240 DOI: 10.1016/j.jpurol.2016.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 12/13/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Predicting the fate of a unilateral non-palpable testis based on its scrotal counterpart has been recommended by some, yet disputed by others, and the question remains open. OBJECTIVE To investigate the accuracy of contralateral testis hypertrophy in predicting the absence of a unilateral non-palpable testis in a Middle Eastern population. STUDY DESIGN This retrospective study included all patients referred to the present institution with unilateral non-palpable testis between June 2010 and August 2014, who had undergone laparoscopy. The scrotal testis was examined by sonography for size and volume, and diagnostic laparoscopy was utilized to determine the state of the cryptorchid testis. RESULTS Of the 135 referred patients, 64 were aged ≤8 years, 29 were 9-18 years, and 42 were >18 years old. Diagnostic laparoscopy revealed 63 intra-abdominal testes, 20 small intra-inguinal testes, 32 vanished testes, and 20 nubbins or aplasia (Summary fig.). Scrotal testis volume was only a modest predictor for absence of the contralateral gonad in adult patients in whom a 22 ml cut-off yielded 64.3% sensitivity and 92.9% specificity. For those aged <18 years, overall accuracy was poor and dropped below 60%. Relative enlargement of contralateral testis in decreasing order of size was observed in patients with primary monorchism, followed by those with secondarily atrophic or nubbin testis, and then those with normal sized inguinal or abdominal testis. DISCUSSION Unlike some previous series, which based their conclusions upon open exploration and mostly studied pre-pubertal subjects, the present results exclusively from laparoscopic exploration suggested that contralateral testis volume is a poor and inconsistent predictor of monorchism in children, and marginally predictive for young adults with unilateral non-palpable testis. This study comprised a reasonably large overall sample size compared with preceding reports; however, the number of patients within in each age group was limited. Greater numbers could allow for statistical comparison stratified by age group, for which this study was not powered. CONCLUSION Contralateral testis volume predicts, with modest accuracy, monorchism in adults with unilateral non-palpable testis. In younger patients, the overall predictive accuracy of scrotal testis size is poor and not consistently dependable.
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Affiliation(s)
- P Shadpour
- Hasheminejad Kidney Center (HKC), Hospital Management Research Center (HMRC), Iran University of Medical Sciences (IUMS), Tehran, Iran.
| | - A H Kashi
- Hasheminejad Kidney Center (HKC), Hospital Management Research Center (HMRC), Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - A Arvin
- Hasheminejad Kidney Center (HKC), Hospital Management Research Center (HMRC), Iran University of Medical Sciences (IUMS), Tehran, Iran
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Abstract
The use of laparoscopic surgery has grown dramatically in recent years in most all types of surgery. Historically, the early use of laparoscopic surgery was for pelvic and groin problems. In this article we review the current technique, indications, benefits and complications of laparoscopy in diagnosis and management of various groin problems in children including undescended testes (non-palpable and palpable) and inguinal hernia.
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Affiliation(s)
- Himanshu Aggarwal
- Albany Medical College and The Urological Institute of Northeastern New York, Albany, NY 12208, USA
| | - Barry A Kogan
- Albany Medical College and The Urological Institute of Northeastern New York, Albany, NY 12208, USA
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Bae KH, Park JS, Jung HJ, Shin HS. Inguinal approach for the management of unilateral non-palpable testis: is diagnostic laparoscopy necessary? J Pediatr Urol 2014; 10:233-6. [PMID: 24206784 DOI: 10.1016/j.jpurol.2013.09.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2013] [Accepted: 09/19/2013] [Indexed: 11/24/2022]
Abstract
OBJECTIVE During the last decade laparoscopy has increasingly been advocated as the primary investigative procedure for the management of the non-palpable testis. We reviewed the medical records in a consecutive series of boys with non-palpable testis to examine the contribution of the initial inguinal approach in the management of unilateral non-palpable testis. MATERIALS AND METHODS Among the 183 consecutive patients with cryptorchidism from 2003 to 2012, there were 21 patients with unilateral and three with bilateral non-palpable testes. All unilateral patients then underwent inguinal and scrotal exploration through an inguinal incision. For those patients with an intra-abdominal peeping testis, the gonad was placed into the scrotum after meticulous cranial mobilization of the spermatic cord. RESULTS Patient age ranged from 11 months to 144 months (mean age: 23 months). Among the 21 unilateral cases, testicular absence or atrophy was confirmed in seven patients with a scrotal nubbin in six, and blind-ending vas and vessels at the external inguinal ring in one patient. Among the remaining 14 patients with sizeable testes, 12 testes were intra-abdominal peeping testes and two testicles were seen within the distal inguinal canal, which may be missed on physical examination owing to patient obesity. The intra-abdominal peeping testicle had the opened processus vaginalis entering the internal ring in which testicle was found. These were fixed into the scrotum successfully by cranial mobilization of spermatic vessel sometimes cutting the internal oblique muscle and by Prentiss and Fowler-Stephen's maneuver. Diagnostic laparoscopy was done on three patients with bilateral cases. CONCLUSIONS Given the result that most of nubbins are within the scrotum and testes with intra-abdominal peeping testes are fixed down safely into the scrotum, the inguinal approach may suffice for the management of unilateral non-palpable testis. Laparoscopy should be reserved for patients with bilateral non-palpable undescended testes.
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Affiliation(s)
- K H Bae
- Department of Urology, Daegu Catholic University Medical Center, Daegu, Republic of Korea
| | - J S Park
- Department of Urology, Daegu Catholic University Medical Center, Daegu, Republic of Korea.
| | - H J Jung
- Department of Urology, Daegu Catholic University Medical Center, Daegu, Republic of Korea
| | - H S Shin
- Department of Urology, Daegu Catholic University Medical Center, Daegu, Republic of Korea
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Abstract
Undescended testis is one of the common surgical disorders in childhood and twenty percent of the undescended testes are nonpalpable. Surgical management is required in almost all cases for the repositioning or removal of the undescended testes and early intervention is preferred for optimal outcome. Use of imaging studies for accurate preoperative localisation of the nonpalpable testis is a wide prevalent practice. However, available evidences have questioned the need of such studies.
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Affiliation(s)
- Manas Ranjan Pradhan
- Department of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India
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Shadpour P, Rezaimehr B. Is laparoscopic re-evaluation justified in cryptorchidism with previous negative open exploration? J Endourol 2011; 26:254-7. [PMID: 22168768 DOI: 10.1089/end.2011.0420] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Nonpalpable testes account for 20% of cryptorchidism. Laparoscopy is now the mainstay in management, but open surgery has been the only option for many patients in the past and even today. We suspected that open exploration may have missed gonads in presumed negative open exploration. As abdominal gonads are even more prone to cancerous degeneration, we proposed laparoscopic re-evaluation to patients with previous inconclusive open exploration for impalpable testis. PATIENTS AND METHODS All boys presenting to our referral center with past history of inconclusive open exploration for nonpalpable testis or with clinical or lab evidence of functional testicular tissue were consecutively offered laparoscopic re-exploration. Standard diagnostic laparoscopy with same-stage laparoscopic orchiopexy or one stage Fowler procedure was employed as required. The presence, number, and site of detected gonads were recorded. RESULTS 141 male patients with nonpalpable testis comprising 171 nonpalpable gonads were laparoscopically explored with no adverse events. Sixteen patients (19 gonads) already had a negative open exploration. Seven gonads were discovered in these boys, 5 iliac and 2 retrovesical. CONCLUSION Although a modest number of samples, our results underscore the prevalence of missed diagnosis. Obviously, laparoscopic re-exploration is indicated when a child with previous bilateral inguinal exploration presents with hormonal evidence of functioning gonadal tissue. Further we now recommend laparoscopic re-evaluation in most patients with nonpalpable testis and history of negative open exploration altogether.
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Affiliation(s)
- Pejman Shadpour
- Hasheminejad Clinical Research Development Center, Hasheminejad Kidney Center (HKC), Tehran University of Medical Sciences (TUMS), Tehran, Iran.
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Guo J, Liang Z, Zhang H, Yang C, Pu J, Mei H, Zheng L, Zeng F, Tong Q. Laparoscopic versus open orchiopexy for non-palpable undescended testes in children: a systemic review and meta-analysis. Pediatr Surg Int 2011; 27:943-52. [PMID: 21476074 DOI: 10.1007/s00383-011-2889-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND Laparoscopic orchidopexy (LO) has been widespread used in the management of non-palpable testis (NPT) in children. However, the real advantages of LO over traditional open orchidopexy (OO) still remain exclusive. METHODS Published studies until August 31, 2010 were searched from Medline, Embase, Ovid, Web of Science, and Cochrane databases. Randomized controlled trials (RCTs) and observational clinical studies (OCSs) with a comparison of LO and OO were included for a systemic review and meta-analysis. RESULTS Out of 226 studies, 2 RCTs and 5 OCSs were eligible for inclusion criteria, comprising 176 cases of LO and 263 cases of OO. The hospital stay of LO was significantly shorter than that of OO (WMD = -0.66; 95% confidence interval [CI] = -0.95 to -0.37; P < 0.00001). However, no significant difference was observed between LO and OO in operative time (WMD = 4.02; 95% CI = -9.89 to 17.93; P = 0.57), time to resume feeding (WMD = -2.29; 95% CI = -6.78 to 2.20; P = 0.32) or full activity (WMD = -9.71; 95% CI = -27.84 to 8.42; P = 0.29), recurrence (OR = 0.60; 95% CI = 0.13 to 2.72; P = 0.51), viable testis rate (OR = 1.61; 95% CI = 0.30 to 8.52; P = 0.58), success rate (OR = 1.41; 95% CI = 0.44 to 4.46; P = 0.56), and testicular atrophy (OR = 1.70; 95% CI = 0.49 to 5.98; P = 0.40). CONCLUSION Although shorter hospital stay is noted in LO, it does not provide significant advantage over open surgery for treating NPT. However, due to the publishing bias, a series of RCTs are necessary to explore the efficiencies of LO in the management of NPT in children.
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Affiliation(s)
- Ju Guo
- Department of Urology, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
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Lintula H, Kokki H, Eskelinen M, Vanamo K. Laparoscopic Versus Open Orchidopexy in Children with Intra-abdominal Testes. J Laparoendosc Adv Surg Tech A 2008; 18:449-56. [DOI: 10.1089/lap.2007.0176] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Affiliation(s)
- Hannu Lintula
- Department of Pediatric Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Hannu Kokki
- Department of Anesthesiology and Intensive Care, Kuopio University Hospital, Kuopio, Finland
| | - Matti Eskelinen
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Kari Vanamo
- Department of Pediatric Surgery, Kuopio University Hospital, Kuopio, Finland
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Abstract
Cryptorchidism, where either one or both testes fails to migrate to the base of the scrotum, affects 4% to 5% of full-term and 9% to 30% of premature males at birth. The testis can be found in any position along its usual line of descent; however, approximately 80% will be located in the inguinal region, just outside the inguinal canal. Early correction, from 3 to 6 months of age, is currently advised. The preferred means of investigation and subsequent surgical intervention are dependent on the position of the cryptorchid testis. Risks associated with cryptorchidism include infertility and malignancy. The aim of appropriate management is to minimize these, and any other, associated complications.
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Affiliation(s)
- John M Hutson
- Department of General Surgery, Royal Childrens Hospital (Melbourne), Parkville, Victoria, Australia.
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Abolyosr A. Laparoscopic versus open orchiopexy in the management of abdominal testis: A descriptive study. Int J Urol 2006; 13:1421-4. [PMID: 17083396 DOI: 10.1111/j.1442-2042.2006.01582.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIMS Treatment of patients with abdominal non-palpable testis (NPT) is still controversial among pediatric urologists. This is a prospective randomized comparative study between open and laparoscopic orchiopexy for management of abdominal testis. The aim of this study was to evaluate the success rate and morbidity of both approaches. METHODS Eighty-two patients with a mean age of 5.3 years were evaluated by laparoscopy for 87 NPT. Patients with viable abdominal testes were randomly treated with either open or laparoscopic orchiopexy procedures. RESULTS On laparoscopy, 75 viable abdominal testes were found. According to location: 41 (47.1%) testes were high abdominal, 27 (31%) testes were low abdominal and 7 (8%) testes were peeping from the internal ring. Laparoscopic first stage Fowler-Stephens orchiopexy was done initially for those with high abdominal testes. For further management, all patients were divided randomly into open (36 cases) and laparoscopic (39 cases) groups where primary (with spermatic vessel preservation) or second stage Fowler-Stephens orchiopexy was done. Statistical analysis was done using Student's t-test. Laparoscopic procedures showed significant less morbidity than the open counterparts. Follow up ranged from 9 to 31 months and included evaluation of testicular site and size. All testes were located satisfactorily inside the scrotum. Five cases of testicular atrophy were encountered (three and two testes with open and laparoscopic second stage Fowler-Stephens orchiopexy respectively) after 1 year follow up. CONCLUSION Results of open versus laparoscopic orchiopexy procedures (primary or staged) are fairly comparable. However, laparoscopy provides significantly less morbidity.
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Affiliation(s)
- Ahmad Abolyosr
- Department of Urology, Assiut University Hospital, Assiut, Egypt.
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Affiliation(s)
- Jeffrey H Haynes
- Division of Pediatric Surgery, Department of Surgery, Virginia Commonwealth University's Medical College of Virginia Hospitals, P.O. Box 980015, Richmond, VA 23298-0015, USA.
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Abstract
OBJECTIVE The optimal initial surgical approach for nonpalpable undescended testis (UDT) is debated. The aim of the present study is to compare the results of initial laparoscopy and inguinal exploration in the management of unilateral nonpalpable undescended testes. METHODS The results of 20 children with unilateral nonpalpable UDT managed by initial laparoscopy (group I) were compared with 20 age-matched children managed by inguinal exploration (group II). The location of testes and results of orchiopexy were compared in both groups. A single surgeon performed all the operative procedures. RESULTS The majority of testes (16/20 group I, 17/20 group II) in both groups were canalicular or low abdominal. Vanishing testes accounted for one-third (13/40) of the testes, the majority (85%) of which were located in the inguinal canal. All children were discharged within 24 hours of the operation. The success of orchiopexy at 4-6 weeks post-operatively was 85% and 86% in the two groups respectively. Retrospectively, only 7/40 (18%) of the testes would benefit from laparoscopy. CONCLUSIONS Initial laparoscopic and inguinal approaches to nonpalpable UDT give comparable results. This report failed to demonstrate any specific advantage of initial laparoscopy in the majority of children with unilateral nonpalpable UDT.
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Bittencourt DG, Miranda ML, Moreira APP, Miyabara S, Bustorff-Silva JM. The role of videolaparoscopy in the diagnostic and therapeutic approach of nonpalpable testis. Int Braz J Urol 2005; 29:345-51; discussion 351-2. [PMID: 15745560 DOI: 10.1590/s1677-55382003000400011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2003] [Accepted: 07/29/2003] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Evaluate the results from the first 5 years of experience with laparoscopy for diagnosis and treatment of nonpalpable testes. MATERIALS AND METHODS Medical records of 51 patients submitted to laparoscopic testicular exploration, during a 5-year period, were retrospectively analyzed. Patients' mean age was 65.7 months (median = 48) on the first procedure. The youngest patient was 10 months and the oldest was 14 years old on the first surgery. Twenty-four (47%) patients presented nonpalpable testes bilaterally, 7 (14%) only at the right side and 20 (39%) at the left, totaling 75 testicular units assessed. Patients who had their testes palpated after anesthetic induction were excluded from the study, and in all other cases, surgical management was based on the testicular position and viability. During the post-operative follow-up, surgical success was classified as palpable testis in scrotal sac, with adequate consistency and volume. RESULTS Nine (12%) testes were not localized, but their vessels and deferent duct were atrophic. Two (3%) testes were intra-abdominal and atrophic, and 2 (3%) gonads, in the same patient, had a dysmorphic aspect. Nineteen (25%) testicular units were located close to the internal inguinal ring (peeping testes) and, in 22 (29%) units, the spermatic vessels and deferent duct penetrated the internal inguinal ring. Eight (10%) testes were located at a distance of less than 2 cm from the internal inguinal ring and 13 (17%) at a distance greater than 2 cm. The 2 intra-abdominal atrophic testes were removed. Inguinotomy was performed in a total of 41 (54%) cases, reaching a surgical success of 89%. Laparoscopic orchiopexy in one stage, without vascular ligation, was performed in 9 (12%) testes, which presented a distance of less than 2 cm from the internal inguinal ring, also with a surgical success index of 89%. Orchiopexy in 2 stages, with ligation of the spermatic vessels, was performed in 13 (17%) testicular units located at a distance greater than 2 cm from the internal inguinal ring, reaching 77% of good results. CONCLUSION Videolaparoscopy is a safe and effective method for diagnosis and treatment of nonpalpable testis.
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Affiliation(s)
- Daniel G Bittencourt
- Section of Pediatric Surgery, School of Medicine, State University of Campinas, Unicamp, Campinas, São Paulo, Brazil.
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Abstract
PURPOSE We investigated use of initial scrotal incision for the management of unilateral nonpalpable testis. MATERIALS AND METHODS Scrotal incision followed by laparoscopy was performed in a consecutive series of 40 boys with unilateral impalpable testis. RESULTS Initial scrotal incision revealed 22 scrotal nubbins and 4 extra-abdominal testes among the 40 patients. Of 13 patients with intra-abdominal testis 6 had a looping vas that was dissected to the internal ring via the scrotal incision, and the incision was used for orchiopexy in 12. Laparoscopy detected 1 case of intra-abdominal vanished testis but falsely diagnosed 6 additional cases based upon blind-ending vas and vessels despite a known scrotal nubbin. It also detected 13 intra-abdominal testes but was inconclusive in 14 cases in which vas and vessels exited the internal ring, not including the 4 patients with extra abdominal testes who did not undergo laparoscopy. CONCLUSIONS Scrotal incision may be sufficient to diagnose testicular loss when a nubbin is encountered, and can detect an extra abdominal testis not palpated with the patient under anesthesia. The incision is used for orchiopexy in those patients with a testis that can be brought to the scrotum in a single stage. Laparoscopy potentially can be reserved for cases in which no nubbin is found and in all cases when a patent processus vaginalis is encountered.
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Affiliation(s)
- Warren Snodgrass
- Division of Pediatric Urology, Children's Medical Center and The University of Texas Southwestern Medical Center, Dallas, Texas 75235, USA.
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Lorenzo AJ, Samuelson ML, Docimo SG, Baker LA, Lotan Y. Cost analysis of laparoscopic versus open orchiopexy in the management of unilateral nonpalpable testicles. J Urol 2004; 172:712-6. [PMID: 15247768 DOI: 10.1097/01.ju.0000130572.64035.7b] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Laparoscopic exploration for the nonpalpable testicle (NPT) has been criticized for increased costs compared with primary inguinal/scrotal exploration, mostly due to high equipment costs and the need for open inguinal/scrotal exploration in many cases. We assessed costs associated with diagnostic laparoscopy vs inguinal/scrotal exploration followed by selective open or laparoscopic treatment for unilateral NPT to identify the most important factors that influence cost. MATERIALS AND METHODS A comprehensive literature review determined the probabilities of intra-abdominal or inguinal nubbins, blind-ending vas/vessels and intra-abdominal or inguinal gonads in patients with unilateral NPT. The costs of anesthesia, equipment and operating room use were obtained from our institution or derived from the literature. A model was created using computer software to compare the costs of initial scrotal/inguinal approach or initial laparoscopic exploration in a theoretical population of boys with unilateral NPT. We established a set of assumptions and generated a series of 1-way sensitivity analyses to detect cost influencing parameters. RESULTS Based on the probabilities of intraoperative anatomical gonadal findings, use of reusable laparoscopic equipment and encompassing the ultimate surgical procedure needed initial laparoscopic evaluation was less costly than initial scrotal/inguinal exploration by 69 US dollars on a population basis. One-way sensitivity analyses showed that initial laparoscopic exploration was less costly if the operative time of laparoscopic exploration did not exceed 19 minutes and the cost of disposable laparoscopic equipment was less than 147 US dollars. CONCLUSIONS On a population basis initial laparoscopic evaluation of the clinically nonpalpable testicle has a cost saving advantage (69 US dollars) over initial inguinal-scrotal exploration when reusable laparoscopic equipment is primarily used, disposable equipment costs are kept low (147 US dollars or less) and operating room time for diagnostic laparoscopy are at national standards (19 minutes or less). These findings hold true for a wide range of probabilities and duration of inguinal exploration time. Given that all of these caveats are easily achievable, cost should not be used as a factor to bias against initial laparoscopic exploration.
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Affiliation(s)
- Armando J Lorenzo
- Department of Urology, University of Texas Southwestern Medical Center at Dallas, 75390, USA
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Franco I. Editorial comment. Urology 2003. [DOI: 10.1016/s0090-4295(03)00228-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Barqawi AZ, Blyth B, Jordan GH, Ehrlich RM, Koyle MA. Role of laparoscopy in patients with previous negative exploration for impalpable testis. Urology 2003; 61:1234-7; discussion 1237. [PMID: 12809907 DOI: 10.1016/s0090-4295(03)00227-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To evaluate the impact of laparoscopy in the treatment of patients with previous negative inguinal exploration for impalpable undescended testes. METHODS A retrospective review was performed of patients who underwent laparoscopy after prior incomplete or "questionable" negative inguinal explorations for nonpalpable undescended testes. RESULTS Twenty-seven males aged 1 to 22 years old, with 30 impalpable testes, underwent laparoscopy after prior negative open exploration. The operative notes were available for all patients. In 9 patients (33%), blind-ending spermatic vessels, vas deferens, and a closed ring were found. However, in the remaining 18 patients (67%), viable intra-abdominal or inguinal gonads (9 patients) and intra-abdominal remnants (9 patients) were identified. In 1 patient, seminoma of an intra-abdominal testis was present. CONCLUSIONS When a patient is referred with an inconclusive previous open exploration for an impalpable gonad, laparoscopy has an important role in establishing or refuting the diagnosis of an absent testis. Moreover, therapeutic laparoscopy provides definitive options to standard open techniques when a viable testis or remnant is encountered. In this study, laparoscopy proved more accurate than open exploration with operative notes available defining the nature of the exploration.
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Affiliation(s)
- Albaha Z Barqawi
- Department of Surgery, University of Colorado School of Medicine, Denver, Colorado, USA
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VAN SAVAGE JOHNG. AVOIDANCE OF INGUINAL INCISION IN LAPAROSCOPICALLY CONFIRMED VANISHING TESTIS SYNDROME. J Urol 2001. [DOI: 10.1016/s0022-5347(05)65799-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- JOHN G. VAN SAVAGE
- From the Division of Urology, Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
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18
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Abstract
PURPOSE Nonpalpable testicles may be due to the vanishing testis syndrome, intra-abdominal position, examination obscured by obesity or scar tissue and rarely testicular agenesis. Laparoscopy is an excellent means of distinguishing these entities without the need for open abdominal exploration. We investigated whether laparoscopy affects the need for an inguinal incision and exploration when no testicle is palpable and the vas and vas deferens are visualized exiting the internal inguinal ring on laparoscopy. MATERIALS AND METHODS In 34 boys 6 to 18 months old (mean age 41) physical examination demonstrated a nonpalpable testicle, including on the right side in 12, on the left side in 17 and bilaterally in 5. The vanishing testis syndrome was diagnosed after laparoscopy when no testicle was palpable despite physical examination done with the patient under anesthesia, spermatic vessels were visualized exiting the internal inguinal ring or spermatic vessels were visualized in the abdomen with or without an identifiable intra-abdominal testicular nubbin. RESULTS Laparoscopy confirmed the vanishing testis syndrome in 16 patients, intra-abdominal testicles in 13 and peeping testes in 1. Adequate examination using anesthesia was not possible in 4 patients with obesity, or previous inguinal or lower abdominal surgery. These boys underwent inguinal exploration after laparoscopy showed the vas and vessels exiting a closed internal inguinal ring. Of the 16 cases of the vanishing testis syndrome orchiectomy with contralateral scrotal orchiopexy was performed in 14 through a median raphe scrotal incision and in 1 through an inguinal incision for an associated inguinal hernia. In the remaining patient who underwent laparoscopy only a blind ending vas and vessels were visualized in the abdomen without an identifiable nubbin. The infraumbilical and median raphe incisions healed without obvious scars. Followup was at least 1 year. CONCLUSIONS When spermatic vessels are visualized exiting the internal inguinal ring on laparoscopy in the setting of a nonpalpable testicle, a median raphe scrotal incision can be made to remove the testicular nubbin associated with the vanishing testicle syndrome. Orchiectomy is possible through this median raphe incision even when the testicle is in the inguinal canal because this distance in young children is small. Cosmesis is excellent since 1 incision is within the umbilicus and the other is on the median scrotal raphe.
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Affiliation(s)
- J G Van Savage
- Division of Urology, Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
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Baker LA, Docimo SG, Surer I, Peters C, Cisek L, Diamond DA, Caldamone A, Koyle M, Strand W, Moore R, Mevorach R, Brady J, Jordan G, Erhard M, Franco I. A multi-institutional analysis of laparoscopic orchidopexy. BJU Int 2001; 87:484-9. [PMID: 11298039 DOI: 10.1046/j.1464-410x.2001.00127.x] [Citation(s) in RCA: 164] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To combine and analyse the results from centres with a large experience of laparoscopy for the impalpable testis with small series, to determine the expected success rate for laparoscopic orchidopexy. METHODS A questionnaire was distributed to participating paediatric urologists; each contributor retrospectively reviewed the clinical charts for their cases of therapeutic laparoscopy for an impalpable testis, detailing 36 variables for each patient. The data were collated centrally into a computerized database. For inclusion, the testis was intra-abdominal (including 'peeping' at the internal ring) at laparoscopic examination, was not managed through an open approach and did not undergo orchidectomy. Three surgical groups were assessed, with success defined as lack of atrophy and intrascrotal position: group 1, primary laparoscopic orchidopexy; group 2, a one-stage Fowler-Stephens (F-S) orchidopexy; and group 3, a two-stage F-S orchidopexy. RESULTS Data were gathered from 10 centres in the USA, covering the period 1990-1999; 252 patients representing 310 testes were included and overall, 15.2% were lost to follow-up. There was no significant difference between success rates in the larger and smaller series. Atrophy occurred in 2.2% of 178 testes, 22.2% of 27 testes and 10.3% of 58 testes in groups 1-3, respectively. Testes were not in a satisfactory scrotal position in 0.6%, 7.4% and 1.7% of groups 1-3, respectively. The mean follow-up for each group was 7.7, 8.6 and 20.0 months, respectively. The overall success for all groups was 92.8% (97.2% group 1; 74.1% group 2; 87.9% group 3), with an atrophy rate of 6.1%. CONCLUSION Laparoscopic orchidopexy for the intra-abdominal testis, in both large and small series, can be expected to have a success rate higher than that historically ascribed to open orchidopexy. Within this series, single-stage F-S laparoscopic orchidopexy resulted in a significantly higher atrophy rate than the two-stage repair. However, when considering both F-S approaches, the laparoscopic approach gave greater success than previously reported for the same open approaches. Despite the weaknesses inherent in a retrospective unrandomized study, we conclude that laparoscopic orchidopexy is, if not the procedure of choice, an acceptable and successful approach to the impalpable undescended testicle.
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Affiliation(s)
- L A Baker
- Brady Urological Institute, The Johns Hopkins Hospital, Baltimore, MD, USA
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Abstract
BACKGROUND Cryptorchidism is a common condition in boys. Approximately 20% of undescended testes are nonpalpable and may be located within the abdominal cavity. Given the potential of these gonads for malignant transformation and infertility, it is essential to determine the presence or absence of a nonpalpable testis. METHODS Radiologic imaging and open surgical exploration have proved to be unreliable. In the hands of experienced surgeons, laparoscopy has become the method of choice for evaluating the nonpalpable testis. RESULTS AND CONCLUSION An increasing number of surgeons are applying laparoscopy in the treatment of nonpalpable testes, and early results are encouraging. Both diagnostic and therapeutic laparoscopy necessitate operative skills. The exact advantages of laparoscopy over conventional surgery in orchidectomy and single- or two-stage orchidopexy need to be determined.
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Affiliation(s)
- P P Godbole
- Department of Paediatric Surgery, The Leeds Teaching Hospitals, St James University Hospital, UK
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Sousa A, Gayoso R, Lopez-bellido D, Reboredo J, Perez-valcarcel J, Fuentes M. Surg Laparosc Endosc Percutan Tech 2000; 10:420-422. [DOI: 10.1097/00019509-200012000-00019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Wolffenbuttel KP, Madern GC. Seminomas complicating undescended intraabdominal testes. AJR Am J Roentgenol 2000; 175:1186-7. [PMID: 11000191 DOI: 10.2214/ajr.175.4.1751186a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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24
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Abstract
BACKGROUND The management of the impalpable undescended testis is controversial. The study examines emerging trends in the management of this problem. METHODS Two groups of boys were treated consecutively and recorded prospectively from 1974 to 1984 and from 1990 to 1998 inclusive. A consistent policy of using the preperitoneal approach for impalpable testis was adopted during both time intervals but during the second study period examination under anaesthesia and diagnostic laparoscopy were introduced to ascertain testicular presence and location. RESULTS Some 919 boys were treated for cryptorchidism during the study period. Ninety boys in the first group (23 per cent) underwent preperitoneal explorations for impalpable testes. Anorchia was present in 18 and orchidectomy was performed in two boys. Thirty boys in the later group (5 per cent) were diagnosed as having impalpable testes. Fifteen boys underwent successful preperitoneal orchidopexy, anorchia was present in 11 and four underwent orchidectomy, carried out for high intra-abdominal testes. CONCLUSION Examination under anaesthesia and subsequent laparoscopic assessment for all impalpable testes has reduced the need for preperitoneal exploration for the impalpable undescended testis. In this large series, division of the testicular vessels in order to secure scrotal placement of the testis was required in one instance only.
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Affiliation(s)
- M E Flett
- Department of Pediatric Surgery, Royal Aberdeen Children's Hospital, UK
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25
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Jones PF, Youngson GG. Re: Benefits of laparoscopy and the Jones technique for the nonpalpable testis. J Urol 1999; 162:169. [PMID: 10379775 DOI: 10.1097/00005392-199907000-00055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
We have tried to review the evidence for the organisation of paediatric surgical care. Difficulties arise because of the lack of published data from district general hospitals concerning paediatric surgical conditions. Hence much of the debate about the surgical management of children is based on anecdotal evidence. However, at a time when the provision of health care is being radically reorganised to an internal market based on a system of purchasers and providers it is more important than ever to understand the issues at stake. Two separate issues have been discussed: the role of the specialist paediatric centre and the provision of non-specialist paediatric surgery in district general hospitals. There are arguments for and against large regional specialist paediatric centres. The benefits of centralisation include concentration of expertise, more appropriate consultant on call commitment, development of support services, and junior doctor training. The disadvantages include children and their families having to travel long distances for care, and the loss of expertise at a local level. If specialist paediatric emergency transport is available the benefits of centralisation far outweigh the adverse effects of having to take children to a regional paediatric intensive care centre. Specialist paediatric centres are aware of the importance of treating children and their parents as a family unit as highlighted by the Platt committee; this is an important challenge and enormous improvements have occurred to provide proper accommodation for families while their children are treated in hospital. To keep these arguments of large distances and separation from the home in context, one paediatric intensive care unit in Victoria, Australia, providing a centralised service to a region larger in are than England and with a similar admission rate, has a lower mortality rate than the decentralised paediatric intensive care provided in the Trent region of the UK. There is clear evidence that all neonatal surgery and anaesthesia should be conducted only by specialists. The debate now centres around the number of complex surgical cases a unit should treat to maintain its specialist status. The NHS executive, in its guidelines on contracting for specialist services, emphasises that "Sensible contracting needs to take into account the optimum population size not only for the stability of contracted referrals but also to give sufficient 'critical mass' for clinical effectiveness." Achieving this balance has consequences, not just for the maintenance of surgical expertise, but for the essential ancilliary services. There is clear evidence in anaesthesia that anaesthetists doing small numbers of neonatal procedures had significantly worse results. The same seems to be true in the fields of oncology, radiology, pathology, and intensive care. The reasons why the results of management of certain paediatric conditions are better at specialist centres are open to speculation. Presumably greater exposure to rare complex cases, concentration of expertise, more peer review, and a trickle down effect of the multidisciplinary approach all help to keep health care workers up to date with current world practice. In addition, it allows for appropriate specialist on call rotas and dedicated junior staff. If insufficient numbers of specialist surgical cases are being treated at a centre then the whole multidisciplinary team suffers. The 1989 NCEPOD report states "that paediatricians and general surgeons must recognise that small babies differ from other patients not only in size, and that they pose quite separate problems of pathology and management." The need for large centres of paediatric surgical expertise is now accepted by the Royal College of Surgeons of England, the British Association of Paediatric Surgeons, the Senate of Surgery of Great Britain and Ireland, the Royal College of Paediatrics and Child Health, the Royal College of Anaesthetists, the Audit
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Affiliation(s)
- G S Arul
- Department of Paediatric Surgery, Bristol Royal Hospital for Sick Children, UK
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Gheiler EL, Barthold JS, González R. Benefits of laparoscopy and the Jones technique for the nonpalpable testis. J Urol 1997; 158:1948-51. [PMID: 9334646 DOI: 10.1016/s0022-5347(01)64188-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE We report on the role of diagnostic laparoscopy combined with the Jones suprainguinal approach to orchiopexy in the treatment of abdominal testes. MATERIALS AND METHODS A retrospective review was done of 209 boys with 265 cryptorchid testes who underwent orchiopexy between January 1994 and March 1996. A subset of patients with nonpalpable testis underwent diagnostic laparoscopy and according to the laparoscopic findings either standard inguinal or suprainguinal extraperitoneal orchiopexy. RESULTS Of 209 patients 47 had 63 impalpable testes. Laparoscopy was done on 31 patients (42 testes). Findings at laparoscopy revealed 29 (69%) abdominal, 7 (17%) intracanalicular and 6 (14%) vanishing testes. A satisfactory result with scrotal position of the testis and no atrophy was obtained in 18 of 19 patients operated via the Jones approach combined with diagnostic laparoscopy. The only patient with unsatisfactory result underwent ligation of the spermatic vessels at the time of operation. In contrast, satisfactory results were achieved for only 7 of 10 intra-abdominal testes after diagnostic laparoscopy and standard inguinal orchiopexy despite universal spermatic vessel ligation. Of these 10 testes 2 ended in an inguinal location and 1 atrophied. CONCLUSIONS Laparoscopy was helpful in determining surgical approach in most cases. The suprainguinal approach allowed most abdominal testes to be placed in the scrotum without vascular ligation.
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Affiliation(s)
- E L Gheiler
- Department of Pediatric Urology, Children's Hospital of Michigan, Wayne State University, Detroit, USA
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Godbole PP, Morecroft JA, Mackinnon AE. Laparoscopy for the impalpable testis. Br J Surg 1997. [DOI: 10.1111/j.1365-2168.1997.02817.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Law GS, Pérez LM, Joseph DB. Two-stage Fowler-Stephens orchiopexy with laparoscopic clipping of the spermatic vessels. J Urol 1997; 158:1205-7. [PMID: 9258174 DOI: 10.1097/00005392-199709000-00136] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE We report the outcome of a staged approach to the intra-abdominal testicle and provide baseline data on operative time, postoperative course and testicular survival. MATERIALS AND METHODS We retrospectively reviewed the records of 441 boys (547 undescended testes). There were 105 boys (24%) with 124 nonpalpable testes (23%). All patients underwent laparoscopy. Ligation of spermatic vessels was performed as stage 1 on 20 abdominal testes (4%) in 18 boys (4%). Stage 2 orchiopexy was done using an open technique. RESULTS Two-stage orchiopexy in 18 boys included a bilateral procedure in 2, of which 1 was asynchronous and 1 was synchronous. Average operative time was 55 minutes for stage 1 and 67 minutes for stage 2. Stage 1 and 2 procedures were performed on an outpatient basis in 18 and 17 (94%) boys, respectively. There were no complications after stage 1 and 1 wound infection developed after stage 2. One testis with no vas deferens was determined to be nonviable at stage 2. The remaining 19 testes (95%) were considered viable at a followup of 6 months or greater. Viability was based on testicular size and consistency similar to those of the contralateral testis. CONCLUSIONS Laparoscopic ligation of spermatic vessels as a stage 1 procedure is a natural extension of laparoscopy. A staged approach provides adequate viability of the intra-abdominal testis.
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Affiliation(s)
- G S Law
- Department of Pediatric Urology, University of Alabama, Birmingham Children's Hospital, USA
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Law GS, Perez LM, Joseph DB. Two-Stage Fowler-Stephens Orchiopexy With Laparoscopic Clipping of the Spermatic Vessels. J Urol 1997. [DOI: 10.1016/s0022-5347(01)64428-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- G. Stanford Law
- From the Department of Pediatric Urology, University of Alabama at Birmingham Children's Hospital, Birmingham, Alabama
| | - Luis M. Perez
- From the Department of Pediatric Urology, University of Alabama at Birmingham Children's Hospital, Birmingham, Alabama
| | - David B. Joseph
- From the Department of Pediatric Urology, University of Alabama at Birmingham Children's Hospital, Birmingham, Alabama
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Abstract
Various approaches to the management of the impalpable testis in cases of cryptorchidism have been advocated. The authors' experience over the past 13 years was reviewed to try to determine an optimal approach. Of 1,305 patients with undescended testicles seen between February 1982 and December 1995, 157 boys (12.03%) had impalpable testes with 17 having bilateral impalpable testes for a total of 174 impalpable testes. A hernia sac was present in 155 impalpable testes with a testicle present in all cases. No hernia sac was found in 19 impalpable testes, five of which had no testicle present. This was confirmed by either open exploration or laparoscopy. One hundred forty-eight boys underwent groin exploration as initial treatment, 13 of these had bilateral impalpable testes. In addition to the five absent testicles with no hernia sac, one patient with a hernia sac and no testicle evident benefited from subsequent laparoscopy to identify an intraabdominal testicle. All other patients underwent routine orchidopexy or orchidectomy (one case with grossly malformed testicle). Nine boys underwent laparoscopy as initial treatment, four of these had bilateral impalpable testes. Two abnormal testicles were found and removed. Groin exploration and subsequent orchidopexy was definitive treatment in all other cases. The association of a hernia sac with an impalpable undescended testicle is very significant (P < .00001 Fisher's Exact test). The absence of a sac therefore may reflect an alternate diagnosis. When no sac is found with a testicle in the groin, this may represent an ectopic testicle. When no sac is found with no testicle, this may represent a vanishing testicle. From this experience the authors conclude that groin exploration should be the initial approach to impalpable testes. The presence of a hernia sac with an absent testicle demands further exploration; the absence of a hernia sac with an absent testicle suggests a vanishing testicle and may need no further exploration.
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Affiliation(s)
- W O'Hali
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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