Use of laparoscopy as the initial surgical approach of impalpable testes: 10-year experience

Does the presence of blind-ended vas deferens and spermatic vessels in laparoscopic exploration of non-palpable testes conclusively indicate testicular absence?

Objective

The purpose of this study was to determine whether the presence of blind-ended vas deferens and spermatic vessels (VDSV) during laparoscopic exploration of non-palpable testes (NPT) indicates testicular absence or atrophy.

Materials and methods

A retrospective analysis was conducted on clinical data of patients diagnosed with NPT and treated with surgical intervention at our center from April 2013-April 2023. The dataset encompassed information such as the children's age, affected side, size of the contralateral testis, surgical procedures employed, outcomes, and histopathological examination results. All patients underwent physical examination and ultrasonography preoperatively, followed by a combination of laparoscopic exploration and exploration through inguinal or scrotal incisions during surgery. Long-term follow-up was conducted postoperatively.

Results

A total of 476 cases comprising 504 NPT were included in this study: 302 cases on the left side, 146 cases on the right side, and 28 cases bilaterally. All patients underwent surgical treatment within 6-126 months (median 13 months). During laparoscopic exploration, blind-ended VDSV were found in 90 testes (72 on the left side, 18 on the right side), while exploration through inguinal or scrotal incisions revealed 52 (57.8%) testicular nodules with atrophy, which were excised, leaving 38 (42.2%) without any findings. Histopathological examination of atrophic nodules revealed fibrosis as the most common finding in 41 cases (78.8%), followed by involvement of the vas deferens in 33 cases (63.5%), calcification in 24 cases (46.2%), epididymis in 23 cases (44.2%), and hemosiderin deposition in 7 cases (13.6%). Fibrosis, calcification, hemosiderin deposition, involvement of the vas deferens, and epididymis were found in combination in 47 specimens (90.4%). Seminiferous tubules (SNT) were found in 3 specimens (5.7%), and germ cells (GC) were found in 1 specimen (1.9%).

Conclusion

The presence of blind-ended VDSV during laparoscopic exploration of NPT does not necessarily indicate testicular absence or disappearance. It is possible that atrophic testicular nodules are located within the inguinal canal or scrotum. This understanding contributes to the management of non-palpable testes. Considering their unpredictable malignant potential, we recommend excision.

The optimum cut-off value of contralateral testis size in the prediction of monorchidism in children with nonpalpable testis: A systematic review

BACKGROUND

Contralateral Testis Hypertrophy (CTH) is a clinical marker that could be used to guide the choice of the main surgical strategy. In patients with a Non-palpable Testis (NPT), the degree of CTH as measured by testicular length or volume has been shown to be able to predict whether the undescended testis will survive.

OBJECTIVE

The purpose of this study was to establish the proper cut-off for identifying non-viable testes based on the current literature.

DESIGN

We systematically searched several medical databases as well as Google Scholar search engines for references and citations. All the studies that reported CTH as a result of NPT in prepubertal boys were included. Data from the included articles was gathered by two independent reviewers. The checklist developed by the Joanna Briggs Institute (JBI) was used to evaluate the methodological quality of the studies that were included. Due to the incredibly high degree of heterogeneity among the studies, no meta-analysis was done.

RESULTS

The current systematic review included 17 studies that assessed the cut-off point to detect non-viable testis. The size and length of the testes were taken into consideration based on our findings. We found that different studies reported various ideal cut-off values for predicting non-viable testes, which can be brought on by various measuring techniques, evaluation ages, and patient groupings. The difference in testis volume was greater than the difference in its length, which can be attributable to the fact that some studies used an orchidometer to measure the testis's length directly or indirectly.

CONCLUSION

According to the results of our study, it seems that defining a cut point for diagnosis of CTH based on the size of the testis, cannot demonstrate the absence of a non-palpable testis.

Management of the undescended testis in children: An American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee Systematic Review

PURPOSE

Management of undescended testes (UDT) has evolved over the last decade. While urologic societies in the United States and Europe have established some guidelines for care, management by North American pediatric surgeons remains variable. The aim of this systematic review is to evaluate the published evidence regarding the treatment of (UDT) in children.

METHODS

A comprehensive search strategy and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were utilized to identify, review, and report salient articles. Five principal questions were asked regarding imaging standards, medical treatment, surgical technique, timing of operation, and outcomes. A literature search was performed from 2005 to 2020.

RESULTS

A total of 825 articles were identified in the initial search, and 260 were included in the final review.

CONCLUSIONS

Pre-operative imaging and hormonal therapy are generally not recommended except in specific circumstances. Testicular growth and potential for fertility improves when orchiopexy is performed before one year of age. For a palpable testis, a single incision approach is preferred over a two-incision orchiopexy. Laparoscopic orchiopexy is associated with a slightly lower testicular atrophy rate but a higher rate of long-term testicular retraction. One and two-stage Fowler-Stephens orchiopexy have similar rates of testicular atrophy and retraction. There is a higher relative risk of testicular cancer in UDT which may be lessened by pre-pubertal orchiopexy.

To determine the sensitivity, specificity, and diagnostic accuracy of diffusion-weighted MRI in localization of non-palpable undescended testes taking laparoscopic findings as the gold standard: A cross-sectional study from Pakistan

Background

Cryptorchidism, undescended testes, is a pathological condition that is due to failure of descent of testes in the scrotum. This study was aimed to determine the diagnostic accuracy of diffusion-weighted magnetic resonance imaging (DW-MRI) in localization of undescended testes taking laparoscopic findings as the gold standard.

Methods

A cross-sectional study was conducted in the radiology department of a tertiary care hospital from September 27, 2018 to September 26, 2019. A total of 416 patients were included. Abdomen-pelvic and scrotal ultrasound were performed. Preoperative abdominal and pelvic DW-MRI was performed with a 1.5-T MRI system using a body coil. All study patients underwent laparoscopic exploration. Intra-abdominal atrophic testes were treated with laparoscopic orchiectomy and orchiectomy samples were taken for histopathologic examination. DW-MRI findings were correlated with laparoscopic findings. A 2 x 2 table was used to calculate the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of DW-MRI taking laparoscopy as the gold standard.

Results

The mean age was 17.08 ± 7.99 years and the mean BMI was 19.36 ± 4.96 kg/m². In our study, 34.1% of cases were diagnosed as undescended testes localized by DWI-MRI and 51% of cases were diagnosed as undescended testes localized via laparoscopy. Sensitivity, specificity, PPV, NPV and accuracy were 65.1%, 98%, 97.2%, 73% and 81.3% respectively.

Conclusion

DW-MRI improves the detection of undescended testes. DW-MRI can be a recommended imaging tool to increase the preoperative diagnostic accuracy of MRI in localizing nonpalpable undescended testes.

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Undescended testis or cryptorchidism is the most common congenital genitourinary anomaly in boys.

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This study was aimed to determine the DW-MRI in localization of undescended testes taking laparoscopic findings as the gold standard.

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DW-MRI improves the detection of undescended testes.

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DW-MRI can be a recommended imaging tool to increase the preoperative diagnostic accuracy of MRI in localizing nonpalpable undescended testes.

Open controversies on the treatment of undescended testis: An update

Cryptorchidism is a common congenital malformation in pediatric urology. Although there have been many studies on the etiology of the disease, it has not been fully clarified, and while its diagnostic and treatment models have gradually approached standardization and systematization, some controversies regarding treatment remain. Additionally, although ultrasound is a non-invasive examination without ionizing radiation, its role in the evaluation of cryptorchidism remains controversial. The main basis for treating cryptorchidism is orchidopexy, and the main view on treatment age is that treatment should be performed between 6 and 12 months after birth, but no more than 18 months after birth. The view on hormone therapy is still controversial because most scholars believe that early surgery is the key to treatment. There are many surgical treatment methods for cryptorchidism, including traditional open surgery and laparoscopic surgery, which provide satisfactory results. In conclusion, the treatment of undescended testis (UDT) had been largely standardized, apart from the treatment of high intra-abdominal testis (IAT), which remains a matter of debate.

Surgical exploration for impalpable testis: Which should be first, inguinal exploration or laparoscopic abdominal exploration?

PURPOSE

To discuss an optimal surgical approach for impalpable testis in children, our own treatment results and those reported in the literature were reviewed.

MATERIALS AND METHODS

Seventy-two impalpable testes were diagnosed in 68 patients: unilateral in 64 patients and bilateral in 4 patients. All patients underwent surgical exploration at the ages of 6 to 140months (median, 15months). The inguinal canal was initially explored, and abdominal exploration was performed with laparoscopy when an extra-abdominal testis was not identified. In addition, articles regarding surgical exploration for impalpable testis, published over the last 20years, were retrieved and the results were examined.

RESULTS

Testes were detected by inguinal exploration in 28 of 72 (39%) impalpable testes: intracanalicular in 22 testes and at the internal inguinal ring (peeping or low abdominal testis) in 6 testes. All these testes were treated by conventional inguinal orchidopexy. Laparoscopic exploration was performed in 44 (61%) impalpable testes, and 4 (5.6%) high abdominal testes were detected and treated by two-stage Fowler-Stephens orchidopexy. Vanishing or absent testis was the final diagnosis in the remaining 40 testes (55.6%). The literature review showed that the ratios of intra- and extra-abdominal testes were lower in the articles that reported the results of inguinal or scrotal exploration than in those of laparoscopic exploration, although the difference was not significant.

CONCLUSIONS

Considering the relatively low incidence of high abdominal testis, we recommend to start with inguinal exploration for impalpable testis. When an extra-abdominal testis is not detected, transinguinal laparoscopic exploration should be indicated.

LEVEL OF EVIDENCE

Treatment study, Level IV.

Impalpable Testis: Evaluation of Diagnostic and Treatment Procedures and Our Treatment Protocol

Introduction

The aim of this study is to present our treatment protocol for impalpable testis.

Material and Methods

In a retrospective study we analyzed clinical data including diagnostic procedures, intraoperative findings, final diagnosis, treatment modality, and outcome of patients with impalpable testis who underwent surgery from January 2010 until December 2015.

Results

Ninety-one patients were admitted under the diagnosis of impalpable testis. In 39 patients ultrasound detected testis in the inguinal canal and orchidopexy was done. In 25 patients (48.08%) laparoscopy showed the entrance of the spermatic cord into the inguinal canal. Open exploration of the inguinal canal was done, testicular remnant removed, and appropriate testicular prosthesis implanted. Twenty patients (20/52) underwent orchidopexy of the abdominal testis (46.51%), 4 of which underwent Fowler-Stevens procedure in two stages, and in 16 patients deliberation of the testis and spermatic cord was sufficient to place the testis into the scrotum.

Conclusions

Excision of the testicular nubbin is highly recommendable, as well as implantation of the testicular prosthesis at the time of orchiectomy.

The Nonpalpable Testis: A Narrative Review

PURPOSE

While the nonpalpable testis represents a small portion of all cryptorchid testes, it remains a clinical challenge for pediatric urologists. Controversy exists surrounding the best evaluation and management of this entity. In this review we update what is known about the nonpalpable testis, including the etiology, preoperative evaluation and best surgical management as well as novel techniques and ongoing controversies.

MATERIALS AND METHODS

We searched PubMed® and MEDLINE® from January 2000 to January 2017 using relevant key terms. Of 367 articles 115 were considered for inclusion based on a priori design. Using a narrative review format, an update on the evaluation and management of the nonpalpable testis including novel concepts and techniques was synthesized.

RESULTS

The nonpalpable testis should be evaluated by physical examination only. Imaging is not indicated for routine cases. The optimal surgical approach and technique remain debatable but several novel techniques have been described. Due to the rarity of the nonpalpable testis, randomized controlled trials and other quality comparisons are difficult. Therefore, management remains controversial.

CONCLUSIONS

Evaluation and management of the nonpalpable testis remain difficult, and some aspects are still debated. Future research should focus on multi-institutional collaborative trials to determine the optimal operative management.

Low-pressure capnoperitoneum reduces stress responses during pediatric laparoscopic high ligation of indirect inguinal hernia sac: A randomized controlled study

BACKGROUND

We aimed to evaluate the effect of different capnoperitoneum pressures on stress responses in pediatric laparoscopic inguinal hernia repair.

METHODS

In this prospective randomized controlled study, 68 children with indirect inguinal hernia who underwent high ligation of hernia sac were randomly divided into 3 groups: high-pressure group (12 mm Hg, HP group, n = 26); low-pressure group (8 mm Hg, LP group, n = 20); open operation group (OP group, n = 22). Heart rate (HR), blood pressure, and end-tidal CO2 (PetCO2) were recorded, as well as the levels of adrenocorticotropic hormone (ACTH) and cortisol (COR) were measured by ELISAs before operation, during operation, and after operation, respectively.

RESULTS

After establishing capnoperitoneum, HR, blood pressure, and PetCO2 were significantly increased in the HP group compared with the OP and LP groups (P < 0.05). Comparing the intraoperatively measured ACTH and COR concentrations of the HP group to the LP group, we noted higher values in the first (P < 0.05). There was no significant difference in the postoperative concentrations of ACTH and COR among the HP, LP, and OP groups.

CONCLUSIONS

Laparoscopic surgery under LP capnoperitoneum or open operation may reduce stress responses and are superior to HP capnoperitoneum.