Laparoscopy for the Impalpable Undescended Testicle or Intersex Evaluation

Cryptorchidism is the most common disorder of male sexual differentiation, affecting 0.8 percent of infants at one year of age, 3 percent of full-term newborns, and 21 percent of premature babies. Approximately 20 percent of undescended testicles are nonpalpable, either in the scrotum or in the inguinal area, and in 20 to 50 percent of children with a nonpalpable testis, the testis is absent. Early investigation and treatment of nonpalpable testis are essential to decrease the incidence of infertility and to allow adequate follow-up for possible testicular malignancies.

Diagnostic laparoscopy is indicated for patients with nonpalpable testis or an intersex problem. After a thorough physical examination has been accomplished, laparoscopy may be used and has a direct impact on any subsequent surgical procedure. For example, if the testis is absent and blind-ending vessels are seen, an open exploration can be avoided. If, however, a testicle is present, the precise location with laparoscopy determines the optimal incision for any open procedure. If an orchiopexy is considered, the first part of a Fowler-Stephens procedure may be performed laparoscopically. This results in minimal manipulation of the testicle. Furthermore, if the testicle is dysplastic, it may be removed laparoscopically.

A testicle that cannot be located and palpated on careful physical examination of the inguinal or scrotal areas, is defined as nonpalpable. In such a case, intra-abdominal location, true agenesis, the “vanishing testis,” hypoplasia, and ascent of a canalicular testicle on examination are all possibilities that have to be investigated.

Abdominal inspection starts with an assessment of the insertion site to evaluate the safety of using a 5 mm port and continues with the evaluation of the spermatic vessels and vas deferens on the normal side. Only the affected side is assessed, and the spermatic vessels and vas deferens are followed to the internal inguinal ring. When both, the spermatic vessels and the vas deferens meet and enter the internal inguinal ring, the intervention is concluded. If a small intra-abdominal testis is observed, two additional trocars are inserted in the two sides of the lower abdomen, and laparoscopic orchiectomy is performed after clipping of the spermatic vessels and the vas deferens. When an apparently normal testis is observed inside the abdomen, the spermatic vessels are clipped as high as possible from the testicle, in order to avoid inadvertent production of ischemia. In this way, the first stage of the Fowler-Stephens procedure is accomplished. In the second stage, performed six months later, the laparoscope is inserted as in the first stage. When an atrophic testis is found, laparoscopic orchiectomy is performed, as described before. When a normal-sized intraabdominal testicle is observed, laparoscopic guided orchiopexy follows, without difficulty. In this way, fruitless inguinal explorations are avoided.

Laparoscopy has gradually become the gold standard for the diagnosis and proper treatment of the nonpalpable testis in children. At diagnosis, laparoscopy allows precise location of an undescended testicle and is the only diagnostic modality capable of establishing the definitive diagnosis of testicular absence. Laparoscopy precisely defines the intraabdominal anatomy with an accuracy rate of 99 percent.

Complications following laparoscopy for diagnosis and treatment of intra-abdominal testicles are infrequent. Preperitoneal insufflation is undoubtedly the most common and may be as high as 5 percent. More serious complications, including intestinal or vascular injuries, as well as injuries to the urinary bladder and ureter, have been reported but are rare. They may be reduced or avoided by the “open” introduction of a Hasson blunt trocar, thus avoiding blind puncture with a veress needle.




Operative Technique

After placement of the veress needle into the abdominal cavity, insufflation is begun. During insufflation, the intraabdominal pressure should rise slowly at a rate of 0.5 liters/ minute in pediatric patients and the abdomen of the child should become diffusely tympanic. Most children require carbon dioxide volumes between 0.5 and 2.0 liters. Following proper insufflation, the veress needle is removed and trocars are placed. When placing trocars, it is important not to advance these too deeply in the abdomen in order to avoid injury to the underlying bowel and vascular structures. After placement of the umbilical 10 mm trocar, the laparoscope is introduced into the abdominal cavity. The actual pressure of 10 mm Hg suffices for diagnostic procedures. For more complex procedures, the pressure of 12 to 15 mm Hg is desirable and allows for better maintenance of an adequate pneumoperitoneum.

The abdomen is inspected in the midline between the obliterated umbilical arteries in the urachus. On the pelvic sidewall, the spermatic vessels may be seen coursing towards the internal inguinal ring. If a testicle is palpable in the scrotum, the vas deferens on that side is usually quite obvious as it travels through the inguinal ring to the retrovesical recess. In most children, the external iliac vessels are easily seen as there is minimal extraperitoneal pelvic fat. The cord structures may be further identified by placing slight traction on the spermatic cord and pulling down on the descended testicle. This will cause a dimpling of the peritoneum and the spermatic vessels are easily seen near the internal ring. Indirect hernias and patent processus vaginalis may also be noted.
After inspecting the side of the normal testicle, attention is focused on the side with the undescended, impalpable gonad. If a patent processus vaginalis is noted, gonads or remnants may be present distally. However, the absence of a patent processus does not eliminate the possibility of a gonadal remnant in the inguinal area. If the cord structures are seen extending through the inguinal ring with a patent processus, the testicle may not be visible initially. Gentle pressure on the external canal will push a canalicular testicle back through the internal ring. Although canalicular testes may be managed with a standard, open inguinal orchidopexy, the benefit of laparoscopy in these cases is to assess cord length and testicular mobility. This will have a direct impact on the planned surgical approach.

During a diagnostic laparoscopy, an atraumatic grasper may be placed under direct vision to allow manipulation of bowel loops. In most cases, only two ports are needed. If the testicular absence is suspected the inspection is accomplished by direct observation of blind-ending spermatic vessels. Often the vas may end blindly at the same site or nearby, but it is the determination of the spermatic vessels that is pathognomonic for a nonexistent gonad. In those patients with a blind-ending vas, it is important that inspection is carried as high up along the sidewall towards the lower pole of the kidney as possible. If blind-ending vessels are not seen, close observation of this area is necessary. Laparoscopic inspection of the lower pole of the kidney suffices to rule out rare, high-placed gonads. Inspection of the abdominal cavity is not necessary in these patients whose spermatic vessels are blind-ending, in order to declare testicular absence.

In patients with an intersex, condition biopsy should be taken from dysplastic gonad or it may be removed. A biopsy may be accomplished with a biopsy needle passed directly into the abdomen under laparoscopic control. If an orchiectomy is to be performed, the dysplastic gonad is isolated. The spermatic vessels are identified and clipped. The vessels are then cut and the stump inspected to ensure adequate hemostasis. If a testicle is seen, it may be brought down into the scrotum with a Fowler-Stephens procedure. When performing a Fowler-Stephens procedure, the technique is similar to removing a testicle. Once the testicle is clearly identified, the dissection is limited to the cephalad surface of the testicle to identify the spermatic artery.

This dissection will not disturb the vessels of the vas deferens, which will form the major blood supply of the testicle. Initially, the spermatic artery is identified and a window is created around the vessel. A clip applier is placed through a 10 mm trocar site that has access to the spermatic artery. Two clips are placed proximal and two clips distally on the artery. The artery is then cut with scissors. In some circumstances, electrocautery may be used to coagulate the spermatic artery before the vessel is cut. This maneuver is the first step of a Fowler-Stephens procedure and can be accomplished with a minimal amount of intraabdominal dissection. During the next stage of surgery the testicle is brought down into the scrotum on its enhanced blood supply. This two-stage procedure has been successful not only in patients with long vasal loops but also in patients with high abdominal testis and short vas deferens.

In some patients, an impalpable testicle may be proximal to the internal ring in such a way that its vessels allow adequate mobilization. In these instances, a single-stage orchidopexy may be performed. This is done laparoscopically using three ports. Two 5 mm ports are placed in a lateral position and one 10 mm trocar in the midline. A peritoneal incision lateral to the spermatic cord is made. The spermatic cord is rolled medially and elevated from the retroperitoneal tissues. The gubernaculum is opened adjacent to the patent processus vaginalis. The anterior peritoneum of the gubernaculum is then opened laterally. If a loop of the vas deferens is identified, it is reflected in the cephalad direction. The testicle is grasped and the gubernacular attachments are cauterized and divided. The vas deferens are then mobilized by opening the peritoneum medially. With adequate dissection, the testicle will be able to be moved around the pelvis.

A small transverse skin incision is created at the base of the hemiscrotum and carried down through Dartos fascia. A subcutaneous pouch is created and the testicle is pulled down into the pouch. A small clamp is passed through the canal that has been developed into the peritoneal cavity. The gubernacular reflections of the lower pole of the testis can then be grasped and the testicle brought down the hemiscrotum without tension. The testicle is secured in the Dartos pouch and the skin incision is closed.  The Foley catheter and nasogastric tube may be removed in the operating room. Patients are usually given oral antibiotics for 24 hours and discharged from the hospital on the same day. Diets are advanced as tolerated.

Laparoscopy now constitutes the reference technique for the diagnosis and treatment of the nonpalpable testis. It is a simple procedure, allowing a definitive diagnosis and two-stage relocation without increasing the risk of testicular atrophy. Diagnostic laparoscopy also identifies the specific location of the intra-abdominal testicle, facilitating the development of an optimal surgical strategy. The good results reported in most series have established the laparoscopic management of the nonpalpable testis as “state-of-the-art,” with results superior to those achieved with open surgical techniques regarding morbidity, complication rate, and length of hospital stay.




Other Laparoscopic Pediatric Urological Procedures

Many other pediatric conditions may be treated using laparoscopy. If nephrectomy in the pediatric patient is planned, a retroperitoneal approach may have a distinct advantage in certain older children. Laparoscopic pyeloplasty for ureteropelvic junction obstruction has also been performed with very encouraging results. Bladder auto augmentation, another innovative procedure, is performed by incising the detrusor muscle to increase the capacity of the bladder. Other laparoscopic pediatric procedures such as hernia repairs and partial nephrectomy also have been performed. In pediatric laparoscopy, the greatest risk of complications occurs at the time of access. Some surgeons have eliminated this risk by using the Hasson trocar technique rather than the veress needle technique. In children, the peritoneal space is small and the surgeon should be familiar with working in a smaller environment. The safety of pediatric laparoscopy is well established and more and more pediatric surgeons are nowadays switching over to laparoscopy.




Laparoscopic Pediatric Nephrectomy

It is perhaps the most popular urologic indication for the laparoscopic procedure. The first cases reported in the international literature were managed using the transperitoneal approach, but the subsequent reports of nephrectomy in children were based on retroperitoneoscopy. In children, the indications denote exclusively benign diseases such as multicystic or dysplastic kidneys causing renal hypertension, nonfunctioning kidneys associated with reflux nephropathy, or obstructive uropathy, xanthogranulomatosis, pyelonephritis, protein-losing nephropathy, and occasionally, nephrolithiasis or nephropathy causing uncontrollable hypertension. The relative contraindications are malignant renal tumors, previous intra-abdominal or retroperitoneal surgery, renal trauma attributable to poor endoscopic vision into the perinephric hematoma, severe cardiopulmonary disease or severe coagulopathy, and morbid obesity with a high positioned kidney attributable to difficult renal access retroperitoneally.
In cases of vesicoureteral reflux associated with a grossly refluxing megaureter, the ureter must be sectioned near the ureterovesical junction at the level of the bladder, whereas in the absence of a grossly refluxing megaureter, the ureter can be divided either by electrocautery or between ligatures or clips at a convenient distance from the renal tissue. The extraction of the kidney can be achieved by using endobag.




Stone Removal

Retroperitoneoscopic stone removal is another procedure that presents several advantages for children. The indications are large stones entrapped at the level of the pelvis unresponsive to medical treatment. Three ports are generally necessary, one for the telescope, two for the working instruments, and sometimes a fourth trocar for a retractor to lift the renal parenchyma. The first step of the operation is to place a uretheral probe first via cystoscopy then lumboscopy. The pelvis then is opened with scissors, after which the stone extracted and removed with an endobag.




Renal Biopsy

Renal biopsy can be performed with only one trocar, using a 10 mm operative telescope with an operative channel to introduce the biopsy instrument, if necessary, another 5 mm port can be introduced.




Adrenalectomy

Resection of the adrenal glands can be performed laparoscopically or via retroperitoneoscopy. It has various advantages over conventional open surgery. With regard to tumor size, in cases of adrenal masses smaller than 5 to 6 cm, laparoscopy or lumboscopy provides an excellent access route. If the mass is larger than 6 cm, the open approach is preferable. Although the specific indications will continue to be defined, they generally include adrenal benign cysts, pheochromocytoma, adenoma, and aldosteronoma. In the case of neuroblastoma or other malignant tumors affecting children, it is preferable to adopt an open approach. Good knowledge of the adrenal pathophysiology and surgical anatomy is fundamental to the success of this procedure. Moreover, it is important to keep in mind the potential bleeding risk during dissection, especially on the right side, where the dissection may be more difficult because of the short adrenal vein and proximity of the vena cava.




Dismembered Pyeloplasty

Open pyeloplasty has been widely accepted as the surgical treatment of choice for pyeloureteral junction obstruction in children. The success rate for this procedure exceeds 90 percent. With the rapid advent of minimally access surgical techniques, laparoscopic dismembered pyeloplasty through a transperitoneal route has been described for both adults and children. Although the procedure is technically demanding and requires advanced laparoscopic surgical suturing techniques for meticulous pelviureteric anastomosis, encouraging results projecting success rates comparable with those achieved through an open approach have been reported. The first laparoscopic dismembered pyeloplasty used to treat ureteropelvic junction obstruction was described in 1992. Since that, other reports have been published describing the use of either laparoscopy or lumboscopy. The first step of the procedure is to identify the pyeloureteral junction and the planned line of pelvic reduction. A 4/0 polydioxanone suture over a straight needle then is passed percutaneously through the abdominal wall to the upper pole of the renal pelvis, then passed back through the abdominal wall again at the same point. This serves as a ‘‘hitch stitch’’ to stabilize and present the pelvis. The pyeloureteral junction is dismembered, the pelvis trimmed, and the upper ureter spatulated. Pelviureteric anastomosis then is performed using continuous 6/0 polydioxanone sutures for infants and younger children and 5/0 polydioxanone sutures for older patients. A double pigtail transanastomotic ureteric stent usually is left in situ for a few weeks postoperatively. Certainly, well-performed laparoscopy and intracorporeal suturing and knotting are necessary in the performance of this procedure. Currently, video surgical pyeloplasty is performed only in few centers with extensive experience in pediatric laparoscopic urology.




Bladder Autoaugmentation

Bladder auto augmentation by seromyotomy via laparoscopic technique has been used in selected cases to treat poor bladder capacity. This technique is easy to perform using laparoscopy, but in pediatric urology, an entero-cystoplasty or a gastrocystoplasty generally is preferred for the treatment of patients with decreased bladder capacity.




Ureteral Reimplantation

The bladder is first drained and then insufflated with carbon dioxide to 10 to 12 mm Hg pressure. The bladder is anchored to the anterior abdominal wall with one or two separated stitches inserted percutaneously under cystoscopic guidance. Under the cystoscopic vision, a camera port is first inserted over the dome of the bladder. Two other working ports with an umbrella mechanism then are inserted on either side of the bladder’s lateral wall over the suprapubic skin crease. The refluxing ureter is isolated and dissected free as with the Cohen procedure. The ureteric hiatus is repaired with interrupted 5/0 polydioxanone sutures. After the creation of a submucosal channel, a ureteroneocystostomy is performed according to the Cohen procedure using separated 6/0 stitches. A urethral catheter is left in situ only for 24 hours postoperatively.




Excision of Prostatic Utricles

The prostatic utricles, an enlarged diverticulum in the posterior urethra of males, was first described by Englisch in 1874.
Although most prostatic utricles are asymptomatic and do not need any surgical intervention. Some patients manifest symptoms as a result of infection or enlarged utricles and have been associated with recurrent urinary tract infections, stone formation, disturbed urination, recurrent epididymitis, infertility, and neoplastic degeneration. Surgical excision is the recognized treatment of choice. Surgical access to the prostatic utricle always has been a major hurdle because it lies deep within the pelvis. The first step in the operation consists of a cystourethroscopy for cannulation of the prostatic utricle. The cystoscope is left in situ inside the prostatic utricle to facilitate subsequent identification during laparoscopy. The bladder dome is hitched upward to the anterior abdominal wall by a 4/0 PDS suture inserted percutaneously under laparoscopic vision. The peritoneal reflection is incised using electrocautery, starting immediately behind the bladder. The prostatic utricle is easily identified with the guidance of illumination from the cystoscope. Using a 5 mm ultrasonic scalpel, the prostatic utricle is completely mobilized and divided at its confluence with the urethra. The urethral defect is either closed by intracorporeal suturing using fine vicryl, or simply by coagulation. The excised prostatic utricle is removed through the supraumbilical camera port.




Complicated Urachal Disease

The urachus is an obliterated fibrous cord extending from the allantoic duct remnant at the umbilicus to the apex of the bladder. Traditional surgical management of benign urachal disease involves the radical excision of all anomalous tissue with a cuff of bladder tissue via the open approach. Some authors advocate the use of such aggressive surgery only for persistent and recurrent cases. However, there is the potential for malignant change and a high-risk of recurrent symptoms in conservatively managed cases. The laparoscopic approach to the complete excision of urachal abnormalities is performed via a three-part approach. The cyst is identified and removed with a cuff of the bladder dome. The bladder defect is closed in two layers, and the indwelling urinary catheter is removed after 2 days.

Laparoscopic procedures have evolved greatly in pediatric urology during the past few years. With time and greater experience, surgeons began to prefer retro- peritoneoscopy for cases of urologic pathology, despite the major difficulties associated with the smaller operating chamber. Moreover, lumboscopy meets all the criteria of open renal surgery, according to which all urologic interventions are performed via the retroperitoneal route without transgressing the abdominal cavity. One main problem with retroperitoneal approach is that access to the bladder base or the ureterovesical junction may be difficult in older children. In addition, the retroperitoneal approach does not allow a thorough search of the peritoneal cavity for a small dysplastic and ectopic kidney, nor does it accommodate a complex ureterocele excision or bladder base reconstruction. To overcome these problems a selective approach to the diseased kidney and ureter depending on the involved pathology is necessary. The position of the diseased kidney, the presence or absence of a refluxing ureter, and the need for ureterocelectomy and bladder base reconstruction are the main determining factors. Nephrectomy for non-functioning reflux nephropathy kidneys or duplex moiety necessitating resection of a grossly dilated megaureter, especially in children older than 5 years preferably is undertaken via a lateral extraperitoneal approach. Finally, nephrectomy for small dysplastic kidneys associated with ureteric ectopia and urinary incontinence as well as complex duplex excision with extensive ureterocelectomy and lower urinary tract reconstruction should be performed via a transperitoneal laparoscopic approach. The possible urologic indications for laparoscopic surgery can be divided into diagnostic, ablative, and reconstructive procedures. For cases of the nonpalpable testis, laparoscopy is considered a better diagnostic examination and operative procedure for an orchidopexy. With regard to operative laparoscopic urologic procedures, most well- established clinical indications concern ablative procedures. To date, laparoscopic nephrectomy seems to be the procedure most frequently applied in pediatric urology.

The rapid advent of robotic technology will greatly enhance the dexterity and precision control of surgical manipulation in a small confined space of a pediatric patient. It may significantly shorten the learning curve for advanced laparoscopic procedures.