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Laparoscopic Diagnosis and Treatment of Nonpalpable Testes
Table 2: Distribution of surgery done in intra-abdominal testicular units excessive estrogen exposure during pregnancy, intrauterine
1
Stephen growth retardation, and prematurity. It has been stated that
Single-stage Fowler stage 1 Laparoscopic around 4–5% of males are born with undescended testes, which
laparoscopic Stephen mobilization of vessels may be unilateral or bilateral. This incidence decreases to around
Procedure orchidopexy Fowler stage 2 and open orchidopexy 1–2% at the age of 3 months, due to the spontaneous descent in
2
Total number 49 60 2 the first few months of life. The risk of neoplastic changes in an
of testicular intra-abdominal testis is about 5%. In about 9 out of 10 men with
units bilateral undescended testes and in about a third of men with
a unilateral undescended testis, azoospermia may be present.
Increased risk of infertility, malignant changes, trauma, and a
with peeping testicular units, four required open orchidopexy, while realistic possibility of psychological stigma on patients with
in three patients, single-stage laparoscopic orchidopexy was done. cryptorchid testis warrants its treatment. 3
In case hypoplastic spermatic vessels with vas deferens enter a Descent of testes is a complex embryological process. Most
closed deep inguinal ring, the testis was deemed atrophic and literature reviews suggest that the complex remodeling and
further surgery for the removal of nubbin and placement of migration of the gubernaculum into the scrotum under the effects of
prosthesis was planned at puberty. androgens and calcitonin gene related peptide (CGRP) production by
Of the 49 patients with intra-abdominal right nonpalpable the genitofemoral nerve are the possible causes of cryptorchidism.
testicular units, 31 were intra-abdominal; of these, 12 were Inadequacy of androgen production by the developing testis as a
amenable to single-stage laparoscopic orchidopexy, 2 patients result of subnormal pituitary or placental stimulation is the cause
needed laparoscopic mobilization with inguinal exploration of testicular maldescent. Androgens act through the genitofemoral
for long loop vas, and 19 needed two-stage procedure. Out nerves; hence, a minor deficiency of either of the two nerves may
of 10 patients with peeping testicular units, 9 required open be the cause of unilateral undescended testis. 3
orchidopexy, while in 1 patient, single-stage laparoscopic Radiological imaging may be done by ultrasound, computed
orchidopexy was done. Six intracanalicular testicular units tomography (CT), and magnetic resonance imaging (MRI). Several
underwent open orchidopexy. data with ultrasonography (USG) have shown a sensitivity of 44%
Thirty-three patients had bilateral nonpalpable testicular units. and a specificity of 70%. Elder, in 2002, suggested USG to be
5
Of these 66 units, 46 were intra-abdominal testes. Of these, 19 unnecessary to assess boys with nonpalpable testes. 6
testicular units were possible to bring down by single-stage bilateral The timing of the surgery is controversial. The principle of
orchidopexy and 27 testicular units required two-stage surgery. Out orchidopexy is based on the idea that temperature effect is
of five peeping testicular units, four required open orchidopexy, reversible once the testis is placed in the scrotum and it aims
while in one patient, single-stage laparoscopic orchidopexy to prevent abnormal gonocyte maturation. Currently, around
was done. Six intracanalicular testicular units underwent open 6–12 months of age is taken as the age for surgery in most pediatric
orchidopexy. Out of nine atrophic testicular units, five had centers. Therefore, it is recommended that undescended testes
diagnostic laparoscopy, one unit had laparoscopic nubbinectomy, (UDT) surgery should be done in the first year of life (most probably
and the rest three had open nubbinectomy. within 3–6 months). The surgical principle for cryptorchidism is
When we studied the location of the intra-abdominal testis testicular mobilization that includes separation and ligation of the
according to the location in relation to the deep inguinal ring, we processus vaginalis and other investing structures of the testes and
found that 51 of the testicular units were located within 2 cm of their attachments, before relocating them within the scrotum. 3
the deep inguinal ring. Of these, 49 cases underwent single-stage Current studies in the literature suggest that nonpalpable testes
laparoscopic orchidopexy and 2 patients required laparoscopic should be managed laparoscopically. Radiological investigations
mobilization followed by open orchidopexy due to long loop may or may not be used as an adjunct. Laparoscopic management
1
vas. Sixty testicular units were found beyond 2 cm from the deep of nonpalpable testis was first described by Jordan et al. in 1992.
inguinal ring and all were managed by two-stage Fowler–Stephens In 1976, Cortesi et al. introduced a diagnostic laparoscopy as
laparoscopic orchidopexy (Table 2). a treatment modality for the nonpalpable testis. Index study
7
There were no complications after the surgical procedure. There emphasizes the role of laparoscopy as an invaluable tool for the
were no inguinal or scrotal infections. Patients were discharged on holistic management of nonpalpable testes as it has helped in the
the same evening or the next day, depending on parental comfort localization of all the 182 nonpalpable testicular units.
and distance from the hospitals. Boys with bilateral repairs were It has been reported that approximately one in five
generally kept for one night. cryptorchid testes is not palpable. It might be intra-abdominal,
2
Single-stage orchidopexy was tougher in older children. intracanalicular, atrophic, or even totally absent. Vanishing testis
Testicular placement in older boys was frequently high scrotal, reportedly results from perinatal vascular accidents or intrauterine
despite the near distance from the ring and pliable vessels. testicular torsions. Vanishing testis needs no further intervention
We saw no testicular losses after Fowler–Stephens first-stage after the diagnosis, and in these cases, laparoscopy is most
orchidopexy. Testicular placement was satisfactory after the second advantageous as it avoids an inguinal exploration. In atrophic
stage in all patients operated by staged the Fowler–Stephens testis, the atrophic element needs to be removed and inguinal
technique. exploration is unnecessary without testicular implant placement
1
in the same sitting. Index study had 41 patients with atrophic and
dIscussIon vanishing testis. The inguinal exploration was deferred in these
Cryptorchid or undescended testes are those which fail to cases. These boys will require testicular implant at puberty, when
migrate to the base of the scrotum and occupy a final position the excision can be done through the inguinal incision. Elder had
either in the groin or within the abdomen; the risk factors being, observed that testicular vessels and vas entering a closed deep

World Journal of Laparoscopic Surgery, Volume 14 Issue 3 (September–December 2021) 159