Needlescopic Orchiopexy for the Intra-abdominal Testis

Abstract

Source: Gill IS, Ross JH, Sung GT, Kay R. Needlescopic surgery for cryptorchidism: the initial series. J Pediatr Surg. 2000;35:1426–1430.Urologic laparoscopy was first used in 1976 to confirm the existence and location of the intra-abdominal testis in cryptorchidism. The recent development of instruments and optics with diameters of less than 2 mm has made it possible to treat cryptorchidism with needlescopic surgery. Gill and colleagues from the Cleveland Clinic present a series of 8 pediatric and 2 adult patients (age range 8 months to 37 years; median age 13 months) who underwent 12 needlescopic procedures. All 8 pediatric procedures involved orchiopexies (2 were bilateral). The 2 adults underwent orchiectomy. The procedure was completed successfully on all 10 patients, and there were no interoperative or postoperative complications. All cases were performed on an outpatient basis, and pediatric patients required no postoperative morphine-derivative analgesics before discharge. The authors argue that laparoscopic procedures offer several advantages including atraumatic mobilization of the internal spermatic vessels, decreased morbidity, minimization of analgesic requirements, and improved cosmetic results.Over the past 2 decades, the recommended age for orchiopexy has decreased from pre-teen to pre-school age.1 Pediatricians are recognizing that children with undescended testis should be referred for pediatric surgical consultation during their first year of life because of an increased risk of infertility associated with delay.1 While the palpable undescended testis is still best approached through a standard inguinal incision, needlescopic surgery is gaining support as an alternative to inguinal incision and exploration for the intra-abdominal testis. This small case series demonstrates that this new technique can be performed as an outpatient procedure. The disadvantages of this procedure include slightly longer operative time, limited visualization in some retro-peritoneal sites, the delicate nature of these tiny instruments and the need for a bloodless field because these small scopes have potential to cause inadvertent bowel and other visceral injury. Needlescopic orchiopexy requires a skilled laparoscopist who has considerable experience with a variety of undescended testes (including those in a high retroperitoneal location).Gill et al’s series adds to our increasing experience with this laparoscopic procedure.2–4 Recent reviews confirm that the palpable testis is reliably managed within the ambulatory setting through a conventional inguinal incision, while the intra-abdominal (non-palpable) testis can be successfully managed by laparoscopic orchiopexy.5 This report is intended to expand pediatricians’ awareness of the management options for cryptorchidism, a diagnosis commonly made in the primary care setting, and to reinforce patient referral within the first year of life. Pediatricians should inquire about the availability of needlescopic surgery within their community before advising parents of this option.See also: “Risk to developing germ cells from hormonal treatment of cryptorchidism,” AAP Grand Rounds, July 2000;4:2–3; and “The ectopic testis: another form of undescended testis,” AAP Grand Rounds, September 2000;4:25–26.