Intra-abdominal Testes Research Articles

Ergebnisse der laparoskopischen Orchidopexie beim nicht palpablen Hoden

Laparoscopy is an established diagnostic procedure but is less frequently used as a therapeutic method for impalpable testes. To compare the results of the classic two-stage orchidopexy described by Fowler-Stephens with a testicular vessel-sparing single-stage approach in the management of intra-abdominal testes we retrospectively analyzed our data.From January 2005 to September 2010, 105 patients (mean age 32 months) underwent laparoscopy for impalpable testes. In cases of intra-abdominal testes, laparoscopic orchidopexy was performed either in a two-stage procedure including initial ligation of the testicular vessels or as a direct single-stage procedure without ligation of the vessels. The results of both approaches were evaluated postoperatively clinically and by ultrasonography. Among the 122 impalpable testes 63 were located intra-abdominally; single-stage orchidopexy was performed in 29 testes whereas a two-stage approach was conducted in 14 testes. Fourteen gonads had to be removed due to atrophy and in six cases no testis was found at all. In the other 59 cases inguinal exploration followed resulting in 22 orchidopexies, 34 removals and 3 blind-ending vessels. During a mean follow-up of 17 months none of the 29 testes treated by single-stage orchidopexy atrophied or reascended. By contrast, two cases of atrophy, one reascent and one subumbilical wound infection occurred after the two-stage procedure. Considering our excellent experiences with single-stage management, we conclude that the single-stage approach is a reliable, safe and efficacious treatment modality of intra-abdominal testes. However, the two-stage procedure including testicular vessel ligation should be restricted to high abdominal testes with very short vessels.

Embryonal carcinoma in androgen insensitivity syndrome

Embryonal cell carcinoma is a rare clinical entity. We report a case of a 20-year-old patient who presented with lump lower abdomen for last two months with primary amenorrhea and poorly developed secondary sexual characteristics. Ultrasonography (USG) whole abdomen showed lower abdominal mass approximately 15×15×10 cm, probably neoplastic changes in intra-abdominal testis, with mild ascites, no uterus and ovaries. Fine needle aspiration cytology from the tumor mass reported the possibility of non-seminomatous germ cell tumor, possibly embryonal carcinoma. The patient received three cycles of neo-adjuvant chemotherapy (Regime Bleomycin, Etoposide and Cisplatin) followed by laparotomy, at laparotomy (L) orchidectomy with removal of tumor, (R) orchidectomy, omentectomy and appendisectomy was performed. Postoperatively the patient received two more cycles of chemotherapy of the same regime. The patient has been under close follow-up for the last three years with no evidence of disease.

Sonographic localization of nonpalpable testis: Tracking the cord technique

Objective:To evaluate the value of USG as a diagnostic tool to locate nonpalpable testis (NPT), using a new technique of tracking the spermatic cord.Materials and Methods:This technique was used in 197 instances of NPT over a period of 7 years. The presence or absence of the cord in the inguinal canal was recorded. The visualized spermatic cord was tracked down to the testis in extra-abdominal location. If spermatic cord was not visualized, the USG was extended up to look for intra-abdominal testis. The location and size of the testis were recorded, and the findings were compared with those seen at surgery.Results:The status of NPT was predicted by sonography in 191 instances. The testis was canalicular in position in 53, abdominal in 76, ascending in 5, ectopic in 8, and moving in 5 cases. There were three instances of tumor in the NPT and one case of torsion. The testes were atrophic in 36 instances. The testis was not visualized by USG in 10 instances. In four of them, spermatic cord was seen in inguinal canal, indicating vanished testes. In one patient, there was an atrophic testis with inguinal hernia. Diagnostic laparoscopy was necessary in only five cases and showed abdominal testes in two cases and the cord entering the internal ring in three cases. There were one false-positive and four false-negative results with this technique.Conclusion:USG, with the tracking the cord technique, is a sensitive diagnostic tool in NPT. It is useful for selecting the ideal therapeutic surgical approach and helps avoid diagnostic laparoscopy in most of the patients.

567 DIAGNOSTIC PERFORMANCE OF ULTRASOUND IN LOCALIZING NON-PALPABLE TESTES: A SYSTEMATIC REVIEW AND META-ANALYSIS

You have accessJournal of UrologyPediatrics: Imaging/Infections & Vesicoureteral Reflux1 Apr 2011567 DIAGNOSTIC PERFORMANCE OF ULTRASOUND IN LOCALIZING NON-PALPABLE TESTES: A SYSTEMATIC REVIEW AND META-ANALYSIS Gregory Tasian and Hillary Copp Gregory TasianGregory Tasian San Francisco, CA More articles by this author and Hillary CoppHillary Copp San Francisco, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1377AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Ultrasound is frequently obtained during the pre-surgical evaluation of boys with non-palpable undescended testes, but its clinical utility is uncertain. We performed a meta-analysis of published studies to determine the diagnostic performance of ultrasound in localizing non-palpable testes in pediatric patients. METHODS English language articles were identified by searching MEDLINE, EMBASE, and the Cochrane Library from inceptions to March 2010, and through manual bibliographic searches. We included observational studies of subjects less than 18 years who had pre-operative ultrasound evaluation for non-palpable testes, and whose testis position was determined by surgery. 12 (1.7%) studies met selection criteria, from which data on 591 testes was extracted. Articles were reviewed, selected, and abstracted by 2 independent reviewers. Data on testis location determined by ultrasound and surgery were extracted, from which ultrasound performance characteristics (true positives, false positives, false negatives, and true negatives) were derived. Meta-analysis was performed using a random-effects regression model; composite estimates of sensitivity, specificity, and likelihood ratios were calculated. RESULTS For localizing a non-palpable testis, ultrasound has a sensitivity of 45% (95% CI 29%–61%) and a specificity of 78% (95% CI 43%–94%). The positive and negative likelihood ratios are 1.48 (95% CI 0.54–4.03) and 0.79 (95% CI 0.46–1.35), respectively. A positive ultrasound increases and negative ultrasound decreases the probability that a non-palpable testis is located within the abdomen from 55% to 64% and 49%, respectively. Significant heterogeneity limited the precision of these estimates, which meta-regression revealed to be attributable to inter-study variability in the reporting of selection criteria, ultrasound methodology, and differences in the proportion of intra-abdominal testes. CONCLUSIONS Ultrasound does not reliably localize non-palpable undescended testes and, therefore, is not useful for surgical decision-making. We recommend against using ultrasound to evaluate boys with cryptorchidism, which could reduce annual health care expenditures by tens of millions of dollars. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e228-e229 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gregory Tasian San Francisco, CA More articles by this author Hillary Copp San Francisco, CA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

559 LAPAROSCOPIC ORCHIECTOMY FOR TESTICULAR NUBBIN IN IMPALPABLE TESTIS

You have accessJournal of UrologyPediatrics: Congenital Anomalies - Lower Urinary Tract & Genitalia1 Apr 2011559 LAPAROSCOPIC ORCHIECTOMY FOR TESTICULAR NUBBIN IN IMPALPABLE TESTIS Yasuyuki Naito, Akihiro Kawauchi, Kazumi Kamoi, Jintetsu Soh, and Tsuneharu Miki Yasuyuki NaitoYasuyuki Naito Kyoto, Japan More articles by this author , Akihiro KawauchiAkihiro Kawauchi Kyoto, Japan More articles by this author , Kazumi KamoiKazumi Kamoi Kyoto, Japan More articles by this author , Jintetsu SohJintetsu Soh Kyoto, Japan More articles by this author , and Tsuneharu MikiTsuneharu Miki Kyoto, Japan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1284AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Recently many cases of laparoscopic treatments for impalpable testes have been reported. Generally, laparoscopy is performed first, followed by laparoscopic orchiopexy in cases of intra-abdominal testes. If the testis is not observed intra-abdominally, it is a common practice to explore the inguinal canal to remove the nubbin. From 1996, we have used a different technique to detach the inguinal canal intra-abdominally and to remove the nubbin without incision in the groin or scrotum. We present herein the outcomes of pure laparoscopic orchiectomy for testicular nubbin in impalpable testis. METHODS Laparoscopic orchiectomy were performed for 35 cases in our department from 1996 to 2010. At first laporoscopy from the umbilical port (5mm) were performed for impalpable testis. For the cases with vas deferens and spermatic artery and vein entering into the internal inguinal ring, the inguinal canal was detached intra-abdominally without incision in the groin to remove the nubbin followed by closing internal ring and the peritoneum. We used additional two ports (5 and 3mm) for laporoscopic orchiectomy. RESULTS The operation time of the laparoscopic orchiectomy procedure (including laparoscopic observation) in 35 cases ranged from 45 to 105 minutes (median: 65 minutes). We were able to close internal ring and the peritoneum completely by 5-0 absorbable suture. The average of hospital stay was 1.5 days. There were no complications in any cases of orchiectomy. All patients showed no inguinal hernia after operation. The latest case, we performed laparoendoscopic single site surgery (the umbilical single port) for the same condition. The operation time was 75minutes. CONCLUSIONS It seems to be feasible to diagnose and remove the testicular nubbin in the inguinal canal laparoscopically without incision in the groin or scrotum. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e226 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Yasuyuki Naito Kyoto, Japan More articles by this author Akihiro Kawauchi Kyoto, Japan More articles by this author Kazumi Kamoi Kyoto, Japan More articles by this author Jintetsu Soh Kyoto, Japan More articles by this author Tsuneharu Miki Kyoto, Japan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Laparoscopic Management of Nonpalpable Testis: New Treatment Strategy

We established a new strategy for nonpalpable testis, including intra-abdominal testis, testicular nubbins, and intracanalicular testis, to correct these conditions by laparoscopic procedures. Of the 53 boys (mean age, 24.5 months), nonpalpable testis was on the right side in 13, on the left in 34, and bilateral in 6. Three boys with nonpalpable testis involved contralateral palpable undescended testis. We applied only laparoscopic treatment without open inguinal incision for all cases. After laparoscopic orchiopexy and orchiectomy, we performed subsequent laparoscopic inguinal ring and/or peritoneal defect closure to prevent postoperative inguinal hernia formation, and concurrent laparoscopic repair for cases of contralateral undescended testes and open processus vaginalis under the same anesthesia. All boys underwent laparoscopic treatment immediately after laparoscopic evaluation. We performed laparoscopic orchiopexy for 22 cases with intra-abdominal testes. Twenty-seven boys underwent laparoscopic groin exploration, and 24 underwent subsequent laparoscopic orchiectomy for testicular nubbins, and 3 underwent subsequent laparoscopic orchiopexy for intracanalicular testes. In two boys with testicular nubbin, an open processus vaginalis was present. Forty-nine boys underwent laparoscopic inguinal ring and/or peritoneal defect closure after orchiopexy or orchiectomy to prevent inguinal hernia formation or hydrocele testis. Concurrent laparoscopic contralateral inguinal closure was performed for two cases with opened contralateral processus vaginalis. Our new strategy is useful because all patients with nonpalpable testis could be treated successfully by only laparoscopic management, avoiding open inguinal incision, preventing inguinal hernia formation, and enabling the concurrent repair of contralateral undescended testis and open processus vaginalis.

Laparoendoscopic single site orchiopexy

We report a laparoendoscopic single site orchiopexy in a 2-year-old boy with a right nonpalpable testis. Diagnostic laparoscopy using a 5-mm port revealed a right intraabdominal testis. The 5-mm port site was extended to accommodate the smallest commercially available triport, and orchiopexy was performed. The operative time was 55 minutes, and the estimated blood loss was minimal. There were no complications, and surgical and cosmetic results were excellent. Laparoendoscopic single site surgery is a feasible technique for orchiopexy of the nonpalpable testis.

The development and anatomy of the gubernaculum in Hoxa11 knockout mice

Background The gubernaculum is central to testicular descent, with recent evidence suggesting that it elongates to the scrotum like a limb bud. Homeobox (Hox) genes involved in limb bud outgrowth are expressed within the gubernaculum. Mice with homozygous Hoxa11 gene deletions have bilateral cryptorchidism. This study investigated the precise anatomical effects of Hoxa11 mutation on the mouse gubernaculum. Methods The pelvises of postnatal mice (n = 46; days 1-10) with Hoxa11 knockout (n = 19), heterozygotes (n = 11), and wild-type (n = 16) mice were serially sectioned and stained with hematoxylin and eosin. Immunohistochemistry was performed for the presence of desmin. Results Hoxa11 mutant mice had intraabdominal cryptorchid testes and highly convoluted vas deferentia. The gubernacular bulbs were abnormal, with no “outgrowth” and persistence of the prenatal “swelling reaction.” Desmin immunostaining revealed the lack of undifferentiated mesenchymal cells usually seen as a “swirl” within the bulb and decreased formation of cremaster muscle. Conclusions Hoxa11 may be involved in forming the growth center seen as the “swirl” of mesenchyme within the gubernacular bulb, consistent with these cells being required for gubernacular elongation during testicular descent. Hoxa11 mutations may well contribute to failure of gubernacular migration in boys with cryptorchidism.

Diagnostic Performance of Ultrasound in Nonpalpable Cryptorchidism: A Systematic Review and Meta-analysis

Ultrasound is frequently obtained during the presurgical evaluation of boys with nonpalpable undescended testes, but its clinical utility is uncertain. To determine the diagnostic performance of ultrasound in localizing nonpalpable testes in pediatric patients. English-language articles were identified by searching Medline, Embase, and the Cochrane Library. We included studies of subjects younger than 18 years who had preoperative ultrasound evaluation for nonpalpable testes and whose testis position was determined by surgery. Data on testis location determined by ultrasound and surgery were extracted by 2 independent reviewers, from which ultrasound performance characteristics (true-positives, false-positives, false-negatives, and true-negatives) were derived. Meta-analysis of 12 studies (591 testes) was performed by using a random-effects regression model; composite estimates of sensitivity, specificity, and likelihood ratios were calculated. Ultrasound has a sensitivity of 45% (95% confidence interval [CI]: 29-61) and a specificity of 78% (95% CI: 43-94). The positive and negative likelihood ratios are 1.48 (95% CI: 0.54-4.03) and 0.79 (95% CI: 0.46-1.35), respectively. A positive ultrasound result increases and negative ultrasound result decreases the probability that a nonpalpable testis is located within the abdomen from 55% to 64% and 49%, respectively. Significant heterogeneity limited the precision of these estimates, which was attributable to variability in the reporting of selection criteria, ultrasound methodology, and differences in the proportion of intraabdominal testes. Ultrasound does not reliably localize nonpalpable testes and does not rule out an intraabdominal testis. Eliminating the use of ultrasound will not change management of nonpalpable cryptorchidism but will decrease health care expenditures.

Intra-Abdominal Testis: Histological Alterations and Significance of Biopsy

Intra-abdominal testes represent only 5% of undescended testes. Review of the literature reveals that few data exist on the histological analysis of intra-abdominal testes. We studied histological alterations in intra-abdominal testes in relation to patient age at orchiopexy. A total of 57 boys underwent laparoscopy for impalpable undescended testes between October 2002 and June 2005. Testicular biopsies were taken from intra-abdominal testes, fixed in 3% glutaraldehyde, embedded in Epon, sectioned at 1 micron thickness and stained with toluidine blue. Histomorphometric analysis was performed by light microscopy. Effect of age at operation on histological evaluation of abdominal testes was also studied. Testicular biopsies from 29 patients with intra-abdominal testes showed the histological alterations of decreased mean diameter of seminiferous tubules, germinal cell depletion (55%) and presence of microliths (6.9%). As age at orchiopexy increases, deviation from the norm is more evident and absence of germ cells on biopsy becomes more pronounced, reaching a rate of 93% after age 3 years. Further studies on orchiopexy with or without biopsy in the first few months of life would likely improve our understanding and treatment of cryptorchidism.

Radiology-Pathology Conference: mature teratoma arising from an intra-abdominal undescended testis in a 7-month-old infant

We report a rare case of an intra-abdominal testicular mature teratoma in a 7-month-old male infant presenting with a palpable abdominal mass and unilateral undescended testis. We describe the pathology, clinical presentation, and imaging findings of this entity. Clinical features accompanied by characteristic radiologic findings guide a provisional diagnosis that is confirmed by histologic analysis following surgical removal of the tumor. The pathogenesis and radiologic findings of testicular mature teratomas in the prepubertal population share many similarities to that of mature ovarian teratomas commonly seen in females of reproductive age. Awareness of this entity will permit the radiologist to suggest timely diagnosis and intervention when presented with a similar case.

Diagnostic Performance of Diffusion-Weighted MRI in the Detection of Nonpalpable Undescended Testes: Comparison With Conventional MRI and Surgical Findings

The aim of this feasibility study was to evaluate the role of diffusion-weighted MRI in the evaluation of nonpalpable undescended testes. Thirty-six boys with undescended testes underwent preoperative abdominal and pelvic MRI to identify the location of the testes. MRI included free-breathing diffusion-weighted imaging (DWI) with b values of 50, 400, and 800 s/mm(2), a T1-weighted turbo spin-echo sequence, and a T2-weighted fat-suppressed turbo spin-echo sequence. After laparoscopic examinations, two observers independently reviewed the preoperative images. The DW images alone were reviewed first, followed by the conventional MR images alone and the conventional MR and the DW images together. The laparoscopic and MRI findings were compared. Sensitivity, specificity, and accuracy in the identification of nonpalpable undescended testes were calculated for DWI, conventional MRI, and the combination of DWI and conventional MRI. The combination of DWI and conventional MRI was the most sensitive and most accurate technique. Observer 1 found 31 undescended testes, and observer 2, 30 testes with this technique. Sensitivity was 0.91 and 0.88 for observers 1 and 2, and accuracy was 0.92 and 0.86. With DWI alone, observer 1 located 30 testes, and observer 2, 28 testes (sensitivity, 0.88 and 0.82; accuracy, 0.86 and 0.81). Using conventional MRI alone, both observers located 29 testes (sensitivity, 0.85; accuracy, 0.86 and 0.84). The accuracy of locating testes was superior with the combination of DWI and conventional MRI for both observers (accuracy, 0.92 and 0.86). An intraabdominal atrophic testis managed by laparoscopic orchiectomy was found by neither observer with DWI or with conventional MRI. Use of DWI with a high b value yields information that complements conventional MRI findings, improving identification and location of nonpalpable undescended testes. We recommend the use of conventional MRI in addition to DWI to increase the preoperative sensitivity and accuracy of identifying and locating nonpalpable testes.

Findings of fat‐suppressed T2‐weighted and diffusion‐weighted magnetic resonance imaging in the diagnosis of non‐palpable testes

To evaluate the magnetic resonance imaging (MRI) findings, diagnostic accuracy and clinical usefulness of fat-suppressed T2-weighted and diffusion-weighted imaging (DWI) in the management of non-palpable testes. In all, 56 children (63 non-palpable testes) aged 8 months-11 years (mean 24.7 months) with non-palpable testes were enrolled. T1- and T2-weighted imaging, as well as fat-suppressed T2-weighted imaging and DWI were performed during MRI examination, and the imaging results were compared with surgical findings. In the 63 non-palpable testes, MRI identified 22% (14/63) as intra-abdominal, 20% (13/63) as intra-canalicular, 29% (18/63) as testicular nubbins, and 29% (18/63) as unidentifiable. Although it was difficult to confirm their presence in the abdominal cavity using T1- and T2-weighted imaging alone, additional assessment, including fat-suppressed T2-weighted imaging and DWI facilitated the detection of intra-abdominal testes more easily because they were imaged at a markedly higher signal intensity. The sensitivity, specificity and positive and negative predictive values for the MRI vs the operative findings were 100, 97.3, 96.3, and 100%, respectively. The overall prediction accuracy was 98.4%. Additional MRI assessments, fat-suppressed T2-weighted imaging and DWI are useful examinations to improve the preoperative diagnostic accuracy of non-palpable testes.

Testicular cancer: Management challenges in an African developing country

Advances in oncology have greatly improved the prognosis of testicular cancer. In developing countries, however, the outcome is still poor. Twenty-four patients managed for testicular cancer at two centres (University of Nigeria Teaching Hospital, Enugu, Nigeria, and JAMA Urological Clinic, Enugu) between April 1984 and March 2003 were prospectively studied. Histopathological data were obtained in all cases. Peak age incidence was 20 - 29 years. Testicular swelling was the principal complaint in 23 patients. The mean interval between onset of symptoms and presentation was 5.3 months. Two patients (8.3%) presented with stage 1 disease, 7 (29.2%) with stage 2, 7 (29.2%) with stage 3, and 8 (33.3%) with stage 4. Seventy-five per cent of tumours were right-sided, and 25% were left-sided. Treatment consisted of radical orchidectomy in all patients and cisplatin-based chemotherapy and radiotherapy in some patients. One patient with a tumour in an intra-abdominal testis underwent laparotomy. The most common histological types were seminoma and embryonal carcinoma. A fifth of the patients died, while half were lost to follow-up. The mean follow-up period was 9 months. Morbidity and mortality of testicular cancer is high in developing countries. Late presentation, poverty, paucity of resources and the high cost of newer imaging modalities and treatment are major challenges to management. Better health funding and education regarding testicular self-examination is essential.

Laparoscopic orchiopexy for non-palpable testes: outcome of two techniques

Objective To assess the outcome of laparoscopic orchiopexy and the two-stage Fowler Stephens technique for managing patients with impalpable testis in terms of safety, feasibility and efficacy. Patients and methods This study included 78 patients who presented with 88 non-palpable testes to the outpatient clinic of Sohag university hospital in 2005–2009, and underwent laparoscopy by the same surgeon. Intra-abdominal testes were managed by laparoscopic orchiopexy if low, two-stage Fowler–Stephens technique if high, and orchiectomy if atrophic. Children were evaluated postoperatively to check the location and size of the testicle and to exclude any other complication. Results Median age at presentation was 16 months (range 11–42 months). Four testes were absent while inguinal exploration was necessary for six testes with the vas entering the internal ring. Of the 78 intra-abdominal testes, 45 were identified as high (Fowler–Stephens in 43; orchiectomy in two atrophic testes) and 33 as low (orchiopexy). Follow up was 3–55 months (mean 34 months). Twelve patients (12 testes) were lost to follow up (7 Fowler–Stephens; 5 orchiopexy). On follow up, the testes were normal sized and well positioned in the scrotum in 28/28 and 32/36 testes in the orchiopexy and Fowler–Stephens groups with an overall success rate of 100% and 88.8%, respectively. Two testes showed testicular displacement and two showed testicular atrophy in patients of the Fowler–Stephens group. Conclusion Laparoscopy provides a safe and accurate modality for diagnosing and managing patients with non-palpable testes, with excellent outcomes.

Persistent Mullerian Duct Syndrome in a Miniature Schnauzer Dog with Signs of Feminization and a Sertoli Cell Tumour

A 5-year-old male Miniature Schnauzer was presented with unilateral cryptorchidism and signs of feminization. Abdominal ultrasonography revealed an enlarged right testis and a large, fluid-filled cavity that appeared to arise from the prostate. Computed tomography revealed the cavity to be consistent with an enlarged uterine body, arising from the prostate, and showed two structures resembling uterine horns that terminated close to the adjacent testes. The dog had a normal male karyotype, 78 XY. Gonadohysterectomy was performed and both the surgical and the histological findings confirmed the presence of a uterus in this male animal, resulting in a diagnosis of persistent Mullerian duct syndrome (PMDS). The enlarged intra-abdominal testis contained a Sertoli cell tumour. Computed tomography proved to be an excellent diagnostic tool for PMDS.

Spermatogenesis After 1-Stage Fowler-Stephens Orchiopexy in Experimental Cryptorchid Rat Model

To evaluate the validity of 1-stage Fowler-Stephens orchiopexy, we performed this procedure for intra-abdominal testes in an experimental cryptorchid rat model and assessed postoperative spermatogenesis. Cryptorchidism in rats was induced by injecting flutamide into the abdomen of pregnant Sprague Dawley rats for 7 days (days 14 to 20 of gestation). Four-week-old cryptorchid rats were divided into the 4 groups of sham operation (group 1, 7 rats), orchiopexy only (group 2, 7), spermatic vessel ligation only (group 3, 7), and spermatic vessel ligation and orchiopexy (1-stage Fowler-Stephens orchiopexy, group 4, 7). The testes were removed 12 weeks after birth in all groups, and testicular weight, testicular histopathological findings and presence of sperm in the epididymis were examined. All operated testes had reticulated vessels on the tunica albuginea. There were no statistically significant differences in the testicular weight between groups 1 (mean +/- SD 0.47 +/- 0.04 gm) and 4 (0.30 +/- 0.19), suggesting that Fowler-Stephens orchiopexy did not induce significant testicular atrophy. However, seminiferous tubule diameters in group 4 were significantly smaller than in group 1 (p <0.001), and no sperm was observed in the epididymis of group 4 rats, suggesting that Fowler-Stephens orchiopexy reduced seminiferous tubule diameters and did not improve spermatogenesis. Although Fowler-Stephens orchiopexy is a good procedure to maintain testicular size and correct cosmetic deformity of an absent scrotum, it may not significantly contribute to the improvement of spermatogenesis.

Laparoscopic Management of Impalpable Testis in Children, New Classification, Lessons Learned, and Rare Anomalies

Cryptorchidism is the most common genitourinary anomaly in male children. About 20% of cryptorchid testicles are impalpable. Laparoscopy has become one of the important diagnostic modalities for the management of impalpable testes. The aim of the present study was in highlighting the lessons and rare anomalies encountered during the management of impalpable testes in children over a period of 10 years in a single pediatric surgery center and to establish a new classification that better describes the anomalies. A retrospective review of 93 laparoscopic explorations for nonpalpable testes between 1998 and 2008 was conducted. Demographic data, intraoperative findings and management, associated anomalies, and postoperative follow-up were collected and analyzed. A new laparoscopic classification is described. Age range was 7 months to 8 years. Twenty bilateral versus 73 unilateral impalpable testes were operated on. Four groups were established with subgroups in each group. Group 1 (vanishing syndrome) had 44 cases, group 2 (peeping testes) had 21 cases, group 3 (intra-abdominal testes) had 38 cases, and group 4 (disorders of sex development) had 10 cases. Associated anomalies included 4 cases of Down syndrome, 7 cases of neurologic impairment, 3 of renal anomalies, 3 of cardiac anomalies, and 1 case of eye anomalies. Follow-up range was 1-6 years. A new laparoscopic classification is presented that better describes the anomalies and help-in planning the treatment of impalpable testes. Impalpable testes with Down syndrome are sometimes associated with bizarre anatomy. Parents should be well informed of all the possible findings, especially in bilateral cases.

Is Staging Beneficial for Fowler-Stephens Orchiopexy? A Systematic Review

Fowler and Stephens showed that by dividing the spermatic vessels a high intra-abdominal testis could be placed in the scrotum. Testicular atrophy is a potential complication of this technique. We conducted a systematic review to determine whether single or 2-stage Fowler-Stephens orchiopexy results in better testicular viability. We searched electronic databases, clinical trial registries and gray literature. We included reports describing boys younger than 18 years with a primary outcome of "testicular viability and position." We performed a meta-analysis using random effects models. Heterogeneity was assessed using forest plot and I(2) statistic. We identified 1,807 citations and included 61 articles. Single stage Fowler-Stephens orchiopexy was discussed in 9 articles, a 2-stage procedure in 36 and both approaches in 16. There were no randomized controlled trials, and most studies were cohort or case series. The pooled estimate of success rates was 80% for single stage Fowler-Stephens orchiopexy (95% CI 75 to 86) and 85% for 2-stage Fowler-Stephens orchiopexy (95% CI 81 to 90). The pooled odds ratio of single stage vs 2-stage Fowler-Stephens orchiopexy was 2.0 (95% CI 1.1 to 3.9) favoring the 2-stage procedure. There was no difference in the success rate between laparoscopic and open techniques in either single or 2-stage Fowler-Stephens orchiopexy. There was no evidence of asymmetry on the funnel plot. There were no complications reported with single stage, while ileus, hematoma and infection were the most common complications with 2-stage Fowler-Stephens orchiopexy. Both techniques have a fairly high success rate but 2-stage Fowler-Stephens orchiopexy appears to carry a higher rate of success than the single stage approach (85% vs 80%, OR 2 in favor of 2-stage). Laparoscopic and open techniques had the same success rate. However, the level of evidence of the studies was low, and a study of a more robust design, such as a randomized controlled trial, should be performed.

Laparoscopic Stephen-Fowler Stage Procedure: Appropriate Management for High Intra-Abdominal Testes

The length of testicular vessels is the main length-limiting factor to bring down the testes in the scrotum. Fowler and Stephen proposed the division of testicular vessels, high and as far from the testes as possible to maintain collateral blood supply, to treat high intra-abdominal testes. Cortesi introduced the diagnostic laparoscopy and Jorden first did the laparoscopic orchiopexy for nonpalpable testes. We had done Fowler-Stephen staged orchiopexy for high intra-abdominal testes, in which both stages were done laparoscopically. In total, 17 testes of 13 patients had undergone laparoscopic staged Fowler-Stephen orchiopexy. The decision to perform a staged Fowler-Stephen orchiopexy was based on the distance of the testis from the deep inguinal ring on laparoscopy. If distance was more than 2.5 cm, then we proceeded to a laparoscopic staged Fowler-Stephen orchiopexy. In the first stage, testicular vessels were cauterized by bipolar diathermy. Laparoscopic second-stage Fowler-Stephen procedure was done 6 months after the first stage. Patients were regularly followed, and the success of the procedure was assessed by the size of the testes and the position in the scrotum. Testicular vascularity was assessed by color Doppler ultrasonography. There was no testicular atrophy on second stage and on follow-up. All testes were in the scrotum with good size on follow-up. There was no complication related to laparoscopy. In cases of high intra-abdominal testes, the staged Fowler-Stephen procedure should be the procedure of choice. This procedure yields a high success rate. Transaction of vessels by bipolar diathermy is a very safe, cost-effective method.