Peeping Testes Research Articles

Modified Traction Technique for Intraabdominal Testes With Short Vessels

ObjectiveTo assess the safety and efficacy of modified testicular traction technique in treatment of intraabdominal and peeping testes with short vessels. Patients and methodsIn the pediatric surgery unit, Sheikh Khalifa Medical City, Abu Dhabi, UAE, and in the pediatric urology unit, Ibn Sina Hospital, Kuwait, Forty testes in 32 patients were operated using the modification of staged traction laparoscopic-orchiopexy. The modified technique involved intracorporeal placement of suture, gabernacular sparing, no intraabdominal dissection and shorter traction duration as short as 7 days without the need of inguinal incision. ResultsAll patients tolerated both stages of surgery well without any intra-operative nor post-operative complications. The 1 year follow up period proved successful outcome in all the cases. ConclusionThe modified staged traction laparoscopic orchiopexy is safe, successful and feasible in intra-abdominal and peeping testes.

Early Experience with Laparoscopic Surgery for Undescended Testis at a Tertiary Hospital in Ibadan (2015-2019)

Background: Undescended testis (UDT) is of concern to the patient. If not treated may be complicated by trauma, torsion, male sub-fertility, and testicular cancer. In Nigeria it is commonly treated by open orchidopexy or orchidectomy. We report our experience with the laparoscopic management of undescended testes in the Western part of Nigeria.
 Methodology: The aim of this study was to report our early experience with the laparoscopic treatment of undescended testis in our centre. The study was conducted between January 2015 and December 2019. The data studied were age, unilateral or bilateral UDT, operation performed, pre-and intra-operative findings, operation time, and the outcome. The data were represented in tables and with operative pictures. Ethical clearance was obtained.
 Results: A total 12 patients were treated which consisted of 7 children and 5 adults with a mean age of 11 (6-17) years and 35.2 (29-42) years respectively. Preoperatively, 9 patients had transperitoneal laparoscopic orchidopexy, orchidectomy or varicocelectomy. The laparoscopic findings were peeping testis (5), intraabdominal testis (8), intracanalicular (5), and one absent testis. All the post-orchidopexy testes remained in the scrotum at 18 months of follow up. In the adults, there was improvement in the semen parameters in 2 men while 3 had persistent azoospermia.
 Conclusion: In our setting, laparoscopy for undescended testis is feasible, safe, diagnostic, and therapeutic. In infertile men with undescended testis and unilateral varicocele, laparoscopic varicocelectomy results in improved semen quality.

Which case is best for scrotal incision as the initial surgical approach in unilateral non-palpable testis?

Approximately 50-70% of unilateral non-palpable testis are vanishing testis and almost all are located in the scrotum. Laparoscopy has been performed increasingly as the initial procedure for management of unilateral non-palpable testis, but is unnecessary except in the minority of intra-abdominal testis. The aim of this prospective study is to examine validity of the initial scrotal incision when unilateral non-palpable testes show contralateral testicular hypertrophy and palpable intra-scrotal nubbin. We prospectively enrolled 21 patients with unilateral non-palpable testes which confirmed by palpation under general anesthesia at our institute between May 2016 and April 2019. Contralateral testicular length and volume were measured with ultrasonography. A testicular length > 1.6 cm or testis volume > 1.0 ml was considered contralateral testicular hypertrophy. In cases where unilateral non-palpable testes show contralateral testicular hypertrophy and palpable intra-scrotal nubbin, the initial scrotal incision were performed. Of the 21 patients with unilateral non-palpable testis, 12 had (57.1%) vanishing testis with scrotal nubbin in 10, inguinal nubbin in 2. Among the remaining 9 patients with sizeable testes, 5 were intra-abdominal testis and 4 were peeping testis. Of the 10 cases of scrotal nubbin, initial scrotal incision was performed in 7 cases (70.0%). Initial laparoscopy was performed in 14 cases, of which 9 cases of sizeable testis, 3 cases of scrotal nubbin, and 2 cases of inguinal nubbin which showed contralateral testicular hypertrophy but no palpable nubbin in scrotum. Contralateral testicular hypertrophy and palpable intra-scrotal nubbin was significantly predictive with 70% sensitivity and 100% specificity (P<0.001). In patients with unilateral non-palpable testis, when palpable nubbin in scrotum and/or contralateral testicular hypertrophy are present, initial scrotal incision is appropriate. In the case of contralateral testicular hypertrophy with no palpable nubbin in the scrotum, initial inguinal incision is more appropriate. Other cases should proceed to laparoscopy.

Gubernaculum Testis and Cremasteric Vessels Preservation During Laparoscopic Orchidopexy for Intra-Abdominal Testis: Effect on Testicular Atrophy Rates

PurposeGubernaculum-sparing laparoscopic orchidopexy (GSLO) - which involves anatomical delivery of the testis through the internal inguinal ring (IIR) - has been proposed as an alternative to Conventional Laparoscopic Fowler-Stephens Orchidopexy (CLO) maximizing collateral blood supply and potentially reducing atrophy rates. Herein, we test this hypothesis by comparing the 2 techniques. Materials and MethodsThe primary (dependent) outcome of this study was the rate of testicular atrophy, which was defined as palpation of a nubbin or the inability to palpate a testis (complete atrophy) on postoperative physical examination at 3 and 12 months. Doppler ultrasound was obtained routinely to further confirm the diagnosis of testicular atrophy. The following independent variables were captured: age at surgery, type of procedure (CLO vs. GSLO), surgical approach (single vs. 2-stage), location of IAT (high vs. low), and patency of the IIR ResultsMean and median age at surgery were 25.7±13.3 and 22 months respectively. Laparoscopy was carried-out for NPT, showing: vanishing IAT in 120 (29%), peeping testes in 80 (19%) and IAT in 212 (51%; 104-low and 108-high). A 1-stage procedure was performed in 44(21%) cases and 2-stage in 168 (79%). CLO was undertaken in pts 46 (22%) and GSLO in 166(78%), based on surgeon preference. The overall atrophy rate was 6.6% (14/212). 13 of 46 testes atrophied after CLO vs 1 of 166 following GSLO (28.3% vs 0.6%, p=<0.01). ConclusionsGSLO is a feasible alternative to CLO. Our findings suggest that preservation of additional vascular supply to the testis (cremasteric vessels and deferential artery as opposed.

Surgical Management of the Undescended Testis: Recent Advances and Controversies.

Undescended testis (UDT) is the most common disorder of sexual development in boys and affects 3.5% of male newborns. Although approximately half of newborn UDTs descend spontaneously, some boys develop an ascending testis later in childhood. Recent guideline recommendations advocate orchiopexy by 18 months of age to maximize potential for fertility and perhaps reduce the risk for testicular carcinoma in the future. For palpable testes, a standard inguinal approach is appropriate. However, the prescrotal approach is often effective for low inguinal testes and reduces surgical time and patient discomfort with an equivalent success rate in boys with an ascending testis. Some advocate monitoring until adolescence to determine whether the testis will spontaneously descend into the scrotum, but data do not support this approach. Instead, prompt orchiopexy is recommended. In boys with a nonpalpable testis, approximately 50% are abdominal or high in the inguinal canal and 50% are atrophic, typically in the scrotum. Routine inguinal/scrotal ultrasound is not recommended, although in an older boy who is overweight, it is appropriate. If the patient has contralateral testicular hypertrophy, scrotal exploration is appropriate, and removal of the testicular remnant and contralateral scrotal orchiopexy to prevent future contralateral testicular torsion is recommended. In most cases, diagnostic laparoscopy is advised to determine whether the testis is abdominal. For the abdominal testis, there are numerous treatment options. If the testis is mobile or a peeping testis just distal to the internal inguinal ring, standard one-stage laparoscopic or open orchiopexy should be attempted using the Prentiss maneuver. If the testicular vessels are short or the testis is not mobile, a two-stage Fowler-Stephens orchiopexy is appropriate. The second stage can be performed laparoscopically or open. Another option is microvascular testicular autotransplantation, which is a technically demanding procedure. Surgical results of abdominal orchiopexy are highly variable, short term, and highly subjective. Prospective clinical trials with follow-up into adolescence and adulthood are necessary to assess the success of various surgical approaches.

593 Laparoscopic versus open orchiopexy in the management of peeping testis: A multi-institutional prospective randomized study

Objective: Peeping testis is an inconsistently palpable/seen undescended testis that migrates back and forth at the internal inguinal ring. Both open and laparoscopic orchio- pexy are effective forms of management. The present study aimed to evaluate the efficacy and safety of both approaches. Patients and methods: Between September 2007 and January 2012, 46 peeping inguinal testes were randomly treated with either open (25 cases) or laparoscopic (21 cases) orchiopexy pro- cedures. Spermatic vessels were preserved for all cases. Operative details, postoperative morbidity and final testicular site and size were recorded. Results: Themedianageofthechildrenwas2.5years(range0.5e12.0).Thefollow-upperiodran- ged from 1.0 to 5.5 years. Of these testes, 20 in the open surgery group and 19 in the laparoscopic

Is Stephen-fowler staged approach the correct answer for orchidopexy in a peeping testis?

Is Stephen-fowler staged approach the correct answer for orchidopexy in a peeping testis?

Laparoscopic versus open orchiopexy in the management of peeping testis: A multi-institutional prospective randomized study

ObjectivePeeping testis is an inconsistently palpable/seen undescended testis that migrates back and forth at the internal inguinal ring. Both open and laparoscopic orchiopexy are effective forms of management. The present study aimed to evaluate the efficacy and safety of both approaches. Patients and methodsBetween September 2007 and January 2012, 46 peeping inguinal testes were randomly treated with either open (25 cases) or laparoscopic (21 cases) orchiopexy procedures. Spermatic vessels were preserved for all cases. Operative details, postoperative morbidity and final testicular site and size were recorded. ResultsThe median age of the children was 2.5 years (range 0.5–12.0). The follow-up period ranged from 1.0 to 5.5 years. Of these testes, 20 in the open surgery group and 19 in the laparoscopic group maintained correct intrascrotal position (P = 0.428). Re-do orchiopexy was indicated for two cases in the surgical group (P = 0.493). No cases of testicular atrophy or hernia were encountered. ConclusionOpen and laparoscopic orchiopexy procedures for peeping testes are fairly comparable. However, laparoscopy is relatively more effective, as two re-do orchiopexies were required in the open surgical group.

Inguinal approach for the management of unilateral non-palpable testis: Is diagnostic laparoscopy necessary?

ObjectiveDuring the last decade laparoscopy has increasingly been advocated as the primary investigative procedure for the management of the non-palpable testis. We reviewed the medical records in a consecutive series of boys with non-palpable testis to examine the contribution of the initial inguinal approach in the management of unilateral non-palpable testis. Materials and methodsAmong the 183 consecutive patients with cryptorchidism from 2003 to 2012, there were 21 patients with unilateral and three with bilateral non-palpable testes. All unilateral patients then underwent inguinal and scrotal exploration through an inguinal incision. For those patients with an intra-abdominal peeping testis, the gonad was placed into the scrotum after meticulous cranial mobilization of the spermatic cord. ResultsPatient age ranged from 11 months to 144 months (mean age: 23 months). Among the 21 unilateral cases, testicular absence or atrophy was confirmed in seven patients with a scrotal nubbin in six, and blind-ending vas and vessels at the external inguinal ring in one patient. Among the remaining 14 patients with sizeable testes, 12 testes were intra-abdominal peeping testes and two testicles were seen within the distal inguinal canal, which may be missed on physical examination owing to patient obesity. The intra-abdominal peeping testicle had the opened processus vaginalis entering the internal ring in which testicle was found. These were fixed into the scrotum successfully by cranial mobilization of spermatic vessel sometimes cutting the internal oblique muscle and by Prentiss and Fowler-Stephen's maneuver. Diagnostic laparoscopy was done on three patients with bilateral cases. ConclusionsGiven the result that most of nubbins are within the scrotum and testes with intra-abdominal peeping testes are fixed down safely into the scrotum, the inguinal approach may suffice for the management of unilateral non-palpable testis. Laparoscopy should be reserved for patients with bilateral non-palpable undescended testes.

Laparoscopy-assisted orchiopexy versus laparoscopic two-stage fowler stephens orchiopexy for nonpalpable testes: Comparative study

Background/Purpose:To assess the outcome of the primary laparoscopy-assisted orchiopexy (LAO) and the laparoscopic two-stage Fowler Stephens orchiopexy (FSO) for managing patients with nonpalpable testis in terms of safety, feasibility and efficacy.Materials and Methods:This study included 94 patients (110 nonpalpable testes) who underwent laparoscopy at King Khalid University Hospital, Riyadh between July 1998 and June 2012. Patients were evaluated postoperatively to check the location and size of testes and to exclude any other complications.Results:Mean age at presentation was 24+/−19 months (9-96 months). Orchiectomy was done for 5 atrophic testes. 36 open orchiopexy was done for 29 canalicular testes and 7 peeping testes. 35 LAO were done for 1 canalicular testis, 5 peeping testes, 16 low intraabdominal testes and 13 high intraabdominal testes. 34 FSO were done for 23 high intraabdominal testes, 9 low intraabdominal testes and 2 peeping testes. Median follow up was 12 months (1-84 months) and 6 patients were lost to follow up. The overall success rates for LAO and FSO were 88% and 63%, respectively. Overall testicular atrophy rates were 3% and 30% for LAO and FSO, respectively (OR 0.08 [95% CI, 0.01-0.69], P = 0.006). For high intraabdominal testes, the atrophy rates were 3% and 20% for LAO and FSO, respectively (OR 0.14 [95% CI, 0.02-1.21, P = 0.049).Testicular displacement rates were 9% and 7% for LAO and FSO, respectively (OR 1.5, 95% CI, 0.24-9.59, P = 0.514).Conclusions:Laparoscopy provides a safe and accurate modality for diagnosing and managing patients with nonpalpable testes. LAO appears to be feasible and effective in management of high intraabdominal testes. Further well-conducted comparative studies are needed.

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.

Laparoscopic Orchiopexy for Palpable Undescended Testes: A Five-Year Experience

Most recent reports of laparoscopic orchiopexy concern nonpalpable testes. We report the results of this approach in patients with undescended palpable testes. Between January 1999 and September 2004, 28 patients with 30 undescended palpable testes were treated by laparoscopic orchiopexy performed by the same surgeon. Patients with palpable cryptorchidism were included. Patients with nonpalpable testes, retractable, or vanishing testes were excluded. The mean age of the patients was 25 months (range, 8 months-5 years) and the mean weight was 16 kg (range, 8-24 kg). We used a 4-port technique (one 10-mm, two 2-3 mm, and one 5-mm), a 4-mm scope, and 2-3 mm instruments. The mean operative time was 50 minutes. The complication rate was 13.3% (4/28), all in the first two years, at the beginning of the learning curve. The remaining testes were descended by laparoscopy; 5 (16.6%) were peeping testes. We had 10 (33.3%) left and 16 (53.3%) right palpable cryptorchidia cases, plus 4 testes (13.3%) that were bilateral undescended and palpable. No hernia was found in 8 (28.6%) cases; a homolateral hernia was found in 18 (64.3%) cases, and we did not close the processus vaginalis, we only resected the membranes. We found 2 (7.1%) with contralateral hernia in which we did close the processus vaginalis. On follow-up ranging 5 months-5 years, 29 of these testes maintain good size and a correct position, with no recurrent inguinal hernia. The laparoscopic approach is a safe way to descend the palpable testicle. Although this is not a large series, it shows that laparoscopic orchiopexy of palpable undescended testes can be done without a higher complication rate than the open procedure (13.3% vs. 12.2%), with several of the advantages of the laparoscopic approach.

The role of videolaparoscopy in the diagnostic and therapeutic approach of nonpalpable testis

Evaluate the results from the first 5 years of experience with laparoscopy for diagnosis and treatment of nonpalpable testes. Medical records of 51 patients submitted to laparoscopic testicular exploration, during a 5-year period, were retrospectively analyzed. Patients' mean age was 65.7 months (median = 48) on the first procedure. The youngest patient was 10 months and the oldest was 14 years old on the first surgery. Twenty-four (47%) patients presented nonpalpable testes bilaterally, 7 (14%) only at the right side and 20 (39%) at the left, totaling 75 testicular units assessed. Patients who had their testes palpated after anesthetic induction were excluded from the study, and in all other cases, surgical management was based on the testicular position and viability. During the post-operative follow-up, surgical success was classified as palpable testis in scrotal sac, with adequate consistency and volume. Nine (12%) testes were not localized, but their vessels and deferent duct were atrophic. Two (3%) testes were intra-abdominal and atrophic, and 2 (3%) gonads, in the same patient, had a dysmorphic aspect. Nineteen (25%) testicular units were located close to the internal inguinal ring (peeping testes) and, in 22 (29%) units, the spermatic vessels and deferent duct penetrated the internal inguinal ring. Eight (10%) testes were located at a distance of less than 2 cm from the internal inguinal ring and 13 (17%) at a distance greater than 2 cm. The 2 intra-abdominal atrophic testes were removed. Inguinotomy was performed in a total of 41 (54%) cases, reaching a surgical success of 89%. Laparoscopic orchiopexy in one stage, without vascular ligation, was performed in 9 (12%) testes, which presented a distance of less than 2 cm from the internal inguinal ring, also with a surgical success index of 89%. Orchiopexy in 2 stages, with ligation of the spermatic vessels, was performed in 13 (17%) testicular units located at a distance greater than 2 cm from the internal inguinal ring, reaching 77% of good results. Videolaparoscopy is a safe and effective method for diagnosis and treatment of nonpalpable testis.

Avoidance of inguinal incision in laparoscopically confirmed vanishing testis syndrome.

Nonpalpable testicles may be due to the vanishing testis syndrome, intra-abdominal position, examination obscured by obesity or scar tissue and rarely testicular agenesis. Laparoscopy is an excellent means of distinguishing these entities without the need for open abdominal exploration. We investigated whether laparoscopy affects the need for an inguinal incision and exploration when no testicle is palpable and the vas and vas deferens are visualized exiting the internal inguinal ring on laparoscopy. In 34 boys 6 to 18 months old (mean age 41) physical examination demonstrated a nonpalpable testicle, including on the right side in 12, on the left side in 17 and bilaterally in 5. The vanishing testis syndrome was diagnosed after laparoscopy when no testicle was palpable despite physical examination done with the patient under anesthesia, spermatic vessels were visualized exiting the internal inguinal ring or spermatic vessels were visualized in the abdomen with or without an identifiable intra-abdominal testicular nubbin. Laparoscopy confirmed the vanishing testis syndrome in 16 patients, intra-abdominal testicles in 13 and peeping testes in 1. Adequate examination using anesthesia was not possible in 4 patients with obesity, or previous inguinal or lower abdominal surgery. These boys underwent inguinal exploration after laparoscopy showed the vas and vessels exiting a closed internal inguinal ring. Of the 16 cases of the vanishing testis syndrome orchiectomy with contralateral scrotal orchiopexy was performed in 14 through a median raphe scrotal incision and in 1 through an inguinal incision for an associated inguinal hernia. In the remaining patient who underwent laparoscopy only a blind ending vas and vessels were visualized in the abdomen without an identifiable nubbin. The infraumbilical and median raphe incisions healed without obvious scars. Followup was at least 1 year. When spermatic vessels are visualized exiting the internal inguinal ring on laparoscopy in the setting of a nonpalpable testicle, a median raphe scrotal incision can be made to remove the testicular nubbin associated with the vanishing testicle syndrome. Orchiectomy is possible through this median raphe incision even when the testicle is in the inguinal canal because this distance in young children is small. Cosmesis is excellent since 1 incision is within the umbilicus and the other is on the median scrotal raphe.

IS HUMAN CHORIONIC GONADOTROPIN USEFUL FOR IDENTIFYING AND TREATING NONPALPABLE TESTIS?

We evaluated the efficacy of human chorionic gonadotropin (HCG) for identifying and treating nonpalpable testis. We then compared the cost-effectiveness of this approach to that of laparoscopy. We reviewed patient charts during a 15-month period and identified 51 boys (64 testes) who underwent surgery to correct cryptorchidism. There were nonpalpable testes in 17 cases and bilateral cryptorchidism in 2 for a total of 19 impalpable testes. All patients were offered a full course of HCG. Those electing hormonal treatment received intramuscular injection of 2,000 IU/m.2 HCG (maximum 1,500 IU/injection) 3 times weekly for 3 weeks. A full course of HCG was given in 8 patients (10 testes). Of the 10 testes 8 became palpable after HCG treatment, including 1 atrophic nubbin located in the inguinal canal. Of the 2 testes that remained impalpable 1 discovered at the level of the renal vessels had complete epididymal nonunion and 1 was located closer to the inguinal ring. All 9 untreated patients underwent laparoscopy, which identified 3 intra-abdominal, 3 vanished and 2 peeping testes, and 1 atrophic testis in the inguinal canal. HCG therapy is valuable for identifying and treating nonpalpable testis. Using this agent enabled the testicle to be detected while avoiding the risks and cost associated with the laparoscopic procedure.

Laparoscopic Orchidopexy for the Nonpalpable Testis

Background: The management of the nonpalpable testis continues to evoke controversy. Laparoscopy has been utilized as a diagnostic tool for localization. More recently, it has afforded us a surgical tool with which to perform orchidopexy. Methods: Over the past two years, 12 patients have undergone laparoscopic orchidopexy. Six gonads were defined as a "peeping testis," and six were true intra-abdominal testes. Results: The six patients with peeping testis had a successful one-stage laparoscopic procedure, defined as a testis in the scrotum without atrophy. Of the six patients with a true intra-abdominal testis, three had a successful one-stage procedure, and three requiring a staged procedure. Among those having a staged procedure, one was successful, one developed testicular atrophy, and one required testis removal because both the vas deferens and vessels were too short. Conclusion: Laparoscopic orchidopexy provides a significant advance for the management of the intra-abdominal testis. However, we must separate the intra-abdominal testis from the peeping testis if we are to get a true handle on the success rate.