Unilateral Nonpalpable Testis Research Articles

THE MANAGEMENT OF UNILATERAL NONPALPABLE TESTIS: HOW TO MANAGE THE BOYS WITH BLIND ENDING VESSELS ON INITIAL LAPAROSCOPY

You have accessJournal of Urology1 Apr 2008THE MANAGEMENT OF UNILATERAL NONPALPABLE TESTIS: HOW TO MANAGE THE BOYS WITH BLIND ENDING VESSELS ON INITIAL LAPAROSCOPY Yuichiro Yamazaki, Mari Suzuki, Yoshiyuki Shiroyanagi, Daisuke Matsuno, and Yukichi Tanaka Yuichiro YamazakiYuichiro Yamazaki More articles by this author , Mari SuzukiMari Suzuki More articles by this author , Yoshiyuki ShiroyanagiYoshiyuki Shiroyanagi More articles by this author , Daisuke MatsunoDaisuke Matsuno More articles by this author , and Yukichi TanakaYukichi Tanaka More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(08)60287-6AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "THE MANAGEMENT OF UNILATERAL NONPALPABLE TESTIS: HOW TO MANAGE THE BOYS WITH BLIND ENDING VESSELS ON INITIAL LAPAROSCOPY." The Journal of Urology, 179(4S), p. 98 © 2008 by American Urological AssociationFiguresReferencesRelatedDetails Volume 179Issue 4SApril 2008Page: 98 Advertisement Copyright & Permissions© 2008 by American Urological AssociationMetricsAuthor Information Yuichiro Yamazaki More articles by this author Mari Suzuki More articles by this author Yoshiyuki Shiroyanagi More articles by this author Daisuke Matsuno More articles by this author Yukichi Tanaka More articles by this author Expand All Advertisement PDF downloadLoading ...

Additional Benefit of Laparoscopy for Nonpalpable Testes: Finding A Contralateral Patent Processus

To determine the incidence of contralateral patent processus vaginalis discovered at laparoscopy in patients presenting with a unilateral nonpalpable testis. From August 1997 through February 2006, 159 boys underwent laparoscopic exploration for a unilateral nonpalpable testis. The data were retrospectively reviewed to determine the incidence of contralateral patency, and the results were analyzed with respect to age at repair and side and size of the unilateral nonpalpable testis. The median age of the patients was 1.2 years (range 2 months to 16 years). The nonpalpable testis was on the left side in 100 patients (63%) and on the right side in 59 (37%). The testis was absent in 13 patients (8%), atrophic in 78 (49%), and of normal size in 68 (42%). The overall incidence of a contralateral patent processus vaginalis was 19% (30 of 159). A contralateral patent processus vaginalis was seen in 21% of the boys younger than 2 years old, 19% of boys 2 to 5 years old, and 12% of boys older than 5 years. The incidence of a contralateral patent processus vaginalis was no different for patients with right (20%) versus left (18%) nonpalpable testes. Patients with normal-size testes (34%) had a much greater rate of a contralateral patent processus vaginalis than did those with an atrophic/absent testis (8%) (P <0.001). Our data suggest that the incidence of a contralateral patent processus vaginalis is considerable in patients presenting with a unilateral nonpalpable testis. This is another benefit of laparoscopy in patients with nonpalpable testes.

Scrotal Exploration for Unilateral Nonpalpable Testis

We previously reported initial scrotal exploration for unilateral nonpalpable testis, followed by laparoscopy when a viable testis was not found. Although we concluded that scrotal exploration could often make laparoscopy unnecessary, the knowledge that patients with presumed nubbins would undergo laparoscopy meant that the surgeon did not have to decide whether findings were definitive. In a second series of consecutive patients laparoscopy was used only when it appeared indicated. Boys with unilateral nonpalpable testis underwent initial scrotal exploration. Laparoscopy was only performed when neither a nubbin nor a testis was found, when there was a patent processus vaginalis and/or when gross findings suggesting a nubbin were thought inconclusive. There were 43 patients, including 30 (70%) with monorchism and 13 (30%) with an extra-abdominal (7) or intra-abdominal (6) testis. Of 30 patients found to have monorchism laparoscopy was performed only in 7 (23%), including 2 with scrotal nubbins with a patent processus vaginalis, 1 with a questionable nubbin, 1 with a definitive nubbin but preoperative magnetic resonance imaging suggesting a testis and 3 with an empty scrotum (intra-abdominal vanished testis in 1 and inguinal nubbins in 2). The finding of monorchism was strongly predicted by a contralateral descended testicular length of 1.8 cm or greater. Scrotal exploration is potentially definitive for the diagnosis and management of extra-abdominal testes and nubbins in patients with unilateral nonpalpable testis. Laparoscopy is only definitive when an intra-abdominal testis is found, which occurs in a minority of cases.

Presentation of fused vas deferens

Transverse testicular ectopia is a rare condition that usually presents as a unilateral nonpalpable testis and a contralateral descended testis with an associated hernia. Currently, with the use of diagnostic laparoscopy, transverse testicular ectopia is found before groin exploration. We reviewed 2 cases that were referred to our institution. Both patients had a common vas deferens with proximal fusion. To our knowledge, a fused vas deferens has only been reported three other times in published reports. Our second case is unique in that this is the first time a common vas deferens has been reported outside of transverse testicular ectopia.

Laparoscopyvs inguinal exploration for nonpalpable undescended testis

The optimal initial surgical approach for nonpalpable undescended testis (UDT) is debated. The aim of the present study is to compare the results of initial laparoscopy and inguinal exploration in the management of unilateral nonpalpable undescended testes. The results of 20 children with unilateral nonpalpable UDT managed by initial laparoscopy (group I) were compared with 20 age-matched children managed by inguinal exploration (group II). The location of testes and results of orchiopexy were compared in both groups. A single surgeon performed all the operative procedures. The majority of testes (16/20 group I, 17/20 group II) in both groups were canalicular or low abdominal. Vanishing testes accounted for one-third (13/40) of the testes, the majority (85%) of which were located in the inguinal canal. All children were discharged within 24 hours of the operation. The success of orchiopexy at 4-6 weeks post-operatively was 85% and 86% in the two groups respectively. Retrospectively, only 7/40 (18%) of the testes would benefit from laparoscopy. Initial laparoscopic and inguinal approaches to nonpalpable UDT give comparable results. This report failed to demonstrate any specific advantage of initial laparoscopy in the majority of children with unilateral nonpalpable UDT.

MAGNETIC RESONANCE ANGIOGRAPHY FOR THE NONPALPABLE TESTIS: A COST AND CANCER RISK ANALYSIS

For the unilateral nonpalpable testis standard management is open surgical or laparoscopic exploration. An ideal imaging technique would reliably identify testicular nubbins and safely allow children to forgo surgical exploration without compromising future health or fertility. Our goal was to perform a cost and risk analysis of magnetic resonance angiography (MRA) for unilateral nonpalpable cryptorchid testes. A search of the English medical literature revealed 3 studies addressing the usefulness of MRA for the nonpalpable testicle. We performed a meta-analysis and applied the results to a hypothetical set of patients using historical testicular localization data. Analysis was then performed using 3 different management protocols-MRA with removal of testicular nubbin tissue, MRA with observation of testicular nubbin tissue and diagnostic laparoscopy. A cancer risk and cost analysis was then performed. MRA with observation of testicular nubbin tissue results in 29% of patients avoiding surgery without any increased cost of care. Among the 29% of boys with testicular nubbins left in situ and observed the highest estimated risk was 1 in 300 of cancer developing, and 1 in 5,300 of dying of cancer. A protocol using MRA with observation of inguinal nubbins results in nearly a third of boys avoiding surgical intervention at a similar cost to standard care without any significant increased risk of development of testis cancer.

INITIAL SCROTAL INCISION FOR UNILATERAL NONPALPABLE TESTIS

We investigated use of initial scrotal incision for the management of unilateral nonpalpable testis. Scrotal incision followed by laparoscopy was performed in a consecutive series of 40 boys with unilateral impalpable testis. Initial scrotal incision revealed 22 scrotal nubbins and 4 extra-abdominal testes among the 40 patients. Of 13 patients with intra-abdominal testis 6 had a looping vas that was dissected to the internal ring via the scrotal incision, and the incision was used for orchiopexy in 12. Laparoscopy detected 1 case of intra-abdominal vanished testis but falsely diagnosed 6 additional cases based upon blind-ending vas and vessels despite a known scrotal nubbin. It also detected 13 intra-abdominal testes but was inconclusive in 14 cases in which vas and vessels exited the internal ring, not including the 4 patients with extra abdominal testes who did not undergo laparoscopy. Scrotal incision may be sufficient to diagnose testicular loss when a nubbin is encountered, and can detect an extra abdominal testis not palpated with the patient under anesthesia. The incision is used for orchiopexy in those patients with a testis that can be brought to the scrotum in a single stage. Laparoscopy potentially can be reserved for cases in which no nubbin is found and in all cases when a patent processus vaginalis is encountered.

HOW WELL DOES CONTRALATERAL TESTIS HYPERTROPHY PREDICT THE ABSENCE OF THE NONPALPABLE TESTIS?

We assessed the accuracy of contralateral testis hypertrophy for predicting monorchia in patients with a nonpalpable testis. From May 1993 to September 1998 we evaluated 60 patients 7 months to 11 years old for a unilateral nonpalpable testis. Four patients were excluded from study who had received human chorionic gonadotropin or had signs of puberty. We correlated contralateral testis hypertrophy, defined as testis volume greater than 2 cc or testis length greater than 2 cm., with presence or absence of the nonpalpable testis. We also recorded the degree to which contralateral testis length less than 2.1 cm. correlated with the presence or absence of the nonpalpable testis. Laparoscopy and open exploration were performed in 52 and 4 cases, respectively. Contralateral testis hypertrophy greater than 2 cm. was noted in 16 patients, including 14 (87.5%) with monorchia and 2 (12.5%) with an intra-abdominal testis. Of the 15 patients with a contralateral measurement of 1.8 to 2.0 cm. 14 had monorchia (93%) and 1 had a tiny ovotestis. Of the 25 patients with a contralateral measurement of less than 1.8 cm. 13 (52%) had testes that were intra-abdominal in 11 and canalicular in 2. The optimal cutoff value for contralateral enlargement was 1.8 cm. (p = 0.00061). The most common laparoscopic finding in patients with contralateral testis hypertrophy greater than 2 cm. was blind ending vessels proximal to the internal ring in 56%. Contralateral testis hypertrophy is common in patients with a nonpalpable testis. Hypertrophy 1.8 cm. or greater predicts monorchia with an accuracy of about 90%. The finding of contralateral testis hypertrophy provides useful information for preoperative counseling, allowing us to inform parents that the nonpalpable testis is most likely absent. Exploration is still required. Laparoscopy is particularly advantageous in contralateral testis hypertrophy since it was the only procedure required in about half of our cases.

Laparoscopic Evaluation of the Nonpalpable Testis: A Prospective Assessment of Accuracy

To assess diagnostic accuracy, laparoscopy and surgical exploration were prospectively performed in 104 children with 126 nonpalpable testes. Laparoscopic localization of the testis was correct in 90% (114 of 126 testes) and was nondiagnostic in 8% largely due to preperitoneal insufflation. No surgical complications occurred. Using the criteria of blind-ending vas deferens and spermatic vessels as diagnostic of an intra-abdominal vanishing testis, the accuracy of diagnosis was 100% but the inability to identify either vas or vessels was associated with intra-abdominal testes in 2 of 3 cases. Identification of canalicular vas deferens and spermatic vessels was associated with testes in 36 of 75 cases (48%). Bilateral nonpalpable testes were significantly less likely to have an absent testis (5%) than a unilateral nonpalpable testis (59%), suggesting the possibility of different pathophysiological mechanisms in those entities. Diagnosis and surgical management of nonpalpable testes were directly impacted by laparoscopy in 42 of 117 testes (36%) by identifying intra-abdominal vanishing testis, the location of an intra-abdominal testes or the need for retroperitoneal exploration when vas deferens and spermatic vessels were not found. Accurate knowledge of testis location in 97% of the testes facilitated development of an appropriate surgical strategy (that is laparoscopic/laparoscopic assisted versus open procedure).

Laparoscopy for evaluation of cryptorchid testis

Four male patients with a unilateral nonpalpable testis were considered for laparoscopy. Preoperative evaluation by computerized tomography and ultrasonography failed to demonstrate cryptorchid testis. Laparoscopy clearly identified the anatomy in all 4 cases. Two patients had an absent testis, 1 patient underwent orchiectomy for a dysmorphic testis, and 1 patient underwent orchiopexy for a testis located within the inguinal canal. Pediatric laparoscopy is an effective and safe adjunct in the management of cryptorchid testis.

Laparoscopy: Its selected use in patients with unilateral nonpalpable testis after human chorionic gonadotropin stimulation

Laparoscopy: Its selected use in patients with unilateral nonpalpable testis after human chorionic gonadotropin stimulation

Laparoscopy: Its Selected Use in Patients with Unilateral Nonpalpable Testis after Human Chorionic Gonadotropin Stimulation

Laparoscopy has been used to help evaluate patients with a unilateral nonpalpable testis. This procedure can be performed quickly just before exploration with the patient under the same anesthetic. With laparoscopy it has been possible to localize either a testis or the course of the spermatic vessels in 100 per cent of the patients. Preoperative knowledge of testis location is helpful to plan the location of the incision as well as the type of repair. The incidence of vanishing testis in our series is much higher than that reported previously. This difference is attributed to a careful examination with the patient under anesthesia and preoperative treatment with human chorionic gonadotropin, which made many testes palpable. These results indicate that laparoscopy can be performed safely and quickly, and that it is helpful to manage patients with a unilateral nonpalpable testis.

Unilateral Abdominal Cryptorchidism

The unilateral non-palpable undescended testis is considered separately from other forms of cryptorchidism. It is less likely to be fertile, it is more prone to malignancy and it is more difficult to place. Removal rather than orchiopexy often is in the best interests of the child.

Venographic Localization of the Non-Palpable Undescended Testis in Children

In cases of bilateral non-palpable undescended testes in which human chorionic gonadotropin stimulation has shown the presence of testicular tissue and in cases of unilateral non-palpable undescended testes selective transfemoral gonadal venography with a modified Seldinger technique has been used for the preoperative localization of the non-palpable testis. Since the undescended testis may be located anywhere along the course of its embryologic descent, that is from the level of the renal fossa to its exit from the inguinal canal, preoperative localization will aid in the surgical management. Gonadal venography has proved to be accurate and safe, and has aided in the determination of the extent of surgical exploration in 9 children with 12 non-palpable undescended testes (6 right and 6 left).