Unilateral Nonpalpable Testis Research Articles

Ipsilateral and contralateral patent processus vaginalis in pediatric patients with a unilateral nonpalpable testis.

This study aimed to investigate the incidence of patent processus vaginalis (PPV) in pediatric patients with a unilateral nonpalpable testis and explore the associated factors. From May 2014 to April 2017, 152 boys who were diagnosed with a unilateral nonpalpable testis and underwent laparoscopy in Shanghai Children's Hospital (Shanghai, China) were included in this study. The data were collected and reviewed, and the results were analyzed regarding the age at operation, side, development, and position of the nonpalpable testis. The mean age of the patients was 2.6 (standard deviation: 2.3) years. The testis was absent in 14 cases, nonviable in 81 cases, and viable in 57 cases. The incidence of PPV was 37.5% (57 of 152) on the ipsilateral side and 16.4% (25 of 152) on the contralateral side. The ipsilateral PPV was more prevalent when the nonpalpable testis occurred on the right side (P < 0.01). Besides, patients with a viable testis had a greater incidence of ipsilateral PPV than those with a nonviable or absent testis (P < 0.01). Moreover, this rate was the highest when the testis was in the abdominal cavity and the lowest when the testis was in the scrotum (both P < 0.01). However, the incidence of contralateral PPV was independent of all the factors. In conclusion, in children with a nonpalpable testis, the incidence of an ipsilateral PPV was significantly related to the side, development, and position of the testis, while it was independent of these factors on the contralateral side.

Clinical Efficacy of Laparoscopic Orchiopexy With the Modified Prentiss Maneuver for Non-palpable Testis Near the Internal Ring.

ObjectiveTo compare the clinical efficacy and safety of laparoscopic orchiopexy with the modified Prentiss maneuver (LOMPM) and laparoscopic trans-inguinal orchiopexy (LTIO) for the treatment of non-palpable testis (NPT) <1 cm from the internal ring.MethodsChildren with unilateral NPT who underwent laparoscopic orchiopexy at our center between February 2018 and January 2021 were retrospectively analyzed. According to the surgical method, they were divided into LOMPM and LTIO groups. The operation time, postoperative pain degree, postoperative complications and follow-up results were compared between the two groups.ResultsA total of 98 patients were included in this study, including 41 cases in the LOMPM group and 57 cases in the LTIO group. All patients underwent successful surgery. The LOMPM group was superior to the LTIO group in terms of postoperative testicular position (lower scrotm: 90.2 vs. 71.9%, P = 0.026). There were no significant differences in operation time, postoperative pain score, and complications between the two groups. Preoperative testicular volume, postoperative testicular volume, and testicular growth rate in the LOMPM group were comparable to those in the LTIO group. There were no testicular atrophy, inguinal hernia and hydrocele in both groups after operation.ConclusionsLOMPM was comparable in safety to LTIO, but LOMPM had a good post-operative testicular position, and was suitable for the treatment of NPT near the internal ring.

Proportion of Testicular Absence and Position of Testis in Unilateral Nonpalpable Undescended Testis in a Tertiary Teaching Hospital in South India

Introduction: Undescended testis is a common surgical problem in children which needs to be treated by one and a half year of age. When testis is non palpable, it could be either absent, and when present intra-abdominal or inguinal. Methodology: A hospital based retrospective study was conducted in department of paediatric surgery, Thiruvananthapuram. Study population consisted of children treated with nonpalpable undescended testis from January 2016 to June 2021. Results: Mean age of intervention was 43.7 months (range 7 to 153 months). Incidence of absent testis was 30.97%. in 156 children who had ipsilateral undescended testis, 92 had intra-abdominal testis and 43 had inguinal testis. Presence of nubbin of testis in ipsilateral scrotum and contralateral testicular hypertrophy were suggestive of absent ipsilateral testis (p &lt;0.001). Testis is absent in 11.3% only when ipsilateral hemi scrotum is under developed. Conclusion: Proportion of absent testis is 30.97% in children with unilateral undescended testis. Presence of nubbin of testis in ipsilateral scrotum and contralateral testicular hypertrophy are predictive of ipsilateral testicular absence. Keywords: Undescended testis, atrophic testis, Contralateral hypertrophy.

Detection of monorchidism in boys with unilateral undescended testes: clinical benefits and limitations of contralateral testicular size

Contralateral testicular size was recommended as an effective measurement in prediction of monorchidism in some previous studies but a few argued it as invalid. Further investigation was demanded. To investigate the effectiveness of contralateral testicular size in prediction of monorchidism in patients with unilateral non-palpable undescended testes (NPT) aged between 9 and 48 months. Total of 707 patients aged between 9 and 48 months and diagnosed with unilateral undescended testes (UDT) between January 2016 and December 2018at the study department were enrolled. In accordance with physical examinations and surgical findings, patients were divided into three groups: palpable UDT (group A, n=609), non-palpable but viable testes (group B, n=57) and monorchidism (group C, n=41). Contralateral testicular length and volume were evaluated with ultrasonography. Comparison of contralateral testicular size between three groups and calculation of optimal cut-off value and diagnostic performance of it among NPT were performed. The length and volume of contralateral testes of group C were larger than of group A (P<0.01) and group B (P<0.01), whereas these differences between groups were small. Among patients with NPT, a receiver operating characteristic curvewas used to determine the optimal cut-off value. It revealed that both a testicular length of 17.5mm and a volume of 1.05ml provided the highest Youden's index for prediction of monorchidism. The sensitivity and specificity for testicular length were 34.1% and 94.7%, and volume were 34.1% and 93%, respectively. The predictive accuracy for testicular length and volume were 69.4% and 65.7%, respectively. Even though the negative predictive valuewas merely 66.6% (54/81) and 66.2% (53/80), the positive predictive value (PPV) reaches to 82.3% (14/17) and 77.7% (14/18) for testicular length and volume. Several factors including choosing of measurement tools, age range, ethnicity, and selection bias of cohorts may be accounted for the huge differences among cut-off values and predictive accuracy. The diagnostic performance of contralateral testicular size in prediction of monorchidism in patients with NPT was poor. But the PPV was relatively promising. Contralateral testicular hypertrophy can provide information for surgical planning. The overall diagnostic performance of contralateral testicular size in prediction of monorchidism in poatients with UDTaged between 9 and 48 months was poor. But the efficiency of cut-off value predicting absence of viable testes was relatively higher. This value should be objectively applied but only as a reference which would not be a complete replacement of laparoscopy exploration.

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.

EFFICACY OF LAPAROSCOPY IN THE MANAGEMENT OF UNILATERAL NONPALPABLE TESTIS

Background:Undescended testis is one of the most common malformations seen in the field of pediatric surgery. The most problematic aspect of undescended testis is the diagnosis and treatment of nonpalpable testis. Laparoscopy has been widely used for the diagnosis and treatment of nonpalpable testis. Objective:To evaluate the role of laparoscopy in the diagnosis and treatment of unilateral nonpalpable undescended testis. Methods:This is a prospective study carried out in the period from December 2012 to December 2017 in the Pediatric Surgery Department of a tertiary hospital in Baghdad. We used laparoscopy in the diagnosis and treatment of 40 patients aged between one and 12 years (median age 4.9 years) with unilateral nonpalpable undescended testis. Boys with a palpable testis at any point were excluded from the study. Surgical procedure was individualized according to the laparoscopic findings either by one stage laparoscopic orchiopexy, two stage Fowler-Stephens procedure or laparoscopic orchiectomy. Results:Laparoscopy was able to diagnose the site of the nonpalpable testes in all the patients. Out of 40 nonpalpable undescended testes, 26 testes (65%) were intra-abdominal (12 testes were low intra-abdominal, 14 testes were high intra-abdominal). In 9 patients, (22.5 %), the vas deferens and spermatic vessels were found entering the internal inguinal ring. In 3 patients, (7.5 %), the testes were vanishing, and the testes were absent in 2 patients (5%). All patients with low intra-abdominal testes (n=12) were subjected to one stage laparoscopic orchiopexy through the normal inguinal ring. Out of 14 patients with high intra-abdominal testes, 7 patients underwent two staged Fowler-Stephens laparoscopic procedures, while three patients were treated by laparoscopic Prentiss maneuver and the remaining 4 patients underwent immediate laparoscopic orchiectomy due to presence of an atrophied testis. Patients with the vas deferens and spermatic vessels entering the internal inguinal ring (n=9) were treated by orchiopexy via conventional inguinal approach. Conclusion:Laparoscopy for unilateral nonpalpable testis has an excellent diagnostic yield combined with high success rate following repair. Keywords:Laparoscopy, nonpalpable undescended testis, Fowler-Stephens procedure Citation:Zain AZ, Mohammed NH, Fadil SZ, Abdul-Hassan BA. Efficacy of laparoscopy in the management of unilateral nonpalpable testis. Iraqi JMS. 2019; 17(3&amp;4): 223-230. doi: 10.22578/IJMS.17.3&amp;4.9

Undescended Testes and Laparoscopy: Experience from the Developing World

Background Cryptorchidism or undescended testes is the most common disorder of the male endocrine glands in children. With the advancements in laparoscopic techniques and instruments, laparoscopic orchidopexy has become the standard procedure in the management of nonpalpable undescended testes. Aim To evaluate and determine the therapeutic role, sensitivity, and specificity of laparoscopy in localizing nonpalpable testes and the mean operative time, the conversion rate (and reasons thereof), postoperative wound infection, postoperative stay, and time taken for return to daily activities following laparoscopic orchidopexy or orchidectomy. Materials and Methods This was a prospective study carried out in the Postgraduate Department of Surgery, Government Medical College, Srinagar, J&K, India, from May 2008 to August 2011. All patients who presented to the outpatient department with complaints of absent testes were examined, and the ones with nonpalpable testes were included in the study. Results The mean operative time for bilateral and unilateral nonpalpable testis was 102.76 and 53.67 minutes, respectively. Minor postoperative wound infections were noted in 4 of our patients. Mean duration of hospital stay was 14.23 hrs for unilateral cases and 16.27 hrs for bilateral cases. Patients who underwent laparoscopic orchidopexy resumed their normal activities within 4 ± 1 days. Conclusion Laparoscopy clearly demonstrates the anatomy and provides visual information upon which a definitive decision can be made for further management of the undescended nonpalpable testis.

Initial laparoscopy and optimized approach for unilateral nonpalpable testis: review of 8-year single-center experience

We evaluated the role of initial laparoscopy and optimized approach in cases of unilateral nonpalpable testis. Seventy-four patients with nonpalpable testes were presented. We excluded 9 patients, with palpable testes under anesthesia. Laparoscopy was offered to 65 patients. Contralateral testis hypertrophy with length ≥ 1.8cm was confirmed in 47 patients. Ultrasound results were available for 35 patients. Age ranged from 1 to 10years. Of 65 nonpalpable testes, right side comprised 23 (35.4%) and the left 42 (64.6%). Laparoscopy revealed intra-abdominal testis in 18 patients (27.7%), blind-ending vessels and vas in 8 (12.3%), and vas and vessels traversing the internal ring in 39 (60%). Treatment of intra-abdominal testes included Fowler-Stephens orchiopexy in 7 patients, laparoscopic orchiopexy in 9, and laparoscopic orchiectomy in 2. In 8 patients with blind-ending vas and vessels, laparoscopy was terminated. In 39 patients with vas and vessels traversing the internal ring, scrotal exploration was performed in 36 patients with closed internal ring and inguinal exploration in 3 with open internal ring. Vanished testes were present in 43/47(91.5%) of patients with contralateral testis hypertrophy ≥ 1.8cm. Ultrasound detected the presence of a testis in only 4/11 (36.3%) of patients, although it could not identify vanished testis. Initial laparoscopy should be retained as one of the standard treatment for nonpalpable testis. It was the only required modality in 26 patients (40%) and optimized further treatment in 39 patients (60%) by evaluation of the condition of the internal ring.

Impact of Preoperative Ultrasonographic Evaluation for Detection of a Viable Testis in Patients With a Unilateral Nonpalpable Testis.

To investigate the impact of preoperative ultrasonography (US) for detecting a viable testis in patients with a unilateral nonpalpable testis. Patients with a unilateral nonpalpable testis or unilateral palpable undescended testis who underwent preoperative US were enrolled. Patients were divided into 3 groups as follows: nonpalpable testis/no testis (n = 27), which included patients who had a unilateral nonpalpable testis with no viable testis detected at surgery; nonpalpable testis/viable testis (n = 10), which included patients who had a unilateral nonpalpable testis with a viable testis identified at surgery; and palpable undescended testis (n = 63), which included patients who had a unilateral palpable undescended testis. Preoperative US findings were compared among each group. The testicular volume on the contralateral descended side in the nonpalpable testis/no testis group was significantly greater than that in the nonpalpable testis/viable testis and palpable undescended testis groups. When a testicular volume of 0.54 mL was used as the cutoff value, the sensitivity, specificity, positive predictive value, and negative predictive value for the presence of the affected testis were 75.3%, 100%, 100%, and 60.0%, respectively. The testis on the affected side was detected in none of the nonpalpable testis/no testis group, 7 of the nonpalpable testis/viable testis group, and all of the palpable undescended testis group. When a visible testis on the affected side and a testicular volume of 0.54 mL or less were defined as positive, all patients in the nonpalpable testis/viable testis and palpable undescended testis groups had positive findings versus none in the nonpalpable testis/no testis group. Preoperative US provides valuable information for predicting the presence of a viable testis in patients with a unilateral nonpalpable testis by estimating both the unaffected testis and the affected side.

Blind ending vessels on diagnostic laparoscopy for nonpalpable testis: Is a nubbin present?

The traditional management paradigm for nonpalpable testis (NPT) has been that inguinal or scrotal exploration for a nubbin may be omitted when blind ending vessels are observed during diagnostic laparoscopy. Our aim was to examine whether blind ending vessels excluded the presence of a nubbin in a series of boys who underwent exploration in this setting. Using a surgical database and chart review, pre-pubertal boys (≤12 years) with the diagnosis of undescended or atrophic testis who underwent a diagnostic laparoscopy for unilateral NPT between 2000 and 2015 were retrospectively identified. Physical exam, procedural and pathologic findings were confirmed by chart review. 595 boys underwent diagnostic laparoscopy for NPT by 11 surgeons. Of these, 318 had an intra-abdominal testis and 18 underwent diagnostic laparoscopy alone. Of the remaining 259, 32 had an open internal ring and inguinal or scrotal exploration was performed. The remaining 227 with a closed ring comprised the cohort for our analysis, of whom 188 had vessels entering the ring, 36 had blind ending vessels, and in three the vessel status was unavailable. In the 188 boys with vessels entering the ring, 164 (87%) had a nubbin excised during inguinal or scrotal exploration, of which 93% were grossly identified as an atrophic testis. Pathology confirmed the presence of hemosiderin in 44% and calcifications in 54%. In the 36 boys with blind ending vessels, 26 (72%) had a nubbin excised during inguinal or scrotal exploration, of which 96% were grossly identified as an atrophic testis. Pathology confirmed hemosiderin in 54% and calcifications in 58%. All seven cases with both blind ending vas and vessels had an atrophic testis grossly identified. Of all 207 excised remnants in this series, nubbins with viable testicular elements (seminiferous tubules in 11, germ cells in two) were only excised during cases that reported a non-atretic vas or any vessels entering the internal ring. In this large multi-institutional series, blind ending vessels were associated with a nubbin noted during inguinal or scrotal exploration in the majority of cases. Based on this series if the surgeon's goal is to remove all nubbins, exploration is necessary regardless of vessel appearance. However, viable testicular elements were rarely identified and only when either a non-atretic vas or any vessels were observed to enter the ring.

610 - Is diagnostic laparoscopy justified for the initial management of unilateral non-palpable testis?

610 - Is diagnostic laparoscopy justified for the initial management of unilateral non-palpable testis?

Scrotal testis size in unilateral non-palpable cryptorchidism, what it can and cannot tell: Study of a Middle Eastern population

Predicting the fate of a unilateral non-palpable testis based on its scrotal counterpart has been recommended by some, yet disputed by others, and the question remains open. To investigate the accuracy of contralateral testis hypertrophy in predicting the absence of a unilateral non-palpable testis in a Middle Eastern population. This retrospective study included all patients referred to the present institution with unilateral non-palpable testis between June 2010 and August 2014, who had undergone laparoscopy. The scrotal testis was examined by sonography for size and volume, and diagnostic laparoscopy was utilized to determine the state of the cryptorchid testis. Of the 135 referred patients, 64 were aged ≤8 years, 29 were 9-18 years, and 42 were >18 years old. Diagnostic laparoscopy revealed 63 intra-abdominal testes, 20 small intra-inguinal testes, 32 vanished testes, and 20 nubbins or aplasia (Summary fig.). Scrotal testis volume was only a modest predictor for absence of the contralateral gonad in adult patients in whom a 22ml cut-off yielded 64.3% sensitivity and 92.9% specificity. For those aged <18 years, overall accuracy was poor and dropped below 60%. Relative enlargement of contralateral testis in decreasing order of size was observed in patients with primary monorchism, followed by those with secondarily atrophic or nubbin testis, and then those with normal sized inguinal or abdominal testis. Unlike some previous series, which based their conclusions upon open exploration and mostly studied pre-pubertal subjects, the present results exclusively from laparoscopic exploration suggested that contralateral testis volume is a poor and inconsistent predictor of monorchism in children, and marginally predictive for young adults with unilateral non-palpable testis. This study comprised a reasonably large overall sample size compared with preceding reports; however, the number of patients within in each age group was limited. Greater numbers could allow for statistical comparison stratified by age group, for which this study was not powered. Contralateral testis volume predicts, with modest accuracy, monorchism in adults with unilateral non-palpable testis. In younger patients, the overall predictive accuracy of scrotal testis size is poor and not consistently dependable.

Outcomes of Laparoscopic Treatment Modalities for Unilateral Non-palpable Testes.

To date, laparoscopy has gradually become the gold standard for treatment of non-palpable testicles (NPT) with different success and complication rates. In this study, we aimed to evaluate outcomes of laparoscopic approaches for NPT. We reviewed data of 82 consecutive patients who underwent laparoscopic treatment for unilateral NPT at two institutions by two high volume surgeons from 2004 January to 2014 December. Laparoscopic-assisted orchidopexy (LAO) and two-stage Fowler-Stephens technique (FST) was performed for 45 and 37 patients, respectively. Age (at surgery), follow-up time, laterality of testes, and postoperative complications were analyzed. Modified Clavien classification system (MCCS) was used for evaluating complications. The median age (at surgery) and median follow-up time were 18 (range: 6-56) and 60 (range: 9-130) months, respectively. Overall success rate for two laparoscopy techniques was 87.8% during the maximal follow-up time. We observed wound infection in two, hematoma in one, testicular atrophy in five, testicular re-ascending in two patients at follow-up period. There was no statistical difference between two laparoscopic techniques for grade I (five vs. two patients, p = 0.14) and grade IIIb MCCS complications (five vs. two patients, p = 0.44). Our results have shown that two laparoscopic approaches have low complication rates.

Is there an optimal contralateral testicular cut-off size that predicts monorchism in boys with nonpalpable testicles?

ObjectiveTo identify a contralateral testicular cut-off size that would predict monorchism (intra-abdominal vanishing testis or inguinal/scrotal nubbin) in boys with unilateral nonpalpable testis (NPT). Materials and methodsBoys with cryptorchidism, treated by a single surgeon at a tertiary care center from 2009 to 2013, were grouped based on intra-operative findings: boys with a solitary gonad (monorchism group, M) and two control groups: intra-abdominal testis (IAT) and palpable undescended testis (pUDT). Immediately before the procedures, the contralateral descended testes were measured using callipers. Boys with NPT underwent diagnostic laparoscopy. Sensitivity, specificity, positive and negative predictive values, likelihood ratios and receiver operating characteristic (ROC) curves were calculated. ResultsOut of the 324 boys with cryptorchidism, 58 were found to have pUDT and 85 had NPT. Of these 85 boys with NPT, 50 had an IAT and 35 had monorchism. Mean ages at surgery for groups M, IAT and pUDT were similar (28.0, 31.3 and 30.4 months, respectively; P = 0.4). Mean length of the contralateral descended testes in groups M, IAT and pUDT was 24.3, 16.5 and 18.8 mm, respectively. Contralateral testicular cut-off lengths of 18, 19 and 20 mm had positive likelihood ratios (LR+) of 6.5, 7.4 and 10.1, respectively. The area under the ROC curve was 95% (95% CI: 91–100%). ConclusionA contralateral testicular cut-off length of 19–20 mm had the best accuracy in predicting monorchism in boys aged 11–30 months with unilateral NPT.

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.

The value of finding a closed internal ring on laparoscopy in unilateral nonpalpable testis

PurposeThere is an ongoing debate about whether initial laparoscopy is as efficient as initial extra-abdominal exploration for unilateral nonpalpable testis. The aim of this study was to clarify whether the finding of a closed internal ring on laparoscopy accurately predicts extra-abdominal findings in unilateral nonpalpable testis. MethodsBoth laparoscopy and subsequent extra-abdominal exploration were prospectively performed in consecutive patients with unilateral nonpalpable testis. Laparoscopic findings were reviewed with respect to the status of the vas deferens, spermatic vessels, and the appearance of the internal ring. Except for patients with an abdominal testis, all patients underwent subsequent open exploration regardless of the laparoscopic findings. Open explorations were primarily performed by scrotal incision. During open exploration, any testicular remnants were removed and evaluated histologically. ResultsA total of 100 patients with unilateral nonpalpable testis were evaluated, of whom 15 had an abdominal testis. Of the 85 patients without an abdominal testis, an open internal ring was recognized in only 8. Of the remaining 77 with a closed internal ring, subsequent open exploration revealed testicular nubbins in all patients (100%), regardless of the laparoscopic findings of the vessels and vas. Nine nubbins were associated with intra-abdominal vanishing vessels above the closed internal ring. All nubbins were confirmed by histological findings, and the incidence of viable germ cell elements was 7.4%. ConclusionsWhen laparoscopy demonstrates no abdominal testis in patients with unilateral nonpalpable testis, the finding of a closed internal ring on laparoscopy is always associated with the presence of an extra-abdominal nubbin, regardless of the status of the vessels and the vas at the internal ring. Subsequent extra-abdominal exploration can be obviated in this circumstance if nubbin excisions are skipped. Initial diagnostic laparoscopy for unilateral nonpalpable testis provides not only the intra-abdominal findings, but also exact prediction of the extra-abdominal findings in patients with a closed internal ring.

Laparoscopic classification of the impalpable testis

Purpose We present a classification for the nonpalpable testis (NPT) based on laparoscopic findings and suggest guidelines for the interpretation of these findings. Patients and methods From October 2002 to December 2010, 121 patients with NPT underwent laparoscopy at two tertiary centers of Pediatric surgery in Egypt. The lower abdomen and pelvis were inspected to identify the following structures and their inter-relationships: the internal inguinal ring (and its patency), spermatic vessels, vas deferens, and testis. The laparoscopic findings were documented by one of the authors who attended all procedures, and video recordings were available in some cases. Further management was dependent on laparoscopic findings, classification, and plan of treatment. Results The study included 117 patients with 142 nonpalpable testes. Their mean age was 4.9 years. Among patients with unilateral NPT, a contralateral palpable undescended testicle was always associated with a viable NPT (100%), whereas a contralateral scrotal testis had an equal chance (50%) of finding a viable NPT, without a significant difference whether it was right or left sided. Conclusion Failure of normal testicular descent leads to a spectrum of anatomical variations that can be precisely and safely defined by laparoscopy in about two-thirds of patients with nonpalpable testes. In the remaining one-third of patients, including inguinal exploration after laparoscopy can help us to exclude a missed viable inguinal testis. Keywords : cryptorchidism, laparoscopy, testis

Management of the Looping Vas Deferens During Laparoscopic Orchiopexy

A number of variables should be assessed during laparoscopic orchiopexy, including vas anatomy. A looping vas deferens enters the inguinal canal and loops back to the abdominal cavity. This anatomical variant is not uncommonly encountered. Some groups considered this condition in their laparoscopic classification of nonpalpable testis. We present our experience with managing the looping vas during laparoscopic orchiopexy. We identified this condition in 18 procedures. In 14 cases it was possible to bring the vas back to the abdominal cavity. In 3 cases the loop could not be brought back laparoscopically and an inguinal incision was used. After the vas was dissected free and dropped into the abdominal cavity pneumoperitoneum was resumed and the procedure was completed laparoscopically. A Web based survey was done to test the value of this method. A total of 17 procedures were completed successfully with preservation of the vas deferens while in 1 the vas was inadvertently cut. A looping vas did not significantly affect operative time. All 18 testes were viable and retained the scrotal position on followup scrotal Doppler ultrasound. Verification of vasal anatomy is a crucial step that should be completed before any dissection. Bringing a looping vas back to the abdominal cavity is usually feasible laparoscopically but in a few cases this may require a small incision to dissect the vasal loop from its inguinal attachments.

Optimal Cutoff Value of Contralateral Testicular Size for Prediction of Absent Testis in Japanese Boys With Nonpalpable Testis

To investigate the accuracy of contralateral testicular hypertrophy in Japanese boys with a nonpalpable testis and to determine the optimal cutoff value of the contralateral testicular size to predict the absence of the testis. From December 2003 to November 2009, we evaluated 55 boys <60 months old (mean age 19.4) with a unilateral nonpalpable testis and compared their findings with those of a control group. The control group included 20 age-matched boys with 40 testes. The nonpalpable status of the testes was diagnosed by physical examination, and the contralateral testis was measured with calipers before surgery. A sensitivity and specificity analysis were performed using computer software. At surgery, the testis was found in 22 of the 55 boys and was absent in 33. Of the 33 boys with an absent testis, 4 had a blind-ending vessel and 29 had an atrophic cord and testicular nubbin in the canal or scrotum. The mean contralateral testicular length and volume in the boys with an absent testis was 22.4 mm and 2.20 cm(3) compared with 16.6 mm and 1.10 cm(3) in the boys with the testis present and 16.6 mm and 1.18 cm(3) in the controls, respectively (P < .01). The predictive accuracy, sensitivity, and specificity for an absent testis was 87.3%, 81.8%, and 95.5% for the length and 85.5%, 84.8%, and 86.4% for the volume, respectively, at the optimal cutoff value of 21 mm in length and 1.6 cm(3) in volume. Our data have shown that contralateral testicular hypertrophy strongly indicates an absent testis in Japanese boys. The optimal cutoff for contralateral testicular hypertrophy with calipers was 21 mm and 1.6 cm(3). This result has provided valuable information for preoperative counseling and treatment planning.

Scrotal nubbins associated with blind‐ending spermatic vessels and a normal vas deferens on laparoscopy

To determine whether a scrotal nubbin is present in children with unilateral non-palpable testis when diagnostic laparoscopy demonstrates blind-ending vessels and a normal vas deferens entering a closed internal ring. Eighty consecutive patients with a unilateral nonpalpable testis were retrospectively reviewed. Patients underwent initial diagnostic laparoscopy, and, if needed, subsequent inguinal exploration was performed. On inguinal exploration, any testicular remnant or nubbin-like tissue was removed and evaluated histologically. Patients with a patent processus vaginalis were excluded from this analysis. Overall, 60 of the 80 patients had neither an abdominal testis nor a patent processus vaginalis. Of these 60, 34 patients had both a vas deferens and spermatic vessels entering a closed internal ring, and all of these underwent inguinal exploration. A total of 17 patients had both a blind-ending vas deferens and blind-ending spermatic vessels; no inguinal exploration was attempted. In nine patients, laparoscopy revealed blind-ending vessels with a normal vas deferens entering the closed internal ring. Of these nine, six underwent inguinal exploration, and a scrotal nubbins was found in three. At histological examination, hemosiderin deposit and calcification were seen in the nubbin tissue. No viable germ cell was detected in these specimens. A laparoscopic finding of blind-ending vessels above the closed internal ring does not mean intra-abdominal vanished testis, regardless of the appearance of the vas deferens.