Anorchia Research Articles

The Vanishing Testis

Of patients with cryptorchidism, 5% have no palpable gonad. Physical examination or scrotal exploration demonstrates tissue nubbins or small nodules that constitute the vanishing testis syndrome. At the University of Chicago Hospitals (Chicago, IL; 2004-2008), 30 surgical pathology specimens from 29 patients with this clinical diagnosis underwent scrotal exploration. Histologic and immunohistochemical comparison was done with 7 fetal testes, 8 surgically removed nonneoplastic testes, and 2 cryptorchid testes. Routine histologic studies showed no seminiferous tubules in 18 cases (60%), fibrosis in all (100%), calcifications in 16 (53%), and hemosiderin deposits in 9 (30%). In 12 cases with seminiferous tubules (40%), there were Sertoli cells only. Scrotal exploration in such cases is clinically driven and results in the removal of any tissue present. Although published studies suggest the risk for future tumor development is low, possibly absent, the definitive removal of a testicle is established by an awareness of the histologic spectrum exhibited by testicular remnants.

Laparoscopic management of impalpable testes: comparison of different techniques

Laparoscopy is an important modality for management of impalpable testes. We present long-term outcomes of intra-abdominal testes managed by either single stage orchidopexy or two-stage Fowler Stephen's orchidopexy (FSO) over 12years. Data were prospectively collected and retrospectively analyzed on patients who underwent laparoscopy for impalpable testes between 1998 and 2010. Demographic data, intra-operative findings, management, histology and follow-up findings were collected and analyzed. Fisher's Exact test was used for statistical analysis. Laparoscopy was performed for 168 impalpable testes (78 left, 58 right and 16 bilateral). Patients were between 8months and 15years of age (median 1year 10months). Ninety-three testes were found to have cord structures entering the inguinal ring (canalicular), 65 were intra-abdominal and 10 had blind ending vas and/or vessel. Fifty-seven (34%) testes were atrophic and underwent orchidectomy; 100 (60%) testes underwent orchidopexy: either two-stage FSO (48) or single stage orchidopexy (52) and 10 (7%) had findings consistent with 'vanishing testes'. Histopathologically, the excised remnants (34%) showed no viable testicular tissue. The follow-up was a median of 8months (3months to 6years). Four patients were lost to follow-up (two each after FSO and single stage orchidopexy) while, two FSO are awaiting follow-up. At follow-up, 36/44 testes (FSO) and 13/13 testes (single stage orchidopexy) are in the scrotum and of good size. Eight testes had atrophied after two-staged FSO. Canalicular testes are often difficult to palpate (55%). Laparoscopy allows direct visualization and definitive management. There is no statistically significant difference between the results following single stage orchidopexy or two-stage FSO for impalpable testes.

Bilateral vanished testes diagnosed with a single blood sample showing very high gonadotropins (follicle-stimulating hormone and luteinizing hormone) and very low inhibin B

In boys with cryptorchidism median serum values of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) are higher and median serum values of inhibin B lower than in normal controls. Serum values of inhibin B reflect the state of germinative epithelium in cryptorchid testes. The aim of the study was to evaluate whether a simple blood sample of gonadotropins and inhibin B could diagnose bilateral vanished testes. Group I included five boys (4 months to 6 years and 3 months old) with bilateral vanished testes at laparoscopy. Group II included 82 boys with bilateral cryptorchidism younger than 7 years of age at surgery for bilateral cryptorchidism (median age 1 year and 9 months). The serum levels of hormones for the patients with vanished testes were: inhibin B 5?18 pg/ml, FSH 41-191 IU/l and LH 3.9?56 IU/l. The patients all had karyotype 46,xy. The serum levels of hormones from group II were: inhibin B median 122 (range 20?404) pg/ml, FSH median 0.8 (range 0.2?3.5) IU/l and LH median 0.2 (range 0.1-3.2) IU/l. The serum levels of inhibin B, FSH and LH from the boys with vanished testes were significantly different from the serum levels of the boys with bilateral cryptorchidism (p = 0.0026, p < 0.0001 and p < 0.0001, respectively). The serum values of gonadotropins and inhibin B from boys with bilateral vanished testes were significantly different from those of bilateral cryptorchid boys, indicating no germinative epithelium, no Sertoli cells and compensatory high gonadotropins. If such abnormal serum values are obtained from boys with bilateral non-palpable testes, tubular tissue is not present and surgery can be avoided.

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.

Bilateral abdominal cryptorchidism with large left testicular seminoma and failed right urogenital union

This is a case report of a 32-year-old male with bilateral intra-abdominal cryptorchidism. A large seminoma had developed on the left testis with paraaortic lymph nodes metastasis. The tumour was excised easily. The right testis was found just inside the deep inguinal ring, without the vas deferens in the spermatic cord. The patient requested orchidopexy despite the well-explained risk of cancer development. Therefore, a second right groin incision was performed. In the right inguinal canal, there was a normal-looking vas deferens that ended in an atrophic nubbin of fibrous tissue without an epididymis. This is the sixth case in the literature of failed urogenital union resulting in complete separation of testis and vas deferens. The patient underwent orchidopexy and had four cycles of chemotherapy, which led to complete remission of the metastasis. This case highlights the fact that an impalpable undescended testis and finding of blind-end vas deferentia are not enough to establish the diagnosis of vanished testis. The decision to undergo orchiectomy in cases of bilateral cryptorchidism after puberty is also discussed. In our opinion, the choice should be made by the patient after a discussion of the risk for cancer development in the salvaged testis.

Laparoscopic-Assisted Management of Impalpable Testis in Patients Older than 10 Years

Cryptorchidism affects 1% of male births. The majority of patients with undescended testis are identified and treated in childhood, but a significant proportion of them especially in third-world countries are neglected and present late. Herein, we present our initial experience of managing impalpable testis in older children and adults with laparoscopic assistance. This study was conducted from 2003 through 2008 at LUMHS Jamshoro. Thirty-two patients with 40 impalpable testes were included in this study. Diagnostic laparoscopy was performed in 32 anesthetized patients. Laparoscopic-assisted orchiopexy or orchiectomy was performed in patients with intraabdominal testis. Testicular vessels and vas deferens were mobilized and after obtaining sufficient length were brought through the posterior wall of the inguinal canal by creating a neo-inguinal ring medial to the epigastric vessels after a small inguinal incision. Of 40 impalpable testis, ultrasound localized 16 (40%) of them, and on laparoscopy, 36 (90%) were localized, 30 (75%) as intraabdominal and in 6 (15%) cases vas and vessels were entering into the internal inguinal ring (intracanalicular). The remaining 4 patients were diagnosed as having vanishing testis (anorchia). Laparoscopic orchiectomy was performed in 14 (35%) of these testes, while single-stage laparoscopic-assisted orchiopexy using Prentiss' maneuver was performed in 16 (40%) testis. No major complications occurred. Seven testes were associated with ipsilateral hernias and were simultaneously repaired laparoscopically. Laparoscopic-assisted single-stage orchiopexy is a safe and successful procedure for intraabdominal testis in adolescents and older patients. The additional benefit of shortening the usual course of spermatic cord was beneficial to fix the testis in the scrotum without tension.

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.

Histologic Evaluation of the Testicular Remnant Associated with the Vanishing Testes Syndrome: Is Surgical Management Necessary?

There is controversy surrounding the optimal management of the testicular remnant associated with the vanishing testes syndrome. Some urologists advocate the need for surgical exploration, whereas others believe this is unnecessary. These differing opinions are based on the variable reports of viable germ cell elements found within the testicular remnants. To better understand the pathology associated with this syndrome and the need for surgical management, we reviewed our experience regarding the incidence of viable germ cell elements within the testicular remnant. An institutional review board-approved, retrospective review was performed of all consecutive patients undergoing exploration for a nonpalpable testis at Eastern Virginia Medical School and Geisinger Medical Center between 1994 and 2006. Patients who were found to have spermatic vessels and a vas deferens exiting a closed internal inguinal ring were included in this analysis. Fifty-six patients underwent removal of the testicular remnant. Patient age ranged from 11 to 216 months. In 8 of the specimens (14%), we identified viable germ cell elements. In an additional 4 patients (7%), we identified seminiferous tubules without germ cell elements. In our review, we identified that a significant number of testicular remnants associated with the vanishing testes syndrome can harbor viable germ cell elements or seminiferous tubules. The exact fate of these residual elements remains unknown; however, there may exist the potential for malignant transformation. Given the potential for malignant degeneration, we believe that these remnants should be removed.

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.

Right Testicular Necrosis and Left Vanishing Testis in a Neonate

We describe a rare case of right testicular necrosis and left vanishing testis in a neonate. The patient presented with a right swollen testis and left non-palpable testis at birth. Exploratory laparotomy was performed at 23 days after birth, and the right testis was extirpated because of extensive necrosis due to torsion of the spermatic cord. Histopathological examination revealed a massively necrotic testicular structure with hypertrophy of Leydig cells. Hypergonadotropinemia was also recognized before operation. On laparoscopy at the age of 5.3 years, a normal left vas deferens and spermatic vessels exiting through the internal inguinal ring were confirmed, although the patient's left testis was not found in the intraperitoneal cavity. An hCG test demonstrated no response of serum testosterone. These findings suggested a diagnosis of left vanishing testis due to testicular regression. We therefore speculated that bilateral asynchronous testicular torsion had occurred prenatally in this patient.

Routine Contralateral Orchiopexy for Children with a Vanished Testis

The aim was to determine whether routine contralateral orchiopexy is justified in a child with a vanished testis from intrauterine torsion. A retrospective study of thirty-one consecutive boys with a vanished testis who underwent contralateral orchiopexy with the sutureless technique over an eight-year (1995 - 2002 inclusive) period was carried out. Operative findings were analyzed. All patients have been followed to date and interviewed by telephone. Of the thirty-one patients, 22 had testicular abnormalities (71 %). Five patients (16 %) had abnormalities that could predispose them to metachronous torsion. These included bell clapper deformity (3), horizontal lie (1), and ectopic testis (1). Other abnormalities were abnormal epididymal-testicular fusion (2), hydrocele (2), and one testis did not show compensatory hypertrophy. Sixteen percent of patients had testicular abnormalities that could predispose them to metachronous torsion. There was no morbidity from the operation and no post-orchiopexy torsion on follow-up. Therefore, routine contralateral orchiopexy in a boy with a vanished testis appears to be safe and effective. A large multicenter trial should be done to investigate these preliminary findings. If confirmed, contralateral orchiopexy should be advocated.

An Analysis of the Genetic Factors Involved in Testicular Descent in a Cohort of 14 Male Patients With Anorchia

Reproduction, Fertility and Populations Unit (G.V., K.M.), Institut Pasteur, 75724 Paris, France; Pediatric Endocrinology Unit (M.-N.A., R.B.), Hopital Bicetre, Assistance Publique-Hopitaux de Paris and Universite Rene Descartes, 94275 Paris, France; Physiology Laboratory (C.T.), Hopital Necker-Enfants Malades, Assistance Publique-Hopitaux de Paris, 95743 Paris, France; and Anthony Private Clinic (H.L.), 92160 Anthony, France

Urogenital nonunion—the case for laparoscopy for the impalpable testis

A case of urogenital nonunion is presented to illustrate the importance of laparoscopy for the impalpable testis. A 4-year-old boy with an impalpable left testis underwent laparoscopy. This revealed not only the vas deferens entering the deep inguinal ring but also a small intraabdominal testis supplied by the testicular vessels. Exploration of the inguinal canal revealed the vas deferens terminating in a nubbin of tissue. Histology identified epididymal structures both adjacent to the testis and in the terminal nubbin of the vas deferens. This is an example of urogenital nonunion. Complete separation of the vas and testis with epididymal structures attached to each is very unusual, with only four other cases reported. Laparoscopy should be the initial procedure for impalpable testis. A blind-ending vas deferens found on exploration of the inguinal canal might be taken as evidence of the vanishing testis syndrome. However, this conclusion should not be drawn unless laparoscopy has demonstrated testicular vessels entering the internal inguinal ring.

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.

Reply: Duplication of the Testis With Contralateral Anorchism

Reply: Duplication of the Testis With Contralateral Anorchism

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.

Long-Term Outcome of Laparoscopically Managed Nonpalpable Testes

We evaluated laparoscopic diagnostic findings in 108 impalpable testes, and analyzed the success rate and long-term outcome of either direct laparoscopic orchiopexy or the 2-stage Fowler-Stephens procedure. A total of 84 children with 108 impalpable testes and a mean age of 1.9 years underwent laparoscopy between 1992 and September 2000. Long-term outcome with regard to viability and location of the testes was evaluated. Of the 108 testes 72 were located intra-abdominally, of which 28 were managed by direct laparoscopic orchiopexy, 29 were managed by a 2-stage laparoscopic Fowler-Stephens procedure and 15 were vanishing. The remaining 36 testes were inguinally located during exploration and orchiopexy, except for 5 vanishing testes. In all cases the operation proceeded as planned. After a mean followup of 6.2 years all laparoscopically managed testicles were in a normal scrotal position with normal perfusion as revealed by color flow Doppler sonography. Two testicles became atrophic after a 2-stage Fowler-Stephens procedure. Morbidity was low in all children. The laparoscopic approach allows not only diagnosis, but also adequate therapy regardless of whether direct orchiopexy or a 2-stage procedure is performed. Our long-term results clearly demonstrate that even in the patients undergoing the 2-stage procedure the laparoscopic approach is safe and efficient, and leads to excellent results concerning viability of the affected testicles. Progress and experience gained during recent years are encouraging in continuing laparoscopic procedures in children.

Adult nonpalpable testis: is laparoscopy always required?

Laparoscopy is widely used in the diagnosis and treatment of nonpalpable testes. Some nonpalpable testes are vanishing testes. In such cases, unnecessary laparoscopic interventions can be avoided by a careful selection of cases. Between 1996 and 2001, laparoscopic intervention was applied to 107 patients with nonpalpable testes. Of the cases, 23 were bilateral and 84 were unilateral. Patients were between 19 and 27 years of age (average age, 23 years). Diagnostic ultrasonography was performed in 44 of the 84 patients with nonpalpable testes. Dimensions of the scrotal testis were determined by the Prader orchiometer method. The dimensions of the opposite scrotal testis (of the scrotal nubbin) and the abdominal testis were compared with the dimensions of 20 normal, healthy individuals' scrotal testis (control group). Results were evaluated by the Mann-Whitney U test. During laparoscopy, 24 (28.5%) of the patients were found to have a vanishing testis. The vas deferens and the testicular blood vessels ended bluntly at the anterior edge of the interior inguinal ring in one patient, inside the inguinal canal in five patients, and in the scrotum in 18 patients. Among the 84 patients with nonpalpable testes, no testis was found in any of the 18 patients with palpable scrotal nubbins. The opposite scrotal testes were hypertrophic in 17 (70.8%) of 24 patients who had vanishing testis (P < .05), and they were hypertrophic in 22 (36%) of the 60 patients (P > .05) who had laparoscopically identified intraabdominal testes. We conclude that clinical and radiologic diagnosis is sufficient for adult patients with nonpalpable testicles and palpable scrotal nubbins and hypertrophic contralateral scrotal testes. Laparoscopic intervention should be applied to patients who do not have palpable scrotal nubbins.

The presence or absence of an impalpable testis can be predicted from clinical observations alone.

To evaluate, in a prospective study, the accuracy of predicting the presence or absence of unilateral or bilateral impalpable testes from a clinical examination, particularly whether the contralateral descended testis (CDT) is hypertrophied. Whether the ipsilateral scrotal appendages were palpable, and the size of the CDT, were determined before surgery in a series of patients, and compared with age-matched controls. Between 1992 and 2000, 100 impalpable testes in 86 consecutive patients (mean age at orchidopexy 45 months, range 6-223; 66% <36 months) were evaluated and treated. In addition to the presence or absence of palpable ipsilateral scrotal appendages, the size of the CDT, when present, and the intraoperative findings were recorded. Logistic regression analysis was used to model the probability of the presence or absence of the testis, as determined by the preoperative clinical findings alone. Of the 86 testes that were located at surgery, 50 (58%) were intracanalicular, 28 (32%) intra-abdominal and the remainder (10%) were in the superficial inguinal pouch. Of 13 patients with the 'vanishing testis syndrome', the atrophic testicle was intracanalicular in nine, in the upper scrotum in three and intra-abdominal in only one. All viable testes were successfully relocated in the scrotum, with one atrophic after surgery. The positive predictive value (PPV, with 95% confidence interval) of a testis being present when the ipsilateral appendages were palpable and the CDT was not hypertrophied was 0.93 (0.83-0.97). Conversely, the PPV of the impalpable testis being absent when the appendages were impalpable and the CDT was hypertrophied was 0.95 (0.64-0.99). When evaluating and surgically treating impalpable testes, the presence of palpable ipsilateral scrotal appendages and a CDT with no hypertrophy is associated with a 93% likelihood of discovering a testis that can be successfully relocated to the scrotum. Conversely, when the ipsilateral scrotal appendages cannot be palpated and the CDT is hypertrophied, there is a 96% probability that the impalpable testis is absent (vanishing testis syndrome). This readily available information may be valuable in preoperative counselling and planning.

The difficult orchidopexy: the value of the abdominal pre-peritoneal approach.

To analyse the outcome of using the abdominal pre-peritoneal (APP) approach to orchidopexy. During an 8-year period, the experience of one surgeon in the management of 553 boys (median age 4.5 years, range 1-13) with undescended testes (596 testes) was assessed. The analysis emphasized those patients who had an orchidopexy performed using the APP approach detailing; the original position of the testis at exploration, whether successful placement within the scrotum was possible, and whether atrophy or ascent of the gonad occurred subsequently. In 98 boys (110 testes) the testes were impalpable or high within the inguinal canal and they were explored using the APP approach. Of the 34 testes (31%) which were found abdominally, 12 were high intra-abdominal and the remaining 22 just deep to the internal inguinal ring. These included seven bilateral and 20 unilateral intra-abdominal testes. The remaining 76 undescended testes included five with bilateral high testes, 29 high unilateral testes, 13 repeat orchidopexies, 17 'vanishing testis syndrome' and seven atrophic testes. The remaining 486 undescended testes were treated using a standard orchidopexy and were therefore excluded from analysis. The value and advantages of this operative approach and its place in the management strategy of the difficult orchidopexy are discussed.