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THE MANAGEMENT OF NONPALPABLE TESTIS WITH COMBINED GROIN EXPLORATION AND SUBSEQUENT TRANSINGUINAL LAPAROSCOPY
0022-5347/02/1672-0674/0 THE JOURNAL OF UROLOGY® Copyright © 2002 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 167, 674 – 676, February 2002 Printed in U.S.A.
THE MANAGEMENT OF NONPALPABLE TESTIS WITH COMBINED GROIN EXPLORATION AND SUBSEQUENT TRANSINGUINAL LAPAROSCOPY KAZUHIRO KANEMOTO, YUTARO HAYASHI, YOSHIYUKI KOJIMA, KEIICHI TOZAWA, TOHRU MOGAMI and KENJIRO KOHRI From the Department of Urology, Nagoya City University Medical School, Nagoya, Japan
ABSTRACT
Purpose: About 20% of all cryptorchid testes are nonpalpable. Although surgical exploration was previously the method of choice for management, laparoscopy from the inferior edge of the umbilicus has been established as a useful method of finding a testis that is nonpalpable. However, conventional subumbilical laparoscopy is unnecessary when the testis or its remnant is located below the internal inguinal ring. We evaluated the efficacy of transinguinal laparoscopy after inguinal exploration for a nonpalpable testis. Materials and Methods: While 30 patients each had a unilateral nonpalpable and a contralateral descended palpable testis, 3 had a unilateral nonpalpable and a contralateral undescended palpable testis. When we identified neither a normal testis nor a spermatic cord at exploration of the inguinal canal, we subsequently performed laparoscopic observation through the internal inguinal ring. Results: Of the 30 patients with a unilateral nonpalpable and a contralateral descended testis 8 required transinguinal laparoscopy. However, the procedure was avoided in 22 patients because the testis, its remnant or testicular vessels and vas deferens were detected by inspecting the inguinal region. Conclusions: Further extended incision into a Pfannenstiel incision was unnecessary in cases of blind ending vas and vessels in the peritoneum with transinguinal laparoscopy. In addition, laparoscopy was avoided in 22 of the 30 children (73.3%) with a unilateral nonpalpable and a contralateral scrotal testis. Our strategy of initial inguinal exploration followed by transinguinal laparoscopy for nonpalpable testis may become a reasonable alternative. KEY WORDS: testis, abnormalities, laparoscopy
A nonpalpable testis represents a complex diagnostic and therapeutic challenge to urologists because an accurate diagnosis is not easily made by radiological and physical examinations.1 Therefore, groin exploration has been the mainstay of examination for nonpalpable testes and has been expected to contribute not only to an exact diagnosis, but also to decisive treatment. Since Cortesi et al performed laparoscopic observation to diagnose a nonpalpable testis,2 the efficacy of laparoscopy for nonpalpable testis has been advocated and laparoscopic procedures have largely replaced surgical exploration for evaluating nonpalpable testes. On the other hand, others have pointed out that a large number of patients with nonpalpable testes ultimately undergo inguinal exploration, although laparoscopic examination from the inferior edge of the umbilicus is initially performed.3– 6 Because of this controversy, we performed laparoscopy through the divided inguinal canal in cases in which neither testicular vessels nor vas deferens was identified macroscopically in the inguinal canal. MATERIALS AND METHODS
We reviewed the records from November 1993 to December 2000 to identify all cases in which 1 testis was not palpated at the groin or in the scrotum. Although detailed physical examination was performed at least 3 times by 2 pediatric urologists at our outpatient clinic, 1 testis was not palpated in 33 patients 1 to 12 years old. While 30 patients each had Accepted for publication September 21, 2001.
1 nonpalpable and 1 contralateral descended palpable testis, 3 had 1 nonpalpable and 1 contralateral undescended palpable testis. Of these 33 testes 20 (60%) were on the left and 13 (40%) were on the right side. In the patients with a unilateral nonpalpable testis an ipsilateral inguinal skin incision was made and the inguinal canal was divided before laparoscopy. When the testis, its remnant or testicular vessels and vas deferens were detected in patients who underwent exploration through an inguinal incision, orchiectomy or orchiopexy was performed as appropriate. When the testicular vessels and vas deferens were not identified macroscopically in the spermatic cord, transinguinal laparoscopy was performed. After grasping and opening the patent processus vaginalis or peritoneum near the internal inguinal ring an appropriate size trocar was inserted into the intraperitoneal space under direct vision (fig. 1). Laparoscopy was then performed through the trocar to locate the intraperitoneal testis or testicular vessels and vas deferens. A 0-degree lens was used to introduce the laparoscope through the trocar, and a 30, 70 or 120-degree lens was used for laparoscopic examination. Similarly transinguinal laparoscopy was performed in a patient in whom a spermatic cord was not detected inside the canal. In patients with 1 unilateral nonpalpable and 1 contralateral undescended palpable testis the ipsilateral inguinal canal was divided on the palpable side. A trocar was then inserted through the inguinal patent processus and the laparoscope was manipulated into the contralateral lower quadrant for further examination.
674
675
MANAGEMENT OF NONPALPABLE TESTIS
FIG. 1. For transinguinal laparoscopy trocar was inserted into intraperitoneal space under direct vision at internal inguinal ring and laparoscopy was performed to locate intra-peritoneal testis or identify testicular vessels and vas deferens.
internal inguinal ring, taking advantage of the divided inguinal canal. Since testicular vessels and a vas deferens were observed running toward the internal ring, we considered them to represent vanishing testes and subsequently performed orchiectomy. In 3 patients with 1 unilateral nonpalpable testis and 1 contralateral undescended palpable testis an inguinal skin incision was made on the side of the palpable testis and the laparoscope was manipulated into the contralateral lower abdomen. Intra-abdominal testes were observed in 2 patients through the laparoscope from the contralateral groin. We delivered it into the scrotum in 1 case but in the other we performed orchiectomy after determining that sufficient cord length would not be obtained. The remaining patient did not have an intra-abdominal testis, and the hypoplastic spermatic vessels and vas deferens were visualized entering the inguinal canal through the internal ring. Therefore, we performed groin exploration and removed the vanishing testis. In all 3 patients we performed orchiopexy on the palpable side after the transinguinal laparoscopy. No complications developed in any patients in this series.
RESULTS
DISCUSSION
Transinguinal laparoscopy was required in 8 of the 30 patients with 1 unilateral nonpalpable and 1 contralateral descended testis, while the procedure was avoided in 22 because the testis, its remnant or testicular vessels and vas deferens were detected by inspecting the inguinal region (fig. 2). A canalicular testis in 2 of the 22 cases was detected by groin exploration and orchiopexy was done. The remaining 20 testes characterized as vanishing were eventually removed when the spermatic cord was discovered to consist of testicular vessels and vas deferens only. Of the 8 patients who had transinguinal laparoscopy a nonpalpable testis in a 12-year-old boy was located in the peritoneal cavity near the internal inguinal ring. In each of the other 4 patients who underwent laparoscopy because a spermatic cord was not detected inside the canal by inguinal exploration a blind ending vas deferens and spermatic vessels were observed above the internal inguinal ring but no testis or epididymis was identified. The laparoscope was then removed and the inguinal canal was closed. In the remaining 3 cases remnants of a testis were detected in the inguinal canal via an inguinal incision and removed. Although cord structures were identified in the divided inguinal canal, they were so tiny that we did not observe testicular vessels or a vas deferens. Therefore, we inserted a laparoscope from the
About 20% of all undescended testes are nonpalpable.7, 8 They represent a variety of testicular situations, such as intra-abdominal or intra-canalicular, absent and atrophic testis, which is called vanishing testis. A nonpalpable testis represents a complex diagnostic and therapeutic challenge to urologists because it is still difficult to identify the position of the nonpalpable testis preoperatively by radiological and digital examination.1 Laparoscopic procedures have largely replaced surgical exploration and are widely performed to evaluate nonpalpable testes. Laparoscopy can be done to confirm a testis that is not palpable and obtain information on its location, when present. Furthermore, laparoscopy for nonpalpable testes has currently been applied to laparoscopic ligation of the spermatic vessels as stage 1 of a 2-stage FowlerStephens operation9 or laparoscopic orchiopexy10 in patients with an intra-abdominal testis. Although laparoscopy performed from the inferior umbilical edge is useful for treating a nonpalpable testis, it has been suggested that not all cases require such laparoscopy. Conventional laparoscopy for nonpalpable testes can eliminate unnecessary exploratory surgery in patients with vanished testes, although the incidence is reportedly low at 11%,3 14%4 and 15%.5, 6 However, a 34% rate was reported by Cortes et al.11
FIG. 2. Management algorithm and results in 30 patients with 1 unilateral nonpalpable and 1 contralateral descended palpable testis. Values represent number of patients.
676
MANAGEMENT OF NONPALPABLE TESTIS
Gulanikar et al stated that laparoscopic examination for nonpalpable testis should be considered only when the disorder cannot be diagnosed by inguinal exploration.9 We agree with that opinion and performed laparoscopic examination when a nonpalpable testis was not identified by inspection of the inguinal canal. As performed, laparoscopic examination for nonpalpable testes was not done through the inferior umbilical edge but through the divided inguinal canal, which advanced groin exploration. On the other hand, Ferro et al insisted that all nonpalpable testes would be diagnosed by and treated with a combined inguinal-abdominal approach and laparoscopic examination may be replaced by a modified inguinal approach.12 When they did not detect a nonpalpable testis at the usual exploration of the inguinal canal, they extended the skin incision and divided the external oblique fascia and conjoined tendon. Eventually they achieved intraperitoneal exploration. The advantages of our strategy of inguinal laparoscopy over the combined inguinal-abdominal approach and direct intraperitoneal observation of Ferro et al is that no further extension of the incision is necessary in cases of a blind ending vas and vessels.12 We cannot deny the criticism that our procedure may be more invasive in cases of intraperitoneal blind ending vas and vessels since we incise approximately 2 cm. of groin skin and split the inguinal canal. Additional surgical exploration is unnecessary when conventional umbilical laparoscopy is elected. However, we agree that inguinal exploration can eliminate the need for laparoscopy in many patients with a nonpalpable testis. Laparoscopy was unnecessary in 22 of our 30 patients (73.3%) who had 1 unilateral nonpalpable and 1 contralateral scrotal testis because the testis or its remnant was revealed by incising the inguinal skin and dividing the canal. In conclusion, our strategy of initial inguinal exploration followed by transinguinal laparoscopy for nonpalpable testes may become a reasonable alternative. REFERENCES
1. Friedland, G. W. and Chang, P.: The role of imaging in the management of the impalpable undescended testis. AJR Am J Roentgenol, 151: 1107, 1998 2. Cortesi, N., Ferrari, P., Zambarda, E. et al: Diagnosis of bilateral abdominal cryptorchidism by laparoscopy. Endoscopy, 8: 33, 1976 3. Levitt, S. B., Kogan, G. W., Engel, R. M. et al: The impalpable testis: a rational approach to management. J Urol, 120: 515, 1978 4. Kirsch, A. J., Escala, J., Duckett, J. W. et al: Surgical management of the nonpalpable testis: the Children’s Hospital of Philadelphia experience. J Urol, 159: 1340, 1998 5. Bloom, D. A.: Two-step orchiopexy with pelviscopic clip ligation of the spermatic vessels. J Urol, 145: 1030, 1991 6. Jordan, G. H., Robey, E. L. and Winslow, B. H.: Laparoendoscopic surgical management of the abdominal/transinguinal undescended testicle. J Endourol, 6: 159, 1992 7. Moore, R. G., Peters, C. A., Bauer, S. B. et al: Laparoscopic evaluation of the nonpalpable testis: a prospective assessment of accuracy. J Urol, 151: 728, 1994 8. Naslund, M. J., Gearhart, J. P., Jeffs, R. D. et al: Laparoscopy: its selected use in patients with unilateral nonpalpable testis after human chorionic gonadotropin stimulation. J Urol, 142: 108, 1989 9. Gulanikar, A. C., Anderson, P. A., Schwarz, R. et al: Impact of diagnostic laparoscopy in the management of the unilateral impalpable testis. Br J Urol, 77: 455, 1996 10. Tennenbaum, S. Y., Lerner, S. E., Mcaleer, I. M. et al: Preoperative laparoscopic localization of the nonpalpable testis: a critical analysis of a 10-year experience. J Urol, 151: 732, 1994 11. Cortes, D., Throup, J. M., Lenz, K. et al: Laparoscopy in 100
consecutive patients with 128 impalpable testis. Br J Urol, 75: 281, 1995 12. Ferro, F., Lais, A., Bagolan, P. et al: Impact of primary surgical approach in the management of the impalpable testis. Eur Urol, 22: 142, 1992 EDITORIAL COMMENT These authors recommend that before laparoscopic evaluation for nonpalpable testis inguinal exploration should be performed. If the testis is not located in the inguinal canal, laparoscopy can then be performed through the internal ring and opened peritoneum, much as is done in some circles to determine whether there is a contralateral hernia in a child with a clinically evident unilateral hernia. It is interesting to note that 60% of nonpalpable testes were on the left side and more than two-thirds had evidence of a vanished testis (perinatal torsion). This incidence is much the same as in other series. When the left testis is nonpalpable, clinicians should be alerted to the probable diagnosis. Two patients had intracanalicular undescended testes and intra-abdominal testes were present in only 3 of the 33 in the 2 groups. We have observed and concluded that perinatal torsion appears to be almost exclusively an intrascrotal event.1 Therefore, it is reasonable to consider scrotal exploration as the first step for determining whether a testis is present. It decreases morbidity, risks and cost. If the remnants of an atrophic testis are evident in the scrotum, and often they are tiny and may consist of nothing more than a nubbin of hemosiderin with a tiny fiber of atrophic spermatic cord extending proximal, nothing further need be done. Some may consider fixing the contralateral solitary testis to prevent any risk of torsion in the future, although the risk is probably no greater than in otherwise normal individuals since perinatal torsion and the intravaginal torsion that generally occurs in older males have different etiologies. The argument made against the approach that we advocate is that one may confuse the remnants in the scrotum with a long looping vas. It may occur if one does not carefully inspect the tissue before excising it and rule out a patent processus vaginalis. In patients with a nonpalpable testis and long looping vas the processus is always patent and that finding is always associated with some testicular tissue proximal. In that circumstance further surgery is indicated with the approach dictated by surgeon preference. On the other hand, van Savage recently advocated laparoscopy as the initial procedure in patients with nonpalpable testes despite vanished testes in 14 of 16 children on midline scrotal exploration, such as we advocate.2 Scrotal exploration followed laparoscopic visualization of the closed internal ring with vas and vessels exiting the site. We recently treated a patient with a nonpalpable testis who underwent negative scrotal exploration with a closed internal ring, and vas and vessels exiting as visualized on laparoscopic inspection. Since the findings were contradictory, inguinal exploration was done. An intracanalicular testis was identified with the external ring completely occluded and the processus vaginalis obliterated. The clue to the correct diagnosis was the absence of any remnant tissue or tunica vaginalis in the scrotum. Laparoscopic findings alone would have suggested testicular atrophy. These authors would have made the correct diagnosis in that case with their primary inguinal exploration. Since the majority of patients with a nonpalpable testis, particularly when the left side is affected, have had perinatal torsion and atrophic testis can be identified in the scrotum, it seems unreasonable to perform initially laparoscopy, which is the current vogue, or inguinal exploration. When scrotal exploration is negative, our approach is then to perform standard subumbilical diagnostic laparoscopy. If an intra-abdominal testis is identified, I prefer a lower midline abdominal incision and perform extraperitoneal orchiopexy. Some would do this procedure completely via laparoscopy. A. Barry Belman Children’s National Medical Center Washington, D. C. 1. Belman, A. B. and Rushton, H. G.: Is the vanished testis always a scrotal event? BJU Int, 87: 480, 2001 2. Van Savage, J. G.: Avoidance of inguinal incision in laparoscopically confirmed vanishing testis. J Urol, 166: 1421, 2001
Vol. 167, 674 – 676, February 2002 Printed in U.S.A.
THE MANAGEMENT OF NONPALPABLE TESTIS WITH COMBINED GROIN EXPLORATION AND SUBSEQUENT TRANSINGUINAL LAPAROSCOPY KAZUHIRO KANEMOTO, YUTARO HAYASHI, YOSHIYUKI KOJIMA, KEIICHI TOZAWA, TOHRU MOGAMI and KENJIRO KOHRI From the Department of Urology, Nagoya City University Medical School, Nagoya, Japan
ABSTRACT
Purpose: About 20% of all cryptorchid testes are nonpalpable. Although surgical exploration was previously the method of choice for management, laparoscopy from the inferior edge of the umbilicus has been established as a useful method of finding a testis that is nonpalpable. However, conventional subumbilical laparoscopy is unnecessary when the testis or its remnant is located below the internal inguinal ring. We evaluated the efficacy of transinguinal laparoscopy after inguinal exploration for a nonpalpable testis. Materials and Methods: While 30 patients each had a unilateral nonpalpable and a contralateral descended palpable testis, 3 had a unilateral nonpalpable and a contralateral undescended palpable testis. When we identified neither a normal testis nor a spermatic cord at exploration of the inguinal canal, we subsequently performed laparoscopic observation through the internal inguinal ring. Results: Of the 30 patients with a unilateral nonpalpable and a contralateral descended testis 8 required transinguinal laparoscopy. However, the procedure was avoided in 22 patients because the testis, its remnant or testicular vessels and vas deferens were detected by inspecting the inguinal region. Conclusions: Further extended incision into a Pfannenstiel incision was unnecessary in cases of blind ending vas and vessels in the peritoneum with transinguinal laparoscopy. In addition, laparoscopy was avoided in 22 of the 30 children (73.3%) with a unilateral nonpalpable and a contralateral scrotal testis. Our strategy of initial inguinal exploration followed by transinguinal laparoscopy for nonpalpable testis may become a reasonable alternative. KEY WORDS: testis, abnormalities, laparoscopy
A nonpalpable testis represents a complex diagnostic and therapeutic challenge to urologists because an accurate diagnosis is not easily made by radiological and physical examinations.1 Therefore, groin exploration has been the mainstay of examination for nonpalpable testes and has been expected to contribute not only to an exact diagnosis, but also to decisive treatment. Since Cortesi et al performed laparoscopic observation to diagnose a nonpalpable testis,2 the efficacy of laparoscopy for nonpalpable testis has been advocated and laparoscopic procedures have largely replaced surgical exploration for evaluating nonpalpable testes. On the other hand, others have pointed out that a large number of patients with nonpalpable testes ultimately undergo inguinal exploration, although laparoscopic examination from the inferior edge of the umbilicus is initially performed.3– 6 Because of this controversy, we performed laparoscopy through the divided inguinal canal in cases in which neither testicular vessels nor vas deferens was identified macroscopically in the inguinal canal. MATERIALS AND METHODS
We reviewed the records from November 1993 to December 2000 to identify all cases in which 1 testis was not palpated at the groin or in the scrotum. Although detailed physical examination was performed at least 3 times by 2 pediatric urologists at our outpatient clinic, 1 testis was not palpated in 33 patients 1 to 12 years old. While 30 patients each had Accepted for publication September 21, 2001.
1 nonpalpable and 1 contralateral descended palpable testis, 3 had 1 nonpalpable and 1 contralateral undescended palpable testis. Of these 33 testes 20 (60%) were on the left and 13 (40%) were on the right side. In the patients with a unilateral nonpalpable testis an ipsilateral inguinal skin incision was made and the inguinal canal was divided before laparoscopy. When the testis, its remnant or testicular vessels and vas deferens were detected in patients who underwent exploration through an inguinal incision, orchiectomy or orchiopexy was performed as appropriate. When the testicular vessels and vas deferens were not identified macroscopically in the spermatic cord, transinguinal laparoscopy was performed. After grasping and opening the patent processus vaginalis or peritoneum near the internal inguinal ring an appropriate size trocar was inserted into the intraperitoneal space under direct vision (fig. 1). Laparoscopy was then performed through the trocar to locate the intraperitoneal testis or testicular vessels and vas deferens. A 0-degree lens was used to introduce the laparoscope through the trocar, and a 30, 70 or 120-degree lens was used for laparoscopic examination. Similarly transinguinal laparoscopy was performed in a patient in whom a spermatic cord was not detected inside the canal. In patients with 1 unilateral nonpalpable and 1 contralateral undescended palpable testis the ipsilateral inguinal canal was divided on the palpable side. A trocar was then inserted through the inguinal patent processus and the laparoscope was manipulated into the contralateral lower quadrant for further examination.
674
675
MANAGEMENT OF NONPALPABLE TESTIS
FIG. 1. For transinguinal laparoscopy trocar was inserted into intraperitoneal space under direct vision at internal inguinal ring and laparoscopy was performed to locate intra-peritoneal testis or identify testicular vessels and vas deferens.
internal inguinal ring, taking advantage of the divided inguinal canal. Since testicular vessels and a vas deferens were observed running toward the internal ring, we considered them to represent vanishing testes and subsequently performed orchiectomy. In 3 patients with 1 unilateral nonpalpable testis and 1 contralateral undescended palpable testis an inguinal skin incision was made on the side of the palpable testis and the laparoscope was manipulated into the contralateral lower abdomen. Intra-abdominal testes were observed in 2 patients through the laparoscope from the contralateral groin. We delivered it into the scrotum in 1 case but in the other we performed orchiectomy after determining that sufficient cord length would not be obtained. The remaining patient did not have an intra-abdominal testis, and the hypoplastic spermatic vessels and vas deferens were visualized entering the inguinal canal through the internal ring. Therefore, we performed groin exploration and removed the vanishing testis. In all 3 patients we performed orchiopexy on the palpable side after the transinguinal laparoscopy. No complications developed in any patients in this series.
RESULTS
DISCUSSION
Transinguinal laparoscopy was required in 8 of the 30 patients with 1 unilateral nonpalpable and 1 contralateral descended testis, while the procedure was avoided in 22 because the testis, its remnant or testicular vessels and vas deferens were detected by inspecting the inguinal region (fig. 2). A canalicular testis in 2 of the 22 cases was detected by groin exploration and orchiopexy was done. The remaining 20 testes characterized as vanishing were eventually removed when the spermatic cord was discovered to consist of testicular vessels and vas deferens only. Of the 8 patients who had transinguinal laparoscopy a nonpalpable testis in a 12-year-old boy was located in the peritoneal cavity near the internal inguinal ring. In each of the other 4 patients who underwent laparoscopy because a spermatic cord was not detected inside the canal by inguinal exploration a blind ending vas deferens and spermatic vessels were observed above the internal inguinal ring but no testis or epididymis was identified. The laparoscope was then removed and the inguinal canal was closed. In the remaining 3 cases remnants of a testis were detected in the inguinal canal via an inguinal incision and removed. Although cord structures were identified in the divided inguinal canal, they were so tiny that we did not observe testicular vessels or a vas deferens. Therefore, we inserted a laparoscope from the
About 20% of all undescended testes are nonpalpable.7, 8 They represent a variety of testicular situations, such as intra-abdominal or intra-canalicular, absent and atrophic testis, which is called vanishing testis. A nonpalpable testis represents a complex diagnostic and therapeutic challenge to urologists because it is still difficult to identify the position of the nonpalpable testis preoperatively by radiological and digital examination.1 Laparoscopic procedures have largely replaced surgical exploration and are widely performed to evaluate nonpalpable testes. Laparoscopy can be done to confirm a testis that is not palpable and obtain information on its location, when present. Furthermore, laparoscopy for nonpalpable testes has currently been applied to laparoscopic ligation of the spermatic vessels as stage 1 of a 2-stage FowlerStephens operation9 or laparoscopic orchiopexy10 in patients with an intra-abdominal testis. Although laparoscopy performed from the inferior umbilical edge is useful for treating a nonpalpable testis, it has been suggested that not all cases require such laparoscopy. Conventional laparoscopy for nonpalpable testes can eliminate unnecessary exploratory surgery in patients with vanished testes, although the incidence is reportedly low at 11%,3 14%4 and 15%.5, 6 However, a 34% rate was reported by Cortes et al.11
FIG. 2. Management algorithm and results in 30 patients with 1 unilateral nonpalpable and 1 contralateral descended palpable testis. Values represent number of patients.
676
MANAGEMENT OF NONPALPABLE TESTIS
Gulanikar et al stated that laparoscopic examination for nonpalpable testis should be considered only when the disorder cannot be diagnosed by inguinal exploration.9 We agree with that opinion and performed laparoscopic examination when a nonpalpable testis was not identified by inspection of the inguinal canal. As performed, laparoscopic examination for nonpalpable testes was not done through the inferior umbilical edge but through the divided inguinal canal, which advanced groin exploration. On the other hand, Ferro et al insisted that all nonpalpable testes would be diagnosed by and treated with a combined inguinal-abdominal approach and laparoscopic examination may be replaced by a modified inguinal approach.12 When they did not detect a nonpalpable testis at the usual exploration of the inguinal canal, they extended the skin incision and divided the external oblique fascia and conjoined tendon. Eventually they achieved intraperitoneal exploration. The advantages of our strategy of inguinal laparoscopy over the combined inguinal-abdominal approach and direct intraperitoneal observation of Ferro et al is that no further extension of the incision is necessary in cases of a blind ending vas and vessels.12 We cannot deny the criticism that our procedure may be more invasive in cases of intraperitoneal blind ending vas and vessels since we incise approximately 2 cm. of groin skin and split the inguinal canal. Additional surgical exploration is unnecessary when conventional umbilical laparoscopy is elected. However, we agree that inguinal exploration can eliminate the need for laparoscopy in many patients with a nonpalpable testis. Laparoscopy was unnecessary in 22 of our 30 patients (73.3%) who had 1 unilateral nonpalpable and 1 contralateral scrotal testis because the testis or its remnant was revealed by incising the inguinal skin and dividing the canal. In conclusion, our strategy of initial inguinal exploration followed by transinguinal laparoscopy for nonpalpable testes may become a reasonable alternative. REFERENCES
1. Friedland, G. W. and Chang, P.: The role of imaging in the management of the impalpable undescended testis. AJR Am J Roentgenol, 151: 1107, 1998 2. Cortesi, N., Ferrari, P., Zambarda, E. et al: Diagnosis of bilateral abdominal cryptorchidism by laparoscopy. Endoscopy, 8: 33, 1976 3. Levitt, S. B., Kogan, G. W., Engel, R. M. et al: The impalpable testis: a rational approach to management. J Urol, 120: 515, 1978 4. Kirsch, A. J., Escala, J., Duckett, J. W. et al: Surgical management of the nonpalpable testis: the Children’s Hospital of Philadelphia experience. J Urol, 159: 1340, 1998 5. Bloom, D. A.: Two-step orchiopexy with pelviscopic clip ligation of the spermatic vessels. J Urol, 145: 1030, 1991 6. Jordan, G. H., Robey, E. L. and Winslow, B. H.: Laparoendoscopic surgical management of the abdominal/transinguinal undescended testicle. J Endourol, 6: 159, 1992 7. Moore, R. G., Peters, C. A., Bauer, S. B. et al: Laparoscopic evaluation of the nonpalpable testis: a prospective assessment of accuracy. J Urol, 151: 728, 1994 8. Naslund, M. J., Gearhart, J. P., Jeffs, R. D. et al: Laparoscopy: its selected use in patients with unilateral nonpalpable testis after human chorionic gonadotropin stimulation. J Urol, 142: 108, 1989 9. Gulanikar, A. C., Anderson, P. A., Schwarz, R. et al: Impact of diagnostic laparoscopy in the management of the unilateral impalpable testis. Br J Urol, 77: 455, 1996 10. Tennenbaum, S. Y., Lerner, S. E., Mcaleer, I. M. et al: Preoperative laparoscopic localization of the nonpalpable testis: a critical analysis of a 10-year experience. J Urol, 151: 732, 1994 11. Cortes, D., Throup, J. M., Lenz, K. et al: Laparoscopy in 100
consecutive patients with 128 impalpable testis. Br J Urol, 75: 281, 1995 12. Ferro, F., Lais, A., Bagolan, P. et al: Impact of primary surgical approach in the management of the impalpable testis. Eur Urol, 22: 142, 1992 EDITORIAL COMMENT These authors recommend that before laparoscopic evaluation for nonpalpable testis inguinal exploration should be performed. If the testis is not located in the inguinal canal, laparoscopy can then be performed through the internal ring and opened peritoneum, much as is done in some circles to determine whether there is a contralateral hernia in a child with a clinically evident unilateral hernia. It is interesting to note that 60% of nonpalpable testes were on the left side and more than two-thirds had evidence of a vanished testis (perinatal torsion). This incidence is much the same as in other series. When the left testis is nonpalpable, clinicians should be alerted to the probable diagnosis. Two patients had intracanalicular undescended testes and intra-abdominal testes were present in only 3 of the 33 in the 2 groups. We have observed and concluded that perinatal torsion appears to be almost exclusively an intrascrotal event.1 Therefore, it is reasonable to consider scrotal exploration as the first step for determining whether a testis is present. It decreases morbidity, risks and cost. If the remnants of an atrophic testis are evident in the scrotum, and often they are tiny and may consist of nothing more than a nubbin of hemosiderin with a tiny fiber of atrophic spermatic cord extending proximal, nothing further need be done. Some may consider fixing the contralateral solitary testis to prevent any risk of torsion in the future, although the risk is probably no greater than in otherwise normal individuals since perinatal torsion and the intravaginal torsion that generally occurs in older males have different etiologies. The argument made against the approach that we advocate is that one may confuse the remnants in the scrotum with a long looping vas. It may occur if one does not carefully inspect the tissue before excising it and rule out a patent processus vaginalis. In patients with a nonpalpable testis and long looping vas the processus is always patent and that finding is always associated with some testicular tissue proximal. In that circumstance further surgery is indicated with the approach dictated by surgeon preference. On the other hand, van Savage recently advocated laparoscopy as the initial procedure in patients with nonpalpable testes despite vanished testes in 14 of 16 children on midline scrotal exploration, such as we advocate.2 Scrotal exploration followed laparoscopic visualization of the closed internal ring with vas and vessels exiting the site. We recently treated a patient with a nonpalpable testis who underwent negative scrotal exploration with a closed internal ring, and vas and vessels exiting as visualized on laparoscopic inspection. Since the findings were contradictory, inguinal exploration was done. An intracanalicular testis was identified with the external ring completely occluded and the processus vaginalis obliterated. The clue to the correct diagnosis was the absence of any remnant tissue or tunica vaginalis in the scrotum. Laparoscopic findings alone would have suggested testicular atrophy. These authors would have made the correct diagnosis in that case with their primary inguinal exploration. Since the majority of patients with a nonpalpable testis, particularly when the left side is affected, have had perinatal torsion and atrophic testis can be identified in the scrotum, it seems unreasonable to perform initially laparoscopy, which is the current vogue, or inguinal exploration. When scrotal exploration is negative, our approach is then to perform standard subumbilical diagnostic laparoscopy. If an intra-abdominal testis is identified, I prefer a lower midline abdominal incision and perform extraperitoneal orchiopexy. Some would do this procedure completely via laparoscopy. A. Barry Belman Children’s National Medical Center Washington, D. C. 1. Belman, A. B. and Rushton, H. G.: Is the vanished testis always a scrotal event? BJU Int, 87: 480, 2001 2. Van Savage, J. G.: Avoidance of inguinal incision in laparoscopically confirmed vanishing testis. J Urol, 166: 1421, 2001