- Email: [email protected]
Controversy in cryptorchidism: the value of laparoscopy and fertility outcomes
We will be awaiting the conclusion of the above trial, which is still a few years off, in the hope that the answers will clarify many of the questions about LVR.
PARVIS J. SADIGHI, MD Berkshire Medical Center Pittsfield, Massachusetts PII S0149-7944(00)00374-3
REFERENCES 1. Cooper JD. Technique to reduce air leaks after resection of emphysematous lung.
Ann Thorac Surg. 1994;57:1038-1039. 2. Wong K. Goldstraw P. Feffect of fibrin glue in reduction of postthoracotomy
alveolar air leak. Ann Thorac Surg. 1997;64:979-981. 3. Knudson RJ, Gaensler EA. Surgery for emphysema. Ann Thorac Surg. 1965;1:332-
362. 4. Brantigan DC, Mueller E. Surgical treatment of pulmonary emphysema. Ann Surg.
1957;23:789-804. 5. Cooper JD, Trulock EP, Triantafillon AN, et al. Bilateral pneumectomy (volume
reduction) for chronic obstructive pulmonary disease. J Thorac Card Vasc Surg. 1995;109:106-116. 6. Hazelrigg S, Boley T, Johnstone D, et al. Thoracic laser bullectomy: a prospective
study with three-month results. J Thorac Card Vasc Surg. 1996;112:319-327. 7. McKenna RJ, Brenner M, Mullin MJ, et al. A randomized prospective trial of
stapled lung reduction versus laser bullectomy for diffuse emphysema. J Thorac Card Vasc Surg. 1996;111:317-322. 8. Cooper JD, Lefrak SS. Lung reduction surgery: five years on. Lancet. 1999;
353(suppl I):26-27.
Urology Controversy in Cryptorchidism: The Value of Laparoscopy and Fertility Outcomes Guest Reviewers: Kevin Satisky, MD, and Benjamin G. Hines, Jr, MD REVIEWER COMMENTS
This study presents an overview of laparoscopic evaluation of the nonpalpable testis at 1 particular institution. The study cannot comment on other institutions’ experiences, nor can it take into account the laparoscopic skill of other surgeons. An interesting point is that this study matched the national literature in the percentage of the findings in the lo-
CURRENT FINDINGS IN DIAGNOSTIC LAPAROSCOPIC EVALUATION OF THE NONPALPABLE TESTIS. Cisek LJ, Peters CA, Atala A, Bauer SB, Diamond DA, Retik AB. J Urol 1998;160:1145-1149. Objective: Examination of the current findings and contribution of the diagnostic laparoscopic evaluation in the management of nonpalpable testis. Design: Retrospective chart review with subsequent literature review. Setting: Children’s Hospital and Harvard Center for Minimally Invasive Surgery, Harvard Medical School, Cambridge, Massachusetts.
CURRENT SURGERY • Volume 58/Number 3 • May/June 2001
279
Participants: Patients from all cases of undescended testis in which laparoscopy was planned preoperatively from September 1992 to 1996. A total of 225 (263 nonpalpable testis) patients were reviewed in this study with a mean age of 32 months and a median age of 14.5 months. Results: Forty patients (46 testes), 18%, were excluded when the examination under anesthesia revealed testicular location, and another 2 patients were excluded because of incomplete records. Of the remaining 215 testes, which were explored laparoscopically, 45.7% would have been found during inguinal exploration. Intra-abdominal vanishing testes were present in 9.8% of the patients. Forty-nine percent were intraabdominal, and 40% were distal (inguinal, scrotal, or perineal), with the remaining 11% being transinguinal. A total of 61% of the testes were viable (37.2% intraabdominal and 12.1% inguinal). When testes were discovered distal to the internal ring during laparoscopy, normal-appearing vas and vessels were associated with a 45% chance of having a viable testis, whereas atretic vas and vessels were not identified with a viable testis. A conventional inguinal incision would have provided optimal exposure for operative management in 34% of the cases.
REVIEWER COMMENTS (Con’t)
cation of nonpalpable testes. This study had adequate numbers, and the authors were able to account for each patient in the study.
Conclusions: The authors reported that unnecessary abdominal exploration was avoided in 13.2% of the cases. Laparoscopic evaluation aptly detected intra-abdominal vanishing testes (found in 10% of cases and 16% in the literature), thus, avoiding extensive open intra-abdominal exploration. They also comment that a typical incision for inguinal exploration would have been unnecessary or left the surgeon compromised in 66% of the cases compared with the laparoscopic incision and that 34% of the cases probably did not benefit from laparoscopy versus inguinal exploration. A thorough examination under anesthesia reduced the number of uninformative laparoscopic evaluations. Therefore, laparoscopy has a role in the evaluation of the nonpalpable testis in the appropriately selected patient.
LAPAROSCOPIC FOWLER-STEPHENS ORCHIOPEXY FOR THE HIGH ABDOMINAL TESTIS. Lindgren BW, Franco I, Blick S, et al. J Urol 1999;162:990994. Objective: To assess the outcomes of the laparoscopic Fowler–Stephens orchiopexy performed in both 1 and 2 stages. Design: Retrospective review of charts. Setting: Long Island Jewish Medical Center—Schneider Children’s Hospital, New Hyde Park, NY, and Westchester Medical Center, Valhalla, NY. Participants: A total of 108 patients had a total of 126 nonpalpable testes. Mean patient age was 44 months, ranging from 11 to 120 months. Results: A total of 51 testes (40%) out of the 126 nonpalpable testes (108 patients) were intra-abdominal. Of those 51, 18 (in 14 patients) testes were found in which a laparoscopic Fowler–Stephens orchiopexy was performed. Five were treated with a 2-stage procedure, 13 with a 1-stage procedure, with 2 requiring an inguinal incision. Two patients were hospitalized after the second stage because of a prolonged ileus. No other complications were reported, except the atrophy of 2 testes in which the patients had undergone previous surgery. A mean follow-up of 6 months occurred, with 89% of the testes in scrotal position and without atrophy. Conclusions: The laparoscopic Fowler–Stephens orchiopexy can be a reasonable approach for the high abdominal testis when vessel length prevents adequate mobilization to reach the scrotum. If the 2 patients that had previous surgery were excluded, the success rate would have been 100%; otherwise, the success rate was 89%.
280
REVIEWER COMMENTS
This article is trying to look at the success of the laparoscopic Fowler–Stephens orchiopexy in a larger number of cases. Although the authors make mention of the incidental reports, they fail to discuss much about the outcomes in the literature; a table comparison would have been nice and simple. In the study, it was noted that the success rate was 100% if one excluded cases with previous surgery, although 1 of those was a stage 1 of a 2-stage laparoscopic Fowler–Stephens orchiopexy. With the limited numbers, the authors made good use of the bilateral cases by using different procedures in each testis in 2 of the patients (1- vs 2-stage laparoscopic Fowler–Stephens orchiopexy). Overall, this is a good study, but more numbers are needed at different institutions to accurately assess the efficacy and safety of this new technique.
CURRENT SURGERY • Volume 58/Number 3 • May/June 2001
REVIEWER COMMENTS
This study was performed in 2 phases. The first phase consisted of a paternity questionnaire that included over 1200 patients with a history of unilateral cryptorchidism. The data presented here are only from 84 of the participants that lived nearby the institution, thereby giving only a limited sample of the cases. All cases of surgery in these patients were performed between the years of 1955 and 1974. No cases of bilateral cryptorchidism are included in this study. Also, considerably less cases of surgery exist by age 2 (10 out of 84). Better follow-up with the individual patients would have greatly aided this study. Of interest is that although trends of inhibin B and FSH are noted, most of the values fall into normal ranges. This article supports the idea of fertility benefits in early orchiopexy, but it still lacks the numbers to prove this particular benefit or suggest a definitive physiologic correlation. Further examination of new cases of early orchiopexy and hormone measurements would be of interest.
AGE AT UNILATERAL ORCHIOPEXY: EFFECT ON HORMONE LEVELS AND SPERM COUNT IN ADULTHOOD. Coughlin MT, Bellinger MF, and Lee PA. J Urol 1999;162:986-989. Objective: To determine if correlation exists among inhibin B, follicle stimulating hormone (FSH), luteinizing hormone (LH), testosterone, sperm density, and age at orchiopexy. Design: Questionnaire followed by analyzing blood and semen samples with statistical correlation. Setting: Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania. Participants: Eighty-four men with a history of unilateral cryptorchidism. Results: A comparison using Pearson’s correlation showed that age at orchiopexy had significant effects on inhibin B and FSH. Age at orchiopexy was inversely correlated with inhibin B levels (r ⫽ ⫺0.274, p ⫽ 0.012) and positively correlated with FSH (r ⫽ 0.229, p ⫽ 0.036). A linear trend was noted between age of orchiopexy and inhibin B (p ⫽ 0.032) and testosterone (p ⫽ 0.029). Conclusions: Age at orchiopexy significantly affects inhibin B and FSH levels in men. Men who underwent orchiopexy by age 2 had higher levels of inhibin B and lower FSH profiles. Therefore, a benefit of early orchiopexy may be to preserve future fertility in cryptorchid boys.
REVIEWER SUMMARY The patient that presents with the nonpalpable testis poses a difficult question for the surgeon. What is the best approach, a laparoscopic evaluation or a direct inguinal approach? A consensus does not exist in the recent literature. Part of the problem is that laparoscopic evaluation loses its advantage if a high number of nonpalpable testes are found to have an inguinal location, where a direct inguinal incision is the procedure of choice. So, the ultimate question remains, where are the testes located and can that be determined before laparoscopic evaluation? It was reported here that many cases (up to 18%) with inguinal testes can be found during an examination under anesthesia. Others have also recommended the examination under anesthesia in their approach to the nonpalpable testes.1 This substantially decreases the number of unnecessary laparoscopic evaluations, but does any other way exist to improve on this number? In the Retik and associates study, the authors felt that many of the current imaging techniques do not give enough information to be of any more value than the examination under anesthesia. One new study suggests that Gadolinium-enhanced magnetic resonance angiography may provide the information needed to accurately locate the testes.2 This particular study boasted a sensitivity of 96% and a specificity of 100% for locating nonpalpable testes. They report that based on Gadolinium-enhanced magnetic resonance angiography and ultrasound findings, laparoscopy would have been avoided 78% of the time. However, the cost effectiveness was not assessed nor were the numbers very high in this study (23 nonpalpable testes). Some feel that the laparoscopic evaluation is not preferable, whereas others feel that this approach is not cost effective or provides better outcomes. Snyder and associates refer to their experiences with nonpalpable testes at the Children’s Hospital of Philadelphia (Philadelphia, Pennsylvania).3 In their paper, they feel that the inguinal approach to orchiopexy with transperitoneal mobilization of the vas and vessels without transection is highly successful in the intra-abdominal cryptorchid testis and that it should be the preferred technique for management. A recent study out of Italy compared open surgery with laparoscopic evaluation followed by surgery.4 They concluded that no differences in outcomes existed, except that the laparoscopic group had increased operative cost and time. The study did not mention other factors such as
CURRENT SURGERY • Volume 58/Number 3 • May/June 2001
281
infection rates, hospital days, scar formation, adhesion formation, or patient discomfort. It should also be noted that no laparoscopic orchiopexies or other therapeutic laparoscopic procedures were performed after laparoscopic evaluation in the study. Also of interest, especially to the parents of cryptorchid children, is that of fertility. Will this patient be able to have children in the future, and does a surgical option exist that can improve fertility outcomes? Coughlin and associates propose using FSH and sperm counts as markers for infertility in former cryptorchid men.5 Interestingly, in their initial study, they were unable to make a correlation to fertility and age at orchiopexy; however, a correlation was made in their follow-up paper in this report. Perhaps cryptorchidism may be a selection strategy to prevent the passage of improperly functioning genes or new mutations in the germ line. Infertility in men is poorly understood, and many investigators are trying to piece together this puzzle. One interesting fact about sperm is that specific glycolytic isoenzymes are found only in sperm that are necessary for energy production. One such enzyme is GAPD-S. It may be that these enzymes play a crucial role in fertility. The structural aspects of GAPD-S have been studied extensively, including by this reviewer, which hopefully will shed light on the role of this enzyme in spermatogenesis and fertility.6-8 It appears that even today no consensus agreement exists on the value of laparoscopic evaluation of the nonpalpable testes. Because of the nature of laparoscopy, results are going to vary on an institutional basis. One would expect the examination under anesthesia to be able to detect up to 18% of nonpalpable testis and to make the laparoscopic evaluation a better choice. This is especially true if a laparoscopic repair is subsequently performed for the intra-abdominal testis. It would make sense to convert a laparoscopic evaluation into a laparoscopic repair if feasible. The literature presented here suggests that laparoscopic evaluation and treatment is a viable option.
KEVIN SATISKY, MD BENJAMIN G. HINES, JR, MD Brody School of Medicine East Carolina University Greenville, North Carolina PII S0149-7944(00)00420-7
REFERENCES 1. Flett ME, Jones PF, Youngson GG. Emerging trends in the management of the
impalpable testis. Brit J Surg. 1999;86:1280-1283. 2. Yeung CK, Tam YH, Chan YL, Lee KH, Metreweli C. A new management algo-
rithm for impalpable undescended testis with gadolinium enhanced magnetic resonance angiography. J Urol. 1999;162:998-1002. 3. Kirsch AJ, Escala J, Duckett JW, et al. Surgical management of the nonpalpable testis:
the Children’s Hospital of Philadelphia experience. J Urol. 1998;159:1340-1343. 4. Ferro F, Spagnoli A, Zaccara A, De Vico A, La Sala E. Is preoperative laparoscopy
useful for impalpable testis? J Urol. 1999;162:995-997. 5. Lee PA, Bellinger MF, Coughlin MT. Correlations among hormone levels, sperm
parameters and paternity in formerly unilaterally cryptorchid men. J Urol. 1998; 160:1155-1157. 6. Welch JE, Schatte EC, O’Brien DA, Eddy EM. Expression of a glyceraldehyde
3-phosphate dehydrogenase gene specific to mouse spermatogenic cells. Biol Reproduct. 1992;46:869-878. 7. Bunch DO, Welch JE, Magyar PL, Eddy EM, O’Brien DA. Glyceraldehyde
3-phosphate dehydrogenase-S protein distribution during mouse spermatogenesis. Biol Reproduct. 1998;52:834-841. 8. Satisky KF, Miki K, Eddy EM. Unpublished results. NIEHS, Durham, NC,
1998-1999. 282
CURRENT SURGERY • Volume 58/Number 3 • May/June 2001
PARVIS J. SADIGHI, MD Berkshire Medical Center Pittsfield, Massachusetts PII S0149-7944(00)00374-3
REFERENCES 1. Cooper JD. Technique to reduce air leaks after resection of emphysematous lung.
Ann Thorac Surg. 1994;57:1038-1039. 2. Wong K. Goldstraw P. Feffect of fibrin glue in reduction of postthoracotomy
alveolar air leak. Ann Thorac Surg. 1997;64:979-981. 3. Knudson RJ, Gaensler EA. Surgery for emphysema. Ann Thorac Surg. 1965;1:332-
362. 4. Brantigan DC, Mueller E. Surgical treatment of pulmonary emphysema. Ann Surg.
1957;23:789-804. 5. Cooper JD, Trulock EP, Triantafillon AN, et al. Bilateral pneumectomy (volume
reduction) for chronic obstructive pulmonary disease. J Thorac Card Vasc Surg. 1995;109:106-116. 6. Hazelrigg S, Boley T, Johnstone D, et al. Thoracic laser bullectomy: a prospective
study with three-month results. J Thorac Card Vasc Surg. 1996;112:319-327. 7. McKenna RJ, Brenner M, Mullin MJ, et al. A randomized prospective trial of
stapled lung reduction versus laser bullectomy for diffuse emphysema. J Thorac Card Vasc Surg. 1996;111:317-322. 8. Cooper JD, Lefrak SS. Lung reduction surgery: five years on. Lancet. 1999;
353(suppl I):26-27.
Urology Controversy in Cryptorchidism: The Value of Laparoscopy and Fertility Outcomes Guest Reviewers: Kevin Satisky, MD, and Benjamin G. Hines, Jr, MD REVIEWER COMMENTS
This study presents an overview of laparoscopic evaluation of the nonpalpable testis at 1 particular institution. The study cannot comment on other institutions’ experiences, nor can it take into account the laparoscopic skill of other surgeons. An interesting point is that this study matched the national literature in the percentage of the findings in the lo-
CURRENT FINDINGS IN DIAGNOSTIC LAPAROSCOPIC EVALUATION OF THE NONPALPABLE TESTIS. Cisek LJ, Peters CA, Atala A, Bauer SB, Diamond DA, Retik AB. J Urol 1998;160:1145-1149. Objective: Examination of the current findings and contribution of the diagnostic laparoscopic evaluation in the management of nonpalpable testis. Design: Retrospective chart review with subsequent literature review. Setting: Children’s Hospital and Harvard Center for Minimally Invasive Surgery, Harvard Medical School, Cambridge, Massachusetts.
CURRENT SURGERY • Volume 58/Number 3 • May/June 2001
279
Participants: Patients from all cases of undescended testis in which laparoscopy was planned preoperatively from September 1992 to 1996. A total of 225 (263 nonpalpable testis) patients were reviewed in this study with a mean age of 32 months and a median age of 14.5 months. Results: Forty patients (46 testes), 18%, were excluded when the examination under anesthesia revealed testicular location, and another 2 patients were excluded because of incomplete records. Of the remaining 215 testes, which were explored laparoscopically, 45.7% would have been found during inguinal exploration. Intra-abdominal vanishing testes were present in 9.8% of the patients. Forty-nine percent were intraabdominal, and 40% were distal (inguinal, scrotal, or perineal), with the remaining 11% being transinguinal. A total of 61% of the testes were viable (37.2% intraabdominal and 12.1% inguinal). When testes were discovered distal to the internal ring during laparoscopy, normal-appearing vas and vessels were associated with a 45% chance of having a viable testis, whereas atretic vas and vessels were not identified with a viable testis. A conventional inguinal incision would have provided optimal exposure for operative management in 34% of the cases.
REVIEWER COMMENTS (Con’t)
cation of nonpalpable testes. This study had adequate numbers, and the authors were able to account for each patient in the study.
Conclusions: The authors reported that unnecessary abdominal exploration was avoided in 13.2% of the cases. Laparoscopic evaluation aptly detected intra-abdominal vanishing testes (found in 10% of cases and 16% in the literature), thus, avoiding extensive open intra-abdominal exploration. They also comment that a typical incision for inguinal exploration would have been unnecessary or left the surgeon compromised in 66% of the cases compared with the laparoscopic incision and that 34% of the cases probably did not benefit from laparoscopy versus inguinal exploration. A thorough examination under anesthesia reduced the number of uninformative laparoscopic evaluations. Therefore, laparoscopy has a role in the evaluation of the nonpalpable testis in the appropriately selected patient.
LAPAROSCOPIC FOWLER-STEPHENS ORCHIOPEXY FOR THE HIGH ABDOMINAL TESTIS. Lindgren BW, Franco I, Blick S, et al. J Urol 1999;162:990994. Objective: To assess the outcomes of the laparoscopic Fowler–Stephens orchiopexy performed in both 1 and 2 stages. Design: Retrospective review of charts. Setting: Long Island Jewish Medical Center—Schneider Children’s Hospital, New Hyde Park, NY, and Westchester Medical Center, Valhalla, NY. Participants: A total of 108 patients had a total of 126 nonpalpable testes. Mean patient age was 44 months, ranging from 11 to 120 months. Results: A total of 51 testes (40%) out of the 126 nonpalpable testes (108 patients) were intra-abdominal. Of those 51, 18 (in 14 patients) testes were found in which a laparoscopic Fowler–Stephens orchiopexy was performed. Five were treated with a 2-stage procedure, 13 with a 1-stage procedure, with 2 requiring an inguinal incision. Two patients were hospitalized after the second stage because of a prolonged ileus. No other complications were reported, except the atrophy of 2 testes in which the patients had undergone previous surgery. A mean follow-up of 6 months occurred, with 89% of the testes in scrotal position and without atrophy. Conclusions: The laparoscopic Fowler–Stephens orchiopexy can be a reasonable approach for the high abdominal testis when vessel length prevents adequate mobilization to reach the scrotum. If the 2 patients that had previous surgery were excluded, the success rate would have been 100%; otherwise, the success rate was 89%.
280
REVIEWER COMMENTS
This article is trying to look at the success of the laparoscopic Fowler–Stephens orchiopexy in a larger number of cases. Although the authors make mention of the incidental reports, they fail to discuss much about the outcomes in the literature; a table comparison would have been nice and simple. In the study, it was noted that the success rate was 100% if one excluded cases with previous surgery, although 1 of those was a stage 1 of a 2-stage laparoscopic Fowler–Stephens orchiopexy. With the limited numbers, the authors made good use of the bilateral cases by using different procedures in each testis in 2 of the patients (1- vs 2-stage laparoscopic Fowler–Stephens orchiopexy). Overall, this is a good study, but more numbers are needed at different institutions to accurately assess the efficacy and safety of this new technique.
CURRENT SURGERY • Volume 58/Number 3 • May/June 2001
REVIEWER COMMENTS
This study was performed in 2 phases. The first phase consisted of a paternity questionnaire that included over 1200 patients with a history of unilateral cryptorchidism. The data presented here are only from 84 of the participants that lived nearby the institution, thereby giving only a limited sample of the cases. All cases of surgery in these patients were performed between the years of 1955 and 1974. No cases of bilateral cryptorchidism are included in this study. Also, considerably less cases of surgery exist by age 2 (10 out of 84). Better follow-up with the individual patients would have greatly aided this study. Of interest is that although trends of inhibin B and FSH are noted, most of the values fall into normal ranges. This article supports the idea of fertility benefits in early orchiopexy, but it still lacks the numbers to prove this particular benefit or suggest a definitive physiologic correlation. Further examination of new cases of early orchiopexy and hormone measurements would be of interest.
AGE AT UNILATERAL ORCHIOPEXY: EFFECT ON HORMONE LEVELS AND SPERM COUNT IN ADULTHOOD. Coughlin MT, Bellinger MF, and Lee PA. J Urol 1999;162:986-989. Objective: To determine if correlation exists among inhibin B, follicle stimulating hormone (FSH), luteinizing hormone (LH), testosterone, sperm density, and age at orchiopexy. Design: Questionnaire followed by analyzing blood and semen samples with statistical correlation. Setting: Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania. Participants: Eighty-four men with a history of unilateral cryptorchidism. Results: A comparison using Pearson’s correlation showed that age at orchiopexy had significant effects on inhibin B and FSH. Age at orchiopexy was inversely correlated with inhibin B levels (r ⫽ ⫺0.274, p ⫽ 0.012) and positively correlated with FSH (r ⫽ 0.229, p ⫽ 0.036). A linear trend was noted between age of orchiopexy and inhibin B (p ⫽ 0.032) and testosterone (p ⫽ 0.029). Conclusions: Age at orchiopexy significantly affects inhibin B and FSH levels in men. Men who underwent orchiopexy by age 2 had higher levels of inhibin B and lower FSH profiles. Therefore, a benefit of early orchiopexy may be to preserve future fertility in cryptorchid boys.
REVIEWER SUMMARY The patient that presents with the nonpalpable testis poses a difficult question for the surgeon. What is the best approach, a laparoscopic evaluation or a direct inguinal approach? A consensus does not exist in the recent literature. Part of the problem is that laparoscopic evaluation loses its advantage if a high number of nonpalpable testes are found to have an inguinal location, where a direct inguinal incision is the procedure of choice. So, the ultimate question remains, where are the testes located and can that be determined before laparoscopic evaluation? It was reported here that many cases (up to 18%) with inguinal testes can be found during an examination under anesthesia. Others have also recommended the examination under anesthesia in their approach to the nonpalpable testes.1 This substantially decreases the number of unnecessary laparoscopic evaluations, but does any other way exist to improve on this number? In the Retik and associates study, the authors felt that many of the current imaging techniques do not give enough information to be of any more value than the examination under anesthesia. One new study suggests that Gadolinium-enhanced magnetic resonance angiography may provide the information needed to accurately locate the testes.2 This particular study boasted a sensitivity of 96% and a specificity of 100% for locating nonpalpable testes. They report that based on Gadolinium-enhanced magnetic resonance angiography and ultrasound findings, laparoscopy would have been avoided 78% of the time. However, the cost effectiveness was not assessed nor were the numbers very high in this study (23 nonpalpable testes). Some feel that the laparoscopic evaluation is not preferable, whereas others feel that this approach is not cost effective or provides better outcomes. Snyder and associates refer to their experiences with nonpalpable testes at the Children’s Hospital of Philadelphia (Philadelphia, Pennsylvania).3 In their paper, they feel that the inguinal approach to orchiopexy with transperitoneal mobilization of the vas and vessels without transection is highly successful in the intra-abdominal cryptorchid testis and that it should be the preferred technique for management. A recent study out of Italy compared open surgery with laparoscopic evaluation followed by surgery.4 They concluded that no differences in outcomes existed, except that the laparoscopic group had increased operative cost and time. The study did not mention other factors such as
CURRENT SURGERY • Volume 58/Number 3 • May/June 2001
281
infection rates, hospital days, scar formation, adhesion formation, or patient discomfort. It should also be noted that no laparoscopic orchiopexies or other therapeutic laparoscopic procedures were performed after laparoscopic evaluation in the study. Also of interest, especially to the parents of cryptorchid children, is that of fertility. Will this patient be able to have children in the future, and does a surgical option exist that can improve fertility outcomes? Coughlin and associates propose using FSH and sperm counts as markers for infertility in former cryptorchid men.5 Interestingly, in their initial study, they were unable to make a correlation to fertility and age at orchiopexy; however, a correlation was made in their follow-up paper in this report. Perhaps cryptorchidism may be a selection strategy to prevent the passage of improperly functioning genes or new mutations in the germ line. Infertility in men is poorly understood, and many investigators are trying to piece together this puzzle. One interesting fact about sperm is that specific glycolytic isoenzymes are found only in sperm that are necessary for energy production. One such enzyme is GAPD-S. It may be that these enzymes play a crucial role in fertility. The structural aspects of GAPD-S have been studied extensively, including by this reviewer, which hopefully will shed light on the role of this enzyme in spermatogenesis and fertility.6-8 It appears that even today no consensus agreement exists on the value of laparoscopic evaluation of the nonpalpable testes. Because of the nature of laparoscopy, results are going to vary on an institutional basis. One would expect the examination under anesthesia to be able to detect up to 18% of nonpalpable testis and to make the laparoscopic evaluation a better choice. This is especially true if a laparoscopic repair is subsequently performed for the intra-abdominal testis. It would make sense to convert a laparoscopic evaluation into a laparoscopic repair if feasible. The literature presented here suggests that laparoscopic evaluation and treatment is a viable option.
KEVIN SATISKY, MD BENJAMIN G. HINES, JR, MD Brody School of Medicine East Carolina University Greenville, North Carolina PII S0149-7944(00)00420-7
REFERENCES 1. Flett ME, Jones PF, Youngson GG. Emerging trends in the management of the
impalpable testis. Brit J Surg. 1999;86:1280-1283. 2. Yeung CK, Tam YH, Chan YL, Lee KH, Metreweli C. A new management algo-
rithm for impalpable undescended testis with gadolinium enhanced magnetic resonance angiography. J Urol. 1999;162:998-1002. 3. Kirsch AJ, Escala J, Duckett JW, et al. Surgical management of the nonpalpable testis:
the Children’s Hospital of Philadelphia experience. J Urol. 1998;159:1340-1343. 4. Ferro F, Spagnoli A, Zaccara A, De Vico A, La Sala E. Is preoperative laparoscopy
useful for impalpable testis? J Urol. 1999;162:995-997. 5. Lee PA, Bellinger MF, Coughlin MT. Correlations among hormone levels, sperm
parameters and paternity in formerly unilaterally cryptorchid men. J Urol. 1998; 160:1155-1157. 6. Welch JE, Schatte EC, O’Brien DA, Eddy EM. Expression of a glyceraldehyde
3-phosphate dehydrogenase gene specific to mouse spermatogenic cells. Biol Reproduct. 1992;46:869-878. 7. Bunch DO, Welch JE, Magyar PL, Eddy EM, O’Brien DA. Glyceraldehyde
3-phosphate dehydrogenase-S protein distribution during mouse spermatogenesis. Biol Reproduct. 1998;52:834-841. 8. Satisky KF, Miki K, Eddy EM. Unpublished results. NIEHS, Durham, NC,
1998-1999. 282
CURRENT SURGERY • Volume 58/Number 3 • May/June 2001