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Gonadal venography for preoperative localization of nonpalpable testes in adults
GONADAL
VENOGRAPHY
LOCALIZATION
FOR PREOPERATIVE
OF NONPALPABLE
TESTES IN ADULTS STANLEY ERNEST JUAN
H. GREENBERG, J. RING,
M.D.
M.D.
OLEAGA,
M.D.
ALAN J. WEIN,
M.D.
From the Division of Urology, Department of Surgery, and the Department of Radiology, University of Pennsylvania School of Medicine, and the Veterans Administration Hospital, Philadelphia, Pennsylvania
ABSTRACT - Gonadal uenography was attempted in an effort to locate preoperatiuely ten nonpalpable testes in adults. Infive attempts, neither selective catheterization nor complete visualization of the gonadal vein could be accomplished and no definitive infomzation was obtained regarding the presence or location of a gonad. However, in 4 cases we were able either to visualize the position of the nonpalpable testis or predict correctly the absence of testicular tissue by the appearance of an abrupt termination or absence of the gonadal vein. One false negative study was obtained.
Some degree of cryptorchism is reported to be present in 0.8 per cent of male infants at the age of one year and in at least 0.3 per cent of men of military age. Bilateral maldescent is found in one tenth of the adult cases of cryptorchism, and true anorchia is said to represent 3 per cent of the cryptorchid pool.’ When a suspected maldescended testis is not palpable, an appropriate surgical approach may be difficult to plan, especially if the patient is obese. We have atto localize nonpalpable tempted, therefore, testes prior to surgical exploration by selective gonadal venography. Material
and Methods
Results
Nine men, ranging in age from twenty-five to fifty-live years, with 10 nonpalpable testes, underwent gonadal venography. A 6.3 F cobrashaped visceral catheter was introduced into the femoral vein by the standard Seldinger technique, advanced into the left renal vein, and manipulated into the mouth of the testicular
UROLOGY
/ APRIL 1979 / VOLUME
XIII.
vein. (If a valve is present, a “J’‘-shaped guidewire may be necessary to direct the catheter into the vein.) The right testicular vein was found by searching the anterior aspect of the inferior vena cava just below the renal veins or where it occasionally enters the right renal vein. Venography was performed by injecting 10 to 12 cc. of 60% meglumine-sodium diatrizoate (Renografin-60) at a rate of 2 to 3 cc./sec. and obtaining serial radiographs at a rate of one film per second for ten seconds. All patients underwent exploratory surgery to confirm the venographic findings.
NUMBER 4
Table I summarizes the venographic and surgical results in our 9 patients. Selective catheterization of the gonadal vein was successful in 3 men with nonpalpable testes on the left. In 1 man the intra-abdominal position of the testis was correctly identified; the other 2 patients were found to have an abrupt
453
TABLE
Case
Age (Years)
I. Venographic
and surgical results in 9 men with nonpalpable
Side of Undescended Testis
Findings Venographic
Surgical
testis
Testis found just inside internal inguinal ring Vas remnant found; no testicular tissue Vas in scrotum; thrombosed left gonadal vein; no testicular tissue Testis found at external inguinal ring Testis found at external inguinal ring No testicular tissue found Testis found above level of internal inguinal ring Testis found in inguinal canal
1
35
Left
Intra-abdominal
2
34
Left
3
34
Left
Abrupt termination of gonadal vein 4 cm. from renal vein Gonadal vein catheterized but could not be visualized distally
4
55
Left
5
54
Left
6 7
27 25
Left Right
No gonadal vein demonstrated Intra-abdominal testis
8
45
Right
9
40
Bilateral
Unable selectively to catheterize gonadal vein Both gonadal veins demonstrated but selective catheterization incomplete
Small testicular vein which could not be selectively catheterized No gonadal vein demonstrated
termination of the gonadal vein, and the arteriographer correctly predicted that surgical exploration would reveal no testicular tissue. The or unvenographic studies were unsatisfactory successful in 3 men with nonpalpable testes on the left. In one of these patients, whose gonadal vein was too narrow for selective catheterization, surgical exploration revealed a testis at the external inguinal ring. No left gonadal vein could be demonstrated in 2 patients. One of these men was found to have a testis at the level of the external inguinal ring, and the other had no testicular tissue on the left side. Two patients had nonpalpable testes on the right side, and the venographic study correctly localized an intra-abdominal testis in one of them. Attempts to catheterize the gonadal vein of the other man were unsuccessful. Surgical exploration revealed a testis in the inguinal canal. The remaining patient in our series had bilaterally nonpalpable testes. Although gonadal veins were present bilaterally, the arteriographer was unable to catheterize them selectively and could obtain no information regarding testicular location. At surgical exploration no testes were found. Comment It is now possible ism by hormonal
454
testes
to diagnose bilateral testing.2 However,
anorchwhen
No testicular
tissue found
neither testis is palpable but functioning testicular tissue is demonstrable, and in cases of unilateral nonpalpable testis, surgical exploration is still’indicated. Preoperative localization of the gonad permits better planning of the surgical procedure and shortens the operative time. Weiss, Glickman, and Lytton3 demonstrated the usefulness of gonadal venography in children with nonpalpable testes and pointed out its advantages over arteriography and herniography. Glickman, Weiss, and Itzchak4 attempted 21 venograms in a series of 15 children and young adults. An internal spermatic vein was demonstrated in 15 of the studies. Two venographic failures were reported, one because of gonadal vein valves and the other because of an apparently anomalous left gonadal vein that was not visualized radiographically but was found at surgery. One of our patients (Case 5) had a false negative result, probably because of a similarly anomalous left testicular vein. The remaining venograms in their series demonstrated absence of the testicular vein, which was confirmed surgically. Diamond et al. 5 demonstrated that venography was more accurate in locating a nonpalpable testis on the left side (79 per cent) than on the right side (42 per cent). In our 9 patients ten gonadal venograms were attempted, and in 4 cases the nonpalpable testis was satisfactorily located (Fig. 1A) or a correct prediction of absent testicular tissue was made
UROLOGY
/ APRIL1979 / VOLUMEXIII,
NUMBER4
FIGURE 1. (A) Pampinifk-m plexus of right intra-abdominal testis demonstrated by selective testicular vein catheterization; epididymal veins also visualized in inguinal area, (B) Absent left gonadal vein; adrenal and lumbar veins demonstrated arising from renal vein; no testis or gonadal vessels found at surgery.
on the basis of the venographic findings (Fig. 1B). The absence of testicular tissue is usually indicated by an abrupt termination of the gonadal vein, although in some cases of anorchia the entire testicular vein is congenitally absent. We encountered more technical difficulties in selective gonadal vein catheterization of these older patients than have been reported by other authors. We do agree, however, that venography is useful in the preoperative evaluation of selected patients with cryptorchism, and additional experience may enable us to rely solely on this technique to diagnose the unilateral absence of testicular tissue in some of these men.
UROLOGY
/
APRIL
1979
/
VOLUME
XIII,
NUMBER
4
Philadelphia,
3400 Spruce Street Pennsylvania 19104 (DR. GREENBERG)
References 1. Allen TD: Disorders of the male genitalia, in Kelalis, P. P., King, L. R., and Belman, A. B., Eds.: Clinical Pediatric Urology, Philadelphia, W. B. Saunders Co., 1976, pp. 636-668. 2. Tosi SE, and Morin LJ: The vanishing testis syndrome: indications for conservative therapy, J. Ural. 115: 758 (1976). 3. Weiss RM, Glickman MG, and Lytton B: Venographic localization of the nonpdpable undescended testis in children, ibid. 117: 513 (1977). 4. Glickman, MG, Weiss RM, and Itzchak Y: Testicular venography for undescended testes, Am. J. Roentgenol. 129: 67 (1977). 5. Diamond AB, Meng CH, Kodroff M, and Goldman SM: Testicular venography in nonpalpable testis, ibid. 129: 71 (1977).
VENOGRAPHY
LOCALIZATION
FOR PREOPERATIVE
OF NONPALPABLE
TESTES IN ADULTS STANLEY ERNEST JUAN
H. GREENBERG, J. RING,
M.D.
M.D.
OLEAGA,
M.D.
ALAN J. WEIN,
M.D.
From the Division of Urology, Department of Surgery, and the Department of Radiology, University of Pennsylvania School of Medicine, and the Veterans Administration Hospital, Philadelphia, Pennsylvania
ABSTRACT - Gonadal uenography was attempted in an effort to locate preoperatiuely ten nonpalpable testes in adults. Infive attempts, neither selective catheterization nor complete visualization of the gonadal vein could be accomplished and no definitive infomzation was obtained regarding the presence or location of a gonad. However, in 4 cases we were able either to visualize the position of the nonpalpable testis or predict correctly the absence of testicular tissue by the appearance of an abrupt termination or absence of the gonadal vein. One false negative study was obtained.
Some degree of cryptorchism is reported to be present in 0.8 per cent of male infants at the age of one year and in at least 0.3 per cent of men of military age. Bilateral maldescent is found in one tenth of the adult cases of cryptorchism, and true anorchia is said to represent 3 per cent of the cryptorchid pool.’ When a suspected maldescended testis is not palpable, an appropriate surgical approach may be difficult to plan, especially if the patient is obese. We have atto localize nonpalpable tempted, therefore, testes prior to surgical exploration by selective gonadal venography. Material
and Methods
Results
Nine men, ranging in age from twenty-five to fifty-live years, with 10 nonpalpable testes, underwent gonadal venography. A 6.3 F cobrashaped visceral catheter was introduced into the femoral vein by the standard Seldinger technique, advanced into the left renal vein, and manipulated into the mouth of the testicular
UROLOGY
/ APRIL 1979 / VOLUME
XIII.
vein. (If a valve is present, a “J’‘-shaped guidewire may be necessary to direct the catheter into the vein.) The right testicular vein was found by searching the anterior aspect of the inferior vena cava just below the renal veins or where it occasionally enters the right renal vein. Venography was performed by injecting 10 to 12 cc. of 60% meglumine-sodium diatrizoate (Renografin-60) at a rate of 2 to 3 cc./sec. and obtaining serial radiographs at a rate of one film per second for ten seconds. All patients underwent exploratory surgery to confirm the venographic findings.
NUMBER 4
Table I summarizes the venographic and surgical results in our 9 patients. Selective catheterization of the gonadal vein was successful in 3 men with nonpalpable testes on the left. In 1 man the intra-abdominal position of the testis was correctly identified; the other 2 patients were found to have an abrupt
453
TABLE
Case
Age (Years)
I. Venographic
and surgical results in 9 men with nonpalpable
Side of Undescended Testis
Findings Venographic
Surgical
testis
Testis found just inside internal inguinal ring Vas remnant found; no testicular tissue Vas in scrotum; thrombosed left gonadal vein; no testicular tissue Testis found at external inguinal ring Testis found at external inguinal ring No testicular tissue found Testis found above level of internal inguinal ring Testis found in inguinal canal
1
35
Left
Intra-abdominal
2
34
Left
3
34
Left
Abrupt termination of gonadal vein 4 cm. from renal vein Gonadal vein catheterized but could not be visualized distally
4
55
Left
5
54
Left
6 7
27 25
Left Right
No gonadal vein demonstrated Intra-abdominal testis
8
45
Right
9
40
Bilateral
Unable selectively to catheterize gonadal vein Both gonadal veins demonstrated but selective catheterization incomplete
Small testicular vein which could not be selectively catheterized No gonadal vein demonstrated
termination of the gonadal vein, and the arteriographer correctly predicted that surgical exploration would reveal no testicular tissue. The or unvenographic studies were unsatisfactory successful in 3 men with nonpalpable testes on the left. In one of these patients, whose gonadal vein was too narrow for selective catheterization, surgical exploration revealed a testis at the external inguinal ring. No left gonadal vein could be demonstrated in 2 patients. One of these men was found to have a testis at the level of the external inguinal ring, and the other had no testicular tissue on the left side. Two patients had nonpalpable testes on the right side, and the venographic study correctly localized an intra-abdominal testis in one of them. Attempts to catheterize the gonadal vein of the other man were unsuccessful. Surgical exploration revealed a testis in the inguinal canal. The remaining patient in our series had bilaterally nonpalpable testes. Although gonadal veins were present bilaterally, the arteriographer was unable to catheterize them selectively and could obtain no information regarding testicular location. At surgical exploration no testes were found. Comment It is now possible ism by hormonal
454
testes
to diagnose bilateral testing.2 However,
anorchwhen
No testicular
tissue found
neither testis is palpable but functioning testicular tissue is demonstrable, and in cases of unilateral nonpalpable testis, surgical exploration is still’indicated. Preoperative localization of the gonad permits better planning of the surgical procedure and shortens the operative time. Weiss, Glickman, and Lytton3 demonstrated the usefulness of gonadal venography in children with nonpalpable testes and pointed out its advantages over arteriography and herniography. Glickman, Weiss, and Itzchak4 attempted 21 venograms in a series of 15 children and young adults. An internal spermatic vein was demonstrated in 15 of the studies. Two venographic failures were reported, one because of gonadal vein valves and the other because of an apparently anomalous left gonadal vein that was not visualized radiographically but was found at surgery. One of our patients (Case 5) had a false negative result, probably because of a similarly anomalous left testicular vein. The remaining venograms in their series demonstrated absence of the testicular vein, which was confirmed surgically. Diamond et al. 5 demonstrated that venography was more accurate in locating a nonpalpable testis on the left side (79 per cent) than on the right side (42 per cent). In our 9 patients ten gonadal venograms were attempted, and in 4 cases the nonpalpable testis was satisfactorily located (Fig. 1A) or a correct prediction of absent testicular tissue was made
UROLOGY
/ APRIL1979 / VOLUMEXIII,
NUMBER4
FIGURE 1. (A) Pampinifk-m plexus of right intra-abdominal testis demonstrated by selective testicular vein catheterization; epididymal veins also visualized in inguinal area, (B) Absent left gonadal vein; adrenal and lumbar veins demonstrated arising from renal vein; no testis or gonadal vessels found at surgery.
on the basis of the venographic findings (Fig. 1B). The absence of testicular tissue is usually indicated by an abrupt termination of the gonadal vein, although in some cases of anorchia the entire testicular vein is congenitally absent. We encountered more technical difficulties in selective gonadal vein catheterization of these older patients than have been reported by other authors. We do agree, however, that venography is useful in the preoperative evaluation of selected patients with cryptorchism, and additional experience may enable us to rely solely on this technique to diagnose the unilateral absence of testicular tissue in some of these men.
UROLOGY
/
APRIL
1979
/
VOLUME
XIII,
NUMBER
4
Philadelphia,
3400 Spruce Street Pennsylvania 19104 (DR. GREENBERG)
References 1. Allen TD: Disorders of the male genitalia, in Kelalis, P. P., King, L. R., and Belman, A. B., Eds.: Clinical Pediatric Urology, Philadelphia, W. B. Saunders Co., 1976, pp. 636-668. 2. Tosi SE, and Morin LJ: The vanishing testis syndrome: indications for conservative therapy, J. Ural. 115: 758 (1976). 3. Weiss RM, Glickman MG, and Lytton B: Venographic localization of the nonpdpable undescended testis in children, ibid. 117: 513 (1977). 4. Glickman, MG, Weiss RM, and Itzchak Y: Testicular venography for undescended testes, Am. J. Roentgenol. 129: 67 (1977). 5. Diamond AB, Meng CH, Kodroff M, and Goldman SM: Testicular venography in nonpalpable testis, ibid. 129: 71 (1977).