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Groin exploration for nonpalpable testes: Laparoscopic approach
Groin Exploration for Nonpalpable Testes: Laparoscopic Approach By J. Schleef, S. von Bismarck, K. Burmucic, A. Gutmann, and J. Mayr Graz, Austria
Purpose: Diagnostic laparoscopy (DL) is the technique of choice for exploration of nonpalpable testes (NPT). Nevertheless, groin exploration is necessary to evaluate the cord and gonadal structures entering the internal ring. This retrospective analysis evaluates our hypothesis that hypoplastic cord structures entering the internal ring predicts absence of a viable testicle and a laparoscopic groin exploration in these cases can reduce the number of unnecessarily performed open groin exploration (OGE).
Three appeared normal at DL with a viable testis followed by an orchidopexy. Seventeen were hypoplastic without patent processus. During LGE no viable testis was detected: blindending cords, no biopsy (n ⫽ 4); testicular regression syndromes (n ⫽ 3), early fetal regression (n ⫽ 6), no residual testicular structures (n ⫽ 4).
Materials: A retrospective review was performed of 23 boys with 26 NPTs who were operated on from June 1998 to October 2000 to evaluate our protocol for NPT using DL and OGE.
Conclusions: This experience confirms the authors’ hypothesis and criteria for LGE in all cases. The authors conclude that LGE is a helpful tool in the diagnostic workup of NPT to avoid unnecessary OGE and is a further step in the minimally invasive approach to all kinds of findings of NPT. J Pediatr Surg 37:1552-1555. Copyright 2002, Elsevier Science (USA). All rights reserved.
Results: Of 26 NPTs in 23 boys, 3 bilateral intraabdominal testis were detected (2 Fowler Stephens; 1 standard orchidopexy). Twenty cord structures entered the internal ring.
INDEX WORDS: Nonpalpable testis, vanishing testis, laparoscopic groin exploration, minimally invasive apporach.
N
ONPALPABLE TESTIS (NPT) is a common clinical entity, and laparoscopy is the technique for diagnosis and treatment of children with this entity. NPT is a preliminary clinical diagnosis, and laparoscopy is used to gain a precise information about the presence and the possible location of the testis.1 The testis may be present and located at different intraabdominal sites, being “vanished” with the result of a small remnant or nubbin or completely absent. For the prior group, 3 different techniques are established: First, a primary translocation from the abdomen into the scrotum2; second, a 2-step approach according to Fowler Stephens,3 and third, a free transplantation of the testis into the scrotum with microanastomosis of the vessels.4 In vanishing testis, the site of blind-ending cord structures can be intraabdominal in the inguinal canal, at the level of the superficial inguinal ring, or in the scrotum. There still is controversy about the necessity of groin exploration and resection of the blind-ending duct or the nubbin.5,6 Our first experiences with laparoscopy showed From the Clinic of Pediatric Surgery, University of Graz Medical School and the Department of Anesthesiology, University of Graz, Graz, Austria. Address reprint requests to Dr. med. Ju¨rgen Schleef, Clinic of Pediatric Surgery, University of Graz–Medical School, Auenbruggerplatz 34, A-8036 Graz, Austria. Copyright 2002, Elsevier Science (USA). All rights reserved. 0022-3468/02/3711-0008$35.00/0 doi:10.1053/jpsu.2002.36183 1552
that hypoplastic cord structures entering the closed internal inguinal ring are rarely associated with a normal testis when an additional open groin exploration (OGE) was performed. According to this observation, we established a protocol for nonpalpable testis, where the findings of a vanishing testis and a duct entering the internal inguinal ring do not result necessarily in an open exploration of the inguinal canal but in a laparoscopic groin exploration (LGE). The results of this strategy are evaluated retrospectively. MATERIALS AND METHODS A retrospective study was performed including all boys with the diagnosis of (NPT) operated on at our institution from June 1998 to October 2000. The criteria included pre-, intra-, and postoperative data; the intraoperative findings; and the histologic examinations. The protocol including clinical examination, ultrasound scan, and operative procedure, is described below.
Preoperative and Operative Strategy After clinical examination and the diagnosis of NPT an abdominal and inguinal ultrasound scan is performed. If a testis is detected in the inguinal canal or at the level of the internal ring, a standard OGE with orchidopexy is performed. If no testis is detected by ultrasound scan in the inguinal region, the child is referred to a diagnostic laparoscopy with a prior clinical examination of the groin under anesthesia. If a testis is palpated, a standard open procedure is performed. When the testis is not palpable, a diagnostic laparoscopy is performed. The standard laparoscopic procedure is: Foley catheter in the bladder; 2-mm instruments and ports in the right and left abdominal position (Tyco, Austria); 5-mm laparoscope 30° wide angle (Olympus, Germany); CO2
Journal of Pediatric Surgery, Vol 37, No 11 (November), 2002: pp 1552-1555
NONPALPABLE TESTES: LAPAROSCOPIC APPROACH
1553
Fig 1. Algorithm for the management of NPT.
pressure according to the body weight of the patient. The inguinal region is inspected. In case of a present testis, a one-stage procedure for transposition of the testicle to the scrotum is attempted. In case of high position or short vessels7 the patient undergoes a 2-step FowlerStephens operation. If no testis is detected, the attention is focused on the presence of a patent processus and on the size and course of the spermatic cord and the internal ring. If an inguinal hernia (or a patent processus vaginalis) is present, an OGE is performed. If the cord is ending intraabdominally, the end—mostly a small nubbin—is resected. If the cord and vessels are of normal size and shape (compared with the opposite side) and entering the internal ring an, OGE of the inguinal canal is performed, assuming a normal testis. In case of a small and hypoplastic cord and vessels, an LGE passing through the internal ring is the next step. The cord structures are dissected carefully. The end of the blind-ending cord—with or without testicular remnant—is resected. No closure of the region of the internal ring and the peritoneum is attempted. In all cases of an absent testis, the patient undergoes a routine transcrotal orchidopexy on the opposite side (Fig 1).
RESULTS
From June 1998 to Oct 2000, 198 boys (age 4, 6 years; range, 3 weeks to 16 years) were operated on for 233 undescended testis. One hundred Seventy-three underwent a standard orchidopexy according to Shoemaker (right, n ⫽ 90; left, n ⫽ 73; bilateral, n ⫽ 35). In 26 boys the clinical diagnosis of NPT was confirmed by ultrasound scan (23 unilateral, 3 bilateral). In 3 children (unilateral NPT), the palpation under anesthesia showed a testis in an inguinal position, and the Shoemaker procedure was performed without further laparoscopy. Twenty-three boys underwent a diagnostic laparoscopy. In 2 boys, bilateral abdominal testis were detected, and a Fowler Stephens procedure was initialized. In one boy, bilateral peeping testis of normal size could be detected, and a standard orchidopexy was performed. In 3 boys cord structures were of normal size
and diameter compared with the contralateral side and entered the inguinal ring. In 2 of these cases a groin exploration, an orchidopexy, and biopsy of the testis was performed. One had a laparoscopic-assisted orchidopexy. In the remaining 17 boys, the cord structures entered the inguinal ring but appeared to be hypoplastic, and no patent processus vaginalis could be seen. The exploration of the inguinal canal was performed laparoscopically through the opened internal ring (LGE), which was not reconstructed at the end. No secondary inguinal hernia was observed so far. In 4 cases, the structures ended at the level of the internal ring, and obviously no remnant could be seen. These patients underwent no resection of the blind-ending duct. In 13 children, a resection of the nubbin or the remnant was performed by ligature or bipolar coagulation and resection. In all patients a standard transscrotal orchidopexy was performed at the contralateral side, which is the routine approach in children with unilateral viable testicle in our clinic for years. No complication—neither surgical nor from the part of anesthesia— occurred during the operation. In the early postoperative period one boy with a vanishing testis on the one side had a wound infection at the scrotal incision after the contralateral orchidopexy. A second boy had a hematoma at the umbilicus. Postoperative Follow-Up All children were controlled regularly up to 6 months after initial surgery. No late surgical complications (inguinal hernias or incisional hernia) were observed in this period. The cosmetic results were excellent.
1554
SCHLEEF ET AL
Table 1. Laparoscopic Findings and Treatment for 26 NPT Finding
Vas and vessels entering the internal ring (normal size) Vas and vessels entering the internal ring (hypoplastic) Vas and vessels entering the internal ring (hypoplastic)
Intraabdominal testic (deep position) Intraabdominal testis (high position)
Number
Unilateral
3
3
4
4
13
13
1 2
Histology A total of 13 specimens were examined. In 4 cases in which the cord structures ended at the level of the internal ring, no nubbin or testicular remnant was detected laparoscopically. No histology was obtained. In 4 cases, the remnant was resected showing no residual testicular structures. Three cases showed findings described as a testicular regression syndrome. In 6 specimens the histology findings were compatible with an early fetal regression of the gonad (Table 1). DISCUSSION
NPT is a clinical diagnosis with different underlying morphologic findings. To clarify this situation, diagnostic laparoscopy is the method of choice. The purpose of this study was to analyze retrospectively our strategy in NPT without abdominal location of the testis. If the cord structures enter the internal ring, the groin exploration is the method of choice to investigate the presence of testicular structures. In this group of patients, no open groin exploration (OGE) was performed when hypoplastic structures entered a closed inguinal ring. Our results and experience with LGE show that the hypothesis that there is no closed inguinal ring with hypoplastic cord structures and normal testis in the groin, was, in all cases, valuable. Even in the 3 boys in whom normal cord structures compared with the contralateral side entered the inguinal ring, the further procedure showed testicles in all. Grady et al5 presented 14 cases of 35 patients with NPT hypoplastic cord structures entering the inguinal ring. In all patients, no viable testicular structures were detected during OGE.5 They described this finding as inguinal vanishing testis. Topuzlu Tekant et al8 analyzed their cases of NPT. In 13 cases of NPT the cord structures entered the internal ring, but the OGE could not show a testicle. In a survey of 87 cases of NPT, Ballie et al2 had 44 laparoscopic examinations with cord structures entering the internal ring. All underwent an OGE
Bilateral
Procedure
2 OGE and orchidopexy; 1 laparoscopic assisted orchidopexy LGE (blind ending) no histology
1 2
LGE ⫹ 13 resections of the nubbin (histology: 3 testicular regression syndrom; 6 early fetal regression; 4 no residual testicular structures) 1 OGE and orchidopexy Fowler Stephens
with viable intracanicular testis in 13 cases, a remnant or nubbin in 22 and no remnant in 9. The cord structures were not described concerning size and form. The investigators emphasized the point that an experienced laparoscopist would be able to distinguish between normal and hypoplastic cord structures, which would be predictive concerning the presence of a viable testicle.2 Furthermore, the patency of a processus vaginalis is strongly correlating with the presence of a viable testis.9 If a groin exploration in NPT is necessary in cases of hypoplastic cord structures entering the inguinal ring, is still a controversial topic in the literature. Some investigators conclude from their findings that usually there is no viable testicular tissue in vanishing testis, and no resection of the remnant is necessary.5 Instead, Merry et al10 examined the resected specimens in vanishing testis in 47 cases. They found viable testicular cords in 4 (9%). Because the risk for testicular neoplasia in cryptorchidism is elevated (2% to 3%),11 we would suggests that inguinal exploration should be performed in all patients with structures entering the inguinal ring. The remnant, if present, should be resected.6,12 We routinely perform in unilateral monorchidism a transscrotal orchidopexy. It is easy to carry out and might reduce the risk of torsion and potentially render the patient anorchidic, as reported by others.13-15 Closing the peritoneum in the inguinal region after exploration was never performed in our series. Because there is no patent processus in these cases and no open foramen present, a herniation should not occur. Different investigators who perform laparoscopic orchidopexy report that they do not close the native internal ring when the orchidopexy is perform through a separate way, and there is no evidence of children returning with a hernia.7,12 LGE is a valuable tool in the diagnostic and therapeutic approach of NPT. It helps avoid unnecessary OGE and is a further step in the minimally invasive approach to all kinds of findings of NPT.
NONPALPABLE TESTES: LAPAROSCOPIC APPROACH
1555
REFERENCES 1. Vaysse P: Laparoscopy and impalpable testis—A prospective multicentric study (232 cases). GECI Groupe d’Etude en Coeliochirurgie Infantile. Eur J Pediatr Surg 4:329-332, 1994 2. Baillie CT, Fearns G, Kitteringham L, et al: Management of the impalpable testis: The role of laparoscopy. Arch Dis Child 79:419-422, 1998 3. Clark DA, Borzi PA: Laparoscopic orchidopexy for the intraabdominal testis. Pediatr Surg Int 15:454-456, 1999 4. Lima M, Domini M, Libri M, et al: Video laparoscopic evaluation of the nonpalpable Testis: 36 consecutive Explorations in 16 Months. J Laparoendosc Adv Surg Techn Part B 1:211-216, 1997 5. Grady RW, Mitchell ME, Carr MC: Laparoscopic and histologic evaluation of the inguinal vanishing testis. Urology 52:866-869, 1998 6. Plotzker ED, Ruston HG, Belman AB, et al: Laparoscopy for nonpalpable testes in childhood: Is inguinal exploration also necessary when vas and vessels exit the ring? J Urol 148:635-637, 1992 7. Lindgren W, Franco I, Blick S, et al: Laparoscopic FowlerStephens orchidopexy for the high abdominal testis. J Urol 162:990994, 1999
8. Topuzlu Tekant G, Emir H, Eroglu E, et al: Experience with laparoscopy in nonpalpable testis. Eur J Pediatr Surg 11:177-181, 2001 9. Elder JS: Laparoscopy for impalpable testes: Significance of the patent processus vaginalis. J Urol 152:776-778, 1994 10. Merry C, Sweeney B, Puri P: The vanishing testis: Anatomical and histological findings. Eur Urol 31:65-67, 1997 11. Cortes D, Visfeldt J, Moller H, et al: Testicular neoplasia I cryptorchid boys at primary surgery:case series. BMJ 319:888-889, 1999 12. Humphrey GM, Najmaldin AS, Thomas DF: Laparoscopy in the management of the impalpable undescendend testis. Br J Surg 85:983985, 1998 13. Harris BH, Webb HW, Wilkinson AH Jr, et al: Protection of the solitary testis. J Pediatr Surg 17:950-952, 1982 14. Sidler D, Brown RA, Millar AJ, et al: A 25-year review of the acute scrotum in children. S Afr Med J 87:1696-1698, 1997 15. Al-Salem AH: Intra-uterine testicular torsion: Early diagnosis and treatment: BJU International 83:1023-1025, 1999
Purpose: Diagnostic laparoscopy (DL) is the technique of choice for exploration of nonpalpable testes (NPT). Nevertheless, groin exploration is necessary to evaluate the cord and gonadal structures entering the internal ring. This retrospective analysis evaluates our hypothesis that hypoplastic cord structures entering the internal ring predicts absence of a viable testicle and a laparoscopic groin exploration in these cases can reduce the number of unnecessarily performed open groin exploration (OGE).
Three appeared normal at DL with a viable testis followed by an orchidopexy. Seventeen were hypoplastic without patent processus. During LGE no viable testis was detected: blindending cords, no biopsy (n ⫽ 4); testicular regression syndromes (n ⫽ 3), early fetal regression (n ⫽ 6), no residual testicular structures (n ⫽ 4).
Materials: A retrospective review was performed of 23 boys with 26 NPTs who were operated on from June 1998 to October 2000 to evaluate our protocol for NPT using DL and OGE.
Conclusions: This experience confirms the authors’ hypothesis and criteria for LGE in all cases. The authors conclude that LGE is a helpful tool in the diagnostic workup of NPT to avoid unnecessary OGE and is a further step in the minimally invasive approach to all kinds of findings of NPT. J Pediatr Surg 37:1552-1555. Copyright 2002, Elsevier Science (USA). All rights reserved.
Results: Of 26 NPTs in 23 boys, 3 bilateral intraabdominal testis were detected (2 Fowler Stephens; 1 standard orchidopexy). Twenty cord structures entered the internal ring.
INDEX WORDS: Nonpalpable testis, vanishing testis, laparoscopic groin exploration, minimally invasive apporach.
N
ONPALPABLE TESTIS (NPT) is a common clinical entity, and laparoscopy is the technique for diagnosis and treatment of children with this entity. NPT is a preliminary clinical diagnosis, and laparoscopy is used to gain a precise information about the presence and the possible location of the testis.1 The testis may be present and located at different intraabdominal sites, being “vanished” with the result of a small remnant or nubbin or completely absent. For the prior group, 3 different techniques are established: First, a primary translocation from the abdomen into the scrotum2; second, a 2-step approach according to Fowler Stephens,3 and third, a free transplantation of the testis into the scrotum with microanastomosis of the vessels.4 In vanishing testis, the site of blind-ending cord structures can be intraabdominal in the inguinal canal, at the level of the superficial inguinal ring, or in the scrotum. There still is controversy about the necessity of groin exploration and resection of the blind-ending duct or the nubbin.5,6 Our first experiences with laparoscopy showed From the Clinic of Pediatric Surgery, University of Graz Medical School and the Department of Anesthesiology, University of Graz, Graz, Austria. Address reprint requests to Dr. med. Ju¨rgen Schleef, Clinic of Pediatric Surgery, University of Graz–Medical School, Auenbruggerplatz 34, A-8036 Graz, Austria. Copyright 2002, Elsevier Science (USA). All rights reserved. 0022-3468/02/3711-0008$35.00/0 doi:10.1053/jpsu.2002.36183 1552
that hypoplastic cord structures entering the closed internal inguinal ring are rarely associated with a normal testis when an additional open groin exploration (OGE) was performed. According to this observation, we established a protocol for nonpalpable testis, where the findings of a vanishing testis and a duct entering the internal inguinal ring do not result necessarily in an open exploration of the inguinal canal but in a laparoscopic groin exploration (LGE). The results of this strategy are evaluated retrospectively. MATERIALS AND METHODS A retrospective study was performed including all boys with the diagnosis of (NPT) operated on at our institution from June 1998 to October 2000. The criteria included pre-, intra-, and postoperative data; the intraoperative findings; and the histologic examinations. The protocol including clinical examination, ultrasound scan, and operative procedure, is described below.
Preoperative and Operative Strategy After clinical examination and the diagnosis of NPT an abdominal and inguinal ultrasound scan is performed. If a testis is detected in the inguinal canal or at the level of the internal ring, a standard OGE with orchidopexy is performed. If no testis is detected by ultrasound scan in the inguinal region, the child is referred to a diagnostic laparoscopy with a prior clinical examination of the groin under anesthesia. If a testis is palpated, a standard open procedure is performed. When the testis is not palpable, a diagnostic laparoscopy is performed. The standard laparoscopic procedure is: Foley catheter in the bladder; 2-mm instruments and ports in the right and left abdominal position (Tyco, Austria); 5-mm laparoscope 30° wide angle (Olympus, Germany); CO2
Journal of Pediatric Surgery, Vol 37, No 11 (November), 2002: pp 1552-1555
NONPALPABLE TESTES: LAPAROSCOPIC APPROACH
1553
Fig 1. Algorithm for the management of NPT.
pressure according to the body weight of the patient. The inguinal region is inspected. In case of a present testis, a one-stage procedure for transposition of the testicle to the scrotum is attempted. In case of high position or short vessels7 the patient undergoes a 2-step FowlerStephens operation. If no testis is detected, the attention is focused on the presence of a patent processus and on the size and course of the spermatic cord and the internal ring. If an inguinal hernia (or a patent processus vaginalis) is present, an OGE is performed. If the cord is ending intraabdominally, the end—mostly a small nubbin—is resected. If the cord and vessels are of normal size and shape (compared with the opposite side) and entering the internal ring an, OGE of the inguinal canal is performed, assuming a normal testis. In case of a small and hypoplastic cord and vessels, an LGE passing through the internal ring is the next step. The cord structures are dissected carefully. The end of the blind-ending cord—with or without testicular remnant—is resected. No closure of the region of the internal ring and the peritoneum is attempted. In all cases of an absent testis, the patient undergoes a routine transcrotal orchidopexy on the opposite side (Fig 1).
RESULTS
From June 1998 to Oct 2000, 198 boys (age 4, 6 years; range, 3 weeks to 16 years) were operated on for 233 undescended testis. One hundred Seventy-three underwent a standard orchidopexy according to Shoemaker (right, n ⫽ 90; left, n ⫽ 73; bilateral, n ⫽ 35). In 26 boys the clinical diagnosis of NPT was confirmed by ultrasound scan (23 unilateral, 3 bilateral). In 3 children (unilateral NPT), the palpation under anesthesia showed a testis in an inguinal position, and the Shoemaker procedure was performed without further laparoscopy. Twenty-three boys underwent a diagnostic laparoscopy. In 2 boys, bilateral abdominal testis were detected, and a Fowler Stephens procedure was initialized. In one boy, bilateral peeping testis of normal size could be detected, and a standard orchidopexy was performed. In 3 boys cord structures were of normal size
and diameter compared with the contralateral side and entered the inguinal ring. In 2 of these cases a groin exploration, an orchidopexy, and biopsy of the testis was performed. One had a laparoscopic-assisted orchidopexy. In the remaining 17 boys, the cord structures entered the inguinal ring but appeared to be hypoplastic, and no patent processus vaginalis could be seen. The exploration of the inguinal canal was performed laparoscopically through the opened internal ring (LGE), which was not reconstructed at the end. No secondary inguinal hernia was observed so far. In 4 cases, the structures ended at the level of the internal ring, and obviously no remnant could be seen. These patients underwent no resection of the blind-ending duct. In 13 children, a resection of the nubbin or the remnant was performed by ligature or bipolar coagulation and resection. In all patients a standard transscrotal orchidopexy was performed at the contralateral side, which is the routine approach in children with unilateral viable testicle in our clinic for years. No complication—neither surgical nor from the part of anesthesia— occurred during the operation. In the early postoperative period one boy with a vanishing testis on the one side had a wound infection at the scrotal incision after the contralateral orchidopexy. A second boy had a hematoma at the umbilicus. Postoperative Follow-Up All children were controlled regularly up to 6 months after initial surgery. No late surgical complications (inguinal hernias or incisional hernia) were observed in this period. The cosmetic results were excellent.
1554
SCHLEEF ET AL
Table 1. Laparoscopic Findings and Treatment for 26 NPT Finding
Vas and vessels entering the internal ring (normal size) Vas and vessels entering the internal ring (hypoplastic) Vas and vessels entering the internal ring (hypoplastic)
Intraabdominal testic (deep position) Intraabdominal testis (high position)
Number
Unilateral
3
3
4
4
13
13
1 2
Histology A total of 13 specimens were examined. In 4 cases in which the cord structures ended at the level of the internal ring, no nubbin or testicular remnant was detected laparoscopically. No histology was obtained. In 4 cases, the remnant was resected showing no residual testicular structures. Three cases showed findings described as a testicular regression syndrome. In 6 specimens the histology findings were compatible with an early fetal regression of the gonad (Table 1). DISCUSSION
NPT is a clinical diagnosis with different underlying morphologic findings. To clarify this situation, diagnostic laparoscopy is the method of choice. The purpose of this study was to analyze retrospectively our strategy in NPT without abdominal location of the testis. If the cord structures enter the internal ring, the groin exploration is the method of choice to investigate the presence of testicular structures. In this group of patients, no open groin exploration (OGE) was performed when hypoplastic structures entered a closed inguinal ring. Our results and experience with LGE show that the hypothesis that there is no closed inguinal ring with hypoplastic cord structures and normal testis in the groin, was, in all cases, valuable. Even in the 3 boys in whom normal cord structures compared with the contralateral side entered the inguinal ring, the further procedure showed testicles in all. Grady et al5 presented 14 cases of 35 patients with NPT hypoplastic cord structures entering the inguinal ring. In all patients, no viable testicular structures were detected during OGE.5 They described this finding as inguinal vanishing testis. Topuzlu Tekant et al8 analyzed their cases of NPT. In 13 cases of NPT the cord structures entered the internal ring, but the OGE could not show a testicle. In a survey of 87 cases of NPT, Ballie et al2 had 44 laparoscopic examinations with cord structures entering the internal ring. All underwent an OGE
Bilateral
Procedure
2 OGE and orchidopexy; 1 laparoscopic assisted orchidopexy LGE (blind ending) no histology
1 2
LGE ⫹ 13 resections of the nubbin (histology: 3 testicular regression syndrom; 6 early fetal regression; 4 no residual testicular structures) 1 OGE and orchidopexy Fowler Stephens
with viable intracanicular testis in 13 cases, a remnant or nubbin in 22 and no remnant in 9. The cord structures were not described concerning size and form. The investigators emphasized the point that an experienced laparoscopist would be able to distinguish between normal and hypoplastic cord structures, which would be predictive concerning the presence of a viable testicle.2 Furthermore, the patency of a processus vaginalis is strongly correlating with the presence of a viable testis.9 If a groin exploration in NPT is necessary in cases of hypoplastic cord structures entering the inguinal ring, is still a controversial topic in the literature. Some investigators conclude from their findings that usually there is no viable testicular tissue in vanishing testis, and no resection of the remnant is necessary.5 Instead, Merry et al10 examined the resected specimens in vanishing testis in 47 cases. They found viable testicular cords in 4 (9%). Because the risk for testicular neoplasia in cryptorchidism is elevated (2% to 3%),11 we would suggests that inguinal exploration should be performed in all patients with structures entering the inguinal ring. The remnant, if present, should be resected.6,12 We routinely perform in unilateral monorchidism a transscrotal orchidopexy. It is easy to carry out and might reduce the risk of torsion and potentially render the patient anorchidic, as reported by others.13-15 Closing the peritoneum in the inguinal region after exploration was never performed in our series. Because there is no patent processus in these cases and no open foramen present, a herniation should not occur. Different investigators who perform laparoscopic orchidopexy report that they do not close the native internal ring when the orchidopexy is perform through a separate way, and there is no evidence of children returning with a hernia.7,12 LGE is a valuable tool in the diagnostic and therapeutic approach of NPT. It helps avoid unnecessary OGE and is a further step in the minimally invasive approach to all kinds of findings of NPT.
NONPALPABLE TESTES: LAPAROSCOPIC APPROACH
1555
REFERENCES 1. Vaysse P: Laparoscopy and impalpable testis—A prospective multicentric study (232 cases). GECI Groupe d’Etude en Coeliochirurgie Infantile. Eur J Pediatr Surg 4:329-332, 1994 2. Baillie CT, Fearns G, Kitteringham L, et al: Management of the impalpable testis: The role of laparoscopy. Arch Dis Child 79:419-422, 1998 3. Clark DA, Borzi PA: Laparoscopic orchidopexy for the intraabdominal testis. Pediatr Surg Int 15:454-456, 1999 4. Lima M, Domini M, Libri M, et al: Video laparoscopic evaluation of the nonpalpable Testis: 36 consecutive Explorations in 16 Months. J Laparoendosc Adv Surg Techn Part B 1:211-216, 1997 5. Grady RW, Mitchell ME, Carr MC: Laparoscopic and histologic evaluation of the inguinal vanishing testis. Urology 52:866-869, 1998 6. Plotzker ED, Ruston HG, Belman AB, et al: Laparoscopy for nonpalpable testes in childhood: Is inguinal exploration also necessary when vas and vessels exit the ring? J Urol 148:635-637, 1992 7. Lindgren W, Franco I, Blick S, et al: Laparoscopic FowlerStephens orchidopexy for the high abdominal testis. J Urol 162:990994, 1999
8. Topuzlu Tekant G, Emir H, Eroglu E, et al: Experience with laparoscopy in nonpalpable testis. Eur J Pediatr Surg 11:177-181, 2001 9. Elder JS: Laparoscopy for impalpable testes: Significance of the patent processus vaginalis. J Urol 152:776-778, 1994 10. Merry C, Sweeney B, Puri P: The vanishing testis: Anatomical and histological findings. Eur Urol 31:65-67, 1997 11. Cortes D, Visfeldt J, Moller H, et al: Testicular neoplasia I cryptorchid boys at primary surgery:case series. BMJ 319:888-889, 1999 12. Humphrey GM, Najmaldin AS, Thomas DF: Laparoscopy in the management of the impalpable undescendend testis. Br J Surg 85:983985, 1998 13. Harris BH, Webb HW, Wilkinson AH Jr, et al: Protection of the solitary testis. J Pediatr Surg 17:950-952, 1982 14. Sidler D, Brown RA, Millar AJ, et al: A 25-year review of the acute scrotum in children. S Afr Med J 87:1696-1698, 1997 15. Al-Salem AH: Intra-uterine testicular torsion: Early diagnosis and treatment: BJU International 83:1023-1025, 1999