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Laparoscopic and histologic evaluation of the inguinal vanishing testis
PEDIATRIC UROLOGY
LAPAROSCOPIC AND HISTOLOGIC EVALUATION OF THE INGUINAL VANISHING TESTIS RICHARD W. GRADY, MICHAEL E. MITCHELL,
AND
MICHAEL C. CARR
ABSTRACT Objectives. Visual inspection of the spermatic cord vessels and vas deferens during laparoscopy now frequently determines further treatment. We set out to explore the implications of atretic spermatic cord vessels and vas deferens entering the inguinal ring, a finding noted on laparoscopic examination in some patients with a nonpalpable testis, and that we refer to as the inguinal vanishing testis. Methods. We reviewed our series of 35 patients with nonpalpable testes with regard to the laparoscopic, surgical, and histopathologic findings of the involved gonadal structures. Results. We noted atretic vessels and vas deferens entering the inguinal ring in 14 patients in this series. All 14 patients underwent open inguinal exploration. Histopathologic findings revealed fibrosis and hemosiderin deposits alone in 13 patients. One specimen had a microscopic focus of residual seminiferous tubules. No specimen contained dysgenetic gonadal tissue. Conclusions. We submit that patients with inguinal vanishing testes do not need to undergo inguinal exploration to remove residual testicular tissue. Only rarely will viable seminiferous tubules be found, so the risk of malignant degeneration is remote. The histopathologic findings suggest that the inguinal vanishing testis occurs secondary to a vascular accident in utero or in the neonatal period. UROLOGY 52: 866–869, 1998. © 1998, Elsevier Science Inc. All rights reserved.
C
ryptorchidism has been recognized as early as the time of Galens and Vesalius.1 In 1876, John Hunter more clearly defined the cryptorchid testis as a heterogeneous entity rather than one pathophysiologic process.2 To date, no specific cause for failure of testis descent has been identified, although a combination of hormonal and mechanical factors have been implicated in the pathophysiology of this condition. Hereditary predisposition to cryptorchidism is also well recognized. The nonpalpable testis represents a subset of undescended testes and is restricted to those testes that are impalpable despite careful physical examination. The nonpalpable testis comprises 10% to 50% of undescended testes reported in various series.3– 6 Nonpalpable testes are a heterogeneous group; their assessment reveals subsets of absent testes, intra-abdominal testes, and testes or testicFrom the Department of Pediatric Urology, Children’s Hospital and Regional Medical Center, Seattle, Washington Reprint requests: Richard W. Grady, M.D., Department of Pediatric Urology, Children’s Hospital and Regional Medical Center, 4800 Sand Point Way NE, P.O. Box 5371/CH-81, Seattle, WA 98105 Submitted: March 31, 1998, accepted (with revisions): May 21, 1998
866
© 1998, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
ular remnants located in the inguinal canal that were missed on physical examination. Because of this heterogeneity, laparoscopy has emerged as a valuable tool in the evaluation and localization of the nonpalpable testis. During our evaluation of patients with undescended or nonpalpable testes, we have identified a subset of patients with nonpalpable testes who have atretic spermatic vessels entering the internal inguinal ring noted on laparoscopic examination and spermatic cord remnants on inguinal exploration. We have labeled this finding as the inguinal vanishing testis and explore the implications of this finding. MATERIAL AND METHODS Between 1993 and 1997, 214 boys underwent exploration and/or orchidopexy for undescended testes at Children’s Hospital and Regional Medical Center in Seattle. Mean patient age was 23 months. Diagnostic laparoscopy is routinely performed at our institution for the evaluation and localization of the nonpalpable testis and was performed in 32 of 35 patients who were diagnosed with a nonpalpable testis on physical examination during their preoperative clinic visit. These 35 patients underwent diagnostic laparoscopy and, when appropriate, open surgical inguinal exploration for nonpalpable testes. All operations were performed with the patient induced and main0090-4295/98/$19.00 PII S0090-4295(98)00326-4
FIGURE 1. Laparoscopic view of atrophic spermatic cord vessels (left) and contralateral normal spermatic cord vessels (right) entering the internal inguinal ring. tained under general anesthesia. Our technique is similar to that described by Moore et al.7 Each patient also underwent another physical examination under anesthesia to confirm the diagnosis of a nonpalpable testis. Before initiating laparoscopy, a urethral catheter was placed to empty the bladder, and an orogastric tube was used to decompress the stomach. Our technique involves the use of an infraumbilical Veress needle placed percutaneously into the peritoneal cavity, which is then filled with carbon dioxide to 20 mm Hg pressure. A 5-mm trocar was then placed through a small infraumbilical incision to permit intraperitoneal examination with a 5-mm laparoscope. Comparison between the normal side and the affected side was performed in all cases, with routine examination of the unaffected side performed first in unilateral cases of nonpalpable testis. Presence of spermatic vessels and vas deferens was noted along with the caliber and size of each. These findings were recorded using digital photography through the laparoscopic lens system in all cases. Inguinal exploration was performed when laparoscopy revealed spermatic vessels and vas deferens entering the inguinal ring regardless of the caliber of these structures. All specimens were sent for histopathologic evaluation.
RESULTS Of 35 patients in this series, 14 had intra-abdominal testes identified by laparoscopy. One patient had blind ending spermatic vessels and vas deferens, a finding known as the vanishing abdominal testis. Fourteen patients were noted to have atretic spermatic cord vessels entering the internal inguinal ring along with the vas deferens. Of note, this finding was also associated with a closed internal inguinal ring in these cases. Four patients were found to have a vas deferens entering into the internal inguinal ring associated with absent spermatic vessels on laparoscopic examination. No gonadal tissue was identified in association with these four specimens. An inguinal testis was palpated during an examination under anesthesia in 3 cases. Vascular atresia was noted by visual identification of a reduced number of narrow spermatic cord vessels. We compared these findings with the contralateral spermatic cord vessels in those cases with a palpably normal descended contralateral testis and noted a marked discrepancy in all cases (Fig. 1). We performed inguinal exploration in all 14 patients, with gross identification and removal of residual tissue under loupe magnification. HisUROLOGY 52 (5), 1998
FIGURE 2. Histopathologic view of inguinal gonadal remnant without residual germinal tissue. Note hemosiderin deposition and fibrosis.
topathologic evaluation revealed fibrosis and hemosiderin deposits in 13 of the specimens, with no evidence of germinal tissue (Fig. 2). However, one specimen had several seminiferous tubules. This finding was associated with hemosiderin deposition and hemorrhage, consistent with recent infarction (Fig. 3). This specimen came from a 13-month-old patient who presented with no symptoms of pain or discomfort. No specimen in this series demonstrated evidence of testicular dysplasia or intratubular germ cell neoplasia on histopathologic examination. COMMENT The utility of laparoscopy to locate viable undescended testes, testicular remnants, or absent testes has been well documented. Various series report success rates of 90% to 95% in the localization of nonpalpable testes with laparoscopy.7–9 Investigators in some of these series have also reported the finding of hypoplastic vessels and/or vas deferens; a finding we have termed the inguinal vanishing testis.7–12 This finding was noted in 18% to 47% of the cases in these series (Table I). We noted this 867
FIGURE 3. Histopathologic view of inguinal gonadal remnant with residual seminiferous tubules on lower aspect of photograph.
finding on laparoscopy in 36% of the cases in our series. Histopathologic results from these cases were also available in some of these series. Typical histopathologic findings in these specimens included fibrosis, hemosiderin deposition, and microcalcification. Seminiferous tubules were also noted in 0% to 5% of the specimens, depending on the series (Table I). No series has reported the finding of germinal dysplasia or intratubular germ cell neoplasia in any of these specimens. The histopathologic findings reported in our series and other series support the hypothesis that these testes experienced an ischemic injury, subsequent necrosis, and atrophy due to an in utero or neonatal vascular accident such as torsion of the spermatic cord vessels during testicular descent.6,13–16 True crytorchidism, by contrast, is currently believed to be a multifactorial event involving mechanical and endocrine factors; we believe the difference in the etiology of the true cryptorchid testis versus the inguinal vanishing testis also confers a markedly different risk of malignant degeneration between these two gonad populations. Castilho8 and others contend that the finding of 868
hypoplastic spermatic vessels entering into the inguinal ring with or without a vas deferens precludes the need for a confirmatory inguinal exploration. However, other investigators such as Moore et al.7 believe that “this observation is not sufficiently specific or reliable to obviate the need for inguinal exploration.” The concern in this situation largely resides with the question of malignant degeneration of residual germinal tissue in these specimens. Le Conte first recognized the tumor potential of the undescended testis in 1851.17 Since then, the increased risk of malignant degeneration of the cryptorchid testis has been estimated at 20 to 46 times that of the general population.18,19 However, the location of these testes confers a significantly different degree of risk. Intra-abdominal testes are six times more likely to develop a testis tumor than the undescended testis located in an inguinal position.17 Furthermore, although previous investigators have documented the occurrence of testicular cancer in undescended inguinal testes or previously cryptorchid inguinal testes that had been brought into the scrotum surgically, no data are available about these patients or these cryptorchid testes before these patients presented with cancer.20 The infrequent finding of seminiferous tubules or other germinal tissue in the surgical specimens of patients with inguinal vanishing testes also supports the contention that the risk of malignant degeneration is quite low in this population. Cendron et al.21 recently presented a histologic evaluation of 25 vanishing testis specimens and noted no identifiable testicular elements in any of these cases. Immunohistochemistry was required in 3 cases to distinguish atrophic cremasteric cells from Leydig cells. These findings corroborate those noted in other series. Certainly, inguinal exploration can be performed by any competent surgeon. The morbidity with this procedure is low but not nonexistent. Potential complications include injury to the ileoinguinal nerve, hematoma formation, and wound infection. Exploration for an inguinal testis remnant can also be time consuming because the atretic remnant may not be readily apparent. The patient is also left with a surgical scar that may not have been necessary. So, inguinal exploration can be performed with minimal risk, time, and effort in these patients, but should it be? CONCLUSIONS The histologic evaluation of inguinal testicular remnants suggests that these organs became ischemic and atrophied during descent in utero or shortly after birth. No evidence currently exists to suggest that these remnants are likely to undergo UROLOGY 52 (5), 1998
TABLE I. Reported series Series
Year
Castilho8 Plotzker et al.9 Diamond et al.10 Lou et al.11 Tannenbaum et al.12 Moore et al.7 Present series
1990 1992 1992 1994 1994 1994 1998
Inguinal Vanishing Testis 8 23 40 25 30 35 14
(18) (35) (42) (67) (28) (47) (36)
Presence of Seminiferous Tubules 0 (0.0) 3 (5.0) NA NA 3 (3.0) 2 (1.5) 1 (3.0)
KEY: NA 5 not available. Numbers in parentheses are percentages.
malignant degeneration; the vast majority of the specimens in our series and other series reported in the literature contain no gonadal tissue at all. On the basis of these observations, inguinal exploration in the setting of atrophic spermatic vessels entering the inguinal ring—the laparoscopic findings of the inguinal vanishing testis—although technically feasible, appears unnecessary in the treatment of these patients. REFERENCES 1. Elder JS, and Marshall FF: Cryptorchidism and Related Anomalies. Praeger, New York, 1982. 2. Hunter J: Observations on the state of the testes in the foetus and on the hernia congenital, in Hunter W (Ed): Medical Commentaries, Part I. London, A. Hamilton, 1762. 3. Redman JF: Impalpable testis: observations based on 208 consecutive operations for undescended testes. J Urol 124: 379 –381, 1980. 4. Tibbs DJ: Unilateral absence of the testis. Eight cases of true monorchism. Br J Surg 48: 601– 603, 1961. 5. Smolko MJ, Kaplan GW, and Brock WA: Location and fate of the nonpalpable testis in children. J Urol 129: 1204 – 1206, 1983. 6. Abeyartne WA, Aherne WH, and Scott JE: The vanishing testis. Lancet 2: 823– 824, 1969. 7. Moore RG, Peters CA, Bauer SB, et al: Laparoscopic evaluation of the nonpalpable testis: a prospective assessment of accuracy. J Urol 151: 728 –731, 1994. 8. Castilho LN: Laparoscopy for the nonpalpable testis: how to interpret the endoscopic findings. J Urol 144: 1215– 1218, 1990. 9. Plotzker ED, Rushton HG, Belman AB, et al: Laparoscopy for nonpalpable testes in childhood: is inguinal exploration also necessary when vas and vessels exit the inguinal ring? J Urol 148: 635– 638, 1992.
UROLOGY 52 (5), 1998
10. Diamond DA, and Caldemone AA: The value of laparoscopy for 106 impalpable testes relative to clinical presentation. J Urol 148: 632– 634, 1992. 11. Lou CC, Lin JN, Tung TC, et al: Anatomical findings of the vanishing testis. Chang Keng I Hsueh 17: 121–124, 1994. 12. Tannenbaum SJ, Lerner SE, McAleer IM, et al: Preoperative laparoscopic localization of the nonpalpable testis: a critical analysis of a 10-year experience. J Urol 151: 732–734, 1994. 13. Gong M, Geary ES, and Shortliffe LM: Testicular torsion with contralateral vanishing testis. Urology 48: 306 –307, 1996. 14. Huff DS, Wu H-Y, Snyder HM, et al: Evidence in favor of the mechanical (intrauterine torsion) theory over the endocrinopathy (cryptorchidism) theory in the pathogenesis of testicular agenesis. J Urol 146: 630 – 631, 1991. 15. Sutcliffe JR, Wilson-Storey D, and Smith NM: Antenatal testicular torsion: only one cause of the testicular regression syndrome? J R Coll Surg Edinb 41: 99 –101, 1996. 16. Smith NM, Byard RW, and Bourne AJ: Testicular regression syndrome—a pathological study of 77 cases. Histopathology 19: 269 –272, 1991. 17. Johnson DC, Woodhead DM, and Pohl DR: Cryptorchidism and testicular tumorigenesis. Surgery 63: 919 –922, 1968. 18. Gilbert JB, and Hamilton JB: Incidence and nature of tumors in ectopic testes. Surg Gynecol Obstet 71: 731–734, 1940. 19. Campbell HE: Incidence of malignant growth of the undescended testicle. Arch Surg 44: 353–357, 1942. 20. Batata MA, Whitmore WF, Chu CH, et al: Cryptorchidism and testicular cancer. J Urol 124: 382–387, 1980. 21. Cendron M, Schned AR, and Ellsworth PI: Vanishing testis syndrome: simplified management based on histologic studies. Presented at the Meeting of the American Academy of Pediatrics, New Orleans, Louisiana, November 1997.
869
LAPAROSCOPIC AND HISTOLOGIC EVALUATION OF THE INGUINAL VANISHING TESTIS RICHARD W. GRADY, MICHAEL E. MITCHELL,
AND
MICHAEL C. CARR
ABSTRACT Objectives. Visual inspection of the spermatic cord vessels and vas deferens during laparoscopy now frequently determines further treatment. We set out to explore the implications of atretic spermatic cord vessels and vas deferens entering the inguinal ring, a finding noted on laparoscopic examination in some patients with a nonpalpable testis, and that we refer to as the inguinal vanishing testis. Methods. We reviewed our series of 35 patients with nonpalpable testes with regard to the laparoscopic, surgical, and histopathologic findings of the involved gonadal structures. Results. We noted atretic vessels and vas deferens entering the inguinal ring in 14 patients in this series. All 14 patients underwent open inguinal exploration. Histopathologic findings revealed fibrosis and hemosiderin deposits alone in 13 patients. One specimen had a microscopic focus of residual seminiferous tubules. No specimen contained dysgenetic gonadal tissue. Conclusions. We submit that patients with inguinal vanishing testes do not need to undergo inguinal exploration to remove residual testicular tissue. Only rarely will viable seminiferous tubules be found, so the risk of malignant degeneration is remote. The histopathologic findings suggest that the inguinal vanishing testis occurs secondary to a vascular accident in utero or in the neonatal period. UROLOGY 52: 866–869, 1998. © 1998, Elsevier Science Inc. All rights reserved.
C
ryptorchidism has been recognized as early as the time of Galens and Vesalius.1 In 1876, John Hunter more clearly defined the cryptorchid testis as a heterogeneous entity rather than one pathophysiologic process.2 To date, no specific cause for failure of testis descent has been identified, although a combination of hormonal and mechanical factors have been implicated in the pathophysiology of this condition. Hereditary predisposition to cryptorchidism is also well recognized. The nonpalpable testis represents a subset of undescended testes and is restricted to those testes that are impalpable despite careful physical examination. The nonpalpable testis comprises 10% to 50% of undescended testes reported in various series.3– 6 Nonpalpable testes are a heterogeneous group; their assessment reveals subsets of absent testes, intra-abdominal testes, and testes or testicFrom the Department of Pediatric Urology, Children’s Hospital and Regional Medical Center, Seattle, Washington Reprint requests: Richard W. Grady, M.D., Department of Pediatric Urology, Children’s Hospital and Regional Medical Center, 4800 Sand Point Way NE, P.O. Box 5371/CH-81, Seattle, WA 98105 Submitted: March 31, 1998, accepted (with revisions): May 21, 1998
866
© 1998, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
ular remnants located in the inguinal canal that were missed on physical examination. Because of this heterogeneity, laparoscopy has emerged as a valuable tool in the evaluation and localization of the nonpalpable testis. During our evaluation of patients with undescended or nonpalpable testes, we have identified a subset of patients with nonpalpable testes who have atretic spermatic vessels entering the internal inguinal ring noted on laparoscopic examination and spermatic cord remnants on inguinal exploration. We have labeled this finding as the inguinal vanishing testis and explore the implications of this finding. MATERIAL AND METHODS Between 1993 and 1997, 214 boys underwent exploration and/or orchidopexy for undescended testes at Children’s Hospital and Regional Medical Center in Seattle. Mean patient age was 23 months. Diagnostic laparoscopy is routinely performed at our institution for the evaluation and localization of the nonpalpable testis and was performed in 32 of 35 patients who were diagnosed with a nonpalpable testis on physical examination during their preoperative clinic visit. These 35 patients underwent diagnostic laparoscopy and, when appropriate, open surgical inguinal exploration for nonpalpable testes. All operations were performed with the patient induced and main0090-4295/98/$19.00 PII S0090-4295(98)00326-4
FIGURE 1. Laparoscopic view of atrophic spermatic cord vessels (left) and contralateral normal spermatic cord vessels (right) entering the internal inguinal ring. tained under general anesthesia. Our technique is similar to that described by Moore et al.7 Each patient also underwent another physical examination under anesthesia to confirm the diagnosis of a nonpalpable testis. Before initiating laparoscopy, a urethral catheter was placed to empty the bladder, and an orogastric tube was used to decompress the stomach. Our technique involves the use of an infraumbilical Veress needle placed percutaneously into the peritoneal cavity, which is then filled with carbon dioxide to 20 mm Hg pressure. A 5-mm trocar was then placed through a small infraumbilical incision to permit intraperitoneal examination with a 5-mm laparoscope. Comparison between the normal side and the affected side was performed in all cases, with routine examination of the unaffected side performed first in unilateral cases of nonpalpable testis. Presence of spermatic vessels and vas deferens was noted along with the caliber and size of each. These findings were recorded using digital photography through the laparoscopic lens system in all cases. Inguinal exploration was performed when laparoscopy revealed spermatic vessels and vas deferens entering the inguinal ring regardless of the caliber of these structures. All specimens were sent for histopathologic evaluation.
RESULTS Of 35 patients in this series, 14 had intra-abdominal testes identified by laparoscopy. One patient had blind ending spermatic vessels and vas deferens, a finding known as the vanishing abdominal testis. Fourteen patients were noted to have atretic spermatic cord vessels entering the internal inguinal ring along with the vas deferens. Of note, this finding was also associated with a closed internal inguinal ring in these cases. Four patients were found to have a vas deferens entering into the internal inguinal ring associated with absent spermatic vessels on laparoscopic examination. No gonadal tissue was identified in association with these four specimens. An inguinal testis was palpated during an examination under anesthesia in 3 cases. Vascular atresia was noted by visual identification of a reduced number of narrow spermatic cord vessels. We compared these findings with the contralateral spermatic cord vessels in those cases with a palpably normal descended contralateral testis and noted a marked discrepancy in all cases (Fig. 1). We performed inguinal exploration in all 14 patients, with gross identification and removal of residual tissue under loupe magnification. HisUROLOGY 52 (5), 1998
FIGURE 2. Histopathologic view of inguinal gonadal remnant without residual germinal tissue. Note hemosiderin deposition and fibrosis.
topathologic evaluation revealed fibrosis and hemosiderin deposits in 13 of the specimens, with no evidence of germinal tissue (Fig. 2). However, one specimen had several seminiferous tubules. This finding was associated with hemosiderin deposition and hemorrhage, consistent with recent infarction (Fig. 3). This specimen came from a 13-month-old patient who presented with no symptoms of pain or discomfort. No specimen in this series demonstrated evidence of testicular dysplasia or intratubular germ cell neoplasia on histopathologic examination. COMMENT The utility of laparoscopy to locate viable undescended testes, testicular remnants, or absent testes has been well documented. Various series report success rates of 90% to 95% in the localization of nonpalpable testes with laparoscopy.7–9 Investigators in some of these series have also reported the finding of hypoplastic vessels and/or vas deferens; a finding we have termed the inguinal vanishing testis.7–12 This finding was noted in 18% to 47% of the cases in these series (Table I). We noted this 867
FIGURE 3. Histopathologic view of inguinal gonadal remnant with residual seminiferous tubules on lower aspect of photograph.
finding on laparoscopy in 36% of the cases in our series. Histopathologic results from these cases were also available in some of these series. Typical histopathologic findings in these specimens included fibrosis, hemosiderin deposition, and microcalcification. Seminiferous tubules were also noted in 0% to 5% of the specimens, depending on the series (Table I). No series has reported the finding of germinal dysplasia or intratubular germ cell neoplasia in any of these specimens. The histopathologic findings reported in our series and other series support the hypothesis that these testes experienced an ischemic injury, subsequent necrosis, and atrophy due to an in utero or neonatal vascular accident such as torsion of the spermatic cord vessels during testicular descent.6,13–16 True crytorchidism, by contrast, is currently believed to be a multifactorial event involving mechanical and endocrine factors; we believe the difference in the etiology of the true cryptorchid testis versus the inguinal vanishing testis also confers a markedly different risk of malignant degeneration between these two gonad populations. Castilho8 and others contend that the finding of 868
hypoplastic spermatic vessels entering into the inguinal ring with or without a vas deferens precludes the need for a confirmatory inguinal exploration. However, other investigators such as Moore et al.7 believe that “this observation is not sufficiently specific or reliable to obviate the need for inguinal exploration.” The concern in this situation largely resides with the question of malignant degeneration of residual germinal tissue in these specimens. Le Conte first recognized the tumor potential of the undescended testis in 1851.17 Since then, the increased risk of malignant degeneration of the cryptorchid testis has been estimated at 20 to 46 times that of the general population.18,19 However, the location of these testes confers a significantly different degree of risk. Intra-abdominal testes are six times more likely to develop a testis tumor than the undescended testis located in an inguinal position.17 Furthermore, although previous investigators have documented the occurrence of testicular cancer in undescended inguinal testes or previously cryptorchid inguinal testes that had been brought into the scrotum surgically, no data are available about these patients or these cryptorchid testes before these patients presented with cancer.20 The infrequent finding of seminiferous tubules or other germinal tissue in the surgical specimens of patients with inguinal vanishing testes also supports the contention that the risk of malignant degeneration is quite low in this population. Cendron et al.21 recently presented a histologic evaluation of 25 vanishing testis specimens and noted no identifiable testicular elements in any of these cases. Immunohistochemistry was required in 3 cases to distinguish atrophic cremasteric cells from Leydig cells. These findings corroborate those noted in other series. Certainly, inguinal exploration can be performed by any competent surgeon. The morbidity with this procedure is low but not nonexistent. Potential complications include injury to the ileoinguinal nerve, hematoma formation, and wound infection. Exploration for an inguinal testis remnant can also be time consuming because the atretic remnant may not be readily apparent. The patient is also left with a surgical scar that may not have been necessary. So, inguinal exploration can be performed with minimal risk, time, and effort in these patients, but should it be? CONCLUSIONS The histologic evaluation of inguinal testicular remnants suggests that these organs became ischemic and atrophied during descent in utero or shortly after birth. No evidence currently exists to suggest that these remnants are likely to undergo UROLOGY 52 (5), 1998
TABLE I. Reported series Series
Year
Castilho8 Plotzker et al.9 Diamond et al.10 Lou et al.11 Tannenbaum et al.12 Moore et al.7 Present series
1990 1992 1992 1994 1994 1994 1998
Inguinal Vanishing Testis 8 23 40 25 30 35 14
(18) (35) (42) (67) (28) (47) (36)
Presence of Seminiferous Tubules 0 (0.0) 3 (5.0) NA NA 3 (3.0) 2 (1.5) 1 (3.0)
KEY: NA 5 not available. Numbers in parentheses are percentages.
malignant degeneration; the vast majority of the specimens in our series and other series reported in the literature contain no gonadal tissue at all. On the basis of these observations, inguinal exploration in the setting of atrophic spermatic vessels entering the inguinal ring—the laparoscopic findings of the inguinal vanishing testis—although technically feasible, appears unnecessary in the treatment of these patients. REFERENCES 1. Elder JS, and Marshall FF: Cryptorchidism and Related Anomalies. Praeger, New York, 1982. 2. Hunter J: Observations on the state of the testes in the foetus and on the hernia congenital, in Hunter W (Ed): Medical Commentaries, Part I. London, A. Hamilton, 1762. 3. Redman JF: Impalpable testis: observations based on 208 consecutive operations for undescended testes. J Urol 124: 379 –381, 1980. 4. Tibbs DJ: Unilateral absence of the testis. Eight cases of true monorchism. Br J Surg 48: 601– 603, 1961. 5. Smolko MJ, Kaplan GW, and Brock WA: Location and fate of the nonpalpable testis in children. J Urol 129: 1204 – 1206, 1983. 6. Abeyartne WA, Aherne WH, and Scott JE: The vanishing testis. Lancet 2: 823– 824, 1969. 7. Moore RG, Peters CA, Bauer SB, et al: Laparoscopic evaluation of the nonpalpable testis: a prospective assessment of accuracy. J Urol 151: 728 –731, 1994. 8. Castilho LN: Laparoscopy for the nonpalpable testis: how to interpret the endoscopic findings. J Urol 144: 1215– 1218, 1990. 9. Plotzker ED, Rushton HG, Belman AB, et al: Laparoscopy for nonpalpable testes in childhood: is inguinal exploration also necessary when vas and vessels exit the inguinal ring? J Urol 148: 635– 638, 1992.
UROLOGY 52 (5), 1998
10. Diamond DA, and Caldemone AA: The value of laparoscopy for 106 impalpable testes relative to clinical presentation. J Urol 148: 632– 634, 1992. 11. Lou CC, Lin JN, Tung TC, et al: Anatomical findings of the vanishing testis. Chang Keng I Hsueh 17: 121–124, 1994. 12. Tannenbaum SJ, Lerner SE, McAleer IM, et al: Preoperative laparoscopic localization of the nonpalpable testis: a critical analysis of a 10-year experience. J Urol 151: 732–734, 1994. 13. Gong M, Geary ES, and Shortliffe LM: Testicular torsion with contralateral vanishing testis. Urology 48: 306 –307, 1996. 14. Huff DS, Wu H-Y, Snyder HM, et al: Evidence in favor of the mechanical (intrauterine torsion) theory over the endocrinopathy (cryptorchidism) theory in the pathogenesis of testicular agenesis. J Urol 146: 630 – 631, 1991. 15. Sutcliffe JR, Wilson-Storey D, and Smith NM: Antenatal testicular torsion: only one cause of the testicular regression syndrome? J R Coll Surg Edinb 41: 99 –101, 1996. 16. Smith NM, Byard RW, and Bourne AJ: Testicular regression syndrome—a pathological study of 77 cases. Histopathology 19: 269 –272, 1991. 17. Johnson DC, Woodhead DM, and Pohl DR: Cryptorchidism and testicular tumorigenesis. Surgery 63: 919 –922, 1968. 18. Gilbert JB, and Hamilton JB: Incidence and nature of tumors in ectopic testes. Surg Gynecol Obstet 71: 731–734, 1940. 19. Campbell HE: Incidence of malignant growth of the undescended testicle. Arch Surg 44: 353–357, 1942. 20. Batata MA, Whitmore WF, Chu CH, et al: Cryptorchidism and testicular cancer. J Urol 124: 382–387, 1980. 21. Cendron M, Schned AR, and Ellsworth PI: Vanishing testis syndrome: simplified management based on histologic studies. Presented at the Meeting of the American Academy of Pediatrics, New Orleans, Louisiana, November 1997.
869