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Laparoscopy-assisted orchiopexy for recurrent undescended testes in children
Journal of Pediatric Surgery (2009) 44, 806–810
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Laparoscopy-assisted orchiopexy for recurrent undescended testes in children☆ Qiangsong Tong ⁎,1 , Liduan Zheng 1 , Shaotao Tang, Yongzhong Mao, Yong Wang, Yuan Liu, Jiabin Cai, Qinglan Ruan Department of Pediatric Surgery, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province 430022, China Received 10 May 2008; revised 23 July 2008; accepted 23 July 2008
Key words: Recurrent undescended testis; Laparoscopy-assisted orchiopexy; Reoperation
Abstract Objective: Reoperative orchidopexy is a technical challenge to pediatric surgeons. The laparoscopyassisted procedure is described for securing the testis in the scrotum in patients with a past history of open orchidopexy and testes in an unsatisfactory position. Patients and Methods: Thirty-one patients with 35 abnormally positioned testes (4 bilateral) were evaluated. All patients had a past history of inguinal surgery, and ages ranged between 2.5 and 13 years (mean, 5.5 years). Previous surgical procedures included 32 orchiopexies and 3 testicular detorsion of undescended testis. If needed, inguinal dissection was performed to loose the adherence between the cord and inguinal canal. Laparoscopic orchidopexy was applied to allow the testis to remain in the scrotum without tension. Patients underwent follow-up every 3 months after the operation with physical and ultrasound examinations. Results: Ten low inguinal testes were treated directly with open inguinal redo orchidopexy, whereas laparoscopy-assisted orchidopexy was possible in 23 (92%) of the remaining 25 reoperations. In 2 (8%) of these cases, severe scarring was present between the cord and the inguinal canal impeding the laparoscopy-assisted orchidopexy. For laparoscopy-assisted procedure, the operation time was 42 to 67 minutes (mean = 52 min). After the laparoscopy-assisted reoperations, 23 (92%) testes remain within the scrotum after a mean follow-up of 22 months (range, 6-32 months). Conclusion: When feasible, laparoscopy-assisted orchiopexy is a simple and effective technique for securing testicles in reoperative orchiopexy procedures. © 2009 Elsevier Inc. All rights reserved.
☆ Supported by the National Natural Science Foundation of China (mos. 30200284, 30600278, 30772359) and Program for New Century Excellent Talents in University (NCET-06-0641). ⁎ Corresponding author. Tel.: +86 27 63776478. E-mail address: [email protected] (Q. Tong). 1 Q. Tong and L. Zheng contributed equally to this work.
0022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2008.07.024
Cryptorchidism is a common urological problem. The incidence of undescended testis is between 0.8% and 1.5% by the end of the first year of life [1]. Most of the testes that descend during the first year actually do so during the first 3 months after birth [1]. Important potential longstanding sequelae of cryptorchidism include infertility and testicular cancer. The incidence of carcinoma in situ is determined to be 1.7% among patients with cryptorchidism, especially
Laparoscopy-assisted orchiopexy for recurrent undescended testes among those 18 to 20 years of age [2]. Therefore, early diagnosis and management of undescended testis are needed to preserve fertility and to improve early detection of testicular malignancy. Orchidopexy is a common surgical procedure for undescended testes in children. The position and size of the testis is satisfactory in 74% to 92%, depending on its initial position [3]. After orchiopexy or groin surgery, the position of testis may remain unsatisfactory. Only 1% to 10% of patients who require orchiopexy need a second surgery to replace the testes into the scrotum [4]. The cause of this complication, which requires a reoperation, is difficult to determine. Difficulties in achieving adequate length of testicular vessels are encountered in reoperative orchidopexies [4]. Inguinal mobilization of testicular vessels together with extensive retroperitoneal dissection cannot deliver the testis in satisfactory position in some of these cases [5]. Difficulty in mobilization, as well as significant complications including atrophy, have led to a multitude of approaches to this dilemma [5,6]. With ongoing advances of minimally invasive surgery, the use of laparoscopy in the diagnosis and treatment of undescended testes is now commonplace [7]. Over the last 5 years, there has been a push by pediatric surgeons and pediatric urologists to utilize laparoscopy in more of a primary role for establishing the diagnosis and location of the undescended testes [7]. The stable incidence of undescended impalpable testes and the ever-progressing utilization of laparoscopy have led to the commonplace utilization of laparoscopy in the treatment of these impalpable testes [8]. Several reports recommend laparoscopy as the gold standard for the evaluation and treatment of impalpable testes, allowing for localization of the testis, characterization of the testis and associated structures (vas deferens, testicular vessels) and subsequent treatment options [9-11]. Herein, we describe a combined approach using laparoscopic mobilization of testicular vessels and inguinal dissection in operation on recurrent undescended testis.
1. Patients and methods 1.1. Patients Between November 2000 and September 2007, 31 patients with previous groin surgery and 35 abnormally positioned testes underwent reoperative orchiopexy in Union Hospital of Tongji Medical College, China. Of these cases, 32 were previous orchiopexies, and 3 were testicular detorsions of undescended testis. Most of them were undertaken at other centers, resulting in unavailability of the operational details. The mean interval between original operation and reoperation was 2.4 years (range, 0.6-4.2 years). Patient ages at time of reoperation ranged between 2.5
807
and 13 years (mean, 5.5 years). Of the 35 testes, 17 were clinically palpable on physical examination, and the remaining 18 were clinically impalpable and detected by ultrasound examination. After the surgery, patients were examined every 3 months, and ultrasonography was performed at the first year. This study was approved by the ethics committee of Tongji Medical College.
1.2. Surgical procedure For palpable inguinal testes, open inguinal dissection was initially performed. An incision was made through the previous inguinal incision, and it was lengthened if necessary. Sharp dissection was used to release the distal and lateral attachments of scar tissue attached to the testis. Using a hemostat placed between the spermatic cord and the canal floor, a posterior plane was created gently until the cord was seen to enter the internal ring. If there was still inadequate length of the vessels despite reoperative inguinal mobilization of the testis, laparoscopic procedure was performed to mobilize the testicular vessels. All clinically impalpable cases of recurrent undescended testes were confirmed with laparoscopic examination under general anesthesia. Diagnostic laparoscopy was performed with insertion of a 5-mm umbilical port for 30° camera. CO2 pneumoperitoneum was maintained at a pressure of 8 to 10 mm Hg. Two additional 5-mm trocars were inserted in the midclavicular line at the level of the first trocar if further laparoscopic maneuver was needed. For high inguinal and peeping testes, the laparoscopyassisted orchidopexy was performed. If needed, the inguinal dissection was undertaken to loose the adherence between the cord and inguinal canal. The peritoneum was incised around the internal ring. The peritoneum overlying the spermatic vessels was incised on either side (laterally and medially), and the 2 incisions were joined proximally to leave a strip of posterior peritoneum adherent to the spermatic vessels distally. Dissection was continued cranially as far as necessary to gain enough length of the spermatic vessels to allow tension-free orchiopexy. Then, the peritoneum superior to the vas deferens was incised to gain additional vasal length. Periodically the testis was moved toward the contralateral internal ring as an average estimate of whether sufficient length had been attained to move it to the scrotum. When adequate mobilization of the testis and sufficient length of spermatic vessels were obtained, a small transverse skin incision was done and dartos pouch was created in the ipsilateral hemiscrotum. The artery forceps was passed through the scrotal incision and was pushed just over the pubic tubercle to pierce the peritoneum lateral to the medial umbilical ligament and medial to the inferior epigastric vessels. Then the testis was gently delivered to the scrotum. Creation and dilatation of the neo ring and testicular delivery was done under direct laparoscopic control. Any tension observed on the testicular vessels after pulling out the testis was released by further
808
Q. Tong et al. Table 1
Location of undescended testes and management
Location of testes
No. of cases IH
ID
IO
LAO
Low inguinal (n = 16) High inguinal (n = 14) Peeping (n = 5)
2 4 2
16 8 0
10 0 0
5 13 5
IH indicate inguinal hernia; ID, inguinal dissection; IO, inguinal orchidopexy; LAO, laparoscopy-assisted orchidopexy.
scrotum, the testis was fixed into the dartos pouch using absorbable sutures and the scrotal incision was closed. Postoperative evaluation includes physical and ultrasound examinations to determine the size, position, and viability of the testes.
2. Results In this series, 14 testes were found within the upper inguinal canal and 16 testes at the low inguinal canal, with associated inguinal hernia in 8 cases (Fig. 1, Table 1). Five testes within 2 cm proximal to the internal inguinal ring were found as “peeping” testes (Fig. 1, Table 1). Laparoscopyassisted orchidopexy was needed in 25 recurrent undescended testes, whereas the remaining 10 low inguinal testes were treated directly with open inguinal orchidopexy (Fig. 2,
Fig. 1 Laparoscopic examination of undescended testes. All clinically impalpable cases of recurrent undescended testes were confirmed with laparoscopic examination under general anesthesia. A, In most of the cases, the internal ring was closed. B, In some cases, the undescended testes were associated with inguinal hernia. C, Five testes were found to be within 2 cm proximal to the internal inguinal ring as “peeping” testis.
mobilization of the spermatic vessels. If tension still existed, the strip of fascia attached to the cord was fixed either to the pubic bone or to the tendinous part of the gracilis muscle with 2 nonabsorbable stitches. After being put into the
Fig. 2 The management algorithm. Combined inguinal dissection and laparoscopy-assisted orchidopexy was applied to treat recurrent undescended testes. For low inguinal testes, open inguinal orchidopexy was performed. If there was still inadequate length of the vessels despite reoperative inguinal mobilization of the testis, laparoscopic procedure was performed to mobilize the testicular vessels. For high inguinal and peeping testes, the laparoscopyassisted orchidopexy was performed. If needed, the inguinal dissection was undertaken to loose the adherence between the cord and inguinal canal.
Laparoscopy-assisted orchiopexy for recurrent undescended testes Table 1). The laparoscopy-assisted procedure was needed or helpful in 23 (92%) of the 25 recurrent undescended testes. Among them, 14 testes needed inguinal dissection to release the attachments of scar tissue attached to the testis. In 2 (8%) of the 25 recurrent testes, severe scarring was present between the cord and the inguinal canal impeding the laparoscopy-assisted orchidopexy; the testes were positioned superior to the external ring for further surgical treatment. Finally, in 23 (92%) cases treated by laparoscopy-assisted orchidopexy, the testis was descended into the scrotum and fixed with dartos pouch. For laparoscopy-assisted procedure, the operation time was 42 to 67 minutes (mean, 52 minutes) (Table 2). All patients recovered well postoperatively without complications. The hospital stay was 3 to 5 days (mean, 3.5 days) (Table 2). The time for patients returning to normal activities was 7 to 11 days (mean, 8.2 days) (Table 2). All these results were not significantly different from those of open inguinal orchidopexy for 10 low inguinal testes (Table 2). The patients were followed up for a period of 6 to 32 months (mean, 22 months). In 23 testes treated by laparoscopyassisted orchidopexy, 21 (91.3%) were in good size, and the other 2 (8.7%) were atrophic (Table 3). Twenty-three testes were found to be in satisfactory positions, with 20 (86.9%) of them at scrotal base and 3 (13.1%) at mid scrotum (Table 3). The viability of testis was normal in 19 unilateral cases when compared with the contralateral testis and 1 bilateral case (Table 3). No inguinal hernia was found during the follow-up for all patients (Table 3). In 10 recurrent undescended testes treated by open inguinal orchidopexy, 8 (80.0%) were found to be at scrotal base, whereas the other 2 (20.0%) was at mid scrotum and atrophic (Table 3). The viability of testis was normal in 7 unilateral cases (70.0%) when compared with the contralateral testis.
3. Discussion The undescended testis represents one of the most common disorders of childhood, affecting 0.8% of infants at 1 year of age, 3% of full-term newborns, and 21% of premature babies [1]. Approximately 20% of undescended testes are impalpable, and in 20% to 50% of children with impalpable testis, the testis is absent [1]. Extra-abdominal
Table 2
Summary of intraoperative and postoperative data
Characteristic
LAO
IO
No. of cases Operative time (min) Oral feeding (hr) Hospital stay (days) Return to normal activities (days)
23 10 52.1 ± 4.9 (42-67) 48.5 ± 3.6 (35-55) 7.3 ± 1.2 (6-12) 7.5 ± 2.1 (6-13) 3.5 ± 1.4 (3-5) 3.6 ± 1.8 (3-6) 8.2 ± 1.7 (7-11) 8.7 ± 2.2 (8-12)
Table 3
809 Postoperative follow-up results
No. of cases Testicular size Good Atrophic Testicular position Bottom of scrotum Neck of scrotum Testicular viability Viable Not viable Inguinal hernia Ipsilateral Contralateral
LAO
Percent (%)
IO
Percent (%)
23
100
10
100
21 2
91.3 8.7
8 2
80.0 20.0
20 3
86.9 13.1
8 2
80.0 20.0
21 2
91.3 8.7
7 3
70.0 30.0
0 0
0 0
0 1
0 10.0
cryptorchid testes most often can be delivered to a dependent scrotal location by standard orchiopexy techniques, whereas those located high within the abdomen usually require division of the internal spermatic vasculature to reach the scrotum [12]. In the current study, most of the recurrent patients described were referred from other centers and received open primary orchiopexy. Therefore, the details of previous surgeries were not available. Before the reoperations, whether excessive upward tension after the initial surgery was responsible for the failure was not known. However, we suspected that this could be a major contributing factor. In 1976, Cortesi et al. [13] first used laparoscopy to locate undescended testis. Since then, this procedure has gained wide popularity because it has minimal morbidity and is not time-consuming. In addition, laparoscopy has been used successfully to perform both orchiopexy and orchiectomy for intraabdominal testis [2]. Over the past 2 decades, there has been an evolution in the surgical treatment of undescended testis [2]. In our center, diagnostic laparoscopy is performed in all clinically impalpable undescended testes. In the current study, we found that most of the impalpable undescended testes located at the upper inguinal canal level and 5 testes within 2 cm proximal to the internal inguinal ring as “peeping” testes. In addition, we found that 8 cases were associated with inguinal hernia, suggesting that the first orchiopexy failed because an inadequate operation was performed. In a recent study, Riquelme et al [14] reported that the resection of processus vaginalis as the most important step of pediatric hernia repair, even without closure of the internal ring during laparoscopic orchidopexy. The hernia space can be occupied by scar tissue, and the deperitonealized area will close completely over the internal inguinal ring [14]. We agree to this opinion based on our findings in previous cases of laparoscopic orchidopexy. Therefore, the internal ring of associated inguinal hernias was not closed with sutures in our cases.
810 Reoperative orchidopexy is a technical challenge to pediatric surgeons, and a satisfactory testicular position may not be achieved [5]. Laparoscopy allows extensive mobilization of testicular vessels to gain additional length [5]. In this study, we found that open inguinal orchidopexy was feasible in some of the low inguinal testes without laparscopic assistance. However, the other recurrent cases presented excessive tension for the descent of testes into the scrotum. For these involved cases of unfavorable testicular position after previous surgery, combined inguinal dissection and laparoscopic orchidopexy was performed for canalicular testis with a looping vas deferens. The testicular vessels were mobilized from just proximal to the internal inguinal ring to the level of cecum and sigmoid colon, respectively. Fixing the testis to the scrotum by the confection of a dartos pouch or a transfixant stitch requires the use of a mobile area (the scrotum) that offers no resistance to the upper traction (cord). We believe that laparoscopic assistance is useful in reoperative orchiopexy to improve mobilization and avoid tension that may have caused the initial failure. For peeping and proximal inguinal testes, reoperative inguinal dissection is not necessary if laparoscopic mobilization can be achieved without intensive attachments of scar tissue to the testis. In addition, during the procedure, the sac distal to the testes must be well visualized to avoid trauma or injury to the adnexa or vas deferens. In the en block mobilization technique described by Cartwright et al [4], a strip of the external oblique aponeurosis remains attached to the spermatic cord. Fixing this strip to the pubic bone or to the tendinous part of the muscles of area avoids subsequent tension to the distal part of cord, allowing the testis to remain in the scrotum without tension [6]. In our series, after inguinal dissection and laparoscopic mobilization of testicular vessels, most of the spermatic cord was free of tension. In only 2 cases, fixation of the external oblique aponeurosis of spermatic cord to pubic bone was needed. Therefore, laparoscopic orchidopexy was possible in most of recurrent undescended testes. For this procedure to be effective, adherence between the cord and inguinal canal must be dissected enough to support the laparoscopic dissection of spermatic cord within the abdomen. In 2 of our cases, severe scarring was present between the cord and the inguinal canal impeding the laparoscopy-assisted orchidopexy. In 100% of the cases treated by laparoscopy-assisted orchidopexy, the testis remains in the scrotum after a mean follow-up of 22 months (range, 6-32 months). When feasible, laparoscopy-assisted orchiopexy is a simple and effective procedure for securing testicles in reoperative orchiopexy, avoiding tension in the distal part of the spermatic cord.
Q. Tong et al.
4. Conclusion Although the historical reports for the management of undescended testes have emphasized the effectiveness and success of open techniques, the more recent data are overwhelming centered on laparoscopy as a means for improving diagnostic ability and effecting treatment options. This study highlights the application of laparoscopy in reoperative orchiopexy, which strengthen its advantage in this extensive mobilization of testicular vessels to gain additional length. A prospective randomized controlled trial would provide the surgeons and physicians caring for the children suffering from recurrent undescended testis with statistically sound scientific data, upon which to base optimal management; however, until that can be accomplished, the data to date support the role of laparoscopy in patients with recurrent undescended testis.
References [1] Smolko MJ, Kaplan GW, Brock WA. Location and fate of the nonpalpable testis in children. J Urol 1983;129:1204-6. [2] El-Anany F, Gad El-Moula M, Abdel Moneim A, et al. Laparoscopy for impalpable testis: classification-based management. Surg Endosc 2007;21:449-54. [3] Docimo SG. The results of surgical therapy for cryptorchidism: a literature review and analysis. J Urol 1995;154:1148-52. [4] Cartwright PC, Velagapudi S, Snyder III HM, et al. A surgical approach to reoperative orchiopexy. J Urol 1993;149:817-8. [5] Leung MW, Chao NS, Wong BP, et al. Laparoscopic mobilization of testicular vessels: an adjunctive step in orchidopexy for impalpable and redo undescended testis in children. Pediatr Surg Int 2005;21:767-9. [6] Palacio MM, Sferco A, Garcia Fernanndez AE, et al. Inguinal cordopexy: a simple and effective new technique for securing the testes in reoperative orchiopexy. J Pediatr Surg 1999;34:424-5. [7] Gatti JM, Ostlie DJ. The use of laparoscopy in the management of nonpalpable undescended testes. Curr Opin Pediatr 2008;19:349-53. [8] Baker LA, Docimo SG, Surer I, et al. A multi-institutional analysis of laparoscopic orchidopexy. BJU Int 2001;87:484-9. [9] Patil KK, Green JS, Duffy PG. Laparoscopy for impalpable testes. BJU Int 2005;95:704-8. [10] Papparella A, Parmeggiani P, Cobellis G, et al. Laparoscopic management of nonpalpable testes: a multicenter study of the Italian Society of Video Surgery in Infancy. J Pediatr Surg 2008;40:696-700. [11] Argos Rodriguez MD, Unda Freire A, Ruiz Orpez A, et al. Diagnostic and therapeutic laparoscopy for nonpalpable testis. Surg Endosc 2003; 17:1756-8. [12] Yucel S, Ziada A, Harrison C, et al. Decision making during laparoscopic orchiopexy for intra-abdominal testes near the internal ring. J Urol 2007;178:1447-50. [13] Cortesi N, Ferrari P, Zambarda E, et al. Diagnosis of bilateral abdominal cryptorchidism by laparoscopy. Endoscopy 1976;8:33-4. [14] Riquelme M, Aranda A, Rodriguez C, et al. Incidence and management of the inguinal hernia during laparoscopic orchiopexy in palpable cryptoorchidism: preliminary report. Pediatr Surg Int 2007;23:301-4.
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Laparoscopy-assisted orchiopexy for recurrent undescended testes in children☆ Qiangsong Tong ⁎,1 , Liduan Zheng 1 , Shaotao Tang, Yongzhong Mao, Yong Wang, Yuan Liu, Jiabin Cai, Qinglan Ruan Department of Pediatric Surgery, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province 430022, China Received 10 May 2008; revised 23 July 2008; accepted 23 July 2008
Key words: Recurrent undescended testis; Laparoscopy-assisted orchiopexy; Reoperation
Abstract Objective: Reoperative orchidopexy is a technical challenge to pediatric surgeons. The laparoscopyassisted procedure is described for securing the testis in the scrotum in patients with a past history of open orchidopexy and testes in an unsatisfactory position. Patients and Methods: Thirty-one patients with 35 abnormally positioned testes (4 bilateral) were evaluated. All patients had a past history of inguinal surgery, and ages ranged between 2.5 and 13 years (mean, 5.5 years). Previous surgical procedures included 32 orchiopexies and 3 testicular detorsion of undescended testis. If needed, inguinal dissection was performed to loose the adherence between the cord and inguinal canal. Laparoscopic orchidopexy was applied to allow the testis to remain in the scrotum without tension. Patients underwent follow-up every 3 months after the operation with physical and ultrasound examinations. Results: Ten low inguinal testes were treated directly with open inguinal redo orchidopexy, whereas laparoscopy-assisted orchidopexy was possible in 23 (92%) of the remaining 25 reoperations. In 2 (8%) of these cases, severe scarring was present between the cord and the inguinal canal impeding the laparoscopy-assisted orchidopexy. For laparoscopy-assisted procedure, the operation time was 42 to 67 minutes (mean = 52 min). After the laparoscopy-assisted reoperations, 23 (92%) testes remain within the scrotum after a mean follow-up of 22 months (range, 6-32 months). Conclusion: When feasible, laparoscopy-assisted orchiopexy is a simple and effective technique for securing testicles in reoperative orchiopexy procedures. © 2009 Elsevier Inc. All rights reserved.
☆ Supported by the National Natural Science Foundation of China (mos. 30200284, 30600278, 30772359) and Program for New Century Excellent Talents in University (NCET-06-0641). ⁎ Corresponding author. Tel.: +86 27 63776478. E-mail address: [email protected] (Q. Tong). 1 Q. Tong and L. Zheng contributed equally to this work.
0022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2008.07.024
Cryptorchidism is a common urological problem. The incidence of undescended testis is between 0.8% and 1.5% by the end of the first year of life [1]. Most of the testes that descend during the first year actually do so during the first 3 months after birth [1]. Important potential longstanding sequelae of cryptorchidism include infertility and testicular cancer. The incidence of carcinoma in situ is determined to be 1.7% among patients with cryptorchidism, especially
Laparoscopy-assisted orchiopexy for recurrent undescended testes among those 18 to 20 years of age [2]. Therefore, early diagnosis and management of undescended testis are needed to preserve fertility and to improve early detection of testicular malignancy. Orchidopexy is a common surgical procedure for undescended testes in children. The position and size of the testis is satisfactory in 74% to 92%, depending on its initial position [3]. After orchiopexy or groin surgery, the position of testis may remain unsatisfactory. Only 1% to 10% of patients who require orchiopexy need a second surgery to replace the testes into the scrotum [4]. The cause of this complication, which requires a reoperation, is difficult to determine. Difficulties in achieving adequate length of testicular vessels are encountered in reoperative orchidopexies [4]. Inguinal mobilization of testicular vessels together with extensive retroperitoneal dissection cannot deliver the testis in satisfactory position in some of these cases [5]. Difficulty in mobilization, as well as significant complications including atrophy, have led to a multitude of approaches to this dilemma [5,6]. With ongoing advances of minimally invasive surgery, the use of laparoscopy in the diagnosis and treatment of undescended testes is now commonplace [7]. Over the last 5 years, there has been a push by pediatric surgeons and pediatric urologists to utilize laparoscopy in more of a primary role for establishing the diagnosis and location of the undescended testes [7]. The stable incidence of undescended impalpable testes and the ever-progressing utilization of laparoscopy have led to the commonplace utilization of laparoscopy in the treatment of these impalpable testes [8]. Several reports recommend laparoscopy as the gold standard for the evaluation and treatment of impalpable testes, allowing for localization of the testis, characterization of the testis and associated structures (vas deferens, testicular vessels) and subsequent treatment options [9-11]. Herein, we describe a combined approach using laparoscopic mobilization of testicular vessels and inguinal dissection in operation on recurrent undescended testis.
1. Patients and methods 1.1. Patients Between November 2000 and September 2007, 31 patients with previous groin surgery and 35 abnormally positioned testes underwent reoperative orchiopexy in Union Hospital of Tongji Medical College, China. Of these cases, 32 were previous orchiopexies, and 3 were testicular detorsions of undescended testis. Most of them were undertaken at other centers, resulting in unavailability of the operational details. The mean interval between original operation and reoperation was 2.4 years (range, 0.6-4.2 years). Patient ages at time of reoperation ranged between 2.5
807
and 13 years (mean, 5.5 years). Of the 35 testes, 17 were clinically palpable on physical examination, and the remaining 18 were clinically impalpable and detected by ultrasound examination. After the surgery, patients were examined every 3 months, and ultrasonography was performed at the first year. This study was approved by the ethics committee of Tongji Medical College.
1.2. Surgical procedure For palpable inguinal testes, open inguinal dissection was initially performed. An incision was made through the previous inguinal incision, and it was lengthened if necessary. Sharp dissection was used to release the distal and lateral attachments of scar tissue attached to the testis. Using a hemostat placed between the spermatic cord and the canal floor, a posterior plane was created gently until the cord was seen to enter the internal ring. If there was still inadequate length of the vessels despite reoperative inguinal mobilization of the testis, laparoscopic procedure was performed to mobilize the testicular vessels. All clinically impalpable cases of recurrent undescended testes were confirmed with laparoscopic examination under general anesthesia. Diagnostic laparoscopy was performed with insertion of a 5-mm umbilical port for 30° camera. CO2 pneumoperitoneum was maintained at a pressure of 8 to 10 mm Hg. Two additional 5-mm trocars were inserted in the midclavicular line at the level of the first trocar if further laparoscopic maneuver was needed. For high inguinal and peeping testes, the laparoscopyassisted orchidopexy was performed. If needed, the inguinal dissection was undertaken to loose the adherence between the cord and inguinal canal. The peritoneum was incised around the internal ring. The peritoneum overlying the spermatic vessels was incised on either side (laterally and medially), and the 2 incisions were joined proximally to leave a strip of posterior peritoneum adherent to the spermatic vessels distally. Dissection was continued cranially as far as necessary to gain enough length of the spermatic vessels to allow tension-free orchiopexy. Then, the peritoneum superior to the vas deferens was incised to gain additional vasal length. Periodically the testis was moved toward the contralateral internal ring as an average estimate of whether sufficient length had been attained to move it to the scrotum. When adequate mobilization of the testis and sufficient length of spermatic vessels were obtained, a small transverse skin incision was done and dartos pouch was created in the ipsilateral hemiscrotum. The artery forceps was passed through the scrotal incision and was pushed just over the pubic tubercle to pierce the peritoneum lateral to the medial umbilical ligament and medial to the inferior epigastric vessels. Then the testis was gently delivered to the scrotum. Creation and dilatation of the neo ring and testicular delivery was done under direct laparoscopic control. Any tension observed on the testicular vessels after pulling out the testis was released by further
808
Q. Tong et al. Table 1
Location of undescended testes and management
Location of testes
No. of cases IH
ID
IO
LAO
Low inguinal (n = 16) High inguinal (n = 14) Peeping (n = 5)
2 4 2
16 8 0
10 0 0
5 13 5
IH indicate inguinal hernia; ID, inguinal dissection; IO, inguinal orchidopexy; LAO, laparoscopy-assisted orchidopexy.
scrotum, the testis was fixed into the dartos pouch using absorbable sutures and the scrotal incision was closed. Postoperative evaluation includes physical and ultrasound examinations to determine the size, position, and viability of the testes.
2. Results In this series, 14 testes were found within the upper inguinal canal and 16 testes at the low inguinal canal, with associated inguinal hernia in 8 cases (Fig. 1, Table 1). Five testes within 2 cm proximal to the internal inguinal ring were found as “peeping” testes (Fig. 1, Table 1). Laparoscopyassisted orchidopexy was needed in 25 recurrent undescended testes, whereas the remaining 10 low inguinal testes were treated directly with open inguinal orchidopexy (Fig. 2,
Fig. 1 Laparoscopic examination of undescended testes. All clinically impalpable cases of recurrent undescended testes were confirmed with laparoscopic examination under general anesthesia. A, In most of the cases, the internal ring was closed. B, In some cases, the undescended testes were associated with inguinal hernia. C, Five testes were found to be within 2 cm proximal to the internal inguinal ring as “peeping” testis.
mobilization of the spermatic vessels. If tension still existed, the strip of fascia attached to the cord was fixed either to the pubic bone or to the tendinous part of the gracilis muscle with 2 nonabsorbable stitches. After being put into the
Fig. 2 The management algorithm. Combined inguinal dissection and laparoscopy-assisted orchidopexy was applied to treat recurrent undescended testes. For low inguinal testes, open inguinal orchidopexy was performed. If there was still inadequate length of the vessels despite reoperative inguinal mobilization of the testis, laparoscopic procedure was performed to mobilize the testicular vessels. For high inguinal and peeping testes, the laparoscopyassisted orchidopexy was performed. If needed, the inguinal dissection was undertaken to loose the adherence between the cord and inguinal canal.
Laparoscopy-assisted orchiopexy for recurrent undescended testes Table 1). The laparoscopy-assisted procedure was needed or helpful in 23 (92%) of the 25 recurrent undescended testes. Among them, 14 testes needed inguinal dissection to release the attachments of scar tissue attached to the testis. In 2 (8%) of the 25 recurrent testes, severe scarring was present between the cord and the inguinal canal impeding the laparoscopy-assisted orchidopexy; the testes were positioned superior to the external ring for further surgical treatment. Finally, in 23 (92%) cases treated by laparoscopy-assisted orchidopexy, the testis was descended into the scrotum and fixed with dartos pouch. For laparoscopy-assisted procedure, the operation time was 42 to 67 minutes (mean, 52 minutes) (Table 2). All patients recovered well postoperatively without complications. The hospital stay was 3 to 5 days (mean, 3.5 days) (Table 2). The time for patients returning to normal activities was 7 to 11 days (mean, 8.2 days) (Table 2). All these results were not significantly different from those of open inguinal orchidopexy for 10 low inguinal testes (Table 2). The patients were followed up for a period of 6 to 32 months (mean, 22 months). In 23 testes treated by laparoscopyassisted orchidopexy, 21 (91.3%) were in good size, and the other 2 (8.7%) were atrophic (Table 3). Twenty-three testes were found to be in satisfactory positions, with 20 (86.9%) of them at scrotal base and 3 (13.1%) at mid scrotum (Table 3). The viability of testis was normal in 19 unilateral cases when compared with the contralateral testis and 1 bilateral case (Table 3). No inguinal hernia was found during the follow-up for all patients (Table 3). In 10 recurrent undescended testes treated by open inguinal orchidopexy, 8 (80.0%) were found to be at scrotal base, whereas the other 2 (20.0%) was at mid scrotum and atrophic (Table 3). The viability of testis was normal in 7 unilateral cases (70.0%) when compared with the contralateral testis.
3. Discussion The undescended testis represents one of the most common disorders of childhood, affecting 0.8% of infants at 1 year of age, 3% of full-term newborns, and 21% of premature babies [1]. Approximately 20% of undescended testes are impalpable, and in 20% to 50% of children with impalpable testis, the testis is absent [1]. Extra-abdominal
Table 2
Summary of intraoperative and postoperative data
Characteristic
LAO
IO
No. of cases Operative time (min) Oral feeding (hr) Hospital stay (days) Return to normal activities (days)
23 10 52.1 ± 4.9 (42-67) 48.5 ± 3.6 (35-55) 7.3 ± 1.2 (6-12) 7.5 ± 2.1 (6-13) 3.5 ± 1.4 (3-5) 3.6 ± 1.8 (3-6) 8.2 ± 1.7 (7-11) 8.7 ± 2.2 (8-12)
Table 3
809 Postoperative follow-up results
No. of cases Testicular size Good Atrophic Testicular position Bottom of scrotum Neck of scrotum Testicular viability Viable Not viable Inguinal hernia Ipsilateral Contralateral
LAO
Percent (%)
IO
Percent (%)
23
100
10
100
21 2
91.3 8.7
8 2
80.0 20.0
20 3
86.9 13.1
8 2
80.0 20.0
21 2
91.3 8.7
7 3
70.0 30.0
0 0
0 0
0 1
0 10.0
cryptorchid testes most often can be delivered to a dependent scrotal location by standard orchiopexy techniques, whereas those located high within the abdomen usually require division of the internal spermatic vasculature to reach the scrotum [12]. In the current study, most of the recurrent patients described were referred from other centers and received open primary orchiopexy. Therefore, the details of previous surgeries were not available. Before the reoperations, whether excessive upward tension after the initial surgery was responsible for the failure was not known. However, we suspected that this could be a major contributing factor. In 1976, Cortesi et al. [13] first used laparoscopy to locate undescended testis. Since then, this procedure has gained wide popularity because it has minimal morbidity and is not time-consuming. In addition, laparoscopy has been used successfully to perform both orchiopexy and orchiectomy for intraabdominal testis [2]. Over the past 2 decades, there has been an evolution in the surgical treatment of undescended testis [2]. In our center, diagnostic laparoscopy is performed in all clinically impalpable undescended testes. In the current study, we found that most of the impalpable undescended testes located at the upper inguinal canal level and 5 testes within 2 cm proximal to the internal inguinal ring as “peeping” testes. In addition, we found that 8 cases were associated with inguinal hernia, suggesting that the first orchiopexy failed because an inadequate operation was performed. In a recent study, Riquelme et al [14] reported that the resection of processus vaginalis as the most important step of pediatric hernia repair, even without closure of the internal ring during laparoscopic orchidopexy. The hernia space can be occupied by scar tissue, and the deperitonealized area will close completely over the internal inguinal ring [14]. We agree to this opinion based on our findings in previous cases of laparoscopic orchidopexy. Therefore, the internal ring of associated inguinal hernias was not closed with sutures in our cases.
810 Reoperative orchidopexy is a technical challenge to pediatric surgeons, and a satisfactory testicular position may not be achieved [5]. Laparoscopy allows extensive mobilization of testicular vessels to gain additional length [5]. In this study, we found that open inguinal orchidopexy was feasible in some of the low inguinal testes without laparscopic assistance. However, the other recurrent cases presented excessive tension for the descent of testes into the scrotum. For these involved cases of unfavorable testicular position after previous surgery, combined inguinal dissection and laparoscopic orchidopexy was performed for canalicular testis with a looping vas deferens. The testicular vessels were mobilized from just proximal to the internal inguinal ring to the level of cecum and sigmoid colon, respectively. Fixing the testis to the scrotum by the confection of a dartos pouch or a transfixant stitch requires the use of a mobile area (the scrotum) that offers no resistance to the upper traction (cord). We believe that laparoscopic assistance is useful in reoperative orchiopexy to improve mobilization and avoid tension that may have caused the initial failure. For peeping and proximal inguinal testes, reoperative inguinal dissection is not necessary if laparoscopic mobilization can be achieved without intensive attachments of scar tissue to the testis. In addition, during the procedure, the sac distal to the testes must be well visualized to avoid trauma or injury to the adnexa or vas deferens. In the en block mobilization technique described by Cartwright et al [4], a strip of the external oblique aponeurosis remains attached to the spermatic cord. Fixing this strip to the pubic bone or to the tendinous part of the muscles of area avoids subsequent tension to the distal part of cord, allowing the testis to remain in the scrotum without tension [6]. In our series, after inguinal dissection and laparoscopic mobilization of testicular vessels, most of the spermatic cord was free of tension. In only 2 cases, fixation of the external oblique aponeurosis of spermatic cord to pubic bone was needed. Therefore, laparoscopic orchidopexy was possible in most of recurrent undescended testes. For this procedure to be effective, adherence between the cord and inguinal canal must be dissected enough to support the laparoscopic dissection of spermatic cord within the abdomen. In 2 of our cases, severe scarring was present between the cord and the inguinal canal impeding the laparoscopy-assisted orchidopexy. In 100% of the cases treated by laparoscopy-assisted orchidopexy, the testis remains in the scrotum after a mean follow-up of 22 months (range, 6-32 months). When feasible, laparoscopy-assisted orchiopexy is a simple and effective procedure for securing testicles in reoperative orchiopexy, avoiding tension in the distal part of the spermatic cord.
Q. Tong et al.
4. Conclusion Although the historical reports for the management of undescended testes have emphasized the effectiveness and success of open techniques, the more recent data are overwhelming centered on laparoscopy as a means for improving diagnostic ability and effecting treatment options. This study highlights the application of laparoscopy in reoperative orchiopexy, which strengthen its advantage in this extensive mobilization of testicular vessels to gain additional length. A prospective randomized controlled trial would provide the surgeons and physicians caring for the children suffering from recurrent undescended testis with statistically sound scientific data, upon which to base optimal management; however, until that can be accomplished, the data to date support the role of laparoscopy in patients with recurrent undescended testis.
References [1] Smolko MJ, Kaplan GW, Brock WA. Location and fate of the nonpalpable testis in children. J Urol 1983;129:1204-6. [2] El-Anany F, Gad El-Moula M, Abdel Moneim A, et al. Laparoscopy for impalpable testis: classification-based management. Surg Endosc 2007;21:449-54. [3] Docimo SG. The results of surgical therapy for cryptorchidism: a literature review and analysis. J Urol 1995;154:1148-52. [4] Cartwright PC, Velagapudi S, Snyder III HM, et al. A surgical approach to reoperative orchiopexy. J Urol 1993;149:817-8. [5] Leung MW, Chao NS, Wong BP, et al. Laparoscopic mobilization of testicular vessels: an adjunctive step in orchidopexy for impalpable and redo undescended testis in children. Pediatr Surg Int 2005;21:767-9. [6] Palacio MM, Sferco A, Garcia Fernanndez AE, et al. Inguinal cordopexy: a simple and effective new technique for securing the testes in reoperative orchiopexy. J Pediatr Surg 1999;34:424-5. [7] Gatti JM, Ostlie DJ. The use of laparoscopy in the management of nonpalpable undescended testes. Curr Opin Pediatr 2008;19:349-53. [8] Baker LA, Docimo SG, Surer I, et al. A multi-institutional analysis of laparoscopic orchidopexy. BJU Int 2001;87:484-9. [9] Patil KK, Green JS, Duffy PG. Laparoscopy for impalpable testes. BJU Int 2005;95:704-8. [10] Papparella A, Parmeggiani P, Cobellis G, et al. Laparoscopic management of nonpalpable testes: a multicenter study of the Italian Society of Video Surgery in Infancy. J Pediatr Surg 2008;40:696-700. [11] Argos Rodriguez MD, Unda Freire A, Ruiz Orpez A, et al. Diagnostic and therapeutic laparoscopy for nonpalpable testis. Surg Endosc 2003; 17:1756-8. [12] Yucel S, Ziada A, Harrison C, et al. Decision making during laparoscopic orchiopexy for intra-abdominal testes near the internal ring. J Urol 2007;178:1447-50. [13] Cortesi N, Ferrari P, Zambarda E, et al. Diagnosis of bilateral abdominal cryptorchidism by laparoscopy. Endoscopy 1976;8:33-4. [14] Riquelme M, Aranda A, Rodriguez C, et al. Incidence and management of the inguinal hernia during laparoscopic orchiopexy in palpable cryptoorchidism: preliminary report. Pediatr Surg Int 2007;23:301-4.