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Laparoscopy for nonpalpable testes
Laparoscopy for Nonpalpable Testes By Shumyle Alam and Jayant Radhakrishnan Chicago, Illinois
Purpose: Laparoscopy is now considered integral to the management of nonpalpable testes, although its benefits are not clearly documented. The authors prospectively determined the value of laparoscopy in patients with nonpalpable testes.
with orchiopexy for 17 testes (6 intraabdominal and 9 at the deep ring) and removal of 10 atrophic nubbins. It was only useful in avoiding retroperitoneal dissection for 5 (14%) vanishing testes, and it may have been of benefit for 3 testes treated with a 2-stage Fowler-Stephens orchiopexy.
Methods: Between December 1997 and October 2001, 37 patients with 40 nonpalpable testes were scheduled for laparoscopy followed by definitive treatment. Laparoscopy was cancelled in 4 patients (5 testes) because their testes became palpable under anesthesia. In the remaining 33 patients (35 testes), it was determined at the time of surgery whether, as a consequence of laparoscopy: (1) retroperitoneal exploration was avoided (2) definitive treatment was facilitated.
Conclusions: The majority of our patients with nonpalpable testes could have been treated through an inguinal incision with laparoscopy being reserved for situations in which the testis was not identified on inguinal exploration. J Pediatr Surg 38:1534-1536. © 2003 Elsevier Inc. All rights reserved.
Results: Laparoscopy did not alter the management of 27 testes (77%) that were treated through an inguinal incision
INDEX WORDS: Testes, undescended, nonpalpable, laparoscopy.
D
Institutional Review Board approval was not required because there was no deviation from the current standard of care for nonpalpable testes. Furthermore, the patients in this purely observational study were referred to one of the authors for management of nonpalpable testes.
IAGNOSTIC LAPAROSCOPY for nonpalpable testes was first carried out in 1976 by Cortesi et al.1 Since then, it has gained such great acceptance that some investigators consider laparoscopic orchiopexy to be the treatment of choice for all nonpalpable testes.2,3 Our initial enthusiasm for laparoscopy was tempered over time by an impression that it did not alter the diagnosis or treatment of these patients materially. We carried out this prospective study to try to identify its role. MATERIALS AND METHODS From December 1997 through October 2001, all phenotypically normal boys in whom the testis was not palpable on examination in the clinic were included in the study. Patients with prune belly syndrome, abdominal wall defects, ambiguous genitalia, and those who had a prior inguinal exploration were excluded. We identified 40 nonpalpable testes in 37 patients ranging in age from 1 to 15 years. Of the 40 nonpalpable testes, 19 were on the left, 15 on the right, and 3 were bilateral. Our protocol consisted of examination under anesthesia followed by laparoscopy and definitive treatment. Examination and definitive treatment in all patients was carried out by one of the authors; however, in an effort to reduce observer bias, other experienced laparoscopists performed laparoscopy.
From the Departments of Surgery and Urology, University of Illinois, Chicago, IL. Address reprint requests to Jayant Radhakrishnan, MD, Clinical Professor of Surgery and Urology, University of Illinois, Chicago, 1502 71st St, Darien, IL 60561. © 2003 Elsevier Inc. All rights reserved. 0022-3468/03/3810-0020$30.00/0 doi:10.1016/S0022-3468(03)00509-8 1534
RESULTS
Five testes that became palpable under anesthesia consisted of the left testis from a bilateral case and 4 right-sided testes. Laparoscopy was carried out for the remaining 35 nonpalpable testes in 33 patients (Table 1). Orchiopexy was carried out through an inguinal approach in 17 patients. Two testes were found in the inguinal canal, and 9 were at the internal inguinal ring. Six intraabdominal testes were all situated within 1 cm of the internal inguinal ring. The Prentiss maneuver4 was required in 5 of 6 intraabdominal testes, 6 of 9 located at the internal inguinal ring and 1 of the 2 that were in the inguinal canal. All 17 testes are in good position and viable on follow-up examination at 6 months or longer. Laparoscopy was not of value in these patients. For 3 intraabdominal testes, in 2 patients, the first stage of a Fowler-Stephens orchiopexy was carried out through the laparoscope.5 This decision was not made because of a high intraabdominal location but because of the presence of adhesions around the testicle in a unilateral case and the possibility of better salvage in a patient with bilateral intraabdominal testes. Second-stage orchiopexy was carried out 6 months later through an inguinal incision. All 3 testes are in the scrotum and viable on follow-up examination 6 months after the second stage. Journal of Pediatric Surgery, Vol 38, No 10 (October), 2003: pp 1534-1536
LAPAROSCOPY FOR NONPALPABLE TESTES
1535
Table 1. Operative Findings Testes
Abdomen (n ⫽ 13) Internal ring (n ⫽ 9) Inguinal (n ⫽ 11) Scrotum (n ⫽ 2)
Nubbins
Total
Right
Left
Total
Right
Left
9 9 2 0
3 6 0 0
6 3 2 0
4 0 9 2
1 0 4 0
3 0 5 2
NOTE. Total patients, 37; total testes, 40, right, 15, left, 19, bilateral, 6 (3 patients); testes palpable under anesthesia, 5, right, 4, left side of bilateral, 1; nonpalpable testes and nubbins in study, 35, right 12, left, 19, bilateral, 4 (2 patients).
Of the remaining 15 nonpalpable testicles, 4 had a blind-ending vas deferens and vessels located intraabdominally but close to the deep inguinal ring. These 4 would have been subjected to retroperitoneal dissection had they been approached through an inguinal incision. A fifth patient had a tiny nubbin in the inguinal area, which was not recognizable as an atrophic testis. He also would have had a retroperitoneal dissection if preliminary laparoscopy had not shown the vas deferens and vessels exiting the internal ring. An easily recognized nubbin of atretic testis with its vas deferens and vessels was found in the groin of 8 patients and in the scrotum of 2. Thus, in this group, 10 of 15 patients were not benefited by laparoscopy. In all, laparoscopy was of definite value in 14% (5 of 35), whereas it clearly was of no value in 77% (27 of 35) of nonpalpable testes. We are not in a position to say whether survival of the 3 testes treated with a 2-stage Fowler-Stephens orchiopexy was benefited by laparoscopy. There were no complications related to the inguinal and scrotal incisions; however, laparoscopy by the closed technique resulted in a trocar-related injury to the iliac vein in 1 patient. In 2 patients, drainage from the umbilical wound required local cleansing and dressing changes for a week. All patients except the 1 with iliac vein injury were treated as outpatients. Twenty-seven of our patients were too young to give us objective data regarding pain and discomfort. However, parents indicated no obvious difference in the need for analgesics or return to normal activity between patients who were subjected to laparoscopy alone as compared with those that had nubbins removed through an inguinal incision. DISCUSSION
Diagnostic laparoscopy was advocated initially because of concern that a high intraabdominal testicle could be missed by retroperitoneal dissection from an inguinal approach.1 In our experience, the 22 intraabdominal testicles or atrophic nubbins were all within 1
cm of the internal inguinal ring. This is in accordance with the studies of Huff et al6 who showed that intraabdominal testicular descent does not occur in the human fetus and the tail of the epididymis and the testis are in close proximity to the internal inguinal ring by the 28th postovulatory day. Interestingly, in one prospective study evaluating the sensitivity of diagnostic laparoscopy for nonpalpable testes, surgical exploration showed intraabdominal testes in 2 of 3 patients who, on laparoscopy, were believed to have absence of the testis. Furthermore, in this series, no missed intraabdominal testis was found on laparoscopy of 4 patients who presented after prior inguinal exploration had not shown a testis.7 When atretic cord structures are seen exiting the internal inguinal ring, testicular atrophy is believed to be the result of a third trimester vascular accident, which leaves a calcified and fibrotic nubbin. It has been suggested that these nubbins do not have to be excised because they have no viable testicular tissue or malignant potential.8,9 One of our 10 patients with atrophic nubbins had viable testicular tissue. Although there is considerable variation in the literature, in general, 10% of testicular nubbins contain viable testicular tissue.3,9,10 Furthermore, an intratubular germ cell neoplasm has been reported in the testicular remnant of a 9-year-old boy.10 Another advantage claimed for laparoscopy is the ability to carry out a 2-stage Fowler-Stephens orchiopexy, which is believed to have better results than the original procedure.2,11,12 This possibly is true; however, the literature also indicates a higher incidence of FowlerStephens orchiopexies in patients treated laparoscopically2,7,11 when compared with series in which open orchiopexies were carried out.13,14 We believe this laparoscopic bias toward Fowler-Stephens orchiopexies may make for better results. Laparoscopy also is believed to produce less pain and discomfort,11 a better cosmetic result,3 and the ability to place the incision based on the location of the testis.7 We are unable to quantify postoperative pain and discomfort, because the majority of our patients were too young. However, no obvious difference in analgesic use or return to activity was identified between patients who had laparoscopy alone and those who had a nubbin removed through an inguinal incision. In addition, the small, inguinal skin crease incision resulted in an almost invisible scar in 6 months. Finally, we did not find preoperative localization to be of value because, even for intraabdominal testes, we used the same inguinal skin incision rather than a Pfannenstiel or midline incision. Pediatric urologic laparoscopy produces intraabdominal adhesions in 10% of cases,15 and adds expense, time,16 and the risk of injury to intraabdominal organs12
1536
ALAM AND RADHAKRISHNAN
and vascular structures. We had a serious vascular injury when the laparoscopist chose to use the closed technique. All subsequent laparoscopies were carried out by the open technique through the inferior umbilical crease. The 2 superficial umbilical infections could possibly be ignored, because they healed with local wound cleansing and dressing changes within a week, without need for local or systemic antibiotics and no cosmetic or functional deformity resulted. In our opinion, they were problems because both these patients could have been treated adequately without laparoscopy. Two incidental issues are worth discussing. First, whereas undescended testes are more common on the right side, review of the literature shows great variability in laterality of salvageable nonpalpable testes and nubbin remnants with a slight preponderance of left-sided lesions.2,3,5,7,8,14,17 We found 2 left-sided nubbin remnants for every 1 on the right and a slight preponderance of salvageable testes on the left. Secondly, examination under anesthesia is considered essential before operation for nonpalpable testes because 20% become palpable under anesthesia.17 We believe that our considerably
lower incidence of 12.5% is a reflection of the exhaustive efforts we make in the clinic to locate the testis. Based on our findings, we no longer carry out preliminary laparoscopy in all patients with nonpalpable testes because we do not believe that its limited benefit overcomes the risk or the added expense. Patients with unilateral nonpalpable testes are first explored through an inguinal incision. A laparoscope is available in case the testis or nubbin remnant is not identified in the groin or close to the deep inguinal ring on entering the peritoneum. The laparoscope could then be passed through the hernia sac.18 In the first 6 months after closure of this study, we operated on 2 patients with unilateral nonpalpable testes. In both instances, nubbin remnants were easily identified in the inguinal area, and laparoscopy was avoided. For patients with bilateral nonpalpable testes laparoscopy could be of value in decision making and in carrying out a 2-stage Fowler-Stephens orchiopexy. Laparoscopy also is of value for patients who present after a previous inguinal exploration in which a testicle or remnant was not identified.
REFERENCES 1. Cortesi N, Ferrari P, Zambarda E, et al: Diagnosis of bilateral abdominal cryptorchidism by laparoscopy. Endoscopy 8:33-34, 1976 2. Lindgren BW, Darby EC, Faiella L, et al: Laparoscopic orchiopexy: Procedure of choice for the nonpalpable testis? J Urol 159:21322135, 1998 3. Van Savage JG: Avoidance of inguinal incision in laparoscopically confirmed vanishing testes syndrome. J Urol 166:1421-1424, 2001 4. Prentiss RJ, Weickgenant CJ, Moses JJ, et al: Undescended testes: Surgical anatomy of spermatic vessels, spermatic surgical triangle and lateral spermatic ligament. J Urol 83:686-691, 1960 5. Bloom DA: Two-step orchiopexy with pelviscopic clip ligation of the spermatic vessels. J Urol 145:1030-1033, 1991 6. Huff DS, Lockett E, Discher W, et al: Computer assisted threedimensional reconstruction in the study of epididymal-testicular descent. J Urol 159:78, 1998 (Suppl; abstr 295) 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. Godbole PP, Morecraft JA, Mackinnon AE: Laparoscopy for the impalpable testis. Br J Surg 84:1430-1432, 1997 9. Papparella A, Zamparelli M, Cobellis G, et al: Laparoscopy for nonpalpable testis: Is inguinal exploration always necessary when the
cord structures exit the inguinal ring? Pediatr Endosurg & Innovative Techniques 3:29-33, 1999 10. Rozanski TA, Wojno KJ, Bloom DA: The remnant orchiectomy. J Urol 155:712-714, 1996 11. Jordan GH, Winslow BH: Laparoscopic single stage and staged orchiopexy. J Urol 152:1249-1252, 1994 12. Caldamone AA, Amaral JF: Laparoscopic stage 2 FowlerStephens orchiopexy. J Urol 152:1253-1256, 1994 13. Koota DH, Rushton HG, Belman AB: Management of the intraabdominal testis: The open approach revisited. J Urol 157 part 2:90, 1997 (abstr 348) 14. Kirsch AJ, Escala J, Duckett JW, et al: Surgical management of the nonpalpable testis: The Children’s Hospital of Philadelphia experience. J Urol 159:1340-1343, 1998 15. Moore RG, Kavoussi L, Bloom D, et al: Postoperative adhesion formation after urological laparoscopy in the pediatric population. J Urol 153:792-795, 1995 16. Ferro F, Spagnoli A, Zaccara A, et al: Is preoperative laparoscopy useful for impalpable testis? J Urol 162:995-996, 1999 17. Carr M: The nonpalpable testes. AUA Update Series 20:226233, 2001 18. Wulkan ML, Weiner ES, VanBalen N, et al: Laparoscopy through the open ipsilateral sac to evaluate presence of contralateral hernia. J Pediatr Surg 31:1174-1177, 1996
Purpose: Laparoscopy is now considered integral to the management of nonpalpable testes, although its benefits are not clearly documented. The authors prospectively determined the value of laparoscopy in patients with nonpalpable testes.
with orchiopexy for 17 testes (6 intraabdominal and 9 at the deep ring) and removal of 10 atrophic nubbins. It was only useful in avoiding retroperitoneal dissection for 5 (14%) vanishing testes, and it may have been of benefit for 3 testes treated with a 2-stage Fowler-Stephens orchiopexy.
Methods: Between December 1997 and October 2001, 37 patients with 40 nonpalpable testes were scheduled for laparoscopy followed by definitive treatment. Laparoscopy was cancelled in 4 patients (5 testes) because their testes became palpable under anesthesia. In the remaining 33 patients (35 testes), it was determined at the time of surgery whether, as a consequence of laparoscopy: (1) retroperitoneal exploration was avoided (2) definitive treatment was facilitated.
Conclusions: The majority of our patients with nonpalpable testes could have been treated through an inguinal incision with laparoscopy being reserved for situations in which the testis was not identified on inguinal exploration. J Pediatr Surg 38:1534-1536. © 2003 Elsevier Inc. All rights reserved.
Results: Laparoscopy did not alter the management of 27 testes (77%) that were treated through an inguinal incision
INDEX WORDS: Testes, undescended, nonpalpable, laparoscopy.
D
Institutional Review Board approval was not required because there was no deviation from the current standard of care for nonpalpable testes. Furthermore, the patients in this purely observational study were referred to one of the authors for management of nonpalpable testes.
IAGNOSTIC LAPAROSCOPY for nonpalpable testes was first carried out in 1976 by Cortesi et al.1 Since then, it has gained such great acceptance that some investigators consider laparoscopic orchiopexy to be the treatment of choice for all nonpalpable testes.2,3 Our initial enthusiasm for laparoscopy was tempered over time by an impression that it did not alter the diagnosis or treatment of these patients materially. We carried out this prospective study to try to identify its role. MATERIALS AND METHODS From December 1997 through October 2001, all phenotypically normal boys in whom the testis was not palpable on examination in the clinic were included in the study. Patients with prune belly syndrome, abdominal wall defects, ambiguous genitalia, and those who had a prior inguinal exploration were excluded. We identified 40 nonpalpable testes in 37 patients ranging in age from 1 to 15 years. Of the 40 nonpalpable testes, 19 were on the left, 15 on the right, and 3 were bilateral. Our protocol consisted of examination under anesthesia followed by laparoscopy and definitive treatment. Examination and definitive treatment in all patients was carried out by one of the authors; however, in an effort to reduce observer bias, other experienced laparoscopists performed laparoscopy.
From the Departments of Surgery and Urology, University of Illinois, Chicago, IL. Address reprint requests to Jayant Radhakrishnan, MD, Clinical Professor of Surgery and Urology, University of Illinois, Chicago, 1502 71st St, Darien, IL 60561. © 2003 Elsevier Inc. All rights reserved. 0022-3468/03/3810-0020$30.00/0 doi:10.1016/S0022-3468(03)00509-8 1534
RESULTS
Five testes that became palpable under anesthesia consisted of the left testis from a bilateral case and 4 right-sided testes. Laparoscopy was carried out for the remaining 35 nonpalpable testes in 33 patients (Table 1). Orchiopexy was carried out through an inguinal approach in 17 patients. Two testes were found in the inguinal canal, and 9 were at the internal inguinal ring. Six intraabdominal testes were all situated within 1 cm of the internal inguinal ring. The Prentiss maneuver4 was required in 5 of 6 intraabdominal testes, 6 of 9 located at the internal inguinal ring and 1 of the 2 that were in the inguinal canal. All 17 testes are in good position and viable on follow-up examination at 6 months or longer. Laparoscopy was not of value in these patients. For 3 intraabdominal testes, in 2 patients, the first stage of a Fowler-Stephens orchiopexy was carried out through the laparoscope.5 This decision was not made because of a high intraabdominal location but because of the presence of adhesions around the testicle in a unilateral case and the possibility of better salvage in a patient with bilateral intraabdominal testes. Second-stage orchiopexy was carried out 6 months later through an inguinal incision. All 3 testes are in the scrotum and viable on follow-up examination 6 months after the second stage. Journal of Pediatric Surgery, Vol 38, No 10 (October), 2003: pp 1534-1536
LAPAROSCOPY FOR NONPALPABLE TESTES
1535
Table 1. Operative Findings Testes
Abdomen (n ⫽ 13) Internal ring (n ⫽ 9) Inguinal (n ⫽ 11) Scrotum (n ⫽ 2)
Nubbins
Total
Right
Left
Total
Right
Left
9 9 2 0
3 6 0 0
6 3 2 0
4 0 9 2
1 0 4 0
3 0 5 2
NOTE. Total patients, 37; total testes, 40, right, 15, left, 19, bilateral, 6 (3 patients); testes palpable under anesthesia, 5, right, 4, left side of bilateral, 1; nonpalpable testes and nubbins in study, 35, right 12, left, 19, bilateral, 4 (2 patients).
Of the remaining 15 nonpalpable testicles, 4 had a blind-ending vas deferens and vessels located intraabdominally but close to the deep inguinal ring. These 4 would have been subjected to retroperitoneal dissection had they been approached through an inguinal incision. A fifth patient had a tiny nubbin in the inguinal area, which was not recognizable as an atrophic testis. He also would have had a retroperitoneal dissection if preliminary laparoscopy had not shown the vas deferens and vessels exiting the internal ring. An easily recognized nubbin of atretic testis with its vas deferens and vessels was found in the groin of 8 patients and in the scrotum of 2. Thus, in this group, 10 of 15 patients were not benefited by laparoscopy. In all, laparoscopy was of definite value in 14% (5 of 35), whereas it clearly was of no value in 77% (27 of 35) of nonpalpable testes. We are not in a position to say whether survival of the 3 testes treated with a 2-stage Fowler-Stephens orchiopexy was benefited by laparoscopy. There were no complications related to the inguinal and scrotal incisions; however, laparoscopy by the closed technique resulted in a trocar-related injury to the iliac vein in 1 patient. In 2 patients, drainage from the umbilical wound required local cleansing and dressing changes for a week. All patients except the 1 with iliac vein injury were treated as outpatients. Twenty-seven of our patients were too young to give us objective data regarding pain and discomfort. However, parents indicated no obvious difference in the need for analgesics or return to normal activity between patients who were subjected to laparoscopy alone as compared with those that had nubbins removed through an inguinal incision. DISCUSSION
Diagnostic laparoscopy was advocated initially because of concern that a high intraabdominal testicle could be missed by retroperitoneal dissection from an inguinal approach.1 In our experience, the 22 intraabdominal testicles or atrophic nubbins were all within 1
cm of the internal inguinal ring. This is in accordance with the studies of Huff et al6 who showed that intraabdominal testicular descent does not occur in the human fetus and the tail of the epididymis and the testis are in close proximity to the internal inguinal ring by the 28th postovulatory day. Interestingly, in one prospective study evaluating the sensitivity of diagnostic laparoscopy for nonpalpable testes, surgical exploration showed intraabdominal testes in 2 of 3 patients who, on laparoscopy, were believed to have absence of the testis. Furthermore, in this series, no missed intraabdominal testis was found on laparoscopy of 4 patients who presented after prior inguinal exploration had not shown a testis.7 When atretic cord structures are seen exiting the internal inguinal ring, testicular atrophy is believed to be the result of a third trimester vascular accident, which leaves a calcified and fibrotic nubbin. It has been suggested that these nubbins do not have to be excised because they have no viable testicular tissue or malignant potential.8,9 One of our 10 patients with atrophic nubbins had viable testicular tissue. Although there is considerable variation in the literature, in general, 10% of testicular nubbins contain viable testicular tissue.3,9,10 Furthermore, an intratubular germ cell neoplasm has been reported in the testicular remnant of a 9-year-old boy.10 Another advantage claimed for laparoscopy is the ability to carry out a 2-stage Fowler-Stephens orchiopexy, which is believed to have better results than the original procedure.2,11,12 This possibly is true; however, the literature also indicates a higher incidence of FowlerStephens orchiopexies in patients treated laparoscopically2,7,11 when compared with series in which open orchiopexies were carried out.13,14 We believe this laparoscopic bias toward Fowler-Stephens orchiopexies may make for better results. Laparoscopy also is believed to produce less pain and discomfort,11 a better cosmetic result,3 and the ability to place the incision based on the location of the testis.7 We are unable to quantify postoperative pain and discomfort, because the majority of our patients were too young. However, no obvious difference in analgesic use or return to activity was identified between patients who had laparoscopy alone and those who had a nubbin removed through an inguinal incision. In addition, the small, inguinal skin crease incision resulted in an almost invisible scar in 6 months. Finally, we did not find preoperative localization to be of value because, even for intraabdominal testes, we used the same inguinal skin incision rather than a Pfannenstiel or midline incision. Pediatric urologic laparoscopy produces intraabdominal adhesions in 10% of cases,15 and adds expense, time,16 and the risk of injury to intraabdominal organs12
1536
ALAM AND RADHAKRISHNAN
and vascular structures. We had a serious vascular injury when the laparoscopist chose to use the closed technique. All subsequent laparoscopies were carried out by the open technique through the inferior umbilical crease. The 2 superficial umbilical infections could possibly be ignored, because they healed with local wound cleansing and dressing changes within a week, without need for local or systemic antibiotics and no cosmetic or functional deformity resulted. In our opinion, they were problems because both these patients could have been treated adequately without laparoscopy. Two incidental issues are worth discussing. First, whereas undescended testes are more common on the right side, review of the literature shows great variability in laterality of salvageable nonpalpable testes and nubbin remnants with a slight preponderance of left-sided lesions.2,3,5,7,8,14,17 We found 2 left-sided nubbin remnants for every 1 on the right and a slight preponderance of salvageable testes on the left. Secondly, examination under anesthesia is considered essential before operation for nonpalpable testes because 20% become palpable under anesthesia.17 We believe that our considerably
lower incidence of 12.5% is a reflection of the exhaustive efforts we make in the clinic to locate the testis. Based on our findings, we no longer carry out preliminary laparoscopy in all patients with nonpalpable testes because we do not believe that its limited benefit overcomes the risk or the added expense. Patients with unilateral nonpalpable testes are first explored through an inguinal incision. A laparoscope is available in case the testis or nubbin remnant is not identified in the groin or close to the deep inguinal ring on entering the peritoneum. The laparoscope could then be passed through the hernia sac.18 In the first 6 months after closure of this study, we operated on 2 patients with unilateral nonpalpable testes. In both instances, nubbin remnants were easily identified in the inguinal area, and laparoscopy was avoided. For patients with bilateral nonpalpable testes laparoscopy could be of value in decision making and in carrying out a 2-stage Fowler-Stephens orchiopexy. Laparoscopy also is of value for patients who present after a previous inguinal exploration in which a testicle or remnant was not identified.
REFERENCES 1. Cortesi N, Ferrari P, Zambarda E, et al: Diagnosis of bilateral abdominal cryptorchidism by laparoscopy. Endoscopy 8:33-34, 1976 2. Lindgren BW, Darby EC, Faiella L, et al: Laparoscopic orchiopexy: Procedure of choice for the nonpalpable testis? J Urol 159:21322135, 1998 3. Van Savage JG: Avoidance of inguinal incision in laparoscopically confirmed vanishing testes syndrome. J Urol 166:1421-1424, 2001 4. Prentiss RJ, Weickgenant CJ, Moses JJ, et al: Undescended testes: Surgical anatomy of spermatic vessels, spermatic surgical triangle and lateral spermatic ligament. J Urol 83:686-691, 1960 5. Bloom DA: Two-step orchiopexy with pelviscopic clip ligation of the spermatic vessels. J Urol 145:1030-1033, 1991 6. Huff DS, Lockett E, Discher W, et al: Computer assisted threedimensional reconstruction in the study of epididymal-testicular descent. J Urol 159:78, 1998 (Suppl; abstr 295) 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. Godbole PP, Morecraft JA, Mackinnon AE: Laparoscopy for the impalpable testis. Br J Surg 84:1430-1432, 1997 9. Papparella A, Zamparelli M, Cobellis G, et al: Laparoscopy for nonpalpable testis: Is inguinal exploration always necessary when the
cord structures exit the inguinal ring? Pediatr Endosurg & Innovative Techniques 3:29-33, 1999 10. Rozanski TA, Wojno KJ, Bloom DA: The remnant orchiectomy. J Urol 155:712-714, 1996 11. Jordan GH, Winslow BH: Laparoscopic single stage and staged orchiopexy. J Urol 152:1249-1252, 1994 12. Caldamone AA, Amaral JF: Laparoscopic stage 2 FowlerStephens orchiopexy. J Urol 152:1253-1256, 1994 13. Koota DH, Rushton HG, Belman AB: Management of the intraabdominal testis: The open approach revisited. J Urol 157 part 2:90, 1997 (abstr 348) 14. Kirsch AJ, Escala J, Duckett JW, et al: Surgical management of the nonpalpable testis: The Children’s Hospital of Philadelphia experience. J Urol 159:1340-1343, 1998 15. Moore RG, Kavoussi L, Bloom D, et al: Postoperative adhesion formation after urological laparoscopy in the pediatric population. J Urol 153:792-795, 1995 16. Ferro F, Spagnoli A, Zaccara A, et al: Is preoperative laparoscopy useful for impalpable testis? J Urol 162:995-996, 1999 17. Carr M: The nonpalpable testes. AUA Update Series 20:226233, 2001 18. Wulkan ML, Weiner ES, VanBalen N, et al: Laparoscopy through the open ipsilateral sac to evaluate presence of contralateral hernia. J Pediatr Surg 31:1174-1177, 1996