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Laparoscopy for the impalpable testes: Experience with 53 testes
Laparoscopy
for the Impalpable ByKurt
Testes: Experience
With 53 Testes
F. Heiss and Barry Shandling Toronto, Ontario
0 Impalpable testes constitute approximately 20% of most series of undescended testes. From January 1988 to March 1991, we performed laparoscopies on 53 patients with impalpable testes. Thirty-two of them were found to have normal vasa and vessels entering each internal ring on the side in question. Of these, 14 were found to have “vanishing testes” at exploration, 12 others underwent successful orchiopexy, and the remaining 6 had excisional biopsies of fibrotic testicular remnants. Five patients had no visible vessels and a sixth had a blind-ending vas and vessels adjacent to the internal ring; in these cases no further investigations were deemed necessary. Fifteen patients were found to have abdominal testes and underwent high testicular vessel ligation and division at the time of the laparoscopy; 14 of them have undergone staged orchiopexy 6 months after laparoscopy and one is scheduled for this procedure. A 3-month follow-up of those who had orchiopexy showed excellent results in 10 patients and poor results in 3, all of whom had small testes that were unimproved or worse following vessel ligation. Four boys were spared operations as a result of findings at laparoscopy. Early in the series there was one failed laparoscopy, but it was successfully completed later. The first patient in this series developed peritonitis following the procedure, but it was successfully treated with antibiotics. There were no other complications. Laparoscopy is a safe procedure that allows accurate diagnosis and may prevent additional intervention in the treatment of the absent testes. It facilitates the locating of the impalpable testis and the planning and timing of subsequent orchiopexy. We believe that laparoscopy is the preferred procedure in the management of impalpable testes. Copyright
o 1992 by W.B. Saunders Company
INDEX WORDS: Laparoscopy; ticle; cryptorchidism.
orchiopexy;
undescended tes-
T
General Surgery at The Hospital for Sick Children, Toronto, using laparoscopy to locate the intraabdominal testis. MATERIALS
AND METHODS
The technique of laparoscopy for evaluation of testicular location has been described in the literature.‘,‘Briefly, CO, pneumoperitoneum is induced through a Verres needle inserted through an umbilical incision. Gas flow and intraabdominal pressure are carefully monitored to avoid hypotension from the increased pressure and CO2 narcosis and acidosis from inadequate ventilation. The needle is removed, a large trocar and cannula are passed through the same incision, and a Storz laparoscope (Tuttlingen, Germany) is passed through the cannula. A systematic evaluation of the pelvis is then begun. The space between the internal ring and the colonic mesentery is carefully inspected for the presence or absence of the testicular vessels on both the normal and affected sides (Fig 1). In addition, the course of the vas is inspected from the internal ring deep into the pelvis. No further intervention is carried out in patients with blind-ending or absent vessels. When vessels are found entering the internal ring, immediate groin exploration is performed. In patients with intraabdominal testes at laparoscopy, the testicular vessels are ligated and divided under the same anesthetic, using a retroperitoneal approach. Six months later an orchiopexy is done, taking great care to avoid dividing gubernacular attachments in order to preserve collateral circulation. Our algorithm for management of the impalpable testis is presented in Fig 2. The records for all patients undergoing laparoscopy at this hospital for exploration of intraabdominal testes from 1986 to March 1991 were reviewed. Age, laterality, results of the laparoscopy, and subsequent treatment were recorded, as well as complications and unsuccessful procedures. All these patients were managed as outpatients under general anesthesia and allowed to go home the same day. Patients were seen back 3 to 4 months after the procedure to assess viability of the testis and the success of the procedure. The assessment of the testis included location, size, and the presence or absence of testicular sensation.
WENTY PERCENT of undescended testicles are considered impalpable, being located in the inguinal canal or peritoneal cavity or, in many cases, absent altogether. Several diagnostic procedures have been used to locate or confirm the presence or absence of the testes (venography, arteriography, ultrasound, computed tomography, and magnetic resonance imaging) but none has proved entirely reliable. Laparoscopy has been used for years by gynecologists for the diagnosis and treatment of pelvic disease. Recently urologists and general surgeons have found the technique increasingly useful in performing cholecystectomies, colectomies, nephrectomies, and other procedures. As a diagnostic tool, laparoscopic identification of the intraabdominal testis has become valuable in the planning of the appropriate treatment. Following is an account of the experience from 1986 to 1991 of a member (B.S.) of the Division of
From the Division of Gene& Szrrge?, The Hospital ,for Sick Children. Toronto, Ontario. Presented at the 22nd Annual Meeting of the American Pediatric Surgical Association, Lake Buena Vista, Florida, May 15-18, 1991. Address reprint requests to Bany Shandling, MB, ChB, Division of General Surgery, The Hospital for Sick Children, 555 Universiq Ave. Toronto, Ontario M5G 1X8, Canada. Copyright 0 1992 by W.B. Saunder&sCompatl> 0022-346819212702-0007$03.001/)
Vol27, No 2 (February), 1992: pp 175.179
175
JournalofPediatnc
Surgery,
RESULTS
Fifty-three patients underwent laparoscopy for impalpable testes. The results are summarized in Table 1. Mean age at laparoscopy was 4.5 years, with over 75% of the procedures done between ages 3 and 5. Nine patients (17%) had bilateral undescended testes but none of them had bilateral impalpable testes.
HEISS AND SHANDLING
Table 1. Results of Laparoscopy for Impalpable Testes Patients undergoing laparoscopy
53
Patients with normal vas and vessels enter-
32
ing ring Orchiopexy performed
12
Negative exploration
14 6
Fibrous remnant Patients with absent vessels
5
Patients with blind vessels Patient with absent testes
26 (50%)
Patients with intraabdominal testes and ves-
15 (28%)
sels ligation
Fig 1. Laparoscopicview right internal ring.
of (A) normal vas and (B) vessels entering
Twenty-nine (55%) were left-sided and 15 (28%) were right-sided. Five patients had been previously explored on the affected side before undergoing laparoscopy. Thirty-two patients noted to have a normal vas and vessels underwent immediate groin exploration under the same anesthetic. Twelve had normal testicles found in a canalicular position and underwent orchiopexy. The groin exploration was negative in another 14 patients, and 6 had a biopsy of a small fibrous remnant performed. Six patients were noted to have absent vas and vessels or blind-ending vessels, so no further procedure was carried out. Altogether, evaluation showed that 26 patients (50%) had no testicle on the impalpable side. IMPALPABLE TESTIS
Patients with follow-up completed
13
Patients with good results
10 (77%)
Fifteen patients had intraabdominal testes and underwent testicular vessel ligation and division under the same anesthetic using a retroperitoneal approach. Fourteen subsequently underwent staged orchiopexy 6 months later, and the 15th is awaiting the procedure. Thirteen patients have undergone follow-up 3 to 4 months after orchiopexy and have been assessed for location and testicular viability. Ten of them showed good results based on testicle size and 3 had poor results. Two had a small, atrophic testis at the time of the initial laparoscopy, and the other a small testicle following ligation of the vessels. The latter patient had been previously explored and may have suffered collateral vascular damage at that time. One patient left Canada after a second-stage orchiopexy and was lost to follow-up, and another has undergone endoscopy and vessel division and is awaiting his second procedure. One laparoscopy was unsuccessfully attempted because of instillation of preperitoneal air. The child experienced no ill effects and returned later for repeat general anesthesia and successful endoscopy, which showed an intraabdominal testis. The course of the first patient in this series was complicated by severe peritonitis requiring hospitalization for 7 days and intravenous antibiotics, the result of a technical problem. DISCUSSION
LAPAROSCOPY
/I----. BLIND-ENDING OR ABSENT VESSELS
NORMAL VAS AND VESSELS I
INTRAPERITONEAL TESTIS I
I
NO FURTHER EVALUATION
INGUINAL EXPLORATION I LlGATE AND DIVIDE VESSELS
STAGED ORCHIOPEXY 6 MONTHS LATER VIA INGUINALAPPROACH
Fig 2. Algorithm for management laparoscopy.
of the impalpable testis using
Approximately 4% of full-term, newborn boys have undescended testes, most of which descend during the first year of life. Fewer than 1% of the infants are left with cryptorchidism at 1 year of age, and only 10% of those will be bilateral. Testes may be impalpable in 20% of cryptorchid patients, making the location and subsequent treatment of testes a significant problem in pediatric urology and surgery.3 In an attempt to locate the testis before surgery or to confirm its absence, a variety of procedures using vascular or imaging techniques and direct visualization have been used. Arteriography and venography
LAPAROSCOPY
FOR UNDESCENDED
TESTIS
are invasive, require a separate general anesthetic, and are difficult to perform in the infant. The failure rate is significant.4-h Ultrasound and computed tomography are less invasive and more reliable for locating the canalicular testes, but have a high rate of indicating false negativity for the intraabdominal testes and cannot confirm testicular absence.7,8 Magnetic resonance imaging has been described as promising but its indications and usefulness remain to be determined.’ Identifying the vascular supply is the most reliable method of locating the testes. Laparoscopy provides direct visualization of the testicular vessels and has been reported in several series as being safe and reliable in patients as young as 2 years of age.1,10-‘3 Laparoscopy has long been used by gynecologists for the diagnosis and therapy of pelvic disease. Recently, general surgeons and urologists have also found increasing indications for its use. According to Bloom et al,’ laparoscopy was first described in 1865 as a variation on cystoscopy. The first report of laparoscopy to locate undescended testes was published in 1976,” and the first series using this technique in pediatric patients with impalpable testes was reported by Scott in 1982.l’ Subsequently, several excellent series have been published reporting its effectiveness in locating the testes and its usefulness in the planning of treatment.‘,“‘,‘7,‘“1X Surgeons have attempted to identify the impalpable testis during groin exploration and bring it down into the scrotum at that time. A fibrous remnant or blind-ending vessels would be sufficient to end the exploration. If neither a remnant nor the testis is found, the next steps are a lateral extension of the incision and a retroperitoneal or intraperitoneal exploration, if necessary, to establish the presence or absence of a gonad. Finding an abdominal testis with a vascular supply too short for successful placement in the scrotum at the time of groin exploration leaves the surgeon with few options. The testicle may be brought down as far as the vessels allow and wrapped with silastic covering to minimize adhesions to the delicate vasculature, and plans made to complete a staged orchiopexy later.” An autotransplantation of the testis may be performed, using a microvascular technique; however, this requires a major laparotomy and several hours of anesthesia time in addition to special training.“’ Should the gonad appear atretic and the child have an adequate contralateral gonad, or if the child is postpubertal, an orchiectomy may be appropriate. The work of Fowler and Stephens” describing the vascular supply of the testes prompted attempts to ligate the testicular vessels with the hope of preserving function through collateral blood flow through the vasal and gubernacular attachments. In
177
their experience, orchiopexy was performed under the same anesthetic. Ransley et al” introduced the practice of ligating the testicular vessels and waiting 6 to 12 months before doing an orchiopexy to allow the deferential artery to increase its flow. In spite of the extra time for collateral development, the atrophy rate using this technique was 30%. In contrast to the procedure used by Fowler, Stephens, and Ransley, which aims to mobilize the vas blood supply on a pedicle of peritoneum, we have identified the testis and vas by following the hernia sac to the testis and mobilizing the distal remnant of the testicular vessels. This method allows the testis and vas to be placed in the scrotum without exceptional efforts to create a flap of peritoneum. AI1 of the abdominal gonads in our series have been within 2 cm of the internal ring; thus, we have been able to bring the testis down through the inguinal canal rather than use the Prentiss maneuver to bring it down medial to the epigastric vessels. The results have been gratifying. In the 13 patients who have received follow-up assessment, 10 (77%) have shown excellent results. These data suggest that a wide peritoneal flap may not be required to produce a good result if sufficient time is allowed for collateral blood flow to occur. We have not chosen to “clip” the vessels laparoscopically but to divide them between ligatures via an extraperitoneal gridiron incision. This maneuver greatly facilitates the subsequent orchiopexy in two ways. First, one simply has to tug on the spermatic vessels in the mobilization of the testis to free up its nonvasal vascular attachments. Second, and more important, by ligating the vessels a good distance from the testis, we are able to minimize the risk of damaging collateral branches linking testicular and vasal vessels, thus ensuring an adequate testicular blood supply. Management of the patient with absent vessels, with or without a vas, is a controversial subject. Some investigators believe that when blind-ending vessels are not clearly seen, intraperitoneal exploration is required to confirm the absence of an ectopic testis.‘.’ Others feel that the absence of vessels and testes in the area between the colonic mesentery and the internal ring provides sufficient evidence of the congenital absence of the testis.” ” Indeed, Castilho” states that “. . physicians who have used similar methodology (laparoscopy followed by an operation) have not found any testis outside these limits in the search of more than 300 nonpalpable testes.” We elected not to explore the five patients in this series in whom laparoscopy showed the absence of vessels. The incidence of hemorrhage and infection in association with laparoscopy was 6% and 1.5%, respectively.‘” None of the present patients had bleed-
178
HEISS AND SHANDLING
ing complications, but the first patient in this series developed peritonitis requiring intravenous antibiotics. This complication was technique-related and has not recurred; in fact, we do not use prophylactic antibiotics. Extraperitoneal infusion of CO, is a complication associated with Verres needle placement. If it goes unnoticed, the infusion of gas can obscure landmarks and result in an unsuccessful procedure, requiring repeat anesthetic, as occurred in one of the present patients. Elder suggests the infusion of saline into the peritoneum before the instillation of CO, to avoid this problem.’ However, we suspect that the problem is corrected with experience in that it occurred once early in this series and has not recurred. Perforations of the bowel or bladder are estimated to occur in 1 to 2 cases per 1,000.24 Routine catheter drainage of the bladder and aspiration of the stomach following induction of general anesthesia are recommended to avoid such problems. We do not routinely catheterize the patients because the bladder is empty in most fasting patients. The most serious complication is cardiac arrhythmia or arrest, which occurs in 7 of 1,000 cases.25 Excessive intraabdominal pressure and inadequate ventilation, causing hypoxia and hypercarbia, may lead to decreased venous return and acidosis. We have avoided
this problem by keeping the intraabdominal pressure less than 20 mm Hg and maintaining a normal PCO, through vigilant anesthetic technique and hyperventilation. Laparoscopy should not take longer than 15 minutes. If the testicular vessels need ligation, this can easily be done in 20 to 30 minutes, the same time needed for an inguinal exploration. Thus, the entire procedure, done on a day surgery basis, requires no longer than 60 minutes. Laparoscopic locating of the intraabdominal testes allows careful planning of the procedure, minimizes anesthetic time, and does not risk significant additional morbidity. Laparoscopy is both sensitive and safe. Our staged procedure does not jeopardize collateral blood supply, little additional anesthetic time is required, and morbidity is rare. Appropriate laparoscopic findings may preclude the need for further intervention entirely. Therefore, laparoscopy is the diagnostic method of choice for locating and therapeutic planning when treating a patient with impalpable testis. ACKNOWLEDGMENT This manuscript was prepared with the assistance of Medical Publications, The Hospital for Sick Children, Toronto, Ontario.
REFERENCES 1. Bloom DA, Ayers JWT, McGuire EJ: The role of laparoscopy in management of nonpalpable testes. J Urol (Paris) 94:465-470, 1988 2. Elder JS: Laparoscopy and Fowler-Stephens orchiopexy in the management of the impalpable testis. Urol Clin North Am 16:399-411, 1989 3. Elder JS: The undescended testis: Hormonal and surgical management. Surg Clin North Am 68:983-1005,1988 4. Diamond AB, Meng C-H, Kodroff M, et al: Testicular venography in the nonpalpable testis. AJR Am J Roentgen01 129:71-75,1977 5. Green R Jr: Computerized axial tomography vs spermatic venography in localization of the cryptorchid testies. Urology 26513-517, 1985 6. Naslund MJ, Gearhart JP, Jeffs RD: Laparoscopy: Its selected use in patients with unilateral nonpalpable testis after human chorionic gonadotropin stimulation. J Ural 142:108-l 10, 1989 7. Madrazo BL, Klugo RC, Parks JA, et al: Ultrasonographic demonstration of undescended testes. Radiology 133:181-183,1979 8. Weiss RM, Carter AR, Rosenfield AT: High resolution real-time ultrasonography in the localization of the undescended testis. J Ural 135:936-938,1986 9. Landa HM, Gylys-Morin V, Mattrey RF, et al: Magnetic resonance imaging of the cryptorchid testis. Eur J Pediatr 146:S16S17,1987 (suppl2) 10. Boddy S-AM, Corkery JJ, Gornall P: The place of laparoscopy in the management of the impalpable testis. Br J Surg 72:918-919, 1985 11. Castilho LN: Laparoscopy for the nonpalpable testis: HOW to interpret the endoscopic findings. J Ural 144:1215-1218, 1990 12. Lowe DH. Brock WA, Kaplan GW: Laparoscopy for localization of nonpalpable testes. J Ural 131:728-729, 1984
13. Manson AL, Terhune D, Jordan G, et al: Preoperative laparoscopic localization of the nonpalpable testis. J Ural 134:919920,1985 14. Cortesi N, Ferrari P, Zambarda E, et al: Diagnosis of bilateral abdominal cryptorchidism by laparoscopy. Endoscopy 8:33-34,1976 15. Scott JES: Laparoscopy as an aid in the diagnosis and management of the impalpable testis. J Pediatr Surg 17:14-16,1982 16. Guiney EJ, Corbally M, Malone PS: Laparoscopy and the management of the impalpable testis. Br J Urol63:313-316, 1989 17. Weiss RM, Seashore JH: Laparoscopy in the management of the nonpalpable testis. J Ural 138:382-384, 1987 18. Silber SJ, Cohen R: Laparoscopy for ctyptorchidism. J Urol 124:928-929,198O 19. Corkery JJ: Staged orchiopexy-A new technique. J Pediatr Surg 10:515-5181975 20. Upton J, Schuster SR, Colodny AH, et al: Testicular autotransplantation in children. Am J Surg 145:.514-519,1983 21. Fowler R Jr, Stephens FD: The role of testicular vascular anatomy in the salvage of high undescended testes. Aust N Z J Surg 29:92-106, 1959 22. Ransley PG, Vordermark JS, Caldamone AA, et al: Preliminary ligation of the gonadal vessels prior to orchiopexy for the intra-abdominal testicle. World J Urol2:266-268, 1984 23. Levinson CJ: Complications, in Phillips JM (ed): Laparoscopy. Baltimore, MD, Williams & Wilkins, 1977 24. Ohlgisser M, Sorokin Y, Heifitz M, et al: Gynecologic laparoscopy. A review article. Obstet Gynecol Surg 40:385-396, 1985 25. Penfield AJ: Trocar and needle injuries, in Phillips JM (ed): Laparoscopy. Baltimore, MD, Williams &Wilkins, 1977. p 236
LAPAROSCOPY
FOR UNDESCENDED
TESTIS
179
Discussion XL. Gans (Los Angeles, CA): The authors of this paper have very nicely added to the reported experience in broadening the scope of pediatric laparoscopy. I have no problems with their findings or their recommendations. However, a caveat is in order and I speak from wide experience in this matter. We performed the first laparoscopies done in infants and children. This was in 1969 using prototype instruments provided by the Storz endoscopy company. We devised the technique and the method of performing this procedure in infants and children very much as it is used in most pediatric centers today. We examined the parameters, the indications, the advantages, and the safety of this method and we made our first reports preliminarily in 1971 and in more detail in 1973. This was followed by our motion pictures presented at the national meetings of the American College of Surgeons and the American Academy of Pediatrics and this film is in the library of the American College of Surgeons. We published many other papers and textbook chapters in this country and others and these activities were interspersed with invited lectures and presentations in major pediatric institutions and universities around this country and abroad and including The Hospital for Sick Children, Toronto, the origin of this paper today. Therefore, contrary to statements in this and other papers on pediatric laparoscopy that pediatric laparoscopy was started following the example of adult gynecologists and surgeons, let me set the record straight. Pediatric laparoscopy had a legitimate birth in pediatric surgery and by pediatric surgeons. Herein lies the caveat. With notable exceptions, we failed to convince many of our colleagues of the usefulness of this method and I found the reason why. Many of them would see our reports and pictures and say, “that looks like a neat thing, I’m going to try it.” Then they would pick up the instruments and embark on early trials, which frequently proceeded as fumbling, bumbling, frustrating, unsuccessful, and even dangerous events. The
instruments would be laid aside and the method discarded. I can tell you that in order to do pediatric laparoscopy for any purpose, one must make a commitment to pediatric laparoscopy. Study the details and published reports, observe the procedure actually being done, familiarize yourself with the instruments, play with them, take them apart, and put them back together again so that you can manage the glitches and the snags that sometimes occur, and go to the animal laboratory for trial runs and practice, and then embark on your cases. As the authors of this paper have indicated, the procedure can be done with ease, expediently, successfully, and safely. This method has wide usefulness, the breadth and scope of which may be only in its early stages. R.E. Sonnino (Cleveland, OH): I just have one question which you did touch on during the presentation, but run it by me again. Why do you feel that if you find an intraabdominal testis you should do a retroperitoneal exploration to divide the vessels rather than clipping and dividing them laparoscopically? The tools available today are quite good so you should be able to dissect the vessels fairly specifically. S.J. Shochat (Stanford, CA): I agree and the laser can be used to divide the vessels and avoid an open operation. K.F. Heiss (response): I appreciate the comments made by Dr Gans regarding the history of this procedure. To clarify the comment regarding the retroperitoneal division and ligature of the vessels, we fully agree that the technique and the instruments exist at this time. This is a historical series and the instruments for the ligature or clipping of the vessels and its division have been recently purchased by Dr Shandling so he in turn feels the same way that you do. The division of the vessels is very important in making the second stage procedure as easy as possible to allow the mobilization of the testicle and what’s left of the testicular vessels in order to bring the testicle down to the scrotum.
for the Impalpable ByKurt
Testes: Experience
With 53 Testes
F. Heiss and Barry Shandling Toronto, Ontario
0 Impalpable testes constitute approximately 20% of most series of undescended testes. From January 1988 to March 1991, we performed laparoscopies on 53 patients with impalpable testes. Thirty-two of them were found to have normal vasa and vessels entering each internal ring on the side in question. Of these, 14 were found to have “vanishing testes” at exploration, 12 others underwent successful orchiopexy, and the remaining 6 had excisional biopsies of fibrotic testicular remnants. Five patients had no visible vessels and a sixth had a blind-ending vas and vessels adjacent to the internal ring; in these cases no further investigations were deemed necessary. Fifteen patients were found to have abdominal testes and underwent high testicular vessel ligation and division at the time of the laparoscopy; 14 of them have undergone staged orchiopexy 6 months after laparoscopy and one is scheduled for this procedure. A 3-month follow-up of those who had orchiopexy showed excellent results in 10 patients and poor results in 3, all of whom had small testes that were unimproved or worse following vessel ligation. Four boys were spared operations as a result of findings at laparoscopy. Early in the series there was one failed laparoscopy, but it was successfully completed later. The first patient in this series developed peritonitis following the procedure, but it was successfully treated with antibiotics. There were no other complications. Laparoscopy is a safe procedure that allows accurate diagnosis and may prevent additional intervention in the treatment of the absent testes. It facilitates the locating of the impalpable testis and the planning and timing of subsequent orchiopexy. We believe that laparoscopy is the preferred procedure in the management of impalpable testes. Copyright
o 1992 by W.B. Saunders Company
INDEX WORDS: Laparoscopy; ticle; cryptorchidism.
orchiopexy;
undescended tes-
T
General Surgery at The Hospital for Sick Children, Toronto, using laparoscopy to locate the intraabdominal testis. MATERIALS
AND METHODS
The technique of laparoscopy for evaluation of testicular location has been described in the literature.‘,‘Briefly, CO, pneumoperitoneum is induced through a Verres needle inserted through an umbilical incision. Gas flow and intraabdominal pressure are carefully monitored to avoid hypotension from the increased pressure and CO2 narcosis and acidosis from inadequate ventilation. The needle is removed, a large trocar and cannula are passed through the same incision, and a Storz laparoscope (Tuttlingen, Germany) is passed through the cannula. A systematic evaluation of the pelvis is then begun. The space between the internal ring and the colonic mesentery is carefully inspected for the presence or absence of the testicular vessels on both the normal and affected sides (Fig 1). In addition, the course of the vas is inspected from the internal ring deep into the pelvis. No further intervention is carried out in patients with blind-ending or absent vessels. When vessels are found entering the internal ring, immediate groin exploration is performed. In patients with intraabdominal testes at laparoscopy, the testicular vessels are ligated and divided under the same anesthetic, using a retroperitoneal approach. Six months later an orchiopexy is done, taking great care to avoid dividing gubernacular attachments in order to preserve collateral circulation. Our algorithm for management of the impalpable testis is presented in Fig 2. The records for all patients undergoing laparoscopy at this hospital for exploration of intraabdominal testes from 1986 to March 1991 were reviewed. Age, laterality, results of the laparoscopy, and subsequent treatment were recorded, as well as complications and unsuccessful procedures. All these patients were managed as outpatients under general anesthesia and allowed to go home the same day. Patients were seen back 3 to 4 months after the procedure to assess viability of the testis and the success of the procedure. The assessment of the testis included location, size, and the presence or absence of testicular sensation.
WENTY PERCENT of undescended testicles are considered impalpable, being located in the inguinal canal or peritoneal cavity or, in many cases, absent altogether. Several diagnostic procedures have been used to locate or confirm the presence or absence of the testes (venography, arteriography, ultrasound, computed tomography, and magnetic resonance imaging) but none has proved entirely reliable. Laparoscopy has been used for years by gynecologists for the diagnosis and treatment of pelvic disease. Recently urologists and general surgeons have found the technique increasingly useful in performing cholecystectomies, colectomies, nephrectomies, and other procedures. As a diagnostic tool, laparoscopic identification of the intraabdominal testis has become valuable in the planning of the appropriate treatment. Following is an account of the experience from 1986 to 1991 of a member (B.S.) of the Division of
From the Division of Gene& Szrrge?, The Hospital ,for Sick Children. Toronto, Ontario. Presented at the 22nd Annual Meeting of the American Pediatric Surgical Association, Lake Buena Vista, Florida, May 15-18, 1991. Address reprint requests to Bany Shandling, MB, ChB, Division of General Surgery, The Hospital for Sick Children, 555 Universiq Ave. Toronto, Ontario M5G 1X8, Canada. Copyright 0 1992 by W.B. Saunder&sCompatl> 0022-346819212702-0007$03.001/)
Vol27, No 2 (February), 1992: pp 175.179
175
JournalofPediatnc
Surgery,
RESULTS
Fifty-three patients underwent laparoscopy for impalpable testes. The results are summarized in Table 1. Mean age at laparoscopy was 4.5 years, with over 75% of the procedures done between ages 3 and 5. Nine patients (17%) had bilateral undescended testes but none of them had bilateral impalpable testes.
HEISS AND SHANDLING
Table 1. Results of Laparoscopy for Impalpable Testes Patients undergoing laparoscopy
53
Patients with normal vas and vessels enter-
32
ing ring Orchiopexy performed
12
Negative exploration
14 6
Fibrous remnant Patients with absent vessels
5
Patients with blind vessels Patient with absent testes
26 (50%)
Patients with intraabdominal testes and ves-
15 (28%)
sels ligation
Fig 1. Laparoscopicview right internal ring.
of (A) normal vas and (B) vessels entering
Twenty-nine (55%) were left-sided and 15 (28%) were right-sided. Five patients had been previously explored on the affected side before undergoing laparoscopy. Thirty-two patients noted to have a normal vas and vessels underwent immediate groin exploration under the same anesthetic. Twelve had normal testicles found in a canalicular position and underwent orchiopexy. The groin exploration was negative in another 14 patients, and 6 had a biopsy of a small fibrous remnant performed. Six patients were noted to have absent vas and vessels or blind-ending vessels, so no further procedure was carried out. Altogether, evaluation showed that 26 patients (50%) had no testicle on the impalpable side. IMPALPABLE TESTIS
Patients with follow-up completed
13
Patients with good results
10 (77%)
Fifteen patients had intraabdominal testes and underwent testicular vessel ligation and division under the same anesthetic using a retroperitoneal approach. Fourteen subsequently underwent staged orchiopexy 6 months later, and the 15th is awaiting the procedure. Thirteen patients have undergone follow-up 3 to 4 months after orchiopexy and have been assessed for location and testicular viability. Ten of them showed good results based on testicle size and 3 had poor results. Two had a small, atrophic testis at the time of the initial laparoscopy, and the other a small testicle following ligation of the vessels. The latter patient had been previously explored and may have suffered collateral vascular damage at that time. One patient left Canada after a second-stage orchiopexy and was lost to follow-up, and another has undergone endoscopy and vessel division and is awaiting his second procedure. One laparoscopy was unsuccessfully attempted because of instillation of preperitoneal air. The child experienced no ill effects and returned later for repeat general anesthesia and successful endoscopy, which showed an intraabdominal testis. The course of the first patient in this series was complicated by severe peritonitis requiring hospitalization for 7 days and intravenous antibiotics, the result of a technical problem. DISCUSSION
LAPAROSCOPY
/I----. BLIND-ENDING OR ABSENT VESSELS
NORMAL VAS AND VESSELS I
INTRAPERITONEAL TESTIS I
I
NO FURTHER EVALUATION
INGUINAL EXPLORATION I LlGATE AND DIVIDE VESSELS
STAGED ORCHIOPEXY 6 MONTHS LATER VIA INGUINALAPPROACH
Fig 2. Algorithm for management laparoscopy.
of the impalpable testis using
Approximately 4% of full-term, newborn boys have undescended testes, most of which descend during the first year of life. Fewer than 1% of the infants are left with cryptorchidism at 1 year of age, and only 10% of those will be bilateral. Testes may be impalpable in 20% of cryptorchid patients, making the location and subsequent treatment of testes a significant problem in pediatric urology and surgery.3 In an attempt to locate the testis before surgery or to confirm its absence, a variety of procedures using vascular or imaging techniques and direct visualization have been used. Arteriography and venography
LAPAROSCOPY
FOR UNDESCENDED
TESTIS
are invasive, require a separate general anesthetic, and are difficult to perform in the infant. The failure rate is significant.4-h Ultrasound and computed tomography are less invasive and more reliable for locating the canalicular testes, but have a high rate of indicating false negativity for the intraabdominal testes and cannot confirm testicular absence.7,8 Magnetic resonance imaging has been described as promising but its indications and usefulness remain to be determined.’ Identifying the vascular supply is the most reliable method of locating the testes. Laparoscopy provides direct visualization of the testicular vessels and has been reported in several series as being safe and reliable in patients as young as 2 years of age.1,10-‘3 Laparoscopy has long been used by gynecologists for the diagnosis and therapy of pelvic disease. Recently, general surgeons and urologists have also found increasing indications for its use. According to Bloom et al,’ laparoscopy was first described in 1865 as a variation on cystoscopy. The first report of laparoscopy to locate undescended testes was published in 1976,” and the first series using this technique in pediatric patients with impalpable testes was reported by Scott in 1982.l’ Subsequently, several excellent series have been published reporting its effectiveness in locating the testes and its usefulness in the planning of treatment.‘,“‘,‘7,‘“1X Surgeons have attempted to identify the impalpable testis during groin exploration and bring it down into the scrotum at that time. A fibrous remnant or blind-ending vessels would be sufficient to end the exploration. If neither a remnant nor the testis is found, the next steps are a lateral extension of the incision and a retroperitoneal or intraperitoneal exploration, if necessary, to establish the presence or absence of a gonad. Finding an abdominal testis with a vascular supply too short for successful placement in the scrotum at the time of groin exploration leaves the surgeon with few options. The testicle may be brought down as far as the vessels allow and wrapped with silastic covering to minimize adhesions to the delicate vasculature, and plans made to complete a staged orchiopexy later.” An autotransplantation of the testis may be performed, using a microvascular technique; however, this requires a major laparotomy and several hours of anesthesia time in addition to special training.“’ Should the gonad appear atretic and the child have an adequate contralateral gonad, or if the child is postpubertal, an orchiectomy may be appropriate. The work of Fowler and Stephens” describing the vascular supply of the testes prompted attempts to ligate the testicular vessels with the hope of preserving function through collateral blood flow through the vasal and gubernacular attachments. In
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their experience, orchiopexy was performed under the same anesthetic. Ransley et al” introduced the practice of ligating the testicular vessels and waiting 6 to 12 months before doing an orchiopexy to allow the deferential artery to increase its flow. In spite of the extra time for collateral development, the atrophy rate using this technique was 30%. In contrast to the procedure used by Fowler, Stephens, and Ransley, which aims to mobilize the vas blood supply on a pedicle of peritoneum, we have identified the testis and vas by following the hernia sac to the testis and mobilizing the distal remnant of the testicular vessels. This method allows the testis and vas to be placed in the scrotum without exceptional efforts to create a flap of peritoneum. AI1 of the abdominal gonads in our series have been within 2 cm of the internal ring; thus, we have been able to bring the testis down through the inguinal canal rather than use the Prentiss maneuver to bring it down medial to the epigastric vessels. The results have been gratifying. In the 13 patients who have received follow-up assessment, 10 (77%) have shown excellent results. These data suggest that a wide peritoneal flap may not be required to produce a good result if sufficient time is allowed for collateral blood flow to occur. We have not chosen to “clip” the vessels laparoscopically but to divide them between ligatures via an extraperitoneal gridiron incision. This maneuver greatly facilitates the subsequent orchiopexy in two ways. First, one simply has to tug on the spermatic vessels in the mobilization of the testis to free up its nonvasal vascular attachments. Second, and more important, by ligating the vessels a good distance from the testis, we are able to minimize the risk of damaging collateral branches linking testicular and vasal vessels, thus ensuring an adequate testicular blood supply. Management of the patient with absent vessels, with or without a vas, is a controversial subject. Some investigators believe that when blind-ending vessels are not clearly seen, intraperitoneal exploration is required to confirm the absence of an ectopic testis.‘.’ Others feel that the absence of vessels and testes in the area between the colonic mesentery and the internal ring provides sufficient evidence of the congenital absence of the testis.” ” Indeed, Castilho” states that “. . physicians who have used similar methodology (laparoscopy followed by an operation) have not found any testis outside these limits in the search of more than 300 nonpalpable testes.” We elected not to explore the five patients in this series in whom laparoscopy showed the absence of vessels. The incidence of hemorrhage and infection in association with laparoscopy was 6% and 1.5%, respectively.‘” None of the present patients had bleed-
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ing complications, but the first patient in this series developed peritonitis requiring intravenous antibiotics. This complication was technique-related and has not recurred; in fact, we do not use prophylactic antibiotics. Extraperitoneal infusion of CO, is a complication associated with Verres needle placement. If it goes unnoticed, the infusion of gas can obscure landmarks and result in an unsuccessful procedure, requiring repeat anesthetic, as occurred in one of the present patients. Elder suggests the infusion of saline into the peritoneum before the instillation of CO, to avoid this problem.’ However, we suspect that the problem is corrected with experience in that it occurred once early in this series and has not recurred. Perforations of the bowel or bladder are estimated to occur in 1 to 2 cases per 1,000.24 Routine catheter drainage of the bladder and aspiration of the stomach following induction of general anesthesia are recommended to avoid such problems. We do not routinely catheterize the patients because the bladder is empty in most fasting patients. The most serious complication is cardiac arrhythmia or arrest, which occurs in 7 of 1,000 cases.25 Excessive intraabdominal pressure and inadequate ventilation, causing hypoxia and hypercarbia, may lead to decreased venous return and acidosis. We have avoided
this problem by keeping the intraabdominal pressure less than 20 mm Hg and maintaining a normal PCO, through vigilant anesthetic technique and hyperventilation. Laparoscopy should not take longer than 15 minutes. If the testicular vessels need ligation, this can easily be done in 20 to 30 minutes, the same time needed for an inguinal exploration. Thus, the entire procedure, done on a day surgery basis, requires no longer than 60 minutes. Laparoscopic locating of the intraabdominal testes allows careful planning of the procedure, minimizes anesthetic time, and does not risk significant additional morbidity. Laparoscopy is both sensitive and safe. Our staged procedure does not jeopardize collateral blood supply, little additional anesthetic time is required, and morbidity is rare. Appropriate laparoscopic findings may preclude the need for further intervention entirely. Therefore, laparoscopy is the diagnostic method of choice for locating and therapeutic planning when treating a patient with impalpable testis. ACKNOWLEDGMENT This manuscript was prepared with the assistance of Medical Publications, The Hospital for Sick Children, Toronto, Ontario.
REFERENCES 1. Bloom DA, Ayers JWT, McGuire EJ: The role of laparoscopy in management of nonpalpable testes. J Urol (Paris) 94:465-470, 1988 2. Elder JS: Laparoscopy and Fowler-Stephens orchiopexy in the management of the impalpable testis. Urol Clin North Am 16:399-411, 1989 3. Elder JS: The undescended testis: Hormonal and surgical management. Surg Clin North Am 68:983-1005,1988 4. Diamond AB, Meng C-H, Kodroff M, et al: Testicular venography in the nonpalpable testis. AJR Am J Roentgen01 129:71-75,1977 5. Green R Jr: Computerized axial tomography vs spermatic venography in localization of the cryptorchid testies. Urology 26513-517, 1985 6. Naslund MJ, Gearhart JP, Jeffs RD: Laparoscopy: Its selected use in patients with unilateral nonpalpable testis after human chorionic gonadotropin stimulation. J Ural 142:108-l 10, 1989 7. Madrazo BL, Klugo RC, Parks JA, et al: Ultrasonographic demonstration of undescended testes. Radiology 133:181-183,1979 8. Weiss RM, Carter AR, Rosenfield AT: High resolution real-time ultrasonography in the localization of the undescended testis. J Ural 135:936-938,1986 9. Landa HM, Gylys-Morin V, Mattrey RF, et al: Magnetic resonance imaging of the cryptorchid testis. Eur J Pediatr 146:S16S17,1987 (suppl2) 10. Boddy S-AM, Corkery JJ, Gornall P: The place of laparoscopy in the management of the impalpable testis. Br J Surg 72:918-919, 1985 11. Castilho LN: Laparoscopy for the nonpalpable testis: HOW to interpret the endoscopic findings. J Ural 144:1215-1218, 1990 12. Lowe DH. Brock WA, Kaplan GW: Laparoscopy for localization of nonpalpable testes. J Ural 131:728-729, 1984
13. Manson AL, Terhune D, Jordan G, et al: Preoperative laparoscopic localization of the nonpalpable testis. J Ural 134:919920,1985 14. Cortesi N, Ferrari P, Zambarda E, et al: Diagnosis of bilateral abdominal cryptorchidism by laparoscopy. Endoscopy 8:33-34,1976 15. Scott JES: Laparoscopy as an aid in the diagnosis and management of the impalpable testis. J Pediatr Surg 17:14-16,1982 16. Guiney EJ, Corbally M, Malone PS: Laparoscopy and the management of the impalpable testis. Br J Urol63:313-316, 1989 17. Weiss RM, Seashore JH: Laparoscopy in the management of the nonpalpable testis. J Ural 138:382-384, 1987 18. Silber SJ, Cohen R: Laparoscopy for ctyptorchidism. J Urol 124:928-929,198O 19. Corkery JJ: Staged orchiopexy-A new technique. J Pediatr Surg 10:515-5181975 20. Upton J, Schuster SR, Colodny AH, et al: Testicular autotransplantation in children. Am J Surg 145:.514-519,1983 21. Fowler R Jr, Stephens FD: The role of testicular vascular anatomy in the salvage of high undescended testes. Aust N Z J Surg 29:92-106, 1959 22. Ransley PG, Vordermark JS, Caldamone AA, et al: Preliminary ligation of the gonadal vessels prior to orchiopexy for the intra-abdominal testicle. World J Urol2:266-268, 1984 23. Levinson CJ: Complications, in Phillips JM (ed): Laparoscopy. Baltimore, MD, Williams & Wilkins, 1977 24. Ohlgisser M, Sorokin Y, Heifitz M, et al: Gynecologic laparoscopy. A review article. Obstet Gynecol Surg 40:385-396, 1985 25. Penfield AJ: Trocar and needle injuries, in Phillips JM (ed): Laparoscopy. Baltimore, MD, Williams &Wilkins, 1977. p 236
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Discussion XL. Gans (Los Angeles, CA): The authors of this paper have very nicely added to the reported experience in broadening the scope of pediatric laparoscopy. I have no problems with their findings or their recommendations. However, a caveat is in order and I speak from wide experience in this matter. We performed the first laparoscopies done in infants and children. This was in 1969 using prototype instruments provided by the Storz endoscopy company. We devised the technique and the method of performing this procedure in infants and children very much as it is used in most pediatric centers today. We examined the parameters, the indications, the advantages, and the safety of this method and we made our first reports preliminarily in 1971 and in more detail in 1973. This was followed by our motion pictures presented at the national meetings of the American College of Surgeons and the American Academy of Pediatrics and this film is in the library of the American College of Surgeons. We published many other papers and textbook chapters in this country and others and these activities were interspersed with invited lectures and presentations in major pediatric institutions and universities around this country and abroad and including The Hospital for Sick Children, Toronto, the origin of this paper today. Therefore, contrary to statements in this and other papers on pediatric laparoscopy that pediatric laparoscopy was started following the example of adult gynecologists and surgeons, let me set the record straight. Pediatric laparoscopy had a legitimate birth in pediatric surgery and by pediatric surgeons. Herein lies the caveat. With notable exceptions, we failed to convince many of our colleagues of the usefulness of this method and I found the reason why. Many of them would see our reports and pictures and say, “that looks like a neat thing, I’m going to try it.” Then they would pick up the instruments and embark on early trials, which frequently proceeded as fumbling, bumbling, frustrating, unsuccessful, and even dangerous events. The
instruments would be laid aside and the method discarded. I can tell you that in order to do pediatric laparoscopy for any purpose, one must make a commitment to pediatric laparoscopy. Study the details and published reports, observe the procedure actually being done, familiarize yourself with the instruments, play with them, take them apart, and put them back together again so that you can manage the glitches and the snags that sometimes occur, and go to the animal laboratory for trial runs and practice, and then embark on your cases. As the authors of this paper have indicated, the procedure can be done with ease, expediently, successfully, and safely. This method has wide usefulness, the breadth and scope of which may be only in its early stages. R.E. Sonnino (Cleveland, OH): I just have one question which you did touch on during the presentation, but run it by me again. Why do you feel that if you find an intraabdominal testis you should do a retroperitoneal exploration to divide the vessels rather than clipping and dividing them laparoscopically? The tools available today are quite good so you should be able to dissect the vessels fairly specifically. S.J. Shochat (Stanford, CA): I agree and the laser can be used to divide the vessels and avoid an open operation. K.F. Heiss (response): I appreciate the comments made by Dr Gans regarding the history of this procedure. To clarify the comment regarding the retroperitoneal division and ligature of the vessels, we fully agree that the technique and the instruments exist at this time. This is a historical series and the instruments for the ligature or clipping of the vessels and its division have been recently purchased by Dr Shandling so he in turn feels the same way that you do. The division of the vessels is very important in making the second stage procedure as easy as possible to allow the mobilization of the testicle and what’s left of the testicular vessels in order to bring the testicle down to the scrotum.