Survey: Localization and operation for nonpalpable testes

SURVEY: LOCALIZATION

AND OPERATION

FOR NONPALPABLE TESTES FRANK HINMAN, JR., M.D. From the Department of Urology, University of California School of Medicine, San Francisco, California

Testes that lie above the internal inguinal ring pose a special problem for the surgeon, both for their localization (or demonstration of absente) and for their management.1,2 Such a testis may be absent or smal1 and dysgenetic, and often is associated with abnormal adnexae. Current practice in the management of intraabdominal testes was assessed from published reports and from a questionnaire sent to a representative sample of pediatrie urologists in which their opinion was requested for management of a two-year-old boy with a nonpalpable testis. Localization

of Nonpalpable

Testis

Localization procedures allow selection of the operative approach and may ascertain testicular absente. Administration of gonadotropins preliminary to attempts at localization appears advisable, for although no consensus has been reached on their use to achieve testicular descent, they can make some nonpalpable testes palpable. Even though a recent report was highly critical of luteinizing hormone-releasing hormone (LH-RH) as therapy for cryptorchidism,3 it noted that 4 of the 32 nonpalpable testes either became intermittently palpable or reached the external ring and 14 of 21 intermittently palpable testes became palpable at the external ring. Localization is usually possible by one of three methods: venography and arteriography (vascular techniques); ultrasonography, computed tomography, and magnetic resonance imaging (imaging techniques); and laparoscopy (visualization) .

Vmcular techniques Venography requires

a skillful radiologist4 and is difficult to perform in infants. Venography is particularly useful in the adult where

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orchiectomy is the objective if a testis is found.5 Arteriography is easier, 6-7 but presents a hazard to smal1 vessels. Selective venography requires catheterization of the femoral vein (an approach percutaneously through a jugular vein is occasionally necessary) and passage of a catheter into the right gonadal vein from the vena cava or into the left gonadal vein from the left renal vein.8 The fact that the left vein is more easily entered than the right is fortunate,e since a testis is more commonly absent on the left, making that side the more important one diagnostically. Attempts to catheterize the vein are not uniformly successful. Greenberg and coworker9 failed for technical reasons in 5 of 10 cases, and Weiss, Glickman, and Lytton’O were unable to find the vein twice in 32 cases. Demonstration of the pampiniform plexus is necessary to confirm that a testis is present. Amin and Wheeler” located a plexus in each iliac fossa in 1 patient; Diamond et aLQsuccessfully located 14 testes of 21 (4 retroperitoneally, 4 in the canal, 2 in the superficial pouch) and 4 testes were absent; Pommerville and coworkersI had 4 failures among 11 testes; and the technique has been used in one or more cases by others. 13-15 Although a testis cannot be present without a pampiniform plexus and absente of the plexus or the vein usually indicates testicular absente, the presence of the plexus does not always mean that a testis is present. Venographic studies by Greenberg and coworkers16 in 2 men with 3 impalpable testes indicated that each had a pampiniform plexus, but at operation only a rete testis and epididymis but no gonadal tissue were found. If the vein ends blindly without a plexus, no testis wil1 be found on exploration.10 The termination is usually at the internal inguinal ring, since the spermatic vein also drains the

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epididymis4 In 17 cases of blind-ending vein, 16 had no testis.” If no vein is found, the testis is probably absent, but technical failure must be considered. Among 21 patients reported by Clickman, Weiss, and Itzchakl* the internal spermatic vein was present in 15 and absent in 6 (subsequently shown to have testicular agenesis), but in 2 cases the procedure failed technically. Later, in 10 similar cases without a demonstrable vein, a testis was found at exploration in 2.1° ArteriographylQ can be done in young boys (e.g., Domellof and coworkersa studied 2 boys at age 3). It is claimed to be better than venography, especially because of the absente of false negative results, 7,2obut it carries risks and is not widely used at present. Imaging techniques Ultrasonography is simple and noninvasive and can usually locate the testis in the canal or at the internal ring. 21 Confirmation can be obtained if pressure from the transducer moves the testis around, but one must be careful not to force it intra-abdominally out of range.22 Results from ultrasonography have varied. Weiss, Carter, and Rosenfieldz3 located 21 of 41 nonpalpable testes, but had 2 false positive results. They concluded that ultrasound cannot stand alone as a method for localization. Kullendorff, Hederstrom, and Forsberg located 47 of 55 testes; among 12 nonpalpable testes, 4 were localized, 3 were absent, and no findings were obtained in 5 instances (of which 4 testes were aplastic and 1 was smal1 and intra-abdominal) , Madrazo and coworkers25 localized 8 of 9 in the canal, but were unable to visualize those lying higher. Other reports20~2a~27 are similar, except for that of Pak and coworkers,28 who located a testicular tumor intra-abdominally. Computed tomography is somewhat more efficient than ultrasonography, Rajfer and coworkers2e localized 8 testes at the internal ring in 5 patients, 3 testes at the external ring in 2 patients, and failed to locate a testis in only 2 cases. Wolverson and coworkers30 confirmed the site of 12 of 15 testes, but al1 were within or just outside the canal. Lee3r did locate 3 testes in the lower abdomen and another 5 in the canal. Magnetic resonance imaging (MRI) has the advantage of not involving radiation and may prove capable of evaluating the quality of the testis. One report32 is available concerning 12 undescended testes: one was intra-abdominal;

194

one was absent; and the rest were anterior to the internal inguinal ring. The spermatic cord structures were well-displayed, and the quality of the testis could be evaluated. Three atrophic testes were detected, including the abdominal one, not only by smaller size but also by lower signal intensity. These more easily performed noninvasive imaging techniques may be used to detect nonpalpable testes lying high in the canal but are not as useful for the more difficult problem of the intra-abdominal testis. Visualixation technique Laparoscopy is useful

clinically since it directly confirms the presence and condition of the intra-abdominal testis. Cortese and coworkers33 first reported its use in 1976 in an eighteen-year-old man and included a convincing color photograph in the publication. Since that time laparoscopy has been done in patients of al1 ages.34 A helpful technique is to milk the testis back into the abdomen if it lies in the canal.35 Waiting until the child is three years of age is advised3e although Manson and coworkers3’ had 7 patients less than two years of age. Scott38 in a report on 14 nonpalpable testes located 46 per cent in the abdomen and 8 per cent in the canal; 37 per cent were absent and only 1 was missed (an intra-abdominal testis). Of 45 testes, Malone and Guiney3e found that 60 per cent were intra-abdominal, 15.5 per cent were in the canal, and 24.5 per cent were absent. Manson and coworkers3’ located 16 of 17 nonpalpable testes. Boddy, Corkery, and Gornal13Qby laparoscopy found that 29 of 55 impalpable testes were absent and 18 were intraabdominal. In only 3 boys was an operation needed to locate the testis. Finally, Weiss, Carter, and Rosenfield23 localized 3 of 4 high testes, and Weiss and Seashore35 recently found that among 33 testes, 21 were absent and 7 lay at or beyond the internal ring; only 5 were high abdominal in position. They also noted that, if a hernia is present, the testis wil1 be found in the canal or at the internal ring; it is never intraabdominal. Thus, laparoscopy for intra-abdominal testes allows planning for long-loop orchiopexy or for orchiectomy-or for no intervention when the testis is absent. It is highly reliable, with no false positive and few false negative results (Table 1). It can be done preliminary to orchiopexy under the same anesthesia. Visualization of the gonadal vessels is crucial, since a

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Localization by laparoscopy

TABLE 1.

Per Cent

Cases Abd. Canal Absent Missed

Author

37

7

15.5

24.5

0

32

15

53

5

15

21

63.5

14

46

8

45

60

55 et aPg Weiss and Seashore35 33

scott= Malone and Guiney3e Boddy

15.5

Operations

TABLE 11. Current practice for testicular

localization in the U.S. (respondents: N = 32)

Procedure

1st

Computer tomography Ultrasonography Laparoscopy Venography Arteriography Peritoneoscopy Operation, with or without laparoscopy

1 5 10 2 . . 1 13

Choic2nd 3rd

Reject

.. ..

2 1 1 2 . . . .

6 4 . . 1 4

3

. .

. .

5 1 3 . I

. .

testis is never found separate from their termination. Interestingly, when the testis is absent, not only is there no hernia, but also the vessels either end blindly at the external ring or exit at that sitesg Conclusions

Ultrasound or MRI may be used first for localization since they are noninvasive and avoid radiation. Ultrasound wil1 not detect intra-abdominal testes. Venography may be helpful in some cases but laparoscopy, done at the time of operation, gives the most useful information. Survey Results: Localization (Table 11) The use of computer tomography was limited among the respondents. It was believed by some to be unreliable, insufficiently specific, and unsuitable in infants because of radiation exposure and poor visualization from lack of fat. Opinions on ultrasonography were more favorable, apparently because of its innocuousness. However, it was not generally considered accurate for intra-abdominal testes (“no better than a good physical examination”). Laparoscopy is obviously increasing in favor as ski11and experience are gained. Many of the

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respondents perform it as a preliminary procedure to exploration so that the operation can be omitted or limited if the vessels enter the canal and it can be better planned if the testis is seen high in the abdomen. A contrary view is that, since one is going to explore anyway, laparoscopy is unnecessary. Venography is not in favor in infants, and arteriography is condemned. Exploration was most frequently advocated for localization, with or without preliminary laparoscopy.

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for Nonpalpable

Testis

About one fifth of nonpalpable testes are absent, but of those present, two-thirds lie behind the internal inguinal ring or, more often, are intra-abdominal.40 For these high testes that cannot be placed in the scrotum by standard methods, three different techniques are available: long-loop vas orchiopexy, the FowlerStephens procedure; two-stage orchiopexy; and microscopic autotransplantation. Long-loop va.s orchiopexy

In 1903, Bevan41 reported that he divided the spermatic vessels in 10 per cent of his cases, stating that this was “radical but perfectly safe.” Moschowitz42 first described the long-loop vas variant in cryptorchidism, but it was Fowler and Stephens in 195943 who put the anatomie relationships on a sound basis for application at surgery. Important precautions are avoiding preliminary mobilization of the sac and leaving intact the floor of the canal, the deep epigastric vessels, and the gubernacular vessels.44 Preservation of a pedicle of peritoneum,45 avoidance of dissection of the cord, and high ligation of the gonadal vessels help assure success.’ Use of optica1 magnification is mandatory, especially in infants. Preliminary ligation of the gonadal vessels as a first stage may allow the development of better (and more visible) collateral circulation.4s It may become technically possible to clip the vessels with a laparoscope. In summary, the Fowler-Stephens procedure can achieve a 70 per cent rate of success.l It works because patients suitable for the operation have a poorly developed vascular pedicle (and thus autotransplantation would be a poor choice) . It must be premeditated; once the testis has been freed, it is too late to resort to this procedure. It is a technique particularly adaptable to the intra-abdominal testes found in infants with the prune-belly syndrome.47

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Staged orchiopexy

TABLE111. Orchiectomy for nonpalpable testes

If the cord has already been dissected and found wanting or if an unsuccessful attempt at orchiopexy has been made elsewhere, a staged procedure may allow salvage of the testis. Snyder and Chaffin48 reported the first staged operations, and others have confirmed the value of the procedure. Firor4e in a large series used a two-stage procedure in 62 of 287 operations (21.5%); at the time of the report, both stages had been completed in half of these patients and testicular atrophy had occurred in only 2. Zer, Wolloch, and DintsmansO had an immediate success rate of 90 per cent in 62 cases, but this was less on two-year follow-up depending on whether position or size was evaluated (77% and 64.8%) respectively). Only 17 per cent of testes had atrophied. Kieswetter, Mammen, and Kalyglou51 were successful in 56 of 60 operations, but some patients had palpable testes preoperatively. Persky and Alberts2 had a somewhat lower success rate among the 3 per cent of operations that were staged; 9 were successful, but 4 testes had to be removed. The experience of Livne and Savirs3 led them to doubt that the vessels would elongate after an unsuccessful orchiopexy. Of 10 testes with short vessels at the first operation, 7 stil1 had short vessels with only 3 being brought into the scroturn. Al1 reporters advocate waiting about a year between stages. In 1975, Corkery54 described interring the testis in a Silastic sheath at the first stage, then completing the operation nine to twelve months later. He reported 32 completed cases with only 2 instances of atrophy. Steinhardt, Kroovand, and Perlmutter55 placed a sheath in 9 cases and omitted it in 6. Their overall success rate of 83 per cent revealed little differente between the two approaches. Whether these high testes should be approached through a midline transperitoneal incision (since the intra-abdominal testis truly lies within the peritoneal cavity),5e,57 through a midline preperitoneal incision (especially in bilateral ~ases),~~~~~ or by enlargement of the inguinal incision into a lower abdominal quadrant is not resolved. However, Jones and Bagleneo were able to perform satisfactory orchiopexy in 85 of 86 high testes after gaining adequate exposure by extending the routine incision. In summary, two-staged orchiopexy should be tried after a previously unsuccessful attempt. It is applicable to cases without adequate collat-

196

Data*

No.

Vanishing testis Orchiopexy Orchiectomy Dysplasia Gonadal dysgenesis Postpuberty Fusion failure Short vas Fowler-Stephens ischemia

10 15 (1 failure) 11 4 2 2 1 1 1

‘From Lowe, Broek and Kaplan.B8

era1 circulation for the long-loop vas procedure. For cases in which the surgeon after extensive dissection stil1 cannot place the testis in proper position, having suitable Silastic sheeting at hand may make the second stage easier and more assured of success. Microsvascular autotransplantation

Transplantation of the testis to the scrotum by arterial anastomosis to the inferior epigastric artery with dependence on collaterals for venous drainagee1pB2 is now an accepted procedure. It does require two to three extra hours of anesthesia, and has been described as a “most difficult procedure.” Many authorse3”5 have reported successes. Romas, Janecka, and Krisiloffee placed 3 of 4 testes in prune-belly patients, and Upton and coworkerse7 placed 10 bilateral nonpalpable testes in 7 patients. Wachsman, Dinner, and Handleral had one failure due to venous infarction among 7 cases. In summary, autotransplantation may be the best procedure for bilateral high cases,67 especially in older boys. For unilateral cryptorchidism in infants, the result may not be worth the effort. Exploration wil1 be the first step of any operation, to confirm the conclusions of the localization procedures and to determine which surgical technique is appropriate. In a smal1 number of cases, orchiectomy rather than orchiopexy may be advisable (Table 111). Survey Results: Operative Approaches (Table IV) A two-stage operation was generally advocated when a standard dissection failed and it was then too late for a Fowler-Stephens procedure. It was generally believed that a Silastic sheath can make the second stage easier.

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Current practice for operative approach in the U.S. (rqondents: N = 32) TABLE IV.

-Choice--1st 2nd 3rd Reiect

Operation 2-stage 2-stage with Silastic Fowler-Stephens Fowler-Stephens with preliminary ligation Autotransplantation

25 112 12 3 8 . .

4 4

12 .*

1 . .

‘3’

1:

The Fowler-Stephens operation is the most widely used procedure for those testes not amenable to standard orchiopexy. An appreciable proportion of pediatrie urologists ligate the main vessels at a preliminary stage, especially if marginal vascularity is suspected after compressing the blood supply. Clipping the vessels at laparoscopy may be a substitute for the firststage operation. Autotransplantation provides a fall-back position, although its applicability in infants has not been convincingly demonstrated and it is condemned by some. One respondent supplements the Fowler-Stephens procedure by anastomosing the divided artery to the inferior epigastric artery. An undercurrent of opinion runs that if the contralateral testis is normal and the mesentery short, or if the testis is small, taxing surgical maneuvers are not warranted and orchiectomy is the more sensible course. San Francisco,

California

94143-0738

References 1. Levitt SB, et al: The impalpable testis: a rational approach to management, J Urol 120: 515 (1978). 2. Gibbons MD, Cromie WJ, and Duckett JW Jr: Management of the abdominal undescended testicle, ibid 122: 76 (1979). 3. DeMuinck Keizer-Shrama SMPF, et al: Double-blind, placebo-controlled study of luteinizing-hormone-releasing-hormone nasal spray in treatment of undescended testes, Lancet 1: 876 (1986). 4. Weiss RM, and Glickman MG: Venography of the undescended testis, Urol Clin North Am 9: 387 (1982). 5. Greenberg SH, Ring EJ, Oleaga J, and Wein AJ: Gonadal venography for preoperative localization of nonpalpable testes in ad&, Urology 13: 453 (1979). 6. Domellof L, et al: Angiography of the testicular artery as a diagnostic aid in boys with nonpalpable testis, J Pediatr Surg 13: 534 (1978). 7. Khademi M, Seebode JJ, and Falla A: Selective spermatic arteriography for localization of an impalpable undexended testis, Radiology 136: 627 (1980). 8. Jacobs JB: Selective gonadal venography, Radiology 92: 885 (1969). 9. Diamond AB, et al: Testicular venography in nonpalpable testis, AJR 129: 71 (1977). 10. Weiss RM, Glickman MG, and Lytton B: Clinical implica-

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tions of gonadal venography in management of nonpalpable undescended testis, J Urol 121: 745 (1979). ll. Amin M, and Wheeler CS: Selective testicular venography in abdominal cryptorchidism, ibid 115: 760 (1976). 12. Pommerville P Futter NG, McKay DE, and Desmarais R: The role of gonadal venography in the management of the adult with non-palpable undescended testis, Br J Urol 54: 408 (1982). 13. Freeny PC, Cummings KB, and Simmons JR: Selective testicular venography for localization of nonpalpable testis, Urology 12: 617 (1978). 14. Paramo PG, Gallego J, Paramo PS Jr, and Uson AC: Comparative study of preoperative diagnostic methods for intraabdominal testicles. 1. Resolution of spermatic phlebography, Actas Urol Esp 9: 155 (1985). 15. Vitale PJ, Khademi M, and Seebode JJ: Selective gonadal angiography for testicular localization in patients with cryptorchidism, Surg Forum 25: 538 (1974). 16. Greenberg SH, et al: The falsely positive gonadal venogram: presence of a pampiniform plexus without a gonad, J Urol 125: 887 (1981). 17. Weiss RM, and Lytton B: Value of negative CAT scan, ultrasound and venogram in the management of the nonpalpable undescended testis, Sec Pediat Urol Newsletter, July 21, 1983. 18. Glickman MG, Weiss RM, and Itzchak Y: Testicular venography for undescended testis, AJR 129: 67 (1977). 19. Ben-Menachem Y, deBerardinis MC, and Salinas R: Localization of intraabdominal testes by selective testicular arteriography: a case report, J Urol 112: 493 (1974). 20. Nordmark L, et al: Angiography of the testicular artery. 11. Cryptorchidism and testicular agenesis, Acts Radio1 (Diagn) 18: 167 (1977). 21. Rubin SZ, Mueller DL, Amundson GM, and Wesenberg RL: Ultrasonography and the impalpable testis, Aust NZ J Surg 56: 609 (1986). 22. Wolverson MK, et al: Comparison of computed tomography with high resolution real-time ultrasound in the localization of the impalpable undescended testis, Radiology 146: 133 (1983). 23. Weiss RM, Carter AR, and Rosenfield AT: High resolution real-time ultrasonography in the localization of the undescended testis, J Urol 135: 936 (1986). 24. Kullendorff CM, Hederstrom E, and Forsberg L: Preoperative ultrasonography of the undescended testis, Stand J Urol Nephrol 13: 19 (1985). 25. Madrazo BL, Klugo RC, Pa& JA, and DiLoreto R: Ultrasonic demonstration of undescended testes, Radiology 133: 181 (1979). 26. Wasnick RJ, AliKhan S, and Bain RS: Diagnostic approach to the impalpable testis, J Urol 135: 333A (1986). 27. Bienias B, Musierowicz A, and Jakubowski W: Value of the ultrasonic diagnosis of neoplasms of an undescended testis. Case report, Pol Przegl Radio1 (Warszawa) 48: 237 (1984). 28. Pak K, et al: Computed tomography of carcinoma of the intraabdominal testis: a case report, J Urol 125: 253 (1981). 29. Rajfer J, et al: The use of computerized tomography scanning to localize the impalpable testis, ibid 129: 972 (1983). 30. Wolverson MK, et al: CT in localization of impalpable cryptorchid testes, AJR 134: 725 (1980). 31. Lee JKT, et a& Utility of ccmputed tomography in the localization of the undescended testis. Radioloev 135: 121 (1980). 32. Fritzsche PJ, et al: Undescemled testis%lue of MR imaging, Radiology (in press, 1987). 33. Cortesi N, et aE: Diagnosis of bilateral abdominal cryptorchidism by laparoscopy, Endoscopy 8: 33 (1976). 34. Silber SJ, and Cohen R: Laparoscopy for cryptorchidism, J Urol 124: 928 (1980). 35. Weiss RM, and Seashore JH: Clinical implications of laparoscopy in the management of non-palpable undescended testes, ibid 135: 332A (1986). 36. Malone PS, and Guiney EJ: A comparison between ultrasonography and laparoscopy in localizing the impalpable undescended testis, Br J Urol 57: 185 (1985). 37. Manson AL, et al: Preoperative laparoscopic localization of the nonpalpable testis, J Urol 134: 919 (1985).

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38. Scott JES: Laparoscopy as an aid in diagnosis and management of the impalpable testis, J Pediatr Surg 17: 14 (1982). 39. Boddy SM, Corkery JJ, and Gornall P: The place of laparoscopy in the management of the impalpable testis, Br J Surg 72: 918 (1985). 40. Smolko MJ, Kaplan GW, and Broek WA: Location and fate of the nonpalpable testis in children, J Urol 129: 1204 (1983). 41. Bevan AD: Operation for undescended testicle and congenital inguinal hernia, JAMA 33: 773 (1899). 42. Moschowitz AV: The anatomy and treatment of the undescended testis, Ann Surg 52: 821 (1910). 43. Fowler R Jr, and Stephens FD: The role of testicular vascular anatomy in the salvage of high undescended testes, Aust NZ J Surg 29: 92 (1959). 44. Clatworthy HW Jr, HollanVaugh RS, and Grossfeld JL: The “long loop vas” orchidopexy for the high undescended testis, Am Surg 38: 69 (1972). 45. Johnston JH: Prune belly syndrome, in Eckstein HB, Hohenfellner R, and Williams DI (Eds): Surgical Pediatrie Urology, Philadelphia, WB Saunders Co, 1977, p 244. 46. Ransley PG, et al: Preliminary ligation of the gonadal vesseis prior to orchidopexy for the intraabdominal testicle: a staged Fowler-Stephens procedure, World J Urol 2: 266 (1984). 47. Woodard JR: The prune belly syndrome. Symposium on congenital anomalies of the lower genitourinary tract, Urol Clin North Am 5: 75 (1978). 48. Snyder WH Jr, and Chaffin L: Surgical management of undescended testes; report of 363 cases, JAMA 157: 129 (1955). 49. Firor HV: Two-stage orchiopexy, Arch Surg 102: 598 (1971). 50. Zer M, Wolloch Y, and Dintsman M: Staged orchiorrhaphy. Therapeutic procedure in cryptorchid testicle with a short spermatic cord, ibid 110: 387 (1975). 51. Kiesewetter WB, Mammen K, and Kalyglou M: The rationale and results in two-stage orchidopexies, J Pediatr Surg 16: 631f (1981). 52. Persky L, and Albert DJ: Staged orchiopexy, Surg Gynecol

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Obstet 132: 43 (1971). 53. Livne PM, and Savir A: An experience with two-stage orchiopexy for undescended testis, J Urol 135: 332 (1986). 54. Corkery JJ: Staged orchiopexy-a new technique, J Pediatr Surg 10: 515 (1975). 55. Steinhardt GF, Kroovand RL, and Perlmutter AD: Orchiopexy: planned 2-stage technique, J Urol 133: 434 (1985). 56. Goldman HJ: Transperitoneal exposure in cryptorchidism, ibid 94:163 (1965). 57. Jacobson CE Jr: Midline approach to orchiopexy, ibid 95: 74 (1966). 58. Young HH: Intraabdominal operation for cryptorchidism, Tr Am Assoc Genitourin Surg 35: 115 (1942). 59. Witherington R: Cryptorchism and approaches to its surgical management, Surg Clin North Am 64: 367 (1984). 60. Jones PF, and Baglen FH: An abdominal extraperitoneal approach for the difficult orchiopexy, Br J Surg 66: 14 (1979). 61. Waclcsman J, Dinner M, and Handler M: Results of testicular autotransplantation using the microvascular technique. Experience with 8 intraabdominal testes, J Urol 128: 1319 (1982). 62. Sharlip ID: Testicular revascularization using arterial without venous anastomosis for intraperitoneal cryptorchism, Urology 24: 34 (1984). 63. Martin DC, and Salibian AH: Orchiopexy using microvascular surgical teehnique, J Urol 123: 435 (1980). 64. MacMahon RA, et al: Results of the use of autotransplantation of the intraabdominal testis using microsurgical vascular anastomosis, J Pediatr Surg 15: 92 (1980). 65. Domini R, Lima M, and Appignani A: Autotransplantation of the testicle in paediatric utilizing microsurgical technique, Z Kinderchir 40: 351 (1985). 66. Romas NA, Janecka 1, and Krisiloff M: Role of microsurgery in orchiopexy, Urology 12: 670 (1978). 67. Upton J, Schuster SR, Colodny AH, and Murray JE: Testicular autotransplantation in children, Am J Surg 145: 514 (1983). 68. Lowe DH, Broek WA, and Kaplan GW: Laparoscopy for localization of nonpalpable testes, J Urol 131: 728 (1984).

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