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Pediatr Surg Int (2011) 27:13271330

DOI 10.1007/s00383-011-2970-9

ORIGINAL ARTICLE

Laparoscopic management of impalpable testes: comparison


of different techniques
Rashmi R. Singh Ashok Rajimwale
Shawqui Nour

Accepted: 17 August 2011 / Published online: 1 September 2011


Springer-Verlag 2011

Abstract
Purpose Laparoscopy is an important modality for management of impalpable testes. We present long-term outcomes of intra-abdominal testes managed by either single
stage orchidopexy or two-stage Fowler Stephens orchidopexy (FSO) over 12 years.
Methods Data were prospectively collected and retrospectively analyzed on patients who underwent laparoscopy for impalpable testes between 1998 and 2010.
Demographic data, intra-operative findings, management,
histology and follow-up findings were collected and analyzed. Fishers Exact test was used for statistical analysis.
Results Laparoscopy was performed for 168 impalpable
testes (78 left, 58 right and 16 bilateral). Patients were
between 8 months and 15 years of age (median 1 year
10 months). Ninety-three testes were found to have cord
structures entering the inguinal ring (canalicular), 65 were
intra-abdominal and 10 had blind ending vas and/or vessel.
Fifty-seven (34%) testes were atrophic and underwent
orchidectomy; 100 (60%) testes underwent orchidopexy:
either two-stage FSO (48) or single stage orchidopexy (52)
and 10 (7%) had findings consistent with vanishing testes.
Histopathologically, the excised remnants (34%) showed
no viable testicular tissue. The follow-up was a median of
8 months (3 months to 6 years). Four patients were lost to
follow-up (two each after FSO and single stage orchidopexy) while, two FSO are awaiting follow-up. At followup, 36/44 testes (FSO) and 13/13 testes (single stage
orchidopexy) are in the scrotum and of good size. Eight
testes had atrophied after two-staged FSO.
R. R. Singh (&)  A. Rajimwale  S. Nour
Department of Paediatric Surgery,
Leicester Royal Infirmary, Leicester, UK
e-mail: rashmi.roshan@yahoo.co.uk

Conclusion Canalicular testes are often difficult to palpate (55%). Laparoscopy allows direct visualization and
definitive management. There is no statistically significant
difference between the results following single stage
orchidopexy or two-stage FSO for impalpable testes.
Keywords Impalpable testes  Laparoscopy 
Orchidopexy

Introduction
Cryptorchidism is one of the most common isolated congenital anomaly of the male genitalia affecting 1% of term
infants at the age of 1 year [1]. 20% of these are impalpable [2]. 35 years ago, laparoscopy was first used for the
diagnosis of impalpable testes by Cortesi et al. [3]. Since
then, laparoscopy has been increasingly used for diagnosis
and treatment of intra-abdominal testes [4, 5]. Laparoscopy
not only has the advantage of identifying the location of the
testes and assessing the need for either single or two-staged
orchidopexy, but also of magnification and precision of
dissection. We present our experience with laparoscopic
single stage orchidopexy or two-stage Fowler Stephens
orchidopexy (FSO) for intra-abdominal testes.

Patients and methods


Data for patients who underwent laparoscopy for impalpable testes at our institution, under two consultant
surgeons, between 1998 and 2010 were prospectively
collected into a database. Approval for the study was
obtained from the audit department (University Hospitals
of Leicester [NHS] Trust-audit ID 4931). We reviewed

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their case notes retrospectively. Demographic data, intraoperative findings, management, histology and post-operative follow-up were reviewed in each case. Fishers Exact
test was used for statistical analysis. Laparoscopy was
performed for 168 impalpable testes in patients aged
between 8 months and 15 years (median 1 year 10
months).
At operation, all patients with impalpable testes underwent an examination under anesthesia. Those that were
palpable under anesthesia were excluded from the study.
The remaining underwent laparoscopy, using 5 mm
umbilical camera port and two further 5 mm instrument
ports in the left and right mid-clavicular line. They were
divided into three groups depending upon the laparoscopic
findings (Fig. 1). The cord structures (vas and vessels)
were either blind ending with a closed deep inguinal ring,
entering the deep inguinal ring (canalicular) or ending onto
an intra-abdominal testis. For the blind ending cord structures, no further exploration was performed as these were
vanishing testes [6]. The canalicular testes underwent
groin exploration; and underwent either orchidectomy
(atrophic testes) or orchidopexy (small testes). The intraabdominal testes were classified as high or low in
relation to the iliac vessels and depending upon the ability
of the testes to reach the contralateral deep ring upon
mobilization [7]. All but two of the intra-abdominal testes
were either fixed to the scrotum directly or through staged
FSO [8]. The size of the testes was documented in each
case and a second stage FSO was carried out after
6 months. Two intra-abdominal testes were atrophic and

were removed. All the testes removed were sent for histopathological examination.
Patients were followed-up at 3 months, 6 months and
1 year after the procedure. They were reviewed in the
surgical outpatient clinic by a consultant or registrar. The
position and size of the testes were documented, after
clinical examination. Fisher Exact test was used to analyze
the statistical differences between the different methods of
orchidopexy.

Results
During the study, laparoscopy was performed for 168
impalpable testes (78 left, 58 right and 16 bilateral). These
were performed by a consultant surgeon or by a registrar
under consultant supervision. Patients were aged between
8 months and 15 years (median 1 year 10 months) (Fig. 2).
At laparoscopy, 93 testes were found to be inguinal, 65
intra-abdominal and 10 had blind ending vas and/or vessel
(Fig. 1).
Of the inguinal testes, 55 (33%) testes were atrophic and
had orchidectomy, 37 (22%) had inguinal orchidopexy,
while one had complete dissociation of vas and vessel from
the testis. Of the intra-abdominal testes, 63 (38%) testes
had orchidopexy, either two-stage FSO (48) or single stage
orchidopexy (15) and two testes had orchidectomy
(atrophic). Ten (7%) had only a diagnostic procedure, as
they had a vanishing testes. The intra abdominal (65)
were differentiated as high (48), low (15) or atrophic

Fig. 1 Laparoscopic
management of the impalpable
testes

Total 168

Blind
vas/vessel
10

Inguinal 93
Intra-abdominal
65

Orchidectomy 55

Orchidopexy 37

No further
exploration

Congenital
anomaly 1

Orchidectomy 2

Orchidopexy 15

Direct
orchidopexy
12

123

Two stage
FSO 48

One stage
FSO 3

Pediatr Surg Int (2011) 27:13271330

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Discussion

Fig. 2 Age distribution at laparoscopy for impalpable testes

(2). Forty-eight high intra abdominal testes were treated


with two-stage FSO while 15 had single stage orchidopexy.
Of these 15 low intra-abdominal testes, 12 had conventional orchidopexy, while three had spermatic vessels
clipped and then placed into a dartos pouch (one-staged
FSO). The operating time was a median of 45 min
(20120 min). There were no intra or post-operative
complications. The hospital stay was a median of 1 day
(0.52 days). 6% of the patients had a hospital stay of more
than one night; due to associated medical conditions most
of the others were done as a day case procedure. Histopathological analysis of the 57 excised testes (34%)
showed no viable testicular tissue. The patients were
followed-up for a median of 8 months (3 months to
6 years). Four patients were lost to follow-up (two each
after FSO and single stage orchidopexy) while, two
following FSO are awaiting clinical review. At follow-up,
36/44 (82%) testes (FSO) and 13/13 (100%) testes (single
stage orchidopexy) were within the scrotum and of good
size. Eight testes (18%) had atrophied after FSO.
Fishers Exact test (Table 1) shows that the p value
across inguinal orchidopexy, intra-abdominal single stage
orchidopexy and FSO is greater than 0.05. Therefore, there
is no significant statistical difference in the outcome among
the three methods.

Table 1 p value across the three methods of orchidopexy, using


Fishers Exact test
Normal

Atrophy

p value

Inguinal orchidopexy (I)

28

(I,FS)

Two-stage Fowler Stephens


(FS)

36

(FS,1SO)

= 0.11

Single stage orchidopexy


(1SO)

13

(1SO,IO)

= 0.34

= 0.25

Laparoscopy has been established as the gold standard for


management of impalpable testes [911]. There is limited
role for radiological investigations such as ultrasonography
for intra-abdominal testes [12]. A recent consensus among
the Nordic countries advises referral of children with
impalpable testes before the age of 6 months and orchidopexy before 1 year of age [13]. AbouZeid et al. [14]
have provided important evidence regarding germ cell
depletion being directly related to the age at orchidopexy.
Only 17 (11%) of the children in our series were operated
before the age of 1 year (Fig. 2). This is attributed to the
late referral in most of the children and associated
co-morbid medical conditions such as Noonan, Down and
Prune Belly syndrome in a few of the children. We have
initiated a programme to increase awareness about the
management of impalpable testes among the primary
health care physicians.
Our success rate with two-stage FSO is 82% (36/44),
which is comparable to that in the literature (ranging from
76 to 93%) [10, 11, 1517]. The success in older children
(i.e., more than 2 years of age) has not been encouraging
and this might have skewed our success rate to a low normal
value. We do acknowledge inter-observer variability and
bias affecting the results, as the patients were reviewed in
clinic by a registrar or consultant who might have performed the operation. The key step for the success in FSO is
to assess whether the intra-abdominal testis is high or
low. Once the testis is mobilized, if there is any doubt
about the adequacy of the length of the cord structures, we
opt for the two-stage FSO. We make sure that a wide fold of
peritoneum is mobilized with the vas, as the path of neo
vascularization follows this route. The intra-abdominal
testes, which have an adequate length of the cord, are fixed
into a sub-dartos pouch in the scrotum. Three high intraabdominal testes attained good cord length, following
division of testicular pedicle, hence underwent single stage
FSO. The success of single stage orchidopexy has been
100% (13/13). The canalicular testes were impalpable at
examination under anesthesia, which can be attributed
either to the fact that 59% (55/93) were atrophic, or difficult
to feel due to taut abdominal wall muscles. The atrophic
testes were excised in each case, due to the probability of
the presence of viable germ cells as shown by Bader et al.
[18]. The patients who underwent orchidectomy had contralateral orchidopexy. One patient with single inguinal
testis had complete dissociation of vas and vessel from the
testis, hence was referred for microvascular anastamosis.
As the statistical analysis does not show any significant
difference in the outcomes, the preferred method for
orchidopexy depends on the position of the testes, mobilization and precise dissection.

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Conclusion
The study has shown that laparoscopy should be the
mainstay in the management of impalpable testes. Patients
should be operated by 1 year of age. Judicious application
of the different methods of orchidopexy gives excellent
results.
References
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