Documente Academic
Documente Profesional
Documente Cultură
DOI 10.1007/s00383-011-2970-9
ORIGINAL ARTICLE
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.
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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
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Two stage
FSO 48
One stage
FSO 3
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Discussion
Atrophy
p value
28
(I,FS)
36
(FS,1SO)
= 0.11
13
(1SO,IO)
= 0.34
= 0.25
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1330
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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3. Cortesi N, Ferrari P, Zambarda E et al (1976) Diagnosis of
bilateral abdominal cryptorchidism by laparoscopy. Endoscopy
8:3334
4. Bloom DA (1991) Two-step orchidopexy with pelviscopic clip
ligation of the spermatic vessels. J Urol 145:10301033
5. Jordan GH, Winslow BH (1994) Laparoscopic single stage and
staged orchidopexy. J Urol 152:12491252
6. Scott JE (1982) Laparoscopy as an aid in the diagnosis and
management of the impalpable testis. J Pediatr Surg 17:1416
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21682172
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