Laparoscopy and the Impalpable Testis
ABSTRACT & COMMENTARY
Synopsis: Laparoscopy is a reliable and safe approach for localization of the impalpable testis.
Source: Baillie CT, et al. Management of the impalpable testis: The role of laparoscopy. Arch Dis Child 1998; 79:419-422.
Baillie and associates, pediatric surgeons at the Royal Liverpool Children’s Hospital, performed a retrospective analysis of 87 boys at their hospital undergoing laparoscopy in the initial evaluation of 97 impalpable testes. Fifty-seven testes were either absent (n = 22) or present as a small remnant that was removed at the time of laparoscopy (n = 22). There were 27 intra-abdominal testes, including four hypoplastic testes that were removed at laparoscopy. The remaining 13 testes were in the groin. Conventional operative orchiopexies were performed in 21 cases, with success in 17 cases. Two-stage laparoscopically assisted orchiopexies (Fowler-Stephens procedure) were performed for 13 intra-abdominal testes, with eight satisfactory results. Laparoscopy is valuable for precise location of the impalpable testis.
COMMENT BY JOHN SEASHORE, MD
While only a small percentage of undescended testes are not palpable in the groin, management of these undescended testes is critically important. There are a number of legitimate reasons to perform orchiopexies for undescended testes: growth of the testis, potential for function, cosmesis, psychological reasons, and trauma risk. However, the only life-threatening risk is cancer, which is estimated to occur five times more frequently in patients with undescended testes than in those with normally descended testes and in up to 20% of patients who have an intra-abdominal, dysgenetic gonad. It is imperative to be absolutely sure that a boy with an impalpable testis is not harboring the time bomb of a gonad in the abdomen. Simple exploration of the groin is inadequate. It is wrong to assume that a small nubbin of tissue in the groin is a shriveled testicular remnant, perhaps the result of intrauterine torsion. Even finding a vas is not sufficient, since the vas and testis develop independently and there are well-documented cases of patients who have a blind-ending vas in the groin but later develop cancer in an intra-abdominal testicle. All testicular tissue must be identified and either removed or placed in the scrotum. Surgical orchiopexy does not eliminate or reduce the risk of cancer but facilitates early diagnosis and much-improved prognosis.
Definitive exploration of the abdomen used to be accomplished by laparotomy, but, since laparoscopy was introduced in the 1980s, it has rapidly become the standard approach. The article by Baillie et al is a retrospective review of their experience. Their results and conclusions are similar to other reported series (e.g., imaging studies are inaccurate and unreliable to determine the presence, absence, or location of a nonpalpable testis; and about 60% of these patients in fact do not have a testis on the ipsilateral side, about 30% have an intra-abdominal testis, and 10% actually have a testis in the groin).
It has been argued that in many boys, the testis or blind-ending spermatic vessels will be found or accounted for by groin exploration so laparoscopy is unnecessary. In this series, about half of the testes would have been accounted for by groin exploration. The other half would need definitive abdominal exploration. Traditional open laparotomy is performed either through a midline or extended groin incision, which must be substantial to permit thorough exploration and exclusion of an intra-abdominal testis. These patients all need an overnight stay in the hospital. In contrast, laparoscopy probably allows more thorough exploration, although a direct comparison has never been made. The incisions are certainly smaller: although Baillie et al describe two 10-mm ports and one 5-mm port, a 2-mm telescope and one 5-mm instrument port are usually adequate in our experience. In the United States, both diagnostic and therapeutic laparoscopy for undescended testes are routinely performed in outpatients.
In either case, the key is to identify spermatic vessels as they course through the retroperitoneum from the region of the kidney. These will either lead to an intra-abdominal testis, end blindly, or exit through the internal ring, in which case a subsequent groin exploration is adequate to determine the presence or absence of testicular tissue. Rarely, spermatic vessels cannot be found and it is then essential to explore the retroperitoneum all the way up to the renal hilum. This is certainly much easier laparoscopically than through a limited laparotomy incision.
Definitive management of the intra-abdominal testis is probably easier through the laparoscope also. Orchiectomy for the obviously dysmorphic testis is easily accomplished. While there is no convincing evidence that orchiopexy for the normal appearing intra-abdominal testis ever leads to spermatogenesis, most surgeons and parents are loathe to remove these gonads. The two-stage Fowler-Stephens orchiopexy has long been the standard approach to bring these testes into the scrotum. The first stage, division of the spermatic vessels, is easily performed laparoscopically through a single instrument port and may actually be better than an open procedure since there is only minimal mobilization and disturbance of the testis and, therefore, better preservation of collaterals. The second stage can be done either open or through the laparoscope. Most series of open Fowler-Stephens procedures report relatively normal testicular growth in 30-50% of boys.
In summary, this paper is a nice review of the management of impalpable testes and the role of laparoscopy, but it does not really shed any new light on the subject. Laparoscopy has proved to be effective, safe, and less morbid than laparotomy and is clearly the procedure of choice for evaluating the impalpable testis despite the lack of published randomized studies. (Dr. Seashore is Professor of Pediatrics and Surgery at the Yale University School of Medicine and the Yale-New Haven Children’s Hospital.)
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