37
Ped. Med. Chir. (Med. Surg. Ped.), 2002, 24: 37-40
The nonpalpable testis: an experience of 132
consecutive videolaparoscopic explorations in 6 years
Il testicolo non palpabile:
un’esperienza di 132 esplorazioni videolaparoscopiche consecutive in 6 anni
Lima M., Bertozzi M., Ruggeri G., Dòmini M., Libri M., Pelusi G., Landuzzi V.*, Messina P.
Key words: nonpalpable testis, videolaparoscopy.
Abstract
From may 1995 to may 2001, 114 children with nonpalpable testis
(NPT) were evaluated at our institution (18 babies had bilateral
cryptorchidism). The age range was 1-11 years. When ultrasonography and nuclear magnetic resonance cannot show the
position of the NPT along the normal pathway, video
laparoscopy is essential for diagnostic accuracy. 20 cases were
observed to have blind-ending vas deferens and testicular vessels; therefore, no other procedure was done. 4 had residual
nonfunctional intra-abdominal tissue; in 52 cases, an intraabdominal testis was found, and 17 microvascular and 26 traditional orchidopexies were performed. The remaining 50
patients (six with bilateral cryptorchidism) had normal vas and
spermatic vessels entering the inguinal canal. In 15 cases a normal testis was present, and it was positioned into the scrotum
with the standard technique; in 41 cases an atrophic testis was
found and was removed through an inguinal approach.
Diagnostic laparoscopy permits not only localisation of the
testis but also planning for a better therapeutic program with a
minimally invasive procedure, thus avoiding the knife in 18% of
cases (in our experience 15 % of blind-ending and 3% of
abdominal vanishing testis).
Riassunto
Presso la Clinica chirurgica Pediatrica dell’Università degli Studi
di Bologna dal maggio 1995 al maggio 2001 sono stati valutati per
testicolo non palpabile (TNP) 114 pazienti, 18 dei quali avevano
Chirurgia Pediatrica, Università degli Studi di Bologna
* Servizio di Anestesia e Rianimazione Pediatrica, Azienda Ospedaliera Policlinico S.Orsola Bologna
Gli estratti vanno richiesti a (address for reprints): Prof. Lima M. - Chirurgia Pediatrica Università degli Studi di Bologna - Via Massarenti, 11 - 40138 Bologna (Italia)
TNP bilaterale. L’età dei pazienti è variata da 1 a 11 anni. Quando
l’ecografia e la risonanza magnetica non riescono a mostrare la
posizione del TNP, la videolaparoscopia è essenziale per l’accuratezza diagnostica. In 20 casi sono stati osservati vasi spermatici e
deferente a “fondo cieco” (blind-ending) per cui non abbiamo eseguito alcun’altra procedura. In 4 casi abbiamo riscontrato un residuo tissutale non funzionante (abdominal vanishing testis); in 52
è stato identificato un testicolo endoaddominale: in 17 abbiamo
quindi eseguito orchidopessi microvascolari ed in 26 orchidopessi
tradizionali. I rimanenti 50 pazienti (6 con criptorchidismo bilaterale) avevano vasi spermatici e deferente normali aggettanti nel
canale inguinale. In 15 casi era presente un testicolo eutrofico,
posizionato quindi a livello scrotale mediante orchidopessi standard ; in 41 casi è stato trovato un testicolo atrofico rimosso poi
mediante approccio inguinale.
La diagnostica videolaparoscopica permette non solo la localizzazione del TNP ma anche la pianificazione di un miglior programma terapeutico mediante procedura miniinvasiva evitando, nella
nostra esperienza, l’incisione inguinale nel 18% dei casi (15%
“blind-ending” e 3% “abdominal vanishing testis”).
Introduction
The generally accepted incidence for nonpalpable testes (NPT) is
8% of all cases of cryptorchidism2-5-6. An error in their diagnosis
risks leaving an intra-abdominal normal testis that has a significant
risk of malignant degeneration. Ultrasonography (USG) and
nuclear magnetic resonance (NMR) do not have a high specificity
in the detection of intra-abdominal testes, and they have a high false
negative rate. Video laparoscopy can identify with certainty vanishing intra-abdominal testes and, therefore, is now generally accepted
as the best diagnostic technique for cryptorchidism.
Materials and methods
We performed diagnostic laparoscopy on 114 children with NPT
(18 bilateral). The range was 1-11 years.
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LIMA M. E COLL.
The whole laparoscopic procedure is conducted with the patient
under general anaesthesia. A vescical catheter are placed. It is a
good practice to re-examine the patient after the anaesthetic in
order to determine if it is possible to palpate the testis when the
baby is sleeping, before introducing the first trocar. We practice
“open” laparoscopy, placing a 5 mm. trocar through a small
umbilical incision. The peritoneal cavity is filled with CO2 up to
8 mm.Hg pressure and with a flow of 0,5 L/min. Once obtained
the desired pressure, we insert a 5 mm. telescope through the
umbilical trocar. We begin with exploration of the normal side
and then move to the affected side. If the testis is not intraabdominal, attention is focused on the identification of the vas
deferens and spermatic vessels. We follow them distally to verify if
they enter the internal inguinal ring together (canalicular vas and
vessels). The blind-ending vas and vessel configuration occurs
when the testicular elements abruptly end without entering the
inguinal canal. If a vanishing testis is found, it is moved laparoscopically by placing other two 3 mm. trocars for operative instruments. To test if an intra-abdominal testis can be positioned into
the scrotum with a traditional orchidopexy immediately after the
video laparoscopy or a microvascular one, we try to gently push
the gonad into the internal ring with the telescope. If this maneuver is successful, the testis is pulled down through a traditional
orchidopexy. If ineffective, it is preferable to reposition the testis
with a microvascular autotransplantation at the age of three years.
We do not apply the Fowler-Stephens laparoscopic-staged orchi-
dopexy because our opinion is that the testicular microvascular
autotransplantation is safer then the Fowler-Stephens technique
for future gonadal growth.
The entire video laparoscopy takes about 10 min. when the procedure is finished, the abdomen is emptied of CO2 and the fascia and
skin are closed with absorbable sutures.
Results
The therapeutic algorithm we apply to cryptorchidism is as follows
(Fig. 1):
— High intra-abdominal testis: microvascular autotransplantation110 (“Refluo” technique) 4 through an inguinal approach at the
age of three years.
— Low intra-abdominal testis: immediately traditional orchidopexy (inguinal approach).
— Blind-ending vessels: stop.
— Vanishing testis: immediately laparoscopic excision.
— Vas and spermatic vessels entering into inguinal canal: immediately inguinal exploration and eventual excision of an intracanalicular atrophic gonad (vanishing testis) or traditional orchidopexy if the testis appears normal.
From may 1995 to may 2001 we performed a diagnostic
laparoscopy on 114 children with NPT7 (Fig.2). 18 patients had
bilateral cryptorchidism whose 14 with bilateral cryptorchidism,
positive testicular functionality test, and male karyotype and 4 with
“”
Figure 1
The therapeutic algorithm applied at our Institution for cryptorchidism.
THE NONPALPABLE TESTIS: AN EXPERIENCE OF 132 CONSECUTIVE VIDEOLAPAROSCOPIC
Figure 2
Results of 132 consecutive videolaparoscopic explorations.
negative testicular functionality test and male karyotype. In these
latter four patients we performed video-laparoscopic exploration to
evaluate the presence of an abdominal residual of testicular tissue.
In our experience we found the testis in 51% of cases of NPT.
— An intra-abdominal testis was visualised in 52 cases (40%), leading to 17 microvascular Refluo orchidopexies (9 more cases had
to attend the third year of age) and 26 traditional ones.
— In 56 cases were found to have normal vas and spermatic vessels
entering the inguinal canal (42%); 15 standard orchidopexies, for
intracanalicular testes pushed down by the CO2 pressure, were performed. In the remaining 41 cases we performed the removal of the
intracanalicular testicular draft.
— In 20 cases, blind-ending vessels were observed (15%).
— 4 intra-abdominal vanishing testes was found and excised by
laparoscopic techniques (3%).
In the 18 patients with bilateral cryptorchidism we observed:
— 4 patients with bilateral intracanalicular testes pushed down by
the CO2 pressure;
— 4 patients with bilateral high intra-abdominal testes;
— 2 patients with bilateral low intra-abdominal testes;
— 2 patients with one high and one low intra-abdominal testis;
— 1 patient with one high intra-abdominal testis and one abdominal vanishing testis;
— 1 patient with one intracanalicular testis pushed down by the
CO2 pressure and one intracanalicular vanishing testis ;
— 4 patients with bilateral anorchia.
Discussion
Video-laparoscopy is the most accurate way to localise an NPT8-9.
Other diagnostic procedures, such as USG and NMR, are unreliable and are not specific, especially in the cases of vanishing testes.
More often than not, a surgical exploration is required to avoid the
potential risk of malignant degeneration. Therefore, if a careful
examination has not detected a gonad, a safe diagnostic technique
is imperative.
Video laparoscopy permits us to determine with complete certainty
if the testis is in abdomen or not so that therapeutic procedures can
be promptly planned and accomplished3.
In our series, video laparoscopy provided a definite answer in all
114 patients (18 bilateral). All cases of high intra-abdominal gonads
were treated (17 patients) or will be treated at the age of three years
(9 patients) by microvascular Refluo autotransplantation.
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LIMA M. E COLL.
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