Original Article
105
Testicular Ascent after Laparoscopic Percutaneous Extraperitoneal Closure for Inguinal Hernias Takeshi Shono1,2
Tomoko Izaki1
Ryouichi Nakahori1
1 Department of Pediatric Surgery, Saga-Ken Medical Center Koseikan,
Saga, Japan 2 Department of Pediatric Surgery, Kokura Medical Center, Kitakyushu, Japan 3 Department of Pediatric Surgery, Kyushu University, Fukuoka, Japan
Koichirou Yoshimaru3 Address for correspondence Takeshi Shono, MD, Department of Pediatric Surgery, Saga-Ken Medical Center Koseikan, 400 Nakahara Saga 840-8571, Japan (e-mail: [email protected]).
Abstract
Keywords
► ► ► ►
LPEC inguinal hernia ascending testis orchiopexy
received May 15, 2014 accepted after revision July 2, 2014 published online October 4, 2014
Aim Laparoscopic percutaneous extraperitoneal closure (LPEC) has been widely performed for the repair of pediatric inguinal hernias in Japan. This study aimed to evaluate the testicular ascent and orchiopexy after LPEC in males with inguinal hernias. Methods The medical records of male patients who underwent LPEC procedures for the repair of an inguinal hernia from January 2010 to December 2013 at our institution were reviewed. The patients who underwent orchiopexy after the LPEC procedure were investigated, the characteristics studied were the birth weight of the patients, the age when they underwent LPEC, the mean time from LPEC to orchiopexy, and the location of the affected testes. The LPEC procedure was performed by extraperitoneal circuit suturing around the internal inguinal ring with a long straight special needle (Lapaherclosure; Hakko Medical Co., Tokyo, Japan). Results During the 4-year period of this study, 438 LPECs were performed on 367 male patients. Orchiopexy was performed on 14 testes (3.2%) in 10 patients who had previously undergone LPEC. Five of the 10 patients were extremely low-birth-weight infants. The mean time from LPEC to orchiopexy was 13.2 months. In 7 of these 10 patients, both testes were initially identified in the scrotum at 3 months after LPECs, but they later showed ascending or retractile testes. In another three patients, the ipsilateral testes were elevated early after LPECs, and they were thought to be missed congenital undescended testes. At orchiopexy, 10 of the 14 testes were located in the inguinal region, and the other four testes were retractile. During the orchiopexy, the remaining processus vaginalis was found to adhere to the spermatic cord in all of the patients with ascending testes. Conclusion The postoperative testicular ascent should be carefully examined after the LPEC procedure in patients with pediatric inguinal hernias, especially in extremely lowbirth-weight infants.
© 2015 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0034-1387938. ISSN 0939-7248.
Downloaded by: University of British Columbia. Copyrighted material.
Eur J Pediatr Surg 2015;25:105–108.
Testicular Ascent after LPEC for Inguinal Hernias
Shono et al.
Introduction Laparoscopic percutaneous extraperitoneal closure (LPEC) has been employed as a minimally invasive and effective procedure for the repair of pediatric inguinal hernias in children. LPEC has also been demonstrated to be a safe method, without any major complications during or after the operation.1,2 Postoperative complications have rarely been reported by some authors, which showed the development of wound infections, recurrent inguinal hernias in some of the cases.1,2 In this study, we present our experience with patients who underwent orchiopexy after the LPEC procedure, and discussed the mechanisms associated with testicular ascent after the LPEC procedure.
Methods The institutional review board of our hospital approved the collection of the data from the medical records of 367 male patients who underwent LPEC procedures for the repair of a pediatric inguinal hernia from January 2010 to December 2013. The patients who underwent orchiopexy after the LPEC procedure were investigated. The birth weight of these patients, their age at LPEC, the time from LPEC to orchiopexy, and the position of the affected testes were all examined. The LPEC procedure was performed as described by Takahara et al.1 The patient was placed in a supine position under endotracheal general anesthesia, and the operator stood on the left side of the patient. A small longitudinal incision was made on the umbilicus to introduce an expandable port to gain access to the peritoneal cavity. Following insufflation with CO2 at a flow rate of 1 L/min to a level of 6 mm Hg, a 5-mm 30-degree telescope was inserted through an umbilical port. Then, the abdominal wall was punctured by a special long straight 19-gauge needle (Lapaherclosure; Hakko Medical Co., Tokyo, Japan) in the inguinal region under laparoscopic guidance. The Lapaherclosure had a wire loop to hold a 2–0 nonabsorbable suture at the tip of the needle, and the surgeons manipulated the Lapaherclosure extracorporeally. The neck of the hernia sac was closed by extraperitoneal circuit suturing around the internal inguinal ring (►Fig. 1). The tip of the needle was put forward extraperitoneally to dissect the peritoneum from the underlying tissue, vas and gonadal vessels. After half of the circuit suturing had been completed, a suture was released into the abdominal cavity, and the tip of the needle was pulled to the anterior edge of the internal inguinal orifice, then it was put forward again extraperitoneally on the opposite side of the internal inguinal ring to hold a suture again using the wire loop. Both the ends of the suture were pulled through the punctured wound using the Lapaherclosure, and an extracorporeal knot was tied to close the neck of the hernia sac (►Fig. 2). During these procedures, great care was taken not to injure or involve the vas, gonadal vessels or genitofemoral nerves. Postoperative testicular ascent was identified by regular outpatient follow-up performed by surgeons. Orchiopexy was European Journal of Pediatric Surgery
Vol. 25
No. 1/2015
Fig. 1 Extraperitoneal circuit suturing of the peritoneum by the Lapaherclosure (Hakko Medical Co., Tokyo, Japan). The vas and gonadal vessels were carefully dissected from the peritoneum by manipulating the tip of the Lapaherclosure around the internal inguinal ring. GV, gonadal vessels; IR, internal inguinal ring; La, Lapaherclosure; V, vas.
performed through a scrotal incision in all the cases with ascending and severe retractile testes.
Results During the 4-year period of this study, 438 LPECs were performed on 367 males. Orchiopexy was performed on 14 testes (3.2%) in 10 males who had previously undergone LPEC, although no testicular atrophy was seen in any of the 367 patients. The patient details are described in ►Table 1. The median age of patients at LPEC was 7 months, with a range of 2 to 65 months. Five of the 10 patients who required orchiopexy were extremely low-birth-weight infants. LPECs were performed bilaterally in four patients, and unilaterally in six patients who eventually required orchiopexy. At 3 months after LPEC, both testes were initially identified in the scrotum in seven of these patients (cases 1, 4, 5, 6, 7, 8, and 10), while five of them late showed ascending testes (cases 4, 5, 7, 8, and 10) and another two showed retractile testes
Fig. 2 Complete obstruction of the internal inguinal ring. GV, gonadal vessels; IR, internal inguinal ring; V, vas.
Downloaded by: University of British Columbia. Copyrighted material.
106
Testicular Ascent after LPEC for Inguinal Hernias
Shono et al.
107
Table 1 A summary of the cases that underwent orchiopexy after the LPEC procedure Case
Birth weight (g)
Age at LPEC procedure (mo)
Testis position 3 mo after LPEC
Age at orchiopexy (mo)
Diagnosis at orchiopexy
1
948
6 (bilateral)
Both scrotum
22 (bilateral)
Bilateral retractile testis
2
550
10 (left)
Left inguinal/right scrotum
16 (left)
Left undescended testis
3
751
5 (right)
Right inguinal/left scrotum
8 (right)
Right undescended testis
4
3,306
2 (bilateral)
Both scrotum
11 (bilateral)
Bilateral ascending testis
5
487
6 (bilateral)
Both scrotum
13 (left)
Left ascending testis
6
722
8 (left)
Both scrotum
42 (bilateral)
Bilateral retractile testis
7
2,850
24 (left)
Both scrotum
45 (left)
Left ascending testis
8
4,095
4 (right)
Both scrotum
17 (bilateral)
Bilateral ascending testis
9
2,960
65 (left)
Left inguinal/right scrotum
78 (left)
Left undescended testis
10
3,122
14 (bilateral)
Both scrotum
22 (left)
Left ascending testis
(cases 1 and 6). In the other three patients (cases 2, 3, and 9) the ipsilateral testes were found to be elevated at 3 months after LPEC, and these cases were considered to be cases of congenital undescended testes that were missed because of the large protrusion of the inguinal hernia. The mean time from LPEC to orchiopexy was 13.2 months. A total of 10 of the 14 operated testes were located in the low inguinal region, and the other 4 testes were retractile. During the orchiopexy, the remaining processus vaginalis was found to adhere to the spermatic cord in the patients with postoperative ascending testes (►Fig. 3).
Discussion Iatrogenic cryptorchidism has been reported to occur in approximately 0 to 1.2% of patients who undergo inguinal herniorrhaphy.1–5 Severe adhesion of the spermatic cord in the inguinal canal due to wide dissection during the operation has been thought to cause the postoperative testicular ascent after an open herniorrhaphy.4,5 However, postoperative testicular ascent has rarely been reported after laparoscopic herniorrhaphy, because the dissection of the spermatic
Fig. 3 The remaining processus vaginalis (arrow) was found to adhere to the spermatic cord during orchiopexy in patients with an ascending testis.
cord in the inguinal region is avoided, and the inguinal canal anatomy is not disturbed during the procedure.1–3 In LPEC procedures, minimum dissection of the vas and gonadal vessels from the retroperitoneal membrane is performed at the internal inguinal ring, and the neck of the processus vaginalis (hernia sac) is closed without involving the spermatic cord in the internal inguinal ring.1–3 Therefore, the postoperative adhesion of the spermatic cord in the inguinal canal as seen after open herniorrhaphy is not likely to cause the testicular ascent following LPEC procedures. Ascending or acquired undescended testes are testes which have descended into the scrotum in the early infant period but later ascend.6,7 Late descending testes are also known to ascend in premature infants.8 The incidence of ascending testes has been reported to be 1 to 2% in all the males.9 It has been suggested that an abnormal fibrous remnant of the processus vaginalis may disturb the elongation of the spermatic cord and induce testicular ascent.10 Atwell7 has suggested that ascending testes or retractile testes may be caused by persistence of the processus vaginalis, which is likely to inhibit elongation of the adjacent vas and gonadal vessels. We previously reported that abnormal development of the genitofemoral nerve caused testicular ascent in rodents.11 In our present study, 10 patients underwent orchiopexy after LPEC procedures, and 3 of these patients showed ipsilateral high testes early after LPECs, and were supposed to have been cases of missed congenital undescended testes before the LPEC procedures. In the other seven patients, two patients who were extremely low-birthweight babies showed severe retractile testes, and five patients presented with ascending testes which were speculated to be caused by the remaining processus vaginalis. The incidence of ascending testes was 1.3% of all the male patients who underwent LPECs, which was similar to that of the normal male population. However, the possibility of postoperative ascending testis should be carefully examined, because the remaining processus vaginalis may prevent the elongation of the spermatic cord and cause testicular ascent after a LPEC procedure. European Journal of Pediatric Surgery
Vol. 25
No. 1/2015
Downloaded by: University of British Columbia. Copyrighted material.
Abbreviations: LPEC, laparoscopic percutaneous extraperitoneal closure; mo, month.
Testicular Ascent after LPEC for Inguinal Hernias
Shono et al.
Note The article was presented at: 15th Annual Congress of the European Pediatric Surgeons’ Association; June 18 to June 21, 2014; Dublin, Ireland.
4 Misra D. Iatrogenic ascent of the testes. Br J Urol 1995;75(5):
687–688 5 Kaplan GW. Iatrogenic cryptorchidism resulting from hernia
repair. Surg Gynecol Obstet 1976;142(5):671–672 6 Hutson JM, Beasley SW. Descent of the Testis. London: Edward
Arnold; 1992 7 Atwell JD. Ascent of the testis: fact or fiction. Br J Urol 1985;57(4):
Conflict of Interest None.
474–477 8 John Radcliffe Hospital Cryptorchidism Study Group. Boys with
References 1 Takehara H, Yakabe S, Kameoka K. Laparoscopic percutaneous
extraperitoneal closure for inguinal hernia in children: clinical outcome of 972 repairs done in 3 pediatric surgical institutions. J Pediatr Surg 2006;41(12):1999–2003 2 Takehara H, Ishibashi H, Satoh H, et al. Laparoscopic surgery for inguinal lesions of pediatric patients. In: Proceedings of 7th World Congress of Endoscopic Surgery; June 1–4, 2000; Singapore. 537–541 3 Schier F. Laparoscopic inguinal hernia repair-a prospective personal series of 542 children. J Pediatr Surg 2006;41(6):1081–1084
late descending testes: the source of patients with “retractile” testes undergoing orchidopexy? Br Med J (Clin Res Ed) 1986; 293(6550):789–790 9 Barthold JS, González R. The epidemiology of congenital cryptorchidism, testicular ascent and orchiopexy. J Urol 2003;170(6 Pt 1): 2396–2401 10 Clarnette TD, Rowe D, Hasthorpe S, Hutson JM. Incomplete disappearance of the processus vaginalis as a cause of ascending testis. J Urol 1997;157(5):1889–1891 11 Shono T, Zakaria O, Imajima T, Suita S. Does proximal genitofemoral nerve division induce testicular maldescent or ascent in the rat? BJU Int 1999;83(3):323–326
Downloaded by: University of British Columbia. Copyrighted material.
108
European Journal of Pediatric Surgery
Vol. 25
No. 1/2015
105
Testicular Ascent after Laparoscopic Percutaneous Extraperitoneal Closure for Inguinal Hernias Takeshi Shono1,2
Tomoko Izaki1
Ryouichi Nakahori1
1 Department of Pediatric Surgery, Saga-Ken Medical Center Koseikan,
Saga, Japan 2 Department of Pediatric Surgery, Kokura Medical Center, Kitakyushu, Japan 3 Department of Pediatric Surgery, Kyushu University, Fukuoka, Japan
Koichirou Yoshimaru3 Address for correspondence Takeshi Shono, MD, Department of Pediatric Surgery, Saga-Ken Medical Center Koseikan, 400 Nakahara Saga 840-8571, Japan (e-mail: [email protected]).
Abstract
Keywords
► ► ► ►
LPEC inguinal hernia ascending testis orchiopexy
received May 15, 2014 accepted after revision July 2, 2014 published online October 4, 2014
Aim Laparoscopic percutaneous extraperitoneal closure (LPEC) has been widely performed for the repair of pediatric inguinal hernias in Japan. This study aimed to evaluate the testicular ascent and orchiopexy after LPEC in males with inguinal hernias. Methods The medical records of male patients who underwent LPEC procedures for the repair of an inguinal hernia from January 2010 to December 2013 at our institution were reviewed. The patients who underwent orchiopexy after the LPEC procedure were investigated, the characteristics studied were the birth weight of the patients, the age when they underwent LPEC, the mean time from LPEC to orchiopexy, and the location of the affected testes. The LPEC procedure was performed by extraperitoneal circuit suturing around the internal inguinal ring with a long straight special needle (Lapaherclosure; Hakko Medical Co., Tokyo, Japan). Results During the 4-year period of this study, 438 LPECs were performed on 367 male patients. Orchiopexy was performed on 14 testes (3.2%) in 10 patients who had previously undergone LPEC. Five of the 10 patients were extremely low-birth-weight infants. The mean time from LPEC to orchiopexy was 13.2 months. In 7 of these 10 patients, both testes were initially identified in the scrotum at 3 months after LPECs, but they later showed ascending or retractile testes. In another three patients, the ipsilateral testes were elevated early after LPECs, and they were thought to be missed congenital undescended testes. At orchiopexy, 10 of the 14 testes were located in the inguinal region, and the other four testes were retractile. During the orchiopexy, the remaining processus vaginalis was found to adhere to the spermatic cord in all of the patients with ascending testes. Conclusion The postoperative testicular ascent should be carefully examined after the LPEC procedure in patients with pediatric inguinal hernias, especially in extremely lowbirth-weight infants.
© 2015 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0034-1387938. ISSN 0939-7248.
Downloaded by: University of British Columbia. Copyrighted material.
Eur J Pediatr Surg 2015;25:105–108.
Testicular Ascent after LPEC for Inguinal Hernias
Shono et al.
Introduction Laparoscopic percutaneous extraperitoneal closure (LPEC) has been employed as a minimally invasive and effective procedure for the repair of pediatric inguinal hernias in children. LPEC has also been demonstrated to be a safe method, without any major complications during or after the operation.1,2 Postoperative complications have rarely been reported by some authors, which showed the development of wound infections, recurrent inguinal hernias in some of the cases.1,2 In this study, we present our experience with patients who underwent orchiopexy after the LPEC procedure, and discussed the mechanisms associated with testicular ascent after the LPEC procedure.
Methods The institutional review board of our hospital approved the collection of the data from the medical records of 367 male patients who underwent LPEC procedures for the repair of a pediatric inguinal hernia from January 2010 to December 2013. The patients who underwent orchiopexy after the LPEC procedure were investigated. The birth weight of these patients, their age at LPEC, the time from LPEC to orchiopexy, and the position of the affected testes were all examined. The LPEC procedure was performed as described by Takahara et al.1 The patient was placed in a supine position under endotracheal general anesthesia, and the operator stood on the left side of the patient. A small longitudinal incision was made on the umbilicus to introduce an expandable port to gain access to the peritoneal cavity. Following insufflation with CO2 at a flow rate of 1 L/min to a level of 6 mm Hg, a 5-mm 30-degree telescope was inserted through an umbilical port. Then, the abdominal wall was punctured by a special long straight 19-gauge needle (Lapaherclosure; Hakko Medical Co., Tokyo, Japan) in the inguinal region under laparoscopic guidance. The Lapaherclosure had a wire loop to hold a 2–0 nonabsorbable suture at the tip of the needle, and the surgeons manipulated the Lapaherclosure extracorporeally. The neck of the hernia sac was closed by extraperitoneal circuit suturing around the internal inguinal ring (►Fig. 1). The tip of the needle was put forward extraperitoneally to dissect the peritoneum from the underlying tissue, vas and gonadal vessels. After half of the circuit suturing had been completed, a suture was released into the abdominal cavity, and the tip of the needle was pulled to the anterior edge of the internal inguinal orifice, then it was put forward again extraperitoneally on the opposite side of the internal inguinal ring to hold a suture again using the wire loop. Both the ends of the suture were pulled through the punctured wound using the Lapaherclosure, and an extracorporeal knot was tied to close the neck of the hernia sac (►Fig. 2). During these procedures, great care was taken not to injure or involve the vas, gonadal vessels or genitofemoral nerves. Postoperative testicular ascent was identified by regular outpatient follow-up performed by surgeons. Orchiopexy was European Journal of Pediatric Surgery
Vol. 25
No. 1/2015
Fig. 1 Extraperitoneal circuit suturing of the peritoneum by the Lapaherclosure (Hakko Medical Co., Tokyo, Japan). The vas and gonadal vessels were carefully dissected from the peritoneum by manipulating the tip of the Lapaherclosure around the internal inguinal ring. GV, gonadal vessels; IR, internal inguinal ring; La, Lapaherclosure; V, vas.
performed through a scrotal incision in all the cases with ascending and severe retractile testes.
Results During the 4-year period of this study, 438 LPECs were performed on 367 males. Orchiopexy was performed on 14 testes (3.2%) in 10 males who had previously undergone LPEC, although no testicular atrophy was seen in any of the 367 patients. The patient details are described in ►Table 1. The median age of patients at LPEC was 7 months, with a range of 2 to 65 months. Five of the 10 patients who required orchiopexy were extremely low-birth-weight infants. LPECs were performed bilaterally in four patients, and unilaterally in six patients who eventually required orchiopexy. At 3 months after LPEC, both testes were initially identified in the scrotum in seven of these patients (cases 1, 4, 5, 6, 7, 8, and 10), while five of them late showed ascending testes (cases 4, 5, 7, 8, and 10) and another two showed retractile testes
Fig. 2 Complete obstruction of the internal inguinal ring. GV, gonadal vessels; IR, internal inguinal ring; V, vas.
Downloaded by: University of British Columbia. Copyrighted material.
106
Testicular Ascent after LPEC for Inguinal Hernias
Shono et al.
107
Table 1 A summary of the cases that underwent orchiopexy after the LPEC procedure Case
Birth weight (g)
Age at LPEC procedure (mo)
Testis position 3 mo after LPEC
Age at orchiopexy (mo)
Diagnosis at orchiopexy
1
948
6 (bilateral)
Both scrotum
22 (bilateral)
Bilateral retractile testis
2
550
10 (left)
Left inguinal/right scrotum
16 (left)
Left undescended testis
3
751
5 (right)
Right inguinal/left scrotum
8 (right)
Right undescended testis
4
3,306
2 (bilateral)
Both scrotum
11 (bilateral)
Bilateral ascending testis
5
487
6 (bilateral)
Both scrotum
13 (left)
Left ascending testis
6
722
8 (left)
Both scrotum
42 (bilateral)
Bilateral retractile testis
7
2,850
24 (left)
Both scrotum
45 (left)
Left ascending testis
8
4,095
4 (right)
Both scrotum
17 (bilateral)
Bilateral ascending testis
9
2,960
65 (left)
Left inguinal/right scrotum
78 (left)
Left undescended testis
10
3,122
14 (bilateral)
Both scrotum
22 (left)
Left ascending testis
(cases 1 and 6). In the other three patients (cases 2, 3, and 9) the ipsilateral testes were found to be elevated at 3 months after LPEC, and these cases were considered to be cases of congenital undescended testes that were missed because of the large protrusion of the inguinal hernia. The mean time from LPEC to orchiopexy was 13.2 months. A total of 10 of the 14 operated testes were located in the low inguinal region, and the other 4 testes were retractile. During the orchiopexy, the remaining processus vaginalis was found to adhere to the spermatic cord in the patients with postoperative ascending testes (►Fig. 3).
Discussion Iatrogenic cryptorchidism has been reported to occur in approximately 0 to 1.2% of patients who undergo inguinal herniorrhaphy.1–5 Severe adhesion of the spermatic cord in the inguinal canal due to wide dissection during the operation has been thought to cause the postoperative testicular ascent after an open herniorrhaphy.4,5 However, postoperative testicular ascent has rarely been reported after laparoscopic herniorrhaphy, because the dissection of the spermatic
Fig. 3 The remaining processus vaginalis (arrow) was found to adhere to the spermatic cord during orchiopexy in patients with an ascending testis.
cord in the inguinal region is avoided, and the inguinal canal anatomy is not disturbed during the procedure.1–3 In LPEC procedures, minimum dissection of the vas and gonadal vessels from the retroperitoneal membrane is performed at the internal inguinal ring, and the neck of the processus vaginalis (hernia sac) is closed without involving the spermatic cord in the internal inguinal ring.1–3 Therefore, the postoperative adhesion of the spermatic cord in the inguinal canal as seen after open herniorrhaphy is not likely to cause the testicular ascent following LPEC procedures. Ascending or acquired undescended testes are testes which have descended into the scrotum in the early infant period but later ascend.6,7 Late descending testes are also known to ascend in premature infants.8 The incidence of ascending testes has been reported to be 1 to 2% in all the males.9 It has been suggested that an abnormal fibrous remnant of the processus vaginalis may disturb the elongation of the spermatic cord and induce testicular ascent.10 Atwell7 has suggested that ascending testes or retractile testes may be caused by persistence of the processus vaginalis, which is likely to inhibit elongation of the adjacent vas and gonadal vessels. We previously reported that abnormal development of the genitofemoral nerve caused testicular ascent in rodents.11 In our present study, 10 patients underwent orchiopexy after LPEC procedures, and 3 of these patients showed ipsilateral high testes early after LPECs, and were supposed to have been cases of missed congenital undescended testes before the LPEC procedures. In the other seven patients, two patients who were extremely low-birthweight babies showed severe retractile testes, and five patients presented with ascending testes which were speculated to be caused by the remaining processus vaginalis. The incidence of ascending testes was 1.3% of all the male patients who underwent LPECs, which was similar to that of the normal male population. However, the possibility of postoperative ascending testis should be carefully examined, because the remaining processus vaginalis may prevent the elongation of the spermatic cord and cause testicular ascent after a LPEC procedure. European Journal of Pediatric Surgery
Vol. 25
No. 1/2015
Downloaded by: University of British Columbia. Copyrighted material.
Abbreviations: LPEC, laparoscopic percutaneous extraperitoneal closure; mo, month.
Testicular Ascent after LPEC for Inguinal Hernias
Shono et al.
Note The article was presented at: 15th Annual Congress of the European Pediatric Surgeons’ Association; June 18 to June 21, 2014; Dublin, Ireland.
4 Misra D. Iatrogenic ascent of the testes. Br J Urol 1995;75(5):
687–688 5 Kaplan GW. Iatrogenic cryptorchidism resulting from hernia
repair. Surg Gynecol Obstet 1976;142(5):671–672 6 Hutson JM, Beasley SW. Descent of the Testis. London: Edward
Arnold; 1992 7 Atwell JD. Ascent of the testis: fact or fiction. Br J Urol 1985;57(4):
Conflict of Interest None.
474–477 8 John Radcliffe Hospital Cryptorchidism Study Group. Boys with
References 1 Takehara H, Yakabe S, Kameoka K. Laparoscopic percutaneous
extraperitoneal closure for inguinal hernia in children: clinical outcome of 972 repairs done in 3 pediatric surgical institutions. J Pediatr Surg 2006;41(12):1999–2003 2 Takehara H, Ishibashi H, Satoh H, et al. Laparoscopic surgery for inguinal lesions of pediatric patients. In: Proceedings of 7th World Congress of Endoscopic Surgery; June 1–4, 2000; Singapore. 537–541 3 Schier F. Laparoscopic inguinal hernia repair-a prospective personal series of 542 children. J Pediatr Surg 2006;41(6):1081–1084
late descending testes: the source of patients with “retractile” testes undergoing orchidopexy? Br Med J (Clin Res Ed) 1986; 293(6550):789–790 9 Barthold JS, González R. The epidemiology of congenital cryptorchidism, testicular ascent and orchiopexy. J Urol 2003;170(6 Pt 1): 2396–2401 10 Clarnette TD, Rowe D, Hasthorpe S, Hutson JM. Incomplete disappearance of the processus vaginalis as a cause of ascending testis. J Urol 1997;157(5):1889–1891 11 Shono T, Zakaria O, Imajima T, Suita S. Does proximal genitofemoral nerve division induce testicular maldescent or ascent in the rat? BJU Int 1999;83(3):323–326
Downloaded by: University of British Columbia. Copyrighted material.
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European Journal of Pediatric Surgery
Vol. 25
No. 1/2015
