The Laparoscope
and the Undescended
By D. Wilson-Storey
Testis
and A.E. MacKinnon
Sheffield, England 0 An empty scrotum with an impalpable testis/testes presents a difficult diagnostic and therapeutic problem. Many methods have been used in an attempt at, or as an aid to, the localization of these gonads including venography, ultrasonography, hormone manipulation, and surgical exploration. Laparoscopy has been recommended as an aid to diagnosis. We reviewed our experience with the laparoscope in the diagnosis and management of this problem over a 7-year period. Laparoscopy permitted planning of the approach to orchidopexy, depending on whether the vessels entered the deep inguinal ring. In the latter group 48% of the testes were found to be atrophic. We also found the laparoscope to be of value in performing the first stage of the Fowler-Stephens long loop vas orchidopexy in three cases, with long-term viability of the testes in two of these. Copyright ,I 1992 by W.B. Saunders Company INDEX WORDS: Cryptorchidism,
laparoscopy.
C pediatric
RYPTORCHIDISM is a common problem in surgical practice, accounting for 13.8% of the surgical procedures performed in this unit. In most cases referred for opinion the testis can be found on careful clinical examination. However, the truly impalpable testis presents a difficult problem. These testes may be in an ectopic site, intracanalicular, or, most commonly, intraabdominal. In a proportion of cases the testis may be absent. A variety of methods have been used to locate such testes, including venography, ultrasonography, trial of hormone therapy, and surgical exploration. Recently, the role of laparoscopy has been described in locating these testes.‘~’ To assess the value of the laparoscopy, a retrospective review was made of all cases observed in the surgical outpatient department in the Children’s Hospital, Sheffield, over a 7-year period (1982 through 1988). Included were all boys in whom one or both testes were impalpable and who subsequently underwent examination under anesthesia with or without laparoscopy. MATERIALS
AND METHODS
Over ;i 7-year period (1987 through 1988), 69 boys were encountered in whom either one or both testes were not located on clinical examination. These boys subsequently went on to examination under anesthesia, with or without laparoscopy, followed by either orchidopexy (in one or two stages) or orchidectomy. The length of outpatient follow-up ranged from 6 months to 6 years (mean, 1.4 years). The age at surgery ranged from IO months to 15 years (mean. 3 years 9 months): 52 (75%) were less than 5 years old and 33 (55%) were less than 7 years old at the time of operation. The side of
JoumalofPediatric Surgery, Vol 27, No
1
(January),
1992: on 89-92
undescent was left in 34 cases (49%‘). right in 20 cases (29%)), and bilateral in 15 cases (22%), a total of 84 testes in 69 patients. Sixty (92%) underwent laparoscopy. Of these, 5 failed due to technical problems (eg, subcutaneous CO, leakage). Fifty-five successful laparoscopies were performed for 65 undescended testes. In the remaining 9 cases the testes were palpable on examination under anesthesia and. thus, were excluded from further study.
RESULTS
Based on the laparoscopy findings, the patients were segregated into one of two groups: group A (n = 42) in whom the vas and vessels were seen entering the deep inguinal ring, and group B (n = 23) in whom the testis was visualised at the deep ring (n = 8) or was more proximal (n = 15). The outcome is shown in Fig 1. In group A groin exploration was performed. In 20 cases the testis was located either in the canal (16) or in the superficial inguinal pouch (4) and 16 of these 20 were of normal size. The remaining 4 were less than 50% of the size of the contralateral testis. In these patients 15 had the testis brought into the scrotum in one stage and the remaining 5 required more extensive retroperitoneal dissection and underwent the two-stage procedure. Follow-up showed no change in testicular volume relative to the contralatera1 organ after 3 years following operation. The remaining 22 testes were considered so atrophic or were actually absent at exploration and in these orchidectomy or excision of the remnant at the end of the testicular vessels and vas was performed. Histological examination of the excised specimens showed fibrous tissue or atrophic testicular tissue. Of the 23 patients in group B the testis was found lying close to the deep inguinal ring and there was judged to be adequate vas and vessel length in 11, whereas in 6 the testis was lying at the bifurcation of the iliac vessels with apparently adequate length of vas but inadequate length in the vascular pedicle. In the remaining 6 the vas and vessels were blind-ending (absent or atrophic testis). In the group of 11 with
From the Department of Puediattic .Stqeen: The Childrert :v Hospital, Sheffield. En,$and. Date accepted: September IO, 1990. Address reprint requests to D. Wilson-Storey, FRCS. Senior Rexistrar in Paediatric Surety, The Children k Ho.spital. Western Bank. Shefield SlO 2TH. Ettgland. Copyri$t gj 1992 by W B. Saunders Compare\ 0022-346819212701-0024$03.OOlO
89
No subsequent
testicular atrophy
J
(n = 5)
I
Two-stage orchidopexy
I
(n = 15)
I
One-stage orchidopexy
I
1
Fig 1.
(n=22)
Groin exploration
Testicular vessels + vas
Impalpable
r
orchidopexy
Exploration
8 weeks later
(n = 3)
of testicular vessels
(
vessels (n = 6)
Short testicular
atrophy
(
(
/
testicular atrophy
Onesubsequent
1 lmmedi;;;;loration
Nosubsequent
fn = 11)
length for standard
vessels sufficient
testes
Group B fn = 23) lntraabdominal
Laparoscopic diathermy
Laparoscopy for 65 impalpable testes.
Testes fn = 65)
LAPAROSCOPY
FOR UNDESCENDED
91
TESTIS
adequate vas and vessel length, groin exploration was performed and one-stage orchidopexy was achieved in all cases. Follow-up of these patients showed satisfactory growth of the testis. Of the 6 cases in which the testis had a short vascular pedicle, 3 underwent laparoscopic diathermy of the vascular pedicle following exploration via high approach some 2 months later. Two of these testis appeared normal and the third was then atrophic. The 2 normal-sized testis (maintained on the arterial supply of vas deferens) underwent division of the vascular pedicle and orchidopexy. The atrophic testis was excised. The other 3 testes in this short-vessel group underwent immediate exploration. In 2 cases a standard orchidopexy was performed to upper scrotal level and at 6-month follow-up one testis was of normal size but remaining high within the scrotum while the second testis was atrophic and, therefore, removed. The third patient underwent formal exploration, ligation and division of the testicular vessels, with a subsequent second stage orchidopexy 8 weeks later, this testis being normal in size and site at B-month review. In 5 patients laparoscopy failed (6 testes). Exploration was performed immediately. Of the 6 testes within this group 3 underwent successful one-stage orchidopexy. All were found within the inguinal canal and 3 were found to be atrophic and, therefore, were removed. During the early period of this study there were 5 complications following laparoscopy. In 2 cases, tears were caused in the serosa of the sigmoid colon; in both cases exploration was performed with serosal oversewing and there were no postoperative sequelae. In the remaining 3 cases carbon dioxide escaped into the subcutaneous tissues: all resolved spontaneously. DISCUSSION
The impalpable testis poses two major problems to the surgeon: initially locating the testis and then placing it within the scrotum. Many methods have been recommended in the past to locate these testes, the most recent being laparoscopy.‘-” We have confirmed the value of this in the present study. Laparoscopy for 42 testes showed the vas and testicular vessels to pass into the inguinal canal. However, subsequent groin exploration found only 20 of these testes to be normal and suitable for orchidopexy, whereas 22 were either absent or atrophic (vanishing testis syndrome“). Twenty-three testes were noted to be proximal to the deep inguinal ring. Eleven of these were at the level of the deep inguinal ring with adequate vasal
and vascular length permitting one-stage, uncomplicated orchidopexy. In 6 instances the testis lay proximal to the deep inguinal ring with a normal length of vas but short testicular vessels. This situation was studied in detail by Fowler and Stephens,’ who described the division of the testicular vessels bringing down the testis into the scrotum on the adequate vas, testicular viability being maintained by the arterial supply to the vas (long-loop vas orchidopexy). In 3 of these cases, the testicular vessels were initially clamped laparoscopically and once testicular viability was noted, diathermied. Two months later surgical exploration showed 2 of these testes to be normal and the testicular vessels were divided allowing orchidopexy. The third testis in this group had atrophied and was removed. The other 3 testes in this latter group underwent surgical exploration. In 2 cases a one-stage orchidopexy was performed, one of which subsequently atrophied, whereas the third case underwent formal division of the testicular vessels (FowlerStephens) with a second stage orchidopexy 2 months later with no subsequent complications. Thus, laparoscopy is a valuable adjunct to clinical examination in the search for the undescended testis. It allows visualization of the testis to assess its presence, position, and size, and the relative lengths of the vas deferens and gonadal vessels. This permits planning of further management (orchidopexy, orchidectomy) or, indeed, avoids extensive exploration for an absent testis when a blind-ending vas and vessels has been noted. Complications of laparoscopy were uncommon (8.3%) and occurred early during the learning curve. These included 3 cases of gaseous (CO:) leakage into the subcutaneous tissues (spontaneous resolution) and 2 cases of serosal trauma to the sigmoid colon (both oversewn with no long-term problems). From this study we have shown the value of laparoscopy in the investigation and management of the impalpable testis. It was possible in all cases to demonstrate the course of the testicular vessels and vas deferens, thus locating the testis or its atrophic remnant. We have also shown that the laparoscope can be used therapeutically in performing the first stage of the Fowler-Stephens long loop vas orchidopexy, thus precluding extensive surgical exploration and dissection to bring these testes down into the scrotum. ACKNOWLEDGMENT We wish to thank J.A.S. Dickson for allowing patients and Ann Jones for typing the manuscript.
us to study
his
92
WILSON-STOREY
AND MAcKINNON
REFERENCES 1. Scott JES: Laparoscopy as an aid in the diagnosis and management of the impalpable testis. J Pediatr Surg 17:14-16,1982 2. Malone PS, Guiney EJ: The value of laparoscopy in localising the impalpable undescended testis. Br J Urol 56:429-431. 1984 3. Guiney EJ, Corbally M, Malone PS: Laparoscopy and the management of the impalpable testis. Br J Ural 63:313-316, 1989
4. Abeyaratne MR, Aherne WA, Scott JES: The vanishing testis. Lancet 2:822-824, 1969 5. Fowler R, Stephens FD: The role of testicular vascular anatomy in the salvage of high undescended testis. Aust N Z J Surg 29:92-106,1959
and the Undescended
By D. Wilson-Storey
Testis
and A.E. MacKinnon
Sheffield, England 0 An empty scrotum with an impalpable testis/testes presents a difficult diagnostic and therapeutic problem. Many methods have been used in an attempt at, or as an aid to, the localization of these gonads including venography, ultrasonography, hormone manipulation, and surgical exploration. Laparoscopy has been recommended as an aid to diagnosis. We reviewed our experience with the laparoscope in the diagnosis and management of this problem over a 7-year period. Laparoscopy permitted planning of the approach to orchidopexy, depending on whether the vessels entered the deep inguinal ring. In the latter group 48% of the testes were found to be atrophic. We also found the laparoscope to be of value in performing the first stage of the Fowler-Stephens long loop vas orchidopexy in three cases, with long-term viability of the testes in two of these. Copyright ,I 1992 by W.B. Saunders Company INDEX WORDS: Cryptorchidism,
laparoscopy.
C pediatric
RYPTORCHIDISM is a common problem in surgical practice, accounting for 13.8% of the surgical procedures performed in this unit. In most cases referred for opinion the testis can be found on careful clinical examination. However, the truly impalpable testis presents a difficult problem. These testes may be in an ectopic site, intracanalicular, or, most commonly, intraabdominal. In a proportion of cases the testis may be absent. A variety of methods have been used to locate such testes, including venography, ultrasonography, trial of hormone therapy, and surgical exploration. Recently, the role of laparoscopy has been described in locating these testes.‘~’ To assess the value of the laparoscopy, a retrospective review was made of all cases observed in the surgical outpatient department in the Children’s Hospital, Sheffield, over a 7-year period (1982 through 1988). Included were all boys in whom one or both testes were impalpable and who subsequently underwent examination under anesthesia with or without laparoscopy. MATERIALS
AND METHODS
Over ;i 7-year period (1987 through 1988), 69 boys were encountered in whom either one or both testes were not located on clinical examination. These boys subsequently went on to examination under anesthesia, with or without laparoscopy, followed by either orchidopexy (in one or two stages) or orchidectomy. The length of outpatient follow-up ranged from 6 months to 6 years (mean, 1.4 years). The age at surgery ranged from IO months to 15 years (mean. 3 years 9 months): 52 (75%) were less than 5 years old and 33 (55%) were less than 7 years old at the time of operation. The side of
JoumalofPediatric Surgery, Vol 27, No
1
(January),
1992: on 89-92
undescent was left in 34 cases (49%‘). right in 20 cases (29%)), and bilateral in 15 cases (22%), a total of 84 testes in 69 patients. Sixty (92%) underwent laparoscopy. Of these, 5 failed due to technical problems (eg, subcutaneous CO, leakage). Fifty-five successful laparoscopies were performed for 65 undescended testes. In the remaining 9 cases the testes were palpable on examination under anesthesia and. thus, were excluded from further study.
RESULTS
Based on the laparoscopy findings, the patients were segregated into one of two groups: group A (n = 42) in whom the vas and vessels were seen entering the deep inguinal ring, and group B (n = 23) in whom the testis was visualised at the deep ring (n = 8) or was more proximal (n = 15). The outcome is shown in Fig 1. In group A groin exploration was performed. In 20 cases the testis was located either in the canal (16) or in the superficial inguinal pouch (4) and 16 of these 20 were of normal size. The remaining 4 were less than 50% of the size of the contralateral testis. In these patients 15 had the testis brought into the scrotum in one stage and the remaining 5 required more extensive retroperitoneal dissection and underwent the two-stage procedure. Follow-up showed no change in testicular volume relative to the contralatera1 organ after 3 years following operation. The remaining 22 testes were considered so atrophic or were actually absent at exploration and in these orchidectomy or excision of the remnant at the end of the testicular vessels and vas was performed. Histological examination of the excised specimens showed fibrous tissue or atrophic testicular tissue. Of the 23 patients in group B the testis was found lying close to the deep inguinal ring and there was judged to be adequate vas and vessel length in 11, whereas in 6 the testis was lying at the bifurcation of the iliac vessels with apparently adequate length of vas but inadequate length in the vascular pedicle. In the remaining 6 the vas and vessels were blind-ending (absent or atrophic testis). In the group of 11 with
From the Department of Puediattic .Stqeen: The Childrert :v Hospital, Sheffield. En,$and. Date accepted: September IO, 1990. Address reprint requests to D. Wilson-Storey, FRCS. Senior Rexistrar in Paediatric Surety, The Children k Ho.spital. Western Bank. Shefield SlO 2TH. Ettgland. Copyri$t gj 1992 by W B. Saunders Compare\ 0022-346819212701-0024$03.OOlO
89
No subsequent
testicular atrophy
J
(n = 5)
I
Two-stage orchidopexy
I
(n = 15)
I
One-stage orchidopexy
I
1
Fig 1.
(n=22)
Groin exploration
Testicular vessels + vas
Impalpable
r
orchidopexy
Exploration
8 weeks later
(n = 3)
of testicular vessels
(
vessels (n = 6)
Short testicular
atrophy
(
(
/
testicular atrophy
Onesubsequent
1 lmmedi;;;;loration
Nosubsequent
fn = 11)
length for standard
vessels sufficient
testes
Group B fn = 23) lntraabdominal
Laparoscopic diathermy
Laparoscopy for 65 impalpable testes.
Testes fn = 65)
LAPAROSCOPY
FOR UNDESCENDED
91
TESTIS
adequate vas and vessel length, groin exploration was performed and one-stage orchidopexy was achieved in all cases. Follow-up of these patients showed satisfactory growth of the testis. Of the 6 cases in which the testis had a short vascular pedicle, 3 underwent laparoscopic diathermy of the vascular pedicle following exploration via high approach some 2 months later. Two of these testis appeared normal and the third was then atrophic. The 2 normal-sized testis (maintained on the arterial supply of vas deferens) underwent division of the vascular pedicle and orchidopexy. The atrophic testis was excised. The other 3 testes in this short-vessel group underwent immediate exploration. In 2 cases a standard orchidopexy was performed to upper scrotal level and at 6-month follow-up one testis was of normal size but remaining high within the scrotum while the second testis was atrophic and, therefore, removed. The third patient underwent formal exploration, ligation and division of the testicular vessels, with a subsequent second stage orchidopexy 8 weeks later, this testis being normal in size and site at B-month review. In 5 patients laparoscopy failed (6 testes). Exploration was performed immediately. Of the 6 testes within this group 3 underwent successful one-stage orchidopexy. All were found within the inguinal canal and 3 were found to be atrophic and, therefore, were removed. During the early period of this study there were 5 complications following laparoscopy. In 2 cases, tears were caused in the serosa of the sigmoid colon; in both cases exploration was performed with serosal oversewing and there were no postoperative sequelae. In the remaining 3 cases carbon dioxide escaped into the subcutaneous tissues: all resolved spontaneously. DISCUSSION
The impalpable testis poses two major problems to the surgeon: initially locating the testis and then placing it within the scrotum. Many methods have been recommended in the past to locate these testes, the most recent being laparoscopy.‘-” We have confirmed the value of this in the present study. Laparoscopy for 42 testes showed the vas and testicular vessels to pass into the inguinal canal. However, subsequent groin exploration found only 20 of these testes to be normal and suitable for orchidopexy, whereas 22 were either absent or atrophic (vanishing testis syndrome“). Twenty-three testes were noted to be proximal to the deep inguinal ring. Eleven of these were at the level of the deep inguinal ring with adequate vasal
and vascular length permitting one-stage, uncomplicated orchidopexy. In 6 instances the testis lay proximal to the deep inguinal ring with a normal length of vas but short testicular vessels. This situation was studied in detail by Fowler and Stephens,’ who described the division of the testicular vessels bringing down the testis into the scrotum on the adequate vas, testicular viability being maintained by the arterial supply to the vas (long-loop vas orchidopexy). In 3 of these cases, the testicular vessels were initially clamped laparoscopically and once testicular viability was noted, diathermied. Two months later surgical exploration showed 2 of these testes to be normal and the testicular vessels were divided allowing orchidopexy. The third testis in this group had atrophied and was removed. The other 3 testes in this latter group underwent surgical exploration. In 2 cases a one-stage orchidopexy was performed, one of which subsequently atrophied, whereas the third case underwent formal division of the testicular vessels (FowlerStephens) with a second stage orchidopexy 2 months later with no subsequent complications. Thus, laparoscopy is a valuable adjunct to clinical examination in the search for the undescended testis. It allows visualization of the testis to assess its presence, position, and size, and the relative lengths of the vas deferens and gonadal vessels. This permits planning of further management (orchidopexy, orchidectomy) or, indeed, avoids extensive exploration for an absent testis when a blind-ending vas and vessels has been noted. Complications of laparoscopy were uncommon (8.3%) and occurred early during the learning curve. These included 3 cases of gaseous (CO:) leakage into the subcutaneous tissues (spontaneous resolution) and 2 cases of serosal trauma to the sigmoid colon (both oversewn with no long-term problems). From this study we have shown the value of laparoscopy in the investigation and management of the impalpable testis. It was possible in all cases to demonstrate the course of the testicular vessels and vas deferens, thus locating the testis or its atrophic remnant. We have also shown that the laparoscope can be used therapeutically in performing the first stage of the Fowler-Stephens long loop vas orchidopexy, thus precluding extensive surgical exploration and dissection to bring these testes down into the scrotum. ACKNOWLEDGMENT We wish to thank J.A.S. Dickson for allowing patients and Ann Jones for typing the manuscript.
us to study
his
92
WILSON-STOREY
AND MAcKINNON
REFERENCES 1. Scott JES: Laparoscopy as an aid in the diagnosis and management of the impalpable testis. J Pediatr Surg 17:14-16,1982 2. Malone PS, Guiney EJ: The value of laparoscopy in localising the impalpable undescended testis. Br J Urol 56:429-431. 1984 3. Guiney EJ, Corbally M, Malone PS: Laparoscopy and the management of the impalpable testis. Br J Ural 63:313-316, 1989
4. Abeyaratne MR, Aherne WA, Scott JES: The vanishing testis. Lancet 2:822-824, 1969 5. Fowler R, Stephens FD: The role of testicular vascular anatomy in the salvage of high undescended testis. Aust N Z J Surg 29:92-106,1959
