LAPAROSCOPIC MANAGEMENT OF UNDESCENDED TESTIS
Dr Ghulam Hazrat
Project submitted towards completion of Diploma in Minimal Access Surgery, World Laparoscopy Hospital, Gurgaon, NCR Delhi, INDIA. AUGUST 2007
In present article, the usefulness of laparoscopy in diagnosis and treatment of undescended testis is discussed.
Undesended testis is one of the disorders which is common among children in childhood urology.
Here in the initial experience in laparoscopy management of undescended testis will be presented. Laparoscopy was performed on thirteen patients under general anaesthesia , the inguinal canal has been dissected if vas deferens and the internal spermatic vessel made the ways into the internal inguinal ring , orchiopexy or orchiotomy has been performed laparoscopically in cases of intra abdominal testis.
If the internal spermatic vessles has been found terminated interaperetoineal with a blind end the case is going to be considered as a vanishing testis, 13 boys who have been identified with twenty one impalpable testis were between 18 months up to twenty five years ( median 9.8 years ) fourteen of the twenty one impalpable testis , the vessel and vas deferens were seen through the internal ring and the inguinal region needed dissection and then orchiopexy was performed on twelve testis and orchioctomy was performed on two atrophic testis laparoscopically . Four of the twenty one of the testis were found intra abdominal and were localized . Orchiopexy has been performed laparoscopically on two testis and orchiectomy has been performed in two testis laparoscopically and two have been diagnosed vanishing testis and the one which was absence found unilateral on the left side in one of the cases and in the other found bilateral. Laparoscopy is an excellent and help full for diagnostic parposes as well and laparoscopy is the best technique in the diagnosis of undescended testis especially when sonography, C T scaning, MRI are not informative enough.On the other hand orchiopexy and orchiotomy can be done in patients via laparoscopy in intra abdominal testis so the laparoscopy has the most effective and important role in the treatment and diagnosis of the undescended testis.[2,3,6,9,23,42,]
Aim of Study:
Aim is to examine and valuate the role of laparoscopy management of undescended testes.
Diagnostic Laparoscopy, laparoscopy , undescended testis
Undescended testis is one of the common genital anomalies in the genital system of boys, and is high in the premature boys comparing to term new borns.
Problems associated with undescended testis includes the following:
Material and Methods:
The records on a group of boys who went under diagnostic laparoscopic from 16 patients with 20 undescended testis were found , the data which is collected contains the following , affected side age of the patients ,location of the testis at the time of laparoscopy, operation performed ,complications and the surgeon who performed the surgery .
Cortesi has used laparoscopy for the first time for diagnose of impalpable undescended testis in 1976 and later on Lowe has reported a large number series of impalpable testis in laparoscopy cases.Since 1990 laparoscopy has been used by urologist for the treatment of impalpable tetis and since then orchiopexy and orchiectomy have been used laparoscopically[1 ,2,3,4,5,6,7]
Literature in laparoscopy shows that the accuracy rate of the location of the testis is more then 95% in laparoscopy.Laparoscopy has been help in localize testis and the operation guided by laparoscopy safely and can be used for all ages group. Perinatal torsion is usually cause in absence of testes It is obligatory to assess infuinal canal if spermatic vessels are through the inguinal canal and these vessels might extend to a testis which can be small and might remain in seminiferous tubules and removal must be done in time.
A proper introduction of the neddle and telescope is the great help for reaching the proper diagnose in undescended testis sweft and less traumatic.
All other modalites used for diagnostic like ultrasonography, computerized tomography ,resonance and venography have never been as accurate as laparoscopy and are not reliable especially in cases which are reported negative [24,25,26,27] .
We prefer not to try to reduce the testis via scrotal incision and then and artery forceps has been introduced in the internal ring this is found more traumatic and not very simple . In case if the testis could not be broght to the base of the scrotum then it is wrapped it in a silastic membrane and six mounts and then re explored.If the testis was above the internal ring and associated woth closed internal ring then ligation of the testicular vessels with metal clip is recommended without dissecting aggressively at this stage[26,27,28] and after six mount the testis can be brought to the scrotal base which the artery vessal will be developed well.
In adult, orchiectomy is the choice of treatment, in cases of unpalpable testis unnessessary surgical intervention can be avoided by laparoscopy, helps to localizes the testis and determine paratesticular pathologies and an appropariate surgical procedure can be selected and orchiopexy performed safely and unnessesary operation can be avoided [6,9,13,24,25,26]
If comparing the operation time, laparoscopically is usually longer then open, operation but with experienced hand the duration can be shortened.
And, finnaly laparoscopy is the most important in diagnosis and treatment of undescended testis and has its own advanteges like less complication rate, less severe post operative pain shorter stay in the hospital, less scar and early return to normal activities [12,13,16,23,26,27].
If laparoscopy examination is unsatisfactory for some reason then exploration is still indispensable for the management of undescended testis.
1.Russell RC,Norman SW, Christopher JK. The testis and scrotom. In:Bailey and Loves Short practice of surgery .23rd edn. London: Arnold: 2000.pp.1270-83.
2. Craig AP , Louice RK. Laparoscopy in children and adults . In: Patrick CW, Alan BR, duracott E ,Alan JW, ,editors. Campbell’s urology.7th edn. Philadelphia :WB , Saunders Company :1998.pp.2875-911.
3.Van Savage JU. Avoidance of inguinal incision in laparoscopically confirmed vanishing testis syndrome , J Urol 2001;166:1421-4.
4.Godbole PP Najmaldin AS Laparoscopic orchiodopexy in children, J Endourol 2001.15:251-6
5.Tsujihata M, Miyak O,Yashimura k, MAtsumiya k , TakaharaS,etal. Laparoscopic diagnosis and treatment of nonpalpable testis. Int J Urol 2001,8,692-6.
6.Docimo S G, Peters C, A,Pediatric endourology and laparoscopy ,in : Campbel Urology Walsh P. C. Retik A, B,Vaughan ED Wein A J Philadephia 2002 pp 2564-2592.
7.Storey D W,Mac Kinnon Ak . the laparoscope and the undescended testis J Pediatric Sur 1992,27:89,92.
8.Gill B , Kogan S,Starr S,Reda E,, Levitt S,S.Significance of epididymal and ductal anomalies assodiated with testicular maldescent .J Urol 1989. 142.556.8.
9.Jacob R . congenital anomalies of the testis and scrotum. In : Patrick C W , Alan BR , E, Duracott E , Alan JW, Editors. Campbell;s Urology. 7th edn. Philadelphia;WB . Saunders company; 1998.pp.2172-92.
10. Lee JK , MCClennan BL, Stanley RJ, Sugel SS. Utility of computed tomography in the localization of the undescended testis. Radiology1980;135-121-5.
11. Wolverson MK , Houttuin E, Sundaram M , ShieldsJB. Comparison of computed tomography with high resolution real time ultrasound in the localization of the impalpable testis . Radiology 1983; 146:133-6.
12, Gill I S , Ross J, H ,Sung, G,T,Kay R, Needlescopeic surgery for cryptorchidism :the initial series . J Pediatr Surg , 2000, 35 (10):1426-1430.
13. Kim C, Bennett N , Docimo SG (2005) Missed testis on laparoscopy despite blind – ending vessels and closed processus vaginalis. Urology 65:1226e7-1226e8.
16. Cortesi N, Ferrari P, Zambarda E, Manent A, Baldini A, Morano F.P : Diagnosis of bilateral abdominal cryptorchidism by laparoscopy. Endoscopy , 1976,8(1):33-34.
17.Brock J. W, HolcoMB, G.W, Morgan W,M,. the use oflaparoscopyin the management of the nonpalpable testis. J laparoendosc sur, 1996, 6,: 35-39.
18. Lindgren B. W, Darby E ,C, Faiella L, et , al . laparoscopic orchiopexy: procedure of choice for the nonpalpable testis. J . Urol, 1998. 159 (6):2132- 2135.
19 MOORE R.G, Peters C. A, Bauer S. B, Mandell J, Retik A. B. laparoscopic evaluation of the non palpable testes : a prospective assessment of accuracy J Urol , 1994,151 (3):728-731.
20, Holcomb G. W, Brock J,W,, Neblett W.W. Ed al. laparoscopy for the non palpable testes . Am Surg.1994. 60 (2): 143-147.
21. Cortes, D, Thorup JM, Lenz K , Beck BL , Nielsen OH. Laparoscopy in 100 consecutive patients with 128 impalpable testes. Br J Urol 1995; 1995 ;75:281-7.
22. Dean GT,O, reilly PH , brough WA. Laparoscopy for undescended testis: embryological considerations . Br J Urol 1995:76:806- 7.
23,De Fillippo RE, Barthold JS,Gonzales R. the application of magnetic resonance imaging for the preoperative localization of non palpable testis in obese children :an alternative to laparoscopy . J Urol 2000: 164: 154-5.
24, Lojanapiwat B, Soonthrnpun S, Wudhikarn S. Preoperative laparoscopy in the management of the nonpalpable testis . J Med Assoc Thai 1999; 82:1106-10.
25.Hauser R, Lessing JB , Samuel D, Yavetz H, Peyser MR, Paz GF, Hommonnai Z. management of bilateral non palpable testis : laparoscopy diagnosis and orchidectomy. Int J Androl1994; 17:74-7.
26.El Gohary MA . The role of laparoscopy in the management of impalpable testis. Pediatr Surg Int 1997; 12:463-5.
27. Elder JS. Two-stage Fowler-Stephens orchiopexy in the management of intra – abdominal testes. J Urol 1992, 148:1239-41.
28. Yu TJ, Lai MK , Chen WF, Wan YL.Two-stage orchiopexy with laparoscopic clip ligation of spermatic vessels in prune-belly syndrome. J Pediatr Surg 1995,30:870-2.
29.Youngson GG , Jones PF . Management of the impalpable testis: Long-term results of the preperitoneal approach. J Pediatr Surg, 1991;26:618-20.
30.Merguerian PA , Mevorach RA , Shortliffe LD, cendron M.laparoscopy for the evaluation and management of the non palpable testis. Urology1998;51( Suppl 5 A):3-6.
31.Sousa A, Gayoso R,Lopez- Bellido D, Rebordeo J, Perez –Valcarcel J, Fueintes M. Laparoscopic assessment and orchidectomy for adult undescended testis. Surg laparosc Endosc Percutan Tech 2000;10:420-2.
32.Roque MC, Fernandez GI,Param de Santiago P, Garcia – cuerpo E, Lavaco Castello F (1993) laparoscopic signs of testicular absence. Arch Espan Urol 24: 233-235.
33.cromie WJ (1978) congenital anomalies of the testis , vas, epididymis and inguinal canal.Urol clin North Am 5: 237-257.
34. Poenaru D,Homsy YL,Peloqui F, Andze GO(1994) the value of laparoscopy in the diagnosis and treatment of non-palpable testicular cryptorchidism .prog Urol 4:206-273.
35.Lowe D.H, Broch W.A. Kaplan G.W. Laparoscopy for localization of non palpable testis.J Urol,1984,131.(4):728-729.
36 . Poenaru D, laparoscopic management of the impalpable abdominal testis. Urology 1993; 42:574-8.
37.lindgren BW , et al. laparoscopic orchidopexy procedure of choice for the nonpalpable testis Urol 1998 ; 159:2132-5.
38,Mark SD Davidson PJT. The role of laparoscopy in evaluation of the impalpable undescended testis. Aust NZ J Surg 1997 ; 67:332-4.
39.Gill, B Kagon S , Stars , Reda E, Levitt S . significance of epididymal and ductal anomalies associated with testicular maldescent J , Urol;1989; 142;556-8.
40. Jordan GH, Winslow BH Laparoscopic single stage and staged orchidopexy J Urol .1994; 152, 1249.
41.Thomas R , David AB Arnold C surgery of scrotom and testis in children in Patrick CW , Alan BR Duracott E , Alan JW, Editors. Campbells Urology 7th Edn. Philadelphia WB Saunders Company: 1998 2193-209 pp.
42.Van Savage JU. Avoidance of inguinal incision in laparoscopically confirmed vanishing testis syndrome, J Urol 2001.166,142-4.
43,Tsujihata M, Miyake O, Yashimura K, Kakimoto K , Matsumiya K , Takahara S , etal . Laparoscopic diagnosisand treatment of nonpalpable testis . Int J Urol 2001, 8: 692-6.
44.Bloom Da (1991) Two step orchiopexy with pelvicopic clip ligation of the spermatic vessels . J Urol 145:1030-1033.
45. Ronsley PG, voremark JS , Caldmone AA, bellinger MF (1984) Primininary ligation of the gonadal vessels prior to orchidopexy in the intra abdominal testicle : a staged Fowler – stephens procedure . world J Uro 2: 266-268.
46.Ivanove A , Dewey C, Fahenkamp D , Luning M(1994) MRIT in non palpable testis. Fortschr Geb Rontgenstrahlen Neuen Bildgeb Verfah 160:249-253.
47, Nassar A H M (1995) Laparoscopy assisted orchiopexy : a new approach to the non palpable testis. J Pediatr Surg 30: 39-40.
48. Maghnie M , Vanzulli A , Paesano P , Bragheri R, Palladini G preti P , et al . the accuracy of magnetic resonance imaging and ultrasonography compared with surgical findings in the localization of the undescended testis .Arch Pediatr Adolesc Med 1994; 148:699-703.
49.Rajfer J , Tauber A ,Zinner N, Naftulin E,worthen N , the use of computerized tomography scaning to localize the impalpable testis . J Urol 1983;129:972-4.
50. Antony Ac . Laparoscopy and the management of the non palpable testis . In Thomas RG , Mark AT , John LL, editors . laparoscopy surgery, first Indian Edn. New delhi Jaypee brothers , 1994.pp 161-70.
51.Riquelme M(2002) Laparoscopic orchiopexy for the palpable and non palpable undescended testis (submitted).In: Presented at the amirican academy of pediatrics 2002 national conference and exhibition , October ,pp .18-23 , Boston ( urology section).
52. Glenn J F (ed)(1991) Urologic surgery ,4th edn. Lippincott, Philadelphia.