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Paper text:
undescended testis is the most common congenital urological disorder with an overall incidence of 1.8% to 4% in full - term male newborns and decreases to 1% at age 1 year .
untreated cryptorchidism has deleterious effects on the testis over time , with the risk of malignancy in intraabdominal testis as high as 5% , increasing with age .
therefore , early investigations and treatment of impalpable testis is important to increase the likelihood of fertility and to allow adequate follow - up for possible testicular malignancies .
overall , the majority of patients with undescended testes are identified and treated in childhood , but a significant portion of them in third - world countries present late due to the inaccessibility of healthcare and various other socioeconomic reasons .
historically , surgical exploration has often been used to diagnose and manage impalpable testis . with the advent of laparoscopy ,
a technique reported by cortesi has been used widely in the diagnosis of undescended testis .
the diagnostic and therapeutic management of the nonpalpable testis has changed over the years , and there are many studies on laparoscopic management of nonpalpable testis in pediatric surgery , but very few studies have been performed for the management of older patients . with this background , we evaluated the usefulness of laparoscopy in localization and treatment of impalpable testis by using prentiss ' maneuver to shorten the course of the spermatic cord in adolescents and older patients .
this prospective study was conducted at liaquat university of medical and health sciences , jamshoro , pakistan , from june 2003 to july 2008 .
thirty - eight patients with 46 impalpable testes who were admitted to our institution for management were enrolled in this study .
six patients were lost in follow - up and were excluded from the study ; therefore , 32 evaluable patients with 40 impalpable testes were included in the study .
careful physical examination to palpate and locate the testis was performed with patients in supine and standing positions .
all patients with impalpable testis who were 10 years of age were included in study .
patients with palpable testes , who were < 10 years of age and who did not give consent were excluded from the study . because it was cost effective and noninvasive , ultrasonography ( us ) of the abdomen and pelvis
was performed in all cases . computed tomography ( ct ) and magnetic resonance imaging ( mri ) were not done , because most patients could not afford them , and patients immediately underwent laparoscopic assessment .
all patients were fully informed regarding the laparoscopic - assisted orchiopexy or orchiectomy according to our hospital protocol .
however , in special cases where patients preferred orchiopexy and strictly refused orchiectomy , the wishes of the patients were considered accordingly after counseling in detail and explanation of the possible future consequences .
data were collected in a specially designed proforma document , containing all demographic , operative , and postoperative details for each subject .
laparoscopy was performed with all patients under general anesthesia ( ga ) . before laparoscopy ,
a urethral catheter was placed to empty the bladder , and the patient was placed in a trendelenburg position for laparoscopy .
a 12-mm supraumbilical transverse incision was made , and a 10-mm trocar was inserted under direct vision by using the hasson technique .
two other 5-mm ports were made along the anterior axillary line on either side accordingly for orchiopexy or orchiectomy .
when the testis was diagnosed as intraabdominal , the volume of the testis , length of the vas and vessels , and the association of inguinal hernia were determined . where the testis was found to be atrophic , laparoscopic orchiectomy was the preferred procedure .
a grasper was used to lift up the testis , and spermatic vessels and vas were freed , clipped , and cut with laparoscopic scissors . in cases where the vas deferens and spermatic vessels were seen entering the deep inguinal ring , intraabdominal testis were excluded and the inguinal canal explored . in these cases ,
the inguinal canal was explored by using the open surgical technique , and orchiopexy or orchiectomy was performed taking into consideration the size of the testis , age and wishes of the patient . in the majority of patients in our study ,
when testis was found near the deep ring ( peeping into the internal ring ) or found having a normal size , testis along with its vascular pedicle were mobilized .
dissection was started by incising the peritoneum over the testis , and the pedicle was mobilized carefully as high as possible .
the length of the vas and vessels was measured by using a ruler intraoperatively before and after mobilization .
after sufficient length was obtained , the prentiss ' maneuver was used to shorten the course of the spermatic cord by creating a neo - inguinal ring medial to the epigastric vessels by a small inguinal incision .
testes were brought down into the scrotum and were fixed in a subdartos pouch in a standard fashion as in the open surgical technique .
none of the patients in this study had hypospadias , mllerian ductus remnants , or ambiguous genitalia .
all those patients who underwent orchiopexy were reviewed at 3 months and 1 year after the procedure to assess the postoperative outcome .
all those patients who underwent orchiopexy were reviewed at 3 months and 1 year after the procedure to assess the postoperative outcome .
during the study period , 32 evaluable patients with 40 impalpable testes underwent laparoscopic management of the testis .
ages of patients ranged from 11 years to 37 years with a mean age ( + sd ) of 19.3 + 6.98 years . of 32 patients ,
18 ( 56.25% ) had impalpable testis on the right side , 6 ( 18.75% ) on the left side , and 8 ( 25.00% ) patients had bilateral involvement .
ultrasonography localized 16 ( 40% ) of these impalpable testis , while laparoscopy revealed 36 ( 90% ) , and the remaining 4 ( 10% ) testes were diagnosed as vanishing testis ( anorchia ) as shown in table 1 .
testicular localization by ultrasound versus laparoscopy of 30 intraabdominal testes , single - stage laparoscopic - assisted orchiopexy was successfully performed in 16 ( 40% ) testes , while laparoscopic orchiectomy was performed in 14 ( 35% ) testes .
six testes where vas and vessels entered the internal ring were diagnosed as intracanalicular testis .
they were explored by inguinal incision , inguinal orchiopexy was done in 2 ( 5% ) testes , and inguinal orchiectomy was performed in the remaining 4% of testes .
blind ending vessels were seen in 4 cases , and they were diagnosed as vanishing testes as shown in table 2 .
seven ( 17.5% ) testes were associated with ipsilateral hernia , and hernia repair was done laparoscopically at the same time .
the mean operative time was 20 minutes ( range , 10 to 25 ) for diagnostic laparoscopy , 60 minutes ( range , 45 to 70 ) for orchiectomy , and 90 minutes ( range , 60 to 100 ) for laparoscopic - assisted orchiopexy as shown in table 3 .
procedures and outcomes * * diag = diagnostic ; lap = laparoscopic ; ing = inguinal ; intraabd = intraabdominal ; int = internal .
minor complications were seen in 3 patients : subcutaneous hematoma at the port site in 1 patient and surgical emphysema in 2 patients .
texf}the ability to reproduce has always been of paramount importance , but cryptorchidism / undescended testis may cause infertility .
the diagnostic yield of ultra sonography , computed tomography , and magnetic resonance imaging varies from 32.1% to 67.0% , which is not satisfactory .
many surgical techniques have remained in use for correction of this pathology over the years .
cortesi et al were the first to use laparoscopy as a diagnostic tool for impalpable testes , while jordan described the first laparoscopic orchiopexy in 1992 . since then after the success of laparoscopy in many other fields and improvements in video technology , laparoscopic orchiopexy and orchiectomy have gained considerable support and are used frequently .
the main benefit of laparoscopy lies in the fact that it can be used as a diagnostic tool then converted immediately into a therapeutic tool .
it is not permissible to leave the intraabdominal testis untreated , unless it is a vanishing testis .
another benefit of laparoscopic surgery is that surgery can be done minimally invasively with few holes and a small inguinal incision .
conventional orchiopexy can not produce good results in the case of intraabdominal testis , because the testicular vessels are short and adequate lengthening is not easy .
one- and 2-stage laparoscopic fowler - stephens orchiopexy have been used successfully in pediatric patients .
very few studies have been performed analyzing the laparoscopic management of impalpable testis in older patients .
this is because in the western world patients are identified and treated in childhood due to good health care systems and awareness of the problem . in developing countries , late presentation of undescended testis
is not uncommon ; however , with the introduction and increasing use of laparoscopy in the third world , a few studies have been done in india for management of impalpable testis in adults with satisfactory results inconsistent with the results of this study . in our study , patients were comparatively older compared with patients in other international studies , because of the late presentation of patients in this part of world .
we utilized the benefits of minimally invasive surgery in this age group and performed either orchiectomy or one - stage laparoscopic - assisted orchiopexy in the majority of patients .
there are current recommendations for orchiectomy in postpubertal patients up to age 32 and 50 years .
however , we could not adapt this aggressive approach due to patient 's preference for orchiopexy for various social reasons .
orchiopexy was done after frozen section in this subset of patients who strictly refused orchiectomy .
these patients were informed regarding the future consequences including risk of cancer and were advised to receive regular follow - up . in this study , we used prentiss ' maneuver and shortened the course of vas and vessels by creating a new inguinal ring medial to inferior epigastric vessels . in this way , we were able to bring down the testis and fix it in the subdartos pouch successfully without tension , in all cases . in this laparoscopic - assisted study ,
the spermatic vessels were mobilized as high as possible by laparoscopy , a neo - inguinal ring was created medial to inferior epigastric vessels to shorten the course of the spermatic cord , and the remaining part of the procedure , ie , fixation of testis in the subdartos pouch , was completed by the open surgical method . in our study ,
operative time for single - stage laparoscopic - assisted orchiopexy was 90 minutes compared with other international studies where operative time for laparoscopic orchiopexy was 205 and 180 minutes , respectively .
this short operative time may be because after mobilization , fixation of the testis in the subdartos pouch was performed using open surgery .
however , these international studies were done in pediatric patients , whereas our study was done in comparatively older patients .
laparoscopy is a safe , effective modality in the diagnosis and management of impalpable testis in adolescents and adult men , especially when ultrasonography is not informative . performing the prentiss ' maneuver by shortening the usual path of the spermatic cord medial to the vessels was beneficial for fixing the testis in the scrotum without tension .
laparoscopic - assisted single - stage orchiopexy appears to be a safe , effective procedure for intraabdominal testis in adolescent and older patients .