Laparoscopy vs inguinal exploration for nonpalpable undescended testis
http://www.100md.com
《美国医学杂志》
Rainbow Children's Hospital, Krishna Children's Hospital and Hope Children's Hospital, Hyderabad, Andhra Pradesh, India
Abstract
Objective : The optimal initial surgical approach for nonpalpable undescended testis (UDT) is debated. The aim of the present study is to compare the results of initial laparoscopy and inguinal exploration in the management of unilateral nonpalpable undescended testes. Methods : The results of 20 children with unilateral nonpalpable UDT managed by initial laparoscopy (group I) were compared with 20 age-matched children managed by inguinal exploration (group II). The location of testes and results of orchiopexy were compared in both groups. A single surgeon performed all the operative procedures. Results : The majority of testes (16/20 group I, 17/20 group II) in both groups were canalicular or low abdominal. Vanishing testes accounted for one-third (13/40) of the testes, the majority (85%) of which were located in the inguinal canal. All children were discharged within 24 hours of the operation. The success of orchiopexy at 4-6 weeks post-operatively was 85% and 86% in the two groups respectively. Retrospectively, only 7/40 (18%) of the testes would benefit from laparoscopy. Conclusions: Initial laparoscopic and inguinal approaches to nonpalpable UDT give comparable results. This report failed to demonstrate any specific advantage of initial laparoscopy in the majority of children with unilateral nonpalpable UDT.
Keywords: Testis; Nonpalpable; Undescended; Laparoscopy; Orchiopexy
The optimal initial surgical approach for the nonpalpable undescended testis (UDT) is still debated. Laparoscopy and open surgical exploration are the two options, each with its own advocates. The advocates of laparoscopy report several advantages, chiefly to locate the testis accurately, help in testis mobilization, and remove any atrophic remnants.[1] In contrast, several reports state that nonpalpable UDT can be adequately managed by standard inguinal approach[2], and laparoscopy may only increase the operating time and cost in the majority of such children without actually influencing the results[3]. Many recent studies suggest initial inguinal/scrotal exploration for nonpalpable UDT.[4], [5] Further, several authors have questioned the advantage of staged laparoscopic procedures over the single stage open orchiopexy.[6], [7] In this paper, we report a single surgeon's experience of managing nonpalpable UDT by laparoscopy or inguinal exploration.
materials and Methods
Over a 3.5-year period, twenty children underwent initial laparoscopic evaluation for unilateral nonpalpable UDT (group I). During the same period, 20 age-matched children that had undergone initial inguinal exploration for nonpalpable UDT were considered group II. The operative findings and results were compared between the two groups. Before operation, the author examined all the children to confirm nonpalpability of the testis. Children whose testis became palpable under anesthesia are excluded from this report. No pre-operative radiological investigations were routinely performed to localize the testis. The operative approach (initial laparoscopy or inguinal exploration) was decided based on parental preference, after the parents were explained about both approaches in detail.
The aim of initial laparoscopy in group I was to locate the testicle, remove any atrophic remnants and help in mobilization of the vascular pedicle; after mobilization of the abdominal testis, a small inguinal incision was used to complete the orchiopexy. At laparoscopy, if the vas and vessels were found to enter the deep ring, a standard inguinal incision was used for further exploration. In the primary inguinal exploration group (group II), if the testis was not found in the inguinal canal, a retroperitoneal and intraperitoneal exploration was carried out through the deep ring. In both groups, a viable testis was brought down into the scrotum by mobilization of the spermatic pedicle; spermatic vessel ligation was not employed in any patient in this series. The finding of blind-ending vas and vessels indicated vanishing testis, and further exploration was abandoned after removal of the nubbin of tissue at the termination of the vas and vessels. Testes considered atrophic were removed by whatever approach was employed.
Post-operatively, children in both groups were discharged by 24 hrs and received oral antibiotic for 3-5 days and analgesic (Ibuprofen + Paracetamol) for 2 days. Follow-up examination after orchiopexy was conducted in a week and 4-6 weeks time. After that, a 6-month and 1- year follow-up was advised. The author performed clinical examination of the testes at the follow-up.
Results
The mean patient age (range 10m-11yr) was 3.1 yr for group I and 3.4 y for group II. The location and quality of the testes found at operation in both groups is given in table1. Testes that were at or just above the deep ring (including peeping testes) were considered low abdominal, while testes at or above the level of the iliac vessels were considered high abdominal. About one-third (13/40) of the testes were non-viable, i.e., of vanishing or atrophic variety, and were removed. Only 2 of the 13 vanishing testes were intraabdominal, 1 of which was detected and removed at laparoscopy. Thus, 11 of 13 (85%) vanishing testes were distal to the deep ring. Histological examination of the testicular remnants in these 13 vanishing testes revealed viable germ cells in 1 (8%), while the rest (12/13 or 92%) showed hemosiderin, calcification, fibrous tissue or vas deferens. The remaining 13 testes in group I, and 14 testes in group II underwent orchiopexy. In 4-6 weeks follow-up, 2 testes in each group were found to have atrophied. Thus, orchiopexy was considered successful in 11 of 13 testes (85%) in group I, and 12 of 14 testes (86%) in group II. Three of the 4 testes that atrophied after orchiopexy were high abdominal in position to begin with. By either approach, it was noted that these high testes were placed in the scrotum under significant tension. Of the remaining 23 testes, 15 (64%) were seen after 6 months following surgery, and it was noted that all of them were viable.
Discussion
Nonpalpable UDT has been identified as one of the common and classic indications for pediatric laparoscopy. The main advantages of laparoscopy are accurate localization of the testis and the total avoidance of open exploration in some patients. The main criticism against inguinal exploration for a nonpalpable testicle is that it may fail to locate an intraabdominal testicle. In a report by Lakhoo et al[8], the authors found viable testes in 59% of boys with previous negative inguinal exploration. It may be noted that in that report, the initial inguinal exploration was performed by surgeons (adult urologists and general surgeons) without specialized training in pediatric UDT operations. However, in other reports with large series of patients, when the open exploration was performed by specialist pediatric surgeons or pediatric urologists, exploration through the inguinal or the pre-peritoneal approach resulted in testis identification in all cases of nonpalpable UDT.[2], [9] In the present series, inguinal exploration clearly identified the status of all 20 testes (including 12 at or above the deep ring) for which it was employed. Many of the clinically nonpalpable testes were either canalicular or low abdominal, and could be readily managed by the standard inguinal approach.
Several authors reported excellent results with laparoscopic orchiopexy for nonpalpable testis. Chang et al[1] reported an overall success rate of 96% with laparoscopic orchiopexy for nonpalpable UDT. Similarly, good results have been reported for staged laparoscopic Fowler-Stephens orchiopexy.[10] The unanswered question that still remains is how many of these testes could have been adequately managed by open surgery without laparocsopy. Kirsch et al[2] reported a large experience with 447 nonpalpable testes, all of which were treated through a standard inguinal incision. They concluded that the inguinal approach with transperitoneal mobilization of vas and vessels is highly successful for the intraabdominal cryptorchid testis. Williams et al[11] reported that in 37 of 39 nonpalpable testes, groin exploration was sufficient for deciding and executing treatment. Adam and Allaway[9] reported good results with inguinal exploration followed by the pre-peritoneal approach for 110 impalpable testes. They concluded that the advantages of laparoscopy could be achieved by this simple surgery, with a favorable cost: benefit ratio. In the present report, the success of orchiopexy was similar in both the groups, irrespective of the initial surgical approach employed.
The problem with subjecting all children with nonpalpable UDT to initial laparoscopy is that many nonpalpable testes may be located at or distal to the deep ring. Preoperative radiologic tests, including ultrasonogarphy, are not sensitive to locate the testis in the majority of cases.[8] A significant percentage of these children may have vanishing or atrophic testes, and most of these vanishing testes are located distal to the deep ring, mainly in the inguinal canal.[12] In the present report, one-third of the testes (13/40) was of vanishing type, of which 85% were located distal to the deep ring. Laparoscopy in such cases may be of no use in the management as it simply shows the vas and vessels exiting the deep ring. A significant percentage (about 10% in literature and 8% in the present series) of such remnants may contain viable germ cells[12], [13], [14] with a risk of malignant transformation. Inguinal or scrotal exploration thus becomes mandatory to remove these atrophic nubbins. It is with this realization that some authors currently recommend initial scrotal[4] or inguinal[13] approaches for nonpalpable UDT, laparoscopy being reserved for testes not localized by such exploration. Especially in case of young children, other authors have observed that inguinal exploration alone may suffice without the need for laparoscopy, a finding that prompted them to change their policy from initial laparoscopy to initial inguinal exploration[5].
Only a few earlier reports compared laparoscopic vs open inguinal approach to the nonpalpable UDT. In a randomized control trial, Ferro et al[3] concluded that laparoscopy only increased the operating time and cost without any significant advantage over the open surgery. In the present study, we also compared the two approaches and did not find any significant advantage of initial laparoscopy over initial inguinal exploration in the management of unilateral nonpalpable UDT. The only testes that could have benefited from laparoscopy are the high abdominal testes (7/40 or 18%), where initial laparoscopy offers the advantage of deciding and executing stage 1 of Fowler-stephen's technique. Although the number of patients in the present study is not large, it represents the experience of a single surgeon and both the groups were age-matched, which gives credence to the results. The surgical management of the high-placed UDT is a real problem. Although some authors reported excellent results with laparoscopic mobilization of the spermatic pedicle[15], in the present series, the result of orchiopexy for the very high placed testes was not satisfactory by either of the approaches. The author's current policy is to resort to the low spermatic vessel ligation technique[7] in such cases.
In conclusion, initial laparoscopic and inguinal approaches to nonpalpable UDT give comparable results. We failed to demonstrate any specific advantage of initial laparoscopy in the evaluation of the majority of children with unilateral nonpalpable UDT.
References
1. Chang B, Palmer LS, Franco I. Laparoscopic Orchidopexy: a review of a large clinical series. BJU Int 2001; 87 : 490-493
2. Kirsch AJ, Escala J, Duckett JW, Smith GH, Zderic SA, Canning DA, Snyder HM 3rd. Surgical management of the nonpalpable testis: the Children's Hospital of Philadelphia experience. J Urol 1998; 159: 1340-1343
3. Ferro F, Spagnoli A, Zaccara A, De Vico A, La Sala E. Is preoperative laparoscopy useful for impalpable testis J Urol 1999; 162: 995-996.
4. Snodgrass W, Chen K, Harrison C. Initial scrotal incision for unilateral nonpalpable testis. J Urol 2004; 172: 1742-1745.
5. Dhanani NN, Cornelius D, Gunes A, Ritchey ML. Successful outpatient management of the nonpalpable intra-abdominal testis with staged Fowler-Stephens orchiopexy. J Urol 2004; 172: 2399-3401.
6. King LR. Orchiopexy for imaplapble testis: High spermatic vessel ligation is a safe maneuver. J Urol 1998; 160: 2457-2460.
7. Koff SA, Sethi PS. Treatment of high undscended testes by low spermatic vessel ligation: An alternative to the Fowler-stephens technique. J Urol 1996; 156: 799-803.
8. Lakhoo K, Thomas DFM, Najmaldin AS. Is inguinal exploration for impalpable testis an outdated operation Br J Urol 1996; 77: 452-454.
9. Adam AS, Allaway AJ. The difficult orchiopexy: The value of the abdominal preperitoneal approach. BJU Int 1999; 83: 290-293
10. Law GS, Perez LM, Joseph DB. Two-stage Fowler-Stephens orchiopexy with laparoscopic clipping of the spermatic vessels. J Urol 1997; 158: 1205-1207.
11. Williams EV, Appanna T, Foster ME. Management of the impalpable testis: A six-year review together with a national experience. Postgrad Med J 2001; 77 : 320-322.
12. Merry C, Sweeney B, Puri P. The vanishing testis: Anatomical and histological findings. Eur Urol 1997; 31 : 65-67.
13. Alam S, Radhakrishnan J. Laparoscopy for nonpalpable testis. J Pediatr Surg 2003; 38: 1534-1536.
14. Rozanski TA, Wojno KJ, Bloom DA. The remnant orchiectomy. J Urol 1996; 155: 712-714
15. Esposito C, Vallone G, Settimi A, Gonzalez Sabin MA, Amici G, Cusano T. Laparoscopic orchiopexy without division of the spermatic vessels: Can it be considered the procedure of choice in cases of nonpalpable testis. Surg Endosc 2000; 14: 658-660.(Chandrasekharam V.V S.S)
Abstract
Objective : The optimal initial surgical approach for nonpalpable undescended testis (UDT) is debated. The aim of the present study is to compare the results of initial laparoscopy and inguinal exploration in the management of unilateral nonpalpable undescended testes. Methods : The results of 20 children with unilateral nonpalpable UDT managed by initial laparoscopy (group I) were compared with 20 age-matched children managed by inguinal exploration (group II). The location of testes and results of orchiopexy were compared in both groups. A single surgeon performed all the operative procedures. Results : The majority of testes (16/20 group I, 17/20 group II) in both groups were canalicular or low abdominal. Vanishing testes accounted for one-third (13/40) of the testes, the majority (85%) of which were located in the inguinal canal. All children were discharged within 24 hours of the operation. The success of orchiopexy at 4-6 weeks post-operatively was 85% and 86% in the two groups respectively. Retrospectively, only 7/40 (18%) of the testes would benefit from laparoscopy. Conclusions: Initial laparoscopic and inguinal approaches to nonpalpable UDT give comparable results. This report failed to demonstrate any specific advantage of initial laparoscopy in the majority of children with unilateral nonpalpable UDT.
Keywords: Testis; Nonpalpable; Undescended; Laparoscopy; Orchiopexy
The optimal initial surgical approach for the nonpalpable undescended testis (UDT) is still debated. Laparoscopy and open surgical exploration are the two options, each with its own advocates. The advocates of laparoscopy report several advantages, chiefly to locate the testis accurately, help in testis mobilization, and remove any atrophic remnants.[1] In contrast, several reports state that nonpalpable UDT can be adequately managed by standard inguinal approach[2], and laparoscopy may only increase the operating time and cost in the majority of such children without actually influencing the results[3]. Many recent studies suggest initial inguinal/scrotal exploration for nonpalpable UDT.[4], [5] Further, several authors have questioned the advantage of staged laparoscopic procedures over the single stage open orchiopexy.[6], [7] In this paper, we report a single surgeon's experience of managing nonpalpable UDT by laparoscopy or inguinal exploration.
materials and Methods
Over a 3.5-year period, twenty children underwent initial laparoscopic evaluation for unilateral nonpalpable UDT (group I). During the same period, 20 age-matched children that had undergone initial inguinal exploration for nonpalpable UDT were considered group II. The operative findings and results were compared between the two groups. Before operation, the author examined all the children to confirm nonpalpability of the testis. Children whose testis became palpable under anesthesia are excluded from this report. No pre-operative radiological investigations were routinely performed to localize the testis. The operative approach (initial laparoscopy or inguinal exploration) was decided based on parental preference, after the parents were explained about both approaches in detail.
The aim of initial laparoscopy in group I was to locate the testicle, remove any atrophic remnants and help in mobilization of the vascular pedicle; after mobilization of the abdominal testis, a small inguinal incision was used to complete the orchiopexy. At laparoscopy, if the vas and vessels were found to enter the deep ring, a standard inguinal incision was used for further exploration. In the primary inguinal exploration group (group II), if the testis was not found in the inguinal canal, a retroperitoneal and intraperitoneal exploration was carried out through the deep ring. In both groups, a viable testis was brought down into the scrotum by mobilization of the spermatic pedicle; spermatic vessel ligation was not employed in any patient in this series. The finding of blind-ending vas and vessels indicated vanishing testis, and further exploration was abandoned after removal of the nubbin of tissue at the termination of the vas and vessels. Testes considered atrophic were removed by whatever approach was employed.
Post-operatively, children in both groups were discharged by 24 hrs and received oral antibiotic for 3-5 days and analgesic (Ibuprofen + Paracetamol) for 2 days. Follow-up examination after orchiopexy was conducted in a week and 4-6 weeks time. After that, a 6-month and 1- year follow-up was advised. The author performed clinical examination of the testes at the follow-up.
Results
The mean patient age (range 10m-11yr) was 3.1 yr for group I and 3.4 y for group II. The location and quality of the testes found at operation in both groups is given in table1. Testes that were at or just above the deep ring (including peeping testes) were considered low abdominal, while testes at or above the level of the iliac vessels were considered high abdominal. About one-third (13/40) of the testes were non-viable, i.e., of vanishing or atrophic variety, and were removed. Only 2 of the 13 vanishing testes were intraabdominal, 1 of which was detected and removed at laparoscopy. Thus, 11 of 13 (85%) vanishing testes were distal to the deep ring. Histological examination of the testicular remnants in these 13 vanishing testes revealed viable germ cells in 1 (8%), while the rest (12/13 or 92%) showed hemosiderin, calcification, fibrous tissue or vas deferens. The remaining 13 testes in group I, and 14 testes in group II underwent orchiopexy. In 4-6 weeks follow-up, 2 testes in each group were found to have atrophied. Thus, orchiopexy was considered successful in 11 of 13 testes (85%) in group I, and 12 of 14 testes (86%) in group II. Three of the 4 testes that atrophied after orchiopexy were high abdominal in position to begin with. By either approach, it was noted that these high testes were placed in the scrotum under significant tension. Of the remaining 23 testes, 15 (64%) were seen after 6 months following surgery, and it was noted that all of them were viable.
Discussion
Nonpalpable UDT has been identified as one of the common and classic indications for pediatric laparoscopy. The main advantages of laparoscopy are accurate localization of the testis and the total avoidance of open exploration in some patients. The main criticism against inguinal exploration for a nonpalpable testicle is that it may fail to locate an intraabdominal testicle. In a report by Lakhoo et al[8], the authors found viable testes in 59% of boys with previous negative inguinal exploration. It may be noted that in that report, the initial inguinal exploration was performed by surgeons (adult urologists and general surgeons) without specialized training in pediatric UDT operations. However, in other reports with large series of patients, when the open exploration was performed by specialist pediatric surgeons or pediatric urologists, exploration through the inguinal or the pre-peritoneal approach resulted in testis identification in all cases of nonpalpable UDT.[2], [9] In the present series, inguinal exploration clearly identified the status of all 20 testes (including 12 at or above the deep ring) for which it was employed. Many of the clinically nonpalpable testes were either canalicular or low abdominal, and could be readily managed by the standard inguinal approach.
Several authors reported excellent results with laparoscopic orchiopexy for nonpalpable testis. Chang et al[1] reported an overall success rate of 96% with laparoscopic orchiopexy for nonpalpable UDT. Similarly, good results have been reported for staged laparoscopic Fowler-Stephens orchiopexy.[10] The unanswered question that still remains is how many of these testes could have been adequately managed by open surgery without laparocsopy. Kirsch et al[2] reported a large experience with 447 nonpalpable testes, all of which were treated through a standard inguinal incision. They concluded that the inguinal approach with transperitoneal mobilization of vas and vessels is highly successful for the intraabdominal cryptorchid testis. Williams et al[11] reported that in 37 of 39 nonpalpable testes, groin exploration was sufficient for deciding and executing treatment. Adam and Allaway[9] reported good results with inguinal exploration followed by the pre-peritoneal approach for 110 impalpable testes. They concluded that the advantages of laparoscopy could be achieved by this simple surgery, with a favorable cost: benefit ratio. In the present report, the success of orchiopexy was similar in both the groups, irrespective of the initial surgical approach employed.
The problem with subjecting all children with nonpalpable UDT to initial laparoscopy is that many nonpalpable testes may be located at or distal to the deep ring. Preoperative radiologic tests, including ultrasonogarphy, are not sensitive to locate the testis in the majority of cases.[8] A significant percentage of these children may have vanishing or atrophic testes, and most of these vanishing testes are located distal to the deep ring, mainly in the inguinal canal.[12] In the present report, one-third of the testes (13/40) was of vanishing type, of which 85% were located distal to the deep ring. Laparoscopy in such cases may be of no use in the management as it simply shows the vas and vessels exiting the deep ring. A significant percentage (about 10% in literature and 8% in the present series) of such remnants may contain viable germ cells[12], [13], [14] with a risk of malignant transformation. Inguinal or scrotal exploration thus becomes mandatory to remove these atrophic nubbins. It is with this realization that some authors currently recommend initial scrotal[4] or inguinal[13] approaches for nonpalpable UDT, laparoscopy being reserved for testes not localized by such exploration. Especially in case of young children, other authors have observed that inguinal exploration alone may suffice without the need for laparoscopy, a finding that prompted them to change their policy from initial laparoscopy to initial inguinal exploration[5].
Only a few earlier reports compared laparoscopic vs open inguinal approach to the nonpalpable UDT. In a randomized control trial, Ferro et al[3] concluded that laparoscopy only increased the operating time and cost without any significant advantage over the open surgery. In the present study, we also compared the two approaches and did not find any significant advantage of initial laparoscopy over initial inguinal exploration in the management of unilateral nonpalpable UDT. The only testes that could have benefited from laparoscopy are the high abdominal testes (7/40 or 18%), where initial laparoscopy offers the advantage of deciding and executing stage 1 of Fowler-stephen's technique. Although the number of patients in the present study is not large, it represents the experience of a single surgeon and both the groups were age-matched, which gives credence to the results. The surgical management of the high-placed UDT is a real problem. Although some authors reported excellent results with laparoscopic mobilization of the spermatic pedicle[15], in the present series, the result of orchiopexy for the very high placed testes was not satisfactory by either of the approaches. The author's current policy is to resort to the low spermatic vessel ligation technique[7] in such cases.
In conclusion, initial laparoscopic and inguinal approaches to nonpalpable UDT give comparable results. We failed to demonstrate any specific advantage of initial laparoscopy in the evaluation of the majority of children with unilateral nonpalpable UDT.
References
1. Chang B, Palmer LS, Franco I. Laparoscopic Orchidopexy: a review of a large clinical series. BJU Int 2001; 87 : 490-493
2. Kirsch AJ, Escala J, Duckett JW, Smith GH, Zderic SA, Canning DA, Snyder HM 3rd. Surgical management of the nonpalpable testis: the Children's Hospital of Philadelphia experience. J Urol 1998; 159: 1340-1343
3. Ferro F, Spagnoli A, Zaccara A, De Vico A, La Sala E. Is preoperative laparoscopy useful for impalpable testis J Urol 1999; 162: 995-996.
4. Snodgrass W, Chen K, Harrison C. Initial scrotal incision for unilateral nonpalpable testis. J Urol 2004; 172: 1742-1745.
5. Dhanani NN, Cornelius D, Gunes A, Ritchey ML. Successful outpatient management of the nonpalpable intra-abdominal testis with staged Fowler-Stephens orchiopexy. J Urol 2004; 172: 2399-3401.
6. King LR. Orchiopexy for imaplapble testis: High spermatic vessel ligation is a safe maneuver. J Urol 1998; 160: 2457-2460.
7. Koff SA, Sethi PS. Treatment of high undscended testes by low spermatic vessel ligation: An alternative to the Fowler-stephens technique. J Urol 1996; 156: 799-803.
8. Lakhoo K, Thomas DFM, Najmaldin AS. Is inguinal exploration for impalpable testis an outdated operation Br J Urol 1996; 77: 452-454.
9. Adam AS, Allaway AJ. The difficult orchiopexy: The value of the abdominal preperitoneal approach. BJU Int 1999; 83: 290-293
10. Law GS, Perez LM, Joseph DB. Two-stage Fowler-Stephens orchiopexy with laparoscopic clipping of the spermatic vessels. J Urol 1997; 158: 1205-1207.
11. Williams EV, Appanna T, Foster ME. Management of the impalpable testis: A six-year review together with a national experience. Postgrad Med J 2001; 77 : 320-322.
12. Merry C, Sweeney B, Puri P. The vanishing testis: Anatomical and histological findings. Eur Urol 1997; 31 : 65-67.
13. Alam S, Radhakrishnan J. Laparoscopy for nonpalpable testis. J Pediatr Surg 2003; 38: 1534-1536.
14. Rozanski TA, Wojno KJ, Bloom DA. The remnant orchiectomy. J Urol 1996; 155: 712-714
15. Esposito C, Vallone G, Settimi A, Gonzalez Sabin MA, Amici G, Cusano T. Laparoscopic orchiopexy without division of the spermatic vessels: Can it be considered the procedure of choice in cases of nonpalpable testis. Surg Endosc 2000; 14: 658-660.(Chandrasekharam V.V S.S)