Rationale for the Procedure and/or General Comments
Laparoscopy has been used since 1976 for the evaluation of the non-palpable testis in pediatric patients. The rationale for the procedure has been to decrease the morbidity of open standard surgical exploration for the non-palpable testicle. Furthermore, therapeutic interventions such as orchiopexy and orchiectomy are also feasible using this technique.
Technique
In the operating room under general anesthesia, a second manual palpation is performed to check for testes in the inguinal canal or scrotum. If none is found, the patient is prepped and draped in the usual manner. The primary port is inserted in the periumbilical region. A 5-mm port is placed in the contralateral lower abdominal quadrant for manipulation. A second port can be used for laparoscopic clipping and division of testicular vessels where necessary for the first part of the two-part staged Fowler-Stevens orchiopexy. During this part of the procedure, the testicle is identified and its relation to the spermatic vessels and internal inguinal ring ascertained. A testicle that is normal size for the patient�s age should be salvaged, whereas a testicle that is non-viable should be removed. If no testicle is identified on laparoscopy and blind ending spermatic vessels are seen, the testicle has atrophied and the procedure is terminated. If no testicle is identified, no spermatic vessels are seen, and only the vas deferens is seen going into the inguinal canal, the laparoscopic dissection must continue higher in the retroperitoneum in search of the undescended testicle. The second stage of the procedure is usually performed approximately 6 months later through a high groin incision mobilizing the testicle into the scrotum.
Indications
� Identification of a non-palpable testis on physical exam
Contraindications
� Inability to tolerate the procedure
� Dense abdominal adhesions that may preclude safe access and/or dissection
Risks
� Procedure- and anesthesia-related complications
Benefits
� Decreased morbidity, less pain, and earlier recovery compared with open exploration
Diagnostic Accuracy of the Procedure
Diagnostic laparoscopy identifies the location of a nonpalpable testis with 99-100% accuracy (level III) [1-5]. The procedure reliably demonstrates whether the testicle is present intra-abdominally or whether the vas and the vessels enter the internal inguinal ring. When laparoscopy is applied only for diagnosis, it can still prevent unnecessary abdominal explorations in 13-18% of patients (level III) [1,3]. Inguinal exploration alone may identify up to 34% of testicles and obviate laparoscopy; however, no good predictors exist III) [3]. Laparoscopy by a skilled laparoscopist enables therapeutic intervention (orchidopexy or orchiectomy), minimizes the need for open explorations, and preserves the benefits of the minimally invasive approach. Importantly, physical examination under anesthesia prior to laparoscopy may identify up to 18% of nonpalpable testicles in the groin (level III) [3]. There are little data comparing laparoscopic and open exploration.
Procedure-related Complications and Patient Outcomes
Procedure-related complications have been described to occur in 0-3.2% of patients, the most severe being a bowel injury.
Laparoscopic-assisted orchidopexy has been associated with 0-2.2% testicular atrophy and 97% success rates. This compares favorably with the one-stage Fowler-Stephens orchidopexy (with a 22% atrophy and 74% success rate) and the two-stage Fowler-Stephens orchidopexy (with a 10% atrophy and 88% success rate) (level III) [4,5]. It has been hypothesized that laparoscopic orchidopexy may decrease the rate of testicular atrophy by preserving the vascular supply as it can be performed usually in one stage.
Cost-effectiveness
There are no available data on the cost-effectiveness of the procedure.
Limitations of the Available Literature
The quality of the available literature for laparoscopy in the management of non-palpable testis is limited to level III evidence. No studies compare the open and laparoscopic approach with regard to patient morbidity, and there is inconsistency in the use of preoperative localization studies before laparoscopy. These limitations make strong recommendations difficult.
Recommendations
Patients undergoing DL for nonpalpable testis should have physical examination of the groin under anesthesia before the procedure is started as this approach will identify up to 18% of testicles and obviate the need for the procedure (grade A). Diagnostic laparoscopy should be part of the treatment algorithm of patients with nonpalpable testis as it is likely to improve patient outcomes; however, further higher quality study is needed. (grade C).
Bibliography
1. Lima M, Bertozzi M, Ruggeri G, Domini M, Libri M, Pelusi G, Landuzzi V, Messina P. The nonpalpable testis: an experience of 132 consecutive videolaparoscopic explorations in 6 years. Pediatr Med Chir, 2002 Jan-Feb;24(1):37- 40.
2. Baillie CT, Fearns G, Kitteringham L, Turnock RR. Management of the impalpable testis: the role of laparoscopy. Arch Dis Child, 1998; 79:419-422.
3. Cisek, Lars J, Peters, Craig A.; Atala, Anthony, Bauer, Stuart B, Diamond, David A.; Retik, Alan B. Current findings in diagnostic laparoscopic evaluation of the nonpalpable testis. J Urol. 1998 Sep;160(3 Pt 2):1145-9; discussion 1150.
4. Merguerian PA, Mevorach RA, Shortliffe LD, Cendrn M. Laparoscopy for the evaluation and management of the nonpalpable testicle. Urology. 1998 May;51(5A Suppl):3-6.
5. Baker LA, Docimo SG Surer I, Peters C, Cisek L, Diamond DA, Caldamone A, Koyle M, Strand W, Moore R, Mevorach R, Brady J, Jordan G, Erhard M, Franco I. A multi-institutional analysis of laparoscopic orchidopexy. B J U Int. 2001 apr;87(6):484-9.