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- J Indian Assoc Pediatr Surg
- v.29(1); Jan-Feb 2024
- PMC10883188
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J Indian Assoc Pediatr Surg. 2024 Jan-Feb; 29(1): 39–42.
Published online 2024 Jan 12. doi:10.4103/jiaps.jiaps_46_23
PMCID: PMC10883188
PMID: 38405236
Nachiket Milind Joshi1,2 and Rasik Shamji Shah3,4
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ABSTRACT
Aims and Objectives:
The aim of this study was to objectively assess the long-term results of laparoscopic orchidopexy in patients who were diagnosed clinically to have nonpalpable undescended testis (UDT).
Materials and Methods:
All operated cases of nonpalpable UDT from January, 2000, to January, 2014, were reviewed. After informed consent, all patients were subjected to a color Doppler ultrasound examination to assess the location of the testis, its size, blood supply, and consistency. The size of the testis, operated and nonoperated, was noted down in volume using the formula of 0.71 × length × breath × height.
Results:
A total of 114 patients could be identified, who had undergone laparoscopy for nonpalpable UDT in the study period. Of these, 44 patients (54 units) underwent a color Doppler study to assess the testes. All the testes were found to lie in the scrotum with preserved blood supply. The volume of the operated unilateral testes (mean = 1.605 cm3) was smaller than the normal nonoperated side (mean = 2.524 cm3). The smaller testicular volume was observed in spite of maintained blood supply to the testes. In cases of bilateral UDT, both the testes were smaller in size (mean = 2.2 cm3), but were comparable to each other. In addition, the ultrasound examination revealed the presence of normal hom*ogenous parenchyma of all the testes similar to the nonoperated side.
Conclusion:
Laparoscopic orchidopexy is a safe and effective option in the treatment of nonpalpable UDT. On a long-term basis, it is possible to achieve scrotal position along with preserved blood flow following laparoscopic orchidopexy in all patients suffering from nonpalpable UDT.
KEYWORDS: Color Doppler, impalpable, laparoscopy, size, undescended testis
INTRODUCTION
Undescended testis (UDT) is the most common congenital urological disorder. The incidence of UDT is 1.8%–4% in full-term male newborns[1] and decreases to 1% at age 1 year. The nonpalpable testes account for approximately 20% of UDT.[2,3,4] The overall incidence is even higher for preterm infants, with the most comprehensive studies citing a frequency of 21%–23% for male neonates with a birth weight <2.5 kg. Although UDT is more common on only one side, both testes are affected in nearly 10% of patients.[5,6,7,8] Spontaneous descent after the 1st year of life is uncommon. Untreated cryptorchidism has deleterious effects on the testis over time, with the risk of malignancy in intra-abdominal testis as high as 5%, increasing with age.[9,10,11,12] Therefore, early investigations and treatment of impalpable testis are important to increase the likelihood of fertility and to allow early diagnosis of possible testicular malignancies.
MATERIALS AND METHODS
This study was carried out in a tertiary care multispecialty hospital. Written permission from the Institutional Review Board was sought before the initiation of the study. All operated cases of nonpalpable UDT from January, 2000, to January, 2014, were included. Patients operated for nonpalpable UDT (unilateral/bilateral) with a minimum 6-month postoperative period were included in the study. Patients with chromosomal abnormalities and those who refused to give consent for color Doppler ultrasound examination were excluded from the study.
The size, blood flow, and consistency to the testis on both sides, operated or nonoperated, were noted. The testicular volume was calculated using the formula 0.71 × length × breadth × height.
RESULTS
One hundred and fourteen patients were operated for nonpalpable UDT from January, 2000, to January, 2014. Thirty-four patients had orchidectomy for atrophic testis, and hence, they were excluded from the study. Sixteen patients could not be contacted or they did not respond to the communication. Of the remaining 64, 12 patients refused to come for the Doppler test due to logistic problems, and eight patients refused to consent to undergo a color Doppler ultrasound examination. A total of 44 patients and 49 testes (units) were included in the study [Table 1]. Of these, 34 were unilateral, and 10 were bilateral UDT [Table 2]. Thirty-two out of 44 patients underwent laparoscopic orchidopexy before the age of 1 year, while 12 patients underwent it after the age of 1 year.
Table 1
Total number of patients recorded with nonpalpable undescended testis in the study period
| n (%) | |
|---|---|
| Total | 114 |
| Orchiectomy for atrophic testicl* | 34 (29.8) |
| Did not respond to communication | 16 (14) |
| Refused study due to logistic problem | 20 (17.5) |
| Underwent study | 44 (38.6) |
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Table 2
Type of procedure carried out in unilateral nonpalpable undescended testis
| Type of procedure | Unilateral (n=34) |
|---|---|
| Single-stage lap orchidopexy | 20 |
| Staged SF orchidopexy | 9 |
| Open orchidopexy: Palpable under general anesthesia | 5 |
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SF: Stephen-Fowler rather than scrotal fixation
Of the unilateral, 21 were right undescended and 13 were left undescended [Table 2]. Of the 10 bilateral UDT, five patients underwent orchidectomy on one side for an atrophic testicl* along with orchidopexy on the other side [Table 3]. Thirty-one patients underwent single-stage laparoscopic orchidopexy, while 13 underwent two-stage Stephen–Fowler laparoscopic orchidopexy. Five patients underwent open orchidopexy as the testis became palpable under general anesthesia. Of 44 patients, 40 (>90%) had a low scrotal position, while four testes were near the root of the scrotum. All patients had their blood supply well-preserved.
Table 3
Type of procedure carried out in patients having bilateral nonpalpable undescended testis
| Type of procedure in bilateral cases | Bilateral (n=10) (units=20) |
|---|---|
| Unilateral orchiectomy (in bilateral cases) | 5 |
| Single-stage lap orchidopexy | 11 |
| Staged SF orchidopexy | 4 |
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SF: Stephen-Fowler rather than scrotal fixation
The mean volume of the operated unilateral testes was 1.605 cm3, which was significantly smaller than the normal nonoperated side. In cases of bilateral UDT, the mean volume was 2.524 cm3, and both the testes were comparable to each other [Table 4]. The smaller testicular volume was observed in spite of maintained blood supply to the testes. In addition, the ultrasound examination revealed the presence of normal hom*ogenous parenchyma of all the testes similar to the nonoperated side.
Table 4
Testicular volume in cubic cm after unilateral and bilateral laparoscopic orchiopexy
| Testicular volume (cm3) | |
|---|---|
| Unilateral lap orchiopexy | 1.605 |
| Bilateral lap orchiopexy | 2.2 |
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A total of 34 patients were operated for unilateral nonpalpable testis. In this group, 20 had single-stage lap orchidopexy, nine had two-stage lap orchidopexy, and five had open orchidopexy. In comparison to the normal contralateral side, the mean % volume of testis of patients who underwent single-stage laparoscopic orchidopexy was 76.63%, while the mean % volume of testis of patients who underwent two-stage Stephen-fowler (SF) laparoscopic orchidopexy was 71.6%, and patients who underwent open repair had a mean of 57.64% [Table 5].
Table 5
Statistical analysis of testicular volume with type of procedure
| n | Mean | Std. Deviation | Std. Error | 95% Confidence Interval for Mean | ||
|---|---|---|---|---|---|---|
| Lower Bound | Upper Bound | |||||
| Single stage lap | 20 | 76.6361 | 23.78963 | 4.85604 | 66.5906 | 86.6816 |
| Two stage Lap SF | 9 | 71.6041 | 17.66600 | 5.58648 | 58.9666 | 84.2416 |
| Open | 5 | 57.6494 | 15.62212 | 6.98642 | 38.2520 | 77.0468 |
| Total | 34 | 72.9116 | 21.95478 | 3.51558 | 65.7947 | 80.0285 |
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SD: Standard deviation, SE: Standard error, CI: Confidence interval, GA: General anesthesia, SF: Scrotal fixation, UDT: Undescended testis
The remaining 10 patients had bilateral nonpalpable testis; of this group, five had an atrophic testicl* on one side, which was excised. Of the remaining 15 units, 11 had single-stage orchidopexy, and four had two-stage SF orchidopexy.
DISCUSSION
The standard management of nonpalpable UDT used to be surgical exploration. However, with the advent of laparoscopy, a technique reported by Cortesi et al.[6] has been used widely in the diagnosis of UDT. Even in adolescent and adult patients, laparoscopic orchidopexy is a safe and successful procedure for nonpalpable intra-abdominal UDT.[10]
Five out of 54 units became palpable under general anesthesia. It shows that 10% of patients with nonpalpable UDT can become palpable under anesthesia with adequate muscle relaxation. These testes became palpable and, hence, underwent open orchidopexy. Rest remained nonpalpable, and hence, they underwent laparoscopic orchidopexy.
The present study shows that following unilateral orchidopexy, the growth of testes seems to be retarded in comparison with its contralateral counterpart as well as with the values reported in the literature; this finding was seen even when the age of the patient was <1 year. Similar findings have been observed in several studies that UDT that had been treated surgically in childhood is smaller in adulthood compared to the contralateral normal testis.[11,12,13,14] This may be caused by the primary condition of the testis (prenatal dysgenesis),[14] surgical trauma,[11] or both. Even in open orchidopexy performed for palpable UDT, it may result in vascular damage to the testis, and one study has reported an incidence of atrophy in 5.4% of cases.[15] Ultrasound studies suggest that vascular damage may be more extensive than previously suspected.[16] In addition, the phenomenon of compensatory hypertrophy of the contralateral testis[17,18,19,20,21] may contribute to the significant difference between the testicular volumes of the unilateral nonpalpable UDT compared to its counterpart.
In unilateral nonpalpable UDT, the volume of the operated testis was expressed as percentage by comparing it with normal nonoperated testis. This negated the effect of the difference of age of the patients in the study. This % volume was correlated with the postoperative period to see whether any catch-up growth of testis occurs as the postoperative period increases. There was no or negligible correlation observed using the Pearson’s correlation coefficient.
The volume of the operated unilateral testes (mean = 1.605 cm3) was significantly smaller than the normal nonoperated side (mean = 2.524 cm3). In cases of bilateral UDT, both the testes were smaller in size (mean = 2.2 cm3), but were comparable to each other. The smaller testicular volumes were observed in spite of maintained blood supply to the testes. In addition, the ultrasound examination revealed the presence of normal hom*ogenous parenchyma of all the testes similar to the nonoperated side.
Similarly, the age of the patient was also correlated with the % volume of the testes to find any catch-up growth. Here also, no or negligible correlation was observed.
The three types were found comparable to each other in terms of the difference in the volume of the operated testes (p>0.05) [Figure 1]. The testicular volume was the least with open surgery even when the location of the testis could be brought in the inguinal canal under anaesthesia. This may be due to either trauma associated with open orchidopexy or inadequate mobilization of the testicular vessels leading to more tension. Hence, it may be worth considering laparoscopic orchidopexy in the peeping testicl*, which becomes palpable only under anesthesia to preserve the testicular volume.
Figure 1
Scatter plot for volume of operated testes with post-op period
Taskinen et al.[13] reported long-term results of laparoscopic orchidopexy and found that the operated testis was always smaller than the normal testis, despite the good vascularization as documented on color Doppler ultrasound. The findings are similar to the findings reported by other studies.
The number of studies focusing on long-term follow-up after laparoscopic orchidopexy is scant, and most of the follow-up studies are only clinical based on subjective assessment of the macroscopic aspect of the testicl*, with a paucity of information regarding structure and vascularization of the testis.
In this study, the sample size is relatively small, most of the data were collected retrospectively, and there was a lack of randomization. However, there was no observer or sampling bias due to the strict inclusion and exclusion criteria and objective assessment by color Doppler study; however, recall bias cannot be excluded due to the retrospective nature of data collection.
CONCLUSION
On a long-term basis, it is possible to achieve the scrotal position following laparoscopic orchidopexy in all patients suffering from nonpalpable UDT. In all the operated testes, the blood supply was preserved. In all the operated unilateral nonpalpable UDT, the volume of the testis was lesser compared to the contralateral normally located testis. The operated testis has a good parenchymal structure, which is comparable to the normal contralateral testis. A laparoscopic orchidopexy is a safe and effective option in the treatment of nonpalpable UDT.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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