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Laparoscopic versus Open orchiopexy approach for the management of non- palpable undescended testis

Gouda Mohamed El-labban

Department of General Surgery, Faculty of Medicine, Suez Canal University, Ismailia, Egypt

 

Correspondence

Gouda Mohamed El-labban.
Department of General Surgery,
Faculty of Medicine, Suez Canal University,
Round Road, Ismailia, Egypt
Mobile: 002 010 3530101
Work: 002 064 3381302
Fax: 002 064 3208543
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Abstract

Introduction: Treatment of the cryptorchid testicle is justified due to the increased risk of infertility and malignancy. The optimal initial surgical approach for non-palpable undescended testis is debated. In these cases, the laparoscopic technique is a useful alternative method for diagnosis and treatment.

Aim: To evaluate the use of laparoscopic orchiopexy approach versus open orchiopexy approach in the management of non-palpable undescended testis regarding success rate, operative time, complications, hospital stay, oral feeding and return to normal activities.

Methods: A total of 94 operations of either laparoscopic (group 1; n=46) or open (group 2; n=48) orchiopexy for non-palpable undescended testes were evaluated. The location of testes and results of orchiopexy were compared in both groups.

Results: The majority of testes (38/46 group 1 and 43/48 group 2) in both groups were intra-abdominal. Laparoscopic orchiopexy is similar to open orchiopexy in mean operative time and overall success rate. The success rate was 91.3% and 89.6% in the two groups respectively. Laparoscopic orchiopexy is superior in terms of length of hospital stay, starting oral feeding and return to normal activities.

Conclusions: Laparoscopic and open approaches to non-palpable undescended testis give comparable results. Laparoscopy is the only exploratory procedure that is accurate enough to enable the diagnosis of non-palpable testis and also allow the surgical treatment to be done in the same setting.

Key words: non-palpable, undescended testis, laparoscopy, orchiopexy, cryptorchid

 

INTRODUCTION

Cryptorchidism is the most common genitourinary anomaly in male children. Its incidence can reach 3% in full term neonates, rising to 30% in premature boys [1]. The treatment of the cryptorchid testicle is justified by the increased risk of infertility and malignancy, as well as an associated inguinal hernia and the risk of trauma to the ectopic testicle against the pubis. Furthermore, the psychological stigma of a missing testis for the patient, as well as the parents’ anxiety is also factors that justify this type of treatment [2, 3].

About 20% of cryptorchid testicles are nonpalpable. The treatment of non-descended testicles is mandatory due to the increased risk of infertility, present in up to 40% of the patients, as compared to 6% of control groups, including malignancy, which reaches 20 times that of normal adults [4].

The treatment of the cryptorchid testis before 2 years of age is recommended, treatment is necessary not only for the risk of malignancy, but also for the satisfaction and improvement in the quality of the patient’s life and parents´ concern for their children’s health [5].

In relation to diagnosis, despite a sensitivity of 70-90% in the diagnosis of inguinal testes, ultrasonography is not useful in intra-abdominal cases [6]. Although presenting a better quality, both computed tomography and nuclear magnetic resonance lack sufficient sensitivity and specificity to be considered as gold standard diagnostic tools [7]. More recently, the magnetic angioresonance was introduced with sensibility of 96% and specificity of 100%, but it is still a new method, with high costs, also requiring general anesthesia in children [8].

In relation to the treatment, the use of gonadotrophin for undescended testes presents a success rate of definitive descent to the scrotum of 21 to 56%, with better results in bilateral cases [6]. Surgical treatment via an inguinal incision is the main treatment option for palpable testicles, but can also be employed for the evaluation and treatment of non-palpable testis. In this situation, however, surgical exploration can often require large incisions and extensive dissections, especially in bilateral cases. This can be avoided using laparoscopic evaluation, with a sensitivity and specificity reaching more than 90% [1].

The aim of this report is to compare the outcome of laparoscopic approach with open approach in patients presenting with unilateral non-palpable undescended testis.

PATIENTS AND METHODS

Research groups:

The population included 94 non-palpable undescended testes. The results of 46 non-palpable undescended testes managed by primary laparoscopic orchiopexy approach (group I) were evaluated. The results of 48 testes managed by open orchiopexy approach (group II) were also evaluated. The operative findings and results were compared between the two groups.

The aim of laparoscopy is 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 is used to complete the orchiopexy. At laparoscopy, if the vas and vessels are found to enter the deep ring, a standard inguinal incision is used for further exploration.

In the open orchiopexy, if the testis isn’t found in the inguinal canal, a retroperitoneal and intraperitoneal exploration is carried out through the deep ring. In both approaches, the viable testis is brought down into the scrotum by mobilization of the spermatic pedicle; spermatic vessel ligation isn’t employed in any patient in this series.

The finding of blind-ending vas and vessels indicated vanishing testis and further exploration is abandoned after removal of the nubbin of tissue at the termination of the vas and vessels. The considered atrophic testes are removed. Figure 1 shows the algorithm for a suggested approach to patients with non-palpable testes.

JPSS december 2013 Page 11 Image 0001

Figure 1: Algorithm for a suggested approach to patients with NPT
Abbreviations: IAT= intra-abdominal testis; IIR=internal inguinal ring; NPT = non-palpable testis

Post-operatively, children received oral antibiotic and analgesic. Follow-up examination after orchiopexy is conducted in a week and 4-6 weeks time. After that, a 6-month and 1-year follow-up is advised.

Operative technique:

The laparoscopic technique has previously been described. The laparoscopic findings are summarized in Table 1. Surgical management was performed based on the laparoscopic findings. In cases of intra-canalicular inguinal testis, open surgical exploration is performed.

Table 1. Laparoscopic findings classifications:

 

Absenttestis

 

Agenesis(absenceofspermaticvesselsandvasdeferens).Vanishingtestis

(blindingendingofspermaticvesselsorvas).

 

Canaliculartestis

 

Penetration  ofvasandspermaticvesselsintotheinternalinguinalringwith orwithoutdirectlyseeingthe testis.

 

Abdominaltestis

 

Localizedbetweentheinferior  renalpoleandtheipsilateral  internal  inguinalring.

Canbeanormaloranatrophicgonad.

 

Peepingtestis

 

Primarilyintra-abdominalposition.Thetestisintroducesitselfintotheinguinalcanal duetotheintra-abdominalpressureaugmentation  duringthelaparoscopicprocedure. Usuallyassociatedwithinguinalherniaandreturnstooriginalpositionbypressuring theinguinalregionexternally.

In patients with viable testicles laparoscopic orchiopexy is performed. The peritoneum is incised around the internal ring. The gubernaculum is then transected as far distally as possible to leave enough gubernacular tissue attached to the testis. By grasping the freed gubernaculum, the peritoneum overlying the spermatic vessels is incised on either side (laterally and medially) and the two incisions are joined proximally to leave a strip of posterior peritoneum adherent to the spermatic vessels distally. Dissection is continued cranially as far as necessary to gain enough length of the spermatic vessels to allow tension-free orchiopexy. Then the peritoneum superior to the vas deferens is incised to gain additional vasal length.

Periodically the testis is moved toward the contralateral internal ring as an average estimate of whether sufficient length is attained to move it to the scrotum. When adequate mobilization of the testis and sufficient length of spermatic vessels are obtained, a small transverse skin incision is done and dartos pouch is created in the ipsilateral hemiscrotum. A new inguinal ring is created using artery forceps. The artery forceps is passed through the scrotal incision and is pushed just over the pubic tubercle to pierce the peritoneum lateral to the medial umbilical ligament and medial to the inferior epigastric vessels. The new ring is widened and dilated by opening and closing the artery forceps. Then the gubernaculum is grasped by the artery forceps and the testis is gently delivered to the scrotum. Creation and dilatation of the new ring and testicular delivery is done under direct laparoscopic control. Any tension observed on the testicular vessels after pulling out the testis is released by further mobilization of the spermatic vessels. After being put into the scrotum, the testis is fixed into the dartos pouch using absorbable sutures and the scrotal incision is closed. In cases of low intraabdominal testicle (located at or less than 2 cm from the internal inguinal ring) the procedure is straightforward, without transection of the spermatic vessels.

Outcome measures:

The primary endpoint of this report is the success rate of the two approaches. The secondary outcome measures were operative time, complications, hospital stay, oral feeding and return to normal activities.

Statistical analysis

Normally distributed continuous data were assessed using the Student t test. Categorical data were compared using Fisher’s exact test. Statistical significance was set at P 0.05. Data were analyzed using the Statistical Package of Social Sciences (SPSS) version 16.0 software.

RESULTS

Patient characteristics:

The mean age of the boys were 4.2 years in group 1 and 4.35 years in group 2. Most of the evaluated testes were located intra-abdominally (n=81), number of intra-canalicular testes were 6 and peeping testes were 7. No statistical significant differences between the two groups regarding the clinical characteristics which are summarized in table 2.

Table 2. Clinical characteristics of both groups:

 

Clinicalcharacteristic

Laparoscopicgroup

(n=46)

Opensurgerygroup

(n=48)

 

Pvalue

 

Age(years):

 

Mean

 

4.2

 

4.35

 

0.44

 

Siteoftestis:

Canalicular(%)

4(8.7)

2(4.2)

0.43

Abdominal  (%)

38(82.6)

43(89.6)

Peepingtestes(%)

4(8.7)

3(6.2)


Surgical treatment:

One patient in the laparoscopy group required conversion to open surgery. The operative time as measured from the skin incision to the subcuticular closure was similar for group 1 and 2 (53.7±18 versus 52.8±15.9 minutes, respectively). Laparoscopic group had significantly lower hospital stay period than open surgery group (1.1 ± 0.33 versus 1.9 ± 0.6 days, respectively). Also, laparoscopic orchiopexy group had significantly earlier oral feeding than open orchiopexy group (7.2 ± 2.5 versus 12 ± 5.8 hours, respectively). Group 1 had significantly earlier return to normal activities than group 2 (9 ± 1.9 versus 28 ± 5.5 days, respectively). The operative details are summarized in table 3.

Table 3. Details of surgical treatment (secondary outcome) in both studied groups:



 

Surgical details

Laparoscopic group

(n=54)

Open surgery group

(n=55)

 

P value

Duration of procedure

(minutes):

 

Mean ±SD

 

53.7±18

 

52.8±15.9

 

0.78

Duration of hospital stay

(days):

 

Mean ±SD

 

1.1 ± 0.33 (1–2)

 

1.9 ± 0.6 (1–3)

 

0.008**

 

Oral feeding (hours):

 

Mean ±SD

 

7.2 ± 2.5 (6–12)

 

12 ± 5.8 (6–24)

 

0.004**

Return to normal activities

(days):

 

Mean ±SD

 

9 ± 1.9 (7–12)

 

28 ± 5.5 (21–36)

 

0.000**


Complications and primary outcome measure:

One intra-abdominal complication occurred in laparoscopic group which was spermatic vessels torn. The overall success rate (acceptable scrotal position of the testis without testicular atrophy) was 91.3% in the laparoscopic orchiopexy group and 89.6% in the open orchiopexy group. Seven atrophic testes had occurred in both groups (4 versus 5 testes, respectively). Complications and success rate (primary outcome) of surgical treatment in both studied groups are summarized in table 4.

Table 4. Complications and success rate (primary outcome) of surgical treatment in both studied groups:


Laparoscopic group

(n=46)

Open surgery group

(n=48)

 

P value

 

Complications:

 

Spermatic vessels torn (%)

 

1 (2.2)

 

0

 

0.99

 

No complications  (%)

 

45 (97.8)

 

48 (100)

 

Primary outcome:

 

Success rate (%)

 

42 (91.3)

 

43 (89.6)

 

0.99

 

Failure rate (%)

 

4 (8.7)

 

5 (10.4)


DISCUSSION

Non-palpable undescended testis has been identified as one of the common and classic indications for pediatric laparoscopy [9-11]. The main advantages of laparoscopy are accurate localization of the testis and the total avoidance of open exploration in some patients [12, 13, 14]. The main criticism against inguinal exploration for a non-palpable testicle is that it may fail to locate an intra-abdominal testicle. In a report by Lakhoo et al. [15], 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 undescended testis 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 non-palpable undescended testis [16, 17]. Many of the clinically non-palpable testes are either canalicular or low abdominal, and could be readily managed by the standard inguinal approach. Several authors reported excellent results with laparoscopic orchiopexy for non-palpable testis.

Chang et al. [18] reported an overall success rate of 96% with laparoscopic orchiopexy for non-palpable undescended testis. Similarly, good results have been reported for staged laparoscopic Fowler-Stephens orchiopexy [19]. The unanswered question that still remains is how many of these testes could have been adequately managed by open surgery without laparoscopy. Kirsch et al. [16] reported a large experience with 447 non-palpable 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. [20] reported that in 37 of 39 non-palpable testes, groin exploration was sufficient for deciding and executing treatment. Adam and Allaway [17] reported good results with inguinal exploration followed by the pre-peritoneal approach for 110 non-palpable 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.

Using laparoscopic procedures, the cosmetic aspect is remarkably more favorable as compared to open surgery, and the hospital stay and convalescence are much shorter. In the pediatric age group, these factors may not be so evident for the patient themselves, but certainly will be for the parents, who are able to resume their daily activities earlier. Furthermore, the laparoscopic orchiopexy presents excellent results in terms of diagnosis and therapy of the non-palpable testis, which is why this technique has been routinely incorporated in many centers. The primary orchiopexy without transection of the gonadal vessels is recommended. However, in cases of very high testicles or those with short vessels it is now recommend the two staged laparoscopic technique of Fowler-Stephens [1].

In this report, the success rate of primary laparoscopic orchiopexy was 91.3%. Denes et al. [1] reported that of the 25 testicles submitted to the primary laparoscopic orchiopexy, without vascular transection, 96% were considered successful, with good position and normal morphology, with only one testis developing atrophy.

Conclusion

Primary laparoscopic orchiopexy appears to be a feasible, safe technique for the management of the non-palpable undescended testes. In view of short-term outcome, laparoscopic orchiopexy is similar to open orchiopexy in mean operative time and overall success rate, while it is superior in terms of length of hospital stay, starting oral feeding and return to normal activities.

Acknowledgements

The author would to thank Professor Ahmed Ellabban for his advice and support of this work

 

 

 

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