Laparoscopic management of the impalpable abdominal testis

LAPAROSCOPIC MANAGEMENT OF THE IMPALPABLE ABDOMINAL TESTIS

DAN POENARU, M.D. YVES L. HOMSY, M.D.

FRANCOIS PELOQUIN, M.D. GERVAIS 0. ANDZE, M.D.

From the Division of Pediatric Urology, Hopital Sainte-Justine and The Montreal Children’s Hospital, Universite de Montreal

and McGill University, Montreal, Quebec, Canada

ABSTRACT-Laparoscopy is useful in both diagnosis and management of impalpable testes. Intra-abdominal testicles can be removed laparoscopically if atrophic or can be partly devascularized by spermatic vessel clipping if apparently normal. Assessment of testicular revascularization would be desirable prior to subsequent orchidopexy. A second-stage vasal-based orchidopexy then can be performed once adequate testicular reperfusion via the deferential pedicle is believed to have occurred. We have used both diagnostic and therapeutic laparoscopy in the management of 103 non-palpable testes over a period of six years. Open procedures following laparoscopy included 57 orchidopexies, 11 orchiectomies, and 1 microvascular testicular autotransplant. Thirteen laparoscopic interventions were performed: 5 orchiectomies for atrophic testes and 8 testicular vessel clippings followed by 6 second-stage open inguinal orchidopexies. Color Doppler duplex ultrasonography was not found to be reliable for assessment of testicular revascularization following spermatic vessel clipping. There were 3 complications which were all related to puncture with the Veress needle.

The non-palpable testis presents difficulties both in diagnosis and in management. Localiza- tion by imaging techniques has proved to be unre- liable. Laparoscopic localization is safe and accurate, and does not unduly prolong the operative procedure which usually can be done at the same sitting. The main difficulty in the management of non-palpable testes lies with the testicular pedicle which may be too short to allow adequate descent of the testicle into the scrotum. The Fowler- Stephens procedure, involving division of the spermatic vessels with subsequent collateral testicular revascularization via the deferential vessels, has been advocated in this setting. The procedure is founded on the presence of collaterals between the spermatic and the deferential vessels, which are known to occur in 87 percent of human subjects. However, this technique is associated with a reported 25 to 50 percent rate of testicular loss, which is unacceptable by today’s standards.

Submitted: May 25, 1993, accepted (with revisions): July 29, 1993

An attractive alternative involves initial ligation of the spermatic vessels by laparoscopic means, followed by delayed orchidopexy (second stage Fowler-Stephens). This novel approach relies on a revascularization process of the testis in situ, via collaterals. A second-stage inguinal orchidopexy is then performed after sufficient time is allowed for revascularization to occur. We have found laparoscopy to be useful in the diagnosis of non-palpable testes, as it allows a variety of therapeutic interventions to be performed. In particular, we have used the two-stage Fowler-Stephens procedure for intra-abdominal testes and have attempted to document the process of testicular revascularization.

MATERIAL AND METHODS

Between September 1986 and September 1992, 79 boys with non-palpable testes and 1 pheno- typic girl with androgen insensitivity underwent a total of 85 laparoscopic procedures. The mean age was 5.1 years (range 12 months to 18 years), and 70 percent of the patients were under six

574 UROLOGY / NOVEMBER 1993 / VOLUME 42, NUMBER 5

TABLE I. Location and management of non- palpable testes

Testes Number

Extra-abdominal 20 (19%) Standard orchidopexy 10 Orchiectomy 6 Negative inguinal exploration (“vanishing testis”) 4

Internal Ring 44 (43%] Standard orchidopexy 33 One-stage Fowler-Stephens orchidopexy 1 Orchiectomy 4 Laparoscopic spermatic vessel clipping 3 Open inguinal second stage Fowler-Stephens 3

Intra-abdominal 23 (22%) Standard orchidopexy 5 Microvascular testicular autotransplant 1 Orchiectomy 2 One-stage Fowler-Stephens orchidopexy 2 Laparoscopic spermatic vessel clipping 5 Open inguinal second stage Fowler-Stephens 3 Laparoscopic orchiectomy 5

Intra-abdominal vanishing 16(16%) No treatment 12 Prosthesis placement 3 Exploration 1

years of age. A total of 103 testicles were localized laparoscopically, 46 on the right and 57 on the left. Laparoscopy for bilateral non-palpable testes was performed in 25 cases. We have not routinely used human chorionic gonadotropin in our patients, although a hormonal workup was obtained in bilateral cases.

LA~mosco~zc TECHNIQUE The procedure is carried out as previously de-

scribed.’ Spermatic vessel ligation is accomplished by placement of a clip across the entire spermatic pedicle including the posterior parietal peritoneum as far from the testicle as possible, using a laparoscopic clip applicator. Laparoscopic orchiectomy for atrophic testicles requires an additional S-mm portal used to grasp the testicle and another lo- mm portal for dissection as well as clipping of the vas and of the spermatic vessels. The testicle is then extricated through the lo-mm portal and is small enough not to require morcellation. Irriga- tion and suction of the peritoneal cavity is performed before releasing the pneumoperitoneum.

Following laparoscopic spermatic vessel ligation, intra-abdominal testes were assessed at two- week intervals by external color Doppler duplex ultrasonography. The technique has been described previously.2 Both testicular location and

presence of arterial flow within the testicular parenchyma were recorded. The presence of intra- parenchymal flow was considered as evidence of testicular revascularization. Absence of such flow, however, does not exclude a well-vascularized testis (even in normally descended testes>. The scheduled second procedure therefore included a second-look laparoscopic assessment of the testicular site and presence or absence of neovascularization, followed by a transperitoneal inguinal exploration, division of distal spermatic vessels at the level of the previously placed clip, and vas- based orchidopexy. Attention was paid during this step to keep the dissection lateral to the spermatic vessels so as not to disturb the neovasculature to the vas deferens and to the testicle.

DEFINITIONS Non-palpable testis: testis not palpated by any

examination technique, including preoperatively under general anesthesia.

Extra-abdominal testis: testis located distal to the internal ring as evidenced by spermatic vessels and vas deferens entering an open internal ring.

Intra-abdominal testis: testis visualized above the internal ring on laparoscopy.

Vanishing testis: situation in which spermatic vessels end blindly and no testicular tissue is found.

Atrophic testis: testis measuring less than half of contralateral one or of expected age-specific size.

RESULTS

Eighty-three laparoscopic procedures were un- eventful and allowed a satisfactory assessment of the testes. The mean procedure time for 27 con- secutive laparoscopies was twenty-nine minutes (range, 13 to 100 minutes). Diagnostic procedures took a mean of twenty-two minutes, while therapeutic procedures averaged sixty-six minutes. The mean hospital stay postoperatively was 0.8 days (range, 0 to 2 days).

The results of laparoscopic localization, as well as the procedures performed, are presented in Table I. Testicles seen at the level of the internal ring were managed by inguinal exploration if this appeared to be feasible (from the extent of mobil- ity of the testicle as assessed by pulling on the scrotal skin) or by laparoscopic methods other- wise (as detailed in the algorithm of Figure 1). Four inguinal explorations performed in the extra-abdominal testis group resulted in no testicular tissue found despite identifiable vessels. The open one-stage Fowler-Stephens orchidopexies and the open orchiectomies for intra-abdominal testes, as well as the microvascular autotransplant,

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LAPAROSCOPY

EXTRA-ABDOMINAL INTRA-ABDOMINAL VANISHING TESTIS TESTIS TESTIS

LOW INTRA- ABDOMINAL \ ABDOMINAL

I

\ SPERMATIC VESSEL- SECOND-STAGE

CLIPPING ORCHIDOPEXY

ORCHIDOPEXY ILAPAROSCOPIC or OPEN)

(LAPAROSCOPIC OR OPEN1

FIGURE 1. Algorithm for management of non-palpable testis.

occurred earlier in our series before laparoscopic interventional techniques were well established. In the case of the 16 patients with intra-abdominal vanishing testes, 15 had no further procedures. One patient with vanishing testis early in our series underwent abdominal exploration, which confirmed the laparoscopic diagnosis.

There were 3 complications in our group: 2 pre- peritoneal insufflations and 1 small retroperitoneal hematoma. The pre-peritoneal insufflations occurred despite performing the usual penetration tests of the Veress needle, and subsided without any treatment but required postponement of the laparoscopy The retroperitoneal hematoma was observed immediately on insertion of the video camera, and remained unchanged throughout the ensuing inguinal orchidopexy. Subsequent ultrasound examination failed to show the hematoma, and the patient was discharged uneventfully In our case, the hematoma was located in the right psoas muscle medial to spermatic vessels and was probably caused by the introduction of the Veress needle, although it could possibly have been caused by trocar insertion. This complication is expanded further in the comment section.

The 8 patients with initial laparoscopic clipping of the spermatic vessels were followed with color Doppler duplex ultrasound every two weeks. The testicle undergoing spermatic vessel clipping was considered revascularized based on its intra- parenchymal flow usually between six and eight weeks postoperatively However, intra-abdominal testes were not always visualized by ultrasound, nor was a good Doppler signal obtained consis- tently even from the normal contralateral side. We therefore opted later in the study for delaying the second stage to six months, relying on laparoscopic assessment of the testicular neovasculature. Neovascularization was indeed easily identified in

7 of the 8 cases. The consistent observation was that of a well-developed network of superficial retroperitoneal collaterals extending between the spermatic vessels and the vas deferens.

Other important reasons for performing a “second look laparoscopy” are to ensure that the testicle still appears viable and of acceptable size, despite clipping, to be descended into the scrotum. Division of the spermatic vessels may be done laparoscopically and consideration given to performing the second stage entirely laparoscopically by a modification of the technique described by Jordan.3 To date, 6 of the 8 patients with spermatic vessel clipping underwent their open second-stage orchidopexy. All second stages were successful in bringing an apparently well-vascularized testicle into the scrotum. Testicular nu- clear scans demonstrated viable testes postoperatively in all these patients. Long-term follow-up is not available on these testes nor can their fertility potential be assessed for the present.

Of the 25 patients with bilateral non-palpable testes, 3 underwent laparoscopic interventions- bilateral orchiectomy in 2 and spermatic vessel clipping in one. No complications were encoun- tered in this group.

COMMENT

Cryptorchidism is a common problem in children, affecting 0.8 percent of infants at one year of life, 3 percent of full-term newborns, and 21 percent of premature babies.4 Twenty percent of cryp- torchid testicles are non-palpable.5 These non-palpable testes may present both diagnostic and management difficulties.

Several imaging methods have been used in an attempt to localize non-palpable testicles. These include ultrasound, computed tomography, nu- clear magnetic imaging, scintigraphy, and venog- raphy. The success of these studies has been limited, leading many surgeons to an approach based on direct inguinal exploration followed by abdominal exploration in cases of suspected intra- abdominal testicles.

In terms of management, between 20 percent and 30 percent of non-palpable testicles are intra- abdominal and therefore require abdominal surgical exploration for diagnosis and/or therapy Be- cause of a short vascular pedicle, some testes may require a Fowler-Stephens orchidopexy.’ This involves a one-stage division of spermatic vessels with testicular pull-down and fixation, based on demonstrated collateral testicular vasculature via vasal and cremasteric vessels.8*9 When properly applied in selected patients, the best result that

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can be expected from this technique is success in 70 percent to 90 percent of patients.10y11

The emerging alternative to the Fowler- Stephens one-stage orchidopexy to avoid testicular loss is the staged approach proposed by Rans- ley et al. l2 This allows revascularization to occur in situ after initial spermatic vessel ligation and before the testicle is pulled down. They first applied this procedure to patients with prune belly syndrome who required an open initial procedure for other reasons. The initial reluctance to perform two formal surgical procedures was allevi- ated by the minimally invasive application of laparoscopy to the first stage.13 Results to date with either the laparoscopic two-stage orchidopexy14 and the open two-stage procedurer5 have been satisfactory, and it has been suggested that a two- stage procedure ultimately may result in a lower testicular loss rate.

Laparoscopy has been used since 1976 primarily for the diagnosis of non-palpable testes.t6-18 Re- cently, its use has been extended to removing atrophic testes and clipping the spermatic vessels as the first stage of a two-stage orchidopexy.‘,15 Jor- dan3 has described a one-stage laparoscopic orchidopexy which is probably applicable to the low intra-abdominal testis situated close to the internal ring. Testes situated higher in the abdominal cavity should preferably undergo a staged orchidopexy with laparoscopic clipping in the first stage.

The optimal time interval for adequate testicular revascularization following clipping is not known. Bloom et ~1.‘~ have empirically used a six-month period before the second-stage orchidopexy. We have attempted to quantify the extent of revascularization using color Doppler duplex ultrasonography, but the results were inconsistent. We have, therefore, also adopted a six-month delay before the second stage and added laparoscopic evaluation of testicular neo-vasculature at the time of the second procedure. Based on our limited findings, we believe that a six-month interval between stages is appropriate. It could be argued that second-look laparoscopy might not be considered necessary Laparoscopy in this setting may contribute little to identify the small number of testicles that may have undergone atrophy following clipping be- cause of absent collaterals. These testes still will be recognized and removed through the inguinal exploration. Performing laparoscopy prior to the second stage, however, would make laparoscopic removal of these testes possible, thus avoiding an open procedure. In addition, in the presence of a viable testis, laparoscopic division of the spermatic

vessels and dissection of the vas deferens would permit lowering the testicle laparoscopically as described by Jordan3 (Fig. 1). We recently have attempted this approach and results appear to be promising.

The distribution of various testicular sites found in our series resembles that of previous series. Our results also support the view that laparoscopy can greatly assist in the diagnosis and management of non-palpable testes. In 20 cases (20%) laparoscopy prevented a laparotomy or retroperitoneal dissection by identifying intra-abdominal vanishing testes or allowing removal of atrophic testes. In 8 other cases (8%) laparoscopy was used to increase testicular collateral revascularization in preparation for orchidopexy with spermatic vessel division.

Complications following laparoscopy for undescended testicles are infrequent. Pre-peritoneal in- sufflation is undoubtedly the most common one, and may be as high as 5 percent.19 More serious complications, including intestinal or vascular in- juries, have been reported in other laparoscopic procedures and recently for non-palpable testes as we11.19 These may be reduced or possibly alto- gether avoided by the “open” introduction of a Hasson blunt trocar thus avoiding blind puncture with the Veress needle. The peritoneum seems to be more elastic and does not puncture readily in young subjects, so that actual puncture occurs only after the anterior abdominal wall is some- what approximated to the posterior abdominal wall. Considering that the abdominal cavity is, indeed, much smaller than in the adult, mishaps due to puncture are more prone to occur. We recently were involved in a case with a colleague (not reported m this series) where a vessel was punctured in the mesentery of a two-year-old boy Bleeding was profuse and was accompanied by hypotension, necessitating prompt intra-operative resuscitative measures. At laparotomy, after the evacuation of a half liter of blood, the punctured vessel was identified at the root of the mesentery as a branch of the right superior colic artery. Puncture was attributed to the Veress needle. For- tunately, the vessel bled outside the mesentery, and there was no intra-mesenteric hematoma that collected. The vessel was tied off, and the patient suffered no consequences. As the implications of such complications are potentially tragic, due consideration should be given to abandoning ac- cess by puncture in children in favor of “open” primary trocar insertion by the Hasson technique.

Our algorithm for management of non-palpable testes is presented in Figure 1. One potential

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modification to this approach is the use of laparoscopy immediately following, rather than pre- ceding, inguinal exploration. This attitude, suggested by Naslund et al.,” would potentially restrict the use of laparoscopy only to patients with true intra-abdominal or intra-abdominal vanishing testes. This view is supported by the fre- quent finding of inguinal testicular tissue when- ever vas and spermatic vessels are seen to exit the internal ring. I4 It would appear more logical, however, to perform laparoscopy before rather than after an inguinal exploration.

The role of laparoscopy in the evaluation of bilateral non-palpable testes has been questioned by Naslund et a1.l’ In our study, however, all 25 patients with this condition had a therapeutic procedure (orchidopexy or orchiectomy) performed either by open surgery or laparoscopically, with no complications. We, therefore, consider laparoscopy very useful in bilateral cases. Diamond et a1.19 recently have found laparoscopy useful in 9 of 12 patients with bilateral non-palpable testes and in all 4 patients with previous negative inguinal explorations.

We believe that laparoscopy is an important ad- junct in the management of nonpalpable testes, improving diagnostic accuracy, and simplifying therapy Its full potential is realized only when the entire spectrum of therapeutic laparoscopic modalities is applied. Even though complications are rare, they are usually related to “blind” puncture which should preferably be avoided, particu- larly in younger children.

Yves L. Homsy, M.D. Hdpital Sainte-Justine

3175 Ste-Catherine Rd. Montreal, Quebec H3T 10

Canada

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2. Middleton WD, Siegel BA, Melson GL, Yates CK, and Andriole GL: Acute scrotal disorders: prospective compari- son of color Doppler US and testicular scintigraphy Radiol- ogy 177: 177-181, 1990.

3. Jordan GH, Robey EL, and Winslow BH: Laparoendo- scopic surgical management of the abdominaVtransinguina1 undescended testis. J Endourol 6: 159-163, 1992.

4. Scorer CG: The descent of the testis. Arch Dis Child 39: 605-609, 1964.

5. Levitt SB, Kogan SJ, Engel RM, Weiss RM, Martin DC, and Ehrlich RM: The impalpable testis: a rational approach to management. J Urol 120: 515-520, 1978.

6. Hinman F Jr: Survey: localization and operation for

non-palpable testes. Urology 30: 193-198, 1987. 7. Fowler R, and Stephens FD: The role of testicular vas-

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9. Harrison RG: The distribution of the vasal and cremasteric arteries to the testis and their functional importance. J Anat 83: 267-282,1949.

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11. Boddy SA, Gordon AC, Thomas DE and Browning FS: Experience with the Fowler Stephens and microvascular procedures in the management of intra-abdominal testes. Br J Uro168: 199-202, 1991.

12. Ransley PG, Vordermark JS, Caldamone AA, and Bellinger MF: Preliminary ligation of gonadal vessels prior to orchiopexy for the intra-abdominal testicle: a staged Fowler- Stephens procedure. World J Uro12: 266, 1984.

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14. Plotzker ED, Rushton HG, Belman AB, and Skoog SJ: Laparoscopy for nonpalpable testes in childhood: is inguinal exploration also necessary when vas and vessels exit the inguinal ring? J Urol 148: 635-638, 1992.

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EDITORIAL COMMENT

We also feel that laparoscopy is the most accurate way to localize non-palpable testes and has a great deal to offer as a management modality in such cases. These conclusions are based on our recent review (Moore R.G., Peters C.A., Bauer S.B., Mandell J., and Retik A.: Laparoscopic evaluation of the non-palpable testis: a prospective assessment of accuracy, submitted for publication to J Ural) of 126 non-palpable testes in 104 children. Laparoscopic identification of blind- ending spermatic vessels and vas prior to entering the internal inguinal ring is sufficient to diagnose a vanishing testis which does not require further surgical exploration.

Laparoscopy also identifies the specific location of an intra- abdominal testicle to facilitate development of an optimal surgical strategy. During the past year as we have become more familiar with operative laparoscopy, we have had the occasion to perform laparoscopic surgery on 15 intra-abdominal testes. We performed one orchiectomy for a small organ located below the liver, eight one-stage orchidopexies for

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Laparoscopic management of the impalpable abdominal testis