Open Journal of Urology, 2013, 3, 276-280
Published Online November 2013 (http://www.scirp.org/journal/oju)
http://dx.doi.org/10.4236/oju.2013.37052
Open Access OJU
Laparoscopic Management for Non-Palpable Testis
Abdel-Aziz Ali Emara1,2
1Department of Urology, Al-Azhar University, Cairo, Egypt
2Department of Urology, Ghodran Hospital, Baljurashi, KSA
Received October 10, 2013; revised November 5, 2013; accepted November 12, 2013
Copyright © 2013 Abdel-Aziz Ali Emara. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Purpose: To present our experience with laparoscopic management of the non-palpable undescended testis. Patients
and Methods: Between Nov. 2010 and Oct. 2012, 47 non-palpable testes in 41 patients were evaluated prospectively
by laparoscopy. The age of the patients at the time of surgery varied from 1 to 9 years with a mean age of 2.85 years.
Testicular viability and location were evaluated by physical examination and Doppler ultrasonography after 1 and 3
months. Results: Out of 49 testicular units, 47 (95.9%) were successfully treated by laparoscopic orchiopexy. 45 tes-
ticular units (91.8%) were treated by one-stage laparoscopic orchiopexy, 2 (4.1%) were treated by two-stage laparo-
scopic orchiopexy and 2 (4.1%) diagnosed as vanishing testis with detection of blind end spermatic vessels and vas def-
erens during laparoscopy. Physical examination and Doppler study demonstrated that 46 of 47 testes (97.9%) were vi-
able and 45 of 47 (95.7 %) were located in the low er scrotum and 2 of 47 (4.3%) in the upp er scrotum at the end of fol-
low-up. Conclusion: The laparoscopy is a reliable technique for diagnosis and treatment of the non-palpable in-
tra-abdominal testis with high success and survival rates of the testes.
Keywords: Laparoscopy; Orchiopexy; Undesc ended Testis
1. Introduction
An undescended testis is one of the most common clini-
cal disorders of childhood, occurring in approximately
3% of full-term newborns, 21% of premature newborns,
and 0.8% - 1.8% of 1-year-old boys [ 1]. In the boys w ith
undescended testis, the testis is palpable in the groin in
80% [2] and non-palpable in 20% and 20% - 50% of
those with non-palpable testis, the testis is absent [3]. A
non-palpable testis is defined as, a testis not palpated by
any examination technique, including pre-operatively un-
der anaesthesia [4]. Non-palpable testes have an in-
creased risk of malignant transformation, infertility and
epididymal malformation [5].
Many diagnostic methods have been described of whi c h
the most promising method is the use of diagnostic lapa-
roscopy. Non-palpable undescended testis management
basically includes four surgical techniques: 1) Open or-
chidopexy in stages; 2) Fowler-Stephens orchidopexy in
which spermatic vessels are sectioned and the deferential
artery is preserved in 1 or 2 stages by open or laparo-
scopic approach; 3) Testicular autotransplant with sper-
matic vessel section and microsurgical anastomosis to the
epigastric ve ssels and 4) laparosco pic orchid o pexy.
Of the above mentioned techniques, laparoscopic or-
chidopexy is gaining in popularity, and has an 88% -
100% cure rate [4]. Its advantages are greater dissection
of spermatic vessels and vas defer ens and the creation of
a medial neohiatus that consequently shortens the dis-
tance between the abdominal cavity and the scrotum
during testicular descent. This technique was originally
described for intra-abdominal undescended testis man-
agement but it has also been employed in high palpable
undescended testis with good results [6]. We aimed to
present our experience with laparoscopic management of
the non-palpable, intra-abdominal, undescended testis.
2. Patients and Methods
Study design, patient selection and assessment: This
prospective study was conducted between Nov. 2010 and
Oct. 2012, Patients were consecutively enrolled from
patients referred to the urology and pediatric clinics at
Ghodran Hospital, Baljurashi, Kingdom of Saudi Arabia
(KSA) for treatment of undescended testis. All patients
underwent thorough history-taking, physical examination
and abdominal ultrasonography. A testis was considered
non-palpable if it was not palpable clinically or detected

A. A. EMARA 277
by abdominal ultrasonography. The intra-abdominal van-
ishing testis syndrome (unilateral anorchia) was diag-
nosed if the spermatic vessels and vas deferens were
noted to end blindly during laparoscopy. Accordingly,
surgical exploration was not performed in these cases. If
an intraabdominal testis was identified laparoscopically,
orchiopexy was done. The study protocol was approved
by the Ethics Committee of Ghodran Hospital, KSA and
parents of all patients enrolled in this study provided
written informed consent.
Laparoscopic technique: Diagnostic laparoscopy was
performed in 41 patients with non-palpable testis. A clear
diet was started on the day before surgery and a fasting
of 4 - 8 hours according to their age was applied before
laparoscopy. A single dose of cefazolin sodium 40 mg/kg
was given by IM route for prophylaxis. Before laparo-
scopy, physical examination was repeated under general
anaesthesia in order to palpate the testes. A urethral
catheter was inserted into the bladder. A patient was
placed supine in the frog-leg position and in the 30 de-
grees Trendelenburg position. A U-shaped incision of 1
cm length was made just below the umbilicus. The ante-
rior wall of the abdomen was pulled upwards and then a
10 mm trocar was inserted into the abdominal cavity by
open technique. CO2 was insufflated to achieve pneu-
moperitoneum at a pressure of 10 mm Hg. A zero degree
10 mm laparoscope was inserted and the abdominal or-
gans were inspected. During the diagnostic laparoscopy,
intraperitoneal examination for a unilateral non-palpable
undescended testis began with examination of the normal
contralateral internal inguinal ring, vas deferens and
spermatic vessels. Followed by determination and evalu-
ation of the median (urachus), medial (obliterated um-
bilical artery) and lateral (inferior epigastric artery) um-
bilical ligaments, external iliac vessels, any potential
intra-abdominal testis, the vas deferens, spermatic ves-
sels and the patency of internal ring of the affected side
were determined. Anatomic orientation of the localiza-
tion and volume, mobility of the testis, the distance be-
tween the testes and the inguinal canal, paratesticular
anomalies, lengths of vas deferens and spermatic vessels
and presence of inguinal hernia were assessed to proceed
with either orchiectomy or orchiopexy and either one or
two stage orchiopexy. Blind-ended vas deferens and sper-
matic vessels were considered as vanishing testis.
Mobilization of the testis was performed by incisin g of
the peritoneum over the superior border of the internal
ring. The gubernaculum was identified and mobilized
circumferentially to provide traction by grasping its tes-
ticular end. Dissection was continued distally along the
gubernaculum until the scrotum began to invaginate. The
gubernaculum was transected using electrocautery as far
as possible. Dissection was continued cranially toward
the renal hilum as far as possible to gain enough length
on the spermatic cord to allow tension free orchiopexy.
The peritoneum over the vas may also be incised to gain
additional length. If the spermatic vessels remained too
short, we performed a first stage Fowler Stephens pro-
cedure by placing 2 endoscopy clips as far proximal as
possible on the cord vessels, the vessels were transected
between clips. If adequate leng th was obtained, the tip of
the endoscopy dissector was placed medial to the inferior
epigastric vessels and lateral to the medial umbilical
ligaments on the anterior abdominal wall. Then the dis-
sector tip was directed toward the ipsilateral hemiscro-
tum. A 5 mm trocar cannula was passed over the dissec-
tor through the scrotal incision into the abdominal cavity
and the free end of gubernaculum was grasped and the
testis was brought into approximation with the end of the
trocar. The testis, grasping forceps and trocar were with-
drawn through the scrotum. The cord structures were
inspected to verify that were not twisted. Two 3-zero
polydioxanone sutures were used to complete the or-
chiopexy distally as possible in created sub-dartos pouch.
Finally, the pneumoperitoneum was deflated and the fas-
cia and skin were closed.
The patients underwent the hospital care and medica-
tions (cefazolin sodium 40 mg/kg) and discharged on ou t-
patient medications (amoxicillin 45 mg/kg). They were
invited to visit the outpatient clinic for follow-up.
Follow up: Patien ts wer e follo wed af ter on e week , one
month and 3 months from laparoscopic orchiopexy op-
eration. Detailed medical history and physical examina-
tion were done at each follow-up visit. Scrotal Doppler
ultrasound was performed at 1, 3-month visits.
The time of the procedure, intra-operative complica-
tions, hospital stay, recovery from operation, defined as
the time at which the child returned to his normal pre-
operative activities, and testicular location and viability
were estimated.
3. Results
Forty one patients with non-palp able testis were enrolled
in this study. The mean age of studied patients was 2.85
± 0.85 years (range, one year to 9 years). The non-pal-
pable testis was bilateral in 16 (32.7%), right un ilateral in
23 (46.9%) and left unilateral in 10 (20.4%) (Table 1).
Out of 49 testicular units, diagno stic laparoscop y showed
that 45 were located within 3 cm of the internal inguinal
ring, 2 were more than 3 cm from the internal inguinal
ring and 2 diagnosed as vanishing testis with detection of
blind end spermatic vessels and vas deferens, one at right
side and other at left. None of the patients associated
with oblique inguinal hernia. Of 49 testicular units, 45
(91.8%) were treated by one-stage laparoscopic orchio-
pexy in which the non-palpable testis was located within
3 cm from the internal inguinal ring and two-stage lap ar o-
scopic orchiopexy was performed in 2 (4.1%) in which
the non-palpable testis was located more than 3 cm from
the internal inguin al ring side (Table 2).
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A. A. EMARA
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278
Table 1. Patients’ criteria.
No. of patients 41
No. of testicular units 49
Age, year (mean ± SD) 2.85 ± 0.85
Laterality of intra-abdominal testis No. of testicular units (%)
Unilateral 33 67.3
Right 23 46.9
Left 10 20.4
Bilateral 16 32.7
Table 2. Location of non-palpable testis and its management.
Location No. % Procedure
Within 3 cm of internal ring 45 91.8% One stage laparoscopic orchiopexy
Beyond 3 cm from internal ring 2 4.1% Two stages laparoscopic orchiopexy
Vanishing testis 2 4.1% None
The mean operation time was 22.3 ± 7.8 minutes,
(range, 15 to 30 minutes) for diagnostic laparoscopy;
88.9 ± 20.2 minutes (range, 79 to 110 minutes), for
laparoscopic one stage unilateral orchiopexy; 117.7 ±
11.66 minutes, (range, 95 to138 minutes), for laparo-
scopic one stage bilateral orchiopexy and 177.4 ± 12.6
minutes (range, 153 to 192 minutes), for laparoscopic
two stages unilateral orchiopexy.
All patients who underwent diagnostic laparoscopy
were discharged from the hospital within 6 hours after
the operation. The patients who underwent unilateral or
bilateral laparoscopic orchiopex y were discharged within
24 hours. The mean time for recovery was 3 ± 0.83 days
for diagnostic laparoscopy, 7 ± 2.09 days for laparo-
scopic one stage unilateral orchiopexy, 10 ± 2.8 days for
laparoscopic one stage bilateral orchiopexy and 7 ± 1.9
days for laparoscopic two stages unilateral orchiopexy
for each stage.
Subcutaneous emphysema was reported in only one
case, most probably due to improper placement of first
trocar. None of the patients had late postoperative com-
plications.
The mean operation time, hospital stay, complications
of the operations and recovery periods are summarized in
Table 3.
One month after the laparoscopic orchiopexy, physical
examination and Doppler ultrasonography showed that
46 of 47 testicular units had average size and normal
vascularity, giving a testicular survival rate (TSR) within
1 month of 97.9%. Only one testicular unit (3.1%) was
atrophied and avascular. 45 of 47 (95.6%) were located
in the lower scrotum and 2 of 47 (4.3%) in the upper
scrotum. No changes in testicular size and viability were
found at 3-month follow-up (Table 4).
4. Discussion
The current series represent our experience with laparo-
scopic management of non-palpable testis over 2 years.
Our results were in accordance with previous global re-
sult patterns demonstrating that laparoscopy is an excel-
lent technique not only for diagnosis but also for treat-
ment of non-palpable undescended testis.
Early recognition and surgery for undescended testis,
before 1 year of age, remain the most important interven -
tions to reduce the negative impact of both unilateral and
bilateral cryptorchidism [7]. Since 1976, when Cortesi et
al. [8] first reported a case of abdominal testis identified
by laparoscopy, the laparoscopy founded by many au-
thors a valuable adjunct to clinical examination in the
search of the non-p alpable undescended testes. The treat-
ment of non-palpable testes by laparoscopy was used
only after 1990 as the urologists gained experience with
the method and since then laparoscopic orchiopexy and
orchiectomy have been increasingly used [9,10]. During
the diagnostic laparoscopy, we looking at the internal
inguinal rings for vas deferens (medially) and the tes-
ticular vessels (laterally), in unilateral cases, it is prudent
to inspect the contralateral side especially in the inter-
pretation of findings in relation to the diameter of the
vessels. Laparoscopic detection of the distance of the
testes from the internal ring, the length of the vas defer-
ens and the vessels will give an indication to the ease of
the subsequent orchidopexy. Laparoscopic identification
of blind-ending testicular vessels prior to entering the
internal ring is sufficient to diagnose a vanishing testis,
which does not require further surgical exploration [11,
12].
In the literature, the laparoscopic accuracy rate of in
determination of the location of th e testes was more than
95% [12-14]. Laparoscopy allows the visualization of the
testis, to assess its presence, position, size and the rela-
tive lengths of the vas deferens and the gonadal vessels
which permits the planning of further management (or-
chidopexy or orchidectomy), or indeed avoids extensive
exploration for an absent testis when blind ending vessels

A. A. EMARA 279
Table 3. The mean operation time, hospital stay, complications of the operations and recovery.
Operation time,
minute (mean ± S D) Hospital stay, hour (mean ± SD) Complications No. (%) Recovery, da y (mean ± SD)
Peri-operative Post-operative
Diagnostic laparoscopy 22.3 ± 7.8 6 ± 2.1 1 (%) (subcutaneous emphysema)0 3 ± 0.83
Laparoscopic
unilateral orchiopexy 88.9 ± 20.2 23.4 ± 12.1 0 0 7 ± 2.09
Laparoscopic
bilateral orchiopexy 117.7 ± 11 .66 23.8 ± 15.6 0 0 10 ± 2.8
Laparoscopic
two stages orchiopexy 177.4 ± 12.6 24 ± 11.7 0 0 7 ± 1.9 (for each stage)
Table 4. Testicular survival outcomes of laparoscopic orchiopexy and post operative location of the testis according to the
laparoscopic technique and the loc a tion of the nonpalpable intra-abdominal te stis.
Laparoscopic procedure No. of testicular units Preoperative location of the testisPostoperative location of the testis Testicular survival
One stage laparoscopic
orchiopexy 45 Within 3 cm of inter na l ring Bottom of scrotum 45/45
Two stages laparoscopic
orchiopexy 2 Beyond 3 cm from internal ring High/mid scrotum 1/2
are noted [3]. By lapar oscopy it possible to avoid unne c-
essary surgical interventions in the cases of impalpable
undescended testis. In fact, unnecessary surgical opera-
tions can be avoided in 42% of the cases [15].
Jongwon et al. [3] reported that of 86 testicular units,
17 testicular units (19.8%) were treated by Fowler-Ste-
phens laparoscopic orchiopexy (FSLO). One-stage FSLO
was performed in 14 testicular units (16.3%) and two-
stage FSLO in 3 testicular units (3.5%).
In our study, 47 ou t of 4 9 testicu lar un its (95.9 %) were
treated by laparoscopic orchiopexy. 45 testes (91.8%)
located within 3 cm of the internal inguinal ring were
treated successfully by one-stage laparoscopic orchio-
pexy and 2 testes (4.1%) located more than 3 cm from
the internal inguinal ring were treated by two-stage la-
paroscopic orchiopexy. So, the choice of laparoscopic
technique mostly depended on the distance from the in-
ternal inguinal ring to the non-palpable intra-abdominal
testis.
Riquelme-Heras et al. [4], reporting that twenty-five
patients were released 24 hours after surgery and 2 pa-
tients with a history of bronchial hyperactivity who de-
veloped respiratory symptoms were released 48 hours
after surgery.
In our study, one of most advantages of laparoscopy
are early discharge, rapid recovery, minimal intra-opera-
tive and none postoperative complications.
Samadi et al. [16] conducted PLO in 70.5% and FSLO
in 29.5% of a total of 203 testicular units and reported a
success rate of 95%, which was higher than the 76%
success rate of open surgery. Lindgren et al. [17] did a 6
month clinical follow-up after laparoscopic orchiopexy
and reported a success rate of 93%. Lintula et al. [18]
reported a success rate of 88% for 19 testicular units un-
dergoing laparoscopic orchiopexy and a success rate of
82% for 18 testicular units receiving open surgery, high-
lighting the excellent surgical outcomes of the laparo-
scopic orchiopexy.
Jongwon et al. [3] performed PLO in 80.2% and FSLO
in 19.2% of 86 testicular units. In examination that took
place 3 months after the laparoscopic orchiopexy, the
TSR was 93.7% and the rate of fixation in the lower
scrotum was 76.2%. If classified on the basis of laparo-
scopic techniques, the PLO showed a fixation rate in the
lower scrotum of 79.6%, one-stage FSLO showed a rate
of 63.6% and two stages FSLO showed a r a te of 66.7%.
In our study, the testicular survival rate was 97.9%.
The location of the viable testis after the laparoscopic
orchiopexy was 95.6% in the lower scrotum. Therefore,
the success rate of the laparoscopic orchiopexy for a non-
palpable intra-ab dominal testis was 95.6%. The testicular
survival rate (TSR) not only affected by the size, viabil-
ity of the testis, length and caliber of the spermatic ves-
sels and vas but also by the distance between the testis
and internal ring and subs equently the number of laparo-
scopic orchiopexy stages.
5. Conclusion
The laparoscopy is a reliable technique for diagnosis and
treatment of the non-palpable intra-abdominal testis with
high success and survival rates of the testes. In our study,
the non-palpable testis was properly managed by laparo-
scopy with short hospital stay, rapid recovery and mini-
mal complications.
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