T. ABBAS ET AL
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Prior to surgery, patients were examined under anes-
thesia to confirm that the testes were intra-abdominal.
This was followed by laparoscopic exploration, including
the insertion of a 5 mm port supra-umbilically using a
closed technique and use of a 5 mm 0 camera. Secondary
2 - 3 mm ports were placed under direct vision if re-
quired and a 2 mm atraumatic grasp er was used. Initially,
we tried to identify the testes, testicular vessels, and vas
deferens and whether the internal inguinal rings (IIR)
were open or clos ed.
A “high” position of the testis was defined as being
above the external iliac vessels; orchiopexy for these
patients consisted of a two-stage Fowler-Stephens pro-
cedure. A “low” intra-abdominal testis was usually man-
aged by one-stage laparoscopic orchiopexy. Orchidectomy
was performed on an atrophic testis accompanied by a
contralateral normal testis.
All patients were routinely followed-up at our outpa-
tient clinic. A procedure was defined as “successful” if it
resulted in a palpable testis in the scrotum of similar or
increased size.
3. Results
Between January 2006 and December 2010, 91 patients,
including 9 with bilateral and 8 2 with unilateral impalpa-
ble testes, were scheduled for therapeutic and diagnostic
laparoscopy, for a total of 100 testes. Av erag e patien t ag e
at the time of the surgical intervention was 64.3 months.
We found that the total success of orchiopexy for all
testes was 63.3%. This success rate was achieved fol-
lowing laparoscopic exploration and open orchiopexy for
testes in the region of the IRR, representing the most
frequent finding in bilateral intra-abdominal testes in this
series (78%) (See Figure 1).
There were no complications from laparoscopy in the
immediate or postoperative periods. No port site hernia
was detected on follow-up.
4. Discussion
Testicular descent, although n ot y et fully und erstood, takes
place in two different stages, starting during weeks 8 and
25 of gestation, respectiv ely. Failure of the first phase of
descent is rarer than failure of the second phase, with
failure of the first phase resulting in an intra-abdominal
undescended testis [6].
Cryptorchidism is one of the most common genitouri-
nary disord ers in young boys. Altho ugh the management
of boys with palpable testes has been standardized, there
are no formal guidelines for the management of boys
with non-palpable testes [7].
Clinical examinations have shown that 80% of UDTs
are palpable. Of these, 30% are located in the inguinal
superficial pouch, 20 % in the inguinal canal, an d 45% in
the upper scrotum, with only 5 % in the perineum or thigh.
In contrast, the remaining 20% of UDTs are non-palpable
and are located in the abdominal cavity [8,9].
In peripubertal boys with nonpalpable testes, the pre-
sence of Sertoli cells is easily assessed by measuring se-
rum inhibin B and/or AMH concentrations [10,11]. Inhi-
bin B is undetectable in anorchid boys, but generally
within the normal range in cryptorchid boys [12]. How-
ever, there are no significant differences in these concen-
trations between boys with unilateral and bilateral cryp-
torchidism [13].
Laparoscopy is currently the most reliable diagnostic
modality in the management of impalpable testes. Lapa-
roscopy can clearly visualize anatomy and provides infor-
mation on which a definitive decision can be based [14].
The three main laparoscopic findings are an IAT, ob-
served in 40% of patients, intra-abdominal blind-ending
cord structures in 15% and cord structures entering the
IRR in 45% [15].
We found that laparoscopic management yielded simi-
lar success rates in patients with bilateral and unilateral
impalpable testes, as determined by testicular size.
5. Conclusion
In conclusion, laparoscopy in the management of bi-
lateral impalpable testes should be preceded by careful
cytogenetic and hormonal workup. Laparoscopic man-
agement yielded similar success rates in patients with
bilateral and unilateral impalpable testes, as determined
by testicular size.
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