Surgical Science, 2012, 3, 457-459
http://dx.doi.org/10.4236/ss.2012.39090 Published Online September 2012 (http://www.SciRP.org/journal/ss)
Bilateral Impalpable Testes: A Special Entity of
Tariq Abbas, Ahmed Hayati, Mansour Ali
Hamad General Hospital, Doha, Qatar
Email: email@example.com, firstname.lastname@example.org, email@example.com
Received July 24, 2012; revised August 25, 2012; accepted September 10, 2012
Background: Cryptorchidism is one of the most common genitourinary disorders in young boys. About 1% - 2% of
boys at age of 1 year have an undescended testis (UDT); this disorder is unilateral in about 90% of individuals and
bilateral in about 10%. However, bilateral impalpable testes represent a special category that should be differentiated
from anorchidism as well as male pseu dohermaphroditism. We investigated whether bilateral impalpable testes with its
inherent hormonal and genetic factors has different outcomes in terms of success of orchiopexies compared to unilateral
impalpable testes. Methods: We retrospectively analyzed the demographic and clinical findings, as well as immediate
and 6 month outcomes, in patients diagnosed with bilateral impalpable undescended testes between 2006 and 2010.
Findings were reported after a minimum of 6 months from the last surgical intervention. Results: Nine patients underwen t
laparoscopy for bilateral impalpable testes, 7 of wh om had testes in the region of the internal inguinal ring. The success
rate after laparoscopic exploration and open orchiopexy was 60% while the success rate with unilateral impalpable
testes was 63.3% in the same study. Conclusion: Although laparoscopy is extremely useful in both the diagnosis and
treatment of patients with bilateral impalpable testes, laparoscopy should be preceded by careful cytogenetic and
hormonal workup for this particular group of patients. We found that the success rates of laparoscopic management
of bilateral and unilateral impalpable testes were similar, as shown by testicular size clinically sassed during serial
postoperative outpatient visits.
Keywords: Bilateral Non-Palpable Testis; Laparoscopic; Intra-Ab dominal; Crypt o rchidism
Cryptorchidism is one of the most common genitourinary
disorder s in young boys. About 1% - 2% of boys at age 1
year have an undescended testis (UDT), with the disorder
being unilateral in about 90% and bilateral in about 10%
of cases [1-3]. Almost 20% of undescended testes are
Among the methods used to evaluate and manage un-
descended testes are imaging modalities and various sur-
gical procedures . Over the past two decades, there
have been chan ge s in the surgi cal treatment of undescended
However, bilateral impalpable testes represent a special
category that should be differentiated from anorchidism
as well as male pseudohermaphroditism. We investigated
whether bilateral impalpable testes with its inherent hor-
monal and genetic factors has different outcomes in
terms of success of orchiopexies compared to unilateral
impalpable testes. This was shown by the assessment of
testicular size clinically during serial postoperative out-
Patients under 14 years of age undergoing laparoscopy
for clinically diagnosed impalpable testes between Jan-
uary 2006 and December 2010 in our institution were in-
cluded in the study (Figure 1). Their records were retro-
spectively reviewed. Factors recorded included patient
age at operation, clinical and laparoscopic findings, oper-
ative interventions and outcomes. All patients were fol-
lowed up in the outpatient clinic for at least 6 months.
Figure 1. Percentges of successful orchiopexies in our study
in diffenrent groups.
opyright © 2012 SciRes. SS
T. ABBAS ET AL
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
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.
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 .
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 .
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 . How-
ever, there are no significant differences in these concen-
trations between boys with unilateral and bilateral cryp-
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 .
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% .
We found that laparoscopic management yielded simi-
lar success rates in patients with bilateral and unilateral
impalpable testes, as determined by testicular size.
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.
 D. D. Sweeney, et al., “Minimally Invasive Surgery for
Urologic Disease in Children,” Nature Clinical Practice
Urology, Vol. 4, No. 1, 2007, pp. 26-38.
 A. J. Swerdlow, et al., “Risk of Testicular Cancer in Co-
hort of Boys with Cryptorchidism,” British Medical
Journal, Vol. 314, 1997, pp. 1507-1511.
 F. Hadziselimovic and B. Herzog, “Treatment with a
Luteinizing Hormone-Releasing Hormone Analogue after
Successful Orchiopexy Markedly Improves the Chance of
Fertility Later in Life,” Journal of Urology, Vol. 158, No.
3, 1997, pp. 1193-1195.
 C. Esposito and V. Garipoli, “The Value of 2-Step Lapa-
roscopic Fowler-Stephens Orchiopexy for Intraabdominal
Testes,” Journal of Urology, Vol. 158, No. 5, 1997, pp.
 F. El-Anany, et al., “Laparoscopy for Impalpable Testis:
Classification-Based Management,” Surgical Endoscopy,
Vol. 21, No. 3, 2007, pp. 449-454.
Copyright © 2012 SciRes. SS
T. ABBAS ET AL
Copyright © 2012 SciRes. SS
 J. M. Hutson and M. C. C. Clarke, “Current Management
of the Undescended Testicle,” Seminars in Pediatric Sur-
gery, Vol. 16, No. 1, 2007, 64-70.
 C. Esposito, et al., “Management of Boys with Nonpal-
pable Undescended Testis,” Nature Clinical Practice
Urology, Vol. 5, No. 5, 2008, pp. 252-260.
 J. M. Hutson, “Undescended Testes,” In: M. D. Stringer,
K. T. Oldham and P. D. E. Mouriquand, Eds., Pediatric
Surgery and Urology: Long-Term Outcomes, 2nd Edition,
Cambridge University Press, Cambridge, 2006, pp. 652-
 L. A. Baker, et al., “Cryptorchidism,” In: J. Gearhart, R.
Rink and P. D. E. Mouriquand, Eds., Pediatric Urology,
W.B. Saunders, Philadelphia, 2001, pp. 738-753.
 K. Kubini, et al., “Basal Inhibin B and the Testosterone
Response to Human Chorionic Gonadotropin Correlate in
Prepubertal Boys,” The Journal of Clinical Endocrino-
logy & Metabolism, Vol. 85, No. 1, 2000, pp. 134-138.
 R. Rey, “How to Evaluate Gonadal Function in the Cryp-
torchid Boy. Lessons from New Testicular Markers,”
Journal of Pediatric Endocrinology & Metabolism, Vol.
16, 2003, pp. 357-364. doi:10.1515/JPEM.2003.16.3.357
 N. Lahlou, “Marc Roger Inhibin B in Pubertal Develop-
ment and Pubertal Disorders,” Seminars in Reproductive
Medicine, Vol. 22, No. 3, 2004, pp. 165-174.
 P. Christiansen, A. M. Andersson, N. E. Skakkebaek and
A. Juul, “Serum Inhibin B, FS, LH and Testosterone Lev-
els before and after Human Chorionic Gonadotropin
Stimulation in Prepubertal Boys with Cryptorchidism,”
European Journal of Endocrinology, Vol. 147, 2002, pp.
 S. Y. Tennenbaum, et al., “Preoperative Laparoscopic
Localization of the Non Palpable Testes, a Critical Analy-
sis of a 10-Year Experience,” Journal of Urology, Vol.
164, 2000, pp. 154-155.
 E. Mohamed, M. D. Hassan and M. D. Abdulrahim
Mustafawi, “Laparoscopic Management of Impalpable
Testis in Children, New Classification, Lessons Learned,
and Rare Anomalies,” Journal of Laparoendoscopic &
Advanced Surgical Technique, Vol. 20, No. 3, 2010, pp.