LAPAROSCOPIC VERSUS OPEN ORCHIOPEXY

APPROACH FOR THE MANAGEMENT OF NONPALPABLE

UNDESCENDED TESTISGouda Mohamed Ellabban

Professor of General Surgery Suez Canal University

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].

Introduction About 20% of cryptorchid testicles are

nonpalpable. The treatment of nondescended 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].

Diagnosis Despite a sensitivity of 70-90% in the diagnosis

of inguinal testes, ultrasonography is not useful in intraabdominal cases [6].

Although presenting a better quality, both CT and nuclear magnetic resonance lack sufficient sensitivity and specificity to be considered as gold standard diagnostic tools [7].

More recently, the magnetic angio-resonance 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].

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 nonpalpable 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].

Study population The population included 94 nonpalpable

undescended testes. The results of 46 nonpalpable

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.

Algorithm for a suggested approach to patients with NPT

Operative technique

Lap.operative findings

Clinical characteristics of both groups

Clinical

characteristic

Laparoscopic

group (n=46)

Open surgery

group (n=48)

P value

Age (years):

Mean 4.2 4.35 0.44

Site of testis:

Canalicular (%) 4 (8.7) 2 (4.2) 0.43

Abdominal (%) 38 (82.6) 43 (89.6)

Peeping testes

(%)

4 (8.7) 3 (6.2)

Details of surgical treatment (secondary outcome) in both studied

groupsSurgical

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 ±SD1.1 ± 0.33 (1–2) 1.9 ± 0.6 (1–3) 0.008*

*

Oral feeding (hours):

Mean ±SD7.2 ± 2.5 (6–12) 12 ± 5.8 (6–24) 0.004*

*

Return to normal activities (days):

Mean ±SD9 ± 1.9 (7–12) 28 ± 5.5 (21–36) 0.000*

*

Complications and success rate (primary outcome) of surgical treatment in both

studied groupsLaparoscopic

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)

Conclusion Primary laparoscopic orchiopexy appears

to be a feasible, safe technique for the management of the nonpalpable 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

References 1. Denes FT, Saito FJ, Silva FA, et al. Laparoscopic Diagnosis and

Treatment of Nonpalpable Testis. Int Braz J Urol.2008; 34: 32935.2. Trussell JC, Lee PA: The relationship of cryptorchidism to fertility.

Curr Urol Rep. 2004; 5: 1428.3. MorenoGarcia M, Miranda EB: Chromosomal anomalies in

cryptorchidism and hypospadias. J Urol. 2002; 168: 21702; discussion 2172.

4. Garner MJ, Turner MC, Ghadirian P, Krewski D: Epidemiology of testicular cancer: an overview. Int J Cancer. 2005;116: 3319.

5. Kucheria R, Sahai A, Sami TA, Challacombe B, Godbole H, Khan MS, et al.: Laparoscopic management of cryptorchidism in adults. Eur Urol. 2005; 48: 4537.

6. Kolon TF, Patel RP, Huff DS: Cryptorchidism: diagnosis, treatment, and longterm prognosis. Urol Clin North Am. 2004; 31: 46980.

7. Nguyen HT, Coakley F, Hricak H: Cryptorchidism: strategies in detection. Eur Radiol. 1999; 9: 33643.

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