Thesis on the Role of Laparoscopy in Management of Impalpable Testis in Children

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 (Berkowitz, 1993). 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 are also factors that justifies this type of treatment (Trussel, 2004 and Moreno-Garcia, 2002).
Despite a sensitivity of 70-90% in the diagnosis of inguinal testes, ultrasonography is not useful in intra-abdominal cases (Kolon, 2004). Although presenting a better quality, both computed tomography and nuclear magnetic resonance lack sufficient sensitivity and specificity to be considered as gold standard diagnostic tools (Nguyen, Coakley and Hricak 1999). More recently, the magnetic angioresonance 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 (Eggener, Lotan and Cheng, 2005). 

About 20% of cryptorchid testicles are nonpalpable. In these cases, the laparoscopic technique is a useful alternative method of diagnosis and treatment. In cases of absence testicle, the procedure had been interrupted, whereas in cases of intra- canalicular inguinal testis, open surgical exploration was performed. When intra-abdominal testes were found, immediate laparoscopic orchiectomy was performed for atrophic testicles, while patients with viable testicles was gone through laparoscopic orchiopexy. In cases of low intra-abdominal testicle (located less than 2 cm from the internal inguinal ring) the procedure was straightforward, without transection of the spermatic vessels, while in those located higher (more than 2 cm from the internal inguinal ring) the vessels were sectioned to facilitate the appropriate descent of the testicle to the scrotum. When the vessels were transected, the testis was then be relocated into the scrotum either during the same surgical procedure (primary or one stage Fowler-Stephens) or the relocation is postponed for at least six months after vascular ligature (two stage Fowler-Stephens) (Dénes, 2008).