Search

Introduction: In 2014, the AUA published guidelines regarding the evaluation of cryptorchidism. This multi-institutional study aims to determine if these guidelines reduced the age of referral and the utilization of ultrasound in boys with cryptorchidism. We hypothesize that delayed referral continues, and utilization of ultrasound remains unchanged., Methods: A retrospective review of boys referred for the evaluation of cryptorchidism was performed at 4 academic institutions, collecting data for 1 year prior (2013) and 2 nonconsecutive years following guideline creation (2015 and 2019). Across these time frames, we compared median ages at evaluation and surgery, and rates of patient comorbidities, orchiopexy, and preevaluation ultrasound., Results: A total of 3,293 patients were included. The median age at initial pediatric urology evaluation in all cohorts was 39 months (IQR: 14-92 months). Following publication of the AUA Guidelines, there was no difference ( P = .08) in the median age at first evaluation by a pediatric urologist between 2013 and 2015, and an increase ( P = .03) between 2013 and 2019. Overall, 21.2% of patients received an ultrasound evaluation prior to referral, with no significant difference between 2013 and 2015 ( P = .9) or 2019 ( P = .5) cohorts., Conclusions: Our data suggest that, despite publication of the AUA Guidelines on evaluation and treatment of cryptorchidism, there has been no reduction in the age of urological evaluation or the utilization of imaging in boys with undescended testis. Finding alternative avenues to disseminate these evidence-based recommendations to referring providers and exploring barriers to guideline adherence is necessary to improve care for patients with cryptorchidism.

Purpose: While the nonpalpable testis represents a small portion of all cryptorchid testes, it remains a clinical challenge for pediatric urologists. Controversy exists surrounding the best evaluation and management of this entity. In this review we update what is known about the nonpalpable testis, including the etiology, preoperative evaluation and best surgical management as well as novel techniques and ongoing controversies., Materials and Methods: We searched PubMed® and MEDLINE® from January 2000 to January 2017 using relevant key terms. Of 367 articles 115 were considered for inclusion based on a priori design. Using a narrative review format, an update on the evaluation and management of the nonpalpable testis including novel concepts and techniques was synthesized., Results: The nonpalpable testis should be evaluated by physical examination only. Imaging is not indicated for routine cases. The optimal surgical approach and technique remain debatable but several novel techniques have been described. Due to the rarity of the nonpalpable testis, randomized controlled trials and other quality comparisons are difficult. Therefore, management remains controversial., Conclusions: Evaluation and management of the nonpalpable testis remain difficult, and some aspects are still debated. Future research should focus on multi-institutional collaborative trials to determine the optimal operative management., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Cryptorchidism is one of the most common pediatric disorders of the male endocrine glands and the most common genital disorder identified at birth. This guideline is intended to provide physicians and non-physician providers (primary care and specialists) with a consensus of principles and treatment plans for the management of cryptorchidism (typically isolated non-syndromic)., Materials and Methods: A systematic review and meta-analysis of the published literature was conducted using controlled vocabulary supplemented with key words relating to the relevant concepts of cryptorchidism. The search strategy was developed and executed by reference librarians and methodologists to create an evidence report limited to English-language, published peer-reviewed literature. This review yielded 704 articles published from 1980 through 2013 that were used to form a majority of the guideline statements. Clinical Principles and Expert Opinions were used for guideline statements lacking sufficient evidence-based data., Results: Guideline statements were created to inform clinicians on the proper methods of history-taking, physical exam, and evaluation of the boy with cryptorchidism, as well as the various hormonal and surgical treatment options., Conclusions: Imaging for cryptorchidism is not recommended prior to referral, which should occur by 6 months of age. Orchidopexy (orchiopexy is the preferred term) is the most successful therapy to relocate the testis into the scrotum, while hormonal therapy is not recommended. Successful scrotal repositioning of the testis may reduce but does not prevent the potential long-term issues of infertility and testis cancer. Appropriate counseling and follow-up of the patient is essential., (Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We studied long-term outcomes of orchiopexy at diagnosis of acquired undescended testes using ultrasound to determine testicular volume., Materials and Methods: Patients who had undergone orchiopexy for acquired undescended testis at diagnosis were recruited to assess testicular volume. Testis volume was measured by ultrasound and compared with recently developed normative values for testicular size. For young adults (older than 18 years) volumes were grouped and compared to normative values reported in the literature. In all unilateral cases testicular volume was compared with its counterpart., Results: A total of 155 patients 5.1 to 26.6 years old (181 acquired undescended testes) were included in the study. Mean ± SD followup was 6.6 ± 3.8 years (range 1.4 to 15.5). For all patients 18 years old or younger (125 patients, 143 testes) operated testis volume was 0.1 to 12.7 ml (mean ± SD 2.5 ± 2.9), which was significantly smaller than the normative values (50th percentile) for the same age (p <0.001). Mean ± SD testis volume in young adults (38 testes) was 8.1 ± 3.7 ml, compared to a mean volume of 13.4 ml reported in the literature (p <0.001). In unilateral cases the mean volume of the testes fixed by orchiopexy differed significantly from their counterparts (3.4 ± 3.3 ml vs 4.6 ± 4.6 ml, p <0.001)., Conclusions: The long-term volumes at diagnosis of acquired undescended testes after orchiopexy were significantly less than the normative values at all ages. In unilateral cases the volumes were also significantly less compared to the contralateral testes., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: In recent years several Danish studies of the etiology, time trends and long-term health consequences of cryptorchidism have relied on diagnoses and surgical treatments registered in the National Patient Registry. We evaluated the diagnostic accuracy of these registry data., Materials and Methods: According to the Danish National Patient Registry, 16,168 males were diagnosed with cryptorchidism and 9,244 surgical treatments for cryptorchidism were performed between January 1, 1995 and October 10, 2009. We randomly selected 500 diagnosed cases, of which 284 had been managed surgically. We requested the medical records from the departments making the diagnoses and performing the surgery., Results: We successfully retrieved medical records for 452 diagnosed cases (90%) and 249 operations (88%). Overall positive predictive value of a registry diagnosis of cryptorchidism was 80% (95% CI 77-84) using the testicular position described by the physician performing the clinical examination as the gold standard. Similarly the positive predictive value of the surgical treatment registration was 99% (95% CI 98-100) using the type of procedure performed., Conclusions: The data on cryptorchidism in the Danish National Patient Registry are quite accurate. In etiological research the limited misclassification will in most cases only slightly attenuate estimates of the true relative association. Thus, the registry has the potential to serve as a valuable research tool, although caution should be exercised when studying time trends or geographical differences., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Cryptorchidism is a common finding in infants and young boys. Early repair lessens the extent of testicular injury. We hypothesized that anatomical and socioeconomic factors affect the timing of consultation and treatment for boys with cryptorchidism., Materials and Methods: Under an institutional review board approved protocol we reviewed the records at a single institution of children who underwent exploration for unilateral or bilateral cryptorchidism. Demographic and anatomical factors were recorded., Results: The median age of 677 boys at consultation and surgery was 20.3 and 28.9 months, respectively. Median age at consultation for boys with nonpalpable and palpable testicles was 12.3 and 20.9 months, respectively (p = 0.03). Boys with a concomitant penile anomaly had a younger median age at consultation than boys without a penile anomaly (8.5 vs 20.3 months, p <0.01). Demographic factors did not vary with respect to time to consultation and surgery (p >0.05). Multivariate analysis showed that abdominal site and concomitant penile anomaly were associated with earlier time to consultation (p = 0.02 and <0.01, respectively)., Conclusions: The timing of consultation for boys with undescended testicles does not vary in regard to race, language or insurance type at this tertiary care institution. Instead, anatomical factors influenced age at consultation for boys with cryptorchidism. This suggests that in some geographic regions access to care is not restricted for minorities or noncommercially insured children., (Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Early treatment for cryptorchidism may be necessary to preserve fertility. International guidelines now recommend that congenital cryptorchidism be treated with orchiopexy before age 1 year. Acquired cryptorchidism should be treated at presentation. To our knowledge the rate of adherence to these guidelines in recent years is unknown. Thus, we present data on age at cryptorchidism diagnosis and orchiopexy in recent Danish birth cohorts., Materials and Methods: A population of 508,964 Danish boys born alive from January 1, 1995 to December 31, 2009 was identified using the Danish Civil Registration System. Five birth cohorts were defined, including 1995 to 1997, 1998 to 2000, 2001 to 2003, 2004 to 2006 and 2007 to 2009. The boys were followed in the Danish National Patient Registry for a diagnosis of cryptorchidism and for an orchiopexy procedure. Data were analyzed using the Kaplan-Meier estimator and Cox regression models., Results: During followup 10,094 boys were diagnosed with cryptorchidism, of whom 5,473 underwent orchiopexy. Mean age at diagnosis in boys followed at least 6 years was 3.3 years (95% CI 3.3-3.4) in the 1995 to 1997 cohort, 3.1 (95% CI 3.1-3.2) in the 1998 to 2000 cohort and 2.9 (95% CI 2.8-2.9) in the 2001 to 2003 cohort while mean age at orchiopexy was 3.8 (3.7-3.9), 3.6 (3.5-3.7) and 3.3 years (3.2-3.4), respectively., Conclusions: In the more recent birth cohorts of 1995 to 2009 we observed a shift toward younger age at cryptorchidism diagnosis and orchiopexy., (Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We dissected prevailing assumptions about cryptorchidism and reviewed data that support and reject these assumptions., Materials and Methods: Five questions about cryptorchidism and the risk of testicular cancer were identified because of their implications in parent counseling and clinical management. Standard search techniques through MEDLINE were used to identify all relevant English language studies of the questions being examined. Each of the 5 questions was then examined in light of the existing data., Results: The RR of testicular cancer in a cryptorchidism case is 2.75 to 8. A RR of between 2 and 3 has been noted in patients who undergo orchiopexy by ages 10 to 12 years. Patients who undergo orchiopexy after age 12 years or no orchiopexy are 2 to 6 times as likely to have testicular cancer as those who undergo prepubertal orchiopexy. A contralateral, normally descended testis in a patient with cryptorchidism carries no increased risk of testis cancer. Persistently cryptorchid (inguinal and abdominal) testes are at higher risk for seminoma (74%), while corrected cryptorchid or scrotal testicles that undergo malignant transformation are most likely to become nonseminomatous (63%, p <0.0001), presumably because of a decreased risk of seminoma., Conclusions: Orchiectomy may be considered in healthy patients with cryptorchidism who are between ages 12 and 50 years. Observation should be recommended in postpubertal males at significant anesthetic risk and all males older than 50 years. While 5% to 15% of scrotal testicular remnants contain germinal tissue, only 1 case of carcinoma in situ has been reported, suggesting that the risk of malignancy in these remnants is extremely low.

Purpose: Given that the prevalence of childhood obesity is increasing in the United States, we tested the timely hypothesis that obesity hinders physical examination based localization of the cryptorchid testis., Materials and Methods: Body mass index and percentiles of weight for height and body mass index for age were calculated for boys undergoing surgery for cryptorchidism at the University of California San Francisco Children's Hospital and Children's Hospital of Oakland. Two definitions of obesity were examined, ie greater than 85% or greater than 95% for either percentile. Patients were examined in the office and under general anesthesia before the skin incision. Intraoperative testicular location was recorded for each patient. The numbers of correct and incorrect preoperative determinations of testicular location were stratified by weight classification. Results were analyzed using contingency tables and Fisher's exact test., Results: A total of 161 boys were recruited, accounting for 171 testes. The predictive value of palpating a suspected testis preoperatively with patients under anesthesia was greater than 95% for all weight classifications (p <0.0001). The predictive value of not palpating a testis preoperatively under anesthesia was greater than 56% for obese boys and greater than 42% for nonobese boys (p <0.0001). The concordance rates between examinations in the office and those performed under anesthesia were 90.9% and 82.7% for obese and nonobese boys, respectively (p = 0.51). The predictive value of not palpating a suspected cryptorchid testis in the office was higher in nonobese boys than in obese boys (81% vs 22%, p <0.0001)., Conclusions: In our series childhood obesity did not make preoperative testicular examinations under anesthesia less accurate. However, office examinations may be more accurate in nonobese boys.

Purpose: Recent studies have shown that magnetic resonance arteriography/venography is a highly sensitive tool to identify impalpable testes in young boys. Due to this and the low risk of cancer in testicular nubbins observation has been proposed after the identification of nubbins by magnetic resonance arteriography/venography. We prospectively examined the accuracy of magnetic resonance imaging and magnetic resonance imaging with magnetic resonance arteriography/venography for identifying impalpable testes in a younger cohort of patients typically seen at a pediatric institution in the United States., Materials and Methods: We prospectively studied 26 infants and boys with impalpable testes. Conventional magnetic resonance imaging or magnetic resonance imaging with magnetic resonance arteriography/venography was performed in all patients. All patients subsequently underwent surgical exploration. Surgical and radiological findings were then evaluated for concordance., Results: A total of 26 boys (29 impalpable testes) with a median age of 13 months were evaluated. A subset of 14 boys (14 impalpable testes) also underwent magnetic resonance arteriography/venography. Standard magnetic resonance imaging correctly identified 10 of 12 intra-abdominal testes, 4 of 6 intracanalicular testes, 4 of 10 testicular nubbins and 0 of 1 scrotal testis. Magnetic resonance arteriography/venography correctly identified 4 of 5 intra-abdominal testes, 2 of 3 intracanalicular testes, 2 of 5 testicular nubbins and 0 of 1 scrotal testis. The overall accuracy of magnetic resonance imaging alone and magnetic resonance arteriography/venography for identifying a viable testis or testicular nubbin was 62% and 57%, respectively. The accuracy of magnetic resonance imaging and magnetic resonance arteriography/venography for identifying a viable testis was 74% and 67%, respectively., Conclusions: Preoperative magnetic resonance imaging or magnetic resonance arteriography/venography does not accurately identify or localize impalpable testes in the age group typically presenting to pediatric urologists. Accuracy at our institution is discrepant with that in previous studies. We do not recommend using magnetic resonance imaging or magnetic resonance arteriography/venography for the possible observation of vanishing testes or nubbins and we recommend surgical exploration in all individuals.

Purpose: We evaluated the incidence of cryptorchidism and inguinal hernias in patients with posterior urethral valves, and compared characteristics in patients with and without cryptorchidism or inguinal hernia., Materials and Methods: A total of 200 patients with posterior urethral valves treated between 1953 and 2003 were identified from a hospital database. Patient records were retrospectively reviewed. The state of testicular descent and the presence of inguinal hernias were recorded in 192 patients. Patient characteristics were analyzed., Results: Of 192 patients 31 (16%) had cryptorchidism, which was bilateral in 9 (29%). A total of 21 patients (11%) had inguinal hernias that were not associated with cryptorchid testes. The patients with cryptorchidism, and to some extent the patients with hernias, appeared to have a more severe form of posterior urethral valves than those without cryptorchidism. At the time of diagnosis the median serum creatinine concentration was 100 mumol/l (range 38 to 460) in boys with cryptorchidism and 87 (14 to 593) in boys without cryptorchidism (p = 0.131). At 6-month followup the median serum creatinine levels were 90 mumol/l (range 31 to 573) in patients with cryptorchidism and 45 (19 to 504) in patients without cryptorchidism (p = 0.006). Cryptorchidism was also more common in cases diagnosed neonatally compared to those diagnosed at a later age (14 of 52 patients, 27% vs 14 of 112, 12.5%, respectively, p = 0.027)., Conclusions: The incidence of cryptorchidism and inguinal hernias requiring surgery is high in patients with posterior urethral valves. Patients with cryptorchidism appear to have a more severe form of posterior urethral valves than those with normal testes.

Purpose: Prescrotal orchiopexy is emerging as an alternative surgical approach to undescended testicles. We compare operative times, success rates and complications of single incision prescrotal orchiopexy and the traditional inguinal approach., Materials and Methods: During a 3-year period all patients who underwent prescrotal orchiopexy were retrospectively reviewed and compared to age matched controls operated on via the traditional inguinal approach. Data collected included preoperative and postoperative testicular positioning, operative time and complications, including testicular atrophy and ascent. Exclusion criteria were retractile or ectopic testis, incomplete data, including lack of followup, and a concurrent procedure at the time of orchiopexy., Results: A total of 63 orchiopexies were performed using the prescrotal approach (mean patient age 4.6 years) and the inguinal approach (4.7 years). Average surgical times for the prescrotal and inguinal groups were 34 and 64 minutes, respectively (p = 0.002). Followup ranged from 6 to 42 months. Complication rates between the groups were similar. However, 2 hernias (3%) occurred in the prescrotal group, of which 1 was incarcerated and associated with Meckel's diverticulum, and 1 was a late recurrence., Conclusions: With the paucity of literature on prescrotal orchiopexy potential complications may be underreported. Despite the limitations of sample size, prescrotal orchiopexy may be associated with a 3% risk of postoperative hernia. A single incision prescrotal orchiopexy is still a viable approach for patients with primary palpable undescended testicles. Advantages include shorter operative time, a cosmetically appealing single incision and possibly less pain.

Purpose: We previously reported initial scrotal exploration for unilateral nonpalpable testis, followed by laparoscopy when a viable testis was not found. Although we concluded that scrotal exploration could often make laparoscopy unnecessary, the knowledge that patients with presumed nubbins would undergo laparoscopy meant that the surgeon did not have to decide whether findings were definitive. In a second series of consecutive patients laparoscopy was used only when it appeared indicated., Materials and Methods: Boys with unilateral nonpalpable testis underwent initial scrotal exploration. Laparoscopy was only performed when neither a nubbin nor a testis was found, when there was a patent processus vaginalis and/or when gross findings suggesting a nubbin were thought inconclusive., Results: There were 43 patients, including 30 (70%) with monorchism and 13 (30%) with an extra-abdominal (7) or intra-abdominal (6) testis. Of 30 patients found to have monorchism laparoscopy was performed only in 7 (23%), including 2 with scrotal nubbins with a patent processus vaginalis, 1 with a questionable nubbin, 1 with a definitive nubbin but preoperative magnetic resonance imaging suggesting a testis and 3 with an empty scrotum (intra-abdominal vanished testis in 1 and inguinal nubbins in 2). The finding of monorchism was strongly predicted by a contralateral descended testicular length of 1.8 cm or greater., Conclusions: Scrotal exploration is potentially definitive for the diagnosis and management of extra-abdominal testes and nubbins in patients with unilateral nonpalpable testis. Laparoscopy is only definitive when an intra-abdominal testis is found, which occurs in a minority of cases.

Purpose: The FG syndrome, also known as Opitz-Kaveggia syndrome, is an X-linked disorder characterized by developmental delay, congenital hypotonia, characteristic facial appearance, relative macrocephaly and anomalies affecting the genitourinary, gastrointestinal and musculoskeletal systems. Genitourinary abnormalities in the FG syndrome include cryptorchidism, hypospadias, inguinal hernia, hydrocele and occasional anomalies of renal or ureteral development. To our knowledge no previous study has systematically evaluated the genitourinary aspects of the disorder. We describe the genitourinary anomalies seen in children with the FG syndrome. This report may help elucidate the pathogenic mechanisms responsible for the disorder. Also, we provide a simple checklist for urologists that will help guide referrals for genetics and other specialty consultations., Materials and Methods: We retrospectively reviewed 228 patients with the FG syndrome to identify the frequency of characteristic historical and physical findings. These patients were diagnosed on the basis of a firsthand history and physical examination, or by a careful outside evaluation including detailed records and photographs., Results: Of the patients 90% were male. The overall incidence of any genitourinary anomaly was 48.5% in boys, 13.6% in girls and 44.7% overall. In boys the most common abnormalities were cryptorchidism (24%), hypospadias (14%) and hernia or hydrocele (13%)., Conclusions: The FG syndrome is a disorder with a greater prevalence than previously thought, yet is rarely suspected by urologists. The manifestations may be complex. Identification of patients with syndromal genitourinary anomalies by urologists will enhance the quality of care based on referral of patients for additional evaluation.

Purpose: Retractile testes are thought to represent a normal variant of descended testes in prepubertal boys. We studied retractile testes to determine their natural history., Materials and Methods: We retrospectively reviewed the charts of 122 boys (mean age 5.4 years) who were referred for a suspected undescended testis and were found to have a retractile testis. A retractile testis was defined as a suprascrotal testis that could be manipulated easily into the scrotum and remained there without traction until the cremasteric reflex was induced. The boys were followed by annual examinations, which demonstrated the presence of retractile, descended (nonretractile) or undescended testes, and the presence or absence of a taut or inelastic spermatic cord in association with a retractile testis., Results: Of 204 retractile testes 61 (30%) descended (became nonretractile), 66 (32%) became UDTs and 77 (38%) remained retractile. Of the 62 retractile testes with a taut or inelastic spermatic cord 35 (56%) became UDTs. Of the 61 orchiopexies performed 8 (13%) showed a patent processus vaginalis. Boys in whom UDTs vs descended testes developed were a mean of 4.9 vs 6.6 years old (p = 0.001). The chance of spontaneous descent was 58% in boys 7 years or older, compared to 21% in boys younger than 7 (p <0.0001)., Conclusions: A retractile testis is not a normal variant. Retractile testes have a 32% risk of becoming an ascending or acquired undescended testis. The risk is higher in boys younger than 7 years old, or when the spermatic cord seems tight or inelastic. Boys with retractile testes should be monitored annually until the testes have clearly descended.

Purpose: Testicular biopsy (TBx) performed during orchiopexy in boys with cryptorchidism can help to predict future semen analyses and possibly identify patients at risk for testicular cancer. It has been theorized that TBx can be detrimental to the long-term health of the testis. We examined testicular microlithiasis (TM) and antisperm antibody (ASA) production in cryptorchid TBx., Materials and Methods: A total of 112 males underwent fertility evaluation. These patients had previously undergone orchiopexy and bilateral TBx (mean age 8.6 years) for unilateral or bilateral undescended testis. At a mean age of 19.6 years all patients underwent physical examination and scrotal ultrasound for evaluation of testis size, echotexture and abnormalities. Of 112 patients 57 also underwent direct Immunobead(R) assay with positive controls. Moving sperm free and/or bound to IgG bead complex were counted in the preparation., Results: A total of 29 patients had bilateral and 83 had unilateral undescended testis. Of the 112 patients 26 were black and 86 were white. Four black patients (15.4%) and 4 white patients (4.7%) had testicular microlithiasis. Three patients had bilateral and 5 had unilateral diffuse TM. No tunica albuginea scars or testis masses were noted. In the 57 patients who underwent direct Immunobead assay no semen sample demonstrated evidence of forming bead-sperm complex, ie none had direct ASA., Conclusions: No patient exhibited evidence of direct ASA. Prepubertal open TBx does not increase the rate of TM. We found no evidence of additive testicular damage associated with TBx at the time of orchiopexy.

Purpose: For the unilateral nonpalpable testis standard management is open surgical or laparoscopic exploration. An ideal imaging technique would reliably identify testicular nubbins and safely allow children to forgo surgical exploration without compromising future health or fertility. Our goal was to perform a cost and risk analysis of magnetic resonance angiography (MRA) for unilateral nonpalpable cryptorchid testes., Materials and Methods: A search of the English medical literature revealed 3 studies addressing the usefulness of MRA for the nonpalpable testicle. We performed a meta-analysis and applied the results to a hypothetical set of patients using historical testicular localization data. Analysis was then performed using 3 different management protocols-MRA with removal of testicular nubbin tissue, MRA with observation of testicular nubbin tissue and diagnostic laparoscopy. A cancer risk and cost analysis was then performed., Results: MRA with observation of testicular nubbin tissue results in 29% of patients avoiding surgery without any increased cost of care. Among the 29% of boys with testicular nubbins left in situ and observed the highest estimated risk was 1 in 300 of cancer developing, and 1 in 5,300 of dying of cancer., Conclusions: A protocol using MRA with observation of inguinal nubbins results in nearly a third of boys avoiding surgical intervention at a similar cost to standard care without any significant increased risk of development of testis cancer.

Purpose: We determine whether the finding of a nonpalpable left testis and hypertrophied(2 cc or greater) right testis is predictive of an atrophic (perinatal torsion) left testis., Materials and Methods: Prospectively, all boys with a nonpalpable left testis and hypertrophied right testis seen between May 2000 and May 2002 were included in the study. Testicular measurement was performed preoperatively with an orchidometer. In 19 of 22 boys size was also confirmed intraoperatively. Surgical exploration was done initially through a scrotal incision. Diagnostic laparoscopy was performed in boys in whom intrascrotal tissue that was consistent with a "nubbin" was not found. All tissue removed was submitted for histological evaluation., Results: In 19 of 22 boys tissue was found in the left hemiscrotum that was clinically consistent with a scrotal nubbin, and histological confirmation was absolute in 18. In 1 patient a hollow oval mass attached to a cord extending to the external inguinal ring was found without the other classic histological features of torsion. In 3 cases scrotal exploration was negative and diagnostic laparoscopy was performed. Of this group the pathognomonic findings of a closed internal ring with hypoplastic vas and vessels were noted in 2 cases, and normal vas and vessels were seen to exit an open internal inguinal ring in 1. Inguinal exploration demonstrated an enlarged intracanalicular testis measuring 3 cc in volume, comparable in size to the descended right testicle., Conclusions: The combination of a nonpalpable left testis and an enlarged right testis is highly predictive of perinatal testicular torsion. When both criteria were met 20 of 22 (91%) consecutive patients had histological or laparoscopically confirmed perinatal torsion and 1 had only clinical features. This finding supports the concept of scrotal exploration as the initial procedure in the child who has an empty left hemiscrotum and hypertrophied descended right testis. Laparoscopy should be reserved for boys in whom a distinct remnant is not found on scrotal exploration.

Purpose: In the evaluation and treatment of the nonpalpable testis open surgical exploration and laparoscopy are methods used to differentiate abdominal, infrainguinal (below the internal ring) and atrophic or absent testes. We sought to evaluate the use of bimanual digital rectal examination as an additional tool to localize the nonpalpable testis., Materials and Methods: Forty-one consecutive patients with 45 nonpalpable testes were evaluated in a prospective fashion. Bimanual digital rectal examination was performed with the patients under general anesthesia just before diagnostic laparoscopy or open inguinal exploration. Palpability, location, length and contralateral testicular length were recorded., Results: Twenty-five gonads or spermatic cords (56%) were palpable using the bimanual technique. All positive examinations were confirmed laparoscopically or by open exploration, and the majority of gonads were intra-abdominal (17 of 25, 68%). Seventeen normal appearing gonads underwent orchiopexy and 8 were removed secondary to atrophy, dysgenesis or poor position. Twenty testes (44%) were not palpated using this method. Of these gonads 10 normal appearing testes were found at exploration and underwent orchiopexy. Of the 10 remaining gonads 6 atrophic testes were removed, and 4 hemosiderin laden remnants were thought to represent "vanished testes." Overall, 26 gonads or remnants were intra-abdominal, 10 were "peeping" or canalicular and 9 were infrainguinal. The overall specificity was 100%, with a sensitivity of 60%. The positive predictive value was 100%., Conclusions: Bimanual digital rectal examination is a valuable tool in the evaluation of the nonpalpable testis, and identified the presence and position of the testis in the majority of our cases. Although sensitivity is low, when the testis is palpated by this method, diagnostic laparoscopy to localize the testis may be avoided.

Purpose: We prospectively evaluated the efficacy of human chorionic gonadotropin (HCG) in the treatment of undescended testis and sought to determine whether HCG assists in the differentiation of undescended testis from retractile testis., Materials and Methods: Patients with undescended testes were offered HCG. Testis position, laterality and the presence or absence of a hypoplastic scrotum were noted. The same physician (G. W. K.) recorded physical findings prospectively and stated clinical impression of descent., Results: A total of 67 patients with 90 undescended or retractile testes were treated and evaluated with HCG. Of the 64 undescended testes 13 (20%) descended with HCG therapy, with none requiring subsequent surgery. Of the 26 retractile testes 15 (58%) descended with HCG (p <0.001). Based on physical examination, 100% of retractile testes descended if the testis was in the high scrotal position but only 40% descended if the testis was in the superficial pouch or inguinal area. In the undescended testes group no ectopic or nonpalpable testis descended with HCG. Evaluation of HCG with age demonstrated minimal response (15%) to HCG at less than 24 months, and a peak response between ages 2 and 6 years (75%) with response decreasing thereafter., Conclusions: HCG may have a limited role in the evaluation of undescended testis in patients younger than 2 years. HCG can serve as an adjunct in the clinical diagnosis of retractile testis in older children.

Purpose: Testicular remnants identified during exploration for cryptorchidism contain vascularized fibrous nodules at the termination of the vas deferens, hemosiderin, calcification, a pampiniform plexus or occasionally residual seminiferous tubules that may contain germ cells. An absent testis lacks the features of testicular remnants. To our knowledge testicular remnants have not been described in a crossed ectopic location. We reviewed orchiectomy specimens obtained at exploration for a nonpalpable testis to characterize the features of testicular remnants, including the frequency of seminiferous tubules, germ cells and crossed ectopia, as well as to clarify the diagnostic criteria for testicular remnants., Materials and Methods: From 1990 to mid 2000 medical records and histological slides from 101 boys with nonpalpable testes who had undergone inguinal exploration and orchiectomy were reviewed., Results: Of the 71 testicular remnants identified 7 (9.8%) contained residual tubules, of which 4 (5.6%) contained germ cells. In 4 boys the testis was deemed absent but 3 did not undergo laparoscopic exploration. There were 2 ectopic remnants (2.8%) on the contralateral side-the pelvis or in the scrotum. Both crossed remnants demonstrated dissociation of the testis from the vas/epididymis which remained on the correct side associated with a pampiniform plexus. No müllerian remnants were encountered., Conclusions: Adequate exploration for nonpalpable testis requires laparoscopy with visualization of the contralateral pelvic region because an ectopic remnant may be dissociated from the vas/epididymis and vessels. Identification of a pampiniform plexus, vas and spermatic vessels may not be a reliable indicator of a testicular remnant. Continued removal of testicular remnants is warranted because at least 9.8% contain residual viable tubules.

Purpose: We determine if paternity is reduced among men with monorchidism (absent or removed testis) compared to men with unilateral cryptorchidism corrected during childhood by orchiopexy and controls. The group of men with an absent testis was determined among males presenting during childhood with only 1 descended testis., Materials and Methods: Data were obtained by medical record review and a detailed questionnaire. Only men who had been successful at or attempted paternity for whom we had complete data were included in the study from the entire cohort of 584 men with former cryptorchidism, 23 with absent testis, 26 treated with orchiectomy and 706 controls., Results: Percentages of men reporting success after attempting paternity did not differ among men with an absent testis (15 of 15, 100%), treated with orchiectomy (17 of 20, 85.0%), with corrected unilateral cryptorchidism (313 of 349, 89.7%) and controls (412 of 442, 93.2%). There was no difference for a subgroup of men with cryptorchidism judged to have an atrophic testis at orchiopexy (17 of 20, 85%) or those who underwent orchiectomy at initial attempted orchiopexy (8 of 10, 80%) and men who had subsequently undergone orchiopexy (9 of 10, 90.0%). Paternity was also not reduced in the group of men with only 1 testis (32 of 35, 91.4%) (monorchism plus orchiectomy) compared to either the corrected unilateral cryptorchid group or the control group. Of 637 testes 183 were recorded as impalpable on examination before surgery and 23 testes were absent, including 7 recorded as palpable. In fact, 12.1% (23 of 190) of testes that should have been recorded as impalpable were absent., Conclusions: This study failed to indicate that paternity is diminished among men with a single testis compared with the general population, regardless of the origin of the loss. About 12% of unilateral impalpable testes judged to be impalpable on examination before surgery were found to be absent after surgical exploration.

Purpose: We determined whether testicular size at orchiopexy is predictive of fertility potential and whether size correlates with sperm parameters, hormone levels or testicular volume in adulthood., Materials and Methods: Testicular size obtained from the operative notes of patients who underwent unilateral orchiopexy was classified as normal, small or large for age. These data were compared with outcome data. Paternity data were included on 166 men who reported achieving or unsuccessfully attempting paternity for 12 or more months. Of the men 49 provided blood for hormone level measurement, 43 underwent semen analysis and in 29 testicular volume was determined., Results: In the 166 men, including 98, 65 and 3 with small, normal and large testes for age at orchiopexy, respectively, there was no difference in paternity based on testicular size. Of those who achieved paternity time to conception did not differ based on size. Mean age at surgery also did not differ, nor did the percent of small versus normal testes in the age categories 0 to 2, 3 to 5, 6 to 8 and 9 to 11 years. There was no difference in men with small or normal testicular size at surgery in mean luteinizing hormone, follicle-stimulating hormone, testosterone or inhibin B. Sperm density, motility and morphology, and volume in adulthood of a previously undescended testis, previously descended testis or previously undescended and descended testes did not differ in these 2 groups, although the previously undescended testis was smaller than the contralateral testis., Conclusions: In men with a history of unilateral cryptorchidism small testicular size at orchiopexy is not associated with decreased paternity (89.8%), abnormal hormone levels, a lower sperm count or decreased testicular volume in adulthood.

Purpose: We assessed the accuracy of contralateral testis hypertrophy for predicting monorchia in patients with a nonpalpable testis., Materials and Methods: From May 1993 to September 1998 we evaluated 60 patients 7 months to 11 years old for a unilateral nonpalpable testis. Four patients were excluded from study who had received human chorionic gonadotropin or had signs of puberty. We correlated contralateral testis hypertrophy, defined as testis volume greater than 2 cc or testis length greater than 2 cm., with presence or absence of the nonpalpable testis. We also recorded the degree to which contralateral testis length less than 2.1 cm. correlated with the presence or absence of the nonpalpable testis. Laparoscopy and open exploration were performed in 52 and 4 cases, respectively., Results: Contralateral testis hypertrophy greater than 2 cm. was noted in 16 patients, including 14 (87.5%) with monorchia and 2 (12.5%) with an intra-abdominal testis. Of the 15 patients with a contralateral measurement of 1.8 to 2.0 cm. 14 had monorchia (93%) and 1 had a tiny ovotestis. Of the 25 patients with a contralateral measurement of less than 1.8 cm. 13 (52%) had testes that were intra-abdominal in 11 and canalicular in 2. The optimal cutoff value for contralateral enlargement was 1.8 cm. (p = 0.00061). The most common laparoscopic finding in patients with contralateral testis hypertrophy greater than 2 cm. was blind ending vessels proximal to the internal ring in 56%., Conclusions: Contralateral testis hypertrophy is common in patients with a nonpalpable testis. Hypertrophy 1.8 cm. or greater predicts monorchia with an accuracy of about 90%. The finding of contralateral testis hypertrophy provides useful information for preoperative counseling, allowing us to inform parents that the nonpalpable testis is most likely absent. Exploration is still required. Laparoscopy is particularly advantageous in contralateral testis hypertrophy since it was the only procedure required in about half of our cases.

Purpose: We evaluated the efficacy of human chorionic gonadotropin (HCG) for identifying and treating nonpalpable testis. We then compared the cost-effectiveness of this approach to that of laparoscopy., Materials and Methods: We reviewed patient charts during a 15-month period and identified 51 boys (64 testes) who underwent surgery to correct cryptorchidism. There were nonpalpable testes in 17 cases and bilateral cryptorchidism in 2 for a total of 19 impalpable testes. All patients were offered a full course of HCG. Those electing hormonal treatment received intramuscular injection of 2,000 IU/m.2 HCG (maximum 1,500 IU/injection) 3 times weekly for 3 weeks., Results: A full course of HCG was given in 8 patients (10 testes). Of the 10 testes 8 became palpable after HCG treatment, including 1 atrophic nubbin located in the inguinal canal. Of the 2 testes that remained impalpable 1 discovered at the level of the renal vessels had complete epididymal nonunion and 1 was located closer to the inguinal ring. All 9 untreated patients underwent laparoscopy, which identified 3 intra-abdominal, 3 vanished and 2 peeping testes, and 1 atrophic testis in the inguinal canal., Conclusions: HCG therapy is valuable for identifying and treating nonpalpable testis. Using this agent enabled the testicle to be detected while avoiding the risks and cost associated with the laparoscopic procedure.

Purpose: We compared pathological findings in ectopic and undescended testis to determine whether the pathological evidence supports the hypothesis that the 2 conditions are variants of the same congenital anomaly., Materials and Methods: We identified 24 boys with ectopic testis not in the superficial inguinal pouch of Denis Browne. Seven boys were excluded from study due to unavailable clinical records for 3, contralateral undescended testis in 2 and inadequate biopsy specimens in 2. Pathological findings of ectopic testis in the remaining 17 patients were compared with those of age matched patients with unilateral undescended testis. Total germ cell count, testicular volume, patency of the processus vaginalis and epididymal abnormalities were compared. Data were analyzed using the Wilcoxon matched pairs signed rank and Fisher's exact tests., Results: No difference was noted in total germ cell count (p = 0.33), testicular volume (p = 0.1475), processus vaginalis patency (p = 0.0854) or epididymal abnormalities (p = 1.00) in the 2 groups. Of the 24 boys (8%) with ectopic testis 2 also had a contralateral undescended testis., Conclusions: Similar pathological findings in ectopic and undescended testes as well as the association of ectopic testis with a contralateral undescended testis suggest that ectopic and undescended testes are variants of the same congenital anomaly. Thus, boys with ectopic testis may have an increased incidence of subfertility and testicular malignancy. This spectrum of abnormal testicular position, and its range of pathological conditions and complications may appropriately be called the undescended testis sequence.

Purpose: We evaluated the diagnostic accuracy of preoperative localization of impalpable undescended testis using ultrasound and gadolinium (Gd) enhanced magnetic resonance angiography (MRA)., Materials and Methods: Ultrasound and Gd-MRA were performed prospectively in 21 boys (23 impalpable testes) with cryptorchidism before laparoscopy and surgical exploration. Gd-MRA was done using a 1.5 Tesla magnetic resonance scanner with a turbo field echo technique after bolus intravenous injection of 0.4 mmol./kg. body weight of Gd diethylenetriaminepentaacetic acid. A total of 10 dynamic scans were acquired during 15 minutes after Gd injection to cover the early arterial and delayed venous phases. All patients subsequently underwent diagnostic laparoscopy and definitive surgery., Results: Ultrasound correctly localized 9 of 10 intracanalicular testes but failed to reveal any intra-abdominal or vanishing testes. In contrast, Gd-MRA correctly localized 4 intra-abdominal, all 10 intracanalicular and 8 canalicular vanishing testes. In 1 patient with an intra-abdominal vanishing testis ultrasound and Gd-MRA failed to make the diagnosis. When correlated with the findings of subsequent laparoscopy and surgical exploration, Gd-MRA had a diagnostic sensitivity of 96% and a specificity of 100% for localizing impalpable undescended testes. Based on Gd-MRA and ultrasound findings laparoscopy could have been avoided in 18 of 23 cases (78%). No adverse effect was associated with Gd use in this study., Conclusions: Gd-MRA accurately diagnoses vanishing testes and reliably differentiates intraabdominal from intracanalicular impalpable testes, allowing definite preoperative planning of the surgical approach and avoiding unnecessary laparoscopy. A new management algorithm for impalpable testis in patients with cryptorchidism is proposed based on ultrasound and Gd-MRA findings.

Purpose: We report on the role of diagnostic laparoscopy combined with the Jones suprainguinal approach to orchiopexy in the treatment of abdominal testes., Materials and Methods: A retrospective review was done of 209 boys with 265 cryptorchid testes who underwent orchiopexy between January 1994 and March 1996. A subset of patients with nonpalpable testis underwent diagnostic laparoscopy and according to the laparoscopic findings either standard inguinal or suprainguinal extraperitoneal orchiopexy., Results: Of 209 patients 47 had 63 impalpable testes. Laparoscopy was done on 31 patients (42 testes). Findings at laparoscopy revealed 29 (69%) abdominal, 7 (17%) intracanalicular and 6 (14%) vanishing testes. A satisfactory result with scrotal position of the testis and no atrophy was obtained in 18 of 19 patients operated via the Jones approach combined with diagnostic laparoscopy. The only patient with unsatisfactory result underwent ligation of the spermatic vessels at the time of operation. In contrast, satisfactory results were achieved for only 7 of 10 intra-abdominal testes after diagnostic laparoscopy and standard inguinal orchiopexy despite universal spermatic vessel ligation. Of these 10 testes 2 ended in an inguinal location and 1 atrophied., Conclusions: Laparoscopy was helpful in determining surgical approach in most cases. The suprainguinal approach allowed most abdominal testes to be placed in the scrotum without vascular ligation.

Purpose: We characterized follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels in boys with surgically documented unilateral absent testes (monorchism) to determine whether measurement of gonadotropin levels could distinguish them from boys with unilateral impalpable cryptorchidism., Materials and Methods: Baseline serum gonadotropin levels were prospectively measured in 43 boys 2 months to 14 years old who presented with a unilateral impalpable testis that was confirmed to be absent at surgery. Control serum specimens were obtained from 63 age matched boys undergoing minor surgery with no evidence of hypospadias, or testicular, hormonal or renal diseases. Serum FSH and LH levels were drawn preoperatively and assayed by double antibody radioimmunoassay. A subgroup of 7 boys with monorchism was also evaluated following gonadotropin-releasing hormone (GnRH) stimulation and compared to age matched boys with a unilaterally impalpable testis discovered surgically., Results: In the monorchism group mean plus or minus standard deviation basal FSH was 4.08 +/- 0.28 mIU/ml. and LH was 4.13 +/- 0.33 mIU/ml. In the control group mean basal FSH was 4.36 +/- 1.52 mIU/ml. and LH was 4.66 +/- 0.75 mIU/ml. No statistical difference existed between the 2 groups for mean basal gonadotropin level. While monorchid boys were more likely to have elevated FSH levels (p = 0.016), this was not true for LH (p = 0.21). Since gonadotropin levels less than 5 mIU/ml. are accepted normal values, this threshold was applied to FSH and carried a sensitivity of 23.8%, specificity 93.8%, positive predictive value 71.4% and negative predictive value 65.6%. Lower cutoff values marginally improved sensitivity but reduced specificity. Peak stimulated levels of FSH and LH following GnRH stimulation failed to distinguish between boys with 1 or 2 testes., Conclusions: Baseline FSH is more likely to be elevated in prepubertal boys with monorchism but it does not appear to be clinically useful when sensitivity and predictive value are poor. Similarly, gonadotropin level following GnRH stimulation is not sufficiently sensitive to advocate the use of hormonal measurements to diagnose prepubertal monorchism.

Purpose: We retrospectively evaluated the ability of human chorionic gonadotropin (HCG) to make the nonpalpable cryptorchid testis become palpable and promote testicular descent., Materials and Methods: Through surgical bookings we identified 94 patients younger than 11 years who received HCG between 1984 and 1994 for the diagnosis or treatment of a nonpalpable undescended testis. The dose of HCG was 1,500 IU/m.2 intramuscularly 2 times weekly for 4 weeks. Testis location was determined by physical examination before and after hormone administration, and confirmed at surgical exploration., Results: Of the 99 nonpalpable testes identified in 94 patients 39 (39%) became palpable following HCG administration and only 2 (2%) completely descended. A total of 60 testes remained nonpalpable with the most common reason being an absent or severely atrophic testis (40, 67%). Of the testes remaining nonpalpable after hormonal stimulation 73% were surgically located at or distal to the internal ring., Conclusions: HCG is preoperatively efficacious in causing the nonpalpable undescended testis to become palpable. For patients failing to respond to hormonal stimulation we recommend preliminary inguinal exploration, since most testes or testicular remnants are located within the inguinal canal or immediately below the internal ring.

Purpose: Recent reports in the literature indicate that laparoscopy tends to be seen as the most appropriate approach to the nonpalpable testis for diagnosis and therapy. The aim of our study was to evaluate the real benefits of laparoscopy in terms of diagnostic accuracy, safety, costs and validity of the chosen treatment., Materials and Methods: We compared anatomical findings and results of the treatment of impalpable testes in 2 pediatric surgical groups, including 47 children treated laparoscopically during a 2 1/2-year period and 296 treated with open surgery (classic orchiopexy) in a 6 1/2-year period., Results: There was no significant difference in the diagnosis of abdominal testes (51 versus 50%), whereas a difference was noted in inguinal (4 versus 15%) and absent testes (45 versus 35%). Differences in treatment were more striking. In the laparoscopic group standard orchiopexy was performed in 62.5% of cases versus 83% in the open group. Conversely the rate of Fowler-Stephens repairs increased from 5.5% of open surgery cases to 37.5% of laparoscopic cases. There have been no serious complications in the laparoscopic procedures. To date 6 of the 9 patients who underwent a staged Fowler-Stephens procedure have undergone complete repair (open second stage). A review of the literature revealed a similar but lower tendency to over perform the Fowler-Stephens operation in laparoscopic cases (34%) versus open surgery (8%). Also, in previous series there was a 29% orchiectomy rate during laparoscopy compared to only 5% in classic open surgery. In Italy under current public health programs overall costs of the laparoscopic approach to the nonpalpable testis become noncompetitive when the procedure is extended from only diagnostic to interventional use due to the need for additional trocars and other special instruments. In contrast, private health insurers provide an additional 30% for laparoscopic cases over the cost of open orchiopexy., Conclusions: Laparoscopy is definitively accurate in establishing the differential diagnosis of impalpable testis. The number of Fowler-Stephens repairs in the laparoscopic group seems inordinately high, probably due to a lack of definite standards in the proper assessment of the length of the internal spermatic vessel pedicle and the potential scrotal displacement of the testis. This reason may explain the higher number of orchiectomies reported in the literature.

Purpose: We attempted to apply laparoscopic orchiopexy to the high palpable testis., Materials and Methods: Nine patients (12 testicles) were treated who ranged from 13 months to 13 years old. Laparoscopic techniques were used to mobilize the spermatic vessels and transfer the testis into the scrotum., Results: Unilateral cases were completed in an average of 2.6 hours and bilateral cases in 3.0 hours with no complications. Tests maintained an intrascrotal position with no atrophy during a followup of 1 to 12 months., Conclusions: Laparoscopic orchiopexy for the high palpable undescended testis is possible with minimal morbidity and good short-term results.

Transverse testicular ectopia is a rare but well documented abnormality in which both testes descend through 1 inguinal canal. We report on a 14-month-old boy in whom laparoscopy was diagnostic for this abnormality. Laparoscopic examination of the pelvis is imperative to rule out the presence of müllerian remnants that commonly occur in patients with transverse testicular ectopia. Our case further supports the use of laparoscopy in patients with nonpalpable undescended testes.

Laparoscopy often is performed in the evaluation of boys with an impalpable testis. Previously it has been reported that if laparoscopy disclosed a patent processus vaginalis the testis was likely to be present, whereas if the processus vaginalis was closed then the testis usually was absent. This study was performed to examine this association further. In 111 boys with 124 impalpable testes 45 testes (36%) were viable and suitable for orchiopexy, including 7 that were in the inguinal canal and 38 intra-abdominal testes. Another 79 testes (64%) were absent or vanishing, including 72 in which the cord structures had descended through the internal ring, 5 in which the vas and vessels ended blindly in the abdominal cavity, and 2 in which the testis, vas and vessels could not be identified. When a patent processus vaginalis was present 43 of 47 testes (91%) were viable, whereas if it was closed 75 of 77 (97%) had vanished or were absent. An algorithm for surgical management of the impalpable testis based on laparoscopy findings is proposed.

Laparoscopy was performed on 107 patients 8 months to 18.5 years old (mean age 46.9 months) with 119 nonpalpable testes. The procedure accurately determined the location of the gonad in 95.3% of the patients, while 16 were spared formal surgical exploration with the laparoscopic visualization of blind-ending spermatic vessels and vasa deferentia. Additionally, patency of the internal inguinal ring, determined laparoscopically, was an accurate predictor of testicular salvageability. We advocate the use of laparoscopy for all boys with a nonpalpable gonad in conjunction with operative intervention if necessary.

On surgical exploration for impalpable testes, there is often found nothing or a nubbin of tissue at the end of the spermatic vessels. This situation is commonly referred to as an absent testis. Controversy exists on how to establish correctly this diagnosis and the degree of investigation required. In addition, there is disagreement concerning whether an absent testis results from early torsion or endocrinopathic event. What is accepted is that the spermatic vessels are singularly important in establishing testis location. In this study, the pathological findings of 117 cases of absent testis diagnosed by surgical exploration at our hospital were reviewed. This diagnosis represented 10% of 1,225 patients explored for cryptorchidism from 1985 to 1991. Average patient age at operation was 26.8 months (range 5 months to 14 years). Of these children 78 (67%) presented with an impalpable left testis. At operation 3 patients (3%) underwent laparoscopy only, while all others had groin exploration with or without transperitoneal exposure to ensure identification of spermatic vessels. In 110 cases surgical specimens or nubbins were excised. Pathological study of these remnants revealed vas deferens in 89 cases (81%), epididymal tissue in 40 (36%) and small amounts of seminiferous tubules with germinal elements in 7 (6.4%). Only 26 specimens (24%) had sufficient vascular tissue present to be suggestive of spermatic vessels. A significant number showed the presence of calcification (35.5%) and hemosiderin (30%) deposits within the remnant. A subset of patients with absent testis possesses testicular tissue of presumed increased malignant potential. Therefore, surgical exploration with spermatic vessel identification and remnant removal is the gold standard for the diagnosis and treatment of the absent testis. The surgeon continues to be responsible for spermatic vessel identification, since the vessels may be recognized at pathological examination in less than 25% of the cases. Also, the common finding of calcification and hemosiderin lends weight to the torsion etiology over endocrinopathy for an absent testis.

To assess diagnostic accuracy, laparoscopy and surgical exploration were prospectively performed in 104 children with 126 nonpalpable testes. Laparoscopic localization of the testis was correct in 90% (114 of 126 testes) and was nondiagnostic in 8% largely due to preperitoneal insufflation. No surgical complications occurred. Using the criteria of blind-ending vas deferens and spermatic vessels as diagnostic of an intra-abdominal vanishing testis, the accuracy of diagnosis was 100% but the inability to identify either vas or vessels was associated with intra-abdominal testes in 2 of 3 cases. Identification of canalicular vas deferens and spermatic vessels was associated with testes in 36 of 75 cases (48%). Bilateral nonpalpable testes were significantly less likely to have an absent testes (5%) than a unilateral nonpalpable testis (59%), suggesting the possibility of different pathophysiological mechanisms in those entities. Diagnosis and surgical management of nonpalpable testes were directly impacted by laparoscopy in 42 of 117 testes (36%) by identifying intra-abdominal vanishing testis, the location of an intra-abdominal testes or the need for retroperitoneal exploration when vas deferens and spermatic vessels were not found. Accurate knowledge of testis location in 97% of the testes facilitated development of an appropriate surgical strategy (that is laparoscopic/laparoscopic assisted versus open procedure).

Laparoscopy has changed the treatment approach in the patient with a nonpalpable testis. We report a novel method of laparoscopy to diagnose an atrophic, intra-abdominal testis through a contralateral inguinal peritoneotomy.

We studied the usefulness of radiography for localization of cryptorchid testes. A total of 23 radiographic studies ordered by referring physicians was done for testis localization in 18 boys. Two patients had retractile testes and were followed expectantly. Ultrasonography failed to detect palpable testes in both cases. A total of 16 boys (19 undescended testes) underwent operative exploration and the findings were compared. Ultrasonography correlated with the operative findings in 7 of 12 cryptorchid testes (58%), while computerized tomography and magnetic resonance imaging correlated in only 4 of 12 (33%) and 0 of 1 (0%), respectively. The overall accuracy of radiological testing was 44%. Physical examination was 53% accurate when performed by the referring physician and 84% accurate when done by the attending pediatric urologist. In no case did radiographic assessment influence the decision to operate, the surgical approach or the viability/salvageability of the involved testes. Preoperative radiography for undescended testes is neither necessary nor helpful.

We evaluated 68 prepubertal boys with 84 impalpable testes who were operated upon without using any other diagnostic maneuvers. Of the testes 18 (22%) were absent (anorchism or 'vanished') and 38 (45%) could be placed in a scrotal position with standard orchiopexy. A staged, Fowler-Stephens or microvascular procedure was required for 28 testes (33%), involving orchiectomy in 2 cases, and succeeded in a scrotal position for another 24 testes. In 1 boy 2 testes were fixed outside the inguinal canal. Reexamination after 3 to 9 years showed that 42 of 55 operated testes (76%) were in scrotal position without atrophy, 10 had atrophied and 3 were removed at the second stage operation. We conclude that an exclusive surgical approach has the advantage of providing diagnosis and therapy, and, therefore, it is an effective method.

Laparoscopy was done in 104 consecutive patients with 106 impalpable testes. Three clinical presentations were identified and the value of laparoscopy in each was analyzed. 1) For unilateral impalpable and contralateral normal testes laparoscopic identification of testicular absence was made in 27% of the cases and intra-abdominal testes were found in 16%. Therefore, laparoscopy was of value in 43% of the cases. 2) For bilateral undescended testes (1 or both impalpable) laparoscopy was diagnostic in 75% of the cases (17% had blind-ending spermatic vessels above the internal ring and 58% had intra-abdominal testes). 3) For patients with previous negative inguinal exploration laparoscopic diagnosis was made in 100%.