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Background: There are few studies on cryptorchidism in adults, and its treatment is still controversial., Methods: To summarize the surgical strategy and clinical efficacy of laparoscopic orchidopexy for the treatment of cryptorchidism in adults, 37 adult cryptorchidism patients were retrospectively analyzed between September 2017 and February 2022. All 37 patients underwent laparoscopic orchidopexy, of whom 33 underwent inguinal hernia repair without tension. The intraoperative procedures and surgical techniques were recorded in detail. Preoperative examination and regular postoperative review of color Doppler ultrasound, and reproductive hormone, alpha-fetoprotein, human chorionic gonadotropin, and lactate dehydrogenase levels were performed., Results: All testes descended successfully into the scrotum, including 25 through the inguinal route and 12 through Hesselbach's triangle route. No intraoperative or postoperative complications were observed. The follow-up time was 38.6 (± 19.4) months, and no evidence of testicular malignancy was found during the follow-up period. After analyzing the reproductive hormone levels at 1 year postoperatively in 28 patients with more than 1 year of follow-up, it was found that the patients had a significant increase in testosterone levels and a decrease in follicle-stimulating hormone levels after surgery. None of the patients showed any significant improvement in semen quality after surgery., Conclusion: Our study suggests that laparoscopic orchidopexy is a safe and feasible surgical procedure for the treatment of cryptorchidism in adults, especially high cryptorchidism, which is difficult to treat. After comprehensive consideration, preserving the testis should be preferred for treating cryptorchidism in adults to maximize the protection of the patient's reproductive hormone secretion function., (© 2023. The Author(s).)

Background: Contralateral Testis Hypertrophy (CTH) is a clinical marker that could be used to guide the choice of the main surgical strategy. In patients with a Non-palpable Testis (NPT), the degree of CTH as measured by testicular length or volume has been shown to be able to predict whether the undescended testis will survive., Objective: The purpose of this study was to establish the proper cut-off for identifying non-viable testes based on the current literature., Design: We systematically searched several medical databases as well as Google Scholar search engines for references and citations. All the studies that reported CTH as a result of NPT in prepubertal boys were included. Data from the included articles was gathered by two independent reviewers. The checklist developed by the Joanna Briggs Institute (JBI) was used to evaluate the methodological quality of the studies that were included. Due to the incredibly high degree of heterogeneity among the studies, no meta-analysis was done., Results: The current systematic review included 17 studies that assessed the cut-off point to detect non-viable testis. The size and length of the testes were taken into consideration based on our findings. We found that different studies reported various ideal cut-off values for predicting non-viable testes, which can be brought on by various measuring techniques, evaluation ages, and patient groupings. The difference in testis volume was greater than the difference in its length, which can be attributable to the fact that some studies used an orchidometer to measure the testis's length directly or indirectly., Conclusion: According to the results of our study, it seems that defining a cut point for diagnosis of CTH based on the size of the testis, cannot demonstrate the absence of a non-palpable testis., (Copyright © 2023. Published by Elsevier Ltd.)

Crossed Testicular Ectopia (CTE) or transverse testicular ectopia is an anecdotic urogenital anomaly in which both testes are located on the same side, generally associated with a patent processus vaginalis (PPV). The condition can be detected by ultrasound. Nevertheless, the diagnosis is often missed preoperatively and CTE is recognized intraoperatively. Controversy exists regarding management and the role of diagnostic laparoscopy. The surgical technique depends on the anatomy of vas, vessels and testis found on surgical exploration. Diagnostic laparoscopy can be useful to rule out a vanishing testis and detect Müllerian remnants. We present the case of 8-months infant with no palpable testis on the right side and no signs of inguinal hernia, reporting the management and reviewing the scarce existing literature in this regarding. KEY WORDS: Crossed Testicular Ectopia, Laparoscopy, Ectopia, Testis, Transverse Testicular Ectopia, Urogenital Abnormalities.

Introduction: It is estimated that 1%-2% of male infants have undescended testicles. The reliability of ultrasound (US) to identify the non-palpable undescended testicles (NPUDT) is controversial. Laparoscopy remains the gold standard to diagnose and manage NPUDT., Objective: The objective is to highlight the role of laparoscopy in the management of NPUDT in 2 cities from Sudan over the past decade., Materials and Methods: Patients presented to Gadarif Teaching Hospital and Almak Nimir University Hospital with NPUDT were assessed by clinical examination and US. The testis, when found during laparoscopy, was either brought down to the scrotum in a single or two-stage or removed depending on the findings. Data were collected and analysed., Results: Patients covered the age range between 18 months and 65 years. The average was 12.4. The majority, 94 (67.2%) patients were older than 5 years. The main presenting symptom was either bilateral or unilateral empty scrotum. In 12 (8.4%) patients, the main presenting symptom was primary infertility. US was done in 120 (86.6%) of the patients and failed to see the testis in more than half of them. A single-stage procedure in the form of laparoscopic search assisted with orchidopexy was achieved in 90 (62.9%) patients and orchiectomy in 13 (9.1%) patients, while in 12 (8.4%) patients the testis was not found. Other procedures were applied on the 28 (19.6%) patients who needed staged operation in the form of Fowler Stephen's, in bilateral cases, in 6 (4.2%) patients. Shehata's operation in nine patients (64%) and open orchidopexy for 8 (5.6%) patients. The post-operative complication was encountered in 14 (9.8%) of the patients in this group in the form of bleeding, vassal injury and testicular atrophy., Conclusion: Laparoscopy provides the most accurate interventional option for managing patients with NPUDT. Laparoscopic orchidopexy, whether single stage for low or 2-stages for high intra-abdominal testis, is a proven and effective extension of lap-search with minimal complications., Competing Interests: None

Objective: To find out the clinical presentation, utility of ultrasound for diagnosis, laparoscopic findings and treatment for clinically impalpable testis., Study Design: Cross-sectional study., Place and Duration of Study: Department of Paediatric Surgery, National Institute of Child Health, Jinnah Sindh Medical University Karachi, from September 2019 to April 2020., Methodology: Patients with clinically impalpable testis were included. Ultrasound of inguinal region was done to locate testis. Presence of testis and its position was confirmed at laparoscopy and surgical procedure done according to the findings. Data was stratified according to the age and Chi-square test and Student t-test were applied to find out statistical significance among different variables in children below and above five years of age. A p <0.05 was taken as significant., Results: Ninety-one patients with 113 testes were included. The median age of the children was 48 months. Sixty-nine (75.8%) patients had unilateral undescended testis and 22 (24.2%) bilateral undescended testes. Fifty-three (58.2%) patients were less than five years of age. On ultrasound, testis was found near deep ring in 23 (25.3%) patients. At laparoscopy, 74 (81.3%) testes were found within the abdominal cavity. In 7 (7.7%) patients, only nubbin of tissue was identified and removed. The first stage of Fowler Stephen procedure was done in the majority of the patients. There was statistically no significant difference following stratification in relation to laterality and position of undescended testis (p = 0.556 and p = 0.846, respectively). However, mean size of the testis was found statistically significant (p = 0.032)., Conclusions: Most of the patients were above five years of age. Ultrasound helped in identifying low-lying intra-abdominal testis in more than 80% of patients. Laparoscopy was helpful in further defining the position of the testis and selection of surgical procedure., Key Words: Undescended testis, Cryptorchidism, Laparoscopy, Orchiopexy.

BACKGROUND Ectopic testis is an uncommon congenital anomaly that has been reported in different sites in the body. The anterior abdominal wall is an exceptionally rare variant site for ectopic testis. The purpose of this case report is to highlight the importance of being aware of this rare clinical entity, thereby increasing the chance of preserving an ectopic testis. In addition, this case report shows how a laparoscopic approach is advantageous for better localizing and treating such rare cases, as this is the first reported case of such a condition to be managed with a laparoscopic approach. CASE REPORT This is a rare case of testicular ectopia in an unclassified abdominal wall defect mimicking a Spigelian hernia that occurred in a 1.5-year-old boy. He presented with congenital swelling of the right lower abdominal wall and an empty right hemiscrotum. Diagnostic laparoscopy was performed and the intraoperative findings suggested right testicular ectopia in the anterior abdominal wall defect. The right testis was herniated through an abnormal, unclassified, abdominal wall defect with both a closed inguinal ring and no defect in the semilunar line. Using a laparoscopic approach, the ectopic testis and hernia were managed successfully with primary hernia repair and single-stage orchidopexy. The patient's postoperative recovery was uneventful. At his 10-month follow-up appointment, he had no evidence of hernia recurrence. CONCLUSIONS As demonstrated in this case, laparoscopic surgery, which has not been used in previously reported cases of ectopic testis, aids in proper localization and repair of an anterior abdominal wall defect along with orchidopexy.

Objective: To study the effect of testicular vessel division on testicular volume during laparoscopic staged Fowler Stephens orchiopexy (LSFSO)., Methods: Testicular dimensions were prospectively measured intraoperatively at both first (S1) and second stages (S2) of LSFSO, and with scrotal ultrasound 3-12 months postoperatively. Testicular volumes were compared to reference ranges. Volume changes were tracked with a change of >20% considered clinically significant., Results: A total of 52 nonpalpable testes treated with LSFSO between 2008 and 2018 were included in the study. After a median follow-up of 6.8 (3-91.3) months, 46 (88.5%) testes were palpable in a scrotal location without adjunctive procedures and 39 (75%) maintained vascular flow on duplex ultrasound. One testis retracted to an inguinal position and was successfully treated with inguinal orchiopexy for an overall success of 90.4% (47/52). Of 36 testes with intra- and postoperative testicular volume documentation, only 2 (5.6%) had significant volume loss after S1. Both testes had catch-up growth after S2. Eight (22.2%) testes had significant volume loss after S2. At follow-up, 24 (66.7%) testes were smaller than the mean for age, of which 20 (83.3%) were small at baseline. Only 41.7% of testes larger than mean for age at follow-up, were small at baseline (P = .02)., Conclusion: Significant testicular volume loss does not occur after testicular vessel division at S1, but expected in approximately 1 quarter of testes after S2. We propose that testicular atrophy after LSFSO is primarily due to defective testicular development and rarely due to vascular compromise during S2., (Copyright © 2019 Elsevier Inc. All rights reserved.)

We present a video of our technique for resection of a large prostatic utricle (PU) in a patient who presented initially with disordered sexual development. His karyotype was 46XY, and phenotypically had penoscrotal hypospadias, bifid scrotum, and retractile right testis. An initial micturating cystourethrogram (MCUG) demonstrated the utricle but failed to cannulate the bladder. Being asymptomatic, we carried out staged repair of his hypospadias. Later, he started to have recurrent epididymo-orchitis with resistance to multiple antibiotics. Examination under anaesthesia was done and ruled out meatal or neo-urethral strictures. A subsequent MCUG demonstrated the large utricle and its relation to the bladder. We carried out a cystoscopic-assisted laparoscopic excision. There has been no consensus about the best surgical approach to resect a PU and most known procedures involved extensive pelvic dissection and carried a significant risk of damage to the pelvic nerves. The laparoscopic approach seems to be promising in this field as it provides proper view of the deep pelvis with reasonable magnification, less dissection and shorter postoperative pain and scarring. Cystoscopic assistance in this technique was a great addition to provide counter-traction movement and facilitate proper dissection., (Copyright © 2017 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Background/objective: To compare the curative effect of single-stage and two-stage Fowler-Stephens (F-S) laparoscopic orchidopexy for intraabdominal high testis and explore the appropriate surgical approach., Methods: We performed a prospective analysis of the clinical data of 28 patients who underwent F-S laparoscopic orchidopexy for intraabdominal high testis in our department from May 2012 to April 2015, including 15 cases of the single-stage F-S operation and 13 cases of the two-stage F-S operation. By comparing the two groups preoperative and postoperative (6 months) clinical data of testicular position, testicular volume, and sex hormone levels [testosterone (T), follicle stimulating hormone (FSH), and estradiol (E 2 )], we analyzed the difference in efficacy between the two procedures., Results: Twenty-eight patients completed laparoscopic surgery, no case was converted, and no testis was excised. All patients were followed up for 9-25 months after the operation, with an average follow-up of 16.2 months. The postoperative testicular volume of the single-stage and two-stage F-S groups was not significantly reduced (p>0.05). In both groups, the postoperative T levels were significantly increased compared to the preoperative levels (p<0.05), while the FSH and E 2 levels were significantly decreased (p<0.05). The differences in testicular volume and T, FSH, and E 2 levels between the two surgical procedures were not significant (p>0.05). In the single-stage F-S group, the testes were located in the scrotum in 13 cases and retracted to the lower groin in two cases. In the two-stage F-S group, the testes were located in the scrotum in 12 cases and retracted to the lower groin in one case. The difference in postoperative testicular position between the two groups was not significant (p>0.05)., Conclusion: In the case of testis with good collateral circulation, single-stage F-S laparoscopic orchidopexy had the same safety and efficacy as the two-stage F-S procedure. Surgical options should be based on comprehensive consideration of intraoperative testicular location, testicular ischemia test, and collateral circumstances surrounding the testes. Under the appropriate conditions, we propose single-stage F-S laparoscopic orchidopexy be preferred. It may be appropriate to avoid unnecessary application of the two-stage procedure that has a higher cost and causes more pain for patients., (Copyright © 2017. Published by Elsevier Taiwan.)

Background: The undescended testis represents one of the most common disorders of childhood. Laparoscopy has been widely used both in the diagnosis and treatment of non-palpable testis. In this study, we investigated and evaluated the usefulness of laparoscopy in the diagnosis and treatment of no palpable testis., Patients and Methods: From January 2003 to January 2008, we used laparoscopy in the management of 64 patients with 75 impalpable testes. Their ages varied from 1 to 15 years (median age = 4.6 years). The site and the size of the testes were localised by abdominopelvic ultrasonography in all 64 children for accurate diagnosis. One stage laparoscopic orchiopexy was performed in 26 testes, staged Fowler-Stephens orchiopexy was underwent in 17 testes, while laparoscopic orchidectomy was done in 5 testes. Follow-up by clinical examination and colour Doppler ultrasound was performed in every patient who underwent orchiopexy., Results: There were 11 patients with bilateral non-palpable testes. The overall diagnostic agreement of ultrasound with laparoscopy was seen in only 16 out of 75 testes (21.3%). The results of diagnostic laparoscopy were varied and showed various pathological. Conditions and positioned of the testes, such as 20 low intra-abdominal testes (26.6%), 17 testes were high intra-abdominal (22.7%), and 18 testes (24%) entered the inguinal canal. Associated inguinal hernia was present in 4 patients. After a mean follow-up period of 26 months (6 months - 5 years), all testes were in the bottom of the scrotum except 3 testes were retracted to the neck of the scrotum and atrophy of the testis occurred in 2 patients (2.7%)., Conclusion: Laparoscopy has proven to be the only diagnostic modality where the findings provide a clear dependable direction for the definitive management of impalpable testes, so it allows an accurate diagnosis and definitive treatment in the same sitting., Competing Interests: None

Objectives: Testicular hypertrophy has previously been evaluated as a predictor of monorchism. However, its implication in clinical practice is not well evaluated. The aim of the present study was to examine its value in planning the operative time., Patients and Methods: Medical charts of prospectively recorded data of 76 consecutive patients with unilateral impalpable testis from 2011 to 2014 were reviewed at the present institute. Inclusion criteria included prepubertal patients with non-palpable testes by examination under anesthesia. Contralateral testes were prospectively measured using a Takihara orchidometer. Orchiectomy or orchiopexy was performed according to the viability of the undescended testis (UDT). Collected data included age of surgery, contralateral testicular size, surgical time and laparoscopic findings. A ROC curve was used to define the best cut-off volume of the contralateral testis that can predict ipsilateral testicular viability. The Student's t-test was used to examine if this cut-off volume would be useful in allocating the operative time., Results: Of 76 patients, four palpable testes by examination under anesthesia were excluded. The remaining 72 patients were included in the study. Ipsilateral normal viable testes were found in 26 (36.1%) patients, while 46 (63.9%) had non-viable testes (testicular nubbins or vanishing testes) (Figure). A contralateral testicular volume > 2 ml was significantly predictive for monorchism with 71.7% sensitivity and 100% specificity (P < 0.001). The mean operative time for management of UDT with a contralateral size >2 ml was 50 min, which was significantly shorter than that for UDT with a contralateral size ≤ 2 ml, which was 88 min (P < 0.001)., Discussion: In previously published reports, the cut-off value for testicular hypertrophy that predicts monorchism greatly varied. This is likely due to the different methods used for testicular measurements that make it impractical to make a direct comparison. The usefulness of predicting monorchism before surgery has not previously been used as a guide for allocating operative time in the management of a unilateral non-palpable testicle. This study had some limitations, including a relatively small sample size and involvement of different surgeons, which may have affected the operative time., Conclusion: Using the cut-off volume of a contralateral testis >2 ml as a predictor for monorchism can reduce the allocated operative time by approximately one third., (Copyright © 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Objective: The current study evaluates whether the preoperative scrotal examination in children with non-palpable testes is sufficient in all cases or if laparoscopy is necessary to confirm the examination findings. Are the findings different amongst physicians depending on their level of experience?, Materials and Methods: This retrospective study was done between October 2009 and May 2013. Children with non-palpable testes underwent an examination under anesthesia prior to surgery to feel for a testis or nubbin, followed by a diagnostic laparoscopy to validate the scrotal examination. The test was considered correct if the laparoscopic findings supported the scrotal examination. It was considered incorrect if laparoscopy revealed a different finding., Results: A total of 74 testes were evaluated. All patients underwent examination under anesthesia by the surgeon and senior resident. The findings were recorded separately. Despite careful examination by experienced surgeons under anesthesia, the scrotal examination was incorrect in 14 patients. Four viable testes would have been missed if laparoscopy had not been performed., Conclusion: Laparoscopy should be considered in case of palpable scrotal nubbins to ensure no testis is left within the abdominal cavity., (Copyright © 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Objectives: To evaluate the significance of a scrotum pulling maneuver during diagnostic laparoscopy for impalpable testis in order to determine whether an initial scrotal or inguinal incision should be carried out., Methods: A total of 75 patients undergoing diagnostic laparoscopy were included in the present study. If the vas deferens and spermatic vessels were noted to enter the internal inguinal ring, the affected scrotum was pulled downwards and the movements of the cord structures were observed. If inferior movement of the cord structures at the internal inguinal ring were noted, a scrotal approach was preferred. In the absence of cord structure movement, an inguinal approach was carried out first., Results: In 59 (76.6%) out of 77 impalpable testes, the spermatic vessels and vas deferens were noted to enter the internal inguinal ring. In 41 of the 59 cases (69.5%), the cord structures were observed to move inferiorly when the scrotum was pulled downwards. In these cases, a scrotal incision was carried out first. In 97% (40/41), a nubbin testis was found and was then excised. In 23% (18/59), the cord structures did not move on pulling the scrotum, and an inguinal approach was initially carried out on these cases. A viable testis was found on the inguinal canal in four cases, and a nubbin testis was excised in 14 cases., Conclusions: In patients with impalpable testis undergoing diagnostic laparoscopy, identification of spermatic cord movement along the internal inguinal ring while pulling the scrotum downwards determines the most appropriate surgical approach. This maneuver might also prevent inappropriately placed skin incisions., (© 2015 The Japanese Urological Association.)

The role of laparoscopy in the case of nonpalpable cryptorchidism is both diagnostic and therapeutic. Laparoscopic orchiopexy for nonpalpable testes in the pediatric population has become the preferred surgical approach among pediatric urologists over the last 20 years. In contrast, laparoscopic varicocelectomy is considered one of several possible approaches to the treatment of a varicocele in an adolescent; however, it has many challengers and it has not gained universal acceptance as the gold standard. This article reviews the published evidence regarding these surgical techniques., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: Undescended testis or cryptorchidism is a pathology usually presenting in the newborn or during childhood, rarely diagnosed in the adult man. This article pretends to perform a review of its management in the adulthood., Methods: We present two cases of man with bilateral congenital cryptorchidism diagnosed in the adult. We made a review of the management of this condition in the adult male, based in a research performed in PubMed database., Conclusions: With the use of laparoscopy in the management of men with cryptorchidism, the diagnostic and therapeutic approach in this pathology doesn't differ from that used in childhood. Surgical management is based in the localization of the testis in physical exploration, the risk of testicular cancer and the viability of the gonad in its exploration. Hormonal replacement therapy and fertility preservation techniques should be offered in selected cases to optimize patient health and desires.

Objective: During the last decade laparoscopy has increasingly been advocated as the primary investigative procedure for the management of the non-palpable testis. We reviewed the medical records in a consecutive series of boys with non-palpable testis to examine the contribution of the initial inguinal approach in the management of unilateral non-palpable testis., Materials and Methods: Among the 183 consecutive patients with cryptorchidism from 2003 to 2012, there were 21 patients with unilateral and three with bilateral non-palpable testes. All unilateral patients then underwent inguinal and scrotal exploration through an inguinal incision. For those patients with an intra-abdominal peeping testis, the gonad was placed into the scrotum after meticulous cranial mobilization of the spermatic cord., Results: Patient age ranged from 11 months to 144 months (mean age: 23 months). Among the 21 unilateral cases, testicular absence or atrophy was confirmed in seven patients with a scrotal nubbin in six, and blind-ending vas and vessels at the external inguinal ring in one patient. Among the remaining 14 patients with sizeable testes, 12 testes were intra-abdominal peeping testes and two testicles were seen within the distal inguinal canal, which may be missed on physical examination owing to patient obesity. The intra-abdominal peeping testicle had the opened processus vaginalis entering the internal ring in which testicle was found. These were fixed into the scrotum successfully by cranial mobilization of spermatic vessel sometimes cutting the internal oblique muscle and by Prentiss and Fowler-Stephen's maneuver. Diagnostic laparoscopy was done on three patients with bilateral cases., Conclusions: Given the result that most of nubbins are within the scrotum and testes with intra-abdominal peeping testes are fixed down safely into the scrotum, the inguinal approach may suffice for the management of unilateral non-palpable testis. Laparoscopy should be reserved for patients with bilateral non-palpable undescended testes., (Copyright © 2013 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Persistent mullerian duct syndrome describes a group of patients with a 46 XY karyotype and normal male external genitalia, but internal mullerian structures. A 7-month-old boy presented with a left inguinal hernia, a left undescended testis and a right impalpable testis. Inguinal herniorrhaphy was performed and laparoscopy was done for search of a right impalpable testis and internal genitalia simultaneously. Laparoscopic examination revealed the structure like a mullerian duct remnant along the left spermatic duct in rectovesical fossa and right intra-abdominal testis. The structure like a mullerian duct remnant was not removed to preserve the left spermatic duct. Left orchiopexy and right laparoscopic staged Fowler- Stephens orchiopexy were performed. Chromosomal analysis was 46 XY karyotype and we diagnosed this case as persistent mullerian duct syndrome.

Object: To retrospectively review the value of laparoscopy in the management of impalpable testis., Materials and Methods: In 1993-2006, 182 laparoscopies for impalpable testis were performed for a total of 194 testicular units. Five laparoscopic findings were considered: testicular ectopia, intra-abdominal testis, and cord structures that are blind ending, completely absent (agenesis) or entering the internal inguinal ring., Results: In 62 cases an intra-abdominal testis was found; 18 were classified as high and managed by a laparoscopic Fowler-Stephens procedure. Cord structures entering the inguinal ring were observed in 77 patients and 45 underwent an inguinal exploration: a testis was found in 12 cases and in 33 a remnant was excised. In 35 cases, intra-abdominal blind ending vas and vessels were observed and eight showed testicular agenesis. No major surgical complications were recorded. Follow up ranged from 1 to 3 years., Conclusions: Our study confirms the value of laparoscopy in the management of non-palpable testis, providing a definitive diagnosis by the direct view of spermatic bundle and testis. Ninety-three patients were managed by laparoscopy only, and in 44 it was essential for the subsequent surgical approach. When the internal inguinal ring is patent and/or normal spermatic vessels are present an inguinal exploration is mandatory., (Copyright © 2010 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Testicular autotransplantation is an advanced technique for the correction of high intra-abdominal testicles with inadequate vascular length for repositioning in the scrotum. In the past, surgeons have often avoided this approach due to the extended operative time and the requirement for microsurgical equipment and training. Surprisingly, this procedure remains rare despite the fact that autotransplantation is sometimes the most viable option to relocate the testicle. Further, current advances in laparoscopic surgery allow for testicular harvesting with minimal morbidity and maximal vascular pedicle length. Here, the evolution and an approach combining these two techniques implemented successfully in five patients are presented., (© Thieme Medical Publishers.)

Undescended testis is one of the most common congenital abnormalities of the genitourinary system. In 10-20% of these boys, a testis is located completely inside the abdominal cavity. Multiple operative techniques have been described and are associated with a variable success rate. In this review we evaluate the use of laparoscopy in the management of the non-palpable testis to determine what advantages it might offer over the open technique. On the basis of current evidence it seems that laparoscopy is the only diagnostic and therapeutic procedure that is accurate enough to elucidate the diagnosis of non-palpable testis and also allows surgical treatment to be carried out in the same setting.

Background: Diagnostic laparoscopy is minimally invasive surgery for the diagnosis of intraabdominal diseases. The aim of this review is a critical examination of the available literature on the role of laparoscopy for chronic intraabdominal conditions., Methods: A systematic literature search of English-language articles on MEDLINE, the Cochrane database of evidence-based reviews, and the Database of Abstracts of Reviews of Effects was performed for the period 1995-2006. The level of evidence in the identified articles was graded. The search identified and reviewed six main categories that have received attention in the literature: pelvic pain and endometriosis, primary and secondary infertility, nonpalpable testis, and liver disease., Results: The indications, contraindications, risks, benefits, diagnostic accuracy of the procedure, and its associated morbidity are discussed., Conclusions: The limitations of the available literature are highlighted, and evidence-based recommendations for the use of laparoscopy to stage intraabdominal cancers are provided.

Children presenting with nonpalpable undescended testes are evaluated with diagnostic laparoscopy. The laparoscopic findings of blind-ending vessels and vas deferens are felt to be diagnostic for 'vanished' testes. We present a case of an overweight male in whom the testis was not palpable in the office or under anesthesia and in whom blind-ending vessels were identified on laparoscopy. Inguinal exploration revealed a normal appearing inguinal testis. Although not advocated as a tool in the evaluation of the child presenting with an undescended testis, inguinal ultrasound may have a role in overweight children in whom the examination may be difficult. Furthermore, we would advocate inguinal exploration in overweight children, given the limitations of laparoscopy in this overweight child.

Objective: Reoperative orchidopexy is a technical challenge to pediatric surgeons. The laparoscopy-assisted procedure is described for securing the testis in the scrotum in patients with a past history of open orchidopexy and testes in an unsatisfactory position., Patients and Methods: Thirty-one patients with 35 abnormally positioned testes (4 bilateral) were evaluated. All patients had a past history of inguinal surgery, and ages ranged between 2.5 and 13 years (mean, 5.5 years). Previous surgical procedures included 32 orchiopexies and 3 testicular detorsion of undescended testis. If needed, inguinal dissection was performed to loose the adherence between the cord and inguinal canal. Laparoscopic orchidopexy was applied to allow the testis to remain in the scrotum without tension. Patients underwent follow-up every 3 months after the operation with physical and ultrasound examinations., Results: Ten low inguinal testes were treated directly with open inguinal redo orchidopexy, whereas laparoscopy-assisted orchidopexy was possible in 23 (92%) of the remaining 25 reoperations. In 2 (8%) of these cases, severe scarring was present between the cord and the inguinal canal impeding the laparoscopy-assisted orchidopexy. For laparoscopy-assisted procedure, the operation time was 42 to 67 minutes (mean = 52 min). After the laparoscopy-assisted reoperations, 23 (92%) testes remain within the scrotum after a mean follow-up of 22 months (range, 6-32 months)., Conclusion: When feasible, laparoscopy-assisted orchiopexy is a simple and effective technique for securing testicles in reoperative orchiopexy procedures.

A case of complete separation between an abdominal testis and the epididymis discovered during diagnostic laparoscopy for impalpable testis is presented. A 13-year-old boy with impalpable testis underwent diagnostic laparoscopy for impalpable testis. The vas on the left side was seen entering a closed internal ring while a small testis was found completely separated and medial to the internal ring.

This study was undertaken in order to evaluate the feasibility and safety of performing laparoscopic orchidectomy (LO) in men for unilateral impalpable testis in non-teaching rural hospitals in a developing country. We also investigated the possibility of reducing the cost and length of stay in hospital for patients undergoing LO. This is a prospective analysis of patients with impalpable testis undergoing LO in three non-teaching rural hospitals in the Kashmir Valley from January 2001 to March 2007. The cohort represented men requiring LO aged 15 to 62 (mean 36.2) years. The main outcome parameters assessed included mortality, conversion to an open procedure, complications, reduction in the costs and the length of the hospital stay. Forty-eight men with unilateral undescended testis on physical examination were studied. During laparoscopy the testis was identified near the deep ring in 30 patients, intra-abdominally in 16, and two had blind-ending vas and spermatic vessels near the deep ring. In 46 patients orchidectomy was performed. There were no deaths and none of the patients required conversion to an open procedure. Using reusable instruments, 00 degrees polyglactin sutures and self-made extraction bags, about US$ 300/patient was saved. There was no case of malignancy of the testis on histopathology examination. LO is one of the most satisfactory methods for the management of men with impalpable testis, having both a diagnostic and a therapeutic role especially for patients in the underdeveloped countries. These simple methods can reduce the cost and the length of the hospital stay.

The purpose of this report is to bring attention to a rare variety of non-descended testis which may be easily overlooked. Between 1996 and 2006 diagnostic laparoscopy was performed for non-palpable testes in 209 children with 229 impalpable testes. Eight abdominal testes were encountered in seven patients located in the sub-renal position; the vas was found to be looping in an upward direction to join the epididymis. Laparoscopic Fowler-Stephen procedure was attempted in all these cases, with the loss of two testes and salvage of six.

Objectives: To determine the incidence of contralateral patent processus vaginalis discovered at laparoscopy in patients presenting with a unilateral nonpalpable testis., Methods: From August 1997 through February 2006, 159 boys underwent laparoscopic exploration for a unilateral nonpalpable testis. The data were retrospectively reviewed to determine the incidence of contralateral patency, and the results were analyzed with respect to age at repair and side and size of the unilateral nonpalpable testis., Results: The median age of the patients was 1.2 years (range 2 months to 16 years). The nonpalpable testis was on the left side in 100 patients (63%) and on the right side in 59 (37%). The testis was absent in 13 patients (8%), atrophic in 78 (49%), and of normal size in 68 (42%). The overall incidence of a contralateral patent processus vaginalis was 19% (30 of 159). A contralateral patent processus vaginalis was seen in 21% of the boys younger than 2 years old, 19% of boys 2 to 5 years old, and 12% of boys older than 5 years. The incidence of a contralateral patent processus vaginalis was no different for patients with right (20%) versus left (18%) nonpalpable testes. Patients with normal-size testes (34%) had a much greater rate of a contralateral patent processus vaginalis than did those with an atrophic/absent testis (8%) (P <0.001)., Conclusions: Our data suggest that the incidence of a contralateral patent processus vaginalis is considerable in patients presenting with a unilateral nonpalpable testis. This is another benefit of laparoscopy in patients with nonpalpable testes.

Background: Laparoscopy is used for the diagnosis and treatment of impalpable testes. We reviewed practice and outcomes in our unit over the last 10 years., Methods: Retrospective case-note review of patients undergoing laparoscopy with or without orchidopexy for impalpable testes., Results: Eighty-three patients underwent laparoscopy. Twelve patients had bilateral impalpable testes; 25.3% of testes were identified intra-abdominally, 21% in the internal ring, and 29.5% of cases had vas and vessels entering the deep ring. A 76.5% success rate was achieved following diagnostic laparoscopy and standard open orchidopexy for testes in the region of the internal ring, compared to a 40.0% success rate following one-stage laparoscopic orchidopexy for 'low' intra-abdominal testes., Conclusion: Laparoscopy is useful in managing patients with an impalpable testis from both a diagnostic and therapeutic standpoint. The success rate following laparoscopic orchidopexy in our non-paediatric specialist centre is lower than in most reports from paediatric specialist centres. This suggests the importance of centralization of such complicated, less frequently performed surgical procedures to a specialist centre.

Introduction: Treatment of the cryptorchid testicle is justified due to the increased risk of infertility and malignancy as well as the risk of testicular trauma and psychological stigma on patients and their parents. Approximately 20% of cryptorchid testicles are nonpalpable. In these cases, the videolaparoscopic technique is a useful alternative method for diagnosis and treatment., Materials and Methods: We present data concerning 90 patients submitted to diagnostic laparoscopy for impalpable testicles. Forty-six patients (51.1%) had intra-abdominal gonads. In 25 testicles of 19 patients, we performed a two stage laparoscopic Fowler-Stephens orchiopexy. The other 27 patients underwent primary laparoscopic orchiopexy, in a total of 29 testicles., Results: We obtained an overall 88% success rate with the 2 stage Fowler-Stephens approach and only 33% rate success using one stage Fowler-Stephens surgery with primary vascular ligature. There was no intraoperative complication in our group of patients. In the laparoscopic procedures, the cosmetic aspect is remarkably more favorable as compared to open surgeries. Hospital stay and convalescence were brief., Conclusions: In pediatric age group, the laparoscopic approach is safe and feasible. Furthermore, the laparoscopic orchiopexy presents excellent results in terms of diagnosis and therapy of the impalpable testis, which is why this technique has been routinely incorporated in our Department.

Objective: There is great controversy regarding the best approach to impalpable testis. In this retrospective study we evaluated the accuracy of intraperitoneal laparoscopy, inguinal canal exploration and ultrasound in the diagnosis of impalpable testis., Material and Methods: Over a 2-year period (2004-06), 76 patients with a diagnosis of uni- or bilateral clinically impalpable testis were referred to our center. A preoperative ultrasound evaluation was done and all patients underwent intraperitoneal laparoscopy. An inguinal canal incision and exploration was done in all cases except for patients with high intra-abdominal testes (> 2 cm above the internal ring), for whom laparoscopic dissection, mobilization and orchidopexy were necessary., Results: The mean age of the patients was 15.36 years (range 1-39 years). The undescended testis (UDT) was right-sided in 25% of patients, left-sided in 41% and bilateral in 34%. Intraperitoneal laparoscopy, inguinal canal exploration and ultrasound detected 70.6%, 78.4% and 15.6% of testes, respectively., Conclusions: Laparoscopy changed the management protocol of impalpable UDT in only 21% of cases. Inguinal canal exploration alone was sufficient in the majority of our cases. We recommend laparoscopy for those patients with impalpable UDT in whom an initial inguinal canal exploration proves negative.

We evaluated the results and advantages of laparoscopic examination in 28 patients with 32 nonpalpable testes. Between April 1991 and May 2006, 28 patients, 12 months to 12 years old, with 32 nonpalpable testes underwent diagnostic laparoscopy under general anesthesia before surgical management of the testes. If the blind end of the vas deferens and/or spermatic vessels was observed, the diagnosis of vanishing testis was made, and no further examination or treatment was performed. If intra-abdominal testis was observed, laparoscopic orchiectomy or open orchiopexy was performed. If the internal spermatic vessels and vas deferens entered into the internal inguinal ring, the diagnosis of intra-canalicular testis was made so that the inguinal canal was opened for surgical interventions. Of the 32 nonpalpable testes 10 were on the right side and 22 were on the left side (4 patients had bilateral undescended testes). There were 7 (21.8%) vanishing, 5 (15.6%) intra-abdominal and 20 (62.5%) intra-canalicular testes. There were no complications related to laparoscopy. Laparoscopy can be safely performed to assess the location of the non-palpable testes. Another advantage of the laparoscopic examination is that orchiopexy or orchiectomy can be immediately performed after the examination to avoid a second surgery.

Purpose of Review: The stable incidence of undescended nonpalpable testes and the ever-progressing utilization of laparoscopy has led to the commonplace utilization of laparoscopy in the diagnosis and treatment of these nonpalpable testes. The historical published literature is ambiguous with regard to recommendations regarding the use of laparoscopy in the setting of nonpalpable testes. As a result, this review is timely and necessary in that it is important for the practicing physician and surgeon to review and have available to them the current recommendations for the management of patients with nonpalpable testes., Recent Findings: With ongoing advances of minimally invasive surgery in the face of the limitations of both ultrasound and magnetic resonance imaging, the use of laparoscopy in the diagnosis and treatment of nonpalpable testes is now commonplace. Several reports recommend laparoscopy as the gold standard for the evaluation and treatment of nonpalpable testes, allowing for localization of the testis, characterization of the testis and associated structures (vas deferens, testicular vessels) and subsequent treatment options., Summary: Because of the superior diagnostic capabilities and the ability to provide therapeutic interventions, laparoscopy should be used in the evaluation and treatment of all patients with nonpalpable testes.

During the laparoscopic approach of undescended testis, an associated inguinal hernia is a frequent finding that must be treated at the same time. The objective of this presentation is to show the incidence and management of the inguinal hernia that were found during laparoscopic orchidopexy, reporting how the scar tissue will join the edges of the canal and the parietal peritoneum will grow above. Between January 1999 and December 2002, 31 patients with 33 palpable and nonpalpable undescended testes were treated by laparoscopic orchidopexy. Patients were between 6 months and 9 years. We used four ports, and 2 mm instrument. When an associated inguinal hernia were found we only removed the membranes of the processus vaginalis and did not close the defect. All cases were treated by the same surgeon. The average surgical time was 50 min that included the orchiopexy and the treatment of the associated inguinal hernia. We found inguinal hernia in 23 cases (69.9%). We did not find any inguinal hernia in the opposite side of the undescended testis. In two patients with bilateral undescended testis that were approached in two stages 3 months later we confirmed the closure of the hernia defect. These 23 patients have 21.5 months average follow up and confirm no recurrence. With an average follow up of 21.5 months, we found no inguinal hernia in any of the patients. A larger volume study with longer follow up is needed to confirm that there is no need for closure of the internal inguinal ring during laparoscopic orchidopexy.

Background: The undescended testis represents one of the most common disorders of childhood. The authors evaluated the safety and efficacy of laparoscopy for the abdominal testis and present a classification of the laparoscopic diagnostic findings to facilitate decision making., Methods: Between 2000 and 2005, 95 patients (22 bilateral and 73 unilateral testes, for a total of 117 impalpable testes) with a mean age of 5 years underwent laparoscopy. The testis was managed according to a special classification of the diagnostic findings. Testicular position, size, and viability according to technetium-99m ((99m)Tc) were assessed during the follow-up evaluation., Results: The laparoscopic findings were classified into six types: type 0 (no testis or vanished testis proximal to the internal ring; 9 patients [7.5%]); type 1 (atrophic intracanalicular testis; 6 patients [5.4%], for whom no further intervention was administered); type 2 (testis at the internal ring with looping vas; 15 patients [14.5%], for whom laparoscopic orchiopexy was performed); type 3 (testis at the internal ring without looping of the vas; 29 patients [24.7%], for whom laparoscopic orchiopexy also was performed; type 4 (high abdominal testes; 49 patients [41.9%], with Staged Fowler-Stephens orchiopexy performed for 47 testes and laparoscopic orchidectomy for 2 testes; and type 5 (persistence of Müllerian duct structures [PMDS] or other abnormalities; 7 testes [6%]). After a mean follow-up period of 3 years, the laparoscopic orchiopexy testes were of good size and viable, but four testes (8.7%) were at the neck of the scrotum. The laparoscopically staged Fowler-Stephens orchiopexy group showed atrophy in two testes (4.3%), and all were in the bottom of the scrotum., Conclusions: Classification of the laparoscopic findings facilitates decision making. Laparoscopic orchiopexy is a natural extension of diagnostic laparoscopy for the intraabdominal testis at the internal ring or that seen peeping from it. Laparoscopically staged Fowler-Stephens orchiopexy is the procedure of choice for the high intraabdominal testis not amenable to the one-stage procedure.

Background: Undescended testis is a relatively common condition in boys. The standard treatment is orchiopexy. In adults, orchiopexy is done only if sufficient length can be mobilized. Otherwise, orchiectomy is ideal as undescended testis predisposes to carcinoma. The incidence of carcinoma increases with age. The aim of this study is to highlight the value of laparoscopy in treatment of impalpable testis and simultaneously repair associated hernias. This is our experience in a rural tertiary hospital., Methods: In our rural hospital, it is not uncommon to see men aged 30 years or more presenting with unilateral absence of testis/empty hemiscrotum. A total of 35 patients were studied. Ultrasonography of the abdomen was done to localize the exact position of the testis; it was detected in 12 cases. A computed tomography (CT) scan was done in the other 23 cases and was positive in 16. The testis was found in the retroperitoneum (close to the internal inguinal ring) in 12 cases and in the inguinal canal in 23 cases. There were associated hernias in 9 patients., Results: Laparoscopy accurately identified the exact location of the missing testis and resection was also accomplished and associated hernias were repaired laparoscopically., Discussion: In countries like India, the majority of the population is poor and illiterate. By the time a boy or young man with an undescended testis arrives at the hospital, it is already too late to do orchiopexy. Even though most of our patients had no symptoms, orchiectomy had to be done because of the risk of torsion and malignant transformation. By using laparoscopy in these patients, the advantages of minimally invasive surgery can be utilized., Conclusions: Laparoscopic orchiectomy seems to be advantageous and well received by patients. We preferred the laparoscopic approach for the obvious benefits of less pain, better cosmesis, and early discharge.

Omentum herniated through a 3-mm umbilical port site 6 days after laparoscopic exploration for a nonpalpable testicle in an 18-month-old boy. Fascial closure of even these small sites may be advisable.

Purpose: In paediatric urology, one of the main applications of laparoscopy is the evaluation and treatment of impalpable testis. Herein we present our initial experience with laparoscopy in patients with impalpable testis., Material and Methods: Laparoscopy was performed under general anaesthesia on 13 patients. If the internal spermatic vessels and vas deferens made their way into the internal inguinal ring, the inguinal canal was dissected. Laparoscopic orchiopexy or orchiectomy was performed in cases with intra-abdominal testis. If the internal spermatic vessels found terminated intraperitoneally with a blind-end, the case was considered as a vanishing testis., Results: Thirteen boys, aged from 18 months to 25 years (median 9.8 years) were identified with 21 impalpable testes. 14 of the 21 impalpable testes, the vas and the vessels were through the internal ring, and the inguinal region needed dissection. Orchiopexy was performed on 12 testes and orchiectomy was performed on two atrophic testes. Four of 21 testes were intra-abdominally localized. Laparoscopic orchiopexy was performed in two testes and laparoscopic orchiectomy was performed in two testes. Two boys were diagnosed as vanishing testes; the absence was unilateral on the left side in one case and bilateral in the other., Conclusion: Diagnostic laparoscopy is a very helpful, minimally invasive technique in the diagnosis of impalpable testes especially when ultrasonography and/or computed tomography are not informative enough. In addition, orchiectomy and orchiopexy can be done as laparoscopically in the patients with intra-abdominal testes. Therefore, the laparoscopy has an important role in the diagnosis and treatment of impalpable testes.

Objectives: Little is reported on the management of impalpable testis in adults. We present the impact of laparoscopy in this patient group., Patients and Methods: Twelve adult patients have been referred to our centre over the last year, with impalpable testis. Pre-operative assessment was by either ultrasound or magnetic resonance imaging (MRI) or both. Quality of life and patient satisfaction were assessed by validated SF8 and client satisfaction (CSQ-8) questionnaires. Patients were also administered a self constructed questionnaire specifically looking at the impact of a laparoscopic service on their condition., Results: The mean age was 29 yrs (range: 19-36). Two patients declined treatment. Of ten patients undergoing transperitoneal laparoscopy, five had intra-abdominal testes treated by laparoscopic orchidectomy (none malignant), two had the vas going into the deep ring and needed inguinal orchidectomy for an impalpable nubbin while in three cases there were blind ending vessels and vas. SF8 scores for physical HRQoL were unchanged but mental scores were significantly improved (p < 0.03). All patients were completely satisfied with a mean CSQ-8 score of 30.6 out of a possible 32. The majority of patients indicated that the availability of a laparoscopic service had prompted them to seek medical advice., Conclusions: Laparoscopic examination and orchidectomy is a safe and reliable procedure. Excellent patient satisfaction and quality of life are achievable. In particular mental health scores improve as previous uncertainty is removed. The advent of laparoscopy has encouraged adult patients to seek advice regarding a condition that has been present since childhood. We advocate the use of laparoscopy in evaluating and treating adult patients with maldescended testes.

A case of urogenital nonunion is presented to illustrate the importance of laparoscopy for the impalpable testis. A 4-year-old boy with an impalpable left testis underwent laparoscopy. This revealed not only the vas deferens entering the deep inguinal ring but also a small intraabdominal testis supplied by the testicular vessels. Exploration of the inguinal canal revealed the vas deferens terminating in a nubbin of tissue. Histology identified epididymal structures both adjacent to the testis and in the terminal nubbin of the vas deferens. This is an example of urogenital nonunion. Complete separation of the vas and testis with epididymal structures attached to each is very unusual, with only four other cases reported. Laparoscopy should be the initial procedure for impalpable testis. A blind-ending vas deferens found on exploration of the inguinal canal might be taken as evidence of the vanishing testis syndrome. However, this conclusion should not be drawn unless laparoscopy has demonstrated testicular vessels entering the internal inguinal ring.

Laparoscopy has become a preferred technique to evaluate a nonpalpable testis. It gives excellent visualization of the anatomy to differentiate a viable or absent testis. We present a case of an intra-abdominal testis that was missed on diagnostic laparoscopy. Despite a closed processus vaginalis, an absent vas deferens, and blind-ending vessels above the internal ring, the testis was missed.