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This study aimed to compare the detection and ligation of patent processus vaginalis (PPV) between laparoscopy-assisted transscrotal orchidopexy (LATO) and single scrotal incision orchiopexy (SSIO) for low palpable undescended testis (UDT). We performed a retrospective medical record review of transscrotal orchidopexies performed for low palpable UDT at our institution from 2017 to 2019; 33 and 39 boys underwent LATO and SSIO, respectively. Data collection included patient demographics, incidence of PPV, operative time, and clinical outcomes. All 95 testes were delivered into the scrotum. There was no significant difference between the two groups with respect to patients' age, side, and mean operative time. The incidence of PPV in the LATO group was significantly higher than that in the SSIO group (56.52 vs. 34.69%, P = 0.04). The incidence of contralateral PPV in the LATO group was 45%. One patient in the SSIO group underwent unilateral PV ligation and laparoscopic exploration revealed bilateral PPV owing to metachronous contralateral hydrocele. One patient in the LATO group demonstrated obliterated PV in the initial transscrotal procedure, but an ipsilateral PPV was found in the latter laparoscopic procedure. In conclusion, LATO has a higher detection rate and higher ligation of the PPV than SSIO, suggesting that, LATO may help reduce recurrent PPV-related issues. However, long-term follow-up results are needed to evaluate the advantages and disadvantages in a larger case series.

Cryptorchidism is the most common congenital anomaly of the male genital tract. Cryptorchidism is associated with potentially serious consequences including reduced fertility, increases risk of cancer, susceptibility to torsion and traumatic injury, as well as future psychological problems related to an abnormal scrotal appearance. The mainstay of orchiopexy is to achieve an adequate tension-free and permanent scrotal fixation of the testis; one that prevents recurrent ascent. A number of suggestions have been made regarding keeping the testis in the scrotal position once it was brought down in the scrotum without tension. Several techniques for testicular fixation have been described to date; however, the optimal method remains controversial. We herein introduce a novel scrotal orchidopexy technique. This innovative fixation technique utilizes the sub-scrotal fat as a permanent anchor for fixing the low-lying cryptorchid testicle in the scrotum through a trans-scrotal incision. Therefore, the procedure was named "the fat anchor orchiopexy". We believe our method will give better options for scrotal fixation especially in cases of low-lying cryptorchid testes. This article provides a detailed description of this new fixation technique.

Background: We wish to share our outcome of single median raphe scrotal incision orchiopexy (SMRSO) regarding safety & feasibility of technique by evaluating ease of access, conversion rate, duration of surgery, success rate, complications, and the need for redo-surgery. Methods: We retrospectively analyzed data of 277 orchiopexies performed in our department on 224 patients operated on between June 2016 to June 2019. SMRSO was considered for palpable testes that can be brought to the upper limit of the scrotum under anesthesia. The conventional inguinoscrotal approach was used for high lying testes. A median raphe incision was made to access & mobilize the testis on either side, ligation of processus vaginalis performed, and the testes secured in the scrotal pouch. The approach was utilized for both unilateral and bilateral orchiopexies. Follow-up done at one week, one month & six months to evaluate the outcome. Results: A total of 277 orchiopexies were performed in 224 patients. 237 (86%) orchiopexies were via the median raphe scrotal approach in 184 patients. Out of these, 53 cases had bilateral orchiopexies. 30 (11%) performed via a conventional inguinoscrotal approach and 10 (4%) by laparoscopic approach. The mean duration of surgery for SMRSO was 24 minutes for unilateral and 42 minutes for bilateral cases. Immediate postoperative complications included scrotal hematoma in three (1.6%) cases, Hematoma of the abdominal wall in one case, and scrotal edema in 4 (2%) patients. All complications were treated conservatively & resolved. No wound infection or testicular atrophy was reported. Long-term complications included testicular ascend in three cases [1.6%]. Conclusion: Single-incision Median Raphe Scrotal orchiopexy is an attractive alternative to the standard inguinoscrotal orchiopexy for palpable low lying undescended testes with a better cosmetic outcome. doi: https://doi.org/10.12669/pjms.37.7.4261 How to cite this:Jan IA, Hassan M, Shalaan I, Alshehhi MA. Single Median Raphe Scrotal incision Orchiopexy: A safe & feasible approach for fixation of Palpable Undescended testes. Pak J Med Sci. 2021;37(7):---------. doi: https://doi.org/10.12669/pjms.37.7.4261 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction and importance Cryptorchidism is seen in 3% of fullterm neonates. Rarely, it may cause small bowel obstruction. Knowledge of this presentation of cryptorchidism is essential to treat bowel obstruction arising due to cryptorchidism before the patient suffers complications. Case presentation We present a case of a patient who underwent exploratory laparotomy for small bowel obstruction that did not resolve with conservative management. At laparotomy, on initial exploration, this patient had adhesive bands causing the small bowel obstruction. On further exploration, the bands were found to arise from a cryptorchid testis. Clinical discussion Cryptorchidism is a common finding among newborns and needs to be corrected by 1 year of age. Failure to correct cryptorchidism in a timely manner can result in complications such as bowel obstruction. Conclusion Thorough intraoperative exploration is key at operation for all cases of small bowel obstruction, so as to find and treat anatomic causes of obstruction. Congenital causes of bowel obstruction should be suspected in all unexplained cases of bowel obstruction and may be revealed by careful physical examination and thorough intraoperative exploration., Highlights • Cryptorchidism is common and requires correction by 1 year of age. • Uncorrected cryptorchidism can present with complications such as bowel obstruction. • Complete examination physical including the scrotum, is needed in bowel obstruction. • Thorough intraoperative exploration helps find multiple points of bowel obstruction. • Bowel obstruction in patients without prior surgery needs operative exploration.

Background: Traditional open orchiopexy is still a standard of treatment for palpable undescended testicles. Recently several authors reported successful results using a laparoscopic approach in the treatment of palpable cryptorchidism. The present systematic review and meta-analysis investigated the utility of laparoscopic orchiopexy for palpable cryptorchidism. Methods: Scientific databases (PubMed, Scopus, Web of Science, and EMBASE) were systematically searched for relevant articles using the following terms: (palpable cryptorchidism or palpable undescended testes) AND (laparoscopic orchiopexy or laparoscopic orchiopexy). The inclusion criteria were all children with unilateral or bilateral palpable undescended testes who underwent laparoscopic orchiopexy (LO) compared to children who underwent conventional open orchiopexy (CO). The main outcomes were the proportion of children requiring redo-orchiopexy and the incidence of postoperative complications. Secondary outcomes were duration and the cost of surgery. Results: The final meta-analysis included five studies involving 705 children; LO, n = 369 (52.3%) and CO, n = 336 (47.7%). The majority of the included patients had unilateral palpable cryptorchidism. No significant differences were found in regard to average age at the time of surgery and follow-up periods between the investigated groups. No statistically significant differences were found in regard to redo-orchiopexy rates (RR = 0.22, 95% CI 0.03–1.88, p = 0.17), early complications (RR = 0.66, 95% CI 0.21–2.08, p = 0.48) and incidence of testicular atrophy (RR = 0.36, 95% CI 0.03–3.88, p = 0.40). No significant differences in the operative duration were observed among the groups. Laparoscopy was associated with higher costs in most of the studies. Conclusion: LO is safe and effective in children with palpable cryptorchidism. The rates of redo-orchiopexy as well as an incidence of early complications and testicular atrophy rates are comparable to CO.

Background In 2011 a consensus statement from the British Association of Paediatric Urologists recommended lowering the age at orchidopexy to under 1 year. There are concerns that a younger age at operation may increase postoperative testicular atrophy. The ORCHESTRA study aimed to establish the current age at orchidopexy in a multicentre, international audit and to see whether testicular atrophy was affected by age at operation. Methods The study was undertaken over a 3-month period in 28 centres in boys undergoing orchidopexy for unilateral, palpable undescended testes. Data collection was done using a standardized, predetermined protocol. The primary outcome was postoperative testicular atrophy. Secondary outcomes were wound infections, reoperations, and unplanned hospital stays related to anaesthetic events. Results A total of 417 patients were included, of whom only 48 (11.5 per cent) underwent orchidopexy before 1 year of age. There was no difference in anaesthetic complications in boys aged less than 1 year versus older patients: 0 of 48 (0 per cent) versus 6 of 369 (1.6 per cent) (P = 0.999). Complete follow-up was available for 331 patients (79.4 per cent). There was no difference in atrophy rate between those aged less than 1 year and older boys: 1 of 37 (3 per cent) versus 9 of 294 (3.1 per cent) (P = 0.999). Reoperation rates were 0 of 37 (0 per cent) and 7 of 294 (2.4 per cent) respectively (P = 1.000). There were more wound infections in boys under 1 year of age: 4 of 37 (11 per cent) versus 7 of 294 (2.4 per cent) (P = 0.025). Conclusion Only 11.5 per cent of boys underwent surgery before the age of 1 year. There was no increased risk of postoperative testicular atrophy with early surgery, although there was a higher rate of wound infection. Further study is required to demonstrate that early orchidopexy is not inferior to orchidopexy undertaken in boys aged over 1 year., Prospective, international study of effect of age at orchidopexy on post operative testicular atrophy. Only 11.5% boys received surgery at age

A 10 year-old boy presented to the emergency department with torsion of an Appendix Testis in an undescended testis. The diagnosis was suspected clinically and confirmed by ultrasound imaging. Intra-operatively, the testis was well perfused. A black, necrotic pedunculated Appendix Testis was present, excised and an orchidopexy performed. It is likely that torsion of an Appendix Testis in undescended testes is under-reported. With this case report, we wish to highlight torsion of Appendix Testis as a relevant differential diagnosis in patients presenting with groin swelling and undescended testis.

The trio of perineal soft tissue tumour, anorectal malformation (ARM) and external genitalia abnormality is exceedingly rare. We present a case of a three-month-old infant who presented with bilateral undescended gonads, ARM and perineal mass. Chromosomal study showed a male profile and ultrasound of his groin suggested right intra-abdominal testis, with the left gonad not visualised. He underwent a period of rectal washouts via the perineal fistula before undergoing elective limited posterior sagittal anorectoplasty. He subsequently underwent left single stage orchidopexy, right first stage orchidopexy and excision of the perineal lump at 10 month of age. Histology revealed lobules of adipocytes with intervening fibrous septae with focal areas of myxoid stroma, suggestive of a lipoblastoma. He then underwent second stage right orchidopexy six month later and no recurrence was noted. Only two cases of perineal soft tissue tumour associated with ARM and external genital abnormality were previously reported. It is likely that the large size of the perineal mass contributed to mal-descent of both testes. We postulate that the constellation of anomalies in our patient falls into the category of the urorectal septum malformation sequence.

Background Discuss the superiority of laparoscopic orchiopexy in the treatment of inguinal palpable undescended testes. Methods Inclusion criteria: Preoperative examination and color Doppler ultrasound examination confirmed that the testes were located in the inguinal canal and could not be pulled into the scrotum, except for retractive and ectopic testes. The surgical steps were depicted as follow. The retroperitoneal wall was carved by ultrasonic scalpels, separates the spermatic vessels closed to the inferior pole of the kidney if necessary, dissects the peritoneum of vas deferens, cuts the testicular gubernaculum, and pulls back the testicle into the abdominal cavity. Besides, protect the vas deferens, and descend the testes to the scrotum and fix them without tension. Results There were 773 patients with 869 inguinal undescended palpable testes, 218 cases on the left side, 459 cases on the right side and 96 cases with bilateral undescended testes, whose age ranged from 6 months to 8 years, with an average of 20 months. All testes were successfully operated, no converted to open surgery. The average operation time was (34.8 ± 5.4) min. There were 692 testes have an ipsilateral patent processus vaginalis (89.5%); In 677 cases of unilateral cryptorchidism, 233 cases (34.4%) have a contralateral patent processus vaginalis, and laparoscopic percutaneous extraperitoneal closure the hernia sac carry out during the surgery. There was no subcutaneous emphysema during the operation, no vomiting, no abdominal distension, no wound bleeding and obvious pain after surgery, especially wound infection is rarely. Doppler ultrasound was evaluated regularly after surgery. The patients were followed up for 6 to 18 months. All the testes were located in the scrotum without testicular retraction and atrophy. No inguinal hernia or hydrocele was found in follow-up examination. Conclusion Laparoscopic orchiopexy manage inguinal palpable cryptorchidism is safe and effective, and there are obvious minimally invasive advantages. Furthermore, It could discover a contralateral patent processus vaginalis, and treat at the same time, which avoid the occurrence of metachronous inguinal hernia.

Introduction : Undescended testes are recognised in 1% to 2% of boys during the first year of life, and about 20% of them are impalpable. Ultrasonography (US) may establish the localisation of the testis but the final diagnosis is usually determined laparoscopically. Aim : To evaluate long-term results of laparoscopic treatment of boys with impalpable testes and sensitivity of preoperative ultrasound. Material and methods : Between 2011 and 2015, we operated on 545 boys with undescended testes. Sixty-two of them with 65 impalpable testes were treated laparoscopically – the study group. Mean age was 3.5 years. The study group was divided into 5 groups according to type of treatment. The volume and position of the operated gonad were assessed manually and by ultrasound. Results : In group 1 testicular agenesis was observed in 19 patients. In group 2 revision of the inguinal canal revealed testicular agenesis in 7 and atrophy in 4 patients. In group 3 conversion to classic orchiopexy was performed in 10 patients. In group 4 one-stage orchiopexy was performed in 9 patients on 12 testes. In group 5 a two-stage F-S procedure was performed in 13 patients. Ten testes in group 4 had a volume in the normal range (84%) and also 10 testes in group 5 (77%). Conclusions : Laparoscopy in impalpable testes is the procedure of choice and allows definitive management, even when conversion to open procedure is necessary. Sensitivity of preoperative ultrasound is generally about 60% for true intra-abdominal testes, so diagnostic laparoscopy is necessary.

Transverse Testicular Ectopia which is also known as Cross Testicular Ectopia, is a rare congenital anomaly of undescended testes, that occurs 1 in 4 million. Although the etiology is not accurately understood, but it is classified into 3 types and can be associated with other congenital anomalies such as persistent Mullerian ducts, hypospadias, hernia and etc. here we report a case of this rare anomaly in a 16 months old Afghan child, who underwent bilateral orchidopexy using trans scrotal median raphe incision with 3 months post-operative follow up.

Objective: This report details the findings at operation and challenges of managing undescended testes (UDT) in southeastern Nigeria.Methods: Prospective evaluation of children managed for undescended testis from January 2013 to November 2015 in Enugu, southeastern Nigeria.Results: There were 54 patients with total of 69 undescended testes (39 unilateral, 15 bilateral) involving the left side in 39 and the right side in 30 cases. The median age at operation was 5 years (Range 1 – 15 years). Three (4.35%) testes were localized at suprascrotal position, 12 (17.4%) were emergent, 33 (47.8%) canalicular, 18 (26.1%) abdominal, and 3 (4.35%) were vanishing. The volume of the localized testes ranged from 0.7mls to 8.5mls (mean 2.0mls). Epididymal anomaly was noticed in 31 (47%) with the commonest anomaly being head non-fusion. Age at operation was an independent predictor of testicular volume (OR 4.91). Single stage scrotal repositioning was achieved in 28/37 (75.7%) of cases and was not dependent on age (p=0.58). Testes localized distal to the internal ring are more likely to be mobilized to the scrotum at initial orchidopexy than those located in intraabdominal position (44/48 vs 4/18; p

Transverse testicular ectopia (TTE) is an uncommon anatomical abnormality where both the gonads migrate toward the same hemiscrotum. Embryologically, several theories regarding the origin of TTE have been suggested including adhesion and fusion of developing Wolffian canals, aberrant gubernaculum, testicular adhesions, defective formation of the internal inguinal ring, and traction on the testis by persistent Mullerian structures. To date, about 100 cases of TTE have been reported in the literature. Herein, we report five cases of TTE operated in the Department of Paediatric Surgery, Sardar Patel Medical College, Bikaner, over a period of 5 years. All cases were in the age group of 3 months to 4 years, out of which four were diagnosed preoperatively by clinical examination and ultrasonography (USG). Two of these four cases presented with inguinoscrotal swellings and contralateral undescended testes and other two presented with absence of testes in the scrotum. One case presented with a scrotal abscess which revealed both the testes in the abscess cavity. All five cases were operated upon with herniotomy and transseptal orchidopexy and discharged successfully. TTE, although rare, has a spectrum of presentations and should be kept in mind as a possibility in cases of inguinoscrotal disorders in young age group. A preoperative USG may be helpful in conformation of diagnosis.

Highlights • Agenesis of the pubis is a very rare clinical deformity which can be a sign of urogenital abnormalities. To report a rare condition would help clinicians to diagnose co-morbidities which may affect children remaining life. • This is a rare pattern of associated anomalies confined to a localized region of the body. Somatic mutations may responsible for developmental abnormalities of mesoderm from which the pubic bones and urogenital structures develop. • An isolated X-ray finding of ramus pubis agenesis may associate with cryptorchidism or several other urogenital malformations., INTRODUCTION Agenesis of the pubic bone, as evidenced in the world literature, is a very rare clinical and congenital abnormality. Several disorders may occur with hypoplasia of the pubis. PRESENTATION OF CASE Here, we report a rare longer follow-up case of the congenital unilateral agenesis of the superior ramus of pubic bone with bilateral undescended testes, osteoporosis, cranial malformations, acetabular dysplasia, unilateral shortening of the lower extremity and an abnormal gait pattern. DISCUSSION Somatic mutations may responsible for developmental abnormalities of the mesoderm from which the pubic bones and urogenital structures develop. CONCLUSION An isolated x-ray finding of ramus pubis agenesis may associate with cryptorchidism or several other urogenital malformations.

Background: The use of ultrasonography in the pre-operative localisation of undescended testes has become controversial due to fears about its accuracy. This study was designed to ascertain the accuracy, sensitivity, specifi city, positive predictive value (PPV) and negative predictive value (NPV) of ultrasonography in the localisation of the undescended testes in children.Patients and Methods: A prospective evaluation of all boys undergoing operation for undescended testes at the Lagos University Teaching Hospital, Idi-Araba, Lagos, over a 12 month period was performed. Thepre-operative clinical and ultrasound fi ndings were compared with the fi ndings on surgical exploration.Results: Forty boys with 52 undescended testes were studied. The mean age of the boys at the time of surgery was 4.0 ± 0 years (range 1-11 years). Fortysix (88.5%) testes were localised pre-operatively by ultrasound- 20 of 22 (90.9%) palpable testes and 26 of 30 (86.7%) non-palpable testes. Intra-operatively, 49 (94.2%) of the undescended testes were found while 3 (5.8%) were absent/vanishing testes. Ultrasoundevaluation had an accuracy of 86.5%, sensitivity of 89.8%, and specifi city of 33.3%, PPV of 95.7% and a NPV of 16.7%.Conclusion: Ultrasound assessment is beneficial in pre-operative evaluation of children with undescended testes. Key words: Children, pre-operative assessment, ultrasonography, undescended testes

The aim of this study was to evaluate the testicular volume and structure using ultrasound (US) before and up to 3 years after orchidopexy in children with different age. A total of 128 patients underwent orchidopexy for undescended testes. Afterwards, patients were invited for annual follow-up and control scrotal US. The total number of analyzed testes after orchidopexy was 184. Patients were divided according to age at the time of surgery: group I (2–4 years old), group II (5–7), and group III (8–10). In all patients, the testicular volume ratio was calculated as the operated testes volume versus the control testes mean volume. There was an increase in the median ratio in all age groups, from 0.86 to 0.95 in group I, 0.82 to 0.92 in group II and 0.78 to 0.90 in group III. In group of the patients 2 to 4 years old the growth of the ratio 3 years after surgery was statistically significant. Abnormalities in the structure of the testes, which may indicate severe damage to the testis, were seen in approximately 20% of patients on initial exams. On follow-up exams, this type of structure remained in 7% of patients. Testes with an initial ratio

Objectives We review the various applications of laparoscopic and robotic-assisted laparoscopy in paediatric urology, as the laparoscopic and robotic approach in this population is gradually being recognised. Methods We searched PubMed for human studies in English that were published between 1990 and the present, focusing on laparoscopic nephrectomies and partial nephrectomies, laparoscopic and robotic pyeloplasties and ureteric reimplantation, laparoscopic orchidopexy and varicocelectomy. We also reviewed robotic-assisted laparoscopic urological major reconstructions. Key articles were reviewed, extracting the indications, techniques, and the advantages and disadvantages. Results and conclusions Laparoscopy has a defined place in modern paediatric urological surgery. Laparoscopic nephrectomies, pyeloplasties and abdominal exploration for the evaluation and management of impalpable undescended testicles have become the standard of care. Robotic-assisted laparoscopic surgery is developing as a safe and effective option even for infant patients.

Objective: This study is to evaluate imaging modalities used in unpalpable undescended testes (UDT) patient at our centre. We evaluate the data descriptively. Material & methods: This is a descriptive and retrospective study. Data was taken from medical record in Cipto Mangunkusumo Hospital from January 2010 until June 2014. Sampling method is total sampling. Inclusion criteria for this study was unpalpable UDT patients at Urology Department Cipto Mangunkusumo Hospital, whereas patients with incomplete data and have XX chromosomes were excluded. Results: Mean ages in this study was 9.35 years old (7 month to 41 year old). Diagnostic tools was not performed in half of the patients. Abdominal ultrasound was performed in 9 patients (34.6%), and 4 patients with CT-Scan. We found that most of patients were unilateral UDT (57.7%). Bilateral UDT was found in 11 patients (42.3%). Twenty one patients undergo laparoscopic orchidopexy (80.8%). There were 7 patients undergo full laparoscopy orchidopexy. Fowler Stephen technique applied to 4 patients, and eleven patients underwent inguinal exploration and orchidopexy. Laparoscopic biopsy was performed in 4 patients and agenesis of the testis was found in one patient. There are 13 cases with other abnormalities; hypospadias (38.5%), DSD 46 XY (53.8%), and testicular tumor (7.7%). Conclusion: Unpalpable UDT is adequately diagnosed by history and physical examination. Half of our patient in this study were not performed additional examination such as ultrasound, CT-Scan, and MRI for diagnostic tools and directly underwent laparoscopic orchidopexy. The best management of unpalpable UDT is laparoscopic orchidopexy.