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022-5347/00/1633-0959/0
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THE JOURNAL OF UROLOGY
Vol. 163, 959–960, March 2000
Copyright © 2000 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Printed in U.S.A.
LAPAROSCOPIC DIAGNOSIS AND CLINICAL MANAGEMENT OF A
SOLITARY NONPALPABLE CRYPTORCHID TESTICLE IN A
POSTPUBERTAL MALE
ERIK G. ENQUIST, CONSTANTINE A. STRATAKIS, H. GIL RUSHTON AND
McCLELLAN M. WALTHER
From the Urologic Oncology Branch, National Cancer Institute, and National Institute of Child Health and Human Development,
National Institutes of Health, Bethesda, Maryland, and Department of Pediatric Urology, Children’s National Medical Center,
Washington, D. C.
KEY WORDS: laparoscopy, cryptorchidism, testis
The incidence of cryptorchidism is 0.8% at age 1 year with
1
nonpalpable testes in 13% to 34% of patients. About half of
these nonpalpable testes are intra-abdominal and half are
absent.1 Management of nonpalpable testes requires accu-
rate testicular identification and localization to determine
the best surgical approach. Diagnostic techniques to localize
a nonpalpable testicle, such as ultrasound, magnetic reso-
nance imaging, computerized tomography (CT) and venogra-
phy, are limited by the inability to identify the testis, inabil-
ity to diagnose absent testes reliably, radiation exposure and
lack of application in smaller children.
, 2
CASE REPORT
A 16-year-old boy was referred for anorchia. As a newborn
he had nonpalpable gonads. Electrolytes were normal, karyo-
type was 46XY and he was assigned male gender. At age 2
years he underwent bilateral inguinal and retroperitoneal
exploration with right orchiectomy. The left testicle was not
identified. At age 13 years axillary and pubic hair developed
with penile enlargement and nocturnal erections. Repeat CT
and ultrasound suggested left pelvic testis but repeat ingui-
nal and retroperitoneal exploration was uninformative.
Physical examination at presentation revealed a virilized,
healthy, Tanner IV patient. Abdominal CT did not show a
testicle. However, peripheral serum testosterone was 224
ng./dl. (normal 100 to 800) and left gonadal vein testosterone
was 412 ng./dl.
Because the patient had a solitary testis, laparoscopy and
transabdominal orchiopexy were recommended. At laparos-
copy a small testis was easily identified lateral to the de-
scending colon at the lower pole of the left kidney (see figure).
A laparoscopic single stage Fowler-Stephens orchiopexy was
Intraperitoneal appearance of left testis (to right of dissecting
performed. The testicle was brought through the abdominal
forceps). Descending colon is reflected medially (to left of and above
wall medial to the external inguinal ring and placed into a
forceps). Testicle was at level of lower pole of left kidney. Left
subdartos pouch to allow periodic examination. The patient
testicular artery and vein (small arrowheads) extend superior to
was discharged from the hospital on postoperative day 1 and testis. Vas deferens, with its blood supply (large arrowhead), extends
inferiorly and medially.
returned to his home country. Serum testosterone was 238
ng./dl. at 76-day followup. The patient remained clinically
virilized 1 year after orchiopexy.
tralateral scrotal testis. However, to prevent anorchia and to
DISCUSSION
reposition the testis to allow for surveillance examination,
We report the management of a solitary intra-abdominal
laparoscopic orchiopexy was performed. The patient re-
testis in a postpubertal boy. Laparoscopy, following 2 previ-
quested a single stage procedure because of the limited avail-
ous negative inguinal and retroperitoneal explorations, suc-
ability of medical care.
cessfully identified the abdominal testis. Its location superior
Laparoscopy is becoming the procedure of choice for chil-
to the external iliac vessels correctly predicted the need to
dren with nonpalpable cryptorchid testes. It allows diagnosis
transect testicular vessels to mobilize the testicle into the
of intra-abdominal testes or atretic vas deferens and sper-
scrotum.3 Laparoscopic orchiectomy would have been the
procedure of choice in our patient if there had been a con-
2
matic vessels associated with vanishing or inguinal testes.
Open surgical exploration is avoided in the 10% to 17% of
patients with absent testes diagnosed by blind-ending sper-
Accepted for publication October 7, 1999.
959