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World Journal of SurgeryOfficial Journal of the InternationalSociety of Surgery/SociétéInternationale de Chirurgie ISSN 0364-2313 World J SurgDOI 10.1007/s00268-013-1973-1

Examination Under Anesthesia forManagement of Impalpable UndescendedTestis: A Traditional Technique Revisited

Ossama M. Zakaria, Emad Hokkam,Karam E. El Kadi, Waleed H. Al BuAli,Hazem M. Zakaria, Mohamed Y. Daoud,Sameh A. Shehata, et al.

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Examination Under Anesthesia for Management of ImpalpableUndescended Testis: A Traditional Technique Revisited

Ossama M. Zakaria • Emad Hokkam • Karam E. El Kadi •

Waleed H. Al BuAli • Hazem M. Zakaria • Mohamed Y. Daoud •

Sameh A. Shehata • AbdulRahman S. AlMulhim • Hamed A. AlWadaani

� Societe Internationale de Chirurgie 2013

Abstract

Background Many new tools for management of impal-

pable testes have emerged during the last few years, yet,

not many studies have compared them to the traditional

ways of managing this problem. This work aims to reiterate

the importance of the physical examination under general

anesthesia prior to the surgical procedure in order to decide

the best surgical approach for patients with impalpable

undescended testis, especially in developing countries

where expensive investigations are at premium.

Patients and methods The study included boys who were

treated consecutively and recorded prospectively from

2000 to 2010. Examination under anesthesia (EUA) was

performed during the study period. Those in whom the

testes were palpable underwent the standard orchiopexy

procedure. In those boys where EUA failed to detect the

testes, laparoscopy or extended inguinal exploration was

carried out, and the testes were treated accordingly.

Results On initial clinical evaluation at the outpatient

clinic, 545 boys were recorded to have impalpable testes.

Undescended testis was unilateral in 529 boys and bilateral

in 16 boys. However, on examination under anesthesia only

189 (34.7 %) were impalpable. Among boys in whom the

testes were palpable after EUA, 38 had small-size testes, 18

had normal size, and the remaining 300 boys had a sac or

cord-like structure.

Conclusions Meticulous EUA facilitates the accurate

diagnosis and planning of the surgical approach to patients

with an impalpable testis and should remain part of the

surgeon’s skill set. It is an inexpensive initial evaluation

tool that may help in saving hospital resources, especially

in developing countries.

Introduction

Cryptorchidism is probably the most frequent genital

anomaly encountered in boys, yet this pathology remains

largely unexplained and its long-term prognosis is still

uncertain. Many publications report a single ‘‘best’’

approach to management, and there is ongoing controversy

surrounding the fertility potentials of affected patients after

medical management [1–4].

Approximately 3.5 % of all full-term infants, 30 % of

premature and 100 % of infant with a birth weight of less

than 800 gm have undescended testis [5]. By 3 months of

age, the incidence is reduced to 0.8 %, between 3 months

of age and adulthood the incidence does not change [6, 7].

Thirty percent of undescended testes are bilateral. In 20 %

of cases the testis is impalpable, with 15–20 % of such

nonpalpable testes being absent [4]. Six percent of fathers

with undescended testes also are likely to have children

with the same condition [7, 8].

O. M. Zakaria (&) � W. H. Al BuAli

Division of Pediatric Surgery, Department of Surgery, College of

Medicine, King Faisal University, Riyadh, Kingdom of Saudi

Arabia

e-mail: ossamaz2004@yahoo.com

O. M. Zakaria � E. Hokkam � K. E. El Kadi

Division of Pediatric Surgery, Departments of Surgery, Faculty

of Medicine, Ismailia, Egypt

H. M. Zakaria � M. Y. Daoud � A. S. AlMulhim �H. A. AlWadaani

Department of Surgery, College of Medicine, Dammam

University and KFHU, Al-Khobar, Kingdom of Saudi Arabia

S. A. Shehata

Departments of Surgery, Faculty of Medicine, Alexandria

University, Alexandria, Egypt

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World J Surg

DOI 10.1007/s00268-013-1973-1

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The lower the pre-treatment position of the testis, the

better will be the success rate for treatment and also the

fertility potential later on [8]. Medical treatment is effec-

tive only in 10 % [9]. The most effective treatment is

surgery.

However, most surgeons who deal with children with

cryptorchidism have been faced with the dilemma as to the

next step after identification of a nonpalpable testis in the

outpatient visit. They maybe also faced with the question

of what should be the next step when initial inguinal

exploration has not revealed a gonad distal to the internal

inguinal ring. In such instances, the surgeon cannot be sure

whether the testis is truly absent or whether the search was

merely inadequate [10, 11]. Although laparoscopy has

become an important addition to the surgical evaluation

and treatment of males with impalpable testis [10–12]

examination under anaesthesia of patients with impalpable

testes that has been used for decades may reveal a palpable

testis [12].

The present study aimed to reiterate our local experience

in a developing country on the importance of the physical

examination under general anesthesia prior to the surgical

procedure in order to decide the best surgical approach for

patients with impalpable undescended testis.

Patients and methods

This is a retrospective study that included boys who were

treated consecutively and recorded prospectively from

2000 to 2010 in Ismalia, Egypt. All children clinically

diagnosed to have impalpable undescended testes under-

went EUA. Those in whom the testes were palpable

underwent the standard orchiopexy procedure. In those

children where EUA failed to detect the testes, inguinal

exploration or laparoscopy was performed and the testes

were treated accordingly. Intraoperative data on these

patients were collected for age at operation, site or absence

of the testis after EUA, testicular size, associated inguinal

anomalies (vas, epididymis, and processus vaginalis), sur-

gical approach, and the results of surgery.

Examination under anesthesia was performed with the

option of proceeding with the inguinal approach if a testis was

palpated. However, when the testis remained impalpable

laparoscopy or extended inguinal approach was undertaken.

There were no certain criteria for extended inguinal approach

or laparoscopy. However; in the early period of this study most

patients were treated by the extended inguinal approach,

whereas laparoscopy was performed extensively in the late

period of the study. Whenever impalpable under EUA, a

single-stage Fowler-Stephens procedure was the most com-

mon operation in the early period of this study. In the late cases

we performed a two-stage procedure aimed at decreasing the

postoperative testicular atrophy. The finding of a blind-ending

vas deferens, or vas and vessels entering a closed internal ring

resulted in no further surgery, with testicular regression being

the assumed clinical diagnosis. The presence of vas and ves-

sels entering an open internal ring prompted exploration

through a groin approach. The mean follow-up of the second

group ranged from 2 to 36 months for site, size, and function.

We followed a special algorithm for management of the

16 boys with bilateral impalpable testes after clinical

examination. Other associated genital anomalies were

present in one boy with a bifid scrotum and a penoscrotal

hypospadias; this boy underwent chromosomal analysis as

well as magnetic resonance imaging (MRI) that showed the

presence of the testes. Ten boys underwent a human cho-

rionic gonadotropin (HCG) stimulation test to confirm the

presence of testicular tissue after an increase in testoster-

one, follicle stimulating hormone (FSH), and luteinizing

hormone (LH). The remaining 5 boys underwent EUA

followed by diagnostic laparoscopy.

Results

During the study period, 545 patients were recorded with

impalpable testis on routine clinical examination; 529 had

unilateral impalpable cryptorchidism. Among them 300

testes (56.7 %) were left sided and 229 (43.3 %) were right

sided. In addition 16 boys had bilateral undescended testes

(UDT), for a total of 561 impalpable UDT. The boys

ranged in age from 6 to 44 months with mean age of

12 ± 9.5 months (mean ± SD).

However, on examination under anesthesia only 189

patients (34.7 %) had impalpable testes. The testes were

felt in 56 boys; the testes were noted as small sized in

38/56 and of normal size in 18/56 patients; the remaining

300 boys had a sac or cord like structures (Table 1).

Review of the patients’ charts showed that some pre-

operative diagnostic tests were performed in 383 boys

(70.3 %); including ultrasonographic evaluation (US) in

360 boys (66.1 %), computed tomography in 5 boys,

venography in 3 boys, and MRI in one boy (2 %). The

clinically diagnosed impalpable testes did show different

sites on surgical exploration at different age groups.

Table 1 Gonad finding after examination under anesthesia (EUA)

(n = 545)

Palpable 189 (34.7 %)

Impalpable 356 (78.4 %)

Normal-sized testis 18 (3.3 %)

Small-sized testis 38 (7 %)

A sac-like structure 300 (55 %)

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Standard orchiopexy was performed in 56 boys whose

testes were felt at EUA (either normal or small sized). In

the remaining 300 boys with a palpable sac or cord-like

structures, the operative findings showed that the vas def-

erens/epididymis attachment was recorded in 158 testes.

Normal attachment, that is head and tail fusion of the

epididymis with the testis, was noted in 110 testes; 48

testes had abnormal attachment: head attachment only in

17 (5.7 %), tail attachment only in 9 (3 %), complete

detachment of the epididymis in 17 (5.7 %), detached vas

in 3 (1 %), absent vas in 2 (.7 %). Orchiectomy was per-

formed for cases of complete detachment of vas and epi-

didymis (Table 2).

Laparoscopy or the extended inguinal approach was

performed in the 189 boys with impalpable testis after

EUA to ascertain testicular presence and location. Lapa-

roscopy was performed in 76 boys, and the extended

inguinal approach was performed 113 others.

In the laparoscopy group the vas deferens and the

internal spermatic vessel were seen passing through the

internal ring in 52 boys. The inguinal canal was dissected

and then orchiopexy was performed on 40 boys and

orchiectomy was performed on 12 atrophic testes laparo-

scopically. In the remaining 24 boys, the internal spermatic

vessels were found to terminate intraperitoneally with a

blind end and were considered as vanishing testes.

In extended inguinal approach the testes were not found

in the inguinal canal in 75 boys. A retroperitoneal and

intraperitoneal exploration was carried out through the

deep ring. Viable testes were mobilized down to the

scrotum in 59 boys, orchiectomy was carried out on 7

atrophic testes, and nine boys were considered to have

vanishing testes.

In 38 boys of the roach, the testes were found in the

inguinal canal. Koop orchidopexy (retroperitoneal mobili-

zation of the spermatic vessels and vas) was performed in

14 boys, single-stage Fowler-Stephens orchiopexy in 8

boys, two-stage Fowler-Stephens orchiopexy in 5 boys, and

orchiectomy was performed in 11 boys. Surgical approach

to impalpable testes after EUA is shown in Table 3. The

atrophy rate after these techniques was not recorded, as

most of the patients were lost to follow-up during the study

period. Complete data are recorded in the flowchart

(Fig. 1).

Discussion

The rationale for treatment of the undescended testis is the

prevention of potential complications. Most common

problems associated with undescended testes are testicular

neoplasm, sub-fertility, and testicular torsion [13–15].

It has been proved that in cases of cryptorchid testis

located high in the abdomen, testicular atrophy may take

place in both the undescended testis and its contralateral

peer as a result of the harmful effect of temperature [3, 9,

15]. It is therefore recommended that early intervention is a

must in such cases [16].

Table 2 Pattern of attachment in cord-like structures group (recorded

158 testes)

Finding No. (%)

Normal attachment 110 (36.7)

Abnormal attachment 48 (16)

Head attachment only 17 (5.7)

Tail attachment only 9 (3)

Detachment of the epididymis 17 (5.7)

Detached vas 3 (1)

Absent vas 2 (0.7)

Table 3 Surgical approach to the impalpable testes after EUA

(n = 189)

Procedure No. (%)

Laparoscopy 76 (40.2)

Passing inguinal canal 52 (27.5)

Orchiopexy 40 (21.7)

Orchiectomy 12 (6.3)

Intra-abdominal 24 (12.7)

Extended inguinal approach 113 (59.8)

In the inguinal canal 38 (20.1)

Koop orchidopexy 14 (7.4)

Single-stage Fowler-Stephens orchiopexy 8 (4.2)

Two-stage Fowler-Stephens orchiopexy 5 (2.6)

Orchiectomy 11 (5.8)

Intra-abdominal 75 (39.7)

Orchiopexy 59 (31.2)

Orchiectomy 7 (3.7)

Vanishing testes 9 (4.8)

Fig. 1 A flowchart of the whole data set

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Bevan described the inguinal approach for orchiopexy

100 years ago, which remains the treatment of choice for

palpable undescended testis [17]. However, it is inappro-

priate for an impalpable testis, especially in the intra-

abdominal location, because it results in restricted access

and this has led to a search for another appropriate

approach [13].

The overall accuracy of radiological testing, including

computed tomography, ultrasonography, and magnetic reso-

nance imaging, in localizing a non-palpable testis has been

reported in many studies to be associated with high false

positive and low sensitivity rates [18, 19]. It has been docu-

mented that clinically, physical examination is the most cost

effective tool in the detection of the impalpable testis [19].

Our management of the impalpable testes was EUA

done by a senior staff surgeon to confirm impalpability. If

the testis was palpable, then groin exploration and

orchiopexy was undertaken. However, if no testis was

palpable, laparoscopy per se or the extended inguinal

approach was performed in order to ascertain testicular

presence and location. However, if anorchia was confirmed

during EUA (blind ending vas and vessels), further

exploration was avoided and the boy was considered to

having vanishing testes.

The incidence of true intra-abdominal testis in our series

of impalpable testes was only 21.8 %. In the majority of

patients a testis may be considered impalpable secondary to

a large prepubic fat pad or it may lie within the inguinal

canal and be overlooked, especially when the examination

is conducted by a less experienced junior staff physician.

Therefore, the role of laparoscopy in this group of patients

is controversial [7].

The diagnostic accuracy of laparoscopy for impalpable

testis is well recognized. Yet, in some cases, laparoscopic

findings may be misleading, and a viable gonad may be

missed, with significant medicolegal implications [20, 21].

In recorded data analyzing 107 patients who underwent

laparoscopy for impalpable testis, laparoscopy accurately

determined the location of the gonad in 95 %, and further

intervention was avoided in 15 % by identifying a blind

ending vas and spermatic vessels above the internal

inguinal ring [21].

Increasing experience with the transperitoneal approach

with full mobilization of the testicular vessels and division

of all fibrous bands that restrict their elasticity, gives the

highest chance of successful mobilization into the scrotum

with preservation of the spermatic vessels. It was also the

safest and most effective means of orchiopexy for the true

intra-abdominal testes. Excellent results were also reported

in a systematic review that concluded the pooled estimate

of success rates to be 80 % for single-stage Fowler-Ste-

phens orchiopexy (95 % CI 75–86) and 85 % for two-stage

Fowler-Stephens orchiopexy (95 % CI 81–90). The pooled

odds ratio of the single-stage versus two-stage Fowler-

Stephens orchiopexy was 2.0 (95 % CI 1.1–3.9), favoring

the two-stage procedure. The researchers found no differ-

ence in the success rate between laparoscopic and open

techniques in either single-stage or two-stage Fowler-Ste-

phens orchiopexy [22]. In two patients with atrophic testes,

the histology did not reveal testicular or vasal tissues, so re-

exploration was done.

It can be concluded that clinical diagnosis of impalpable

testis is initially made by examination at the outpatient

department. Heavy patient load and inexperience on the

part of surgeons-in-training may make this assessment

inconclusive. It is therefore recommended that clinical

recognition of impalpable testis should not be considered

absolute in the outpatient department unless the examina-

tion is carried out by an experienced staff member.

Meticulous EUA facilitates safe and accurate planning

of the surgical approach to the patient with impalpable

testis and should remain part of the surgeon’s skills set to

save hospital resources, especially in developing countries,

as it remains an inexpensive initial evaluation.

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