Journal of Pediatric Surgery 51 (2016) 128130

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Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

The anatomic ndings during operative exploration for non-palpable

testes: A prospective evaluation
Katherine W. Gonzalez a, Brian G. Dalton a, Charles L. Snyder a, Charles M. Leys b,
Shawn D. St. Peter a,, Daniel J. Ostlie b
a
b

Department of Pediatric Surgery, Childrens Mercy Hospital, Kansas City, MO

Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI

a r t i c l e

i n f o

Article history:
Received 30 September 2015
Accepted 7 October 2015
Key words:
Undescended testicle
Location
Atrophy
Laparoscopy

a b s t r a c t
Background: We conducted a randomized trial comparing 1 and 2-stage laparoscopic orchiopexy for intraabdominal testes. During recruitment, it became apparent that most patients with non-palpable testes do not
require vascular division. In this report, we outline the location and quality of testes found during operative
exploration in patients who consented for the study but were not randomized.
Methods: Analysis was performed on 80 patients undergoing operative exploration for non-palpable testes
between 2007 and 2014. The location and pathology of undescended testes were analyzed.
Results: There were 87 preoperative non-palpable testes in 80 patients that were consented but not randomized
to 1 or 2 stage orchiopexy with vascular division. Forty (46%) of nonrandomized testes were atrophic or absent,
and 47 (54%) were normal in appearance. Sixty eight testes were evaluated via laparoscopy. The most common
location for normal (81%) and absent/atrophic (70%) testes was the inguinal canal. Atrophic testes were more
often left sided (72.5%) with normal testes equally divided. Patients with atrophic or absent testicles were
more likely to have a closed internal ring (p b 0.01).
Conclusion: This study demonstrates the majority of patients undergoing operative exploration for non-palpable testes
will not require vascular division, and instead would be either atrophic or able to undergo traditional orchiopexy.
Level of Evidence: III
2016 Elsevier Inc. All rights reserved.

Cryptorchidism is a common diagnosis in young boys, and general

consensus is that cryptorchidism is increasing in incidence in the
United States, Canada and Europe [1]. Preterm and low birth weight infants in particular have signicantly higher rates of undescended testes
[2]. Orchiopexy is indicated if the testis is not located in the scrotum
after 6 months as it improves fertility rates and allows close monitoring
for the development of testicular masses. In cases of atrophic testicular
remnants, orchiectomy is indicated to eliminate the long-term malignant risk. As such, the need for orchiopexy, or orchiectomy of testicular
remnants, is a common consultation to pediatric general surgeons and
urologists. At the time of initial consultation, the location of the testis
is assessed, and 20% of undescended testicles will be non-palpable at
the time of exam [3]. We recently completed a prospective, randomized
Author Contributions: Katherine W. Gonzalez: Literature search, data collection, analysis, interpretation and writing, critical revision. Brian GA Dalton: Literature search, data
collection. Charles L. Snyder: Study design, critical revision. Charles M. Leys: Study design,
critical revision. Shawn D. St. Peter: Literature search, study design, data analysis, interpretation and writing, critical revision. Daniel J. Ostlie: Literature search, study design, data
analysis, interpretation and writing, critical revision
Corresponding author at: Childrens Mercy Hospital, 2401 Gillham Road, Kansas City,
MO 64108. Tel.: +1 816 983 6465; fax: +1 816 983 6885.
E-mail address: sspeter@cmh.edu (S.D. St. Peter).
http://dx.doi.org/10.1016/j.jpedsurg.2015.10.031
0022-3468/ 2016 Elsevier Inc. All rights reserved.

trial comparing 1 and 2 stage laparoscopic orchiopexy in patients where

the testicle is high enough to require vascular division [4]. Interestingly,
the majority of patients recruited to the study did not require vascular
division and therefore were not randomized. Given the surprising
predominance of these patients, we sought to outline the location and
quality of testes found during operative exploration in patients who
consented for the study but were not randomized.
1. Methods
We performed a prospective analysis on 80 male patients between
the ages of 5 months and 10 years diagnosed preoperatively with
non-palpable testes that were consented to our aforementioned trial
(#11120216) but did not undergo randomization during the study
period (20072014). Patients enrolled in the trial did not undergo
randomization if the intra-abdominal testis could be retracted to the
contra-lateral internal ring. Eight board certied pediatric surgeons at
a tertiary childrens hospital performed all operations. Patients were excluded if they had undergone previous inguinal or testicular surgery, or
if they were successfully randomized into the prospective randomized
controlled trial. Each patients chart was individually reviewed for demographics and operative details including the location and pathology

K.W. Gonzalez et al. / Journal of Pediatric Surgery 51 (2016) 128130

of undescended testes. Descriptive analysis was performed utilizing percentages. Comparative analysis was performed utilizing chi-squared tests.

2. Results
A total of 107 patients were enrolled into the trial in anticipation to
undergo a 1 or 2 stage laparoscopic orchiopexy. However, based on the
location of a viable testicle or if a nonviable testicle was discovered, 80
patients did not qualify for the study. The remaining 27 patients (25%)
were randomized and therefore represent a viable testicle high enough
in the abdomen to require division of the vessels. In this report, 87 undescended testicles were identied in the 80 patients examined and
the following results reect their particular anatomy.
The median age was 1.3 years (0.412.4 years). Median weight was
11.4 kg (6.383.8 kg). A preoperative ultrasound was performed for 33
(38%) undescended testes, and 16 (48%) had ultrasound results that
correlated with operative ndings.
At the time of operative exploration for testes not requiring ligation
40 (46%) testes were atrophic or absent and 47 (54%) were normal in
appearance. A total of 68 non-palpable testes were evaluated via
laparoscopy because 18 testicles were thought to be palpable after the
induction of general anesthesia; 17 within the inguinal canal and 1
suspected in the scrotum. These patients underwent primary open
inguinal operations. An additional patient had a known inguinal hernia
and the testis was identied within the canal on repair; therefore, diagnostic laparoscopy was foregone.
Atrophic testes were excised, and none were found to have a focus of
malignancy. There were 4 patients with a blind ending vas deferens and
absent testicle. The majority of normal testicles underwent traditional
orchiopexy via open inguinal incisions (Fig. 1).
The most common location for both normal (81%) and atrophic
(70%) testes was the inguinal canal. The remainder of normal appearing
testes were characterized as peeping, dened as moving in and out of
the internal inguinal ring, and a small percentage intraabdominal
(Fig. 2). Atrophic testes were identied more often on the left (72.5%),
whereas normal testes were more equally distributed (right 47% vs
left 53%). Patients with an atrophic or absent testicle were also more
likely to have a closed internal inguinal ring (82.5% vs 42.5%, p b 0.01).

129

3. Discussion
The 2-stage orchiopexy with division of the testicular vessels followed
by orchiopexy has been the historical standard for abdominal testes
which do not have sufcient testicular vessel length to allow for a primary
orchiopexy. However, rationale for this approach based on neovascularization is questionable when the change in blood supply is instant and not
gradual. This argument led to our conducting the pilot trial noted above.
The consultation for non-palpable testis is often difcult for physicians and families due to the unknown factors regarding actual testicular location and natural history of testicular development resulting in
the wide variation of ndings as shown in Fig. 1. This report provides
the rst prospectively collected data that will allow pediatric surgeons
and urologists to provide accurate information to families.
The majority of patients consented for the trial did not require vessel
ligation. This is an important nding to aid consultation in patients with
non-palpable testes, since we can inform families that a substantial portion of non-palpable testes will not require vascular division. A retrospective analysis of 156 patients found that the only signicant
variable for success through multivariate analysis was a primary procedure preserving vascular supply, with success dened as a testis normal
in size and texture at follow up when compared to the contralateral
side. Mean follow up time was 16 months [5]. A recently published systematic review also found 85%100% success when the orchiopexy is
completed without vascular division compared to 63%96% when the
vessels must be divided to bring the testis down [6].
This study also provides further support for the use of laparoscopy in
the management of non-palpable testes. A substantial percentage of patients were found to have inguinal testes whether atrophic or normal.
Those that were palpated in the operating room following anesthetic induction were likely missed in clinic due to difcult body habitus and patient cooperation. However, a signicant portion remained nonpalpable
in the relaxed patient, and diagnostic laparoscopy was key to visualizing
healthy vessels and vas entering the inguinal canal. Laparoscopy also resulted in the identication of blind ending vessels, blind ending vas
deferens and abdominal testes thus avoiding an unnecessary inguinal
exploration in those patients. Laparoscopy has been previously cited
as providing excellent abdominal visualization of the testicular vessels
and vas deferens giving clues to the health of the testicle, which is

Fig. 1. Testicular pathology and surgical approach.

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K.W. Gonzalez et al. / Journal of Pediatric Surgery 51 (2016) 128130

Fig. 2. Intraoperative testicular location.

supported by our results [3,7]. This study also emphasizes the need
for inguinal exploration if an intra-abdominal testis is not identied.
We located the majority of absent and atrophic testicles within the
inguinal canal, after identication of a closed internal inguinal ring
laparoscopically. These atrophic remnants must be excised due to the
risk for malignant degeneration. Even with hypotrophic vessels and
vas deferens leading up to the ring, an atrophic remnant cannot be
excluded without open exploration [8]. We also found that the majority
of normal appearing testicles were within the inguinal canal which has
been supported by retrospective review of both unilateral and bilateral
cryptorchidism [9].
Although a prospective evaluation, this study is limited by the single
center population. However, our hospital serves a large rural and urban
catchment area suggesting that these results should be applicable to the
general pediatric population.
The strength of this study is the ability to counsel patients and their families regarding the distribution of undescended testicles and procedures required. When including the total of testes consented for the trial, both those
who were randomized and those who did not require vessel ligation, we
found that 35% of testes would be absent or atrophic requiring excision,
41% would be normal and the majority able to undergo traditional open
orchiopexy, and only 24% would require vascular division.
4. Conclusion
This study provides new information that should aid pediatric
surgeons and urologists during the consultation and treatment of
patients with non-palpable testes. Our results have shown that the
majority of patients who present with non-palpable undescended
testicles preoperatively will not require vascular division to adequately
perform orchiopexy.
Appendix A. Discussions
Presented by Katherine Gonzalez, Kansas City MO
SHERIF EMIL (Montreal QC)
Thanks for a nice study. Im just curious. You said at the beginning of your presentation that if the testicle reaches the other
side then they do not need a vascular division, but its too late.
If youve mobilized the testicle to try to stretch it, youve kind
of burned the principles of ______. I agree that with laparoscopy actually you can do almost all of them in a single stage, but
I use a simple measurement of 1 cm from the internal ring

when I rst put the scope because once you start to mobilize
the testicle it is sort of beside the point if you do a vascular
division or not. You just disturbed the collateral blood supply.
I am just curious how that decision is made in your institution.
KATHERINE GONZALEZ
So we do have eight different surgeons who are performing this
procedure, but they all put in instruments laparoscopically on
the contralateral side to see if it would reach and I do believe
that they did less dissection than they would have done if they
were actually going to divide the vessels and then based on their
own clinical judgment whether that would require division or not.
UNIDENTIFIED SPEAKER (moderator?)
Im struck by the fact that 40% of your patients had atrophic or
absent testicles so presumably really did not need an operation at all. Is there any imaging or other investigation you
can do to identify those patients preop?
KATHERINE GONZALEZ
So 38% of our patients in the nonrandomized group had an
ultrasound preoperatively but only half of those had results
that were in agreement with what we found intraoperatively,
so that is not something that we routinely use. Although at
least for the absent testes they would not have required an
operation, we would not have known if we hadnt proceeded
with diagnostic laparoscopy to conrm that there is not an
atrophic testis to excise.

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