Overview
Definition:
Laparoscopic orchidopexy is a minimally invasive surgical procedure to locate and bring an undescended testis (testis that has not descended into the scrotum) into the scrotum using laparoscopic techniques
It is indicated for palpable and non-palpable undescended testes, especially those located high in the inguinal canal or abdomen.
Epidemiology:
Undescended testis (UDT) affects 1-3% of term male infants and up to 30% of premature infants
About 80% of UDT are palpable in the inguinal canal, while 20% are non-palpable (intra-abdominal)
Bilateral UDT occurs in approximately 20% of cases
Risk factors include prematurity, low birth weight, breech presentation, and maternal hormonal factors.
Clinical Significance:
Undescended testes are associated with increased risk of testicular germ cell tumors (GCCTs), impaired fertility, and increased likelihood of testicular torsion and inguinal hernias
Early diagnosis and surgical correction by orchidopexy improve fertility potential, reduce the risk of torsion, and facilitate regular surveillance for GCCTs, thus significantly impacting long-term patient outcomes.
Clinical Presentation
Symptoms:
Often asymptomatic during infancy and early childhood
Parents may notice absence of one or both testes in the scrotum
Occasionally, an inguinal bulge may be present, particularly if associated with an inguinal hernia
Symptoms of associated complications like testicular torsion (acute scrotal pain, swelling, erythema) or infertility may manifest later in life.
Signs:
On physical examination, the scrotum may appear underdeveloped or empty in the affected side(s)
A non-palpable testis may be mistaken for an absent testis (anorchia) or retractile testis
Palpable testes are usually found in the inguinal canal or suprapubic region
Associated findings may include an inguinal hernia sac or edema.
Diagnostic Criteria:
The diagnosis of undescended testis is primarily clinical, based on the inability to palpate the testis in the scrotum after birth
The American Academy of Pediatrics (AAP) and the American Urological Association (AUA) guidelines recommend examination of the scrotum at each well-child visit
For non-palpable testes, further investigation is warranted
Absence of testes in the scrotum on palpation in a male infant is the diagnostic criterion.
Diagnostic Approach
History Taking:
Key history includes gestational age at birth, birth weight, family history of UDT or hernias, any previous abdominal surgery, and presence of any other congenital anomalies
Maternal history of hormonal treatments during pregnancy can be relevant
In older children, history of testicular torsion symptoms or concerns about fertility are important.
Physical Examination:
A thorough physical examination focusing on the genitalia is crucial
The examination should be performed in a warm environment with the child relaxed
Palpate for testes in the scrotum, inguinal canal (both superficial and deep rings), and suprapubic region
Differentiate between an undescended, retractile, or absent testis
Assess for associated conditions like hypospadias, chordee, or inguinal hernias
Examine for bilateral testes presence.
Investigations:
For palpable UDT, imaging is generally not indicated as it rarely changes management
For non-palpable UDT, ultrasound may be helpful in locating an inguinal testis but is often inconclusive for intra-abdominal testes
MRI can be more accurate for intra-abdominal testes but is less commonly used
Hormonal assays (e.g., testosterone, FSH, LH, AMH) are typically reserved for cases of suspected bilateral anorchia or ambiguous genitalia
Laparoscopy is the gold standard for diagnosing intra-abdominal testes and guiding surgical management.
Differential Diagnosis:
Retractile testis (testis can be brought into the scrotum and remains there), ectopic testis (testis in an abnormal location outside the normal pathway, e.g., perineal, femoral), anorchia (absence of testis), and vanishing testis syndrome (testis present in embryonic life but lost due to torsion or infarction before or after birth)
Other rare differentials include intersex conditions.
Management
Initial Management:
The primary management for undescended testis is surgical correction, either via open or laparoscopic orchidopexy
The timing of surgery is typically recommended between 6-12 months of age to optimize fertility outcomes and reduce risks
Preoperative counseling with parents regarding the procedure, risks, benefits, and long-term implications is essential.
Medical Management:
Hormonal therapy with human chorionic gonadotropin (hCG) has a limited role and is generally not recommended as a primary treatment for UDT, especially for intra-abdominal testes
Its efficacy is low, and it does not address the anatomical abnormalities or reduce the long-term risks of malignancy and infertility
It may be considered in select cases of bilateral UDT with hypothalamic-pituitary dysfunction, but this is rare.
Surgical Management:
Laparoscopic orchidopexy is the preferred approach for non-palpable UDT and increasingly for palpable UDT in experienced hands
Laparoscopy allows for accurate localization of intra-abdominal testes, assessment of testicular viability, and identification of associated pathology like absent vas deferens or vessels
The procedure involves mobilizing the testis and its cord structures, creating a scrotal pouch, and securing the testis within the scrotum
In cases with a very long cord or if the testis is non-viable, orchiectomy may be performed
For palpable UDT, laparoscopic assessment can help determine if an open orchidopexy is more appropriate.
Supportive Care:
Postoperative care includes pain management with analgesics, wound care to prevent infection, and monitoring for bleeding or hematoma formation
Activity restriction for a few weeks is typically advised
Follow-up appointments are crucial to monitor for wound healing, testicular position, testicular atrophy, and long-term outcomes related to fertility and malignancy risk
Parents should be educated on testicular self-examination in adolescence.
Complications
Early Complications:
Early complications of laparoscopic orchidopexy are rare and can include wound infection, bleeding, hematoma formation in the scrotum or inguinal region, injury to surrounding structures (e.g., vas deferens, blood vessels, bladder), or anesthetic complications
Testicular injury or retraction of the testis out of the scrotum can also occur.
Late Complications:
Late complications include testicular atrophy, infertility due to impaired spermatogenesis, increased risk of testicular germ cell tumors (approximately 3-5 times higher than the general population), chronic scrotal pain, and recurrence of the undescended testis or development of an inguinal hernia
The risk of malignancy is reduced but not eliminated even after orchidopexy.
Prevention Strategies:
Meticulous surgical technique is paramount to minimize complications
Careful dissection to preserve the testicular vessels and vas deferens, adequate cord mobilization, and secure fixation of the testis in the scrotal pouch are essential
Performing the surgery at an appropriate age (6-12 months) is crucial for optimal fertility outcomes
Long-term follow-up allows for early detection and management of potential complications, including regular testicular examination for malignancy surveillance.
Prognosis
Factors Affecting Prognosis:
The prognosis for fertility is primarily influenced by whether the UDT was unilateral or bilateral, the intra-abdominal location of the testis, the time of orchidopexy (earlier is better), and the presence of pre-existing testicular pathology or impaired testosterone production
The risk of malignancy remains elevated compared to a normally descended testis, but orchidopexy facilitates surveillance.
Outcomes:
With timely surgical correction, fertility rates can be significantly improved, especially for unilateral UDT
For bilateral UDT, fertility outcomes are poorer
The risk of testicular cancer is reduced with orchidopexy, but regular lifelong surveillance is recommended
Laparoscopic orchidopexy offers good cosmetic results and typically leads to good functional outcomes.
Follow Up:
Follow-up typically involves regular clinical examinations at 6 months, 1 year, and then annually until puberty, and thereafter lifelong
The focus of follow-up is to assess testicular position, size, consistency, and to screen for signs of malignancy
Adolescents and adults should be educated on the importance of testicular self-examination
Further hormonal assessment might be indicated in specific cases.
Key Points
Exam Focus:
Laparoscopic orchidopexy indications and contraindications
Timing of surgery
Differentiating non-palpable from palpable UDT
Management of intra-abdominal testes
Risks of malignancy and infertility
Postoperative care and follow-up protocols
Complications of the procedure.
Clinical Pearls:
Always examine the scrotum in a warm environment with a relaxed child
If a testis is not palpable, assume it is either intra-abdominal or absent until proven otherwise by laparoscopy
Laparoscopy is the diagnostic modality of choice for non-palpable UDT
For testes with very short cords, consider staged orchidopexy (Fowler-Stephens)
Bilateral UDT with absent vas deferens suggests a genetic syndrome and requires further investigation.
Common Mistakes:
Delaying surgery beyond 12-18 months of age
Relying solely on ultrasound for non-palpable UDT
Inadequate cord mobilization leading to testicular retraction or tension
Failing to assess for associated hernias or other congenital anomalies
Insufficient follow-up leading to missed complications or delayed cancer detection
Not adequately counseling parents about long-term risks.