MY APPROACH to the Non-Palpable Testis
The child with a non-palpable testis (NPT) presents an important clinical problem that can be managed in a clear and logical pathway, yet is frequently handled with uncertainty and confusion by primary care providers.
In the setting of a unilateral NPT, the first issue is to determine if the testis is truly non-palpable. This requires a careful and deliberate exam with the child relaxed and comfortable. There is little justification for ultrasound imaging, as this cannot definitively determine an absent testis; therefore, some surgical intervention will be needed no matter what the findings on the ultrasound. I communicate to the parents that the most important goal is to know where the testis is and be prepared to bring it into the scrotum, or to definitively determine that the testis is not in the abdomen and is absent. At this time, laparoscopy is the most reliable means of determining testicular presence, location, and viability. Therefore, laparoscopy has become the first step in our evaluation and management of the NPT. It is even more appropriate because it is readily integrated with definitive management using laparoscopic orchiopexy at the same setting. We typically aim to perform the diagnostic laparoscopy at 6 to 9 months of age.
At the time of laparoscopy, the child is re-examined under anesthesia to ensure that the testis is not palpable. If it is felt in the inguinal canal, then an inguinal exploration is performed. If we feel a scrotal nubbin that is clearly a nubbin of an atrophic testis, then a very small incision at the scrotal edge is made superiorly and the nubbin exposed and removed. While there is probably a very minimal risk of developing a malignancy, the confirmation of an atrophic testis supports the determination that there is not an intra-abdominal testis. There are documented cases of excision of what is thought to be a remnant of the testis but is a looping vas of an abdominal testis.
If there is no nubbin or palpable testis, then umbilical laparoscopy is performed with a small 30° scope. The normal side is examined first and then the affected side. If the vessels and vas deferens are blind-ending in the abdomen, this is proof of an intra-abdominal vanishing testis. If the vessels are diminutive and with the vas pass through the internal inguinal ring, then this is likely an atrophic testis in the scrotum and we perform a brief exploration as above for a nubbin.
If the testis is seen, its location determines the next step. For intra-abdominal testes within 2 cm of the internal ring and in children under 2 years, a primary laparoscopic orchiopexy using two working ports (ipsilateral mid-clavicular line above the umbilicus and contralateral mid-clavicular line infra-umbilical) is performed, leaving the vessels intact. If the child is older than 2 or the testis is more than 2 cm above the ring, a first-stage Fowler-Stephens orchiopexy is performed by simply clipping the spermatic vessels 1 to 2 cm above the testis. The second stage is performed in 4 to 6 months using two working ports. If the vessels cannot be seen and no testis is seen, it is necessary to expose the spermatic vessels by mobilizing the colon, if needed. Testes have been found in unusual locations, including the deep pelvis, retrocolic, and even at the level of the kidney (often with renal dysplasia). Some of these testes are not salvageable.
Success rates for primary orchiopexies for appropriate testes are about 95%, and about 88% for two-stage Fowler-Stephens orchiopexies. The long-term fertility of the testis that has been brought out of the abdomen is uncertain, but probably not normal; however, it permits easy examination and has a normal appearance.
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