END-2015-0118-ver9-Riquelme_1P.

3d 07/02/15 10:19am Page 1

END-2015-0118-ver9-Riquelme_1P
Type: pediatric endourology
JOURNAL OF ENDOUROLOGY
Volume 29, Number XX, XXXX 2015 Pediatric Endourology
ª Mary Ann Liebert, Inc.
Pp. ---–---
DOI: 10.1089/end.2015.0118

Palpable Undescended Testes:

15 Years of Experience and Outcome
AU5 c in Laparoscopic Orchiopexy

AU1 c Mario Riquelme,1 Rodolfo A. Elizondo, MD,2 and Arturo Aranda 3

Abstract
Background and Purpose: Most of the current literature concerning laparoscopy in patients with cryptorchi-
dism reports on those with nonpalpable testes. The purpose of this study is to share our experience and outcome
in laparoscopic orchiopexy on patients with palpable undescended testes.
Patients and Methods: From January 1999 to July 2014, 240 cryptorchid testes were treated of which 192 (155
patients) were palpable and were operated on by laparoscopy. Before starting, the bladder is emptied with a
Foley catheter. Four trocars are used: One 5 mm for the lens (45 degree), one 10 mm (transscrotal), and two
3 mm placed at the subcostal midclavicular line for the instruments. We localize the deep inguinal ring and open
the peritoneum. The spermatic vessels and vas deferens are dissected in a cephalic direction. The epigastric
vessels are dissected and sectioned to facilitate the localization of the testicle inside the canal. Once found, the
testis is dissected and taken into the abdominal cavity where the gubernaculum testis is cut. A 10-mm trocar is
introduced through the scrotal sac into the peritoneal cavity. The testicle is grabbed and pulled down to the
scrotum where it will be fixed with a 5-0 polypropylene suture in the usual manner.
Results: Of 192 cryptorchid palpable testes treated with laparoscopy, only one procedure was converted to
conventional open orchiopexy because of an ectopic testicle (above the aponeurosis of the oblique muscle). The
rest of the testicles could be moved down to the scrotal sac. Our follow-up ranges from 6 months to 15 years,
and we have not found atrophy in any of the testicles. To date, only two (0.4%) testicles have reascended.
Conclusion: Laparoscopy is a great and safe option for patients with palpable undescended testes, regardless of
its position in the inguinal canal.

Introduction during dissection. Given the rate of complications in open

orchiopexy, there has been a need to look for other treatment

M ost of the current literature that discusses lap-

aroscopy in patients with cryptorchidism reports on
those with nonpalpable testes. Over time, the gold standard
for nonpalpable undescended testes (UDT) has changed from
AU4 c open to laparoscopic orchiopexy.1–3 In 1995, Docimo and
associates1 published the success rates of open orchiopexy by
type of procedure (inguinal, 89%; Fowler-Stephens, 67%,
staged Fowler-Stephens, 77%; transabdominal, 81%; two-
stage, 73%; microvascular, 84%).
It is well known that there is an increased possibility of a
complication occurring depending of the height of the tes-
ticle. It is common that a high intra-abdominal testis presents
with atrophy or recurrence during follow-up because during
surgery, the spermatic vessels and vas deferens can be tense at
the moment of placing the testis in the scrotal sac or damaged
options.
The first laparoscopic-assisted orchiopexy was reported by
Bloom,2 and Jordan and Winslow3 published the first single-
stage laparoscopic orchiopexy. Since then, there has been a
report with a 93% success rate in laparoscopic orchiopexy in
nonpalpable UDT.4 In addition, a large multi-institutional
analysis showed superior success rates when compared with
open orchiopexy.5 There are many articles that report the
benefits of laparoscopic treatment in nonpalpable UDT, but
there are few articles reporting its use in palpable UDT.
Cryptorchidism, also called UDT, is one of the most com-
mon male disorders in childhood, and it can be present in up to
1% to 3% of newborns.6–8 It has been associated with infer-
tility, increased risk of malignancy, testicular torsion, trau-
matic injury against adjacent structures, associated inguinal

1
Department of Pediatric Surgery, Christus Muguerza Hospital, Monterrey, Mexico.
2
General Practice, Monterrey, Mexico.
3
Department of Pediatric Surgery, Wright State University, Dayton, Ohio.

1
END-2015-0118-ver9-Riquelme_1P.3d 07/02/15 10:19am Page 2

2 RIQUELME ET AL.

hernia, and psychological stigma of an empty scrotum. UDT

can be categorized as congenital or acquired, and it can be
defined in different ways, depending of the position of the
testes: Canalicular, prepubic, prescrotal, superficial to the in-
guinal pouch, ectopic, and abdominal.8,9 Besides all these
possibilities, the UDT can be palpable (80%) and nonpalpable
(20%).8,10,11
At present, the gold standard for managing palpable UDT
is open orchiopexy. The disadvantage of this procedure is the
space limitation to achieve a wide and proper dissection of
the spermatic vessels and vas deferens, which is the most
important step in moving the testicle into the scrotal sac.
Because 80% of UDT are palpable, there is a need to im-
prove surgical techniques to provide patients with better
outcomes and fewer complications. We have published a
retrospective study of 30 palpable UDT that were treated by
laparoscopy. We concluded that the laparoscopic approach is
a safe way to perform descent of a palpable testicle.12 The FIG. 2. Identification of internal inguinal ring and its re-
purpose of the present study is to share our experience and lation with the testis and scrotum. AII = internal inguinal
outcome in laparoscopic orchiopexy of 155 patients with ring; test = testis.
palpable testes (192).
nonpalpable testes were excluded from this study. Eight
Patients and Methods
percent of the patients had an associated inguinal hernia.
From January 1999 to July 2014, we treated patients with
240 cryptorchidic testes of which 192 were palpable (155 Surgical technique
patients) and were operated on by laparoscopy at our insti-
The patient is administered general anesthesia and full
tution. All procedures were performed by the same surgeon
muscle relaxation medication. All patients are placed in
(MR). The age of the patients ranged from 10 months to 3
the supine position. The surgeon and first assistant stand at
years; patients had a weight range of 10 to 22 kg. There were
the upper end of the table behind the patient’s head, and the
33 left, 97 right, and 62 bilateral testes that were treated. Of
monitor is placed at the lower end of the table. Before
155 patients, 112 had acquired cryptorchidism. Peeping and
starting, the bladder is emptied with a Foley catheter. We
create a pneumoperitoneum of 10–12 mm Hg with a Veress
needle using a closed technique.
Four trocars are used: One 5 mm for the lens below the
umbilicus (45 degree), one 10 mm (transscrotal), and two
3 mm placed at the subcostal midclavicular line for the in-
struments (Fig. 1). We localize the deep inguinal ring to make b F1
a 360-degree peritoneal flap (Fig. 2). If there is a peritoneal b F2
sac, it is resected before starting the dissection of the testicle.
The spermatic vessels, vas deferens, and peritoneum are

FIG. 3. Modified grasper used to manipulate the vas b 4C

FIG. 1. Abdominal view of trocar placement. deferens.
 END-2015-0118-ver9-Riquelme_1P.3d 07/02/15 10:19am
PALPABLE UNDESCENDED TESTES
4C c
FIG. 4. Clipping and section of the epigastric vessels.
dissected in a cephalic direction to gain length for a proper
nontense descent. This procedure needs to be performed with
caution to prevent damaging of these structures. We use a
modified grasper that has a defect in the middle of the in-
strument that prevents damaging of the structures during
F3 c dissection (Fig. 3).
The epigastric vessels are also dissected and sectioned to
facilitate exploration and localization of the testicle inside the
canal, and to prevent injury during 10-mm trocar placement.
F4 c F5 c (Figs. 4, 5) The epigastric vessels can be grabbed with a
F6 c grasper and displaced laterally during trocar insertion (Fig. 6).
Once the testis is found, it is dissected and liberated from
its vaginal tunic and taken into the abdominal cavity where
the gubernaculum testis is cut. It is extremely important to
inspect the gubernaculum, because frequently a loop of the
vas deferens is found. We perform a maneuver once the
FIG. 5. External view of transscrotal 10 mm trocar
placement.
Page 3
3
FIG. 6. Internal view of 10 mm trocar placement with later- b 4C
alization of epigastric vessels with a grasper to avoid damage.
testicle is inside the abdominal cavity that consists of moving
the testicle to the contralateral deep inguinal canal; if this can
be achieved without trouble, we can be sure that the testicle
can be moved to the scrotum.
A 10-mm trocar is introduced through the scrotal sac into
the peritoneal cavity. We recommend introducing the trocar
through the internal aspect of the epigastric vessels because
this has a shorter distance to the scrotum. If we consider that
the vessels and vas deferens have adequate length, we use the
inguinal canal. During this step, the surgeon needs to be
aware of not twisting the vessels while moving the testicle
because it will produce ischemia and further atrophy. We
prefer to use a 10-mm trocar because we can protect the
testicle during the descent into the scrotal sac. Afterward, the
testicle is grabbed and pulled down to the scrotum where it
will be fixed with a 5-0 polypropylene suture (Fig. 7). b F7
Normal diet and deambulation are started after the surgical
procedure. Postoperative pain management consists of acet-
aminophen every 6 hours and cephalexin every 12 hours;
occasionally, we use nalbuphine hydrochloride every 4 hours
if pain persists during inpatient stay. Ninety percent of our
patients were ambulatory. The other 10% were hospitalized
for a maximum of 48 hours and had bilateral cryptorchidism
or disorder of sexual development.
FIG. 7. Internal view of the original and neo hiatus and its b 4C
relations with important structures. The testis was descended
through the neo hiatus.
 END-2015-0118-ver9-Riquelme_1P.3d 07/02/15 10:20am
4 RIQUELME ET AL.
Results
The mean operative time was 47 minutes. Of 192 palpable
testes treated by laparoscopy, only 1 procedure needed to be
converted to an open procedure because of an ectopic loca-
tion (above the aponeurosis of the oblique muscle). Two
patients had bleeding of the epigastric vessels during trocar
placement that necessitated clipping. One patient had atrophy
of the testicle because of an accidental injury of the spermatic
vessels. We did not damage any abdominal organ during the
procedure. In all of the other patients, testes were moved to
the scrotal sac and only two (0.4%) testes have reascended.
To date, we have a success rate of 97%. All of our patients
had successful pain control with acetaminophen. Our follow-up
ranged from 6 months to 15 years with only one iatrogenic
injury during the learning curve. All of the patients were clini-
cally evaluated with palpation and Doppler ultrasonography.
Discussion
It is the 21st century, and the gold standard for palpable
UDT is still inguinal orchiopexy. Another open approach is
transscrotal orchiopexy (Bianchi technique), which has re-
ported success rates of 98.8% and complication rates of
4.7%.13 Another group reported success rates of 96.9% and
89.5%.14 Although this procedure has a high success rate, it
has higher complication rates when compared with laparo-
scopic orchiopexy and also has obvious anatomic limitations.
It is quite concerning that 80% of the patients have palpable
UDT, and there are not a lot of reports in the literature con-
cerning treatment alternatives to the conventional open orch-
AU2 c iopexy technique. With this procedure, there is limited vision
and dissection because of the small working space, which
challenges the surgeon to avoid lesions of nearby structures
including the testicle. These limitations can increase the rate of
recurrence and testicular atrophy, esspecially in a UDT that is
located high in the abdominal cavity. One of the most im-
portant steps in preventing these complications is the proper
dissection of the spermatic vessels and vas deferens, which can
be achieved with laparoscopy.
Just like in the 1990s, other groups are starting to use lap-
aroscopic-assisted orchiopexy as a treatment option for pal-
pable UDT. This consists of dissecting the spermatic vessels
and vas deferens caudally and then performing an open orch-
iopexy to dissect the testicle and pull it down to the scrotum.
They groups have a success rate of 92% in recurrent UDT.15
Taking advantage of minimally invasive surgical tech-
niques, we can offer the patient a surgical alternative that can
decrease the rate of recurrence and atrophy. It has already
been reported that laparoscopy is not only an effective and
suitable procedure for nonpalpable testes but also for high
palpable testes.16 A recent study by Gallardo and col-
leagues17 shows that laparoscopic orchiopexy is a suitable
option for testicular descent into the scrotal sac regardless of
the height in the inguinal canal or intra-abdominal cavity.
They concluded that laparoscopy should be considered as the
surgical choice for treating patients with cryptorchidism.
Another study from He and coworkers18 reported 103 ingui-
nal canalicular palpable UDT that were managed with laparos-
copy. From 90 patients, only one complication was encountered
and occurred at the beginning of the surgeon’s learning curve.
All of the testes had adequate size and intrascrotal position
without atrophy or recurrence in 6 to 12 months.
Page 4
We present a series of 192 palpable undescended testes that
were all treated by laparoscopy with a success rate of 97%,
which is higher than with conventional orchiopexy. We had
two patients with bleeding of the epigastric vessels that was
produced during the 10-mm trocar placement; after this, we
decided to clip the epigastric vessels before introducing the
trocar to prevent bleeding or to displace them laterally. In ad-
dition, we have used blunt surgical equipment, such as a he-
mostat, to produce a canal before the introduction of the trocar.
A group from Texas has reported bladder injury during
creation of the transperitoneal tunnel with the trocar. This
accident can be prevented with placement of a urethral
catheter and drainage of the urine before introducing the
trocar through the inguinal canal.19 This approach provides
the surgeon with diverse advantages that decrease the rate of
atrophy and recurrence.
Most of the benefits will be centered on a better visuali-
zation of the anatomic structures and proper, wider dissection
of the testicle, which will allow the testes to be brought down
without tension of the spermatic vessels and vas deferens.
There is also the advantage of being able to treat bilateral
UDT and inguinal hernia simultaneously and perform ab-
dominal exploration in patients with disorders of sexual de-
velopment without the need to make more incisions or
schedule the patient for another procedure. This decreased
our complication rate to 3%, which was mostly present at the
beginning of the learning curve from 1999 to 2004; since
then, we have not had any complication during the follow-up
of our patients.12
Conclusion
Laparoscopic orchiopexy should be considered as the
treatment of choice for patients with cryptorchidism regard-
less of location in the inguinal canal and abdominal cavity.
This procedure will decrease the rate of complications about
which the pediatric surgeon is mostly concerned: Atrophy
and recurrence. In addition, patients have the benefit of a
minimally invasive surgical procedure such as less postop-
erative pain, reduced inpatient stay, reduced morbidity, and
better cosmetic results. There is also the advantage of being
able to manage associated contralateral inguinal hernia dur-
ing the operation and perform an extensive abdominal ex-
ploration in patients with cryptorchidism and associated
disorder of sexual development.
We share our experience, outcome, and surgical technique
to show that laparoscopic orchiopexy is another safe surgical
alternative for treating patients with palpable UDT.
Author Disclosure Statement b AU3
No competing financial interests exist.
References b AU4
1. Docimo SG. The results of surgical therapy for cryptor-
chidism: A literature review and analysis. J Urol 1995;154:
1148–1152.
2. Bloom DA. Two-step orchiopexy with pelviscopic clip li-
gation of the spermatic vessels. J Urol 1991;145:1030–
1033.
3. Jordan GH, Winslow BH. Laparoscopic single stage and
staged orchiopexy. J Urol 1994;152:1249–1252.
END-2015-0118-ver9-Riquelme_1P.3d 07/02/15 10:20am Page 5

PALPABLE UNDESCENDED TESTES 5

4. Lindgren B, Darby EC, Faiella L, et al. Laparoscopic 15. Tong Q, Zheng L, Tang S, et al. Laparoscopy-assisted
orchiopexy: Procedure of choice for the nonpalpable testis? orchiopexy for recurrent undescended testes in children.
J Urol 1998;159:2132–2135. J Pediatr Surg 2009;44:806–810.
5. Baker LA, Docimo SG, Surer I, et al. A multi-institutional 16. Docimo SG, Moore RG, Adams J, Kavoussi LR. La-
analysis of laparoscopic orchiopexy. BJU Int 2001;87:484– paroscopic orchiopexy for the high palpable undescended
489. testis: Preliminary experience. J Urol 1995;154:1513–
6. Hutson JM. Undescended testis: The underlying mecha- 1515.
nism and the effects on germ cells that cause infertility and 17. Gallardo AF, Gonzalez JM, Espinosa H, Vazquez H. Ex-
cancer. J Pediatr Surg 2013;48:903–908. perience in laparoscopic orchiopexy in intraabdominal and
7. Papparella A, Romano M, Noviello C, Cobellis G, Nino F, canalicular testes (palpable). Rev Mex Cir Ped 2004;18: b AU6
Del Monaco C, et al. The value of laparoscopy in the 80–85.
management of non-palpable testis. J Pediatr Urol 2010;6: 18. He D, Lin T, Wei G, et al. Laparoscopic orchiopexy for
550–554. treating inguinal canalicular palpable undescended testis.
8. Cobellis G, Carmine N, Nino F, et al. Spermatogenesis and J Endourol 2008;22:1745–1749.
cryptorchidism. Front Endocrinol 2014;5:63. 19. Hsieh MH, Bayne A, Cisek L, et al. Bladder injuries during
9. Kolon TF, Herndon CD, Baker LA, et al; American Ur- laparoscopic orchiopexy: Incidence and lessons learned.
ological Association. Evaluation and treatment of cryptor- J Urol 2009;182:280–285.
chidism: AUA guideline. J Urol 2014;192:337–345.
10. Chung E, Brock GB. Cryptorchidism and its impact on
male fertility: A state of art review of current literature. Can
Address correspondence to:
Urol Assoc J 2011;5:2010–2014.
11. Papparella A, Parmeggiani P, Cobellis G, et al. Laparo-
Dr. Mario A. Riquelme
scopic management of nonpalpable testes: A multicenter Department of Pediatric Surgery
study of the Italian society of video Surgery in Infancy. Christus Muguerza Hospital
J Pediatr Surg 2005;40:696–700. 15 de Mayo #1822 PTE Cons. 4 Col. Maria Luisa
12. Riquelme M, Aranda A, Rodriguez C, et al. Laparoscopic Monterrey, Nuevo Leon 64040
orchiopexy for palpable undescended testes: A five year ex- Mexico
perience. J Laparoendosc Adv Surg Tech A 2006;16:321–324. E-mail: cima_riquelme@hotmail.com
13. Russinko PJ, Siddiq FM, Tackett LD, Caldamone AA. Pre-
scrotal orchiopexy: An alternative surgical approach for the
palpable undescended testis. J Urol 2003;170:2436–2438.
14. Dayanc M, Kibar Y, Irkilata HC, et al. Long-term outcome Abbreviation Used
of scrotal incision orchiopexy for undescended testis. J Urol UDT ¼ undescended testes
2007;70:786–789.
END-2015-0118-ver9-Riquelme_1P.3d 07/02/15 10:20am Page 6

AUTHOR QUERY FOR END-2015-0118-VER9-RIQUELME_1P

AU1: Please insert/verify author degrees (MD, PhD, etc.).

AU2: This procedure. Not clear which procedure is being discussed. Please specify.
AU3: Please verify that the Disclosure Statement is correct.
AU4: All reference numbers have been changed, except 18, because they were not in numerical order in the text. Please
check that they are still correct.
AU5: Please provide a short Tweet (110 characters including spaces) about your article that we can release upon
publication (optional). Please email the Tweet to Paige Casey at Liebert’s Marketing Department at
PCasey@liebertpub.com Please include your manuscript ID number (END-2015-0118) in the subject heading
of your email when responding to Ms. Casey.
AU6: Please verify Reference.