Page 6 - CUA-PUC Canadian guideline for the diagnosis, management and followup of cryptorchidism

Braga et al.

Orchidopexy techniques (NPT) cases, confident palpation of an ipsilateral scrotal
nubbin and identification of contralateral compensatory
Surgical approach to the palpable testicle testicular hypertrophy may preclude diagnostic laparoscopy
by means of initially performing a scrotal incision, which
Inguinal orchidopexy allows for testicular nubbin removal and confirmation of
Palpable testicles are approached most commonly through the vanishing testicle diagnosis. Inguinal exploration and/
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an inguinal incision. High (proximal) ligation of the proces- or laparoscopy can then be reserved for cases in which the
sus vaginalis is an essential surgical step to allow placement initial scrotal approach is non-diagnostic.
of the testis in a sub-dartos pouch within the hemi-scrotum, The phenomenon of contralateral compensatory testicu-
without tension. Fixation sutures through the tunica albugin- lar hypertrophy has been well-described in the literature
ea can be used. The weighted success rate for primary ingui- and shown to correlate with the laparoscopic finding of
nal orchidopexy was 96.4% based on a systematic review. 26 an absent testicle (monorchism) in children with unilat-
eral NPT. 4-10,14 Boys with monorchism were found to have a
mean contralateral testicular length >2 cm or >1.8 cm. 6,10
5
Scrotal orchidopexy Based on these findings, it could be debated that boys with
The scrotal approach for management of cryptorchidism was NPT and contralateral compensatory hypertrophy should
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first described by Bianchi in 1989, and has since gained be initially approached by a scrotal incision to look for a
wide acceptance. 37-41 Evidence suggests that most palpable testicular nubbin, reserving diagnostic laparoscopy only for
testicles can be successfully managed through this inci- cases with a patent processus vaginalis or lack of compensa-
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sion. 37,38 According to a recent review that analyzed 1558 tory hypertrophy. It is critical to highlight the importance
scrotal orchidopexies, recurrence was observed in only of confidently identifying atrophic testicular tissue with
nine cases, testicular hypo/atrophy in five, and surgical site associated vas deferens and gonadal vessels if a scrotal or
infections in 13. A secondary inguinal incision was needed inguinal approach is chosen, as any doubt should trigger
in 3.5% of the boys to facilitate high (proximal) testicular further exploration. Presence of a looping vas or incorrectly
dissection. Overall, success rates ranged from 88‒100%. 42 identifying non-gonadal tissue as a nubbin may lead to
In comparison to standard inguinal orchidopexy, recent misdiagnosis, potentially leaving viable testicular tissue in
evidence from observational studies has suggested that the the abdomen. In uncertain cases or when tissue analysis
scrotal approach has equivalent success rates and compli- is not consistent with atrophic testicular tissue, laparo-
cations, with advantage of a significantly shorter operative scopic exploration should be strongly considered (Level 4
time. 38,39,43 At least two randomized, controlled trials com- evidence, Grade C recommendation).
paring the two techniques (inguinal vs. scrotal) have been If laparoscopy is unavailable, a lengthy inguinal incision
attempted and essentially confirmed those findings; 44,45 extending to the abdominal cavity is sometimes necessary to
however, in one of the studies the authors also report mean rule out the presence of an intra-abdominal testicle. When a
length of stay above two days for both procedures, which laparoscopic approach is chosen, up to three ports may be
questions the generalizability of the conclusions to our envi- needed: a 3 or 5 mm umbilical trocar for the camera and
ronment, where these procedures are almost universally two 3 mm ports for the working instruments. Single-port
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undertaken on an outpatient basis. Furthermore, none of laparoscopic management for the intra-abdominal testicle
these randomized, controlled trials prespecified the minimal has been described and constitutes an alternative option.
clinically important difference in operative time to justify Diagnostic laparoscopy is the most useful modality for
sample size calculation; therefore, their conclusions should assessing NPT, as it permits identification of three surgical
be interpreted with caution. scenarios that will lead to different courses of action:
Our recommendation is that for palpable UDT undergo- 1. Blind-ending vas and vessels indicate a vanishing
ing surgery, both the inguinal and the prescrotal techniques intra-abdominal testicle (IAT), and no further explo-
are acceptable based on the surgeon’s preference and expe- ration is necessary (10‒30% of cases).
rience (Level 2 evidence, Grade B recommendation). 2. Testicular vessels and vas entering the inguinal canal
through the internal inguinal ring. Inguinal explora-
Surgical approach for the non-palpable testicle tion may find a healthy palpable UDT amenable to
standard orchidopexy, or a testicular nubbin either in
If the testicle is not palpable preoperatively, as it may occur the inguinal region or, most commonly, in the scro-
in up to 20% of UDT cases, examination under anesthesia tum. Remnant cord structures are usually removed
(EUA) can sometimes allow identification of the testicle. to confirm the diagnosis and because viable residual
Otherwise, diagnostic laparoscopy is the procedure of testicular elements are present in up to 14% of the
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choice in most centres. In certain non-palpable testicle cases. It should be noted that to date, no cases of
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E256 CUAJ • July 2017 • Volume 11, Issue 7