Preoperative assessment

A thorough history is the initial part of any patient encounter. The pertinent aspects for the patient with an undescended testicle are a birth history (full term or premature), birth weight, a family history of cryptorchidism, the patient’s own medical/surgical history and any genetic syndromes. Prior physical examination findings will be important information to know as well to gauge whether the condition is improving or not.

The physical examination is the most critical component of the diagnostic workup for the cryptorchid testicle. Ensuring that the patient is calm and cooperative, especially in the pediatric age group, allows for more confidence in the observed exam findings. The examiner’s hands and fingers must be in the proper position for an appropriate examination of the scrotum. Ideally, the index finger and/or middle finger of the examining hand are placed over the posterior aspect of the scrotum, with the thumb of that hand positioned over the anterior aspect of the scrotum.

If the testicle is not palpated in the scrotum, the inguinal canal should be examined for retained testicular tissue. For the right‐handed individual, with the index and middle finger of the examiner’s left hand positioned over the inguinal canal, the examiner should palpate the length of the canal while inferomedially sweeping in an attempt to trap the testicle along its projected line of normal descent and if possible express any retained testicular tissue into the scrotum. At the same time, the middle finger, index finger, and thumb of the right hand should be properly positioned to palpate the ipsilateral proximal scrotum for any testicular tissue entering from the inguinal canal. Reducing friction between the examiner’s fingers and the inguinal canal by placing soap on the fingertips can increase the likelihood and sensitivity of palpating an undecended inguinal testicle. If the examiner has difficulty palpating scrotal testes in the older child, the patient should be placed in a sitting knee–chest position to help force the testes into a dependent position or, while seated leaning forward, in crossed‐leg position (“tailor’s position”).

The decision regarding orchiopexy versus orchiectomy in a postpubertal male who presents with unilateral postpubertal cryptorchidism must be made on an individual basis and based upon the health of the contralateral testicle, competing medical comorbidities and fertility/paternity status of the man. The cryptorchid testicle should be saved if it is the only source of testosterone and/or sperm (i.e. if the contralateral testis is absent or abnormal). On the other hand, if the contralateral testis is normal, orchiectomy may be beneficial to avoid potential development of malignancy or torsion. A discussion with the patient about surgery while discussing risks and benefit of surgery is needed while accounting for risks of general anesthetic accounting for patient age and competing comorbidities when present. In certain instances when the crytorchid testicle is identified later in life the theoretical risks of an anesthetic complication may outweigh the risk of malignancy from the intra‐abdominal testicle, making observation a third viable option [13].

Laparoscopic surgical technique for the nonpalpable testicle

Following induction of anesthesia, repeat physical examination is performed to confirm a cryptorchid testicle and to determine whether it is palpable or nonpalpable. Surgical technique is modified accordingly to exam findings. Cisek et al. reported that a nonpalpable undescended testicle in clinic became palpable with exam under anesthesia in 40 patients of their 225 patient series [14]. A palpable undescended testicle will not benefit from laparoscopy and should receive an inguinal exploration. If the testicular examination demonstrates a nonpalpable testicle than proceeding with a diagnostic laparoscopy is indicated. Perioperative antibiotic prophylaxis is recommended and given prior to incision. Drainage of the bladder through urethral catheterization may help minimize bladder injury during the procedure. Although the use of laparoendoscopic single‐site (LESS) surgery for orchiopexy utilizing a single access point for the camera and trocars has been described [15, 16], the surgical technique described in this chapter is standard multiport laparoscopic orchiopexy.

Pneumoperitoneum can be established via Veress needle placed through rectus fascia at the umbilicus or open Hassan technique. Each technique has their own advantages and disadvantages, as described elsewhere (Chapter 84). Following creation of pneumoperitoneum, the placement of the initial trocar through the umbilicus for the laparoscope permits visual inspection of the pelvis and both internal inguinal rings. Putting the patient in Trendelenburg position will allow for intestine to be displaced cranially while inspecting the pelvis. During the intraoperative inspection of the pelvic anatomy the surgeon should be focused on identifying the testicular blood vessels as this will dictate the proper sequence of events. Inspection of the normal contralateral side for a unilateral undescended testicle will assist in acquiring normal orientation under the assumption there is no contralateral occult pathology.

Most commonly, three possible scenarios are encountered for the nonpalpable undescended testicle upon diagnostic laparoscopy. The first is vessels leading to an intra‐abdominal testicle that typically is found within a few centimeters of the internal ring (Figure 118.1a). The laparoscopic identification of an intra‐abdominal testicle permits planning for the definitive procedure and additional trocar placement if laparoscopic orchidopexy or orchiectomy is pursued. The second situation is gonadal vessels that end blindly in the retroperitoneum, indicating that there is no testicle present (Figure 118.1b). Third, the vessels may lead to and exit through the internal inguinal ring into the inguinal canal (Figure 118.1c). Inguinal exploration is carried out if testicular vessels and vas deferens are visualized exiting the internal ring. In one review, 27 patients with 30 nonpalpable testes underwent laparoscopy after previous negative inguinal exploration with the findings of one‐third of patients had blind‐ending spermatic vessels, one‐third had viable intra‐abdominal or inguinal testes, and one‐third had intra‐abdominal remnants [17].

Further mobilization of the intra‐abdominal testicle is accomplished with additional working trocars placed under direct vision with laparoscope. Three or five millimeter trocars can be placed, depending upon the size of the patient, surgeon preference, and whether introduction of a laparoscopic clip applier is anticipated. If the latter is expected then a 5 mm trocar is a better choice. The placement of the working trocars on the abdominal wall depends on whether a unilateral or bilateral procedure will be performed. Trocars placed in the midclavicular line at the level of the umbilicus on each side of the abdomen enable the surgeon to change sides when bilateral orchidopexy is indicated (Figure 118.2). Alternatively, simple incisions in the abdominal wall allow for passage of laparoscopic instruments without using ports [18]. This may lower operative costs, possibly improves cosmesis, and reduces the risk of port‐site hernias.

The tunica albuginea of the testicle can be grasped using an atraumatic grasper to provide traction and more accurately ascertain its proximity to the internal ring. Grasping other structures such as epididymis or vas risks their injury given their delicate nature and should be avoided. Intuitively, the difficulty in placing the intra‐abdominal testicle into the scrotum increases as the distance from the scrotum increases. The need to perform a Fowler–Stephens technique rises as the distance of the intra‐abdominal testicle from the internal ring increases and this will be discussed more in depth later in the chapter. However, it is critical for the surgeon to integrate the information obtained during the diagnostic laparoscopic portion, such as size of testicle, distance of testicle from internal ring, and spermatic cord anatomy, in order to determine if a one‐stage or two‐stage laparoscopic orchiopexy is best for the patient.

Laparoscopic orchiopexy technique (see Video 118.1)

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