Pediatric Cryptorchidism, Hydroceles, and Hernias

Pediatric Cryptorchidism, Hydroceles, and Hernias



Between 3% and 5% of full-term male infants are born with an undescended testicle, and a similar percentage will have an inguinal hernia or hydrocele (1). Cryptorchidism is often associated with a patent processus vaginalis, which predisposes to hydrocele and inguinal hernia formation. The treating urologist must therefore be familiar with the anatomy (Fig. 101.1) and operative techniques employed in treating these common pediatric conditions.


Cryptorchidism includes the strict definition of an absent or nonpalpable testicle as well as an undescended testis that is palpable in the inguinal canal but fails to reach the scrotum. Twenty percent of boys with cryptorchidism have a nonpalpable testis. Of nonpalpable testes, 20% are intra-abdominal,
40% are canalicular or ectopic, and 40% are atrophic or absent. True undescended testicles stop along their normal path of descent into the scrotum. The testis may be located in the abdominal cavity (least common), inguinal canal, or just caudal to the external ring (suprascrotal, most common). Testes may also pass through the external ring into an ectopic location, most commonly located in a superficial inguinal pouch. Up to 10% of cases are bilateral (2), and the incidence of cryptorchidism increases to 30% in premature infants. Low birth weight has also been associated with cryptorchidism, independent of gestational age (3). The majority of testicles descend within the first 6 months of life, and by 1 year of age, the prevalence is 0.8% to 1%.

FIGURE 101.1 Anatomy of inguinal orchiopexy. A: Relationship of the vas deferens, spermatic vessels, and processus vaginalis to investing fascial layers. The transversalis fascia is contiguous with internal spermatic fascia. B: With tension applied to the cord (arrow), the orientation of the fibers of the intermediate stratum investing the retroperitoneal spermatic cord is changed so that fibers become parallel to cord structures. Freeing the vas and vessels from this investing fascia is the most important step in achieving distal testicular displacement. (Reprinted with permission from Hutcheson JC, Cooper CS, Snyder HM III. The anatomical approach to inguinal orchiopexy. J Urol 2000;164:1702-1704. Copyright © 2000 American Urological Association, Inc. Published by Elsevier Inc. All rights reserved.)

Indications for Surgery

Surgical intervention for undescended testicle offers the possibility of improved fertility, correction of associated patent processus vaginalis, prevention of testicular torsion, and improvement in body image. Controversy remains over whether orchiopexy decreases the risk of malignancy, but placement of an undescended testis into the scrotum allows for testicular examination by health care providers as well as the patient (9,10).

At birth, the undescended testicle has been shown to have normal histology; however, delayed germ cell development has been documented in the older infant (11). Histology correlates with testicular position, with worse features associated with higher testes. Because histologic changes related to fertility occur in the undescended testis as early as 1 year of age and spontaneous descent rarely occurs after 6 months, optimal surgical timing is between 6 and 12 months of age. Early surgical intervention has been shown to improve testicular growth (12) and adult Leydig cell function (13). In postpubertal presentation of cryptorchidism, sperm are rarely noted and the testes are at significant risk for malignant change (14,15). Orchiectomy may be considered in this patient cohort if the contralateral testis is located in the scrotum.

Alternative Therapy

Hormonal therapy is an option in the treatment of cryptorchidism because its etiology may be related to an incomplete manifestation of hypogonadotropic hypogonadism. HCG is the only hormone approved for use in cryptorchidism in the United States. Three meta-analyses of randomized controlled studies have been published; all report an overall efficacy of approximately 20%, which on follow-up is decreased to about 15% due to secondary reascent of the testis (16,17,18). This is compared with up to a 95% success rate of primary orchiopexy, which remains the standard of care for the undescended testis.

Surgical Technique

Prior to surgical intervention, the patient should be re-examined under anesthesia. On occasion, a retractile testis descends under anesthesia or a previously nonpalpable testicle becomes palpable, altering the surgical approach. For a palpable testis, an open inguinal or scrotal approach orchiopexy is performed. Prior to the 1970s, surgical management of the nonpalpable testicle also consisted of inguinal exploration with extension of the dissection into the peritoneum if a testis, nubbin, or blind-ending vessels could not be identified. In 1976, Cortesi et al. (19) described using diagnostic laparoscopy for nonpalpable testis, revolutionizing the diagnosis and surgical management of the intra-abdominal undescended testicle.

Diagnostic Laparoscopy

Indications for diagnostic and therapeutic laparoscopy are identical to the goals of open orchiopexy: Determine if a testicle is present and viable, and if so, relocate it into the scrotum. Historically, laparotomy was performed to localize an intra-abdominal testis or diagnose blind-ending vessels if cord vessels were not observed on initial inguinal exploration. This was most often accomplished with a high inguinal (i.e., Jones incision) or Pfannenstiel incision. It is now common practice, especially as the child grows beyond infancy, to proceed with diagnostic laparoscopy when the testicle is nonpalpable.

During diagnostic laparoscopy for the nonpalpable testis, there are three scenarios that are commonly encountered. If blind-ending vessels and vas deferens are present proximal to the internal ring, a vanishing testis is diagnosed and no further action is required. Approximately 10% of boys with nonpalpable testis are found at the time of diagnostic laparoscopy to have blind-ending vessels, indicating the absence of testicular tissue (20). If the vessels and vas deferens are present and appear to enter the internal ring, then inguinal or scrotal exploration is warranted. The final scenario includes the presence of an intra-abdominal testis, which can be located in a variety of positions. For an intra-abdominal testicle the surgeon will need to assess which therapeutic modality is the most appropriate for treatment. If the testicle appears to be atrophic or grossly abnormal, then orchiectomy should be considered. If the testicle appears relatively normal, the ability to mobilize it to the scrotum is assessed, based on the distance of the testicle to the internal inguinal ring and redundancy of the spermatic vessels and vas. Deciding whether to perform a single-stage procedure leaving the vessels intact or to perform a one- or two-stage Fowler-Stephens procedure in which the spermatic vessels will be transected is challenging as no specific set of criteria have been determined. As part of the decision-making process, intraoperative measurement of the distance between the testis and the internal ring, observation of the cord anatomy, or assessment of the ability of the intra-abdominal testicle to reach the opposite inguinal ring after dissection may be helpful. Bilateral laparoscopic orchiopexies can be performed simultaneously or at separate procedures, depending on perceived risk of atrophy.

Diagnostic Laparoscopy Technique. Inhaled NO2 should be avoided in order to avoid bowel distention, and an oral gastric tube should be inserted to decompress the stomach and maximize visualization in the abdomen. The patient is secured to the bed in the supine position at the level of the chest and low thigh with his arms tucked and the legs placed in a slightly abducted position. Securing the child to the table allows for Trendelenburg positioning. Prep and drape the patient for possible conversion to an open procedure. In the sterile field, a Foley catheter is placed to avoid potential bladder injury with trocar placement. Figure 101.2 demonstrates the preferred setup and trocar placement for performing laparoscopic orchiopexy.

FIGURE 101.2 Preferred setup for a left single-stage laparoscopic orchiopexy. A 5-mm radial dilating trocar is placed at the umbilicus. Two 3-mm working ports are placed lateral to the rectus muscles just inferior to the umbilicus. Care is taken to avoid injury to the epigastric vessels. In the event a larger port is needed to accommodate a clip applier, a 5-mm trocar would be used on the contralateral side to ligate the testicular vessels. A 10-mm scrotal port is placed in the final stage of the case when the mobilized intra-abdominal testicle is delivered into the scrotum.

Access into the peritoneum may be achieved via an open Hasson fashion at the umbilicus. Alternatively, Veress needle access to establish pneumoperitoneumin has been shown to be safe and efficacious in children of all ages (21). A 5-mm hidden infraumbilical incision is made in the skin, and scissor dissection is performed at approximately 15- to 20-degree cephalad angle through the umbilical fascia into the underlying adherent peritoneum.

For the umbilical camera port, a 5-mm Step trocar will accommodate a 5-mm camera with a 0-degree lens. The child is placed in Trendelenburg position, and the abdomen is insufflated at 1 to 2 L per minute to a pressure of 10 to 12 cm H2O. General survey of the abdomen is undertaken, inspecting the peritoneal structures for injury that might have occurred during port placement. Next, attention is focused on the evaluation of the pelvis. If an instrument is needed to aid in the inspection, a 5-mm port is placed on the ipsilateral side of the nonpalpable testis, lateral to the rectus and just caudal to the level of the umbilicus. An atraumatic instrument may then be used to sweep the bowel cephalad. Placement of an additional trocar on the contralateral side (lateral to the rectus and just caudal to the umbilicus) is reserved for the need of an additional working port.

In the case of unilateral undescended testicle, the internal ring of the descended testicle is examined first to gain an appreciation of the anatomy. Possible findings on inspecting the affected side of the “nonpalpable” testicle may include blind-ending vessels, cord structures entering the internal ring, or an intra-abdominal testis. Note the status of the processus vaginalis; most undescended testicles are associated with a patent processus.

Blind-Ending Testicular Vessels

Blind-ending gonadal vessels indicate the absence of a testicle. This is the result of in utero testicular torsion that is either an intra-abdominal or intrascrotal event. Vessels will have a “horse tail” appearance; they diverge, do not exit the internal ring, and do not supply obvious testicular tissue (Fig. 101.3). If found during exploration, no further investigation is warranted and the procedure is terminated. It is important to note that the finding of a blind-ending vas deferens during laparoscopy is insufficient to conclude the absence of testicular tissue. Further cephalad inspection toward the aortic origin of the gonadal vessels is then necessary.

FIGURE 101.3 Finding blind-ending and divergent testicular vessels is evidence of a vanishing testicle.

Cord Structures Entering the Internal Ring

Cord structures may be visualized entering a closed internal ring or a patent processus vaginalis (Fig. 101.4). In the instance of a closed internal ring, a groin or scrotal exploration may be performed. If a patent processus vaginalis is present, the laparoscope may be used to inspect the inguinal canal via an antegrade approach. Alternatively, gentle manual retrograde pressure can be placed over the inguinal canal in an attempt to push groin contents (viable testicle versus nubbin)
intra-abdominally. In the instance of a nubbin or testicular remnant, laparoscopic orchiectomy is performed. This is accomplished by either clipping or dividing the cord contents or using a 5-mm instrument designed to seal and divide smaller vessels (i.e., LigaSure or harmonic scalpel). The specimen is grasped and removed from the contralateral 5-mm port. This incision can be widened as needed by spreading the fascia with any clamp while under direct vision from the camera port.

FIGURE 101.4 Laparoscopic view of the inguinal ring with normal cord structures exiting the internal ring.

Intra-abdominal Testis

There are three minimally invasive reconstructive options to address an intra-abdominal testicle: (a) primary laparoscopic orchiopexy, (b) one-stage laparoscopic Fowler-Stephens orchiopexy, and (c) two-stage laparoscopic Fowler-Stephens orchiopexy. Laparoscopic orchiectomy is reserved for an intraabdominal nonviable testis (atrophic nubbin) or a testis that cannot be brought into the scrotum based on an extreme ectopic location or limiting vas or vessel length.

The initial measured distance of the testicle from the internal ring will determine which laparoscopic approach should be utilized and is therefore a predictor of success. “Peeping testes” or those located in close proximity to the internal ring (<2 cm away) can usually be mobilized into the scrotum in a single stage without dividing the testicular vessels (Fig. 101.5). It is important to counsel parents that intra-abdominal ectopic testes and those located >2 cm from the internal ring are at increased risk for surgical failure.

Single-Stage Laparoscopic Orchiopexy

Following abdominal access, insufflation, and additional trocar placement, as outlined earlier, attention is focused on the ipsilateral testicle and internal ring. Fig. 101.6 demonstrates the surgical “map” needed to mobilize a triangular flap of peritoneum demarcated by the testicular vessels laterally and vas deferens medially. The preliminary goal is to create two continuous peritoneotomies parallel to the testicular vessels and vas in order to mobilize the testicle on a well-vascularized peritoneal pedicle.

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Apr 24, 2020 | Posted by in UROLOGY | Comments Off on Pediatric Cryptorchidism, Hydroceles, and Hernias

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