BENEFITS AND AFTERTHOUGHTS OF LAPAROSCOPY FOR THE NONPALPABLE TESTIS

Purpose: Recent reports in the literature indicate that laparoscopy te nds to be seen as the most appropriate approach to the nonpalpable tes tis for diagnosis and therapy. The aim of our study was to evaluate th e real benefits of laparoscopy in terms of diagnostic accuracy, safety , costs and validity of the chosen treatment. Materials and Methods: W e compared anatomical findings and results of the treatment of impalpa ble testes in 2 pediatric surgical groups, including 47 children treat ed laparoscopically during a 2 1/2-year period and 296 treated with op en surgery (classic orchiopexy) in a 6 1/2-year period. Results: There was no significant difference in the diagnosis of abdominal testes (5 1 versus 50%), whereas a difference was noted in inguinal (4 versus 15 %) and absent testes (45 versus 35%). Differences in treatment were mo re striking. In the laparoscopic group standard orchiopexy was perform ed in 62.5% of cases versus 83% in the open group. Conversely the rate of Fowler-Stephens repairs increased from 5.5% of open surgery cases to 37.5% of laparoscopic cases. There have been no serious complicatio ns in the laparoscopic procedures. To date 6 of the 9 patients who und erwent a staged Fowler-Stephens procedure have undergone complete repa ir (open second stage). A review of the literature revealed a similar but lower tendency to over perform the Fowler-Stephens operation in la paroscopic cases (34%) versus open surgery (8%). Also, in previous ser ies there was a 29% orchiectomy rate during laparoscopy compared to on ly 5% in classic open surgery. In Italy under current public health pr ograms overall costs of the laparoscopic approach to the nonpalpable t estis become noncompetitive when the procedure is extended from only d iagnostic to interventional use due to the need for additional trocars and other special instruments. In contrast, private health insurers p rovide an additional 30% for laparoscopic cases over the cost of open orchiopexy. Conclusions: Laparoscopy is definitively accurate in estab lishing the differential diagnosis of impalpable testis. The number of Fowler-Stephens repairs in the laparoscopic group seems inordinately high, probably due to a lack of definite standards in the proper asses sment of the length of the internal spermatic vessel pedicle and the p otential scrotal displacement of the testis. This reason may explain t he higher number of orchiectomies reported in the literature.