SURGICAL-MANAGEMENT OF THE NONPALPABLE TESTIS - THE CHILDRENS-HOSPITAL-OF-PHILADELPHIA EXPERIENCE

Purpose: The management of the nonpalpable testis permits an individua lized operative approach. We analyze the results of surgical managemen t of a large series of patients with a nonpalpable testis. Materials a nd Methods: Between January 1986 and June 1994 we treated 1,866 boys w ith undescended testes. There were 447 testes (24%) that were not palp able at presentation. Intraoperative data on these patients were colle cted for age at presentation, bilateral testes position, testicular si ze, associated inguinal anomalies (vas, epididymis and processus vagin alis) and surgical approach. For intra-abdominal testes postoperative results of 2 surgical techniques, the Fowler-Stephens procedure and Ko op orchiopexy (retroperitoneal mobilization of spermatic vessels and v as) were compared in 76 patients with at least 18 months of followup. Results: Average patient age at presentation was 34 months with 63% pr esenting before age 48 months. Of the impalpable testes 58% were on th e left side, 35% were on the right side and 7% were bilateral. At oper ation 181 testes (41%) were atrophic or absent, 91 (20%) were intraabd ominal with 14 (3.1%) bilateral, 136 (30%) were in the inguinal canal and 39 (9%) were in other locations, including 22 at the pubic tubercl e, 2 in the upper scrotum, 13 in the superficial inguinal pouch and 2 in the perineum. Of the intra-abdominal group associated extratesticul ar malformations were identified in 36 cases (39%). Attachment of the vas deferens to the testis was abnormal in 23 of 64 cases (36%), inclu ding 10 that were completely detached and 13 with head or tail attachm ent only. Of the 91 evaluable cases in the intra-abdominal group 38 (4 2%) had been treated with the Fowler-Stephens repair (5 in 2 stages), 33 (36%) with inguinal orchiopexy and intraperitoneal dissection witho ut dividing the spermatic vessels, 5 with 2-stage procedures and vesse l preservation and 14 (15%) with orchiectomy. One testis was left in s itu. The inguinal approach with intraperitoneal extension was successf ul in defining the testis location or blind-ending vas and vessels in 100% of the cases. A single operation to perform orchiopexy was succes sful in 92% of the cases. Overall, results were considered excellent o r acceptable in 32 of 33 cases (97%) after Koop orchiopexy and 28 of 3 8 (74%) after the Fowler-Stephens orchiopexy. Conclusions: Nonpalpable testes accounted for 24% of the patients presenting with undescended testes. At surgical exploration 39% of impalpable testes were distal t o the external inguinal ring, 41% were atrophic or absent and 20% were intra-abdominal. All cases were treated through a standard inguinal i ncision. These data provide evidence that the inguinal approach to orc hiopexy with transperitoneal mobilization of the vas and vessels witho ut transection is highly successful for the intra-abdominal cryptorchi d testis and, to date, is the preferred technique for the management o f the intra-abdominal undescended testis.