| Abstract|| |
Introduction: It is estimated that 1%–2% of male infants have undescended testicles. The reliability of ultrasound (US) to identify the non-palpable undescended testicles (NPUDT) is controversial. Laparoscopy remains the gold standard to diagnose and manage NPUDT. Objective: The objective is to highlight the role of laparoscopy in the management of NPUDT in 2 cities from Sudan over the past decade. Materials and Methods: Patients presented to Gadarif Teaching Hospital and Almak Nimir University Hospital with NPUDT were assessed by clinical examination and US. The testis, when found during laparoscopy, was either brought down to the scrotum in a single or two-stage or removed depending on the findings. Data were collected and analysed. Results: Patients covered the age range between 18 months and 65 years. The average was 12.4. The majority, 94 (67.2%) patients were older than 5 years. The main presenting symptom was either bilateral or unilateral empty scrotum. In 12 (8.4%) patients, the main presenting symptom was primary infertility. US was done in 120 (86.6%) of the patients and failed to see the testis in more than half of them. A single-stage procedure in the form of laparoscopic search assisted with orchidopexy was achieved in 90 (62.9%) patients and orchiectomy in 13 (9.1%) patients, while in 12 (8.4%) patients the testis was not found. Other procedures were applied on the 28 (19.6%) patients who needed staged operation in the form of Fowler Stephen's, in bilateral cases, in 6 (4.2%) patients. Shehata's operation in nine patients (64%) and open orchidopexy for 8 (5.6%) patients. The post-operative complication was encountered in 14 (9.8%) of the patients in this group in the form of bleeding, vassal injury and testicular atrophy. Conclusion: Laparoscopy provides the most accurate interventional option for managing patients with NPUDT. Laparoscopic orchidopexy, whether single stage for low or 2-stages for high intra-abdominal testis, is a proven and effective extension of lap-search with minimal complications.
Keywords: Cryptorchidism, Gadarif, laparoscopy, non-palpable undescended testicle, Shandi, Sudan
|How to cite this article:|
Elgaili Salah SE, Elssayed Ahmed EO. The role of laparoscopy in non-palpable undescended testicle: Analysis and review of the experience from two cities in Sudan. Afr J Paediatr Surg 2022;19:127-32
|How to cite this URL:|
Elgaili Salah SE, Elssayed Ahmed EO. The role of laparoscopy in non-palpable undescended testicle: Analysis and review of the experience from two cities in Sudan. Afr J Paediatr Surg [serial online] 2022 [cited 2022 Jun 30];19:127-32. Available from: https://www.afrjpaedsurg.org/text.asp?2022/19/3/127/348028
| Introduction|| |
Cryptorchidism is a unilateral or bilateral failure of the testis to reach processus vaginalis or the scrotum by 10–12 weeks after term. It is considered to be one of the most common isolated congenital anomalies, and affects up to 30% of premature infants, and about 3% of full-term males., The abnormality may be unilateral or may affect both sides. Non-palpable undescended testicles (NPUDT) on clinical examination represent approximately 20% of all undescended testicles (UDT), intra-abdominal, inguinal and ectopic or absent all were the differential diagnoses of non-palpable testes. Twenty to forty per cent of non-palpable testes are absent upon surgical exploration atrophic or absent, mostly may be due to in utero spermatic cord torsion and are located abdominally, inguinal or scrotal.,
Multiple risks factors contribute to the causes behind the UDT, with premature infants at the top. Additional factors include low birth weight for gestational age, and family history which has been associated with genetic mutation likely incriminated., Infertility, testicular trauma, torsion and cancers are the main major and serious complications of cryptorchidism.,, Several studies showed that as long as the testes remain undescended, fertility parameters decrease. On the other hand, the risk of change to malignancy can be greatly reduced by performing orchiopexy before puberty to preserve germ cell loss or reverse and decrease the risk of cancer development. The optimum recommended time for surgery is to between 6 months and 1 year of age.,
The use of ultrasound (US) for non-palpable testis is debatable because of its low sensitivity and specificity of approximately 45% and 78%, respectively,,, and the US does not exclude the necessity for laparoscopy.,, US used to localise the testis is of little value. On the other hand, US for non-palpable testis may be justified by cheap non-radiation procedure as well as in few cases may preclude need for laparoscopy if intracanalicular testis.
Surgery for UDTs generally to achieve three goals, either to bring viable testis down to the scrotum or removal of non-viable testis or finally to confirm the absence of testis. Laparoscopy is the gold standard preferred clear diagnostic and definitive therapeutic procedure.,
| Materials and Methods|| |
This is a hospital-based, prospective and observational analytic study including all patients who presented with NPUDT in the study areas during 2010–2020. All the patients underwent laparoscopic search for NPUDT then proceeded to different types of operations following the findings.
This study was conducted in 2 major Sudanese cities outside the capital Khartoum. Started in January 2010 in Gadarif, Eastern Sudan, joined by Shandi, Northern Sudan, in 2015 through to December 2020.
Gadarif is 410 km to the east from Khartoum, the capital of Sudan. It is located near the border with Ethiopia. Gadarif Teaching Hospital is a 170-bed tertiary care facility that serves as a referral centre in Gadarif State. Laparoscopic surgery was introduced in 2006, and the 1st laparoscopic search for NPUDT was performed in January of 2010.
Shandi is one of the major cities in Nahr-Elneel State, Northern Sudan, situated on the east bank of the River Nile 150 km north of Khartoum, inhabited by around 0.7 million residents, mainly farmers. Almak-Nimir is a University Hospital with a total of 300 beds. Laparoscopic surgery was introduced in 2016, while the 1st laparoscopic search for NPUDT was done in January 2017.
The data were collected in a master sheet including patients' demographics, clinical presentation, symptoms, signs, pre-operative ultrasonography, operative findings and post-operative complications.
All patients who underwent laparoscopic procedure for NPUDT.
No patients who presented with an NPUDT were excluded from this study.
The data were analysed using the Statistical Package for the Social Sciences software (SPSS, SPSS Inc, IBM Corp, Armonk, NY), version 22.0. Frequency tables and percentages were generated for all the major parameters.
The study received ethical approval from the Research Board at the Faculty of Medicine, University of Gadarif, Sudan and Shandi University Ethical Committee. Informed patient consent was obtained. Patient data were reserved confidential and used only for research purposes.
| Results|| |
In this study, 143 included patients with UDTs who underwent 169 procedures. The age range was between 1½ and 65 years with an average of 12.25 years and a standard deviation of 11.86 years. The largest group was those under 5 years old in 49 patients accounting for (34.3%), and the smallest group size was 1 (0.7%) patient which was found in the age ranges of 41–45 and 56–60. Two (1.5%) patients were found in the age range 36–40 and the age group above 60 years old. There were no patients in the 46–55 years age group [Figure 1].
While the majority, 125 (87.4%), of patients presented complaining of either right, left or bilateral empty hemi-scrotum, there were 12 patients (8.4%) who were discovered to have empty scrotum during workup for infertility. At the time of presentation, the NPUDT was more common on the left side, 60 patients (42%), followed by bilateral in 42 (29.4%) patients and on the right in 41 (28.7%) of the patients [Figure 2].
US was done on 120 (83.9%) of our patients. UDT was detected intra-abdominally in 45 (31.5%) patients, one seen and the other not-seen in 10 (7%), and both testicles were seen intra-abdominally in 1 (0.7%). It was unable to visualise the UDT in 64 (44.8%) patients [Table 1].
|Table 1: The ultrasound reporting of 120 out of 143 patients with nonpalpable undescended testicle|
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A single-stage lap-assisted procedure was performed on 115 (80.4%) patients while 28 (19.6%) patients required a second-stage operation. The single-stage procedures were successful in mobilising a low intra-abdominal testis and fix it down into the scrotum for 90 (62.9%) patients, of whom 2 (1.4%) patients were found to have Crossed testicular ectopia (CTE) and underwent laparoscopic mobilisation and then trans-septal orchidopexy.
In 12 (8.4%) of the patients, the UDT was not found during the lapsearch procedure. Seven (7%) of them were labelled as testicular agenesis as there was no detected evidence of gonadal vessels, while the other 5 (3.4%) were labelled as vanishing testis as the vas deference and gonadal vessels were ending blindly at the internal ring.
Unilateral orchidectomy was performed on 13 (9.1%) of the patients. Three (2.1%) of them had bilateral UDT underwent an orchidopexy in on side and orchiectomy on the other side. Ten (7%) patients, who are all above 35 years of age, with an intra-abdominal unilateral UDT which is atrophied, had orchiectomy straightaway.
A 2nd stages lap-assisted procedure was required for 28 (19.6%) of the patients as the testis was high intra-abdominal and could not be brought down to the scrotum in a single stage. They, whether unilateral or bilateral, were dealt with according to the intraoperative findings, degree of mobility and length of the gonadal vessels.
Fowler Stephan's Operation (FSO) was performed for 11 (7.7%) patients, where gonadal ligation or clipping and division in the 1st stage. Three months later, the testis can be brought down to the scrotum depending on the artery to the vas for the blood supply. Shehata's operation, describes as gradual controlled traction (GTC), by fixing the testis with a non-absorbable suture to the contralateral anterior abdominal wall in the 1st stage and a lap-assisted orchidopexy was achieved in the 2nd stage was performed on 9 (6.3%) of the patients. In the remaining 8 (5.6%) patients, the testis was mobilised and fixed in the superficial inguinal pouch then underwent open orchidopexy after 8–12 weeks.
The total of bilateral cases performed in 2 stages, was 6 (4.2%) patients. FSO was done bilaterally in 2 (1.4%) patients, FSO in 1 side and lap-assisted orchidopexy on the other 3 (2.1%) and in 1 (0.7%) patient we did an FSO on 1 side combined with GTC on the other side [Table 2].
Follow-up of all patients ranged from 2 to 20 weeks, with an average of 11 weeks. Less than 50% of them showed up after 3 months. Post-operative complications were reported in 14 (9.8%) patients in form of: Significant bleeding and cut vas in single (0.7%) patient for each and testicular atrophy in 12 (8.4%) patients [Figure 3].
| Discussion|| |
There is increased evidence in recent literature that orchidopexy before the age of 1 year significantly improved the growth and function of UDT., Progressive negative histological impact on Leydig cells, and development of germ cells, increases the risk of malignant transformation as long as the testis remains undescended after the age of 12 months. While the optimal timing of orchiopexy has been recommended to be between 6 months and 1 year old,,, Huston in 2013 advised early correction as early as 3–9 months of age, as germ cell loss commences at 3–6 months in UDT.
During the study, we encountered patients ranging from 18 months to 65 years of presentation, with and average age of 12.4 years and a median of 8 years. Ismail et al., in their series of 64 patients, the median age was 4.6 years. In another study from Saudi Arabia, the median age of presentation was 13.7 months, and the median age at the time of orchiopexy was 25 months. In our study, the situation is completely different, the majority of our patients, 96 (67.6%), presented after 5 years of age. Even more, for those who presented before 5 years and the youngest child was 18 months old [Figure 1]. Different factors attributed to the late presentation of UDT. Strong social believe that congenital anomalies are normal and are “God's will” that should not be corrected. This may explain why 12 patients (8.4%) presented for the first time with failure to conceive in adulthood after 2 years of marriage and regular sexual activity. Mohamed and Randa in 2008 concluded that empty scrotum in adults is more prevalent than expected in their 104 patients studied in Khartoum. Another factor is that, for quite a long period of time, the optimum time for orchiopexy was under debate, and numerous studied showed that the average age for orchiopexy at time of surgery is still above the recommended age., It has been reported that lack of awareness among population and lack of understanding of the guidelines to perform routine urological examination among health care provider are the mains a big reason for the delay., Our study was conducted in 2 of the Eastern and Northern main cities of Sudan where there still is shortage of paediatric surgeons and urologists. This makes such services limited to the capital, Khartoum. Despite this, the practice of laparoscopy by general surgeons avail introducing it as a diagnostic and, later on, therapeutic tool in the management of NPUDT. Lots of work and health education among health-care providers, especially midwives and outstation general practitioners in primary health centres, is needed to raise the awareness of early post-natal referral to, at least, a surgeon. Bradshaw et al., in their retrospective study done in the UK concluded that early orchidopexy is not yet achieved due to late referral from primary care centres. They also recommend earlier primary care referral directly from the routine post-natal check to a centre prepared and equipped to perform surgeries for this age group.
We found that 29.4% were bilateral NPUDT, this is consistent with the literature which reports it in 20%–30% of patients with cryptorchidism.,, Bilateral impalpable testes may be associated with other anomalies, such as prune belly syndrome, a posterior urethral valve, abdominal wall defects, or neural tube defects. In this study, there is one case of Prune Belly Syndrome, one case of down syndrome, and another case of hypospadias; disorder of sex development associated bilateral UDTs.
The only radiological examination done in this series was US; it was actually omitted in some of our patients. The high cost, non-availability and the requirement of general anaethesia or sedation for children were the main reasons we did not perform a single computed tomography scan or magnetic resonance imaging on our patients, and instead proceeded directly to diagnostic/therapeutic laparoscopy. Moreover, there is no consensus regarding the efficacy of US imaging for patients with non-palpable testes, as the majority of the studies conclude that US is of little value for various reasons.,,,, Few studies recommend US as a diagnostic image for non-palpable testes. In two-thirds of our patients who had a pre-operative US examination, the testes were not visualised, and it was reported as intra-abdominal in the other third [Table 1]. This finding is consistent with the studies which did not recommend US as a diagnostic procedure.,,,,,
Diagnostic laparoscopy is most often used for non-palpable testes, as it not only allows for the identification of an atrophic or absent testicle but it also provides an opportunity to perform an orchiopexy simultaneously should a viable testis be found. For non-palpable testes, laparoscopy is the gold standard preferred clear diagnostic and definitive therapeutic procedure agreed upon worldwide, but the variations were in the way to bring the intra-abdominal testis to scrotum. Length of the testicular vessels, how far the testis from the scrotum and size and texture of the testis (atrophic or not) were the main factors in determining the operations.
Single-stage operation achieved the goal of surgical operation in almost 80% of our patients. In two-thirds of them, the testis was a low intra-abdominal “peeping testis” where a lap-assisted orchiopexy was performed. In this group, we encountered 2 cases of cross testicular ectopia (CTE) for whom we chose to perform a trans-septal orchidopexy. Orchidectomy was carried out in 8 patients in our series (5.8%) due to small atrophic testes. Two of them were having unilateral small atrophic testes who were between 10 and 15 years, while 6 were above 20 years. This is consistent with the literature which recommends orchidectomy for atrophic unilateral UDT., During laparoscopic search, we failed to identify a UDT in 11 (8%) of our patients, we labelled those with the blind-ending vessels and vas as complete atrophy “Vanishing” in five patients and when no vessels or vas were found as testicular agenesis in 6 patients. This was <15% which is reported in the literature.,
Two-stage operations were performed on 28 patients (19.6%) where a 1st stage was done in different forms. Unilateral high intra-abdominal UDT was the majority. In the beginning of our series, we used to do judicious proximal mobilisation and fix the testis with a prolene 2-0 suture, tension free, in the superficial inguinal pouch when the inner inguinal ring is open, and then 3 months later, an open orchidopexy is performed. This was carried out in eight patients in which we observed 2 have developed testicular atrophy in the 2nd stage. We start doing laparoscopic GCT described by Shehata in 2008 in his preliminary report and demonstrated during The International Conference of Sudanese Association of Pediatric Surgeons in 2012. The laparoscopic assisted GCT was done in nine patients. On the other hand, five patients of the unilateral UDT group underwent 1st stage laparoscopic FSO. There were six patients who presented with bilateral NPUDT in whom laparoscopic FSO was performed. Bilaterally in 2 cases, in 1 side with orchidopexy to other side in 3 cases and in a single patient, we did FSO on side and Shehata's Technique on the other side followed by 2nd stage 3–6 months later. Ghada and Ahmed suggested further studies comparing these known techniques in the laparoscopic management of relatively high UDT.
Elyas et al., in their 2010 Systematic-Review, favoured 2 stages FSO as it appears to carry a higher rate of success than the single-stage approach. This was again augmented in 2018 by Chengjun et al. Meta-analysis, where they found that 2 stages FSO was better than 1 stage, and the 2 stage laparoscopic FSO is the first choice for treating high intra-abdominal cryptorchidism.
We encountered a low rate of post-operative testicular atrophy of 8.4% compared to the literature we reviewed. This can be understood if we consider the big number of more than 50% of patients who quit follow-up after the 1st post-operative visit due to financial, cultural and psychosocial limitations in our country which is more marked in cities outside the capital.
- This study is a facility based, some patients are missed
- Short duration and quitting post-operative follow-up to evaluate testicular atrophy, semen analysis and other complications.
| Conclusion|| |
Laparoscopy provides the most accurate diagnostic and interventional option for managing patients with NPUDT. Laparoscopic orchidopexy, whether single stage for low or 2-stages for high intra-abdominal testis, is a proven logical and effective extension of lapsearch with minimal complications.
Early referral and laparoscopy will improve the outcome in remote areas and a longer period of post-operative follow-up.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hutson JM. Cryptorchidism and hypospadias. In: Feingold KR, Anawalt B, Boyce A, et al
., editors. Endotext. South Dartmouth (MA): MDText.com, Inc.; 2000. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279106/
. [Last updated on 2018 Jul 10].
Cryptorchidism: A prospective study of 7500 consecutive male births, 1984-8. John Radcliffe Hospital Cryptorchidism Study Group. Arch Dis Child 1992;67:892-9.
Acerini CL, Miles HL, Dunger DB, Ong KK, Hughes IA. The descriptive epidemiology of congenital and acquired cryptorchidism in a UK infant cohort. Arch Dis Child 2009;94:868-72.
Sijstermans K, Hack WW, Meijer RW, van der Voort-Doedens LM. The frequency of undescended testis from birth to adulthood: A review. Int J Androl 2008;31:1-11.
Kirsch AJ, Escala J, Duckett JW, Smith GH, Zderic SA, Canning DA, et al
. Surgical management of the nonpalpable testis: The Children's Hospital of Philadelphia experience. J Urol 1998;159:1340-3.
Elder JS. Ultrasonography is unnecessary in evaluating boys with a nonpalpable testis. Pediatrics 2002;110:748-51.
Moore RG, Kavoussi LR, Bloom DA, Bogaert GA, Jordon GH, Kogan BA, et al
. Postoperative adhesion formation after urological laparoscopy in the pediatric population. J Urol 1995;153:792-5.
Scorer CG. The descent of the testis. Arch Dis Child 1964;39:605-9.
Jensen MS, Toft G, Thulstrup AM, Henriksen TB, Olsen J, Christensen K, et al
. Cryptorchidism concordance in monozygotic and dizygotic twin brothers, full brothers, and half-brothers. Fertil Steril 2010;93:124-9.
Lee PA, O'Leary LA, Songer NJ, Coughlin MT, Bellinger MF, LaPorte RE. Paternity after bilateral cryptorchidism. A controlled study. Arch Pediatr Adolesc Med 1997;151:260-3.
Tasian GE, Hittelman AB, Kim GE, DiSandro MJ, Baskin LS. Age at orchiopexy and testis palpability predict germ and Leydig cell loss: Clinical predictors of adverse histological features of cryptorchidism. J Urol 2009;182:704-9.
Pettersson A, Richiardi L, Nordenskjold A, Kaijser M, Akre O. Age at surgery for undescended testis and risk of testicular cancer. N Engl J Med 2007;356:1835-41.
Kogan SJ, Tennenbaum S, Gill B, Reda E, Levitt SB. Efficacy of orchiopexy by patient age 1 year for cryptorchidism. J Urol 1990;144:508-9.
Park KH, Lee JH, Han JJ, Lee SD, Song SY. Histological evidences suggest recommending orchiopexy within the first year of life for children with unilateral inguinal cryptorchid testis. Int J Urol 2007;14:616-21.
Elder JS. Laparoscopy for impalpable testes: Significance of the patent processus vaginalis. J Urol 1994;152:776-8.
Diamond DA, Caldamone AA. The value of laparoscopy for 106 impalpable testes relative to clinical presentation. J Urol 1992;148:632-4.
Moore RG, Peters CA, Bauer SB, Mandell J, Retik AB. Laparoscopic evaluation of the nonpalpable tests: A prospective assessment of accuracy. J Urol 1994;151:728-31.
Vikraman J, Donath S, Hutson Ao JM. Undescended testes: Diagnosis and timely treatment in Australia (1995-2014). Aust Fam Physician 2017;46:152-8.
Teague WJ, King SK. Paediatric surgery for the busy GP – Getting the referral right. Aust Fam Physician 2015;44:890-4.
Kolon TF, Herndon CD, Baker LA, Baskin LS, Baxter CG, Cheng EY, et al
. Evaluation and treatment of cryptorchidism: AUA guideline. J Urol 2014;192:337-45.
Jamalalail YA, Guerra LA, Leonard MP. Selective use of laparoscopy in nonpalpable undescended testes. Urol Ann 2016;8:81-3.
] [Full text]
McEachern R, Houle AM, Garel L, Van Vliet G. Lost and found testes: The importance of the hCG stimulation test and other testicular markers to confirm a surgical declaration of anorchia. Horm Res 2004;62:124-8.
Gapany C, Frey P, Cachat F, Gudinchet F, Jichlinski P, Meyrat BJ, et al
. Management of cryptorchidism in children: Guidelines. Swiss Med Wkly 2008;138:492-8.
Kumar R, Mandal KC, Halder P, Hadiuzzaman M, Mukhopadhyay M, Mukhopadhyay B. Laparoscopy in the evaluation of impalpable testes and its short-term outcomes: A 7 years' experience. J Indian Assoc Pediatr Surg 2017;22:232-6.
] [Full text]
Ritzén EM, Bergh A, Bjerknes R, Christiansen P, Cortes D, Haugen SE, et al
. Nordic consensus on treatment of undescended testes. Acta Paediatr 2007;96:638-43.
Virtanen HE, Cortes D, Rajpert-De Meyts E, Ritzén EM, Nordenskjöld A, Skakkebaek NE, et al
. Development and descent of the testis in relation to cryptorchidism. Acta Paediatr 2007;96:622-7.
Ashley RA, Barthold JS, Kolon TF. Cryptorchidism: Pathogenesis, diagnosis, treatment and prognosis. Urol Clin North Am 2010;37:183-93.
Niedzielski JK, Oszukowska E, Słowikowska-Hilczer J. Undescended testis – Current trends and guidelines: A review of the literature. Arch Med Sci 2016;12:667-77.
Hutson JM. Journal of Pediatric Surgery-Sponsored Fred McLoed Lecture. Undescended testis: The underlying mechanisms and the effects on germ cells that cause infertility and cancer. J Pediatr Surg 2013;48:903-8.
Ismail KA, Ashour MH, El-Afifi MA, Hashish AA, El-Dosouky NE, Negm M, et al
. Laparoscopy in the management of impalpable testis (Series of 64 Cases). Afr J Paediatr Surg 2017;14:65-9.
] [Full text]
Alsowayan OS, Basalelah JH, Alzahrani AM, Alshaibani AM, Alalyani NS, Alsubiani TA, et al
. Age at presentation of undescended testicles: A single-center study in Saudi Arabia. Ann Saudi Med 2018;38:137-9.
Musa MT, Rahman RZ. Empty scrotum in adults. Khartoum Med J 2008;1:69-71.
Berkowitz GS, Lapinski RH, Dolgin SE, Gazella JG, Bodian CA, Holzman IR. Prevalence and natural history of cryptorchidism. Pediatrics 1993;92:44-9.
Nah SA, Yeo CS, How GY, Allen JC Jr, Lakshmi NK, Yap TL, et al
. Undescended testis: 513 patients' characteristics, age at orchidopexy and patterns of referral. Arch Dis Child 2014;99:401-6. doi: 10.1136/archdischild-2013-305225. Epub 2013 Nov 13. PMID: 24225274.
Boehme P, Geis B, Doerner J, Wirth S, Hensel KO. Shortcomings in the management of undescended testis: Guideline intention vs. reality and the underlying causes -insights from the biggest German cohort. BJU Int 2018;122:644-53.
Yi W, Sheng-de W, Lian-Ju S, Tao L, Da-Wei H, Guang-Hui W. Management of undescended testis may be improved with educational updates and new transferring model. Ital J Pediatr 2018;44:58.
Bradshaw CJ, Corbet-Burcher G, Hitchcock R. Age at orchidopexy in the UK: Has new evidence changed practice? J Pediatr Urol 2014;10:758-62.
Hutson JM, Balic A, Nation T, Southwell B. Cryptorchidism. Semin Pediatr Surg 2010;19:215-24.
Shin J, Jeon GW. Comparison of diagnostic and treatment guidelines for undescended testis. Clin Exp Pediatr 2020;63:415-21.
Salah SE, Elhaj KI, Awadelseed YO, Mohammed SG. Crossed testicular ectopia: A case report and review of the literature. Ann Pediatr Surg 2016;12:170-2.
Kucheria R, Sahai A, Sami TA, Challacombe B, Godbole H, Khan MS, et al
. Laparoscopic management of cryptorchidism in adults. Eur Urol 2005;48:453-7.
Sousa A, Gayoso R, Lopez-Bellido D, Reboredo J, Perez-Valcarcel J, Fuentes M. Laparoscopic assessment and orchidectomy for the adult undescended testis. Surg Laparosc Endosc Percutan Tech 2000;10:420-2.
Barthold JS. Abnormalities of the testes and scrotum and their surgical management. In: Wein AJ, editor. Campbell-Walsh Urology. 10th ed., Ch. 132. Philadelphia, Pa: Saunders Elsevier; 2011. p. 3357-596.
Morshed G, Fares A. Laparoscopic gradual traction of the testicular vessels in case of impalpable undescended testes. Int Educ Res J 2016;2:52-7.
Shehata SM. Laparoscopically assisted gradual controlled traction on the testicular vessels: A new concept in the management of abdominal testis. A preliminary report. Eur J Pediatr Surg 2008;18:402-6.
Fowler R, Stephens FD. The role of testicular vascular anatomy in the salvage of high undescended testes. Aust N Z J Surg 1959;29:92-106.
Elyas R, Guerra LA, Pike J, DeCarli C, Betolli M, Bass J, et al
. Is staging beneficial for Fowler-Stephens orchiopexy? A systematic review. J Urol 2010;183:2012-8.
Yu C, Long C, Wei Y, Tang X, Liu B, Shen L, et al
. Evaluation of Fowler-Stephens orchiopexy for high-level intra-abdominal cryptorchidism: A systematic review and meta-analysis. Int J Surg 2018;60:74-87.
Dr. Sami Eldirdiri Elgaili Salah
University of Gadarif, P. O. Box 449, Al Qadarif
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]