The Nonpalpable Testis: A Narrative Review

Abstract

Purpose While the nonpalpable testis represents only a small portion of all cryptorchid testes, it remains a clinical challenge for pediatric urologists. Many controversies about the best evaluation and management exist. This narrative review serves as an update on what is known about the nonpalpable testis: etiology, pre-operative evaluation, the best surgical management, novel techniques, and ongoing controversies. Materials and Methods A Pubmed® and MEDLINE® search limited to January 2000 to January 2017 was performed using relevant key terms. Of 367 articles, a total of 115 manuscripts were considered for inclusion based on an a priori design. Utilizing a narrative review format, an update on the evaluation and management of the nonpalpable testis including novel concepts and techniques was synthesized. Results The nonpalpable testis should be evaluated by physical exam only. Imaging is not indicated for the routine case. The optimal surgical approach and technique remains debated, but several novel techniques have been described. Due to the rarity of the nonpalpable testis, randomized controlled trial and other quality comparisons are difficult. Therefore, several controversies in management remain. Conclusions The evaluation and management of the nonpalpable testis remains difficult and some aspects remain debated. Future research should focus on multi-institutional collaborative trials to determine the optimal operative management.

Surgical Management of Undescended Testis - Timetable and Outcome: A Debate

“…Then laparoscopy/surgery can be postponed some months to identify and, if present, remove testicular remnants/nubbins in order to avoid leaving those absolutely extremely rare remnants/nubbins with left viable germ cells and only casuistic described malignant potential in situ [Thorup et al, 2011a;Shepard and Kraft, 2017].…”

“…Other rarely performed alternative techniques, including among others staged orchidopexy with vessel preservation and auto-transplantation, may be used for selected cases. Especially, high bilateral intraabdominal cases with long distance between the testis and the internal inguinal annular ring and very sparse collateral blood supply in the gubernaculum and around the vas deferens are challenging [Shepard and Kraft, 2017]. Auto-augmentation may theoretically be the most viable option for such cases and was first described in 1976 by Silber and Kelly, and a laparoscopically assisted version was described in 2002 by Tackett et al This single-staged procedure has been shown to decrease the risk of testicular compromise by restoring blood flow immediately, as opposed to variations of Fowler Stephens orchidopexy [Kelly et al, 2010].…”

“…However, the overall success rate of surgical correction of intra-abdominal testes should not be expected to be higher than 80-85% [Taran and Elder, 2006;Elyas et al, 2010;Elder, 2016;Shepard and Kraft, 2017]. The success rate is highly dependent on whether the testis is located close or far from the internal inguinal annular ring and the collateral vascular supply.…”

A practical guide to cryptorchidism for the primary care physician

“…While the routine use of ultrasound (US) by primary care physicians to diagnose cryptorchidism is common, there is no compelling evidence to support its use [20,32]. In a survey by Tasian et al, 67% of respondents ordered imaging as part of pre-surgical evaluation and 96% used US [21].…”

“…The success rate of laparoscopic single stage orchiopexy is reported to range from 87-97% and the 2-stage Fowler-Stephens orchiopexy demonstrates a success rate of 63-96%. The greatest risks following laparoscopic orchiopexy include varying degrees of testicular atrophy and secondary testicular ascent [2,20].…”