Cryptorchidism or undescended testis is the absence of one or both testes from the scrotum. It is the most common birth defect of the male genitals [1]. About 3% of full-term and 30% of premature infant boys are born with at least one undescended testis. However, about 80% of cryptorchid testes descend by the first year of life (the majority within three months), making the true incidence of cryptorchidism around 1% overall.

A testis absent from the normal scrotal position may be:

1. Anywhere along the “path of descent” from high in the posterior (retroperitoneal) abdomen, just below the kidney, to the inguinal ring
2. In the inguinal canal
3. Ectopic, having “wandered” from the path of descent, usually outside the inguinal canal and sometimes even under the skin of the thigh, the perineum, the opposite scrotum, or the femoral canal
4. undeveloped (hypoplastic) or severely abnormal (dysgenetic);
5. missing (vanishing testis).

Undescended testes are associated with reduced fertility, increased risk of testicular germ cell tumors and psychological problems when the boy is grown. Undescended testes are also more susceptible to testicular torsion (and subsequent infarction) and inguinal hernias. Without intervention, an undescended testicle will usually descend during the first year of life, but to reduce these risks, undescended testes can be brought into the scrotum in infancy by a surgical procedure called an orchiopexy .

Undescended testis may be palpable or non palpable, depending on whether the testis is felt at the abnormal location. If palpable the management is straight forward. An open orchidopexy is done by a routine groin approach.

The management of impalpable testis remains controversial. Localization of the site of the impalpable testes helps the surgeon plan the operation most suited for each patient. Ultrasonography, computed tomography, testicular angiography and magnetic resonance imaging (MRI) have all been used with varying success for this purpose[2,3]. If the testis is not palpable, diagnostic laparoscopy is the most reliable way of diagnosing its presence or absence. It is in cases of non palpable testis where the role of laparoscopy is of paramount importance. In children with non-palpable testis the parents should be explained the various possibilities as per the position of the testis.

• Testis maybe present and close to the internal ring(<2cm) or peeping, which may be brought down in one sitting.

• Testis may be present but far away from the internal (>2cms) which maybe brought in 2 stages- Stephen Fowler’s stage I & II. In Stephen fowlers stage I- The testicular vessels are clipped and no further dissection is done around the testis.

• In Stephens Fowlers stage II,which is performed 6 months after stage I- The testis is mobilized alongwith the surrounding peritoneum and brought into the scrotum.

• The testis may be atrophic, in which case an orchidectomy may be done and the opposite side testis may or maynot be fixed depending on the surgeons preference.
• The testis may not be present with blind ending vas and vessels seen- ( Vanishing Testis)The opposite side testis may or maynot be fixed depending on the surgeons preference.
• The Vas and vessels maybe entering the ring upon which the groing maybe explored to see for a viable testis.

Laparoscopy for the impalpable undescended testis offers a simultaneous diagnostic and therapeutic tool. It obviates the need for invasive and/or expensive diagnostic imaging and saves the patient an extensive surgical procedure with equally good results. It is particularly valuable in bilateral cases. Laparoscopic orchidopexy as the treatment of choice for the impalpable undescended testis.

References:

1. Wood, HM; Elder, JS (February 2009). “Cryptorchidism and testicular cancer: separating fact from fiction.”.The Journal of Urology. 181 (2): 452–61
2.  Friedland GW, Chang P. The role of imaging in the management of the impalpable undescended testis. AJR. 1988;151:1107–1111.
3.  Hamidina A, Nold S, Amanwah KS. Localisation of non-palpable testes. Surg Gynecol Obstet. 1984;159:439.