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Reliance of preoperative scrotal examination versus final operative findings in the evaluation of nonpalpable testes
Shirley Y. Godiwalla, M.D., Blake W. Palmer, M.D., Elizabeth Malm-Buatsi, M.D., Bradley P. Kropp, M.D., Dominic Frimberger, M.D..
University of Oklahoma Health Science Center, Oklahoma City, OK, USA.

Introduction: In undescended testes, palpation of the scrotal nubbin is difficult. Some groups rely on their scrotal exam only and remove the nubbin, while other groups perform laparoscopy to confirm the scrotal exam and ensure the absence of an intra-abdominal testis. This study evaluates whether preoperative scrotal examination alone is sufficient or if laparoscopy is necessary to confirm the examination in children with nonpalpable testes.
Method: This retrospective study was performed from October 2009 to May 2013. Children with nonpalpable testes underwent a scrotal examination under anesthesia, both by the surgeon and the senior resident, to feel for a testis or nubbin, followed by diagnostic laparoscopy to validate the scrotal exam and presence of an intra-abdominal testis. During laparoscopy if the spermatic vessels and a vas deferens were seen entering the inguinal ring, scrotal exploration with removal of nubbin and histopathology was reviewed. In case of blind ending vessels no further action was taken. In case of an intra-abdominal testis orchiopexy was performed. Correct findings are: (a) absent scrotal nubbin and laparoscopic finding of blind ending vessels or the presence of an intra-abdominal testis, (b) scrotal nubbin present and absent intra-abdominal testes with vas and vessels entering the inguinal canal. Incorrect findings include: (a) scrotal nubbin and an intra-abdominal testis is present, (b) no scrotal nubbin felt and with laparoscopy, vas and vessels are seen entering the inguinal ring and a nubbin or testis is present in the canal or scrotum.
Results: 71 patients in all, with three having bilateral nonpalpable testes, were enrolled in the study. A total of 74 testes were evaluated. Laparoscopy confirmed the scrotal examination of the surgeon in 60/74 (81%) and the senior resident in 52/74 (70%) cases. In the 14 failed examinations, the surgeon determined a negative exam with an empty scrotum in eight patients, and laparoscopy revealed vas and vessels entering the inguinal canal and scrotal exploration confirmed a nubbin present in all eight cases. In the remaining six patients the surgeon felt a nubbin in the scrotum, but viable intra-abdominal testes were found in three cases and in the other three cases vas and vessels were found entering the canal with findings of one hypoplastic and two viable testes in the inguinal canal. In all 33/74(45%) of the nonpalpable testes were viable and the rest 41/74(55%) were nonviable.
Conclusion: Despite examination under anesthesia by experienced surgeons, the scrotal exam was incorrect in 14 patients. Findings: Six viable testes would have been missed without laparoscopy, (three intra-abdominal and three in the inguinal canal) despite a nubbin being present on scrotal exam. Scrotal exploration for testicular nubbins often finds a small specimen without definite identifiable structures attached. This could be an extension of tunica vaginalis and not atrophic testis, explaining why viable testes were found despite a nubbin present in the scrotum. Laparoscopy should be considered in case of palpable scrotal nubbins to ensure no testis is left intra-abdominal.


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