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Introduction
The traditional management paradigm for nonpalpable testis has been that open exploration for a nubbin may be omitted when blind ending vessels are observed during diagnostic laparoscopy. This management strategy evolved from the presumed etiology of blind ending retroperitoneal cord structures being an intra-abdominal event that occurred prior to completion of testicular descent. However, our multi-institutional experience has been that a nubbin is present in the majority of open explorations. Our aim was to examine whether laparoscopic findings corresponded with the presence or histology of a nubbin when routine open inguinal or scrotal exploration was completed.
Methods
Utilizing an institutional surgical database and the electronic medical record, we retrospectively identified all pre-pubertal boys (≤12 years) with the diagnosis of undescended testis (ICD9 752.51) or atrophic testis (608.3) who underwent a diagnostic laparoscopy for NPT between 2000 and 2015. Procedures performed including completion of an open exploration following diagnostic laparoscopy and NPT on physical exam were confirmed by chart review.
Results
We identified 559 children who underwent diagnostic laparoscopy for NPT at two academic institutions by a total of 13 surgeons. Of those, 318 were found to have an intra-abdominal testis, 14 an extra-abdominal testis on open exploration, an extra-abdominal remnant was located and excised in 209 and 18 underwent diagnostic laparoscopy alone. Regardless of laparoscopic findings in the 209 total cases with excised remnants, 193 (92.3%) were grossly identified in the operative report as atrophic testes, 5 (2.4%) epididymides and 11 (5.3%) isolated cord structures.
Of these 209 children, 26 had blind ending vessels observed on laparoscopy. In 25 of 26 with blind ending vessels an atrophic testis was grossly identified and all 26 had cord structures observed during open exploration. Pathology confirmed the presence of hemosiderin in 53.8% and calcifications in 57.7% of these 25 nubbins. In the 7 cases that had both blind ending vas and vessels and in whom open exploration was completed, all had inguinal or scrotal testicular remnants and cord structures identified. Pathologic evaluation confirmed the presence of hemosiderin in 71.4% and calcification in 85.7%.
From the entire cohort of 209 excised remnants, seminiferous tubules (STs) were observed on hematoxylin and eosin staining of 11 nubbins from cases that reported either non-atretic vas (10) or vessels (6) entering the internal ring. Germ cells (GCs) were identified in 2 cases in which a non-atretic vas entered the internal ring.
Conclusion
In this large multi-institutional series, the finding of blind ending retroperitoneal cord structures on diagnostic laparoscopy was associated with a nubbin on open inguinal or scrotal exploration in the vast majority of cases. This series would suggest that the dogma that open exploration may be omitted in this setting due to an intra-abdominal event is not supported by operative findings. Therefore, if the decision-making process were motivated by a desire to remove all nubbins, open exploration would be advised regardless of laparoscopic findings. However, GCs or STs were rarely identified and only observed when non-atretic vas or vessels were observed.