Benefits and afterthoughts of laparoscopy for the nonpalpable testis

Purpose: Recent reports in the literature indicate that laparoscopy tends to be seen as the most appropriate approach to the nonpalpable testis for diagnosis and therapy. The aim of our study was to evaluate the real benefits of laparoscopy in terms of diagnostic accuracy, safety, costs and validity of the chosen treatment. Materials and Methods: We compared anatomical findings and results of the treatment of impalpable testes in 2 pediatric surgical groups, including 47 children treated laparoscopically during a 2 1/2-year period and 296 treated with open surgery (classic orchiopexy) in a 6 1/2-year period. Results: There was no significant difference in the diagnosis of abdominal testes (51 versus 50%), whereas a difference was noted in inguinal (4 versus 15%) and absent testes (45 versus 35%). Differences in treatment were more striking. In the laparoscopic group standard orchiopexy was performed in 62.5% of cases versus 83% in the open group. Conversely the rate of Fowler-Stephens repairs increased from 5.5% of open surgery cases to 37.5% of laparoscopic cases. There have been no serious complications in the laparoscopic procedures. To date 6 of the 9 patients who underwent a staged Fowler-Stephens procedure have undergone complete repair (open second stage). A review of the literature revealed a similar but lower tendency to over perform the Fowler-Stephens operation in laparoscopic cases (34%) versus open surgery (8%). Also, in previous series there was a 29% orchiectomy rate during laparoscopy compared to only 5% in classic open surgery. In Italy under current public health programs overall costs of the laparoscopic approach to the nonpalpable testis become noncompetitive when the procedure is extended from only diagnostic to interventional use due to the need for additional trocars and other special instruments. In contrast, private health insurers provide an additional 30% for laparoscopic cases over the cost of open orchiopexy. Conclusions: Laparoscopy is definitively accurate in establishing the differential diagnosis of impalpable testis. The number of Fowler-Stephens repairs in the laparoscopic group seems inordinately high, probably due to a lack of definite standards in the proper assessment of the length of the internal spermatic vessel pedicle and the potential scrotal displacement of the testis. This reason may explain the higher number of orchiectomies reported in the literature.