What is the recommended management for an intra‑abdominal testis in a child?

Management of Intra-Abdominal Testis in Children

Laparoscopic orchiopexy should be performed by 18 months of age for intra-abdominal testes, with the specific surgical technique determined by testicular mobility and vessel length at the time of laparoscopy. 1, 2

Diagnostic Approach

• Laparoscopy is mandatory for all non-palpable testes to identify testicular location and vessel anatomy, as radiologic imaging lacks adequate sensitivity and specificity for surgical planning 2, 3
• Approximately 55% of non-palpable testes are intra-abdominal, 30% are in the inguinal-scrotal area, and 15% are absent/vanishing 2
• If contralateral testicular hypertrophy is present, this suggests an atrophic remnant and scrotal exploration with removal of the nubbin is appropriate 4

Surgical Technique Selection Based on Intraoperative Findings

For Mobile Intra-Abdominal Testes

• One-stage laparoscopic orchiopexy without vessel division achieves 89-97% success rates and should be attempted when the testis is mobile or located just distal to the internal inguinal ring 5, 4
• The Prentiss maneuver (medial mobilization of the spermatic vessels) should be used to gain additional length 4
• This approach is significantly more successful than Fowler-Stephens procedures (OR 0.24, p=0.007) 5

For High Intra-Abdominal Testes with Short Vessels

• Two-stage Fowler-Stephens orchiopexy is indicated when testicular vessels are too short for primary orchiopexy 4, 6
• The first stage involves laparoscopic ligation of the spermatic vessels, allowing collateral blood supply to develop through the vasal and gubernacular vessels 7, 6
• The second stage is performed 3-3.5 months later with testicular mobilization and scrotal placement 7, 6
• Success rates for staged Fowler-Stephens are 64-98%, lower than primary orchiopexy but acceptable when vessel length prohibits primary repair 5, 6

Alternative Technique for Borderline Cases

• Laparoscopic dissection of spermatic vessels up to the renal hilum can provide sufficient length to avoid vessel division in select cases 7
• This preserves the primary blood supply while achieving adequate mobilization 7

Indications for Orchiectomy Instead of Orchiopexy

• Laparoscopic orchiectomy should be performed when a normal contralateral testis exists and any of the following are present: 1, 3
  • Very short testicular vessels and vas deferens that preclude safe mobilization
  • Dysmorphic or severely hypoplastic testis
  • Postpubertal age at presentation
• Testicular nubbins (atrophic remnants) should be removed laparoscopically with simultaneous internal ring closure if a patent processus vaginalis is present 8

Critical Timing Considerations

• All orchiopexy procedures must be completed by 18 months of age to preserve fertility potential, as progressive germ cell loss accelerates after 15-18 months 1, 2, 3
• Infants diagnosed at birth should be referred by 6 months if no spontaneous descent occurs 1
• Prepubertal orchiopexy reduces testicular cancer risk by 2-6 fold compared to postpubertal surgery, though baseline risk remains elevated 2.75-8 times normal 1, 2, 3

Technical Pitfalls to Avoid

• Early spermatic cord control at the internal inguinal ring is mandatory before any testicular manipulation to prevent potential tumor spread 3
• Do not rely on ultrasound or other imaging to determine testicular location—proceed directly to diagnostic laparoscopy 2, 3
• Avoid delaying surgery beyond 18 months even if monitoring seems reasonable, as histologic damage is progressive and irreversible 2

Expected Outcomes

• Overall success rate for open surgical intervention exceeds 96% with testicular atrophy risk below 2% 1, 3
• One-stage laparoscopic orchiopexy without vessel division has the highest success rate at 89-97% 5
• Unilateral cryptorchidism has paternity rates similar to the general population, while bilateral disease significantly reduces fertility to 35-53% 2

Long-Term Follow-Up Requirements

• Regular monitoring of testicular position and development throughout childhood and adolescence is necessary 1
• Patients should be taught monthly testicular self-examination after puberty for early cancer detection, as malignancy risk remains elevated despite successful orchiopexy 2
• Counseling should address both infertility and cancer risks at age-appropriate intervals 1, 2