What is a nonpalpable testis?
June 2021
In the Pediatric Surgeon’s Journal, in the previous journeys, I explained what an undescended testis is, what it can cause, how it should be evaluated, when and how it is treated. In the undescended testicle examination, we see that the sack is empty, and we can find the testicles with our hands somewhere outside the sack. What if the sack is empty and the testicle is not palpable?
If a child’s testicles are not palpable, there are three important points for us. First, how old is the child? Newborn baby or toddler? Second, is the test not palpable unilaterally or bilaterally? Third, do we have any genital examination findings in addition to our non-palpable testis finding, such as hypospadias?
But first we need to be sure of our physical examination. Generally, we, pediatric surgeons, do a lot of genital examinations, so we can feel and find the testicle if there is one. However, the child may be very overweight, the examination may not be performed properly due to some body problems. If we have such a doubt, we can get support from ultrasonography. However, as I said in previous cruises, it should be kept in mind that no imaging method is as reliable as physical examination.
If there is a one-sided nonpalpable testicle, if it is not accompanied by hypospadias, the testicle is either in the abdomen or it deviated from the normal descent path, or it could not be fed due to a vascular problem that may occur due to various reasons, died and then disappeared; ie vanishing testis, ie absent testis.
If the unilateral nonpalpable testis is accompanied by hypospadias, we suggest that there may be a sexual development disorder and we evaluate accordingly.
If there is bilateral nonpalpable testis, then age is important. If it is a newborn baby, it is absolutely necessary to make a serious evaluation to rule out sexual development disorders. Chromosome-karyotype studies, some possible enzyme disorders, some blood tests for metabolic diseases, hormone tests should be done and it is necessary to act according to the results.
We have made a short introduction. After all, if there is a child with a nonpalpable testicle, after ruling out the gender development disorder, which is a completely different matter, what do we do? As I said, the reliability of imaging methods is very low. The safest is to look for the testis by surgery. Thus, we diagnose and treat at the same time.
Now let me detail how we do this surgery.
First of all, we do these surgeries as “outpatient surgery”, that is, we do not hospitalize them, they are discharged on the same day. As a timing, we want to do it between 6-12 months, preferably 9-10 months.
We examine the child under general anesthesia again. In a study, it was reported that 18% of the testicles that were not palpable in the outpatient clinic examination were palpable in the examination performed under anesthesia. In our examination, the testis is not palpable, but if we feel the remnants of the testicles that have died and started to disappear in the bag, we can start with an incision made on the scrotum or in the groin. We remove the residual tissue that we feel as a result of our examination.
The tissue called the “gubernaculum”, which is one of the guides in the journey of the testicles from the abdomen to the lower bag, can sometimes seem like testicular remnants to us, or the adipose tissue can mislead us. Then it may be necessary to look inside with laparoscopy. In order to avoid this situation, our clinical practice is to start with laparoscopy. First, we insert a small camera through the navel and look at whether there is a testicle in the abdomen. Meanwhile, we can see if there is a sexual development disorder, if there are genital organ remnants that should not be present in the abdomen, and if there are testicles in the abdomen, we lower them down.
If we see the end of the cord consisting of the veins of the testis and the sperm-carrying duct empty, we think that the testis is destroyed by turning around itself or as a result of the occlusion of the vein, and we end the operation.
If we see that the cord of the testis has entered into the inguinal canal, we terminate the laparoscopy and remove the dead tissue at the end of the cord in the inguinal canal with an incision made in the groin. Because from this tissue, although most of it consists of dead cells, living cells can remain in between, and it is accepted that there is a risk of developing a bad disease from these cells in the future. Discussions on this issue continue.
As the discussions continue, there are different approaches at this stage.
There is no consensus on the timing of residual tissue removal. It is said that the malign disease will not develop immediately. There’s no need to rush it. Do not proceed to inguinal surgery after finishing laparoscopy. Operate before puberty, remove residual tissue, place a prosthesis in the same session, if the prosthesis remains small after puberty, and insert a larger one with a new surgery if desired.
However, parents often state that they may not want the prosthesis in the future, that they do not want the structure that may cause a malignant disease to remain there, and ask us to remove it in the same session. We explain all these things in detail and decide together.
After all, the nonpalpable testis is a topic that needs to be handled a little differently than the undescended testis. Surgery, especially laparoscopic surgery, is at the forefront in its treatment and diagnosis.
We’ve come to the end of another tour. You can watch our videos on youtube, follow us on instagram,
And stay happy.
Prof. Dr. Egemen Eroğlu
June 2021
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