Over the past few years, I have noticed that laparoscopic orchiopexies for intraabdominal testis are easier in infants and toddlers compared to older children.
Recently, I attempted a laparoscopic orchiopexy in a mid-pubertal boy (with the size of a big adult) and found that to be very challenging. Without dividing the testicular vessels, the testis remained where I found it at the internal ring, despite dissecting the vessels and vas as much as possible.
After dividing the testicular vessels, the testis still only reached the groin with considerable tension. Because of the size of the testis and the musculature around the groin, I was not able to bring it out into the groin through the usual 10 mm step trocar; instead, I tried different maneuvers to get the testis to come out. Ultimately once the testis was in the groin, I noticed the size was much smaller than the contralateral testis and decided to remove it. My decision was informed by statement 15 of the AUA guideline on cryptorchidism:
15. In boys with a normal contralateral testis, surgical specialists may perform an orchiectomy (removal of the undescended testis) if a boy has a normal contralateral testis and either very short testicular vessels and vas deferens, dysmorphic or very hypoplastic testis, or postpubertal age. (Clinical Principle)
Chung et al described a 32 times risk of malignancy and no spermatogenesis for intraabdominal testis in men older than 11 years.
Kucheria et al performed laparoscopy on 10 adult patients (mean age 29 years) with non-palpable testis finding 5 viable testes, all which were removed laparoscopically. In the same article, the authors described one patient with one inguinal testis and a contralateral absent testis confirmed laparoscopically, where mobilization of the inguinal testis was impossible due to short vessels.
Grasso et al performed semen analysis on 91 patients that underwent postpubertal orchiopexy for unilateral cryptorchidism (they did not mention if the orchiopexies were inguinal or laparoscopic). Only 15/91 patients had a normal semen analysis. The testis was hypotrophic in 64%. Of the patients that underwent biopsy at the time of the orchiopexy, 9% had a tumor. The authors concluded that orchiectomy might be the treatment of choice due to low chances of improving fertility and the considerable risk of a tumor.
I was not able to find any reported cases of successful laparoscopic orchiopexy after puberty.
I looked back at my case logs and realized I helped an adult urologist with a 2 stage Fowler-Stephens orchiopexy on a 16-year-old several years ago. We were able to bring the testis to the upper scrotum, but it was difficult bringing the testis into the groin due to its size despite using a 12 mm trocar. With a nasal speculum, we stretched the canal first, then replaced the 12 mm trocar and finally brought the testis into the groin. The adult urologist reported a good postoperative outcome. Other than that patient, the oldest patient that I have done a laparoscopic orchiopexy was 8 years-old.
Postpuberty patients found to have intraabdominal testis are at higher risk of malignancy (but still around 1%). These testicles are likely to have no spermatogenesis.
With a contralateral normal testis, one could schedule them for possible laparoscopic orchiopexy –if the family is ok with a 1% risk of cancer– versus orchiectomy. A 2 stage FS is likely the procedure of choice when the family elects to preserve the testis.