Sir,Peeping testis presents itself with a movement in and out of internal inguinal ring. Such a testis may or may not be felt manually, and even the ultrasound done at different times may report the testis as intracanalicular or intra-abdominal. The role of laparoscopy in such cases has been described as diagnostic as well as a therapeutic one.[1] Surgeons have confirmed the presence of testis entering the canal [Figure 1] and then have resorted to conventional open orchidopexy and in few groups have adopted the technique of laparoscopy therapeutically, in getting the gonad to the scrotum.[23]
Figure 1
Laparoscopic view of “peeping testis”
Laparoscopic view of “peeping testis”In the past 5years from 2008 to 2014, our center has experienced 114 patients with uni- or bilateral cryptorchidism, and 43 of them have been “peeping” testes. In 20 of these, a one-stage laparoscopic approach was adopted, while the remaining 23 underwent a Stephen–Fowler staged approach.[4] It was observed in 13 of the single-stage group, that the testis fails to reach the bottom of scrotum in spite of the best of retroperitoneal mobilization. The tightness of the testicular vessels was evident and we had to compromise witha high placement of the testis in the upper part of scrotum. Three of the testes subsequently slipped out of the scrotal sac and disappeared into the superficial inguinal pouch area. In two of these cases, an open local exploration was required to relocate them back in the scrotal pouch. On the other hand, 23 testes underwent two-staged procedure and the interval between the two stages was 6-8 months. In the first stage the testicular vessels were clipped, coagulated at least 3.5 cm proximal to testis. In 8 cases they were divided in the same stage and in 15, they were clipped and coagulated in continuity. In no case was the dissection performed distally in the first stage, and the decision to do the staged approach was arrived at, as soon as the testis was seen at the internal ring.The former classification of “low intra-abdominal” or “highintra-abdominal” gonad (depending on the distance being more than 1.5-2 cm from internal ring) was not followed. The results of the staged approach were excellent. All the testes could be operated upon in the second stage, none had disappeared due to atrophy and they could be easily brought down on the pedicle of peritoneal triangular leaf at the internal ring protecting the neovascular collateral supply from inferior vesical, inferior epigastric, and cremasteric vessels. Ultrasonography (USG) done 3 months subsequent to second stage confirmed their viability with a good size and low placement in the scrotum and none had retracted upwards.The authors strongly recommend the adoption of Stephen–Fowler staged approach in the cases of peeping testes at the level of internal inguinal ring rather than attempting a single-stage orchidopexy, which at times leads to suboptimal placement in the upper scrotal half.
Figure 1