Comparison of Laparoscopic Orchiopexy and Traditional Inguinal Incision Orchidopexy for Palpable Undescended Testes in Cryptorchidism

Background Laparoscopic orchidopexy (LO) has become a standard procedure for the treatment of nonpalpable undescended testes. LO for palpable undescended testes is still controversial. The aim of this study is to explore the method and effect of laparoscopic orchiopexy procedure for palpable undescended testes in children suffering from cryptorchidism. Methods A retrospective study was performed for LO and traditional inguinal incision orchidopexy(TIIO) for palpable undescended testes. Totally 220 children age ranged from 9 months to 96 months with both palpable inguinal canalicular testes were included. 170 patients received LO and 50 patients received TIIO. Patient age, operative time and clinical outcomes were reviewed. Independent t test and Fisher’s exact test were performed by SPSS 25.0 software. Results The mean operative time (30.77 ± 6.02 vs 44.76 ± 6.70 min), postoperative normal activity time (1.25 ± 0.43 vs 2.48 ± 0.68 day) of LO was significantly shorter than TIO group. ( P < 0.05). 47 of 49 cases (95.9%) within 1-year-old were successfully achieved LO. Conclusion LO is an appropriate choice for palpable undescended testes, especially in younger children within one-year-old. The successful percentage of LO decreased with age growing.

3 both palpable inguinal canalicular testes were included (Table 1). LO was performed on 170 patients ages ranged from 9 months to 4 years (mean 16.62 ± 8.43 months), 74 on the left side and 96 on the right. 50 patients ages ranged from 9 months to 96 months (mean 18.37 ± 15.35 months) received TIIO, 23 of them on the left side and 27 on the right. All patients had unilateral palpable undescended testes and the testicles cannot be drawn into the scrotum in the physical examination. Patient age, operative time, the proportion of closure of internal inguinal ring (IIR) and clinical outcomes were reviewed. Follow-up visits were performed to assess the postoperative testes.

Discussion
Cryptorchidism or undescended testes is a common congenital disease in children. Nearly 80 percent of undescended testes are palpable [5].
In 1995, Docimo et al. [6] first reported LO treatment of the palpable undescended testes and then Riquelme et al. summarized that LO is a safe procedure for patients with palpable undescended testes, no more complications were found. Of his 192 patients, only one case was converted to TIIO [7,8].
In recent years, LO has been mostly applied to the treatment of nonpalpable undescended testes and peeping testicles. The results show that laparoscopic surgery was more efficient and more sufficient in the aspect of testicular dissection than traditional surgery. Laparoscopic surgery had become a gold standard for nonpalpable undescended testes [5,9]. However, the application of LO for palpable undescended testes was still controversial.
As far as we knew about the etiology of cryptorchidism, testicular descent occurs in two morphologically distinct phases, the second phase called inguinoscrotal phase which occurs between 25 and 35 weeks of gestation [10]. Testicular descent into scrotum relies on a ligament called gubernaculums testis(GT). The main ingredient of GT is primitive mesenchymal cells, which respond to hormonal cues and differentiate into cremaster muscle, then the testicular extend into scrotum.
Many uncertain reasons prevented the differentiation and remain the testicle in the abdomen or groin in Cryptorchidism [11]. Meanwhile, the GT remained as ligament which leads the testicular could not extend into scrotum.
Surgery of orchidopexy needs to cut off the dysplastic GT as the main procedure to make adequate mobilization of testicles. In LO for palpable undescended testes surgery, if the testicles can be pulled back into the abdominal cavity, the laparoscopic way is more conveniently to cut off the dysplastic GT compared to the traditional way. The subsequent mobilization of testicles would be sufficient and efficient. So, whether the testicles can be pulled back into the abdominal cavity is a key procedure.
In 1975, the American Academy of Pediatrics recommended the optimal age for Orchidopexy was 4-6 years old [12]. Subsequent studies are shown that histopathological changes already become apparent in the first few months of life. In 1996, the American Academy of Pediatrics recommended that Orchidopexy should be performed at or near 1 year of age [13]. From 2008, AWMF of Europe recommended that surgery should be performed before the child's first birthday to minimize the risk of impaired fertility [14].
According to relevant literature reports, the incidence of cryptorchidism associated with an inguinal hernia was 56% [15]. More than 92% of patients with unilateral palpable undescended testes had an ipsilateral IIR unclosed at a median age of 14.9 months [16]. Our study found that 98.0% of children under 1-year-old, the IIR was unclosed. 97.9% of the testicles could be pulled into the abdominal cavity easily to accomplish the LO procedure.
Our study shows that palpable undescended testes associated with an ipsilateral unclosed IIR confirmed during the laparoscopy was more than 90% (91.7) even within 2 years of age. It's seemed that LO is not suitable for the majority of those elder children, especially over two years old. If IIR was closed, the LO surgery would be very hard to achieve, for testicles might be cannot be pulled back into the abdominal cavity in those patients. We have tried to reopen the closed IIR, then we found that it was still hard to pull back the testicles and increased the risk of damage to vas deferens and spermatic vessels. From this study, we found that opening IIR does not necessarily mean hernia. The open IIR is generally exists in cryptorchidism. The proportion of unclosed IIR decreased gradually with the increasing of age.
With regards to the closure of the peritoneal defect after the testicle has been mobilized during LO.
When no ligature or suture was contemplated, the operative time decreased significantly. Rafiei et al. [17] carried out a randomized controlled trial to evaluate the no ligation method for children. He concluded that herniotomy without sac ligation in children saved many times and also prevented many other possible complications such as nerve damage, spermatic cord injury. Riquelme's literature shows that there was no need for closure of the internal inguinal ring during LO [18]. In his study of the staged treatment of LO, they found the peritoneum of the unsutured IIR in the first stage of the operation was completely closed during the second stage of the operation. Khairi et al. [19].
Carried out a prospective study to compare the difference between the IIR conventional suture group and IIR without closure group during LO. They concluded that the closing the peritoneum over the IIR can be omitted in LO, saving operative time and effort, no risk of recurrent inguinal hernia [20,21].

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The author confirms:
•that the work described has not been published before; •that it is not under consideration for publication elsewhere; •that its publication has been approved by all co-authors, if any; •that its publication has been approved (tacitly or explicitly) by the responsible authorities at the institution where the work is carried out.
The author agrees to publish in the Journal indicated below and also in English by BMC surgery journal.
Names of ALL contributing authors: Shaodong Gu, Hong Luo, Yingxun Wang

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Figure 1
Proportion of unclosed IIR and successful raTIIO of testicle can be pulled into the abdominal cavity with age changing.