I think if not palpable testis laparoscopy is the best option.

What is the possibility of locating undescended in MIR and laparoscopy?

MR angiography recently achieved high detection rate above 90% but still worl wide the standard is to do diagnostic laparoscopy as it has the highest sensitivity also it can diagnose cases like vanishing testis, blind ended vas, atrophic testis

Dear Ahmed, USG should still be done in non-palpable testes coz sometimes it may still be in the Inguinal region. Also at induction, you need to palpate again, coz it happens that its canalicular. If both are suggestive of non-palpable then proceed with laparoscopy. MRA is an overkill; not necessary really except may be academic or in associated Renal anomalies.

@ Dr. Patankar, Examination under anesthesia - an excellent point.

The standard is for all cases after examination in anaestesia laparoscopy. This is diagnostic and therapy in any case as a day hospital procedure.

Thank You. Does anyone do microvascular anastomosis anymore?

Examination under anaesthesia and diagnostic laparoscopy ....best option to diagnose undescended testis.

Not every case would need a laparoscopy. Only the bilateral non-palpable ones, that too they need USG and exam under GA as sometimes they could be canalicular; plan could change upon table after induction.

I think it is only occasional that you can feel testis under anesthesia with negative ultrasound.I did 86 cases laparoscopy. Only 4 cases I felt the testis under anesthesia and were excluded from the study. I published my experience in laparoscopy with undescended testis in 2010 endourology Journal B ( October 25, 2010 - VOLUME 24 - ISSUE 5 -

Laparoscopic Orchiopexy Without Division of the Spermatic Vessels for Low Intra-abdominal Testis )

http://online.liebertpub.com/doi/abs/10.1089/vid.2010.0056?journalCode=vid

I do believe in Examination Under Anaesthesia and if not palpable for Laparoscopy.

In case of bilateral maldescensus, you should do endocrinologic (hcg) testing for testis tissue first, look for syndromes, and if you do not find evidence for testis tissue do chromosomes.

For location of maldescended testes, I would recommend a step-wise strategy:

1. Ultrasound by an experienced ped radiologist

2. MRI in anaesthesia (consider the age) or sedation, use the anaesthesia for physical examination!

3. Laparoscopy - which certainly is the gold standard and would also present with a therapeutic option, meaning that you may start with therapy in the same session

First of all: most doctors do not use the right technique in palpating the so called non palpable testes: one should have lubricated fingers! Try it and surprise yourself with your new skills...

thats interesting Pieter - shall try it next time in clinic

I think that examination if not palpable proceed with laparoscopy.

Mri

The diagnosis of an undensceded testis is first clinical if the testis is unpalpable and you don't fill a testicular remnant and the contralateral testis is normal in size i think Laparoscopy is the best option Because you can see directly the spermatic vessels and understand which was the fate of the testis then you may address your surgical strategies

Agree with Dr Alfonso

If the testis is not seen on ultrasonography, you can do examination under anesthesia then laparoscopy

- Clinical examination with a sort of lubricant to start with.

- Examination under anesthesia and then Laparoscopy is the next step with preparation to proceed according to your findings.

- The parents must be informed about the possibilities.

- Ultrasound and MRI can be used but it will not change the plan.

- Bilateral cases may need reoperative investigations to rule out other diseases.

No harm doing USG coz it may pick up a canalicular testes. Its non invasive not costly. Palpation under GA is must coz may pick up an earlier non palpable gonad

Laparsocopy for all non palpable gonads

Agree MRI not necessary

Physical examination is the main method to differentiate between palpable or non-palpable testis. The diagnostic techniques of localization for a non palpable testis have included ultrasound , CT scan and MRI. Each one of these have a false positive and negative rate. Furthermore the diagnoses of testis absence cannot be definitively done and thereby laparoscopic/surgical exploration is necessary.Before laparoscopy an examination under general anaesthesia is always recommended

Sono

The modality of choice after through physical examination for palpable UDT is ultrasonography and in NPT is laparoscopy and or exploration.

For impalpable testes it is recommended that EUA ( Examination under Anaesthesia) be performed first. If testis is palpable on EUA, orchiopexy can be done immediately under the same GA. If not palpable even on EUA , proceed for Diagnostic Laparoscopy and if testis is visualised, it is pexed simultaneously.

Examination if not palpable go on laparoscopy.

Examination in Squatting position is best and then is MRI with its limitations

I agree with Ahmed, I invite to see my paper:

http://online.liebertpub.com/doi/abs/10.1089/lap.2006.16.321

When we do calculation of expected accuracy and benefits vs costs my policy is:

1. physical examination, 2. ultrasound 3. No MRI, no CT scans (too expensive and no prooved improvement of treatment) 4. examination under anesthesia (30% boys dont need laparoscopy) 5. laparoscopy.

Physical examination can found à testis in inguinal position and Ultrasonography can explore it ( morphology and vascularisation) . in High situated testis , USG had à little specificity so MRI or CT scan could be helpfull to the surgical thérapy decision ( surgical orchidopexy or orchidectomy for atrophic testis) , laparoscopy is the better Way the explore for the location of the testis and its descent to the scrotum , which can be done in first indication or after MRI/or CT SCan.

US can be performed in non palpable testes if it is not detected on ordinary examination as it is inexpensive, safe screening diagnostic tool but the best is to do examination in squatting position under general anesthesia if palpable do orchiopexy if not do laparoscopy.

If not palpable, laparoscopy is the ideal investigation

ultrasonography of abdomenif testes are not palpable in scrotum an if not visible then go for MRI..

If US of abdomen and inguinal canals is negative definitely laparoscopy with identification and inspection of testicular vessels should be performed.

Laparacpoy if sono fails

3 year old - and slim

ultrasound works often ver well

laparoscopy is the last option

In non palpable testis, laparoscopy should be performed. Imaging usually doesn't help much.

In a impalpable testis, examination under anesthesia and proceed with Laparoscopy, if not palpable. US is not a reliable investigation and being operator dependent can land in trouble. When Sonologist says testis present, but on exploration if testis is absent, the situation is embarrassing.

To quote from literature, "Ultrasound does not reliably localize nonpalpable testes and does not rule out an intraabdominal testis. Eliminating the use of ultrasound will not change management of nonpalpable cryptorchidism but will decrease health care expenditures". Pediatrics 2011;127:119–128

First ultrasound - not ct - radiation

mir usually need of sedation

laparoscopy as final solution

is a clear triage

sonography is the initial option but MRI is the best imaging option although it does'nt have high acuracy, and finally the best option is laparoscopy

it seems we have a clear triage

for MRI sedation is the disadvantage

from 1987 until 2013 the sensitivity of finding abdominal undesending testes wasnot changed dramatically ( 0.6) although it is specific ( specificity =1).

ultrasound is a sensitive for inguinal site can detect testes in 8 out of 9 case that is near to MRI result (sensitivity 0.86).

ultimately for abdominal undesending testes laparoscopy is suitable for both diagnosis and management .

Ultrasound should be the first step. MRI seco d step.

Laparoscopy for unpalpable testis ( diagnosis plus treatment)

It depends what you ask from the ultrasound. The question should be :Is the testis in the groin or no. NOT Where is the testis.

In a non palpable testis, I do an inguinal ultrasound and the testis is seen at the internal ring or not at all I proceed with laparoscopy and eventually laparoscopic orchidopexy.

MRI should be reserved for the very obese older children or adolescent in whom one wishes to avoid laparoscopy.

References: 1)The application of magnetic resonance imaging for preoperative localization of the nonplapable testis in the obese child: An alternative to laparoscopy. De Filippo RE, Barthold JS, González R. J Urol 2000;164:154-155

2) Male genital anomalies and diseases. González R, Ludwikowski B. In: González R, Ludwikowski B. Handbook of Urological Diseases in Children. Chapter 9, pp. 133-154. Singapore, World Scientific Publishing Co. 2011. ISBN 981-4287-40-7

Ultrasound followed by laparoscopy

Yes - correct

if u can use doppler is helpful

also the twist sign

All imaging modalities sensitivity in UDT ,are not more than 44%

so its not a strong backpone to rely on

but for the answer of the question

yes

Ultrasound is the cost effective choice

Although Ultrasound is the most commonly used imaging modality for UDT, it still not accurate.

Better to do good examination under anesthesia and if the testis is not palpable, proceed with laparoscopy.

Non Palpable tests the modality of choice is diagnostic laparoscopy and proceed for orchiopexy. Ultrasound is cost effective and can be misleading. it si screening modality. Examination under anaesthesia has to be performed before embarking on laparoscopy as the testicular position may vary from examination done when the child is awake