Cain M P, Garra B, Gibbons M D
Section of Pediatric Urology, Georgetown University Medical Center, Washington, D.C., USA.
J Urol. 1996 Aug;156(2 Pt 2):791-4.
Treatment of the patient with a nonpalpable testis is controversial, since a high percent will have an inguinal testis or testicular remnant at exploration. While laparoscopy is an effective modality for localizing the intra-abdominal testis, diagnostic laparoscopy is of limited value for patients with nonpalpable (normal or atrophic) inguinal testes. In an effort to identify preoperatively impalpable inguinal testes, we performed scrotal-inguinal ultrasound.
We evaluated 64 patients (74 nonpalpable testes) in the last 4 years, representing 20% of all those presenting with cryptorchidism. Average patient age was 4.5 years (range 6 months to 17 years). All patients underwent preoperative scrotal-inguinal ultrasound and surgical exploration. Diagnostic laparoscopy was reserved for patients with negative ultrasound and no palpable tissue in the scrotum or groin on a preoperative examination.
Scrotal-inguinal ultrasound correctly identified 40 of the 42 inguinal testes (95% sensitivity), 7 of the 21 atrophic inguinal testes (33% sensitivity) and 1 of the 11 intra-abdominal testes (9% sensitivity). Therefore, scrotal-inguinal ultrasound correctly identified an inguinal testis or remnant for 47 of the 74 nonpalpable testes (64%), eliminating the need for diagnostic laparoscopy in those cases. For 26 of 74 nonpalpable testes with negative ultrasound 13 had an associated palpable inguinal or scrotal nubbin of tissue, and inguinal exploration only was performed, resulting in 9 orchiectomies, 2 inguinal orchiopexies and 2, 2-stage orchiopexies. Of the 13 nonpalpable testes without palpable nubbins and negative scrotal-inguinal ultrasound 8 were intra-abdominal and 5 were atrophic inguinal testes.
Scrotal-inguinal ultrasound identifies patients with nonpalpable testes who will maximally benefit from diagnostic laparoscopy. When diagnostic laparoscopy was limited to nonpalpable testes without palpable nubbins and negative scrotal-inguinal ultrasound, only 13 of 74 (18%) required laparoscopy. Inguinal exploration without further diagnostic studies is appropriate for boys with nonpalpable testes and palpable nubbins.
对触诊不能发现睾丸的患者进行治疗存在争议，因为在探查时很大比例的患者会发现腹股沟睾丸或睾丸残迹。虽然腹腔镜检查是定位腹腔内睾丸的有效方法，但对于触诊不能发现（正常或萎缩）的腹股沟睾丸患者，诊断性腹腔镜检查的价值有限。为了术前识别触诊不能发现的腹股沟睾丸，我们进行了阴囊 - 腹股沟超声检查。
在过去4年中，我们评估了64例患者（74个触诊不能发现的睾丸），占所有隐睾患者的20%。患者平均年龄为4.5岁（范围6个月至17岁）。所有患者均接受了术前阴囊 - 腹股沟超声检查和手术探查。诊断性腹腔镜检查仅用于超声检查阴性且术前检查在阴囊或腹股沟未触及组织的患者。
阴囊 - 腹股沟超声正确识别出42个腹股沟睾丸中的40个（敏感性95%），21个萎缩性腹股沟睾丸中的7个（敏感性33%），以及11个腹腔内睾丸中的1个（敏感性9%）。因此，阴囊 - 腹股沟超声正确识别出74个触诊不能发现的睾丸中的47个（64%）为腹股沟睾丸或残迹，从而在这些病例中无需进行诊断性腹腔镜检查。对于74个超声检查阴性的触诊不能发现的睾丸中的26个，其中13个伴有可触及的腹股沟或阴囊组织小结节，仅进行了腹股沟探查，结果为9例睾丸切除术、2例腹股沟睾丸固定术和2例二期睾丸固定术。在13个触诊不能发现且无明显小结节以及阴囊 - 腹股沟超声检查阴性的睾丸中，8个为腹腔内睾丸，5个为萎缩性腹股沟睾丸。
阴囊 - 腹股沟超声可识别出能从诊断性腹腔镜检查中最大程度获益的触诊不能发现睾丸的患者。当诊断性腹腔镜检查仅限于触诊不能发现且无明显小结节以及阴囊 - 腹股沟超声检查阴性的睾丸时，74例中仅13例（18%）需要进行腹腔镜检查。对于触诊不能发现睾丸但可触及小结节的男孩，无需进一步诊断性检查而直接进行腹股沟探查是合适的。
