Ferro F, Lais A, Gonzalez-Serva L
Department of Pediatric Surgery, Bambino Gesù Children's Hospital, Rome, Italy.
J Urol. 1996 Aug;156(2 Pt 2):795-8; discussion 798. doi: 10.1097/00005392-199608001-00065.
Recent reports in the literature indicate that laparoscopy tends to be seen as the most appropriate approach to the nonpalpable testis for diagnosis and therapy. The aim of our study was to evaluate the real benefits of laparoscopy in terms of diagnostic accuracy, safety, costs and validity of the chosen treatment.
We compared anatomical findings and results of the treatment of impalpable testes in 2 pediatric surgical groups, including 47 children treated laparoscopically during a 2 1/2-year period and 296 treated with open surgery (classic orchiopexy) in a 6 1/2-year period.
There was no significant difference in the diagnosis of abdominal testes (51 versus 50%), whereas a difference was noted in inguinal (4 versus 15%) and absent testes (45 versus 35%). Differences in treatment were more striking. In the laparoscopic group standard orchiopexy was performed in 62.5% of cases versus 83% in the open group. Conversely the rate of Fowler-Stephens repairs increased from 5.5% of open surgery cases to 37.5% of laparoscopic cases. There have been no serious complications in the laparoscopic procedures. To date 6 of the 9 patients who underwent a staged Fowler-Stephens procedure have undergone complete repair (open second stage). A review of the literature revealed a similar but lower tendency to over perform the Fowler-Stephens operation in laparoscopic cases (34%) versus open surgery (8%). Also, in previous series there was a 29% orchiectomy rate during laparoscopy compared to only 5% in classic open surgery. In Italy under current public health programs overall costs of the laparoscopic approach to the nonpalpable testis become noncompetitive when the procedure is extended from only diagnostic to interventional use due to the need for additional trocars and other special instruments. In contrast, private health insurers provide an additional 30% for laparoscopic cases over the cost of open orchiopexy.
Laparoscopy is definitively accurate in establishing the differential diagnosis of impalpable testis. The number of Fowler-Stephens repairs in the laparoscopic group seems inordinately high, probably due to a lack of definite standards in the proper assessment of the length of the internal spermatic vessel pedicle and the potential scrotal displacement of the testis. This reason may explain the higher number of orchiectomies reported in the literature.
文献中的近期报道表明，腹腔镜检查往往被视为诊断和治疗不可触及睾丸的最合适方法。我们研究的目的是从诊断准确性、安全性、成本和所选治疗的有效性方面评估腹腔镜检查的实际益处。
我们比较了2个小儿外科组中不可触及睾丸的解剖学发现和治疗结果，其中一组在2年半的时间里有47名儿童接受了腹腔镜治疗，另一组在6年半的时间里有296名儿童接受了开放手术（经典睾丸固定术）。
在腹腔内睾丸的诊断方面没有显著差异（分别为51%和50%），而在腹股沟睾丸（分别为4%和15%）和睾丸缺如（分别为45%和35%）方面存在差异。治疗方面的差异更为显著。在腹腔镜组中，62.5%的病例进行了标准睾丸固定术，而开放手术组为83%。相反，福勒 - 斯蒂芬斯修复术的比例从开放手术病例的5.5%增加到腹腔镜病例的37.5%。腹腔镜手术中没有出现严重并发症。到目前为止，接受分期福勒 - 斯蒂芬斯手术的9名患者中有6名已完成修复（开放二期手术）。文献回顾显示，与开放手术（8%）相比，腹腔镜病例中过度进行福勒 - 斯蒂芬斯手术的趋势相似但较低（34%）。此外，在之前的系列研究中，腹腔镜检查期间的睾丸切除术发生率为29%，而经典开放手术仅为5%。在意大利，根据当前的公共卫生项目，当腹腔镜检查方法从仅用于诊断扩展到介入使用时，由于需要额外的套管针和其他特殊器械，对于不可触及睾丸的腹腔镜检查总体成本变得缺乏竞争力。相比之下，私人健康保险公司为腹腔镜病例支付的费用比开放睾丸固定术的成本高出30%。
腹腔镜检查在明确不可触及睾丸的鉴别诊断方面肯定是准确的。腹腔镜组中福勒 - 斯蒂芬斯修复术的数量似乎过高，可能是由于在正确评估精索内血管蒂长度和睾丸潜在阴囊移位方面缺乏明确标准。这个原因可能解释了文献中报道的较高的睾丸切除术数量。
