The Impalpable Testis: A Rational Approach to Management

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Abstract
Endocrine tests can reliably predict anorchism in normal phenotypic male subjects less than 35 yr old with 46-XY karyotypes and no obvious mullerian structures on rectal examination, thereby avoiding the need for surgical exploration. There are no reliable endocrine or other tests that exlude the presence of a testis when 1 gonad is impalpable. Surgical exploration will detect a testis in 80% of the cases in the inguinal canal or intra-abdominally. Monorchism or anorchism is proved by definitive identification of blind-ending spermatic vessels. Intraperitoneal exploration is essential when searching for a non-palpable testis that cannot be located retroperitoneally. Gonadal angiography or venography is not recommended as a routine procedure in patients with impalpable testes. Gonadal venography is helpful in those situations in which local thorough retroperitoneal and intraperitoneal exploration is unrewarding and when a separate loin or abdominal incision is being contemplated. Preservation of testicular artery continuity appears preferable to transection and would seem to hold out the best hope for optimum testicular function. Early exploration in infancy appears helpful in this regard. When this is not possible a staged orchiopexy or testicular vessel transection in selected cases with a long loop vas generally is satisfactory. Retained intra-abdominal testes constitute a significant risk to the patient from mortality secondary to malignant degeneration. Exploration is mandatory and orchiopexy is recommended in the prepubertal boy.