Heresy - Is There a Role for Ultrasound in Management of Non-Palpable Testicle?
Benjamin Press, MD, Olamide Olawoyin, MD, Cicero Silva, MD, Angela Arlen, MD, Robert Weiss, MD.
Yale University School of Medicine, New Haven, CT, USA.
BACKGROUND: AUA Guidelines do not support routine use of ultrasound (US) in evaluation of boys with an undescended testicle (UDT) prior to referral to a urologist. Multiple studies including data from the 1980s demonstrate that real time US is inferior to physical examination by a pediatric urologist in detecting an UDT. However, improved US technology, which now permits detection of the non-palpable testis located just proximal to the internal ring, may aid in guiding the surgical approach to the non-palpable testis. We evaluated US findings of boys deemed to have a non-palpable testis and compared them to surgical findings.
METHODS: US of boys with non-palpable testis, as reported by a pediatric urologist on physical exam, during a 3-year period, were reviewed. All US were performed jointly by a technician and pediatric radiologist. Patient demographics, laterality, and intra-operative findings were assessed.
RESULTS: Thirty-two boys with a non-palpable testicle on physical exam underwent scrotal/inguinal US at a median age of 7.5 months (IQR 2.5 - 12.3 months). Three patients had bilateral non-palpable testicles, 21 had a non-palpable left sided testicle and 8 had a non-palpable right sided testicle. Of the 35 non-palpable testes, 5 (14.3%) were identified in the inguinal canal. [Figure 1A] 18 (51.4%) were visualized in an intra-abdominal position just proximal to the internal ring. [Figure 1B] Four (11.4%) nubbins or very atrophic testes were identified in the inguinal region or scrotum and 5 (14.3 %) testes were not identified on US. Three (8.6%) testes were found to be mobile between just proximal to the internal ring and the inguinal canal. Of the 23 patients (26 testes) who had a viable testicle reported on US and underwent surgical exploration, 22 patients (95.6%) had a viable testis on surgical exploration. Three of the 4 cases of testicular nubbins elected for inguinal surgical exploration, with the testicular remnant identified and excised in all. Of the 8 patients with testis that were identified in the inguinal canal, or mobile between abdomen and inguinal canal, 7 avoided a diagnostic laparoscopy and underwent an inguinal orchiopexy. Of the 19 testicles located [in an intra-abdominal position] just proximal to the internal ring, only 3 underwent laparoscopic orchiopexy. All 5 patients with no testis identified on US underwent diagnostic laparoscopy, with 3 intra-abdominal testes identified.
CONCLUSIONS: US in the evaluation of cryptorchidism can guide surgical management in select cases in which a testis is non-palpable following careful examination by a urologist. 
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