| Part one Laparoscopic Assisted Transcrotal Orchidopexy for the Man-agement of Palpable Cryptorchidism: Initial reportObjective:To assess the outcomes of a novel laparoscopic assisted transcrotal orchidopexy(LATO)for palpable cryptorchidism,and evaluate its safety and efficiency.Methods:A retrospective cohort study for single-port LATO was performed between January 2011 and Autume 2011.A 5-mm umbilical incision was made,followed by the insertion of a 5-mm trocar using an open technique.A 5-mm 30 degree lens was introduced to confirm the location and development of affected testes and spermatic cords,as well as the contralateral situation.A transverse incision was made along the middle scrotum,followed by creation of adequate dartos pouch for re-location.The dartos was cut open and further dissected to create a potential “tunnel” into inguinal canal,clearing the lateral tissues around hernia sac along outer front side of peritoneum by means of the laparoscopic guide.The termination of processus vaginalis was found and dissected,a clamp was introduced into the inguinal canal or abdominal cavity through external ring,the testis gubernaculum was clamped and pulled through extra-corporeally,further dissecting the processus vaginalis off of the spermatic cord for mobility.When adequate testicular mobilization was achieved.The descended testis was re-located into scrotal pouch.Laparoscopic percutaneous extra-peritoneal closure of patent processus vaginalis was applied,with an inner two-hooked cannula.The patients were divided into two groups according to their ages,the younger group was under 2 years old,and the older group was over 2 years old.The operative time and post-operative complications between the two groups were compared.Results:1.All of the 23 cases were successfully brought down to the scrotum,and one case was converted to traditional laparoscopic orchidopexy.The remaining 20 cases of 22 testis were successfully induced and fixed by means of scrotal approach under single-port laparoscopic guidance.2.There were 7 cases of cryptorchidism on the left side,12 cases of cryptorchidism on the right side and 2 cases of bilateral cryptorchidism,9 cases accompany with indirect inguinal hernia or hydrocele,and 3 cases of right cryptorchidism combined with contralateral unclosed internal ring during the operation,all of which were fixed as high as the internal ring level simutaneouselly by laparoscopy.Six testis were located near the external ring of the inguinal canal.Fourteen testis were located in the middle of the inguinal canal and three testis were located near the internal ring of the inguinal canal.3.The median age of the patient was 2 years.According to the age group,13 cases were younger than 2 years old,and the operative time was(34.23 ±8.62)min,8 cases were older than 2 years old,and the operative time was(43.75 ± 9.16)min,the difference between the two groups was statistically significant(P<0.05).4.No obvious surgical complications were observed during the peri-operative period.During the follow-up period of 12 to 24 months,all testis were staying in the scrotum,with a good appearance and bilateral scrotum symmetry.No post-operative complications such as testicular ascending,atrophy,hydrocele or inguinal hernia were found.Part two Comparison of Therapeutic Effect of Traditional Laparoscopic and Laparoscopic Assisted Transcrotal OrchidopexyObjective:To compare the feasibility,indication and advantage of traditional laparoscopic orchidopexy(LO)and laparoscopic assisted transcrotal orchidopexy(LATO)for cryptorchid children.Methods:From Autume 2011 to Autume 2012,retrospective reviews of clinical data were conduced for cryptorchid children treated with LO(28 case)and LATO(55 case).Location,lateral,operative time,intra-and postoperation complications were recorded.Results:1.Median age was 2 years(range,2 months-11 years).All testis were delivered successfully.Five LATO procedure were turned to LO,including 3 bilateral and 2 impalpable testis.2.Mean operative time in LO was(35.71±10.16)min,including 3 impalpable,10 bilateral and 3 undescended testis with hernia.Mean operative time in LATO was(31.64±8.72)min,(P=0.03,compared with LO group),including 5 impalpable(9.09%),2 bilateral(3.64%)and 9 with contralateral hernia(16.36%).3.No intra-operative complications were observed.Median follow-up time was 24months(12-36 months).No post-operative complications were found,except for one atrophy found 24 months after LO.Part three Comparison of Different Surgical Approaches with Single- port Laparoscopic Assisted Transcrotal Orchidopexy in the Treatment of Palpable CryptorchidismObjective:To evaluate the clinical efficacy of different surgical approaches in the treatment of palpable cryptorchidism,exploring the more optimal approach for different types of cryptorchidism,and to help the clinical guidance with best surgical approach.Methods:A retrospective study of 698 cases with palpable cryptorchidism who received the first-stage orchidopexy in our hospital was made between Autume 2012 and Autume 2017.According to different surgical approaches,the patients were divided into four groups: the traditional trans-inguinal orchidopexy group(TIO group),the conventional three-port laparoscopic orchidopexy group(LO group),the trans-scrotal orchidopexy group(TSO group)and the single-port laparoscopic assisted trans-scrotal orchidopexy group(LATO group).The operative age,testicular position,lateral position and complications were statistically analyzed,and the therapeutic effect and post-operative complications were compared.Results:1.The median age of the patients was 2 years(6 months ~18 years).All 698 patients with 809 testis was successfully treated with orchidopexy,with a success rate of 99.71%(696/698).2.There were 161 cases in TIO group and 1 case of post-operative testicular atrophy after operation.There were 59 cases in LO group,with one bleeding case turned to TIO approach.There were 249 cases in TSO group and 1 case of posto-perative testicular ascending.There were 229 cases in LATO group,with 18 cases turned to LO for adequate mobilization and one bleeding case turned to TIO approach.3.LATO approach accounted for 37.84% of all the operations in the younger group,and the proportion of the younger patients in the LATO approach group was 68.12%,which was significantly higher than that of other groups.LO group was more appliable for groin cryptorchidism and bilateral cryptorchidism than TIO and TSO.Compared with TIO,TSO and LO,LATO was more appliable for the treatment of cryptorchidism combined with hernia and hydrocele,LO was more appliable for the treatment of inguinal cryptorchidism and bilateral cryptorchidism,and TSO was more appliable for the treatment of cryptorchidism around the outer inguinal ring,P<0.05,and the difference is statistically significant.Conclusions:1.The LATO approach is a safe and effective choice for the treatment of palpable cryptorchidism.High ligation of the hernial sac or processus vaginalis can be performed simultaneously in children with indirect inguinal hernia or hydrocele.For children younger than 2 years old,the noval operation is easier and faster.2.LATO procedure is demonstrated as a feasible,safe and more cosmetic choice for management of palpable cryptorchidism,comparing with LO.When combined with inguinal hernia,no more time is needed for LATO.When testis was bilateral or impalpable with tentional delivering,LO seemed to be more reliable.Staged orchidopexy may be more appliable to avoid testicular atrophy.Conversion to traditional three-port laparoscopic orchidopexy is necessary for adequate mobilization of the spermatic cord in some tentional situations.3.Each of the four surgical approaches has both advantages and disadvantages.LO and LATO approaches are more appliable for testis lying in the inguinal canal,bilateral anomalies and/or cryptorchidism combined with hernia/ hydrocele.LO approach provides adequate mobilization bilaterally.LATO approach is more appliable for patients younger than 2 years.Trans-scrotal orchidopexy is appliable for palpable testis lying around the external inguinal ring,with less incisions.TIO approach is still valuable in the treatment of surgical site bleeding,re-ascending and other accidents. |
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