EL-MINIA MED., BULL., VOL. 19, NO. 2, JUNE, 2008
Hassanen
LAPAROSCOPIC MANAGEMENT OF NONPALPABLE TESTIS
By
Ayman Hassanen, MD.
Department of General Surgery, Minia University Hospital
ABSTRACT:
Aim: There are no standard guidelines for the management of nonpalpable testis (NPT).
The aim was to evaluate the results of laparoscopic diagnosis and treatment of NPT.
Patients and Methods: Between June 2005 and June 2007, 28 NPT in 27 patients
were included in this prospective study. Patients age ranged from 2 years to 22 years
(mean age 8+4 y).
Results: Laparoscopy was successful in localizing the site of testis in 27 of 28 NPT
(96.4%). The sites were: 8 low NPT (28.5%), 4 high NPT (14.3%), 3 peeping NPT
(10.7%) and 3 atrophic nubbins (10.7%). The intra-abdominal vanishing testis
syndrome was diagnosed in 9 NPT (32.2 %). Failed laparoscopy occurred in 1 patient
(3.5%) due to equipment failure. Laparoscopic orchiopexy was done for 11 NPT
(39.2%). Laparoscopic Fowler-Stephens technique was done for 4 high NPT (14.3%)
Laparoscopic orchidectomy was done in 3 atrophic NPT (10.7%). Testicular atrophy
was detected in 3 of 10 NPT (30%) after use of electrocautery versus no cases after
use of ultrasonic harmonic scalpel dissection (Chi-square test, P=0.0001).
Conclusion: Laparoscopy is the diagnostic modality of choice for evaluating the
nonpalpable testis because it is reliable and safe in locating the testis or in proving its
absence. Laparoscopic orchiopexy is feasible, safe and effective with good results.
The use of ultrasonic dissection and mobilization is associated with good outcome.
KEYWORDS:
Cryptorchidism
Diagnosis.
Minimal invasive surgery
exploration in cases of the vanishing
testis syndrome4. The use of laparoscopy for locating NPT was first
reported in 1976 by Cortesi et. al.,5 and
since then multiple reports on use of
laparoscopy have been published6,7.
Laparoscopic treatment is considered
the natural extension of the diagnostic
laparoscopy for the NPT8. In this
prospective study, the laparoscopic
management of NPT is presented as
regard the technique and the results.
INTRODUCTION:
Cryptorchidism affects approximately 1 in 150 boys1. Treatment of
the cryptorchid testicle is justified due
to the increased risk of infertility and
malignancy as well as the risk of
testicular trauma and psychological
impact on patients and their parents2.
Although the management of palpable
testis is standardized, there are no
formal guidelines for the management
of nonpalpable testis (NPT)3. The first
challenge is to determine whether the
testis is even present and, if so, where
it is located. Accurate preoperative
assessment and localization will assist
in selecting the most appropriate
surgical approach and could obviate
the need for inguinal surgical
PATIENTS AND METHODS:
Between June 2005 and June
2007, 28 NPT in 27 patients were
included in this prospective study.
Patient's age ranged from 2 years to 22
years (mean age 8+4). A testis was
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EL-MINIA MED., BULL., VOL. 19, NO. 2, JUNE, 2008
considered nonpalpable if it was not
palpable clinically and by abdominal
ultrasonography. Patients with bilateral
NPT, male phenotype and 46 XY
karyotype were first evaluated with a
human chorionic gonadotropin stimulation test and serum gonadotropin
levels. Diagnosis was anorchism if
such patients failed to respond to
human chorionic gonadotropin by an
increase in serum testosterone and if
basal serum gonadotropin levels were
elevated. A written informed consent
was given by parents. They were
informed about the possible loss or
atrophy of testis and the necessity of a
secondary procedure if a FowlerStevens
staged
procedure
was
necessary.
Hassanen
testis, the vas deferens, spermatic
vessels and the patency of internal
ring. High intra-abdominal NPT were
those located more proximal or
cephalad to iliac vessels. Low intraabdominal NPT were those located
between iliac vessels and the internal
inguinal ring. Peeping testicles were
those in the proximal portion in the
inguinal canal that can easily be seen
or retracted in the abdominal cavity. If
an intra-abdominal testicle was not
present, the vas and vessels were
followed distally to determine whether
they entered the internal ring together
or not. The intra-abdominal vanishing
testis syndrome was diagnosed if the
spermatic vessels and vas deferens
were noted to end blindly proximal to
the internal inguinal ring (fig 1).
Accordingly, inguinal surgical exploration was not performed in these
cases. If the vas deferens and spermatic
vessels were observed to enter the
internal inguinal ring, formal surgical
exploration was done.
After administration of general
anesthesia with endotracheal intubation, the bladder was first drained
with an 8F pediatric catheter. A small
infraumbilical incision was done to
introduce the Veress needle with the
patient in the Trendelenburg position.
The 5 mm laparoscopic trocar was
introduced after insufflation with
carbon dioxide to a pressure less than
10 mm Hg. The patient was placed in
the Trendelenburg position and pelviscopy was performed with 0 and 30
degrees telescopes. The bowel and
great vessels were visualized to rule
out injury during initial instrument
placement.
If an intra-abdominal testis was
identified, laparoscopic orchiopexy
was done. Two further ports 5 mm
were inserted under direct vision: one
in the right iliac fossa and the other one
in the left iliac fossa, and both were at
the midclavicular line. Laparoscopic
Fowler-Stephens technique may be
required in cases of high NPT. The vas
was identified and followed from the
point where it crossed the obliterated
umbilical artery to the epididymis
(fig.2). It was important to note if the
vas looped distally along the gubernaculum into the inguinal canal to avoid
its injury during mobilization of testis.
Mobilization of the testis was performed by incising of the peritoneum over
the superior border of the internal ring
(fig.3). The gubernaculum was
identified and mobilized circumferentially to provide traction by grasping its testicular end (fig 4). Disse-
Intraperitoneal examination for
a unilateral nonpalpable undescended
testis was begun with examination of
the normal contralateral internal
inguinal ring. Anatomic orientation
was facilitated by noting intraperitoneal landmarks as the medial
umbilical ligament, vas deferens,
external iliac vessels, inferior epigastric and spermatic vessels. The
affected side was then inspected to
evaluate any potential intra-abdominal
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EL-MINIA MED., BULL., VOL. 19, NO. 2, JUNE, 2008
ction was continued distally along the
gubernaculum until the scrotum began
to invaginate. The gubernaculum was
transected using electrocautery or
harmonic scalpel as far as possible.
The aim was to use it to manipulate the
testis without its injury. The peritoneum over the spermatic vessels was
freed laterally and medially (fig.5) by
grasping
the
free
edge
of
gubernaculum and swinging the testis
to either side. Dissection was
continued cranially toward the renal
hilum as far as possible to gain enough
length on the spermatic cord to allow
tension free orchiopexy (fig.6). The
peritoneum over the vas may also be
incised to gain additional length. We
avoided injuring the peritoneum that
bridges the spermatic vessels and the
vas since this area may contain
collateral vessels, which may be
important when the laparoscopic
Fowler – Stephens orchiopexy is
required. If the spermatic vessels
remained too short, we performed a
first stage Fowler-Stephens procedure
by placing 2 endoscopy clips as far
proximal as possible on the cord
vessels, the vessels were transected
between clips. If adequate length was
obtained, a laparoscopic orchiopexy
was performed. This was done by
passing an endoscopy dissector into the
5 mm port on the ipsilateral side of the
abdomen. The tip of the dissector was
placed medial to the inferior epigastric
vessels and lateral to the medial
umbilical ligaments on the anterior
abdominal wall. Then the dissector tip
was directed toward the ipsilateral
hemiscrotum. A 5 mm trocar cannula
was passed over the dissector through
the scrotal incision into the abdominal
cavity. The free end of gubernaculum
was grasped and the testis was brought
into approximation with the end of the
trocar. The testis, grasping forceps and
trocar were withdrawn through the
scrotum. The cord structures were
Hassanen
inspected to verify that they were not
twisted. Two 3-zero polydioxanone
sutures were used to complete the
orchiopexy distally as possible.
Finally, the pneuoperitoneum was
deflated and the fascia and skin were
closed. The time of the procedure was
estimated. The patient was discharged
on the second day. Follow-up was
done at one week and then at 1, 3, 6,
and 12 months. The size and site of
testis were evaluated.
STATISTICAL ANALYSIS:
Proportions and percentages
were used to summarize categorized
variables, while descriptive statistics
such as mean + (SD) were used for
numerical values. Chi-square test was
used to investigate the statistical
significance of any categorical values.
P value was considered significant if ≤
0.05.
RESULTS:
A total of 28 NPT in 27
patients were included in this
prospective study. Patients age ranged
from 2 years to 22 years (mean age
8+4 y). Nineteen NPT (67.8%) were in
pre pubertal stage and 9 NPT (32.2%)
were in post pubertal stage. The
distribution of NPT were as follow; 14
(50%) on the right side, 12 (42.8%) on
the left side and 2 (7.2%) bilaterally
(table 1). The patient with bilateral
NPT had a positive human chorionic
gonadotropin
stimulation
test.
Laparoscopy was considered technically successful if the testis was
visualized, the vas deferens and
spermatic vessels were observed
coursing through the internal ring, or
the vas deferens and spermatic vessels
were seen to end blindly. Based on
these criteria, 27 of 28 NPT (96.4%)
were laparoscopically localized or
determined to be absent. The laparoscopic findings were listed in (table 2).
The sites were: 8 low NPT (28.5%), 4
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EL-MINIA MED., BULL., VOL. 19, NO. 2, JUNE, 2008
high NPT (14.3%), 3 peeping NPT
(10.7%) and 3 atrophic nubbins
(10.7%). The intra-abdominal vanishing testis syndrome was diagnosed in
9 NPT (32.2%). Failed laparoscopy
occurred in 1 patient (3.5%) due to
equipment failure.
Hassanen
minutes. The mean hospital stay was
1.8 + 0.6 days.
The complications were listed
in (table 3). The intestine was punctured by the Veress needle in one
patient (3.5%). It was sutured laparoscopically with successful outcome.
Wound infection was detected in one
patient (3.5%).
Laparoscopic orchiopexy was
done for 11 NPT (39.2%) (8 low NPT
(28.5%) and the 3 peeping NPT
(10.7%). Laparoscopic Fowler-Stephens technique was done for 4 high
NPT (14.3%) (two stages were done in
3 NPT (10.7%) and one stage in one
NPT (3.5%). Laparoscopic orchidectomy was done in 3 atrophic NPT
(10.7%). In the present study 6 patients
(21.4%) had undergone prior inguinal
exploration elsewhere, with failure to
locate the testes. The mean laparoscopic operative time was 62 + 14.3
The mean length of follow-up
was 12 + 4.3 months. There have been
three cases with testicular atrophy. All
were detected after use of electrocautery in the dissection and mobilezation of NPT. No cases of testicular
atrophy were detected after dissection
and mobile-zation with ultrasonically
activated shears (Harmonic Scalpel).
The testes were located in the scrotum
in all orchiopexies.
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Hassanen
Table 1: Patient characteristics
Patient characteristics
Unilateral
Right side
Left side
Bilateral
Prepubertal
Postpubertal
Previous inguinal exploration
No.
26
14
12
2
19
9
6
%
92.9
50
42.2
7.1
67.8
32.2
21.4
Table 2: Laparoscopic findings of 28 testes
Laparoscopic findings
Low intra-abdominal
High intra-abdominal
Vanishing testis syndrome
Peeping
Atrophic nubbins
Failed
Total
No.
8
4
9
3
3
1
28
%
28.5
14.3
32.2
10.7
10.7
3.5
100
No.
1
1
1
1
%
3.5
3.5
3.5
3.5
Table 3: Complications
Complications
Small intestinal perforation
Preperitoneal insufflation
Paralytic ileus
Wound infection
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Hassanen
Fig 1: Blind end vas and vessels (vanishing testis).
Fig 2: The vas crosses the obliterated umbilical artery.
Fig.3 Incision of peritoneum over the superior border of internal ring .
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Hassanen
Fig 4: The gubernaculums was dissected circumferentially.
Fig 5: The peritoneum over the vessels was dissected lateral and medial.
Fig 6: The testis after mobilization (during pulling through the internal ring).
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Hassanen
DISCUSSION:
The evaluation and treatment of
NPT can be difficult as evidenced by
the multiple modalities for evaluation
and treatment options9. The classic
treatment has been inguinal exploration
with intra-peritoneal exploration until
the testis or hypo-plastic spermatic
vessels were identified. A high testis
may not be reached and visualization
of the vessels, when they are found,
may be inadequate using this approach.
In our study, we had 6 patients with
previous
inguinal
exploration
elsewhere that failed to diagnose the
absence or presence of testes. In
addition, preoperative knowledge of
testicular position facilitates the
placement of surgical incisions as well
as the choice of operative technique10.
Moreover, the decision to transect the
testicular vessels must be made early in
the exploration so that a wide
peritoneal strip can be left attached to
the vas deferens and testis distally to
preserve the vassal collateral vessels.
Disruption of this collateral supply
may occur during dissection, thus
adversely affecting the outcome11.
definitely prove its absence, which
allows optimal placement of incisions,
more rapid surgical identification of
the gonad and accurate selection of
orchiopexy technique15. The three
main laparoscopic findings in patients
with NPT include: intra-abdominal
testis, or vas deference and spermatic
vessels entering the internal inguinal
ring, and the vanishing testis syndrome
(the vessels and vas terminating
blindly before reaching the internal
inguinal ring)16. Based upon these
criteria, more than 96 % of the
laparoscopic examinations in our series
were successful. This excellent result
was not obtained by any other
modality. Beside its minimal invasive
nature17, laparoscopy has many other
advantages as: better visualization of
testis and vessels18, magnification of
the small collaterals19, permission of
higher dissection of the vessels20,
minimal and gentle handling of the
testis that contributed to preservation
of its delicate blood supply21. In our
study, this was reflected in obtaining
excellent results after laparoscopic
orchiopexy.
Several diagnostic modalities
have been advocated for the
assessment and diagnosis of NBT such
as
CT
or
MRI,
but
only
ultrasonography and laparoscopy have
been adopted into routine use.
Although ultrasonography is simple,
noninvasive and readily available in
every hospital, its use as a test to
ascertain the presence or absence of
NPT is extremely controversial
because intestinal loops full of gas
represent a barrier for ultrasound12.
Then, laparoscopy was used for
localization of NPT and in diagnosis of
vanishing testis syndrome without an
abdominal incision 13.
The early return to normal
activities may be not so important in
pediatric patients, but is very important
for their parents and family. Additionally, laparoscopic visualization of
blind-ending spermatic vessels and vas
deference (9 NPT; 32.2% in our series)
can accurately identify patients with
the intra-abdominal vanishing testis
syndrome and spare them further
operative intervention beyond laparoscopy22.
Laparoscopy has proved to be
successful to do Fowler-Stephene
technique23. In our study, it was done
in 4 NPT. The main advantage was the
higher dissection of the spermatic
vessels. Open surgery may not easily
permit this high dissection of vessels24.
Laparoscopy can accurately
identify the intra-abdominal testis14 or
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In addition, the extensive inguinal
dissection performed in search of intraabdominal testis may decrease the
success of Flower-Stephens orchiopexy.
Hassanen
Complications are reported in
laparoscopy in children as the anterior
wall of the abdomen is thinner
comparing with adults and this is why
the complications are higher in
children especially when an inappropriate Veress needle is used, the
intestine and vessels might be damaged
during insufflation or during insertion
of the needle28. The complication of
intestinal perforation by Veress needle
was reported in one of our early cases.
After this case, our technique was
changed from Veress needle to Hasson
method without further detection of
intestinal injuries.
NPT
is
best
diagnosed
clinically and treated by surgical
orchiopexy at age of 12 months25. In
our study, the mean age was 8±4 years
which is older than the optimum age
for surgery. This was explained by
refusal of the parents to address this
problem early for fear of social
considerations. Some families may
find this is shameful for the future of
their son. Others may delay the time of
surgery for fear of its complications.
Still some patients are detected only on
medical examination before military
registration.
In conclusion, laparoscopy is
the diagnostic modality of choice for
evaluating NPT because it is reliable
and safe in locating the testis or in
proving its absence. Laparoscopic
orchiopexy is feasible, safe and
effective with good results. The use of
ultrasonic dissection and mobilization
is associated with good outcome.
The mobilization of the testis
and its delicate blood supply was done
by electrocautery. It is well known that
electrocautery dissection has its own
hereditary drawbacks. These include:
widespread coagulation, vasospasm,
intimal damage26.
REFERENCES:
1. Esposito C and Garipoli V. The
value of 2-step laparoscopic FlowerStephen's orchiopexy for intraabdominal testis. J. Urol. 1997; 158:
1952-1954.
2. Denes FT, Saito FJ, Silva FA,
Giron AM, Machado M, Srougi M.
Laparoscopic diagnosis and management of nonpalpable testis. Int J Urol
2008;34(3):329-34.
3. Chang B, Palmer L and Franco
I. Laparoscopic orchiopexy: a review
of a large clinical series. B. J. U.
international. 2001;87:490-493.
4. Abolyosr A. Laparoscopic
versus open orchiopexy in the management of abdominal testis: a descriptive
study. Int. J. Urol. 2006;13:1421-1424.
5. Cortesi N, Ferrari P , Zambarda
E, Maneti A, Baldini A, Morano F.
Diagnosis of bilateral abdominal
The harmonic scalpel is a new
device that has been introduced to
surgery during the last decade. It is a
device that uses high-frequency
mechanical energy to cut and coagulate
tissues at the same time27. Laparoscopists were the first ones to use this
method widely. It has been proven to
decrease operation time and complications in studies of laparoscopic
abdominal surgery. Up to our
knowledge, no studies were published
about the results of its use in
laparoscopic mobilization of NPT. In
our study, we used harmonic scalpel in
mobilization of NPT. The results were
encouraging without any recorded
cases of testicular atrophy during 12
months follow-up. This represents a
refinement of our current technique.
84
EL-MINIA MED., BULL., VOL. 19, NO. 2, JUNE, 2008
cryptorchidism
by
laparoscopy.
Endoscopy. 1976;8-23.
6. Argoso R, Unda F, Ruiz O,
Garcid L. Diagnostic and therapeutic
laparoscopy for nonpalpable testis.
Surg. Endosc. 2003;17:11:1756-1758.
7. Casale
P,
Canning
D.
Advancement in laparoscopic instrumentation and refined technique has
allowed laparoscopic orchiopexy being
chosen as a treatment model for
impalpable
testis.
B.
J.
U.
2007;100:1197-1206.
8. El-Anany F, Gad El-Maula M,
Abdel Moneim A, Abdallah A,
Takahashi M, Kanayama H et al.,
Laparoscopy for impalpable testis:
classification-based
management.
Surg. Endosc. 2007;21:449-454.
9. Tsujihata M, Miyak O,
Yashimura
K,
Matsumiya
K.
Laparoscopic diagnosis and treatment
of nonpalpable testis. Int. J. Urol.
2001;8:692-6.
10. Savage V. Avoidance of
inguinal incision in laparoscopically
confirmed vanishing syndrome. J.
Urol. 2001;166:1421-1424.
11. Handa R, Kale R and Harjai M.
Laparoscopic orchiopexy: Is closure of
the internal ring necessary? J. Posgrad.
Med. 2005;51:266-267.
12. Elder JS. Ultrasonography is
unnecessary in evaluating boys with a
nonpalpable testis. Pediatrics. 2002;
110:748-751.
13. Sweemy DD, Marc CS, Steven
GD. Minimally invasive surgery for
urologic disease in children. Nat. Clin.
Pract. Urol. 2007;4:26-38.
14. Docimo SG. The results of
surgical therapy for cryptorchidism: a
literature review and analysis. J Urol.
1995;154:1148-1152.
15. Nassar
AH.
Laparoscopic
assisted orchiopexy: a new approach to
the impalpable testis .J. Ped. Surg.
1995;30:39.
16. Dhanani N, Cornellus D, Gunes
A, Ritchey M. Successful outpatient
Hassanen
management of the nonpalpable intraabdominal testis with staged FowlerStephens orchiopexy. J Urol. 2004;
172:2399-2401.
17. Jordan GH and Winslow BH.
Laparoscopic single stage and staged
orchiopexy. J. Urol. 1994;152:1249.
18. Poenaru D, Homsy Y, Peloquen
F, Andze G. Laparoscopic management of the impalpable abdominal
testis. Urology. 1993;42:574.
19. Wolffenbuttel KP, Kok DJ,
Den Hollander JC, Nijman JM.
Vanished testis: be aware of an abdominal testis .J. Urol.2000;163:957-958.
20. Thomas A, Wojno J, Bloom A.
The remnant orchiectomy. J. Urol.
1996;155:712-714.
21. Kanemoto K, Hayashi Y,
Kojima Y, Tozawa K, Mojami T,
Kohri K. The management of nonpalpable testis with combined groin
exploration and subsequent transinguinal laparoscopy. J. Urol. 2002;167:
674-676.
22. Cisek J, Peters A, Atala A,
Bauer B, Diamond A, Alan R. Current
findings in diagnostic laparoscopic
evaluation of the nonpalpable testis. J.
Urol. 1998;160:1145-1149.
23. Taran I, Elder J S. Results of
orchiopexy for the undescended testis.
Wourld J Urol. 2006;24:231-239.
24. Esposito C, Vallone G, Settimi
A, Sabin G, Amici G, Cusano T.
Laparoscopic orchiopexy without
division of the spermatic vessels: can it
be considered the procedure of choice
in case of intra-abdominal testis? Surg
Endosc. 2000;14:658-660.
25. Christophe G, Peter F, Francos
C, Patrice J, Blaise G, Pascal R, et al.,
Management of cryptorchidism in
children: guidelines. Swiss Med. 2008;
138:492-8.
26. Philip S., Patrick C., Chenyang
Xu, Junyan Gu, Nicholas S., Emile N.
Brown, et al., Harmonic scalpel versus
electrocautery for harvest of radial
artery conduits: Reduced risk of spasm
85
‫‪Hassanen‬‬
‫‪EL-MINIA MED., BULL., VOL. 19, NO. 2, JUNE, 2008‬‬
‫‪and intimal injury on optical coherence‬‬
‫‪tomography. J Thorac Cardiovasc Surg‬‬
‫‪2008;136:1302-8.‬‬
‫‪27. Amaral JF. The experimental‬‬
‫‪development of an ultrasonically acti‬‬‫‪veted scalpel for laparoscopic use.‬‬
‫‪Surg Laparosc Endosc. 1994;4:92-99.‬‬
‫‪28. Lojanapiwat B, Soonthrnpun S,‬‬
‫‪Wudhikam S. Preoperative laparo‬‬‫‪scopy in the management of the‬‬
‫‪nonpalpable testis. J Med Assoc Thai‬‬
‫‪1999;82:1106-10.‬‬
‫عالج الخصية المعلقة الغير محسوسة بواسطة منظار البطن الجراحي‬
‫أيمن حسانين‬
‫قسم الجراحة العامة – مستشفى المنيا الجامعي‬
‫ال توجد خطوط واضحة لعالج الخصية المعلقة و الغير محسوسة‪ ,‬لذلك كان الهدف من‬
‫هذذذا الدراسذذة هذذو تقيذذيا تتذذا م اسذذتخداا متجذذار الذذشطن الجراحذ ذ ت ذذخي و عذذالج الخصذذية‬
‫المعلقذذة الغيذذر محسوسذذةت وإذذد تذذا اجذذراف هذذذا الشحذ ذ إسذذا الجراحذذة العامذذة شمست ذ المتيذذا‬
‫ال ترة من يوتيو ‪ 2005‬وحت يوتيو ‪2007‬ت وإد ا تملت الدراسة عل ‪ 27‬مريضا‬
‫الجامع‬
‫شها ‪ 28‬خصية معلقة تراوحت أعمارها ما شين عامين وحتذ ‪ 22‬عامذا حيذ تذا اجذراف متجذار‬
‫الشطن الجراح لها جميعا وكاتت التتا م كما يل ‪:‬‬
‫تا اجراف متجار الشطن الجراح شتجاح عذدد ‪ 27‬مذن أصذ ‪ 28‬خصذية معلقذة شتسذشة تجذاح‬
‫شلغت ‪ % 96.4‬وكاتذت أمذاكن تواجذد الخصذ كمذا يلذ ‪ 8 :‬خصذ معلقذة سذ ل ‪ ,)% 28.5‬و‬
‫عدد ‪ 4‬خص معلقة عليا ‪ ,)% 14.3‬و عدد ‪ 3‬خصذ شاغةذة مذن ال قذ ‪ )% 10.7‬وعذدد ‪3‬‬
‫شقايذذا خص ذ ضذذامرةت وشلغذذت حذذاالت الخص ذ المتال ذذية الغا لذذة) عذذدد ‪ 9‬خص ذ ‪)% 32.2‬‬
‫وشلغذت تسذشة ال ذ حالذة واحذذدة ‪ )% 3.5‬وحذد ذلذك لتعطذ الجهذذاغ عذن العمذ ت وتذا ت شيذذت‬
‫الخصية شتجاح ‪ 11‬خصية ‪ )% 39.2‬وتا است صا الخصية عن طريق المتجار عدد ‪3‬‬
‫حاالت ‪ )% 10.7‬وإد لوحج حدو ضمور الخصية أ تاف ترة المتاشعة حالذة اسذتخداا‬
‫جهاغ الك الجراح شيتما لا يحد ذلك عتد اسذتخداا جهذاغ الت ذريا شالموجذات ال ذوي صذوتية‬
‫حي كان لذلك داللة احصا يةت‬
‫وإذد تذا اسذتتتاج أن متجذار الذشطن الجراحذ هذو الطريقذة الت خيصذية الم لذ ذ تقيذيا الخصذية‬
‫المعلقة حيذ أتذآ نمذن و دإيذق ذ تحديذد مكذان الخصذية أو التذدلي علذ عذدا وجودهذات وتتذا م‬
‫ت شيذذت الخصذذية ذ كذذيأ الص ذ ن أيضذذا تذذدل عل ذ أتهذذا طريقذذة نمتذذة كمذذا أن اسذذتخداا جهذذاغ‬
‫الموجات ال وي صوتية تحريك الخصية يكون مصحوشا شمردود جيدت‬
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