Question
An 11-month-old boy, who was recently treated for a urinary tract infection, presents for evaluation of an absent right testis. On examination, the right hemiscrotum is empty, and the right testis is not palpable. Ultrasonography (image shown) suggests an undescended right testis, but its exact location cannot be determined with certainty.
What is the most appropriate next step in the management of this child?
| A. |
Observation
|
| B. |
Laparoscopy
|
| C. |
Orchidopexy
|
| D. |
Surgical exploration
|
Show Answer
|
Correct Answer » B
Explanation
|
|
- The ultrasound demonstrates a small ovoid structure suggestive of an undescended testis.
- However, ultrasonography has limited sensitivity and specificity for accurately localizing a non-palpable testis.
- Imaging should not replace surgical evaluation when a testis is non-palpable.
Explanation of the Clinical Scenario
This child has:
- Empty right hemiscrotum
- Non-palpable right testis
- Persistent cryptorchidism at 11 months of age
Normally, spontaneous descent occurs by 6 months of age (corrected age). An undescended testis persisting beyond this age requires surgical evaluation.
For a non-palpable undescended testis, the recommended investigation and initial management is diagnostic laparoscopy, which is considered the gold standard.
B. Laparoscopy
Laparoscopy is the investigation and treatment of choice for a non-palpable undescended testis because it:
- Accurately identifies an intra-abdominal or absent testis.
- Differentiates between an intra-abdominal testis, atrophic testis, and vanishing testis.
- Allows definitive treatment during the same procedure.
- If a viable testis is identified, laparoscopic orchidopexy can be performed.
- If the testis is atrophic, orchidectomy may be performed.
Therefore, diagnostic laparoscopy is the next appropriate step.
Why the Other Options Are Incorrect
A. Observation
- Observation is appropriate only until approximately 6 months of age, as spontaneous descent beyond this age is uncommon.
- At 11 months, surgical management is indicated.
C. Orchidopexy
- Orchidopexy is performed after the testis has been localized.
- In a non-palpable testis, laparoscopy is required first to identify the location and determine the appropriate surgical procedure.
D. Surgical Exploration
- Blind inguinal exploration is not recommended for a non-palpable testis.
- Diagnostic laparoscopy is the preferred initial approach because it can evaluate both the inguinal and intra-abdominal regions.
