The main challenge of surgical repair is tension-free placement of the testes in the scrotum while avoiding damage to the testicular vessels and atrophy of the testicle. In 1959, Fowler and Stephens described a technique for high UDTs; this technique divides the foreshortened testicular artery, allowing the mobilization of the testis to the scrotum [18]. This was later modified in 1984 by Ransley et al. who described a two-stage technique. First, a preliminary vessel ligation is performed, allowing development of collateral vessels; 6–8 weeks later, the testis is placed in the scrotum [19].

Diagnostic laparoscopy for UDT was first introduced by Cortesi in 1976 and is currently the gold standard for the diagnosis of a non-palpable testis [20]. The laparoscopic approach for cryptorchidism was first described in 1994 [21] and has replaced the combined inguinal/retroperitoneal open approach.

A UDT may be situated along its normal route of descent or in an ectopic position . Therefore, the role of the physician is to differentiate between palpable or non-palpable and uni- or bilaterally UDT, which will help determine the treatment algorithm [22]. Assessment of UDT may be difficult in an awake and uncooperative child or in an obese child with a large suprapubic fat pad. Also, distinguishing between a testis and thickened gubernaculum can be challenging, perhaps requiring additional examination in a follow-up visit. The baby is positioned supine in a relaxed environment, and each side is assessed with the index finger sliding from above the inguinal area to block off the external ring. If the testis is identified, it should be grasped by the opposite hand and pulled gently down to the scrotum. Once in the scrotum, it is released. If the gonad stays in the scrotum, the diagnosis of retractile testicle is made, and no surgical procedure is warranted. Should there be any question regarding retractile versus cryptorchid testis , a reevaluation can be scheduled. A non-palpable testis could represent testicular agenesis/dysgenesis, an intra-abdominal UDT, or atrophy from antecedent torsion, the distinctions between them made at laparoscopy. A helpful clinical finding is that in the presence of testicular atrophy , the contralateral testis is often hypertrophied [23].

Laboratory tests are not routinely performed. In older boys, semen analysis can be performed to establish a baseline and subsequently during follow-up to assess sperm quality and motility after surgery. In cases where there is bilateral non-palpable UDT, a human chorionic gonadotropin (HCG) simulation test is helpful to determine if there is any functioning testicular tissue [1]. On occasion, full descent will be noted after HCG, allowing the clinician to arrive at the diagnosis of retractile testes. While the testicles will recede as the hormonal stimulation dissipates, the condition will correct itself at puberty.

Imaging modalities such as US, computed tomography, and magnetic resonance have been used, although these have low sensitivity and specificity in localizing UDT [2, 3]. Even if no intra-abdominal testes are identified with imaging, their presence is not excluded in an intra-abdominal location [2, 3]. Laparoscopic evaluation is still advised, so many clinicians choose to skip imaging altogether in the case of impalpable testicles.

Testicles above the scrotum at 6 months of age are unlikely to descend spontaneously, and surgery should be considered [4, 5]. The appropriate age of orchiopexy has decreased with time; initially orchiopexy was delayed until 5 years of age [1], though others recommended it before 2 years of age [6]. Current recommendations deem that orchiopexy should be performed by age 1 year, as dysplastic changes in the gonad begin to show up at that time, although no improvement in testicular function has been reported.

The indications for surgery are non-palpable abdominal testis , high-canalicular testes, bilateral cryptorchidism, abdominal wall defects, polyorchidism, splenogonadal fusion, and transverse testicular ectopia [7, 24]. A laparoscopic approach may be contraindicated in the presence of extensive prior retroperitoneal or abdominal surgery, prior peritonitis, abdominal wall infection, large hernia, cardiopulmonary disease, or coagulopathy [7].

The testis is a paired organ surrounded by the tunica albuginea and subdivided into numerous lobules by fibrous septa. The seminiferous lobules open into the rete testis, where they join the efferent duct and epididymis, which drains to the vas deferens. The vas courses through the inguinal canal; the seminal vesicles join to form the ejaculatory duct, which opens before the prosthetic urethra. Arterial supply is via the spermatic, vas deferential, and external cremasteric arteries. Venous drainage is through pampiniform plexus, which drains into the internal spermatic vein; the right then joins the IVC, and the left drains directly into the renal vein. Testicular lymphatics drain into the retroperitoneal lymph nodes, the right into the interaortocaval area, and the left into the para-aortic area.

The operative management of a high intra-abdominal testis can be challenging due to the presence of a short spermatic cord that limits testis mobility and precludes a tension-free orchiopexy . The surgeon must be familiar with various techniques to help determine which option is best for each patient.

The patient is catheterized to empty the urinary bladder and then prepped from xiphoid to mid thighs.

The patient is positioned supine, and the surgeon will stand on the side opposite the patient’s undescended testicle, e.g., on the right side of the table for left cryptorchidism. After port placement, the table should be rolled so the side of cryptorchidism is elevated, allowing easier visualization of the retroperitoneum.