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Academic Hospital, Rotterdam Sophia Children's Hospital, 3000 CB Rotterdam, The Netherlands
We read with interest the report about seminomas in intraabdominal testes in three adult patients with a history of inguinal hernia repair or orchiopexy [1]. In these men, the presence of an intraabdominal testis was missed on inguinal exploration during childhood or adolescence. The imaging findings of these tumors are well described.
However, we wonder what the authors mean by their recommendation of follow-up with close examination of the abdomen in patients after prior negative surgical findings. Imaging, mostly sonography, is not the method of first choice because of its lack of sensitivity for revealing an intraabdominal testis [2]. Inguinal exploration is also known to be an unreliable method of investigating an impalpable testis. In a report, laparoscopy revealed 13 of 22 impalpable testes despite previous negative surgical findings at inguinal exploration [3]. The best method to search for an impalpable testis is laparoscopy. In selected cases, an alternative may be an inguinal procedure, but this procedure must include exploration of the abdominal cavity, with the opening of the peritoneum, if a testis or testis remnant cannot be found in the inguinal region. The diagnosis of testicular agenesis is justified only after thorough abdominal and inguinal exploration.
References
1
Northwestern Memorial Hospital, Northwestern University Medical Center,
Chicago IL, 60611
2
Hoag Memorial Hospital, Newport Beach, CA 92660
3
Meridian Regional Imaging, Gurnee, IL 60031
4
Hoag Memorial Hospital, Newport Beach, CA 92660
Thank you for your interest in our article "Seminomas Complicating Undescended Intraabdominal Testes in Patients with Prior Negative Findings from Surgical Exploration" [1]. Your letter emphasizes several important patient treatment issues that complement the imaging evaluation of these patients. We agree that the diagnosis of testicular agenesis is rare and must be a diagnosis of exclusion after thorough abdominal and inguinal exploration and imaging. The detection of intraabdominal testes is important because of the risk of the development of cancer, as shown in our article.
We did not address the management of undescended testes because a number of reasonable approaches exist. Surgical exploration or laparoscopy, often performed without imaging guidance, are important methods that can be used to detect intraabdominal testes not initially identified by palpation or inguinal exploration. At most institutions, laproscopy has replaced laparotomy because of its less invasive nature and low rate of patient morbidity. Laparoscopy has the advantage over imaging studies of revealing that the testis is absent when a blind-ending intraabdominal vas deferens and spermatic vessels are seen.
The role of imaging in undescended testes is controversial. If the patient does not want to undergo an invasive procedure, such as laparoscopy or laparotomy, careful examination using imaging tests, such as MR imaging, CT, or sonography, should be performed. Imaging is most valuable in confirming suspected malignancy. Many urologists perform surgery to detect undescended testes without imaging studies. Others find imaging studies helpful for localizing undescended testes and directing the surgical procedure. Since publication of many of the initial reports, there have been considerable improvements in sonography, helical CT, and MR imaging technology, which presumably will make detection of an undescended testis more likely. If imaging tests fail to localize a testis, laparoscopy or surgical exploration should be performed when indicated [2, 3]. It should be noted that surgery is not always definitive because one of the patients in our study [1] did have prior surgical exploration and hernia repair with clips near the undescended intraabdominal testis in which cancer developed.
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