5 year old boy presented with swelling of left scrotom which increases in size with standing  n decrease with sleep.

He complaint of pain on both testis for 15days...
O/e...left side testis is palabable
         Rt side...inginal hernia ,testis in not palpable separately 
Usg scrotum done...which reported it as...
  Testis not visible in rt scrotum or inguinal region..
    Rt sided hydrocele
     Lt side testis visible in scrotom
What is algorithm of investigation for this case?
What management plan for this case?
Is there any role of MRI or CT for localisation of testis in this case? Or straight away lap exploration?



  • Dr. Anil Takvani
    Dr. Anil Takvani
    17 Apr 2020 09:48:45 PM

    No more investigations in this case.

    Right inguinal exploration is the way to go forward in this case.
    Dissect the sac till deep inguinal ring.
    Open the sac and identify testis and cord.
    Do careful dissection of cord at deep inguinal ring from posterior layer of sac.
    Do high ligation of sac at deep inguinal ring.
    Mobilise cord adequately to reroute testis and cord into scrotum without tension.
    Put the testis in sub dartous pouch.
    Another option in a case of unilateral non palpable testis is laparoscopic exploration.
    But in this case as there is hernia/hydrocele I will prefer to go for an open exploration.
    No role of CT/MRI. Do not waste time and resources.
    As testis is not palpable , do not promise parents that you will bring testis in scrotum for sure. Explain all possibilities...

  • Tikenjit Mazumdar
    Tikenjit Mazumdar
    17 Apr 2020 10:06:17 PM

    Sir as usg is not showing testis in scrotom or inguinal region?what should be d approach...  Inguinal exploration and then lap exploration?or

    confirm location by doing other investigation like mri  and then proceed?
    Parents r not concern about hernia repair,but more concerned about presence or absence of testis.

  • Dr. Anil Takvani
    Dr. Anil Takvani
    17 Apr 2020 10:18:21 PM

    I answered your quarry.

    Inguinal exploration. No to MRI/CT or any other investigations in case of unilateral non palpable testis.
    With negative CT/MRI, you can not say testis is not there.
    With positive comment of presence of testis like structure in CT/MRI, you can not promise presence of testis and you will bring it in scrotum for sure.
    Please find out false positive and false negative with CT/MRI and exact utility of these investigations in cases of UDT!!! 

  • Tikenjit Mazumdar
    Tikenjit Mazumdar
    18 Apr 2020 01:10:43 PM

    Thanks u sir....

    Some more queries I have if I may...
    How we should have proceeded if bilateral testis were not palpable in testsi or groin in this case?

  • Altaf Khan
    Altaf Khan
    18 Apr 2020 10:34:01 PM

    Dear Anil Takvani Sir,

    In this case, since right testis is not visible in scrotum or inguinal region in ultrasound, I feel laparoscopic exploration before inguinal incision will help if testis is located high in the pelvis and we are not able to bring it down by inguinal approach.

  • Dr. Anil Takvani
    Dr. Anil Takvani
    19 Apr 2020 08:11:11 AM

    Dear Dr.  Altaf, 

    I agree with you. 
    I have mentioned laparoscopy in my first response.
    In my experience when patient present clinically with unilateral hernia with undescended testis most of the time testis is there as hernia content. 

  • Dr Prashant Mulawkar
    Dr Prashant Mulawkar
    24 Apr 2020 06:35:49 PM

    No need of CT or MRI

    No Need of laparoscopy
    Clinically the right scrotum is well developed. I am expecting to see the testis in canal
    Explore by inguinal approach, you would mostly get the testis in the canal
    If you do not see the testis in the canal proceed as below
    A: Try to dissect proximally , mostly you would get the testis in retroperitoneum. 
    If you do not get the testis
    B: Consider laparoscopy

    If the scrotum is not well developed (which is not the case here) and the testis is not palpable under anesthesia, consider laparoscopy 

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