A syndrome of non-palpable testis: history and current state of art. Literature Review

Abstract

By to the domestic and foreign literature, non-palpable testes are found in 20% of cases among children with cryptorchidism. Approximately 50% of them are located in the abdominal cavity and 50% are atrophied or vanished ones. Purpose: To systematize data of the scientific literature on the syndrome of non-palpable testes in children. For the review, original articles found in the scientific source engines, such as eLibrary, PubMed, and Scopus, were used.

Most often, literature sources divide non-palpable testes into three types: intra-abdominal, extra-abdominal, and non-viable. Extra-abdominal gonads are often of the normal volume, unlike intra-abdominal gonads which are mostly hypoplastic. Testicular ectopia is one of the variants of non-palpable testes when a testis cannot be detected on the usual migration path from the abdominal cavity. In children with cryptorchidism, testicular ectopia is observed only in 5% of cases, thus making it a rare case which poses certain challenges in diagnostics. There are many controversial issues regarding diagnostic methods and treatment strategies for different types of non-palpable testes in children. Most researchers recommend to use additional visualization options such as ultrasound, computed tomography, magnetic resonance imaging, and laparoscopy to confirm the presence or absence of the gonad. However, a definitive diagnosis is not always possible when based solely on ultrasound findings, as this method has limited sensitivity and specificity in detecting non-palpable gonads. The current publications state that an intra-abdominal testis can be visualized during diagnostic laparoscopy in 49% of case in boys with the non-palpable testicular syndrome and with no gonad found at ultrasound examination. Management of non-palpable testes in children, especially with high intra-abdominal gonad location, remains a highly relevant issue and requires further researches and observations.

Keywords

nonpalpable testes / abdominal cryptorchidism / children

References

[1] Leslie SW, Sajjad H, Villanueva CA. Cryptorchidism. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025.

[2] Razumovskii AYu, editor. Detskaya khirurgiya: natsionalnoe rukovodstvo. 2nd ed., reprint. and add. Moscow: GEOTAR-Media; 2021. (In Russ.)

[3] Xia Q, Kuang T, Lin X, Zhang H. Testicular Tumor Arising From an Intra-abdominal Undescended Testis in a 1-year-old Child: a Case Report and Literature Review. Front Pediatr. 2023;11:1142157. doi: 10.3389/fped.2023.1142157

[4] Shepard CL, Kraft KH. The Nonpalpable Testis: a Narrative Review. J Urol. 2017;198(6):1410–1417. doi: 10.1016/j.juro.2017.04.079

[5] Zhou W, Li S, Wang H, et al. Ultrasound Manifestations and Clinical Features of Nonpalpable Testis in Children. Sci Rep. 2022;12(1):12245. doi: 10.1038/s41598-022-16230-2

[6] Mamoulakis C, Antypas S, Sofras F, et al. Testicular Descent. Hormones (Athens, Greece). 2015;14(4):515–530. doi: 10.14310/horm.2002.1634

[7] Hutson JM, Li R, Southwell B, et al. Regulation of Testicular Descent. Pediatr Surg Int. 2015;31(4):317–325. doi: 10.1007/s00383-015-3673-4

[8] Hadziselimovic F. Involvement of Fibroblast Growth Factors and Their Receptors in Epididymo-Testicular Descent and Maldescent. Mol Syndromol. 2016;6(6):261–267. doi: 10.1159/000444033

[9] Hadziselimovic F. On the Descent of the Epididymo-testicular Unit, Cryptorchidism, and Prevention of Infertility. Basic Clin Androl. 2017;27:21. doi: 10.1186/s12610-017-0065-8

[10] Rey RA, Grinspon RP. Anti-Müllerian Hormone, Testicular Descent and Cryptorchidism. Frontiers in Endocrinology. 2024;15:1361032. doi: 10.3389/fendo.2024.1361032

[11] Sepúlveda X, Egaña PL. Current Management of Non-palpable Testes: a Literature Review and Clinical Results. Transl Pediatr. 2016;5(4):233–239. doi: 10.21037/tp.2016.10.06

[12] Elderwy AA, Kurkar A, Abdel-Kader MS, et al. Laparoscopic Versus Open Orchiopexy in the Management of Peeping Testis: a Multi-institutional Prospective Randomized Study. J Pediatr Urol. 2014;10(4):605–609. doi: 10.1016/j.jpurol.2014.06.006

[13] Punwani VV, Wong JSY, Lai CYH, et al. Testicular Ectopia: Why Does It Happen and what Do We Do. J Pediatr Surg. 2017;52(11):1842–1847. doi: 10.1016/j.jpurol.2014.06.006

[14] Alaqeel SM, Hakeem AH, Almaary JO. Testicular Ectopia in a Child’s Anterior Abdominal Wall: a Case Report and Literature Review. Am J Case Rep. 2020;21:e927495. doi: 10.12659/AJCR.927495

[15] Iliodromiti Z, Karapati E, Sokou R, et al. Bilateral Ectopic Femoral Testes: a Rare Cause of Empty Scrotum. Urol Case Rep. 2020;33:101348. doi: 10.1016/j.eucr.2020.101348

[16] Ngowi BN, Bright F, Mbwambo JS, et al. Perineal Ectopic Testis in Adult: Experience From Tertiary Hospital, Northern Tanzania. Int J Surg Case Rep. 2022;92:106817. doi: 10.1016/j.ijscr.2022.106817

[17] Priam A, Chabani N, Klein C, Haraux E. Scrotal Orchidopexy for Perineal Ectopic Testis. Arch Pediatr. 2022;29(5):404–406. doi: 10.1016/j.arcped.2022.03.005

[18] Piplani R. A Rare Presentation of Transverse Testicular Ectopia and Role of Laparoscopy. Afr J Paediatr Surg. 2023;20(1):74–76. doi: 10.4103/ajps.ajps_133_21

[19] Sipani M, Bhat A, Prabhakar G. Transverse Testicular Ectopia: a Report of Five Cases and Review of Literature. J Indian Assoc Pediatr Surg. 2020;25(6):404–407. doi: 10.4103/jiaps.JIAPS_17_20

[20] Gholizadeh M, Fakhre Yasseri AM. Unilateral Transverse Testicular Ectopia With Recurrence of Inguinal Hernia: a Case Report. J Med Case Rep. 2023 Feb 27;17(1):69. PubMed PMID: 36843109

[21] Mao CK, Yuan-Fang, Cao YS. Management of Pediatric Vanishing Testes Syndrome Based On Pathological Diagnosis: a Single-center Retrospective Study. Sci Rep. 2024;14(1):9437. doi: 10.1038/s41598-024-59583-6

[22] Heksch Ra, Matheson MA, Tishelman AC, et al. Testicular Regression Syndrome: Practice Variation In Diagnosis And Management. Endocr Pract. 2019;25(8):779–786. doi: 10.4158/EP-2019-0032

[23] Elamo HP, Virtanen HE, Toppari J. Genetics of Cryptorchidism and Testicular Regression. Best Pract Res Clin Endocrinol Metab. 2022;36(1):101619. doi: 10.1016/j.beem.2022.101619

[24] Kolon TF, Herndon CDA, Baker LA, et al. Evaluation and Treatment of Cryptorchidism: AUA Guideline. J Urol. 2014;192(2):337–345. doi: 10.1016/j.juro.2014.05.005

[25] Bajaj M, Upadhyay V. Age at Referral for Undescended Testes: Has Anything Changed in a Decade. N Z Med J. 2017;130(1457):45–49.

[26] Smith SC, Nguyen HT. Barriers to Implementation of Guidelines for the Diagnosis and Management of Undescended Testis. F1000Res. 2019;8 doi: 10.12688/f1000research

[27] Niedzielski JK, Oszukowska E, Słowikowska-Hilczer J. Undescended Testis — Current Trends and Guidelines: a Review of the Literature. Arch Med Sci. 2016;12(3):667–677. doi: 10.5114/aoms.2016.59940

[28] Ulubay M. Perineal Ectopic Testis: a Rare Congenital Anomaly. Urol Case Rep. 2019;24:100853. doi: 10.1016/j.eucr.2019.100853

[29] Liu J, Xiu W, Sui B, et al. Open Controversies On the Treatment of Undescended Testis: an Update. Front Pediatr. 2022;10:874995. doi: 10.3389/fped.2022.874995

[30] Vikraman J, Donath S, Hutson Ao JM. Undescended Testes: Diagnosis and Timely Treatment in Australia (1995-2014). Aust Fam Physician. 2017;46(3):152–158.

[31] Zhou W, Li S, Wang H, et al. Ultrasound Manifestations and Clinical Features of Nonpalpable Testis in Children. Sci Rep. 2022;12(1):12245.

[32] Braga LH, Kim S, Farrokhyar F, Lorenzo AJ. Is There an Optimal Contralateral Testicular Cut-off Size That Predicts Monorchism in Boys With Nonpalpable Testicles. J Pediatr Urol. 2014;10(4):693–698. doi: 10.1016/j.jpurol.2014.05.011

[33] Vos A, Vries AM, Smets A, et al. The Value of Ultrasonography in Boys With a Non-palpable Testis. J Pediatr Surg. 2014;49(7):1153–1155. doi: 10.1016/j.jpedsurg.2013.09.011

[34] Iqbal N, Hasan A, Saghir S, et al. Laparoscopic Orchiopexy for Management of Bilateral Non-Palpable Testes. J Ayub Med Coll Abbottabad. 2020;32(4):445–449.

[35] Wang SQ, FY Ren, Wang JH, et al. Diagnostic Value of Multislice Spiral Computed Tomography (CT) Combined With CT Angiography for Intra-abdominal Undescended Testis Secondary Seminomas. Cancer Imaging. 2019;19(1):24. doi: 10.1186/s40644-019-0210-z

[36] Shehata SM, Shehata SMK, Baky Fahmy M. The Intra-abdominal Testis: Lessons From the Past, and Ideas for the Future. Pediatr Surg Int. 2013;29(10):1039–1045. doi: 10.1007/s00383-013-3406-5

[37] Aggarwal H, Kogan BA. The Role of Laparoscopy in Children With Groin Problems. Transl Androl Urol. 2014;3(4):418–428. doi: 10.3978/j.issn.2223-4683.2014.12.11

[38] Mah LW, Durbin-Johnson B, Kurzrock EA. Non-palpable Testis: Is Management Consistent and Objective. J Pediatr Urol. 2020;16(1):62–68. doi: 10.1016/j.jpurol.2019.11.015

[39] Eldirdiri ES, Elssayed O, Elssayed A. The Role of Laparoscopy in Non-palpable Undescended Testicle: Analysis and Review of the Experience From Two Cities in Sudan. Afr J Paediatr Surg. 2022;19(3):127–132. doi: 10.4103/ajps.AJPS_39_21

[40] Gonzalez KW, et al. The Anatomic Findings During Operative Exploration for Non-palpable Testes: a Prospective Evaluation. J Pediatr Surg. 2016;51(1):128–130. doi: 10.1016/j.jpedsurg.2015.10.031

[41] Haid B, Rein P, Oswald J. Undescended Testes: Diagnostic Algorithm and Treatment. Eur Urol Focus. 2017;3(2–3):155–157. doi: 10.1016/j.euf.2017.05.009

[42] Orlov VM, Kogan MI, Sizonov VV, Kagantsov IM. The Volume of the Contralateral Testis in Unilateral Non-palpable Cryptorchidism a Diagnostic Criterion to Optimize Surgical Strategy. Urologiia. 2018;(2)89–93.

[43] Radmayr C, Dogan HS, Hoebeke Piet, et al. Corrigendum to “Management of Undescended Testes: European Association of Urology/European Society for Paediatric Urology Guidelines” [J Pediatr Urol 12 (2016) 335–343]. J Pediatr Urol. 2017;13(2):239. doi: 10.1016/j.jpurol.2017.02.011

[44] Gates RL, Shelton J, Diefenbach KA, et al. Management of the Undescended Testis in Children: an American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee Systematic Review. J Pediatr Surg. 2022;57(7):1293–1308. doi: 10.1016/j.jpedsurg.2022.01.003

[45] Wei Y, Wang Y, Tang X, et al. Efficacy and Safety of Human Chorionic Gonadotropin for Treatment of Cryptorchidism: a Meta-analysis of Randomised Controlled Trials. J Paediatr Child Health. 2018;54(8):900–906. doi: 10.1111/jpc.13920

[46] Shehata S, Hadziselimovic F, Khater D, Kotb M. The Management of Intraabdominal Testis: a Survey of the World Federation of Associations of Pediatric Surgeons (WOFAPS) Practices. Front Pediatr. 2022;10:928069. doi: 10.3389/fped.2022.928069

[47] Chan E, Wayne C, Nasr A. Ideal Timing of Orchiopexy: a Systematic Review. Pediatr Surg Int. 2014;30(1):87–97. doi: 10.1007/s00383-013-3429-y

[48] Suskind A, Hayner-Buchan A, Feustel PJ, Kogan BA. Fibrosis Correlates With Detailed Histological Analysis of Human Undescended Testes. BJU Int. 2008;101(11):1441–1445. doi: 10.1111/j.1464-410X.2007.07406.x

[49] Krishna, O.H & Kotaiah, Mandakini & K., Geetha & G., Santosh & P., Srinivas & Kota, Ramesh. (2019). Cryptorchidism and its Effects on Histomorphology of Testis in Paediatric Age Group. Journal of Evolution of Medical and Dental Sciences. 8(31):2480–2484. doi: 10.14260/jemds/2019/540

[50] Loebenstein M, Thorup J, Cortes D, et al. Cryptorchidism, Gonocyte Development, and the Risks of Germ Cell Malignancy and Infertility: a Systematic Review. J Pediatr Surg. 2020;55(7):1201–1210. doi: 10.1016/j.jpedsurg.2019.06.023

[51] Hadziselimovic F. Temperature Is Not a Major Factor in the Differentiation of Gonocytes Into Ad Spermatogonia and Fertility Outcome in Congenitally Cryptorchid Boys. Basic Clin Androl. 2022;32(1):2. doi: 10.1186/s12610-021-00152-6

[52] Huff DS, Fenig DM, Canning DA, et al. Abnormal Germ Cell Development in Cryptorchidism. Horm Res. 2001;55(1):11–17. doi: 10.1159/000049957

[53] Verkauskas G, Malcius D, Dasevicius D, Hadziselimovic F, et al. Histopathology of Unilateral Cryptorchidism. Pediatr Dev Pathol. 2019;22(1):53–58. doi: 10.1177/1093526618789300

[54] Mechlin CW, Kogan BA. What Lessons Can Be Learned From Testicular Histology in Undescended Testes. Transl Androl Urol. 2014;3(4):365–369. doi: 10.3978/j.issn.2223-4683.2014.10.01

[55] Wayne C, Chan E, Nasr A, Canadian Association of Paediatric Surgeons Evidence-Based Resource. What Is the Ideal Surgical Approach for Intra-abdominal Testes? a Systematic Review. Pediatr Surg Int. 2015;31(4):327–338. doi: 10.1007/s00383-015-3676-1

[56] Neheman A, Shumaker A, Grazi J, et al. Standardized Single-stage Laparoscopic Fowler-Stephens Orchiopexy Regardless of Testis Position: Modification of Technique Eliminates the Need for Intra-operative Decision-making. J Minim Access Surg. 2022;18(4):591–595. doi: 10.4103/jmas.jmas_312_21

[57] Narayanan SK, Puthenvariath JN, Somnath P, Mohanan A. Does the Internal Inguinal Ring Need Closure During Laparoscopic Orchiopexy With Prentiss Manoeuvre. Int Urol Nephrol. 2017;49(1):13–15. doi: 10.1007/s11255-016-1438-1

[58] Alagaratnam S, Nathaniel C, Cuckow P, Duffy P, et al. Testicular Outcome Following Laparoscopic Second Stage Fowler-Stephens Orchidopexy. J Pediatr Urol. 2014;10(1):186–192. doi: 10.1016/j.jpurol.2013.08.005

[59] Bae KH, Park JS, Jung HJ, Shin HS. Inguinal Approach for the Management of Unilateral Non-palpable Testis: Is Diagnostic Laparoscopy Necessary. J Pediatr Urol. 2014;10(2):233–236. doi: 10.1016/j.jpurol.2013.09.022

[60] Arena S, P Impellizzeri, P Perrone, et al. Is Inguinal Orchidopexy Still a Current Procedure in the Treatment of Intraabdominal Testis in the Era of Laparoscopic Surgery. J Pediatr Surg. 2017;52(4):650–652. doi: 10.1016/j.jpedsurg.2016.08.030

[61] Yu C, Long C, Wei Yi, et al. Evaluation of Fowler-Stephens Orchiopexy for High-level Intra-abdominal Cryptorchidism: a Systematic Review and Meta-analysis. Int J Surg. 2018;60:74–87. doi: 10.1016/j.ijsu.2018.10.046

[62] Elder JS. Surgical Management of the Undescended Testis: Recent Advances and Controversies. Eur J Pediatr Surg. 2016;26(5):418–426. doi: 10.1055/s-0036-1592197

[63] Shehata S, Shalaby R, Ismail M, et al. Staged Laparoscopic Traction-orchiopexy for Intraabdominal Testis (Shehata Technique): Stretching the Limits for Preservation of Testicular Vasculature. J Pediatr Surg. 2016;51(2):211–215. doi: 10.1016/j.jpedsurg.2015.10.063

[64] Braga LH, Farrokhyar F, McGrath M, et al. Gubernaculum Testis and Cremasteric Vessel Preservation During Laparoscopic Orchiopexy for Intra-Abdominal Testes: Effect On Testicular Atrophy Rates. J Urol. 2019;201(2):378–385. doi: 10.1016/j.juro.2018.07.045

[65] Jawdat JR, Kocherov S, Chertin B. One-Stage Laparoscopic Orchiopexy for the Treatment of Intraabdominal Testis. Isr Med Assoc J. 2016;18(11):669–672.

[66] Igarashi A, Kikuchi K, Ogushi K, et al. Surgical Exploration for Impalpable Testis: Which Should Be First, Inguinal Exploration or Laparoscopic Abdominal Exploration. J Pediatr Surg. 2018;53(9):1766–1769. doi: 10.1016/j.jpedsurg.2017.10.046

[67] Liu J, Tang R, Wang X, et al. Comparison of Two Types of Staged Laparoscopic Orchiopexy for High Intra-Abdominal Testes in Children: a Retrospective Study From a Single Center. Front Pediatr. 2021;9:677955. doi: 10.3389/fped.2021.677955

[68] Abouheba MAS, Younis W, Elsokary A, et al. Early Clinical Outcome of Staged Laparoscopic Traction Orchidopexy for Abdominal Testes. J Laparoendosc Adv Surg Tech A. 2019;29(4):531–537. doi: 10.1089/lap.2018.0171

[69] Wang CY, Wang Y, Chen XH, et al. Efficacy of Single-stage and Two-stage Fowler-Stephens Laparoscopic Orchidopexy in the Treatment of Intraabdominal High Testis. Asian J Surg. 2017;40(6):490–494. doi: 10.1016/j.asjsur.2016.11.008

[70] Papparella A, De Rosa L, Noviello C. Laparoscopic Fowler-Stephens Orchidopexy for Intra-abdominal Cryptorchid Testis: a Single Institution Experience. Pediatr Med Chir. 2021;42(2) doi: 10.4081/pmc.2020.224

[71] Yang Z, Li S, Yin J, et al. A Prediction Model for Risk Factors of Testicular Atrophy After Orchiopexy in Children With Undescended Testis. Transl Pediatr. 2021;10(4):882–892. doi: 10.21037/tp-20-473

[72] Silber SJ, Kelly J. Successful Autotransplantation of an Intra-abdominal Testis to the Scrotum By Microvascular Technique. J Urol. 1976;115(4):452–454. doi: 10.1016/s0022-5347(17)59240-x

[73] Kelley BP, Higuera S, Cisek LJ, et al. Combined Laparoscopic and Microsurgical Techniques for Testicular Autotransplantation: Is This Still an Evolving Technique. J Reconstr Microsurg. 2010;26(8):555–558. doi: 10.1055/s-0030-1262950

[74] Chao BW, Shakir NA, Hyun GS, et al. Robotic-Assisted Testicular Autotransplantation. Urology. 2022;159:255. doi: 10.1016/j.urology.2021.09.020

[75] Casanova NC, Johnson K, Bowen DK, et al. Two-Step Fowler-Stephens Orchiopexy for Intra-abdominal Testes: a 28-year Single Institution Experience. J Urol. 2013;190(4):1371–1376. doi: 10.1016/j.juro.2013.04.056

[76] Woodford E, Eliezer D, Deshpande A, Kumar R. Is Excision of Testicular Nubbin Necessary in Vanishing Testis Syndrome. J Pediatr Surg. 2018;53(12):2495–2497. doi: 10.1016/j.jpedsurg.2018.08.011

[77] Nataraja RM, Yeap E, Healy CJ, et al. Presence of Viable Germ Cells in Testicular Regression Syndrome Remnants: Is Routine Excision Indicated? a Systematic Review. Pediatr Surg Int. 2018;34(3):353–361. doi: 10.1007/s00383-017-4206-0

[78] He TQ, WenR, Zhao YW, et al. Testicular Regression Syndrome: a Retrospective Analysis of Clinical and Histopathological Features in 570 Cases. Front Pediatr. 2022;10:1006880. doi: 10.3389/fped.2022.1006880

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