Non-palpable testis: is management consistent and objective?

Diagnostic laparoscopy is recommended for boys with non-palpable testis (NPT) by American and European guidelines with the decision to pursue inguinal exploration based upon testicular vessel appearance. We hypothesized that management decisions are not consistent with the guidelines, and that assessment of vessels is subjective.

Pediatric urologist management decisions were evaluated via an electronic survey to determine impact of contralateral testicle size, sonographic findings, surgeon region, and years in practice. In a digital image survey, surgeons were asked to interpret gonadal vessel status of 32 consecutive cases of NPT with absent abdominal testis as normal, atretic, or blind-ending to determine intra- and inter-rater reliability.

Of the 339 participants, more Europeans (49%) chose sonography as the first management step for NPT compared to US surgeons (12%). Regardless of sonographic findings, over 80% chose laparoscopy as the first step. In the presence of normal, atretic, and blind-ending vessels, the decisions to proceed with inguinal/scrotal exploration were 88%, 68%, and 17%, respectively. Contralateral hypertrophy and sonography findings had no significant impact on the decision to proceed with inguinal/scrotal exploration. The visual gonadal vessel survey showed surgeon interpretation of normal or blind-ending vessels had moderate inter-rater reliability. Surgeons did not agree on normal status 37% of the time and did not agree on atretic status 66% of the time. There was no statistical difference between European and US respondents (P = 0.23). Intra-rater reliability was fair for blind-ending vessels. When the first interpretation was blind-ending, the same surgeon changed interpretation of the same image 39% of the time. There was no statistical difference by years of practice.

Non-visualization of NPT on sonography and contralateral testis size had no significant impact upon management decisions. Surgeons chose to pursue inguinal/scrotal exploration based upon laparoscopic gonadal vessel status. However, these interpretations were subjective with low inter- and intra-rater reliability.