Laparoscopic management of intra-abdominal undescended testes: Diagnostic limitations, technique variability, and risk factors for postoperative testicular atrophy.

BACKGROUND

Intra-abdominal undescended testes (IAT) are the most challenging form of cryptorchidism, with high risks of impaired fertility and postoperative atrophy. Laparoscopy is the standard approach, but preoperative imaging is unreliable, intraoperative volume assessment is often difficult, and technique selection varies. Comparative outcome data and the prognostic value of real-world diagnostic limitations remain limited.

OBJECTIVE

To identify diagnostic and anatomical predictors of testicular atrophy after laparoscopic management of IAT and compare outcomes among one-stage vessel-preserving, Fowler-Stephens (FS), and traction techniques over 10 years.

METHODS

A retrospective cohort of boys <18 years undergoing laparoscopic orchiopexy for non-palpable testes from 2015 to 2025 was analyzed. Preoperative imaging availability, intraoperative volume assessment (measurable adequate for age, small for age, non-measurable), subjective appearance, and vas/epididymal anomalies were recorded. Primary outcome was clinical atrophy. Kaplan-Meier and multivariable Cox regression assessed predictors.

RESULTS

Of 332 cases, 282 met criteria (53 one-stage, 128 FS, 101 traction). Clinical atrophy occurred in 65 cases (23.0%): 13.2% one-stage, 29.7% FS, 19.8% traction (p < 0.001). Independent predictors included FS technique (aHR 2.61), volume small for age (aHR 3.45), non-measurable volume (aHR 2.41), hypoplastic appearance (aHR 2.62), and vas/epididymal anomalies (aHR 4.28). Age and surgeon experience were not significant. Clinical and ultrasound assessments showed substantial agreement (κ = 0.78).

CONCLUSIONS

Atrophy risk after laparoscopic management of IAT is driven by testicular size relative to age-appropriate norms, vas/epididymal anomalies, intraoperative volume, and surgical technique. FS orchiopexy carries significantly higher risk than vessel-preserving approaches. Inability to measure volume and subjective hypoplastic appearance are meaningful high-risk indicators. Structured intraoperative documentation and technique-specific family counseling are essential, while postoperative surveillance can rely primarily on clinical examination.