High Intra-Abdominal Undescended Testicle: Why Isn’t It Brought Down in One Session?

On laparoscopy, a testicle is considered high intra-abdominal when it sits clearly distant from the internal ring — in most definitions, more than about 2 cm — and does not reach the opposite internal ring despite mobilization. Sometimes the testicle lies close to the lower pole of the kidney, with very short vessels.

The testicle’s main blood supply comes from the testicular vessel, which originates at kidney level along the posterior abdominal wall. When this vessel is too short, pulling the testicle down to the scrotum stretches it; a stretched vessel has impaired blood flow, and the testicle can shrink (atrophy).

There are two main staged approaches for a high intra-abdominal testicle; both are performed laparoscopically and require two sessions.

Which approach is followed is determined by the laparoscopic findings: how high the testicle sits, the length and course of the vessels, the length of the vas deferens, and the size of the testicle. In our practice, this decision is made during surgery, based on the joint assessment of the two pediatric urology specialists performing the laparoscopy.

• Testicle close to the internal ring with adequate vessel length: single-stage laparoscopic orchiopexy
• Testicle high, vessels short, vas deferens long, and good collateral circulation: Fowler–Stephens (preferably two-stage)
• Testicle high, with preservation of the main vessel as the goal: Shehata traction technique
• Testicle very small or appearing non-functional, especially when the other testicle is normal and the patient is older: orchiectomy is discussed as an option

• The most important thing for families to understand is that a staged approach is not a failure or an ‘unfinished operation.’ It is a strategy planned from the start to protect the testicle, and both the goal of a single session and the possibility of a staged approach are explained together during the consent conversation.

Between the two sessions, the child continues normal life, with no special restrictions. The second session is completed laparoscopically or through the groin and usually results in day surgery or a single overnight stay.

• Even when a staged operation ends with the testicle in the scrotum, it may remain smaller than the other side; the risk of atrophy is higher than with a palpable testicle. For this reason, follow-up occurs several times in the first year and then yearly until adolescence; evaluation continues at adolescence with size, hormone levels, and, if needed, semen analysis. Follow-up continues with the same team as the child transitions from pediatric to adult urology.