1013Vol. 10 | No. 3 | Summer 2013 |U R O LO G Y J O U R N A L Emergency Laparoscopic Orchiectomy for Intra-Abdominal Testicular Torsion- A Case Report Hossein Karami,1 Mohammad Yaghoobi,1 Amin Hasanzadeh Hadad1 INTRODUCTION Undescended testis (UDT) occurs in 1-4% of full-term neonates and in up to 45% of preterm neonates.1 Despite increased susceptibility of torsion in undescended tes-tes, this is a rare condition and a high clinical suspicion is needed to diagnose this emergency. Ultrasound and other imaging modalities are not absolutely reliable for evalu- ation of torsion in UDT. In this case report we used laparoscopy to diagnose torsion in the patient with UDT and find a cure. CASE REPORT The patient was an eighteen-year-old male, a known case of left abdominal UDT, who was admitted to emergency service with left lower abdominal pain. The pain had started suddenly seventeen hours before arrival to hospital. The pain was sustained, localized in the left lower quadrant of abdomen, without radiation to other areas. The patient had nausea and vomiting. There was no change in the color of the abdominal skin and no visible mass in the pain area. Vital signs were normal and no fever was detected. In deep palpation, there was moderate tenderness without rebound at the left lower quadrant of abdomen. Digital rectal examination was normal and there was no evidence of gasterointestinal bleeding. Cell blood count revealed no leukocytosis and there was no pyuria or microscopic hematuria in the urine analysis. Plane and upward abdominal X-rays did not show any positive findings for gasterointestinal prob- Corresponding Author: Hossein Karami, MD Urology and Nephrology Re- search Center (UNRC), Shohada- e-Tajrish Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran Tel: +98 21 22567222 Fax: +98 21 22567282 Email: karami_hosein@yahoo. com Received November 2012 Accepted May 2013 1Urology and Nephrology Re- search Center (UNRC), Shohada- e-Tajrish Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran CASE REPORT 1014 | lems. Ultrasound evaluation of abdomen revealed an intra- abdominal testis in the left side, close to the internal inguinal ring. Arterial blood flow which was suggestive of torsion of the intra-abdominal testis was not detected in the organ. After primary preparation, the patient underwent laparoscopy and an intra-abdominal testis appeared posterior to the internal inguinal ring with gangrenous appearance (Figures 1, 2). Laparoscopic orchiectomy was conducted. The pathology re- port confirmed our primary diagnosis and indicated necrotic testicular tissue. DISCUSSION There is a greater risk of testicular malignancy and infertil- ity for UDT.(1-2) Intra-abdominal testes are more susceptible to malignancy than inguinal UDTs.(3) Torsion occurs more commonly in the UDTs and it has been mentioned to be even up to 13 times higher than normal testes in some studies.(4-5) Malignancy is common in those UDTs manifested with tor- sion. Torsion of UDT was described by Delasiauve in 1840 , Curl- ing in 1857, and Ormond in 1923.(6) Undescended testes are susceptible to torsion perhaps by mechanism of abnormal contractions of cremaster and the greater relative broadness of testis than its mesentery,(7,8) but the mechanism of torsion has not been clearly defined yet. Laparoscopy is the golden standard method for the diagnosis and treatment of intra-abdominal testis. It is wise to use lapa- roscopy to diagnose torsion in emergency situations. Accord- ing to this idea, we used laparoscopy for such purpose in this case. As far as we are aware, there are two reports of using laparoscopy for this purpose up to now.(9,10) However, before using laparoscopy, we should rule out other surgical causes of abdominal pain such as acute peritonitis. By laparoscopy, we can get a direct surgical view and better vision of the intra- abdominal pathology, and additionally, if the testis is viable, therapeutic management will be a possibility by performing laparoscopic orchiopexy. Prophylactic orchiopexy of testis in the contralateral side is controversial though recommended in some articles. Unfortunately, the majority of cases of torsion in intra-ab- dominal testis are diagnosed when the golden time for saving testis has passed and such patients usually undergo orchiec- tomy because of nonviable testis. Teaching the warning signs of torsion to the patients and their parents, will help with early diagnosis and pave the way to save at risk testicle. CONFLICT OF INTEREST None declared. Case Report REFERENCES 1. Hack WW, Sijstermans K, van der Voort-Doedens LM, Meijer RW, Heij HA, Delemarre-van de Waal HA, et al. [Undescend- ed testis: current views and advice for treatment]. Ned Tijd- schr Geneeskd 2008;152:246-52. 2. Schneck FX. Bellinger MF. Abnormalities of the testis and scrotum and their surgical management. In: Patrick C. Walsh, Alan B. Retik, E. Darracott Vaughan, Alan J. Wein, editors; Campbell’s Urology 8th edition. Philadelphia: Saun- ders; 2002. p. 2353-2394. Figure 1. Gangrenous feature of intraabdominal testis Figure 2. The gangrenous intraabdominal testis and spermatic chord 1015Vol. 10 | No. 3 | Summer 2013 |U R O LO G Y J O U R N A L Laparoscopic Orchiectomy for Intra | Abdominal Testicular Torsion-Karami et al 3. Jost A. Embryonic sexual differentiation (morphology, physiology, abnormalities). In: Jones JW Jr, Scott WW, edi- tors; Hermaphroditism Genital Abnormalities and Related Endocrine Disorders 2nd edition. Baltimore: Williams and Wilkins; 1971. p. 16-64. 4. Ein SH. Torsion of an undescended intraabdominal benign testicular teratoma. J Pediatr Surg 1987;22:799-801. 5. Johnson JH. The undescended testis. Arch Dis Child. 1965;40:113-122.. 6. Ormond JK. Torsion of an Intra-Abdominal Testis. Ann Surg 1927;85:280-3. 7. Johnson JH. Abnormalities of the scrotum and the testes. In: Williams DI, editor; Paediatric Urology 2nd edition. London: Butterworth Scientific; 1982. p. 451-465. 8. Candocia FJ, Sack-Solomon K. An infant with testicular tor- sion in the inguinal canal. Pediatr Radiol 2003;33:722-4. 9. Lee KF, Tang YC, Leong HT. Emergency laparoscopic or- chidectomy for torsion of intra-abdominal testis: a case re- port. J R Coll Surg Edinb 2001;46:110-2. 10. Porpiglia F, Destefanis P, Fiori C, Tarabuzzi R, Fontana D. Laparoscopic diagnosis and management of acute intra- abdominal testicular torsion. J Urol 2001;166:600-1.