Ultrasonography is unnecessary and misleading in evaluating boys with a nonpalpable testis and can be a cause of a legal process

Introduction

Several diagnostic modalities have been advocated for the assessment and diagnosis of non-palpable testis (NPT), such as CT or MRI, but only ultrasonography (US) and laparoscopy have been adopted into routine practice. ¹

Although US is simple, non-invasive and readily available in every district hospital, its use as a test to ascertain the presence or absence of an intra-abdominal testis (IAT) is extremely controversial because intestinal loops full of gas represent a barrier for ultrasound.^2,3

In addition, ultrasonographic examination can miss abdominal testes and sometimes other structures are falsely interpreted as a testis as happened in our case. ¹

Case report

A 2-year-old boy came to our attention for a left NPT.

The parents, 2 lawyers, asked us to perform a laparoscopy to pull down a left intra-abdominal testis clearly identified ultrasonographically.

The US performed in another institution showed a right intrascrotal testis of normal size and a left IAT of 0.85 × 0.78 mm² located near the internal inguinal ring (Figure 1). OPEN IN VIEWER

Considering that clinical examination before and under anaesthesia was negative we planned to perform a laparoscopy. Laparoscopy showed no testis on the left side and a blind-ending vas deferens and blind-ending inner spermatic vessels (as in case of vanishing testis) and a large lymph node located near the internal inguinal ring that was closed (Figure 2). OPEN IN VIEWER

At the end of the procedure, the parents were disappointed with the definitive diagnosis because the US performed before surgery clearly showed them that the testis was present and located in an intra-abdominal position.

The parents decided to undertake a legal challenge against the pediatrician, who had required the US, and the radiologist, who had given them false hope by confusing a lymph node with a testis.

The result of the legal challenge was compensation for moral damages by the radiologist to the parents.

Discussion

Although the use of US in case of NPT is controversial, the majority of pediatricians ask for a US in the case of a boy with a NPT.

In 1986, Weiss et al. ⁴ reported a series of 21 patients with NPT, in which the reliability of US was as low as 12%. These authors stated that US is not a satisfactory stand-alone screening modality for the management of NPT. ⁴ About 20 years later, Stéfaniu et al. ⁵ reported that US helped to identify only 45% of NPTs. There has been no improvement in US for patients with NPT in the past few years.^1,3

Considering that intestinal loops full of gas obstruct US, this examination does not provide surgeons with additional information compared with palpation in a cooperative child. ¹

In his 2002 review, Elder ³ concluded that US is unnecessary for assessing boys with NPT, and most of the recent studies agree with this statement.

In our opinion, the only indication for US in patients with NPT is probably in those who have a high BMI, when body habitus prevents the surgeon from palpation of a testis located in the inguinal canal, and particularly in uncooperative children.

Our case clearly shows that in the case of a boy with a NPT, US is unnecessary, misleading and sometimes harmful – not only for the medical practitioners involved but also for the children and their parents, as happened in our case where the pediatrician and the radiologist had a legal challenge filed against them by the parents because they gave them false information about the pathology of their child.