Undescended testis Dr Santosh Jha TMU 1 2

Undescended testis Dr. Santosh Jha TMU 1

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A, 5 th week Testis begins its primary descent; kidney ascends. B, 8 th-9 th weeks. Kidney reaches adult position. C, 7 th month, Testis at internal inguinal ring; gubernaculum (in inguinal fold) thickens and shortens. D, Postnatal life. 3

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Introduction • An undescended testis is one which has filed to descend to the scrotum & is retained at any point along the normal path of descend • Right side: 50% • Left side: 30% • Bilateral: 20% – cryptorchidism 5

Types of undescended testis • • • Lumbar testis Iliac testis: testis remains just deep to the deep inguinal ring Inguinal: testis is in the inguinal canal At the superficial inguinal ring Scrotal testis: – the testis lies in the upper part of the scrotum 6

A, Ectopic testes. Perineal ectopia not shown. B, Undescended testes. Percentages of testes arrested at different stages of normal descent 7

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Undescended testis • Scrotal testis: – The testis lies in the upper part of the scrotum – Also known as a retractile testis – Normal scrotal sac & testis – The testis can be brought down 9

Undescended testis: C/F Symptoms • Underdeveloped scrotum • Infertility • Indirect inguinal hernia 10

Undescended testis: C/F Signs • Empty scrotum 11

Undescended testis: complications • • • Torsion of the testis Epididymo- orchitis Atrophy Sterility Malignancy 12

Undescended testis: management • • Hormone therapy Orchidopexy Orchidectomy Laparoscopic surgery 13

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Undescended testis: hormone therapy • Not used routinely • Indications: – When the surgeon is not sure whether the case is one of retractile testis or not – Bilateral incomplete descended testis associated with hypogenitalism & obesity • The hormone mostly used is human chorionic gonadotrophin 15

Undescended testis: orchidopexy • Treatment of choice • Usually should be done by the age of 5 years but it is unnecessary to do this operation before completion of second birthday of the child 16

Ectopic testis • The testis fails to descend into the scrotum & is deviated from its normal path of descent 17

Position of the ectopic testis • • Superficial inguinal pouch Pubopenile ectopia Perineal ectopia Crural or femoral ectopia 18

Comparison between ectopic & undescended testis Undescended testis • The testis is arrested in its normal path of descent • Usually undeveloped • Undeveloped & empty scrotum on the affected side • Shorter length of spermatic cord • Poor spermatogenesis after 6 yrs • Usually associated with indirect inguinal hernia • Treatment: surgery & HT • Associated with a number of complications • • Ectopic testis The testis deviates from its normal path of descent Fully developed testis Empty but usually fully developed scrotum Longer length of spermatic cord Spermatogenesis is perfect Never associated with indirect inguinal hernia Treatment: basically surgical Complications: liability to injury 19

Workup • Preterm and maternal history, including the use of gestational steroids • • Perinatal history, including documentation of a scrotal examination at birth • The child's medical and previous surgical history • Family history of cryptorchidism or syndromes All boys with nonpalpable testes and normal serum gonadotropin levels must undergo surgical exploration regardless of the results of the h. CG stimulation test. 20

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Management of Cryptorchidism • Proper identification of the anatomy, position, and viability of the undescended testis • • Identification of any potential coexisting syndromic abnormalities • Placement of the testis within the scrotum in timely fashion to prevent further testicular impairment in either fertility potential or endocrinologic function • Attainment of permanent fixation of the testis with a normal scrotal position that allows for easy palpation • No further testicular damage resulting from the treatment Definitive treatment of an undescended testis should take place between 6 and 12 months of age 22

Hormonal Therapy • Exogenous h. CG and • Exogenous Gn. RH or LHRH. • Increases serum testosterone production by stimulation at different levels of the hypothalamic-pituitary-gonadal cascade • Successful results are more commonly reported in older groups of children and in testes that were retractile or below the external inguinal ring. E. g. the lower the pretreatment position, the better the success rate 23

A transverse skin incision is made in an inguinal skin crease 24

• The overall efficacy of hormonal treatment is less than 20% for cryptorchid testes and is significantly dependent on pretreatment testicular location. • Therefore, surgery remains the gold standard for the management of undescended testes. 25

Standard Orchiopexy. • The key steps in this procedure are --(1) complete mobilization of the testis and spermatic cord, (2) repair of the patent processus vaginalis by high ligation of the hernia sac, (3) skeletonization of the spermatic cord without sacrificing vascular integrity to achieve tension-free placement of the testis within the dependent position of the scrotum, and (4) creation of a superficial pouch within the hemiscrotum to receive the testis. 26

ØA transverse inguinal skin incision is made in the midinguinal canal, usually in a skin crease in children younger than 1 year Ø The dermis is opened with electrocautery, and subcutaneous tissue and Scarpa's fascia are opened sharply. ØThe skin and subcutaneous tissue are quite elastic in younger children and allow for a tremendous degree of mobility by retractor positioning for viewing the entire length of the inguinal canal. One should be careful to observe that the testis is in the superficial 27

A, The external ring is opened. B, Cremasteric fibers are dissected from the cord 28

A, High ligation of the processus vaginalis at the internal inguinal ring. B, The ligated processus and the cord structures 29

Separation of the internal spermatic fascia from the cord structures after ligation of the processus vaginalis 30

Formation of a dartos pouch 31

A, Formation of a passage to the scrotum. B and C, Passage of the testis into the scrotal pouch 32

Complications of Orchiopexy Testicular retraction, Hematoma formation, Ilioinguinal nerve injury, Postoperative torsion (either iatrogenic or spontaneous), • Damage to the vas deferens, and • Testicular atrophy • • Devascularization with atrophy of the testis can result from skeletonization of the cord, from overzealous electrocautery 33