Undescended testis Dr.Santosh Jha TMU

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

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

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

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

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

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

Undescended testis: C/F Signs Empty scrotum

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

Undescended testis: management Hormone therapy Orchidopexy Orchidectomy Laparoscopic surgery

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

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

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

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

Comparison between ectopic & 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 HT: hormone therapy

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 hCG stimulation test.

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

Hormonal Therapy Exogenous hCG and Exogenous GnRH 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

A transverse skin incision is made in an inguinal skin crease

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.

Standard Orchiopexy. The key steps in this procedure are --- 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.

One should be careful to observe that the testis is in the superficial A transverse inguinal skin incision is made in the midinguinal canal, usually in a skin crease in children younger than 1 year The dermis is opened with electrocautery, and subcutaneous tissue and Scarpa's fascia are opened sharply. The 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

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

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

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

Formation of a dartos pouch

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

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