1. CRYPTORCHIDISM
Dr.GOVIND
SRMC & RI

2. EMBROLOGY GONADAL RIDGE – COELOMIC EPITHELIUM GERMINAL CELLS- YOLK SAC
SEMINIFEROUS TUBULE
SERTOLI CELLS
TESTOSTERONE & MIS
GUBERNACULUM & CSL

3. Descent ABDOMINAL PHASE 23 weeks INGUINAL PHASE 24-30 weeks
INFRA INGUINAL PART upto 3 months after birth

4. INCIDENCE : 3% general population,30% in preterm
SPONTANOUS DECENT : 70% by 3 months….more so in LBW,B/L,normal pathway &developed scrotum
At 1 year incidence is 1%

5. CLASSIFICATION INTRA ABD…….peeping & ectopic INTRACANALICULAR
SUPRAPUBIC
INFRAPUBIC
ECTOPIC
RETRACTILE
ASCENDING
Atropic/vanishing

6. cryptorchidism 20% nonpalpable 50% inguinal Vanish/present
20% palpable G/A
15% Abd vanishing
35% intra abd

7. THEORY OF DECENT OF TESTES
ENDOCRINE
ANDRIGEN
MIS
ESTROGEN
DECENDIN
GUBERNACULUM (attachments, muscle, morphogenisis)
GFN & CGRP
EPIDIDYMIS
INTA ABD PRESSURE
DIFFRENTIAL GROWTH

8. HISTOLOGICAL CHANGES After I month: leydig cells
After 6 months : volume & Ad spermatozoa
After 1 year : peritubular fibrosis
After 3 years : leydig cells
sertoli cells
germ cells

9. PROBLEMS: FERTILITY Same fertility rate upto 1 year of age
Severe changes at 5 years of age
Paternity index:
B/L crypt corrected ….50%
Unilateral……………75%
Elevated FSH levels

10. PROBLEM : HERNIA Incidence…………90%
? Related to androgen (processes closure)
Usually closes at least by 3 months of age
Post Hcg therapy……….
if P.vaginalis closes testis descends in % cases
if P,vaginalis doesnot close then testis done not descend at all

11. PROBLEM : TUMOUR Increased incidence ( 40 Vs 14 times) Puberty tumors
10% testicular tumor arise form undesended
Higher the testis more chances of malignancy
Seminoma / yolk sac tumor/embryonal
Relative risk……contralateral desended 3.6
contralateral undesended 15%
CIS …………..1.7%

12. PROBLEM : TORSION Increased susceptibility Long mesentery / vas
Related to tumor development
Related to Hcg therapy
?explains vanishing testis

13. INVESTIGATIONS CLINICAL EXAM & EXAM UNDER ANESTHESIA USG CT MRI
LAPAROSCOPY

14. CONSERVATIVE OBSERVATION HCG……..1500IU TWICE WEEKLY FOR 4 WEEKS
GNRH……..1.2 mg nasal spray
twice weekly for 4 weeks
Efficacy ………..20%

15. Hormonal assay Basal FSH/LH levels are raise then consider anorchia
Serum testosterone assay at 2-3 months age
Hcg stimulation test :
500iu on mon , wed, fri
testosterone levels on Saturday…..
( normal raise > 200ng/dl)

16. MIS Glycoprotein by sertoli cells Post puberty MIS synthesis declines
MIS is a more sensitive marker
No testicular tissue……..<1ng/ml
Abnormal testes………….10-15ng/ml
Normal testes……….35-40ng/ml
Low MIS……………..90% cases absent testis
Normal MIS……..98% testis present

17. B/l crypt & normal phallus
Low levels of
MIS
MIS normal
Hcg test
negetive
Hcg test: normal
Orchidopexy
(r/o pmds)
orchidopexy
anorchia

18. Ambiguous genitalia MIS assay Normal: testes + Low.. undetectable
Mixed gonadal dysgenesis
True hermaph.
Testicular regression
Male pseudo herma.
Androgen resistance
Testosterone syn, defect
hypogonadism
Female pseudo
CAH
Vanishing testes

19. UNILATERAL USG LAPAROSCOPY : DECIDE ON TABLE SINGLE STAGE ORCHIDOPEXY
TWO STAGED
ORCHIDECTOMY

20. BILATERAL CRYPTORCHIDISM
KARYOTYPE
TESTOSTRONE AT 2-3 MONTHS AGE
HCG STIMULATION TEST
MIS ASSAY
Laparoscopy
Atleast one side orchidopexy at 9 months

21. SURGERY SIMPLE ORCHIDOPEXY ALBERT & PERSKY PENTRISS KOOP
STEPHEN FOWLER
MICROSURGICAL

22. Standard orchidopexy Open tunica vaginalis…eversion
Dissect internal spermatic fascia,ext.spermatic fascia,cremaster at internal ring
Fix in dartos pouch
Tension free
Pentriss/Albert persky

23. Fowler-Stephens ? Modification of Bevan”s One staged Two staged
Identify…collaterals,long loop,large peritoneal pedicle
Ureter vulnerable
Shortest route to scrotum
Stephen-fowler test
High ligation Vs low ligation

24. microvascular Success rate of 80%
?procedure of choice in high solitary testis
Gibson incision
safe guard inf.epigastric vessels
Spermatic vessels mobilized upto origin & ligated based on a wide peritoneal pedicle
Microvascular surgery
Dartos pouch fixation

25. LAPARASCOPIC SITUATIONS
BLIND ENDING VAS
BLIND ENDING VESSELS
VESSELS ENTERING DEEP RING
MEDIAL ABDOMINAL TESTIS
PELIC TESTIS
SUBHEPATIC/JUXTA SPLENIC