1. Undescended testis
Dr.Santosh Jha
TMU

3. 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.

5. 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

6. 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

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

9. 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

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

11. Undescended testis: C/F
Signs
Empty scrotum

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

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

15. 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

16. 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

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

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

19. 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

20. 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.

22. 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

23. 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

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

25. 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.

26. 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.

27. 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

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

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

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

31. Formation of a dartos pouch

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

33. 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