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

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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

Undescended testis: C/F

Symptoms
Underdeveloped scrotum
Infertility

Indirect inguinal hernia

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Undescended testis: C/F

Signs
Empty scrotum

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Undescended testis: complications

Torsion of the testis Epididymo- orchitis Atrophy Sterility Malignancy

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Undescended testis: management

Hormone therapy Orchidopexy Orchidectomy Laparoscopic surgery

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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

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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

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Ectopic testis

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

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Position of the ectopic testis

Superficial inguinal pouch Pubopenile ectopia Perineal ectopia Crural or femoral ectopia

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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

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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.

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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

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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
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A transverse skin incision is made in an inguinal skin crease

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 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.

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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.

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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

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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

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

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Formation of a dartos pouch

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A, Formation of a passage to the scrotum.

B and C, Passage of the testis into the scrotal pouch

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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
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