UNDESCENDED TESTES

7th Year Surgery Tutorial28th June 2016Dr. PASHI V.

CONTENTS

Introduction EmbryologyRelevant anatomyClinical presentationManagement Complications

Introduction UDT also known as cryptorchismFailure of the testis to descend normally from the abdominal cavity into the scrotumUDT is associated with a variety of potential consequences:Malignancy, infertility, torsion of testis, and inguinal hernia.Treatment of UDT is aimed at minimising these risks.

EMBRYOLOGYNORMAL DESCENT OF TESTES

Germ cells migrate from yolk sac to genital ridges at 6 weeks

The gonads acquire male or female morphological in the 7th week of development

By the 8th week of gestation, Leydig cells begin production of testosterone and sexual differentiation begins

embryology

embryology

DESCENT OF TESTES By the end of 8th week the testes have acquired two

attachments The caudal genital ligament and the gubernaculum Descent is believe to be achieved by:

Abdominal descent by the out growth of the extra abdominal gubernaculum

Inguinal descent by the raising intra abdominal pressure Regression of the extra abdominal gubernaculum facilitates

descent to the scrotum

embryologyFEATURES OF TESTICULAR DESCENCE

The testes will reach the internal ring by 12 weeks, pass through the inguinal canal by 28 weeks and finally in the scrotum by 33 weeks

Endocrine factors probably play a major role in descent– Testosterone induces testis descent in humans– Androgens affect the nuclei of the genitofemoral

nerve to release modulating factors for gubernacular development

embryology

FEATURES OF TESTICULAR DESCENCE Blood supply from the aorta is maintained with testicular

arteries arising from the lumber region The testes emerge from the abdominal cavity carrying

with it the abdominal coverings and peritoneum Peritoneum makes the processus vaginalis Canal portion of processus obliterates, testicular portion

persists as tunica vaginalis Gubernaculum atrophies

embryology

ANATOMYCOVERINGS OF THE TESTIS

CLINICAL PRESENTATION

UDT occurs in 3% of term male infants and in up to 33% of premature male infants.A true UDT has had its descent halted somewhere along the path of normal descent. The ectopic UDT has deviated from the path of normal descent and can be found in the inguinal region, perineum, femoral canal, penopubic area, or even the contralateral hemiscrotum.

Clinical presentationA retractile testis is a normally descended testis that retracts into the inguinal canal as a result of cremaster muscle contraction.

It can be manipulated down into the scrotum on examination without tension and will remain in placeAcquired UDT refers to a testis that was previously descended on examination and can no longer be brought down into the scrotum.

Clinical presentation

Palpable–Normal–Retractile–Ectopic–Undescended

Impalpable–Canalicular– Intra-abdominal–Emergent–Absent

• Agenesis• atrophy

Whitaker/Kaplan Classification for UDT

Clinical presentationMost common dilemma is distinguishing retractile testis from one that may or may not descend spontaneouslyManeuvers used: 1. examine boy in crosslegged position,

2. soaping the examiner’s fingers 3. examining in a warm bath

Physical exam is very important to evaluate retractile testes –Non-palpable testis is intraabdominal, intracanalicular,

absent

To locate the testis is to walk the fingers gently down the inguinal canal from the internal ring toward the scrotum, trying to push subcutaneous structures toward the scrotum.

Bilateral UDT requires hormonal evaluation and challenge–Elevated gonadotropins (FSH) suggest

bilateral anorchia–Normal serum gonadotropins=>hCG

challenge (2000 IU x 3days)–No testosterone response indicates bilateral

anorchia

Imaging Herniography-poor sensitivity and specificityU/S-good for inguinal testes, not reliable if higherCT-may be helpful for bilateral impalpable testes– Difficult to perform in young children

MRI-least invasive, most expensive– Difficult to perform in young children

Imaging Venography-invasive, pampiniform plexus present=>testis present– Non-visualized plexus or blindending does not

eliminate testisAngiography-difficult to perform, high complicationsOverall accuracy of radiologic imaging for UDT = 44%– PE is 53% - 84%

Hormonal Treatment

hCG is given to stimulate Leydig cells to produce testosterone=>descent of testesGnRH is given if basal LH is low and abnormality in GnRH secretion is suspected

Surgical TreatmentBasic principles of orchidopexy are: localization, mobilization, cord dissection, isolation of processus, tension-free relocation to scrotumPexation does not reduce risk of cancerOrchidopexy should be performed before 2 y.o.Orchidectomy is an option for post-pubertal males and dysgenetic testes

Standard OrchidopexyTransverse inguinal incision, watch for testisIdentify testis and divide gubernaculumOpen tunics and evaluate testisOpen external oblique fascia, avoid nerveMobilize spermatic cordFinger dissection to enlarge scrotal cavity mediallyIncise scrotal skin, create dartos pouch

Standard Orchidopexy contn

Pass clamp through pouch into inguinal area and bring testis into pouch by gubernaculum or tunicaPex testis with 4-0 vicryl suturesComplications: atrophy, retraction, torsion, hematoma, nerve or vas injury

Standard Orchidopexy contn

Complications Neoplasm and UDT– 10% of testis CA are in UDT– UDT is 35-48x more likely to have malignancy– Abdominal UDT is 4x more likely than inguinal testis to develop

CA– UDT tumors typically occur around puberty– CIS occurs in 1.7% of UTD– Orchiopexy should be performed between 1-1.5 years old– 1/5 of testis CA in patients w/ hx of UDT occurs in contralateral

testis– Seminoma is most common CA in UDT

Complications contnTorsion and UDT– Increased risk for torsion in UDT due to anatomic

abnormality between testis and mesentery– Incidence is greatest after puberty with increased

testis size–Be aware of abdominal pain and empty

hemiscrotum=> torsed intra-abdominal UDT

Complications contnHernia and UDTProcessus vaginalis should obliterate between the 8th month of gestation and 1st month of lifeUDT results in patent processus vaginalisHernias are found in 90% of patients w/ UDT

Complications contnInfertility and UDTSpermatogenesis is retarded by maldescentBilateral UDT => poor fertilityHigher UDT => more damage to seminiferous tubulesEarlier orchidopexy may improve chances for recovery of spermatogenesisSperm counts in unilateral UDT are much lower than normal – Contralateral testis may also be defective

Futher reading

Fowler-stephens orchidopexyLaparoscopic orchidopexy