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UNDESCENDED TESTIS (CRYPTORCHIDISM)

dr. Moch. Syahroni Far, SpU, M.Kes

INTRODUCTION
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One of the most common male developmental abnormalities (Congenital Anomaly) An undescended testis is one which has failed to descend to the scrotum & is retained at any point along the normal path of descend Frequency 30 % in preterm boys --- risk factor Frequency 3.4 % in term boys, 1 yo incidence 0.8% because of spontaneous descent After 1 yo spontaneus descent is rare Right side: 50%, Left side: 30%, Bilateral: 20%

DEFINITIONS

Cryptorchidism: testis neither resides nor can be manipulated into the scrotum Ectopic: aberrant course Retractile: can be manipulated into scrotum where it remains without tension Gliding: can be manipulated into upper scrotum but retracts when released Ascended: previously descended, then ascends spontaneously

TESTICULAR DEVELOPMENT & DESCENT

6 wk primordial germ cells migrate to genital ridge 7 wk testicular differentiation 8 wk testis hormonally active 10-15 wk external genital differentiation 5-8 wk processus vaginalis 12 wk transabdominal deep inguinal ring 26-28 wk gubernaculum swells to form inguinal canal, testis descends into scrotum

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.
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Syndrome associated Cryptorchidism

Pradder-Willi Syndrome: (deletion on chromosome 15) Hypotonia, Obesity, MR, Short stature, Strabismus Kallman Syndrome: (recessive) anosmia or severe hyposmis Laurence moom biedl syndrome: AR: polydactyly, retinitis pigmentosa, MR, progressive ataxia, Spastic paraplagia

TYPES OF UNDESCENDED TESTIS

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A, Ectopic testes. Perineal ectopia not shown.

B, Undescended testes. Percentages of testes arrested at different stages of normal 17 descent

Comparison between ectopic & undescended testis

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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

SIGNs AND SYMPTOMs

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Underdeveloped scrotum ( Empty Scrotum ) Infertility ( Oligosperm ) Inguinal Pain ( Torsio testis, Trauma ) Inguinal Mass ( Tumour testis,

COMPLICATION
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Torsion of the testis Epididymo- orchitis Atrophy Sterility due to oligosperm 89% of untreated males with bilateral cryptorchidism develop azospermia Malignancy --- Testicular tumour Lifetime risk of neoplasia 2-3%

MANAGEMENT PRINCIPLES
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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

MANAGEMENT
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Observation Medical Hormone therapy Surgery Why is surgery necessary ? Fertility, malignancy, Hernia, protection and cosmetic Orchidopexy Orchidectomy Laparoscopic surgery

HORMONE THERAPY
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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. Other : Exogenous GnRH or LHRH

ORCHIDOPEXY
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The overall efficacy of hormonal treatment is less than 20% for cryptorchid testes Therefore, surgery remains the gold standard for the management of undescended testes. 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

Standard Orchiopexy.
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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.

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.

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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

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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ORCHIDOPEXY COMPLICATIONS

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

THANKS FOR STAYING AWAKE

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THANKs A LOT
I HOPE THAT IT CAN BE USEFUL FOR ALL