2. Undescended Testis Flashcards by Waleed Eldahshan

Alternative name for Undescended Testis

Arrested testes

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INCIDENCE of Undescended Testis

General INCIDENCE

* Side INCIDENCE

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General INCIDENCE in INCIDENCE of Undescended Testis

It occurs in 3% of full term babies

* but more common in premature babies

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Side INCIDENCE in INCIDENCE of Undescended Testis

All congenital anomalies of testis common on the right

Right testis : 50%
Left testis : 30% .
Bilateral: 20%.

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The reason why right undescended testis is more common than left undescended testis in Side INCIDENCE in INCIDENCE of Undescended Testis

due to the later descent of the right testes

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ETIOLOGY of Undescended Testis

1- Bilateral cases

2- Unilateral cases

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Bilateral cases in ETIOLOGY of Undescended Testis

ETIOLOGY

* Association

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ETIOLOGY of Bilateral cases in ETIOLOGY of Undescended Testis

Usually due to a hormonal defect in maternal B-HCG.

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Association of Bilateral cases in ETIOLOGY of Undescended Testis

Usually associated with :

hypogonadism
slipped upper femoral epiphysis

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Etiology of Unilateral cases in ETIOLOGY of Undescended Testis

Due to anatomical barrier to normal descent

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Anatomical barrier to normal descent in Etiology of Unilateral cases in ETIOLOGY of Undescended Testis

Short testicular artery “spermatic vessels”: most important factor
Associated hernial sac.
Inadequate inguinal canal.
Retroperitoneal adhesions fixing the testis in higher places.
Rupture gubernaculums.

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most important Anatomical barrier to normal descent in Etiology of Unilateral cases in ETIOLOGY of Undescended Testis

Short testicular artery “spermatic vessels”

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PATHOLOGY of Undescended Testis

The site of undescended testes in order of frequency
If bilateral, the condition is known as cryptorchidism.
The size and function of the testis
Consequences If left in the abdomen:

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The site of undescended testes in order of frequency in PATHOLOGY of Undescended Testis

1- External ring. most common site

2- Neck of the scrotum.

3- Inguinal canal.

4- Lumbar region (intra-abdominal).

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Most common site of undescended testes in order of frequency in PATHOLOGY of Undescended Testis

External ring

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The size and function of the testis in PATHOLOGY of Undescended Testis

The size and function of the testis remain normal till the age of 6 months
The destruction of the testis starts from 6 months onwards
At 2 years, 40% of germ cells are destructed.
At 6 years, there is complete atrophy of germ cells.

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Consequences If left in the abdomen in PATHOLOGY of Undescended Testis

Effects on

Testes
The seminiferous tubules
The interstitial cells are NOT affected

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Effects on testes in Consequences If left in the abdomen in PATHOLOGY of Undescended Testis

Testes do not grow and becomes atrophic & soft.

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Effects on The seminiferous tubules in Consequences If left in the abdomen in PATHOLOGY of Undescended Testis

The seminiferous tubules become atrophied because of the higher temperature of the abdomen causing failure of spermatogenesis.

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Effects on The interstitial cells in Consequences If left in the abdomen in PATHOLOGY of Undescended Testis

The interstitial cells are NOT affected and hence the 2ry sexual characters and erection are normal

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Clinical picture of Undescended Testis

Symptoms

* Examination

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Symptoms in Clinical picture of Undescended Testis

The mother observes that one side or both side of the scrotum are empty

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Examination in Clinical picture of Undescended Testis

Scrotum
Testis Palpation
Associations

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Scrotum Examination in Clinical picture of Undescended Testis

The affected side of the scrotum is empty & not well developed.

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Testis Palpation in Examination in Clinical picture of Undescended Testis

1. The testis is palpated if arrested in external ring or neck of the scrotum. 2. The testis is difficult to be palpated if arrested in inguinal canal. 3. The testis is not Palpated if intra-abdominal 4. The testis can be identified as it gives sickening sensation when compressed

Associations in Examination in Clinical picture of Undescended Testis

Associated congenital hernia is commonly found in 80-90% of cases

Differential Diagnosis of Undescended Testis

1. Ectopic testis 2. Testicular agenesis. 3. Surgically removed testis. 4. Retractile testis

Retractile testis in Differential Diagnosis of Undescended Testis

Definition Management

Definition of Retractile testis in Differential Diagnosis of Undescended Testis

It is a common condition during childhood due to active cremastric reflex on a small mobile testis.

Management of Retractile testis in Differential Diagnosis of Undescended Testis

* In majority of cases * In difficult cases * Retractile testes require no treatment.

In majority of cases in Management of Retractile testis in Differential Diagnosis of Undescended Testis

* By careful & gentle examination in warm surroundings | * The testis is usually brought by the examiner downwards and medially to scrotum

In difficult cases in Management of Retractile testis in Differential Diagnosis of Undescended Testis

* The "chair test" should be tried. | * The "squatting position test" is an alternative one.

The "chair test" In difficult cases in Management of Retractile testis in Differential Diagnosis of Undescended Testis

* The young patient is asked to sit on a chair and hug his knees to his chest. * Pressure thus directed on to the inguinal canal causes a retractile testis to descend into the scrotum

Difference between Retractile testis and Undescended Testis by

* Scrotum Examination | * Pulling down the testis to the scrotum

Scrotum Examination in Retractile testis in Difference between Retractile testis and Undescended Testis by

Fully developed

Scrotum Examination in Undescended Testis in Difference between Retractile testis and Undescended Testis by

Not well developed

Pulling down the testis to the scrotum in Retractile testis in Difference between Retractile testis and Undescended Testis by

Easily pulled down

Pulling down the testis to the scrotum in Undescended Testis in Difference between Retractile testis and Undescended Testis by

Cannot be pulled down

COMPLICATIONS of Undescended Testis 4 T ( Trauma Torsion Tumour aTrohpy)

1. Liable for trauma and torsion. 2. Malignant change 3. Spermatogenesis will be lost if surgery is delayed and if the condition is bilateral, sterility will follow. 4. Epididymo-orchitis : Extremely rare.

Malignant change in COMPLICATIONS of Undescended Testis

* All types of malignancy may occur especially seminoma * Increase incidence for malignancy 35 times * Due to testicular dysgenesis (histologically abnormal).

Investigations of Undescended Testis

* Indications * Diagnostic Laparoscopy * Radiological investigation

Indications of Investigations of Undescended Testis

for impalpable testis onty

Diagnostic Laparoscopy in Investigations of Undescended Testis

* Investigation of choice. | * Ain shams classification of abdominal undescended testis.

Ain shams classification of abdominal undescended testis in Diagnostic Laparoscopy in Investigations of Undescended Testis

* Mechanism | * Types

Mechanism of Ain shams classification of abdominal undescended testis in Diagnostic Laparoscopy in Investigations of Undescended Testis

According to simplicity of operation

Types of Ain shams classification of abdominal undescended testis in Diagnostic Laparoscopy in Investigations of Undescended Testis

* Type I * Type II * Type III * Type IV

Type I in Types of Ain shams classification of abdominal undescended testis in Diagnostic Laparoscopy in Investigations of Undescended Testis

no testis visualized "vanishing testis" & is thought to be due to intrauterine testicular torsion.

Oral Question: Difference between agenesis and vanishing testis

Do angiography on testicular artery and vein In agenesis no blood vessels are found

Type II in Types of Ain shams classification of abdominal undescended testis in Diagnostic Laparoscopy in Investigations of Undescended Testis

a testis seen at the internal ring with the vas and vessels looping to the internal ring.

Type III in Types of Ain shams classification of abdominal undescended testis in Diagnostic Laparoscopy in Investigations of Undescended Testis

Testis at the internal ring, with vas and vessels going to the testis directly indicating Short vessels

Type IV in Types of Ain shams classification of abdominal undescended testis in Diagnostic Laparoscopy in Investigations of Undescended Testis

Intra-abdominal testis not related to the internal ring.

Radiological investigation in Investigations of Undescended Testis

1. Abdominal U.S or C.T scan. | 2. MRI

Indication of MRI in Radiological investigation in Investigations of Undescended Testis

done if abdominal U.S and C.T scan fail to localize the testis

TREATMENT of Undescended Testis

(l) TREATMENT oF INGUINAL UNDESCENDED TESTIS (lI) TREATMENT oF ABDOMINAL UNDESCENDED TESTIS (lII) TREATMENT oF patients presented late

TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

1. Bilateral testes | 2. If unilateral or failed medical treatment

Bilateral testes in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A single course of HCG

A single course of HCG in Bilateral testes in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

* Therapeutic dose | * Effects of higher dose

Therapeutic dose of A single course of HCG in Bilateral testes in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

500 IU/dose given twice a week for 5 weeks.

Effects of higher dose of A single course of HCG in Bilateral testes in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

* cause precocious puberty, | * induce epiphyseal plate fusion and retard future somatic growth.

If unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

Orchiopexy (best at 1.5 gears)

the reason why Orchiopexy is not done before one year of age in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

Not before 1 year old to give chance for testis descent

Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

* Aim * Principle * In cases of failure to do orchiopexy in one stage

Aim of Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

1. Mobilize the testis to the scrotum. | 2. Retain the testis in the scrotum

Principle of Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

* The cord and testis are mobilized and freed from the surrounding structures. * The associated hernial sac should be excised. * The inferior epigastric artery is sometimes divided * Retain the testis in the scrotum

the reason why The inferior epigastric artery is sometimes divided in Principle of Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

to abolish the angulation of the vas around it.

In cases of failure to do orchiopexy in one stage in Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A. Two stage operation : B. Fowler-Stephens technique : C. Microvascular technique :

Two stage operation In cases of failure to do orchiopexy in one stage in Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

* After maximal mobilization, the testis is anchored with prolene suture * 2nd stage is done after 6 months.

Fowler-Stephens technique In cases of failure to do orchiopexy in one stage in Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

* High division of testicular artery | * provided that the anastomosis between the testicular artery and the artery of the vas is intact

intact Anastomosis between the testicular artery and the artery of the vas in Fowler-Stephens technique In cases of failure to do orchiopexy in one stage in Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis, is known by

* putting a small vascular clamp (bull dog clamp) on the testicular artery as high as possible for several minutes * if the testis does not become ischemic (bluish), the artery is divided

Microvascular technique In cases of failure to do orchiopexy in one stage in Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

Division & re-anastomosis of the testicular vessels at a lower level to the inferior epigastric vessels

Retaining the testis in the scrotum in Principle of Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

1. Bevan's Technique | 2. Benson's Technique

Bevan's Technique in Retaining the testis in the scrotum in Principle of Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

* Alternative name | * Principle

Alternative name for Bevan's Technique in Retaining the testis in the scrotum in Principle of Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

Scrotal stitch

Principle of Bevan's Technique in Retaining the testis in the scrotum in Principle of Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

Fixing the testes to the bottom of the scrotum by a prolene suture, to be removed after 2 weeks

Benson's Technique in Retaining the testis in the scrotum in Principle of Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

* Alternative name | * Principle

Alternative name for Benson's Technique in Retaining the testis in the scrotum in Principle of Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

Extra dartos pouch

Principle of Benson's Technique in Retaining the testis in the scrotum in Principle of Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

Placing the testes in a dartos pouch beneath the skin

TREATMENT oF ABDOMINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

The best surgery now is 2 stage laparoscopic orchiopexy

2 stage laparoscopic orchiopexy in TREATMENT oF ABDOMINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

* 1st stage * 2nd stage * Disadvantages

1st stage in 2 stage laparoscopic orchiopexy in TREATMENT oF ABDOMINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

laparoscopic clipping of the testicular artery allowing the testis to depend on the blood supply from the artery of vas.

2nd stage in 2 stage laparoscopic orchiopexy in TREATMENT oF ABDOMINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

laparoscopic assisted orchiopexy (LAO) 6 months later

Disadvantages of 2 stage laparoscopic orchiopexy in TREATMENT oF ABDOMINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

Only 15% the testis will be atrophied So we take consent from parents

TREATMENT oF patients presented late in TREATMENT of Undescended Testis

a. Cases of late presentation but still before puberty | b. Cases of late presentation after puberty

Cases of late presentation but still before puberty in TREATMENT oF patients presented late in TREATMENT of Undescended Testis

Orchiopexy and not orchiectomy

The reason why we do Orchiopexy and not orchiectomy in Cases of late presentation but still before puberty in TREATMENT oF patients presented late in TREATMENT of Undescended Testis

* For preserving hormonal function. | * Orchiopexy does not diminish the liability for malignancy but improves early diagnosis.

Cases of late presentation after puberty in TREATMENT oF patients presented late in TREATMENT of Undescended Testis

Orchiectomy for a hopeless atrophic testis