UNDESCENDED TESTIS
Introduction
Evidence suggests that the incidence of infertility in undescended testes is reduced by early placement of the testicle in its natural location within the scrotum .orchidopexy is usually performed between 1 and 3 years of age in an attempt to promote normal subsequent development
Introduction
Evidence suggests that the incidence of infertility in undescended testes is reduced by early placement of the testicle in its natural location within the scrotum .orchidopexy is usually performed between 1 and 3 years of age in an attempt to promote normal subsequent development
Definition
confusion arise in the classification of this condition an undescended testis is any testis that fails to descend into the scrotum , and it includes those which adhere to the normal path but fail to descend fully (incomplete or arrest descent )as well as those found in locations remote from the normal path (ectopic) .approximately 3%of male infants have undescended testicle at birth whereas this figure drops to 1%by the age of one year . ectopic testes account for 10%of extrascrotal testes . they usually lie in one of four positions 1- superficial inguinal 2- base of penis 3- perineal 4- femoral an incompletely descended testis can be intra abdominal intracanalicular emergent or
highscrotal
Testicular Developement
The testis originate from the posterior abdominal wall mesoderm the urogenital (wolffian)ridge and migrate into the scrotum by the inguinal canal they are directed along this path by the gubernaculum . the accepted theory is that failure to follow the correct fibromuscular gubernaculum produces an incompletely descended testis
The testis originate from the posterior abdominal wall mesoderm the urogenital (wolffian)ridge and migrate into the scrotum by the inguinal canal they are directed along this path by the gubernaculum . the accepted theory is that failure to follow the correct fibromuscular gubernaculum produces an incompletely descended testis
Incidence
genuinely undescended testes (cryptorchism) occur in 1%of males however 4-5%of males undergo orchidpexy
genuinely undescended testes (cryptorchism) occur in 1%of males however 4-5%of males undergo orchidpexy
Complications
The complications of undescended testis include : associated inguinal hernia in 50% trauma infertility 40% if unilateral ,70% bilateral failure of development of secondary sexual characteristics if bilateral and testes very immature and malignant change 35 fold the predisposition to malignancy (germ cell tumours)and infertility is considered a secondary effect to abnormal testicular location however some testes are dysplastic from the start returning a testis to the scrotum has not conclusively been shown to prevent malignant change but the testis is made more accessible to screening (palpation and or ultrasound ) thereby improving earlier detection of testicular lesions despite the increased risk of malignant change it is important to note that only one boy out of 120 with undescended testes will actually develop malignancy throughout his lifespan
The complications of undescended testis include : associated inguinal hernia in 50% trauma infertility 40% if unilateral ,70% bilateral failure of development of secondary sexual characteristics if bilateral and testes very immature and malignant change 35 fold the predisposition to malignancy (germ cell tumours)and infertility is considered a secondary effect to abnormal testicular location however some testes are dysplastic from the start returning a testis to the scrotum has not conclusively been shown to prevent malignant change but the testis is made more accessible to screening (palpation and or ultrasound ) thereby improving earlier detection of testicular lesions despite the increased risk of malignant change it is important to note that only one boy out of 120 with undescended testes will actually develop malignancy throughout his lifespan
Diagnosis of undescended testis
The diagnosis of cryptorchism is made by the exclusion of a retractile testis . incomplete descent should be suspected when the scrotum is underdeveloped in contrast normal scrotal development and the presence of scrotal rugae suggest a retractile testis . the examination should take place in a warm room on a relaxed child by one hand the testis is milked into the scrotal neck whilst the other catches it and records the lowest limit to which it can be drawn . all retractile testes can be placed deep into the scrotum in this way
The diagnosis of cryptorchism is made by the exclusion of a retractile testis . incomplete descent should be suspected when the scrotum is underdeveloped in contrast normal scrotal development and the presence of scrotal rugae suggest a retractile testis . the examination should take place in a warm room on a relaxed child by one hand the testis is milked into the scrotal neck whilst the other catches it and records the lowest limit to which it can be drawn . all retractile testes can be placed deep into the scrotum in this way
Treatment of undescended testis
By one year all testes should be palpable within the scrotum . if not , orchidopexy is recommended prior to three years of age as beyond this age secondary testicular degeneration is believed to be irreversible . an inguinal incision identifies the testis the guberanculum is divided well below the low - lying vas deferens and the inguinal canal is opened . the cord is mobilized to the level of the deep ring by :division of peritoneal adhesions , ligation of a concurrent inguinal hernia and trimming of any restricting cremasteric fibres . a dartos pouch is fahioned through a transverse scrotal incision and the mobilized testis then button -holed through the dartos to lie within the pouch ensuring that the testicular sinus remains in the lateral position . the testis is then anchored with a suture throgh the tunica albuginea to prevent torsion and displacement . testicular atrophy is recognized surgical complications and occurs in 5% . it can sometimes be avoided by meticulous dissection and preventing fixation under tension , however the incompletely descended testicle can be associated with an unpredictable blood supply . in most cases the above procedure will enable the testis to be brought to lie within the scrotum . in minority of patients however other procedures will be required to lengthen the cord . these include the
HIGH RETROPERITONEAL APPROACH
This approach is routinely performed for the high testis it maintains the integrity of the superficial inguinal ring and allows more proximal dissection to be carried out . staged operations are required for the very high testis
FOWLER - STEPHENS PROCEDURE
This procedure involves proximal ligation of the testicular artery to increase cord length . this procedure relies on the assumption that the artery to the vas and other collaterals will be sufficient to supply the testis . the latter supply should be temporary clamping of the testicular artery.
SILBER - KELLY PROCEDURE
This procedure involves testicular artery and vein division with direct microvascular anastomosis to the internal epigastric vessels . orchidectomy is only required in a minority of cases it may be considered when a normal contralateral testis is present in the patient with hypoplastic testicle and or the patient who has successfully passed puberty . im the lattter groups the undescended testis serves no function and poses only an unnecessary risk of malignant change . when orchidectomy is required a testicular prosthesis matched to the size of the contralateral testicle can be used to preserve cosmosis
By one year all testes should be palpable within the scrotum . if not , orchidopexy is recommended prior to three years of age as beyond this age secondary testicular degeneration is believed to be irreversible . an inguinal incision identifies the testis the guberanculum is divided well below the low - lying vas deferens and the inguinal canal is opened . the cord is mobilized to the level of the deep ring by :division of peritoneal adhesions , ligation of a concurrent inguinal hernia and trimming of any restricting cremasteric fibres . a dartos pouch is fahioned through a transverse scrotal incision and the mobilized testis then button -holed through the dartos to lie within the pouch ensuring that the testicular sinus remains in the lateral position . the testis is then anchored with a suture throgh the tunica albuginea to prevent torsion and displacement . testicular atrophy is recognized surgical complications and occurs in 5% . it can sometimes be avoided by meticulous dissection and preventing fixation under tension , however the incompletely descended testicle can be associated with an unpredictable blood supply . in most cases the above procedure will enable the testis to be brought to lie within the scrotum . in minority of patients however other procedures will be required to lengthen the cord . these include the
HIGH RETROPERITONEAL APPROACH
This approach is routinely performed for the high testis it maintains the integrity of the superficial inguinal ring and allows more proximal dissection to be carried out . staged operations are required for the very high testis
FOWLER - STEPHENS PROCEDURE
This procedure involves proximal ligation of the testicular artery to increase cord length . this procedure relies on the assumption that the artery to the vas and other collaterals will be sufficient to supply the testis . the latter supply should be temporary clamping of the testicular artery.
SILBER - KELLY PROCEDURE
This procedure involves testicular artery and vein division with direct microvascular anastomosis to the internal epigastric vessels . orchidectomy is only required in a minority of cases it may be considered when a normal contralateral testis is present in the patient with hypoplastic testicle and or the patient who has successfully passed puberty . im the lattter groups the undescended testis serves no function and poses only an unnecessary risk of malignant change . when orchidectomy is required a testicular prosthesis matched to the size of the contralateral testicle can be used to preserve cosmosis
THE IMPALPABLE TESTIS
the principal causes of impalpable testes are . congenital absence intra abdominal testis and dysplastic testis neither ultrasound CT or MRI have demonstrated consistent efficacy for the localization of an impalpable testis however testicular venography reliably demonstrates the absence of normal venous plexus in the congenitally absent testis group . laparoscopy has proven the most sensitive investigation for true intra abdominal testes . surgical exploration can reveal a blind - ending vas or a streak gonad
the principal causes of impalpable testes are . congenital absence intra abdominal testis and dysplastic testis neither ultrasound CT or MRI have demonstrated consistent efficacy for the localization of an impalpable testis however testicular venography reliably demonstrates the absence of normal venous plexus in the congenitally absent testis group . laparoscopy has proven the most sensitive investigation for true intra abdominal testes . surgical exploration can reveal a blind - ending vas or a streak gonad
HORMONE THERAPY
Human chorionic gonadotrophin (hCG) or luteinizing hormone releasing hormone (LHRH) have been used to encourage testicular descend used as hormonal manipulation for undescended testes
tags:testis,undescended
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