2. Introduction
One of the commonest surgical problems in males at paediatric surgery
clinic.
One of the causes of vacant scrotum/ Cryptorchidism
CRYPTORCHIDISM – hidden testis
Retractile- 60%
Undescended- 35%
Ectopic- 3%
Ascending- <2%
3. Undescended testis: is arrested
along its normal path of
descent
Retractile testis: can be
manipulated into scrotum
where it remains without
tension
Ectopic testis is located
outside the normal path of
descent
Ascended: previously
descended, then “ascends”
spontaneously
4. Historical perspective
1786, Hunter first drew attention to the mechanism of descent
1820, Rosenmerkal attempted the first surgical orchidopexy but
1877, Annandale performed the first successful orchiopexy
5. Incidence
3.4 % in term boys; by 1 year incidence is 0.8%
Occurs on the right-50%, left-35%, bilateral-10-15%
Approximately 40% of the non-palpable testes are intra-
abdominal, 40% are inguinal, and 20% are atrophic or
absent
No definite racial differences in incidence are reported.
6. The precise molecular and genetic mechanisms underlying cryptorchidism
in humans remain unknown.
Premature infants- 30%
Also more common in low-birth-weight male newborns, IUGR, and twin
gestation.
Birth weight alone is the principal determinant of cryptorchidism at birth
and at 1 year of life, independent of the length of gestation.
9. Anatomy
The 3 arteries- testicular, cremasteric and artery to the vas, all anastomosed
mainly at the head of epididymis hence ligation of the testicular artery is
not necessarily followed by testicular atrophy.
Lymphatic drainage: to the para-aortic lymph nodes at the level of the renal
vessels..
Nerve supply
T10 sympathetic fibres via the renal and aortic plexus.
convey afferent (pain) fibres—hence referred pain from the testis to the
loin.
10. Scrotum
The skin of the scrotum is thin, pigmented & rugose
maintains a temperature 3-4⁰C lower than core body temperature
Its development depends on the descent of testis
11. Embryology
The testes develop in the
retro-peritoneum
At 4 to 6 weeks'
gestation, the genital
ridges organize, followed
by migration of
primordial germ cells
12. 3 phases of descent
1. Trans-abdominal migration of testis to the inguinal ring
2. Development of processus vaginalis and inguinal canal
3. Trans-inguinal descent into the scrotum
13. Testicular differentiation is
initiated in the 7th week by the
SRY gene
8 week testis hormonally active
o Sertoli cells secretes mullerian
inhibiting substance (MIS)
o Leydig cells secrete testosterone
MIS causes degeneration of
mullerian structures
the testes reach the inguinal
region by approximately 12th
week
14. by 28th weeks migrate through
the inguinal canal
32nd week – emerges from
superficial inguinal ring.
35-40th week –descends into the
scrotum
Left testis descends before the
right
About 96% of testes have
descended at birth
15. Descent - result of a complex interaction of
Hormonal and Mechanical factors
Hormonal factors:
Testosterone- regression of cranial suspensory ligament
Dihydrotestosterone
Mullerian-inhibiting factor
HCG
Genital branch of genitofemoral nerve which secret CGRP-calcitonin gene
related peptide(elaborated by testosterone)
Non androgen–insulin like factor 3- enlargement of gubernaculum
16. Descent - result of a complex interaction of
Hormonal and Mechanical factors
Mechanical factors
Shortening and traction of the gubernaculum testis
Enlargement/elongation of processus vaginalis
Intra-abdominal pressure from increase visceral size
Straightening of fetus
Resolution of physiological hernia
Enlargement of testes/growth of epididymis
Propulsive force of the developing cremasteric muscle
17. Complexity of this process suggests
that causative factors for non-descent
are multifactorial.
18. Classification
A. Based on palpation (Kaplan-1993)
Impalpable:
High canalicular
Deep inguinal ring
Intra-abdominal
Accounts for 20% of UDT
Palpable:
Neck of scrotum
Superficial inguinal ring
Low canalicular
Accounts for 80% of UDT
19. B. Based on exploration findings:
intra-abdominal
intracanalicular
extracanalicular (suprapubic or infrapubic), or
ectopic
20. Pathological changes
often macroscopically normal in early childhood but by puberty some
degree of atrophy occur.
Microscopic evidence of tubular atrophy is evident by 5-6 years of age, &
hyalinization is present by the time of puberty.
loss of volume and progressive germ cell depletion starting at 6 months of
age
Other histologic changes include:
decreased tubular diameter, and
decreased numbers of Leydig cells,
atrophy of Leydig cells
degeneration of Sertoli cells
21. Clinical Features
Most patients presents in infancy and around school age. A few present
after puberty.
Absence of one or both testes
swelling in the groin (may be the testis or a hernia)
May present with attacks of pain in the groin due either to recurrent
torsion of the testis or strangulation of an associated hernia.
22. Examination
Marked variation from the norm for height, weight & fat distribution may
suggest anorchia due to possible intersex or pituitary deficiency
± Signs of syndromic features e.g kallmann’s
under developed scrotal skin with little or no rugae & appears triangular in
unilateral UDT or flat in bilateral UDTs
± hypertrophy of contralateral testis
23. Examination
Examination of potential ectopic sites- penile, femoral, & perineal areas if
the testicle cannot be felt.
If there is hypothalamic-pituitary dysfunction, the patient is obese and the
penis small for the age.
Technique:
Examination under anaesthesia is also done for impalpable testis before
exploration
Clinical distinction between retractile and undescended testis may be
difficult
25. Investigations
Abdominal USS
CT Scan
MRI
Because imaging has not been proved to be reliable in demonstrating
whether the testis is present or absent, its routine use is discouraged
26. Laboratory Investigations
Karyotyping
↑ FSH- likely represent bilateral anorchia
HCG Stimulation tests- has clinical use where gonadothrophins are
FBC, Urinalysis, Serum electrolytes
Diagnostic Laparoscopy
27. Complications
Infertility- impairment of germcell maturation
Associated hernia- indirect inguinal hernia usually accompanies a
congenital undescended testis in about 90% cases but rarely symptomatic.
Testicular atrophy: due to pressure effects and histological changes.
Tumour-10% of testicular cancer originate in cryptochid testis.
Torsion
Epididymo-orchitis in a cryptochid right testis can mimic appendicitis
Psychological effects of an empty scrotum
Testicular-Epididymal fusion abnormality
28. Hormonal treatment
Indications
bilateral UDT
hypothalamic-pituitary dysfunction
patients unfit for surgery
when diagnosis of retractile testes is uncertain
LHRH and hCG are used with varying degrees of success
Multiple dosage schedules have been proposed
Success rate low
29. Adverse effects of hormonal therapy
increase in scrotal rugae, pigmentation
growth of pubic hair
increased penile size
priapism
Premature closure of epiphyseal plate
Increased appetite and weight gain
30. Surgery- GOLD STANDARD
Orchidopexy
Should be performed as early as 6months because of rarity of spontaneous
descent after 6mnths possible improvement in fertility
Interval of 6months in bilateral undescended testes
32. Orchidopexy for the palpable UDT
general anesthesia; useful to re-examine the child- previously
nonpalpable testis may become palpable.
groin crease incision is made Careful dissection to expose the external
oblique aponeurosis and the external ring.
34. Rolling the cord structures under a finger may help confirm the exact site
of the canal.
Care inside the canal is taken to identify and preserve the ilioinguinal
nerve.
The cord is isolated by sweeping the cremasteric fibres off it.
37. A high ligation of the hernia sac is performed, and the
remaining structures are skeletonised
38. Manoeuvres to gain sufficient length
dissection of retroperitoneal attachments of the cord (Prentiss
manoeuvre)
Divide (or pass the testis under) the inferior epigastric vessels after
opening the floor of the canal (transversalis fascia), allowing a more
medial and thus direct route to the scrotum.
43. Impalpable UDTs
laparoscopy -best means of identifying intra-abdominal testis, vas and
vessels.
If laparoscopy indicates blind-ending gonadal vessels and vas deferens,
the patient is said to have vanishing testis syndrome and no further
action is necessary
If intra-abdominal testis identified consider staged orchidopexy or
microvascular transfer
If vas vessels seen entering inguinal canal, the groin should be explored
The length of the gonadal vessels is the limiting factor to getting the
intra-abdominal testis into the scrotum
45. Options for intra-abdominal UDT
1. Standard inguinal orchidopexy (has a high failure rate)
2. A two-stage Fowler-Stephens orchidopexy (open or laparoscopy).
The testicular artery is sacrificed.
The rationale is that the testicular arterial supply comes from three
sources.
At a 2nd stage (after 6 months of age, when collaterals have formed), the
testis is brought down on a wide pedicle of peritoneum containing the
remaining vessels.
46. 3. Microvascular testicular autotransplantation
employs microsurgical techniques
reserved for older children with internal spermatic artery large enough to
be anastomosed to inferior epigastric artery.
47. 4. Refluo Testicular Autotransplantation
Provides only venous drainage by microvascular anastomosis of testicular
veins to inferior epigastric veins
Based on discovery that failure in Fowler-Stephens was due to testicular
congestion
Reduced operating time and increased success
48. 5. Jones Preperitoneal Approach
Preperitoneal cavity accessed by splitting abdominal obliques
Testes mobilized transperitoneally and passed to the scrotum through the
inguinal canal or posterior wall
50. Bilateral impalpable testis
Raise suspicion of an intersex condition
karyotype and hormonal profile should be characterized
Can involve measurement of MIS or an HCG stimulation test to detect the
presence or absence of functioning testicular tissue.
51. Postoperative Complications
Haematoma
Infection
unsatisfactory position (requiring revision),
ilioinguinal nerve injury
damage to the vas
testicular atrophy
and torsion testis.
52. Outcome
Early orchidopexy may improve fertility
No evidence that it reduces risk of malignancy but allows early
identification.
