Undescended testis

1. GAURAV NAHAR
DNB UROLOGY RESIDENT,
MMHRC, MADURAI
UNDESCENDED
TESTIS

2. INTRODUCTION
 One of the most common pediatric disorders of male
endocrine glands &
 Most common genital disorder identified at birth.
Cryptorchidism:
A greek word which means ‘hidden testis’
 Retractile- 60%
 Undescended- 35%
 Ectopic- 3%
 Ascending- <2%

3. 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.

4. DEFINITIONS
 Normal scrotal position: positioning of midpoint
of the testis at or below midscrotum.
 Undescended testis: absence of one or both testes
in normal scrotal position.
 Vanishing testes: present initially in development
but are lost owing to vascular accident or torsion
unilaterally (monorchia) or, very rarely, bilaterally
(anorchia).

5.  Agenesis: testis that was never present and
therefore associated with ipsilateral müllerian duct
persistence.
 Congenital cryptorchidism: testes that are
extrascrotal at birth.
 Recurrent cryptorchidism is when testes
descend spontaneously postnatally but subsequently
return to a nonscrotal position.

6.  Testicular ascent or acquired cryptorchidism
: Testes are intrascrotal at birth but subsequently
identified in an extrascrotal position .
 Secondary cryptorchidism- testes that are
suprascrotal after inguinal hernia repair; testicular
retraction- as a complication of orchidopexy.
 Retractile testes are scrotal testes that retract
easily out of scrotum but can be manually replaced in
a stable scrotal position and remain there at least
temporarily.

7. EPIDEMIOLOGY
 Cryptorchidism is one of the most common
congenital anomalies.

 1% to 4% of full-term and 1% to 45% of preterm male
neonates.
 a component of over 390 syndromes.
 familial cluster is 3.6-fold overall, 6.9-fold if a
brother is affected, and 4.6-fold if the father is
affected.

8. ETIO-PATHOGENESIS
 Multifactorial pathogenesis.
 Birth weight is the principal determining factor, at
birth to age one year, independent of the length of
gestation.
 Premature infants- 30%
 More common in low-birth-weight male newborns,
IUGR, and twin gestation.

9. • Testicular descent occur as a result of a complex
interactions of hormonal and mechanical factors
Hormonal factors:
 Testosterone
 Dihydrotestosterone
 Mullerian-inhibiting Substance(MIS/AMH)
 HCG
 Genital branch of genitofemoral nerve which secret
CGRP (elaborated by testosterone)
 Non androgen–insulin like factor 3(INSL-3)

10. Mechanical factors
 Shortening and traction of the gubernaculum testis.
 Enlargement/elongation of processus vaginalis.
 Intra-abdominal pressure from increased visceral size.
 Straightening of fetus.
 Resolution of physiological hernia.
 Enlargement of testes/growth of epididymis.
 Propulsive force of the developing cremasteric muscle.

11. Testicular Descent
 Testicular descent occurs in two phases- transandominal
& transinguinal.
 INSL3(Insulin-like 3, Leydig cell origin) & Testosterone-
key hormones required for testicular descent.
 Transabdominal descent involves differential growth of
vertebrae and pelvis until 23 weeks’ gestation. Afterward
facilitated by the development of the gubernaculum,
processus vaginalis, spermatic vessels, and scrotum.
 A normal hypothalamic-pituitary-gonadal (HPG)axis is a
prerequisite for testicular descent.

12.  Testosterone and its conversion to
dihydrotestosterone (DHT) are also necessary for
continued migration, especially during the
inguinoscrotal phase.
 Release of calcitonin gene-related peptide (CGRP)
from genitofemoral nerve stimulates development
and function of the gubernaculum.
 Enlargement, distal detachment and migration of the
gubernaculum are key events that facilitate and
direct caudal movement of the testis

13.  Intra-abdominal pressure also appears to play a role
in testicular descent most significant during
transinguinal migration to the scrotum, probably in
conjunction with androgens and a patent processus
vaginalis.

14.  Transabdominal descent complete by 10 weeks.
 Traverses inguinal canal between 20-28 weeks.
 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. Nonsyndromic Congenital Cryptorchidism
 Perinatal risk factors associated with cryptorchidism
include prematurity, low birth weight/small for
gestational age, breech presentation, and maternal
diabetes.
 Extrascrotal testes - much less likely to descend by 1
year of age (50%) than high scrotal testes defined as
cryptorchid at birth.
 Spontaneous descent is more likely and may occur
later in premature Infants.

16. Syndromic Cryptorchidism
 Undescended testes are frequently present in
diseases associated with reduced androgen
production and/or action, such as androgen
biosynthetic defects, androgen insensitivity, Leydig
cell agenesis, and gonadotropin deficiency disorders,
AMH biosynthesis or receptor defects.
 Most commonly bilateral.

17.  Certain anomalies are associated with increased risk of
cryptorchidism: Musculoskeletal, central nervous
system( CNS), or abdominal wall/gastrointestinal defects
include
 Classic prune-belly (triad or Eagle-Barrett) syndrome;
 Spigelian hernia & Umbilical hernia
 Cerebral palsy
 Arthrogryposis
 Myelomeningocele
 Omphalocele & Gastroschisis
 Imperforate anus
 Posterior urethral valve
 Renal and T10 to S5 spinal anomalies

18. Genetic Susceptibility
 Polygenic & multifactorial.
 Most probable mode of inheritance- autosomal
dominant with reduced penetrance.
 INSL3, its receptor, relaxin/insulin-like family
peptide receptor 2 (RXFP2), HOXA10, and HOXA11-
most likely candidate genes for human
nonsyndromic cryptorchidism(mouse models).

19. Environmental Risk Factors
 Exposure to antiandrogenic and/or endocrine-
disrupting chemicals(EDCs) may contribute to
cryptorchidism.
 EDCs include phthalates, pesticides, brominated
flame retardants, diethylstilbestrol, and dioxins.
 A subset of boys with cryptorchidism have
measurable abnormalities in pituitary and/or
gonadal hormone secretion during infancy without
syndromic endocrine dysfunction.

20.  Lifestyle factors may also interfere with testicular
descent and function via hormonal or nonhormonal
effects; ex. smoking is associated with
cryptorchidism.

21. Presentation & Diagnosis
 75% to 80%- palpable and
 60% to 70% are unilateral;
 involvement of the right side is more common
overall but less frequent in series of nonpalpable
testes.
 8% of testes-abdominal, 63% canalicular, 24%
prescrotal, and 11% in the superficial inguinal pouch
or ectopic.

22. 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.

23. HISTORY: should cover the following questions:
 Has the testis ever been palpable in the scrotum?
 Was the patient born prematurely?
 Has the patient undergone prior inguinal surgery?
 Is or was the patient's mother on a vegetarian diet?
Was the patient fed soy formula during infancy?
 What was the patient's birth weight?

24. PRENATAL HISTORY:
 Did the patient's parents used an assisted
reproductive technique?
 Did his mother receive hormonal treatment?
 Were there multiple gestations?
FAMILY HISTORY:
 Cryptorchidism
 Hypospadias
 Intersexuality
 Precocious puberty
 Infertility
 Consanguinity

25. PHYSICAL EXAMINATION:
 Patient should be warm and relaxed for the
examination.
 Observation should precede the examination.
 Supine and, if possible, upright cross-legged and
standing positions.
 Abduction of the thighs contributes to inhibition of
the cremaster reflex.
 Document testicular palpability, position, mobility,
size, and possible associated findings such as hernia,
hydrocele, penile size, and urethral position.

26. Palpable Testes
 Undescended testes may be located along the line of
normal descent between the abdomen and scrotum or in
an ectopic position.
 Ectopic:
 Superficial inguinal pouch(m.c.)
 Perirenal
 Prepubic
 Femoral
 Peripenile
 Perineal
 Contralateral scrotal

27.  Gold standard for diagnosis remains careful
examination of a child in several positions and
confirmation of incomplete descent of the testis to a
dependent scrotal position after induction of
anesthesia.

28. Nonpalpable testes
 When a testis is nonpalpable, possible clinical
findings at surgery include:
1. abdominal or transinguinal “peeping” location
(25% to 50%),
2. complete atrophy (“vanishing” testis, 15% to 40%),
and
3. extra-abdominal location but nonpalpable due to
body habitus, testicular size, and/or limited
pts.’cooperation(10-30%).

29.  Diagnosis of a vanishing testis requires
documentation of blind-ending spermatic vessels in
the abdomen, inguinal canal, or scrotum.
 Endocrine evaluation in cases of suspected bilateral
vanishing testis (anorchia) include elevated basal
serum gonadotropin levels and no response to hCG
stimulation.

30. 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

31. Classification contd
B. Based on exploration findings:
 intra-abdominal
 intracanalicular
 extracanalicular (suprapubic or infrapubic), or
 ectopic.

32. Investigation
Imaging
 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

33. Laboratory Investigations
 Karyotyping
 ↑ FSH- likely represent bilateral anorchia
 HCG Stimulation tests- has clinical use where
gonadothrophins are normal
 FBC, Urinalysis, Serum electrolytes
Diagnostic Laparoscopy

34. Complications of Undescended testis
 Infertility
 Associated hernia
o 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.
 Trauma

35.  Tumour:
o 10% of testicular cancer originate in cryptochid testis.
 Torsion
 Epididymo-orchitis in a cryptorchid right testis
can mimic appendicitis
 Psychologic effects of an empty scrotum
 Testicular-Epididymal fusion abnormality

36. ASSOCIATED PATHOLOGY
TESTICULAR MALDEVELOPMENT:
 Reduced total germ cell count
 Impaired transformation of gonocytes to
spermatogonia.
 Delayed disappearance of gonocytes & appearance of
Ad spermatogonia.

37. ANOMALIES OF EPIDIDYMIS, PROCESSUS
VAGINALIS & GUBERNACULUM:
 Anomalies of fusion between the caput and/or cauda
epididymis, elongation and/or looping, and atresia.
 Failure of closure of processus vaginalis &
 Aberrant lateral attachment of gubernaculum.

38. OTHER ASSOCIATED
TESTICULAR ANOMALIES
 Polyorchidism
 Splenogonadal fusion
 Transverse testicular ectopia

39. TREATMENT
GOALS of treatment:
 to optimize testicular function,
 potentially reduce and/or facilitate diagnosis of
testicular malignancy,
 provide cosmetic benefits, and
 prevent complications such as clinical hernia or
torsion.

40.  Observation is indicated for the first 6 postnatal
months to allow spontaneous testicular descent.
 If descent does not occur in the postnatal period
surgical treatment at 6 months of age.

41. Surgical treatment
 Surgery remains the 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.

42. Principles of orchidopexy
(originally described by Bevan in 1899)
 Adequate exposure
 Herniotomy
 Mobilization of cord
 Fixation of testis

43. 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.

45.  The external oblique aponeurosis is opened in line with
the fascia

46.  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.

47.  The gubernaculum is divided

48.  Patent processus is dissected off the vas and vessels.

49.  A high ligation of the hernia sac is performed, and the
remaining structures are skeletonised

50. Manoeuvres to gain sufficient length include:
 Dissection of retroperitoneal attachments of the cord .
 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.(Prentiss manoeuvre).
 Cranial extension of the incision.

51. Superficial scrotal incision

52. Skin separated from dartos muscle

53.  The testis is placed in a sub-dartos pouch.
 Fixation sutures to the testes nolonger recommended

54. Subdartos pouch

55. 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

56. Impalpable UDTs contd
 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

57. Intra-abdominal testis

58. Options for intra-abdominal UDT
1. Standard inguinal orchidopexy(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.

59. Options for intra-abdominal UDT contd
3. Microvascular testicular
autotransplantation
 employs microsurgical techniques.
 reserved for older children with internal spermatic
artery large enough to be anastomosed to inferior
epigastric artery.

60. 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.

61. 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.

62. 6. Orchidectomy :
Reserved for postpubertal men with a contralateral
normally positioned testis.

63. 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.

64. Postoperative Complications
 Haematoma
 Infection
 Unsatisfactory position (requiring revision),
 Ilioinguinal nerve injury
 Damage to the vas
 Testicular atrophy
 Torsion testis.

65. Outcome
 Early orchidopexy may improve fertility
 No evidence that it reduces risk of malignancy but allows
early identification.

66. Thank You..