Updated guidelines on the management undescended testis ; Incidence/ Etiology. Genes and syndromes. Retractile Testis. Laboratory. Role of imaging. Hormonal treatment. Surgery . Complications.

1. SAMEH SHEHATA
Current management of
undescended testis
2020

2. Content
• Incidence/ Etiology.
• Genes and syndromes.
• Retractile Testis.
• Laboratory.
• Role of imaging.
• Hormonal treatment.
• Surgery .
• Complications.

4. INCIDENCE

5. INCIDENCE/EPIDEMIOLOGY
 30 % preterm
4% in term boys;
 1% 3 months
 1% 12 months

6. Etiology
• Multifactorial
• The precise molecular and genetic mechanisms
underlying cryptorchidism in humans remain
unknown.

7. ETIO-PATHOGENESIS
 Birth weight is the principal determining
factor, at birth to age one year,
independent of the length of gestation.

8. Genetic syndromes associated with cryptorchidism
• Prune-belly syndrome (100% of patients)
• Noonan syndrome (50% of patients)
• Klinefelter syndrome (27% of patients)
• FG syndrome (24% of patients)
• Down syndrome (6.5% of patients)
• Other syndromes that carry increased risk for disease
include Beckwith-Wiedemann syndrome, Smith-Lemli-
Opitz syndrome, de Lange syndrome, and Prader-Willi
syndrome

9. Syndromic Cryptorchidism
mostly bilat.
 reduced androgen production
androgen insensitivity, Leydig cell agenesis, and
gonadotropin deficiency disorders, AMH biosynthesis
or receptor defects.
 Diminished intra abd. P.
Prune belly, gastroschisis, omphalocele.

10. Environmental RiskFactors
 Exposure to antiandrogenic and/or endocrine-
disrupting chemicals(EDCs) may contribute to
cryptorchidism.
 EDCs include phthalates, pesticides, brominated
flame retardants, diethylstilbestrol, and dioxins.

11. RETRACTILE TESTIS
What you do?

12. Retractile testis
• Absent at birth .
• Middle of childhood 5-6 y.
• Ten yrs.

13. Retractile testes , Are they all the same?

14. Treatment retractile testis
• Make sure they are truly
retractile!
• Yearly FU till puberty.
• Some will ascend.

15. Difference between ascending and UDT
• No effect on fertility .
• No predisposition to malignancy
• Responds better to hormonal .
• Scrotal approach.

16. CONTRALATERAL HYPERTROPHY
Explore or not?

17. Contralateral hypertophy

18. Cutoff values
•21 mm
•1.6 CC

19. Lab; when?
• Bilateral.
• Associated with hypospadias.

20. Lab; what?
• Karyotyping.
• FSH /LH
• MIS / inhibin
• HCG stimulation test.

21. ROLE OF IMAGING !

22. Most are inaccurate 44%
• US
• CT
• MRI

24. Ultrasonography
• high resolution transducer (> 7.5 MHz)
• 100% of palpable
• 84% of non-palpable UDT
• sensitivity of 76%
• specificity of 100%

25. When to do US?
• Inguinal testis in obese.
• Bilateral UDT
• unilateral nonpalpable testis with
abnormal phallus
–To check int. Genitalia

26. MRI
• sensitivity 90%
• specificity 79%

27. • MRA/MRV 100%
• Expensive
• Needs anesthesia.
• No benefit over Lap.

28. Hormonal treatment for descent
• A meta-analysis of hCG treatment of
cryptorchidism concluded that hCG treatment is no
more effective than placebo. [52]
• American Urological Association guidelines
recommend against the use of hormonal therapy to
induce testicular descent, due to low response rates
and lack of evidence for long-term efficacy. [1]

29. 100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
HCG GNRH PLACEBO SURGERY
Comparison of modalities

30. Hormonal treatment for fertility
• European guidelines note that suggest offering
endocrine treatment for bilateral undescended testes,
to possibly improve further fertility potential. [58]
• hadziselimovic et al (1997) suggested that such patients may
benefit from adjuvant hormonal therapy with resultant increased
numbers of germ cells later in life.
• Bilateral.
• low fertility index on biopsy

31. Palpable UDT ; Timing for surgery !
• Definitive surgical therapy should
be performed between ages 6 and
12 months.

32. Early surgery?
• Potential injury for the delicate
structures .
• Vas and vessels .

33. HERNIAL SAC:
LIGATE OR DIVIDE ?
In UDT

34. Our findings confirm that division without
ligation of a patent processus vaginalis is usually
followed by spontaneous peritoneal scarring and
complete closure of the internal inguinal ring.

35. Scrotal approach

36. THE HIGH PALPABLE !
PEEPING
Inguinal approach !

37. Success vs location
• In a 1995 meta-analysis of orchiopexy by Docimo,
location-based success rates were as follows [60] :
• beyond external ring: 92%
• Canalicular testes: 87%
• Peeping testes: 82%
• Abdominal testes: 74%

39. Conclusions
• In this series, the incidence of post-operative
testicular atrophy
• 5% in the common (low) type
• 9% in the high type.
These numbers and the above risk factors should be
quoted to the caregiver during pre-operative informed
consent

40. IMPALPABLE TESTIS
Surgical options

41. Findings on laparoscopy
• Blind-ending spermatic vessels (20%)
• Intra-abdominal testis (50%)
• (vessels and vas) passing (30%)

42. Surgical Options
• One- stage Fowler
Stephens .
• Two stage Fowler
Stephens.
• Lap Assisted
orchiopexy .
• Shehata
technique.

43. PASSING THROUGH
Inguinal exploration?

44. testicular nubbins do not have viable germ cells
Do not need to be excised on the basis of
malignant potential of residual testicular tissue.

45. SINGLE TESTIS
MONORCHISM
Contralateral pexy ?

47. Postpubertal presentation
• treatment recommendations for postpubertal men
• Men younger than 32 years with a unilateral
undescended testis and normal contralateral testis
should undergo orchiectomy.
• Men older than 32 years with a unilateral
undescended testis should receive close observation
and physical examination

48. Abd testis with persistent Mullerian remnant
Mullerian
remnant

50. •
• Conclusion: The goal of the approach in PMDS
patients is to preserve testes, as well as carry them to
their natural location.
• Leaving the MR in place is a suitable option for blood
circulation of the testes but the long-term results are
still unknown.

51. COMPLICATIONS

52. Fertility
Unilateral
• Normal sperm
count 83%
• Paternity 89%
Bilateral
• 44%
• 33-65%

53. Malignancy
• General population : 4.2/100 000
• (RR) UDT X 2.7‒ 8 12‒ 33 / 100 000.
• Contralateral : slightly increased
• Orchiopexy before puberty reduce but
not eliminate the Relative risk from
5.4 to 2.2.

54. Guidelines
• Age at orchiopexy 6-12 months.
• Retractile testis ; yearly FU for
ascending testis.
• No imaging is required .
• Hormonal treatment is not
recommended to induce testicular
descent.

55. Guidelines
• Hormonal treatment may improve
fertility in some bilateral cases with
delayed germ cell maturation.
• Laparoscopy is the gold standard
for diagnosis and treatment of
impalpable testis.