CRYPTORCHIDISM.pptx

Cryptorchidism is a common condition which needs early treatment

1. CRYPTORCHIDISM DR MUHAMMAD AAMIR PGR UROLOGY TEAM C

2. DEFINITION Retention of testis in the abdomen or arrest of its descent at any point along its natural pathway.

3. EMBRYOLOGY DEVELOPMENT- From genital fold Descent – three phases A-Intra abdominal (1-7 months) B- Canalicular ( 7-8months) C-Scrotal (8-9month)

4. EPIDEMIOLOGY Most common congenital malformation of male neonates. Incidence depends on gestational age full term: 1-4.6% preterm neonates: 1.1-45% Bilateral undesend in upto 30% of cases

5. AETIOLOGY AND PATHOPHYSIOLOGY Specific cause is unknown in most cases May be heterogenous or due to multiple genetic and envoirnmental risk factors e.g abnormal testes or gubernaculm low level of androgens, HCG, LH, Calcitonin, gene related peptide and maternal or paternal hormonal exposure, decreased intraabdominal pressure(prune belly syndrome) prior inguinal surgery of child

6. CLASSIFICATION A. Palpable (80%) Inguinal Ectopic : MC position is superficial inguinal pouch Retractile : overactive cremasteric reflex, upto 1/3 rd ascends B. N on-palpable(20%) Intrabdominal (50-60%) MC found close to internal inguinal ring Inguinal Ectopic Absent a. agenesis b. vanishing testis Mechanism of absent testis include testicular agenesis and atrophy after intrauterine torsion.

7. DIAGNOSTIC EVALUATION HISTORY : Empty scrotum since birth Swelling in the groin which is reducible May present with complication PHYSICAL EXAMINATION: IN standing sitting or squatting position In case of unilateral non palapable teste , contralateral teste need to be examined. A compensatory hypertrophy suggest testicular absence or atrophy. In case of b/l UDT and any sign of DSD such as genital ambiguity or scrotal hyperpigmentation further evaluation including endocrine and genetic assessment becomes mandatory.

8. Continue… IMAGING STUDIES: Ultrasound; lacks diagnostic sentivity MRI; recommended in selected and specific clinical scenarios Diagnostic Laproscopy ; procedure of choice

9. WHY TO TREAT…??? COMPLICATNS; Infertility Trauma Torsion Malignant changes Psychological

10. MANAGEMENT TX SHOULD BE STARTED AT 6-12MONTHS OR 18 MONTHS ATLEAST Medical therapy ; not currently recommended as 20% of descended testes have risk of re-ascend later on.. The higher the testes located prior to therapy the lower the success rate Hcg or GNRH has success rate of 20%. Some studies reported combined HCG and Gnrh therapy to cause successful descent in upto 38% of non-responders to monotherapy .

11. CONTINUE…. SURGICAL MANAGEMENT PALAPABLE TESTIS a- Inguinal orchidopexy Success rate upto 92% Mobiloization of testis and spermatic cord to the level of internal inguinal ring. Dissection and division of all cremasteric fibers. Mobilzed testicle needs to be placed in subdartos pouch within the hemiscrotum without tention .

12. b - Scrotal orchidopexy Success rate 88-100% Done for low position palpable UDT Shorter operative time

13. B- Non palpable testis a-Open transabdominal orchidopexy Success rate 95% The internal ring is approached via muscle splitting incision. Peritoneum opened and testis delivered. A tunnel is created to scrotum and testis is secured

14. b - Fowler-Stephens orchidopexy ; testis lying greater than 2cm above the internal inguinal ring can be done laproscopically as well as open 1-one stage technique Involves proximal cutting and transection of testicular vessels, conservation of collateral arterial blood supply via the deferential atery and cremesteric vessels. The testis is then mobililized and brought down in scrotum.

15. 2-staged technique The procedure is same as one stage technique but testis are mobilized six months later with its new collaterals . MODIFIED FOWLER-STEPHEN TECHNIQUE COMPLICATIONS… A- testicular atrophy B-testicular ascend C-vas derens injury D-wound infections dehiscence and heamatoma .

16. PROGNOSIS Sperm count are reduced in atleast 25% of formerly unilateral and majority of formerly b/l cryptorchoid men but paternity rates in unilateral groups are similar to those in control men. TGCT risk is 2-5 times higher in boys with cryptorchidism especially after pubertal orchoidopexy .