Pediatric urology :Undescended Testis (UDT)

Undescended Testis (UDT)

1. Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai

UNDESCENDED
TESTIS
1

2. Moderators:
Professors:
Prof. Dr. G. Sivasankar, M.S., M.Ch.,
Prof. Dr. A. Senthilvel, M.S., M.Ch.,

Asst Professors:
Dr. J. Sivabalan, M.S., M.Ch.,
Dr. R. Bhargavi, M.S., M.Ch.,
Dr. S. Raju, M.S., M.Ch.,
Dr. K. Muthurathinam, M.S., M.Ch.,
Dr. D. Tamilselvan, M.S., M.Ch.,
Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai.
2

3. 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 Dept of Urology, GRH and KMC,
Chennai.

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
orchidopexy.
4 Dept of Urology, GRH and KMC,
Chennai.

5. DEFINITIONS
Normal scrotal position: positioning of midpoint of the
testis at or below midscrotum.

Undescended testis/Cryptorchidism: 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 Dept of Urology, GRH and KMC,
Chennai.

6. 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 Dept of Urology, GRH and KMC,
Chennai.

7. Testicular ascent or acquired cryptorchidism
: defined as a cryptorchid testis that was
documented as scrotal at a previous examination .

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 Dept of Urology, GRH and KMC,
Chennai.

8. EPIDEMIOLOGY
Cryptorchidism is one of the most common
congenital anomalies.
1% to 9% of full-term and 1% to 45% of preterm male
neonates.
a component of around 500 syndromes.,linked to 387
genes
80-85 percent of cases are isolated or non syndromic.
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 Dept of Urology, GRH and KMC,
Chennai.

9. •Although most studies support a prevalence at birth of 2%
to 4% and at 3 months of age of 1% to 2%, this varies
geographically, with frequency as high as 9% in some studies
(Boisen et al., 2004; Virtanen and Toppari, 2008) .

•Cryptorchidism is more common in Caucasian as compared
with non-Caucasian populations .

•The frequency of spontaneous descent by 3 months of age
in boys identified as cryptorchid at birth was reported as
50% to 87% .
9 Dept of Urology, GRH and KMC,
Chennai.

10. 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.
10 Dept of Urology, GRH and KMC,
Chennai.

11. •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)
11 Dept of Urology, GRH and KMC,
Chennai.

12. 12 Dept of Urology, GRH and KMC,
Chennai.

13. 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.
13 Dept of Urology, GRH and KMC,
Chennai.

14. 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.
14 Dept of Urology, GRH and KMC,
Chennai.

15. 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
15 Dept of Urology, GRH and KMC,
Chennai.

16. 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.
16 Dept of Urology, GRH and KMC,
Chennai.

17. Transabdominal descent complete by 10 weeks.
Traverses inguinal canal between 20-28 weeks.
32
nd week – emerges from superficial inguinal ring.
35-40
th week –descends into the scrotum.
Left testis descends before the right.
About 96% of testes have descended at birth.
17 Dept of Urology, GRH and KMC,
Chennai.

18. Barteczko and Jacob (2000) described five major phases
of testicular descent in the human fetus

Phase 1 (5 weeks),:the caudal mesonephros contacts the future
gubernaculum at the internal inguinal ring.

Phase 2, the genitofemoral nerve (GFN) is seen to accompany the
newly formed gubernaculum (abdominal, interstitial, and
subcutaneous portions) and processus vaginalis (7 weeks);
subsequently, growth of the gubernaculum, deepening of the
processus vaginalis, and extension of cremaster muscle fibers into
the interstitial gubernaculum occurs (8 to 10 weeks).

18 Dept of Urology, GRH and KMC,
Chennai.

19. In Phase 3 (10 to 14 weeks), growth of the testis and regression
of the müllerian ducts and mesonephros occurs; the
gubernaculum is visible as a thin cord in both sexes and begins
its swelling phase in males beginning at 12 weeks, after the testis
is already located at the internal inguinal ring.



In Phase 4 (14 to 20 weeks), swelling of the gubernaculum,
further development of the cremaster muscle, and migration of
the processus vaginalis produce widening of the inguinal canal
19 Dept of Urology, GRH and KMC,
Chennai.

20. . In Phase 5 (20 to 28 weeks), release of the distal subcutaneous
attachment of the gubernaculum and transinguinal passage of the
testis occur. Further caudal movement of the testis into the scrotum
up until the time of birth is accompanied by regression of the
gubernaculum.
20 Dept of Urology, GRH and KMC,
Chennai.

21. 21 Dept of Urology, GRH and KMC,
Chennai.

22. 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.
22 Dept of Urology, GRH and KMC,
Chennai.

23. 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.
23 Dept of Urology, GRH and KMC,
Chennai.

24. •Persistent mül-lerian duct syndrome, a DSD resulting from
defective AMH signaling, is also associated with
cryptorchidism or transverse testicular ectopia.

•More than one-half of prepubertal patients with Klinefelter
syndrome have cryptorchidism.

•Other genomic rearrangements and trisomies, including
Down syndrome (trisomy 21), are associated with
cryptorchidism .
24 Dept of Urology, GRH and KMC,
Chennai.

25. 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;
53% to 80% of Spigelian hernia & Umbilical hernia
7% to 30% of congenital diaphragmatic hernia
16% to 33% of Omphalocele & 5% to 25% of
Gastroschisis
19 % of Imperforate anus

25 Dept of Urology, GRH and KMC,
Chennai.

26. 25% to 54% of cerebral palsy
38% ofArthrogryposis(multiple joint contractures)
15% of Myelomeningocele
12% to 17% of Posterior urethral valve
Renal and T10 to S5 spinal anomalies
26 Dept of Urology, GRH and KMC,
Chennai.

27. 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).
27 Dept of Urology, GRH and KMC,
Chennai.

28. Environmental Risk Factors
Exposure to antiandrogenic and/or endocrine-
disrupting chemicals(EDCs) may contribute to
cryptorchidism.

EDCs include phthalates(to make PVC),
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.
28 Dept of Urology, GRH and KMC,
Chennai.

29. Lifestyle factors may also interfere with testicular
descent and function via hormonal or nonhormonal
effects; ex. smoking is associated with
cryptorchidism.
29 Dept of Urology, GRH and KMC,
Chennai.

30. 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.
In a meta-analysis of surgical patients, testes were
abdominal in 34%, near the internal ring
(“peeping”) in 12%, canalicular in 27%, and
beyond the external ring in 27% (Docimo, 1995)
30 Dept of Urology, GRH and KMC,
Chennai.

31. 31 Dept of Urology, GRH and KMC,
Chennai.

32. 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.
32 Dept of Urology, GRH and KMC,
Chennai.

33. 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?
33 Dept of Urology, GRH and KMC,
Chennai.

34. 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 34 Dept of Urology, GRH and KMC,
Chennai.

35. 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.
35 Dept of Urology, GRH and KMC,
Chennai.

36. 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
36 Dept of Urology, GRH and KMC,
Chennai.

37. 37 Dept of Urology, GRH and KMC,
Chennai.

38. Careful examination of these areas is needed to correctly classify a testis as palpable or
nonpalpable, a critical step that influences further diagnosis and treatment
38 Dept of Urology, GRH and KMC,
Chennai.

39. 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.
39 Dept of Urology, GRH and KMC,
Chennai.

40. 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%).
40 Dept of Urology, GRH and KMC,
Chennai.

41. 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.
Very low or undetectable AMH and INHB, together
with high levels of gonadotropins (LH >5 IU/L and FSH
>2 IU/L in boys 0.5 to 6 years of age or LH or FSH >5
IU/L in boys 6 to 11 years of age) are diagnostic for
anorchia 41 Dept of Urology, GRH and KMC,
Chennai.

42. 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 42 Dept of Urology, GRH and KMC,
Chennai.

43. Classification contd
B. Based on exploration findings:
intra-abdominal
intracanalicular
extracanalicular (suprapubic or infrapubic), or
ectopic.
43 Dept of Urology, GRH and KMC,
Chennai.

44. Investigation
Imaging

Abdominal US.:Overall, the sensitivity and specificity of
ultrasonography in localizing the nonpalpable testis is
45% and 78%, respectively .
MRI. In a recent meta-analysis, the sensitivity and
specificity of MRI in identifying cryptorchid testes was
65% and 100%, respectively, and was higher for inguinal
than for abdominal testes (Krishnaswami et al., 2013).
One indication for MRI may be identification of an
ectopic abdominal testis not localized by laparoscopy
44 Dept of Urology, GRH and KMC,
Chennai.

45. Imaging is not indicated for diagnosis of the
nonpalpable testis, as it has limited accuracy and does
not obviate the need for definitive surgical
intervention
45 Dept of Urology, GRH and KMC,
Chennai.

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

Diagnostic Laparoscopy:Diagnostic
laparoscopy, followed by laparoscopic
orchidopexy if an abdominal testis is present, has
become the preferred approach to the
nonpalpable testis for many clinicians
46 Dept of Urology, GRH and KMC,
Chennai.

47. Laparoscopy is preceded by an examination under anesthesia, which
may be a useful adjunct that helps define the appropriate course of
action .

Important laparoscopic observations include
•the size and position of the spermatic vessels and vas;
• testicular size,
•quality and position if visible; and
•patency of the internal inguinal ring
47 Dept of Urology, GRH and KMC,
Chennai.

48. The combination of a closed internal ring and a blind-ending spermatic
artery and vas confirms an abdominal vanishing testis
,
48 Dept of Urology, GRH and KMC,
Chennai.

49. 49 Dept of Urology, GRH and KMC,
Chennai.

50. •A hernia is frequently but not always associated with a
viable abdominal or distal testis (Elder, 1994; Moore et al.,
1994).
•An atretic spermatic cord coursing through a closed
inguinal ring is suggestive of a distal vanishing testis, but
this finding may be subjective, and, conversely, normal
appearing vessels may be associated with both viable and
vanishing testes .
50 Dept of Urology, GRH and KMC,
Chennai.

51. •Therefore, if laparoscopy does not unequivocally localize
the testis or blind-ending spermatic artery, additional
surgical exploration is needed for definitive diagnosis.
This may be performed laparoscopically after the
placement of additional working ports.

•Laparoscopy is the procedure of choice to confirm or
exclude the presence of a viable or remnant abdominal
testis, unless a prominent scrotal nubbin is palpable with
other clinical signs of monorchism. Contralateral fixation
51 Dept of Urology, GRH and KMC,
Chennai.

52. 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
52 Dept of Urology, GRH and KMC,
Chennai.

53. 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
53 Dept of Urology, GRH and KMC,
Chennai.

54. ASSOCIATED PATHOLOGY
TESTICULAR MALDEVELOPMENT:
Reduced total germ cell count

Impaired transformation of gonocytes to
spermatogonia.

Delayed disappearance of gonocytes & appearance of
Ad spermatogonia.
54 Dept of Urology, GRH and KMC,
Chennai.

55. 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.
55 Dept of Urology, GRH and KMC,
Chennai.

56. 56 Dept of Urology, GRH and KMC,
Chennai.

57. OTHER ASSOCIATED
TESTICULAR ANOMALIES
Polyorchidism
Splenogonadal fusion
Transverse testicular ectopia
57 Dept of Urology, GRH and KMC,
Chennai.

58. 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.
58 Dept of Urology, GRH and KMC,
Chennai.

59. 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 after 6 months of age
preferably by 12 months.
59 Dept of Urology, GRH and KMC,
Chennai.

60. Support for this approach is based on the following
rationale:
(1) spontaneous descent is unlikely in full-term males
after 2 to 6 months of age,
(2) testicular growth is restored after early
orchidopexy at 9 months as compared with 3 years
of age, and
(3) orchidopexy for abdominal testes may be easier
in young infants, soon after mini-puberty .
60 Dept of Urology, GRH and KMC,
Chennai.

61. Medical management
Therapeutic LHRH and/or hCG :
hormonal therapy to stimulate testicular descent is not currently
recommended for treatment of boys with cryptorchidism

Adjuvant Hormonal Therapy ;
Hadziselimovic et al. (1986, 1987a–c) were first to advocate the use of
adjuvant or neoadjuvant LHRH agonist therapy to improve potential
fertility in boys with cryptorchidism .
Currently Although data suggest potential efficacy of adjuvant therapy
in improving fertility potential, the methodologic limitations make
interpretation difficult, and therefore adjuvant therapy is not widely in
use .
61 Dept of Urology, GRH and KMC,
Chennai.

62. 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.
62 Dept of Urology, GRH and KMC,
Chennai.

63. Principles of Inguinal orchidopexy
(originally described by Bevan in 1899
Later by Hutcheson et all 2000)

Adequate exposure
Herniotomy
Mobilization of cord
Fixation of testis
63 Dept of Urology, GRH and KMC,
Chennai.

64. 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
and roule out ectopic testis to expose the external
oblique aponeurosis and the external ring.
64 Dept of Urology, GRH and KMC,
Chennai.

65. 65 Dept of Urology, GRH and KMC,
Chennai.

66. The external oblique aponeurosis is opened in line with
the fascia
66 Dept of Urology, GRH and KMC,
Chennai.

67. 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.
67 Dept of Urology, GRH and KMC,
Chennai.

68. The gubernaculum is divided
68 Dept of Urology, GRH and KMC,
Chennai.

69. Patent processus is dissected off the vas and vessels.
69 Dept of Urology, GRH and KMC,
Chennai.

70. A high ligation of the hernia sac is performed, and the
remaining structures are skeletonised
70 Dept of Urology, GRH and KMC,
Chennai.

71. Manoeuvres to gain sufficient length include:
transection of lateral fascial bands along the cord,
cranial retroperitoneal dissection

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.
71 Dept of Urology, GRH and KMC,
Chennai.

72. Superficial scrotal incision
72 Dept of Urology, GRH and KMC,
Chennai.

73. Skin separated from dartos muscle
73 Dept of Urology, GRH and KMC,
Chennai.

74. The testis is placed in a sub-dartos pouch.
Fixation sutures to the testes nolonger recommended
74 Dept of Urology, GRH and KMC,
Chennai.

75. Subdartos pouch
75 Dept of Urology, GRH and KMC,
Chennai.

76. Transscrotal Orchidopexy
A primary scrotal approach can be considered when
the testis is palpable ,although some surgeons reserve
this approach for testes that are close to or can be
drawn into the scrotum .

An incision along the superior scrotal border is made
as described by Bianchi et al. for any palpable testicles.
Alternatively, a transverse low scrotal approach (Misra
et al., 1997) and midline scrotal approach (Cloutier et
al., 2011) have been described for those testes that can
be drawn into the scrotum .

76 Dept of Urology, GRH and KMC,
Chennai.

77. 77 Dept of Urology, GRH and KMC,
Chennai.

78. •After the testis is delivered, the distal sac and
overlying cremaster are mobilized proximally as far
cranially as possible, “high above the inguinal canal”
(Iyer et al., 1995).

Some cases require conversion to an inguinal approach
for ligation of the sac or to gain further length on the
spermatic cord.

Fixation sutures through the tunica albuginea were
used in many series of scrotal orchidopexy followed by
placement of the testis in a subdartos pouch.
78 Dept of Urology, GRH and KMC,
Chennai.

79. 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
79 Dept of Urology, GRH and KMC,
Chennai.

80. 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
80 Dept of Urology, GRH and KMC,
Chennai.

81. Intra-abdominal testis
81 Dept of Urology, GRH and KMC,
Chennai.

82. 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.
82 Dept of Urology, GRH and KMC,
Chennai.

83. 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.
83 Dept of Urology, GRH and KMC,
Chennai.

84. 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.
84 Dept of Urology, GRH and KMC,
Chennai.

85. 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.
85 Dept of Urology, GRH and KMC,
Chennai.

86. 6. Orchidectomy :
Reserved for postpubertal men with a contralateral
normally positioned testis.
86 Dept of Urology, GRH and KMC,
Chennai.

87. 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.
87 Dept of Urology, GRH and KMC,
Chennai.

88. Postoperative Complications
Haematoma
Infection
Unsatisfactory position (requiring revision),
Ilioinguinal nerve injury
Damage to the vas
Testicular atrophy
Torsion testis.
88 Dept of Urology, GRH and KMC,
Chennai.

89. Outcome
Early orchidopexy may improve fertility

No evidence that it reduces risk of malignancy but allows
early identification.
89 Dept of Urology, GRH and KMC,
Chennai.

90. 90 Dept of Urology, GRH and KMC,
Chennai.

91. 91 Dept of Urology, GRH and KMC,
Chennai.

92. 92 Dept of Urology, GRH and KMC,
Chennai.

93. 93 Dept of Urology, GRH and KMC,
Chennai.

94. Thank You..
94 Dept of Urology, GRH and KMC,
Chennai.