Undescended testes

this presentation covers anatomy of the testis, embryological development, causes, clinical features, complications, differences between various types, investigations, and management of undescended testis.

1. Undescended testes Dr. Rachitha Radhakrishnan Post graduate Dept. of General Surgery VMKVMCH

2. Objectives Anatomy Embryology Factors influencing descent Etiology Clinical features Complications Investigations Treatment Post op complications

3. Anatomy

4. 3 arteries : Testicular Cremasteric A rtery to the vas 3 veins : P ampiniform plexus of veins C remasteric Vein of the vas Lymphatic drainage : para -aortic lymph nodes - level of the renal vessels

5. Nerve supply T10 sympathetic fibres via renal and aortic plexus. convey afferent (pain) fibres —hence referred pain from the testis to the loin.

6. Scrotum S kin of the scrotum is thin, pigmented & rugose M aintains a temperature 3-4⁰C lower than core body temperature D evelopment depends on the descent of testis

7. Em b ryolo g y The testes develop in the retroperitoneum . At 4 to 6 weeks' gestation the genital ridges organize followed by migration of primordial germ cells

8. 7th week - testicular differentiation initiated 8th week - testis hormonally active 12th week - testes reach the inguinal region 28th week - 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

9. 12 TH WEEK- inguinal region

10. 32 nd WEEK – EMERGES FROM SUPERFICIAL RING

11. Factors that influence descent Hormonal factors Mechanical factors

12. Hormonal factors Testosterne Dihydrotestosterone Mullerian inhibiting factor Non androgen insulin like factor 3 Genital branch of genitofemoral nerve which secrete CGRP

13. Mechanical factors Shortening and traction of the gubernaculum 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

14. Failure of any of these mechanisms - testicular non-descent or maldescent Hormonal ( inguinoscrotal ) phase- more commonly deranged

15. Cryptorchidism : A greek word which means ‘hidden testis ’ 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

16. Ectopic testis Undescended testis

17. Undescended testis A rrested in its normal path of descent Usually undeveloped Undeveloped & empty scrotum on the affected side Shorter length of spermatic cord Poor spermatogenesis after 6 years Usually associated with indirect inguinal hernia Treatment: surgery & HT Associated with a number of complications Ectopic testis The testis deviates from its normal path of descent Fully developed testis Empty but usually fully developed scrotum Longer length of spermatic cord Spermatogenesis is perfect Never associated with indirect inguinal hernia Treatment: basically surgical Complications: liability to injury

18. Undescended testis C annot be brought back into the scrotum Scrotum not developed No rugosities Retractile testis Can be p ulled into the scrotum Scrotum developed Rugosities present

19. Aetiology Causes of poor intra-abdominal pressure : Omphalocele Diaphragmatic hernia G astrochisis Eagle -Barrett syndrome Beckwith - wiedeman’s syndrome T risomies Extrophy of bladder

20. Aetiology Retroperitoneal adhesions Obstruction –later adhesion at the deep ring Short vas deferens Short testicular vessel Abnormal insertion of genital branch of genitofemoral nv

21. Classification Based on palpation Impalpable: (20%) High canalicular Deep inguinal ring Intra- abdominal Palpable: (80%) Neck of scrotum Superficial inguinal ring Low canalicular

22. Based on exploration findings : intra - abdominal intracanalicular extracanalicular ( suprapubic or infrapubic ) ectopic

23. Clinical features Present at infancy or school age Absence of one or both testes Swelling in the groin P ain in the groin Indirect inguinal hernia, along with undescended testis.

24. Complications of undescended testis Torsion Epididymo orchitis Sterility Trauma Inguinal hernia Seminoma Mnemonic : TESTIS

25. INVESTIGATIONS Imaging Ultrasound – abdomen and pelvis CT Scan. Gonadal venogram .

26. Laboratory Investigations Karyotyping ↑ FSH- represent bilateral anorchia HCG Stimulation tests Urinalysis Serum electrolytes Diagnostic Laparoscopy

27. Treatment Hormonal (after 8 years) Only indications C ryptorchidism associated with hypogenitalism Obesity D oubtful retractile testis . Surgical – BEST Between 6-12 months

28. Principles of surgery Mobilization of cord. Repair of associated hernia. Adequate scrotal fixation with out tension.

29. Orchidopexy Principles of orchidopexy Adequate exposure Herniotomy Mobilization of cord Fixation of testis

30. For palpable UDT General anesthesia - useful to reexamine P reviously nonpalpable testis may become palpable. G roin crease incision Careful dissection to expose the external oblique aponeurosis and the external ring.

31. GROIN CREASE INCISION

32. The external oblique aponurosis is opened in line with the fascia

33. 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.

34. The gubernaculum is divided

35. the patent processus is dissected off the vas and vessels.

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

37. Maneuvers to gain sufficient length Dissection of retroperitoneal attachments of the cord ( Prentiss maneuver ) Divide inferior epigastric vessels after opening the floor of the canal ( transversalis fascia), allowing a more medial and thus direct route to the scrotum.

38. Superficial scrotal incision

39. Skin separated from dartos muscle

40. The testis is placed in a sub- dartos pouch. Fixation sutures to the testes no longer recommended

41. Subdartos pouch

42. Impalpable testis Diagnostic laparoscopy -best means of identifying intra-abdominal testis, vas and vessels . If indicates blind ending gonadal vessels and vas deferens- vanishing testis syndrome and no further action is necessary

43. If intra-abdominal testis identified Staged orchidopexy M icrovascular transfer If vas vessels seen entering inguinal canal - groin should be explored . The length of the gonadal vessels is the limiting factor to getting the intra-abdominal testis into the scrotum

44. Intra-abdominal testis

45. Options for intra-abdominal UDT Standard inguinal orchidopexy - has a high failure rate Two -stage Fowler-Stephens orchidopexy (open or laparoscopy) . Microvascular testicular reserved for older children with internal spermatic artery large enough to be anastomosed to inferior epigastric artery.

46. Refluo Testicular Autotransplantation Provides only venous drainage by microvascular anastomosis of testicular veins to inferior epigastric veins 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 Orchidectomy usually reserved for postpubertal men with a contralateral normally positioned testis.

47. Bilateral impalpable testis Raise suspicion of an intersex condition. Karyotype and hormonal profile to be sent. M easurement of MIS or HCG stimulation. Test to detect the presence or absence of functioning testicular tissue .

48. Postoperative Complications H a em a toma Infection Unsatisfactory position (requiring revision ) I lioinguinal nerve injury D amage to the vas T esticular atrophy Torsion testis

49. Summary Undescended testis is relatively common and early surgical correction should be done to prevent complications. As soon as the child is born, examine the presence of testis in the scrotum. Examine the inguinal region if not present in the scrotum.

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