Undescended Testis (UDT)

Undescended Testis (UDT)

1. Undescended Testis Eko Indra Pradono

2. DEFINITION Undescended testis or cryptorchidism is the absence of one or both testes in normal scrotal position and during initial clinical evaluation may refer to palpable or nonpalpable testes, which are either cryptorchid or absent.

3. Before descent End of descent

4. Epidemiology Cryptorchidism is one of the most common congenital anomalies, occurring in 1% to 4% of full-term and 1% to 45% of preterm newborn boys ( Sijstermans et al, 2008 ). Factors that predispose to cryptorchidism include   prematurity, low birth weight, small size for gestational age, twinning, and maternal exposure to estrogen during the first trimester .

5. Aetiology and pathophysiology The specific cause of isolated cryptorchidism is unknown in most cases, but indirect evidence suggests that the disease is heterogeneous and most likely the result of multiple genetic and environmental risk factors . It has been postulated that cryptorchidism may be a part of the so-called testicular dysgenesis syndrome (TDS), which is a developmental disorder of the gonads caused by environmental and/or genetic influences early in pregnancy

6. The degeneration of germ cells in maldescended testes is apparent after the first year of life and varies, depending on the position of the testis. During the second year, the number of germ cells declines Early treatment is therefore recommended (after the age of six months surgery should be performed within the subsequent year with age eighteen months the latest) to conserve spermatogenesis and hormone production, as well as to decrease the risk for tumours

7. DIAGNOSIS To best determine testicular position, boys should be examined in the supine and, if possible, upright cross-legged and standing positions testicular palpability, position, mobility, size, and possible associated findings such as hernia, hydrocele, penile size, and urethral meatus position must documented T he majority (75% to 80%) of undescended testes are 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. Diagnosis of a vanishing testis requires documentation of blindending spermatic vessels in the abdomen, inguinal canal, or scrotum Imaging is not indicated for diagnosis of the nonpalpable testis, because it has limited accuracy and does not obviate the need for definitive surgical intervention PALPABLE NON PALPABLE

9. Classification of undescended testes

10.  Algorithm for the management of unilateral non-palpable undescended testis

11. Scrotal asymmetry in a boy with unilateral left cryptorchidism Positions of the ectopic testis

12. Algorithm for management of the undescended testis

13. MANAGEMENT Hormonal treatment Surgical treatment

14. Hormonal treatment Hormonal therapy has been used for a variety of indications in patients with cryptorchidism, including differentiation of retractile from true undescended testes, stimulation of testicular descent or germ cell maturation, and as an adjunct to abdominal orchidopexy Hormone therapy is not currently recommended, given the lack of rigorous data supporting its efficacy Human chorionic gonadotropin or GnRH is not recommended for the treatment of cryptorchidism in adulthood

15. Surgical treatment

16. Inguinal Orchidopexy

17. Trans-Scrotal Orchidopexy

18. Surgical Approach to the Abdominal Testis Once an abdominal testis has been identified, the surgeon must decide whether to proceed with an open or laparoscopic, one- or two-stage orchidopexy with possible spermatic vessel transection. Orchiectomy is appropriate for patients with testes that are poorly viable and/or at higher risk for tumor, which may include testes in postpubertal patients or very small or dysgenetic testes in postpubertal patients, and is in our opinion best performed laparoscopically

19. Open Transabdominal Orchidopexy Laparoscopic Orchidopexy and Fowler-Stephens Orchidopexy

20. Results of Laparoscopic Orchidopexy

21. Despite their limitations, the available data seem to suggest that primary orchidopexy without transection of the spermatic vessels is preferable whenever possible

22. In adolescence removal of intra-abdominal testis (with a normal contralateral testis) can be recommended, because of the theoretical risk of later malignancy. In adulthood, a palpable undescended testis should not be removed because it still produces testosterone . Vascular damage is the most severe complication of orchidopexy and can cause testicular atrophy in 1-2% of cases. In men with non-palpable testes, the post-operative atrophy rate was 12% in those cases with long vascular pedicles that enabled scrotal positioning. Post-operative atrophy in staged orchidopexy has been reported in up to 40% of patients. At the time of orchidopexy , performed in adulthood, testicular biopsy for detection of ITGCNU is recommended. At the time of orchiectomy in the treatment of germ cell tumours biopsy of the contralateral testis should be offered to patients at high risk for ITGCNU

23. Recommendation EAU

24. PROGNOSIS Sperm counts are reduced in at least 25% of formerly unilateral and the majority of formerly bilateral cryptorchid men, but paternity rates in the unilateral group are similar to those in control men. Ad spermatogonia counts may predict fertility potential in males with cryptorchidism. TGCT risk is two to five times higher in boys with cryptorchidism, especially after pubertal orchidopexy

25. Physicians should educate patients and their families about the risks of infertility and TGCT in cryptorchidism and should provide counsel about the potential benefits of testicular self-examination.

26. Reference Hadziselimovic F, Kolon T.F , Yavetz , Wilkerson M .. EAU Guidelines 2019 Jennifer A. Hagerty Julia Spencer Barthold. Chapter 148 : Etiology, Diagnosis, and Management of the Undescended Testis. Campbell- walsh Urology. 11 ed. Philadhelpia : Elsevier, Inc ; 2016

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