undergraduate surgery presentation

1. UNDESCENDED TESTES
7th Year Surgery Tutorial
28th June 2016
Dr. PASHI V.

2. CONTENTS
Introduction
Embryology
Relevant anatomy
Clinical presentation
Management
Complications

3. Introduction
UDT also known as cryptorchism
Failure of the testis to descend normally from the
abdominal cavity into the scrotum
UDT is associated with a variety of potential
consequences:
Malignancy, infertility, torsion of testis, and inguinal
hernia.
Treatment of UDT is aimed at minimising these risks.

4. EMBRYOLOGY
NORMAL DESCENT OF TESTES
 Germ cells migrate from yolk sac to genital ridges at
6 weeks
 The gonads acquire male or female morphological
in the 7th week of development
 By the 8th week of gestation, Leydig cells begin
production of testosterone and sexual
differentiation begins

5. embryology

6. embryology
DESCENT OF TESTES
 By the end of 8th week the testes have acquired two
attachments
 The caudal genital ligament and the gubernaculum
 Descent is believe to be achieved by:
 Abdominal descent by the out growth of the extra abdominal
gubernaculum
 Inguinal descent by the raising intra abdominal pressure
 Regression of the extra abdominal gubernaculum facilitates
descent to the scrotum

7. embryology
FEATURES OF TESTICULAR DESCENCE
 The testes will reach the internal ring by 12
weeks, pass through the inguinal canal by 28
weeks and finally in the scrotum by 33 weeks
 Endocrine factors probably play a major role in
descent
– Testosterone induces testis descent in humans
– Androgens affect the nuclei of the genitofemoral
nerve to release modulating factors for gubernacular
development

8. embryology
FEATURES OF TESTICULAR DESCENCE
 Blood supply from the aorta is maintained with testicular
arteries arising from the lumber region
 The testes emerge from the abdominal cavity carrying
with it the abdominal coverings and peritoneum
 Peritoneum makes the processus vaginalis
 Canal portion of processus obliterates, testicular portion
persists as tunica vaginalis
 Gubernaculum atrophies

9. embryology

10. ANATOMY
COVERINGS OF THE TESTIS

11. CLINICAL PRESENTATION
UDT occurs in 3% of term male infants and in up
to 33% of premature male infants.
A true UDT has had its descent halted
somewhere along the path of normal descent.
The ectopic UDT has deviated from the path of
normal descent and can be found in the inguinal
region, perineum, femoral canal, penopubic
area, or even the contralateral hemiscrotum.

12. Clinical presentation
A retractile testis is a normally descended testis
that retracts into the inguinal canal as a result of
cremaster muscle contraction.
 It can be manipulated down into the scrotum on
examination without tension and will remain in
place
Acquired UDT refers to a testis that was
previously descended on examination and can
no longer be brought down into the scrotum.

13. Clinical presentation
Palpable
– Normal
– Retractile
– Ectopic
– Undescended
Impalpable
– Canalicular
– Intra-abdominal
– Emergent
– Absent
• Agenesis
• atrophy
Whitaker/Kaplan Classification for UDT

14. Clinical presentation
Most common dilemma is distinguishing retractile testis
from one that may or may not descend spontaneously
Maneuvers used: 1. examine boy in crosslegged position,
2. soaping the examiner’s fingers
3. examining in a warm bath
Physical exam is very important to evaluate retractile
testes
– Non-palpable testis is intraabdominal, intracanalicular,
absent

15. To locate the testis is to walk the fingers gently down
the inguinal canal from the internal ring toward the
scrotum, trying to push subcutaneous structures
toward the scrotum.

16. Bilateral UDT requires hormonal evaluation and
challenge
– Elevated gonadotropins (FSH) suggest
bilateral anorchia
– Normal serum gonadotropins=>hCG
challenge (2000 IU x 3days)
– No testosterone response indicates bilateral
anorchia

17. Imaging
Herniography-poor sensitivity and specificity
U/S-good for inguinal testes, not reliable if higher
CT-may be helpful for bilateral impalpable testes
– Difficult to perform in young children
MRI-least invasive, most expensive
– Difficult to perform in young children

18. Imaging
Venography-invasive, pampiniform plexus
present=>testis present
– Non-visualized plexus or blindending does not
eliminate testis
Angiography-difficult to perform, high complications
Overall accuracy of radiologic imaging for UDT = 44%
– PE is 53% - 84%

19. Hormonal Treatment
hCG is given to stimulate Leydig cells to produce
testosterone=>descent of testes
GnRH is given if basal LH is low and abnormality
in GnRH secretion is suspected

20. Surgical Treatment
Basic principles of orchidopexy are: localization,
mobilization, cord dissection, isolation of processus,
tension-free relocation to scrotum
Pexation does not reduce risk of cancer
Orchidopexy should be performed before 2 y.o.
Orchidectomy is an option for post-pubertal males and
dysgenetic testes

21. Standard Orchidopexy
Transverse inguinal incision, watch for testis
Identify testis and divide gubernaculum
Open tunics and evaluate testis
Open external oblique fascia, avoid nerve
Mobilize spermatic cord
Finger dissection to enlarge scrotal cavity medially
Incise scrotal skin, create dartos pouch

22. Standard Orchidopexy contn
Pass clamp through pouch into inguinal area and
bring testis into pouch by gubernaculum or
tunica
Pex testis with 4-0 vicryl sutures
Complications: atrophy, retraction, torsion,
hematoma, nerve or vas injury

23. Standard Orchidopexy contn

24. Complications
Neoplasm and UDT
– 10% of testis CA are in UDT
– UDT is 35-48x more likely to have malignancy
– Abdominal UDT is 4x more likely than inguinal testis to
develop CA
– UDT tumors typically occur around puberty
– CIS occurs in 1.7% of UTD
– Orchiopexy should be performed between 1-1.5 years old
– 1/5 of testis CA in patients w/ hx of UDT occurs in contralateral
testis
– Seminoma is most common CA in UDT

25. Complications contn
Torsion and UDT
– Increased risk for torsion in UDT due to anatomic
abnormality between testis and mesentery
– Incidence is greatest after puberty with increased
testis size
– Be aware of abdominal pain and empty
hemiscrotum=> torsed intra-abdominal UDT

26. Complications contn
Hernia and UDT
Processus vaginalis should obliterate between the 8th
month of gestation and 1st month of life
UDT results in patent processus vaginalis
Hernias are found in 90% of patients w/ UDT

27. Complications contn
Infertility and UDT
Spermatogenesis is retarded by maldescent
Bilateral UDT => poor fertility
Higher UDT => more damage to seminiferous tubules
Earlier orchidopexy may improve chances for recovery
of spermatogenesis
Sperm counts in unilateral UDT are much lower than
normal
– Contralateral testis may also be defective

28. Futher reading
Fowler-stephens orchidopexy
Laparoscopic orchidopexy