:: GUIDE ::

DR. M.K. CHOUHAN

DR. S.P. SINGH
DR. LATIKA SHARMA
:: PRESENTATION BY ::
DR. RAJESH SANI

DEPARTMENT OF SURGERY

DEFINATION :- an undescended testes

is one which has failed to descend to
scrotum and is retained at any point
along the normal path of it descend
CRYPTORCHIDISM- [Greek word,
cryptos (hidden) and orchis (testes)]

Both testes are absent in scrotum

Intra abdominal undescended testes

EMBRYOLOGY

Testicular descent is complex multistage

process.
Gonad developed from genital ridge & up
to 7or 8 weeks, no sexual differentiation &
occupying same region on dorsum of
abdominal wall.
Gonad is held by cranial suspensory
ligament (upper pole) & gubernaculum
(lower pole); gubernaculum is extend up
to skin which later form scrotum.
Mesenchymal tissues around
gubernaculum form inguinal canal
musculature.

TESTICUTAR DESCENT

ENBRYOLOGY (Cont.)

Testis descent along the path of

Gubernaculum.
Proximal Gubernaculum become
hollowed by testis with its peritoneal
covering & processus vaginalis during
descent of testis but distal end is solid
cord like.

EMBROLOGY (Cont.)

Processus vaginalis is obliterated

during this time
Scrotal migration of the gubernaculum
& testis is completed by 35 weeks.
Factors which cause normal descent are
not clearly known
Probably hormonal regulated by
androgen & HCG & other factor like
increase intraadominal pressure,
shortening &active contraction of
gubernaculum.

TYPES OF IMPERFECT DESCENDED TESTES

Retractile testis Testes not located in scrotum & held high up
position due to overactive cremesteric muscles.
Believed due to overactive cremesteric muscles
& failure of complete attachment of lower pole
of testicle to the scrotum by gubernaculum.
Usually bilateral.
Normal in size, well develop scrotum.
When child is asleep or relaxed, testes descend
to normal position
Can be manipulated into scrotum.
Required not any treatment &have normal
fertility.

ECTOPIC TESTIS
Testis that fail to descend into
scrotum & is deviated from its
normal path of descend.
Located into the thighs, the
suprapubic area, or the perineum.
Usually normal in size, with
normal spermatogenic &
androgenic function.

THE FIVE TAILS OF

GUBERNACULUM TESTES

ECTOPIC TESTIS (Cont.)

Spermatic cord is of sufficient length.

No increase risk of malignancy.
More liable to injury
Orchidopexy should be done.

INCIDENCE
About 27% in premature babies and
3.2% in full term infants at birth
Spontaneous descent occurred postnatally
in first 3 month, beyond this it was rare
At the age of one year, incidence was
0.8%.
About 14%of boys has family history.
Right Side
Left Side
Bilateral
53-58%
42-47%
10-25%

CAUSES OF UNDESCENT
Anatomical Abnormality
2. Primary Endocrine Disorder
3. Mechanical Failure Of Descent
1.

1.
2.
3.
4.
5.

Gubernaculum Abnormality
A Shortened Testicular Artery
A Tight Inguinal Canal or Ring
Abnormal Adhesion
Other Abnormality

CAUSE OF UNDESCENT (Cont.)

Shortening of the testicular

artery is typically the limiting
factor for descent.

COMPLICATIONS OF CRYPTORCHIDISM

DECREASED SPERMATOGENIC
FUNCTION

Failure of seminiferous tubules to

mature normally, with resultant
inability of the undescended testes
to produce normal, mature sperm
Degeneration of seminiferous
tubules are due to location of
undescended testis in the region
of high temperature then the
scrotal temperature.

Decrease spermatogenic function

(cont.)
Scrotal temperature is 1-1.5
degree C lower then that of
abdomen and this low
temperature are required
for proper spermatogenic
function

HERNIA

Accompanying Indirect inguinal

hernia is present more > 65% case &
patent processus vaginalis in 95%
Hernia may become symptomatic
during first few months of life &
require repair then orchidopexy
should be done simultaneously,
because later re-operation in scared
wound may risk serious injury to the
testicular blood supply

TORSION
There may be torsion of testes
associated with crytochidism due
to mobility of testes in superficial
inguinal pouch.

PSYCHOLOGICAL FACTORS

Considerable anxiety &

embarrassment often
present with felling of
physical interiority &
concern about virility

DEVELOPMENT OF MALIGNANCY

Relative risk of malignant

transformation is 15 times in
unilateral & 33 times in
bilateral undescended testes
then normally descended
testes.
Abdominal cryptorchid testis 5
times more likely to develop
malignancy than inguinal.

DEVELOPMENT OF MALIGNANCY (cont.) )

Directly correlate to degree of

degeneration & dysplasia of
seminiferous tubules.
Age of presentation is same as in
normal descended testes (20-40years)
Seminoma constitutes about in 60%
cases
Teratocarcinoma, embryonal cacinoma&
adult teratomas reported.

DEVELOPMENT OF MALIGNANCY (cont.)

Age at which orchidopexy is

performed appears to be a critical
factor in relation to malignant
transformation
When orchidopexy done earlier the
incidence is less.
Only 5 cases out of 166 cases of
malignancy found when orchidopexy
done before 10 year of age (Martin &
Menck)

ASSOCIATED ANOMALIES
Urinary tract abnormalities
About 9% have major & another 9%
have minor abnormalities
Renal hypoplasia, renal agenesis,
ureteropelvic obstruction and horseshoe
shape kidney are common
IVP are indicated in first year of life when
urinary symptoms present
Testicular-epididymal fusion
abnormalities may present, and interfere
with fertility

DIAGNOSIS

Aim of exam. is to identify the presence

or absence of palpable gonad and to
determine lowest position that it will sit
comfortably without undue tension & to
differentiate the true undescended
testis from retractile or ectopic testis.
Examination should be conducted in
warm surrounding &with child relax.
80-90% of undescended testis are
palpable in inguinal region or can be
squeezed out of inguinal canal

DIGNOSIS (Cont.)

When palpable then note the size of testis

& compare with contra lateral testis &
male for same age also regard for
consistency & shape
If after several examination the surgeon
is unable to palpate the testis, it is
probably located within the abdomen,
atrophic or absent.
Hypoplasia of hemi scrotum suggests that
the testis has never been within it.
In case of associated hernia, examination
should be done after reduction of hernia

DIGNOSIS (Cont.)

3
4

Useful criteria for distinguishing

retractile testes, which does not required
any treatment, as follow retractile testis.
Can be brought fully to the bottom of
scrotum without difficulty.
Remain in scrotum after manipulation
without immediate retraction.
Normal in size, fully developed scrotum
History that the testis resides
spontaneously in the scrotum some of
times.

DIGNOSIS (cont.)

Abdominal & inguinal USG & CT Scan

useful to locate the position of
impalpable testis.
Laparoscopy
1 identify the position of intra
abdominal testis
2 Exclude the possibility of
secondary atrophy.
3 Ligation of testicular vessels in
two stage operation.

HORMONE TREATMENT

Based on the principle that undescended testes is

deficiency of hypothalamic pituitary gonadal
axis.
HCG & LHRH are use & LHRH has slightly good
result then HCG.
Bilateral cryptorchid testes near the scrotal
entrance or retractile testes respond more
favorable.
Mainly helpful in which no mechanical limiting
factors for descent.
Most conclude that hormone cause descent of only
those testes that ultimately would have descended
without treatment .
Now a day rarely uses.

SURGICAL TREATMENT

Based on assumption that early

intervention prevent secondary
degeneration of testes caused by high
temperature.
Timing of surgery remain controversial.
Most surgeons prefer orchidopexy after
one year of age during second or third
year of life.
Children presenting with concomitant
symptomatic inguinal hernia should have
orchidopexy done at the same time that
the inguinal herniotomy is performed.

SURGICAL TREATMENT (Cont.)

Objective of repair in lengthening the

spermatic cord by freeing up the
testicular vessels in retroperitoneal tissue
or alter the course of testicular artery to
place a direct course to scrotum from the
origin of artery.
Retaining the testis in scrotum by
fixation.

SURGICAL TREATMENT (Cont.)

Lengthening of Spermatic Court

Open the inguinal canal by skin crease

inguinal incision.

Testis in superficial inguinal pouch or pubic

region easily seen & by traction gubernaculum
to be identified & divide.

Cremaster muscle fibres are stripped &

processus viginalis is dissected off from vas &
vessel up to deep inguinal ring, than
transfixation at there.

Extra length may be achieved by freeing up

the lateral side of gonadal vessels in
retroperitoneal space

SURGICAL TREATMENT (Cont.)

If required, straightening the path of

testicular artery should be done by
incising the fascia tranvasalis medial to
deep inguinal ring & division of inferior
epigastric vessel & dissection of t.
vessels up to lower pole of kidney & vas
over bladder & creating new internal
inguinal ring just lateral to pubis.
A Microvascular anaestomosis can be
performed, with transection of testicular
vessels & reanaestomosis to inferior
epigastric vessels.

A DARTOS POUCH

B - OMBREDANNE'S OPERATION

C - EXTERNAL ANCHORAGE
OPERATION

D - KEETLEY-TOREK OPERATION

Repairing The Testis in Scrotum

Fowler-Stephens procedure (longloop vas orchidopexy)
- Testicular vessels are divided high
up which permit sufficient mobility
to testis
- Blood supply to testis derived from
artery to vas, & cremestric vessels.
- No dissection is performed in cord.

COMPLICATION OF ORCHIDOPEXY
In expert hand less than 5%.
1. Secondary atrophy at testis
2. Failure of testis to reach
scrotum.
3. Occlusion of vas deferens.
4. Haematoma.
5. Wound infection.

CONCLUSION
current practise is to early
orchidopexy during second or third
year of life because after two years
of life degenerative changes are
inevitable, & protect from
malignancy to some extend.
Fertility to good extent can be
achieved by orchidopexy up to 10
years & upto same extent till puberty
after that it is rare.

CONCLUSION (Cont.)

Orchidectomy is only indicated in

atrophied, under develop testis
after puberty & incompletely
develop testes that can not be
brought down to scrotum with
contralateral testis is normal.