Abnormalities of the testes Abnormalities of the testes

and scrotum and their and scrotum and their

surgical management surgical management

Dr. S. VahidiDr. S. Vahidi

Undescended testis Undescended testis Definition:Definition:

Testes located anywhere between the Testes located anywhere between the abdominal cavity and just outside the anatomic abdominal cavity and just outside the anatomic scrotumscrotum

Abnormally position testisAbnormally position testis– Cryptorchidism = hidden testis Cryptorchidism = hidden testis

UDTUDT

Ectopic Ectopic

– Un descended testisUn descended testis

Multiple etiologies Multiple etiologies diversity of this congenital diversity of this congenital disorders disorders

Incidence Incidence

One of the most common congenital One of the most common congenital anomalies at birth anomalies at birth 3% of full-term male newborns3% of full-term male newborns1.6-1.9% unilateral 1.6-1.9% unilateral 30.3% in prematures30.3% in prematures– Preterm- low birth weight -twin - small for Preterm- low birth weight -twin - small for

gestational age gestational age

70-77% spontaneously descend, by 3 month.70-77% spontaneously descend, by 3 month.1% at 1 year of age 1% at 1 year of age

EpidemiologyEpidemiology

Gestational age Gestational age

Birth weightBirth weight

PrematurityPrematurity

Genetic- hormonal- environmental Genetic- hormonal- environmental

Classification Classification

Variation in testicular size & consistency Variation in testicular size & consistency

Epididymial & vassal anomalies Epididymial & vassal anomalies

Patent processos vaginalisPatent processos vaginalis

Cryptorctidism: paplable- non palaplable: Cryptorctidism: paplable- non palaplable: – Intra abdominalIntra abdominal– Absent (vanishing)Absent (vanishing)– AtrophicAtrophic– Missed on Ph.E. Missed on Ph.E.

Cryptorchidism Cryptorchidism

Intra abdominalIntra abdominalIntra canalicularIntra canalicularExtra canalicularExtra canalicular– Supra Pubic Supra Pubic – Infra PubicInfra Pubic

EctopicEctopic– Denis-browne pouchDenis-browne pouch– Transverse scrotalTransverse scrotal– FemoralFemoral– PerinealPerineal– Prepenile Prepenile

Retractile testis Retractile testis

Over active cremasteric reflexOver active cremasteric reflex

GroinGroin

3-7 years of age3-7 years of age

Infertility?Infertility?

Delayed spontaneous T. Ascent Delayed spontaneous T. Ascent

Theories of Descent & maldescent Theories of Descent & maldescent

3 phase of descending3 phase of descending1.1. Trans abdominalTrans abdominal 23 week23 week

2.2. Trans inguinal Trans inguinal

3.3. Extra canalicularExtra canalicular 23 week23 week

Endocrine factorsEndocrine factors

GubernaculumGubernaculum

EpididymisEpididymis

Intra abdominal pressureIntra abdominal pressure

Histopathology Histopathology

Endocrine factors Endocrine factors

Normal hypothalamic- pituitary-gonadal axis Normal hypothalamic- pituitary-gonadal axis testicular descent testicular descent

Androgenes: testosterone & DHT Androgenes: testosterone & DHT inguinal-scrotal phase inguinal-scrotal phase of descent of descent

Mullerian inhibiting substance (MIS)?Mullerian inhibiting substance (MIS)?

Estrogen?Estrogen?

Descendin: gubernacular specific growth factor Descendin: gubernacular specific growth factor

Gubernaculum Gubernaculum

Major factor responsible for testicular descentMajor factor responsible for testicular descent

Physiologic mechanism?Physiologic mechanism?

Testicular descent: Testicular descent: – Hormonal factorsHormonal factors– Mechanical factors Mechanical factors

Genito femoral nerve and calcitonin Genito femoral nerve and calcitonin Gene- related peptide?Gene- related peptide?

Epididymis Epididymis

Epididymal abnormalities Epididymal abnormalities cryptorchidism cryptorchidism

Fertility in UDTFertility in UDT

– Germ cell developmentGerm cell development

– EP. Anomalies EP. Anomalies

Intra abdominal pressure Intra abdominal pressure

Defects or agenesis of abdominal wall Defects or agenesis of abdominal wall muscularsmusculars UDTUDT

Significant Role in trans inguinal descent Significant Role in trans inguinal descent

Histopathology Histopathology

Leidig cellsLeidig cells– Degeneration of sertoli cellsDegeneration of sertoli cells– Delayed disappearance of gonocytesDelayed disappearance of gonocytes– Delayed appearavice of (Ad) spermatogoniaDelayed appearavice of (Ad) spermatogonia– Failure of primary spermatocytes to developFailure of primary spermatocytes to develop Germ cellsGerm cells

Similar pathology in the contralateral descended Similar pathology in the contralateral descended testistestis< 2 years of age < 2 years of age

Consequences of UDT Consequences of UDT

InfertilityInfertility

NeoplasiaNeoplasia

HerniaHernia

Torsion Torsion

Consequences of UDTConsequences of UDT

InfertilityInfertility– Bilateral or unilateral UDTBilateral or unilateral UDT– Early or delayed orchiopexy Early or delayed orchiopexy

Neoplasia Neoplasia – 10% of T. tumors arise from UDTs10% of T. tumors arise from UDTs– T. tumors in UDT: 1/2550T. tumors in UDT: 1/2550– T. tumors in population: 1/100,000T. tumors in population: 1/100,000

Neoplasia (continued)Neoplasia (continued)

Presentation time: pupertyPresentation time: puperty

Orchiopexy affect the T. tumor?Orchiopexy affect the T. tumor?

The age of orchiopexy and T. tumor?The age of orchiopexy and T. tumor?

The location of T. & T. tumorThe location of T. & T. tumor

Seminoma is most common T. tumorSeminoma is most common T. tumor

The cause of increased Risk: temprature or The cause of increased Risk: temprature or intrinsic pathologic process?intrinsic pathologic process?

Routine T. biopsy during child hood orchiopexy? Routine T. biopsy during child hood orchiopexy?

Hernia Hernia

Patent processus vaginalis in >90% of Patent processus vaginalis in >90% of UDTUDT

Patent processus vaginalis affect the Patent processus vaginalis affect the hormonal treatment of UDThormonal treatment of UDT

T. Torsion T. Torsion

Work-up of UDTWork-up of UDT

80% palpable80% palpable

20% non palpable 20% non palpable

– 20% absent20% absent

– 30% atrophic30% atrophic

– 50% intra abdominal 50% intra abdominal

Work-up of UDTWork-up of UDT

History History – Preterm H.Preterm H.– Perinatal H.Perinatal H.– Past medical & surgical H.Past medical & surgical H.– Family H.Family H.

Ph.EPh.E– Other birth defectOther birth defect– Genital examinationGenital examination– Contralateral testis Contralateral testis

ParaclinicParaclinic– Accuracy of radiologic testing in UDT is 44% Accuracy of radiologic testing in UDT is 44%

Workup in Bilateral UDTWorkup in Bilateral UDT– Hormonal workup (HCG stimulation test)- FSH- inhibin B- MIS Hormonal workup (HCG stimulation test)- FSH- inhibin B- MIS

Management of UDTManagement of UDT

Tenets of treatmentTenets of treatment1.1. Proper identification of the Anatomy- Proper identification of the Anatomy-

position- viabilityposition- viability2.2. identification of coexisting syndromeidentification of coexisting syndrome3.3. Placement of the testis within the scrotumPlacement of the testis within the scrotum4.4. Permanent fixation and easy palpationPermanent fixation and easy palpation5.5. No further T. damageNo further T. damage

Definitive treatment should occur Definitive treatment should occur before 1 year of agebefore 1 year of age

Indication for orchiectomy in UDTIndication for orchiectomy in UDT

Post pubescent malesPost pubescent males

Contralateral normal T.Contralateral normal T.

Anatomically & morphologically abnormalAnatomically & morphologically abnormal

Too far from scrotum Too far from scrotum

Hormonal therapy Hormonal therapy

1.1. HCGHCG

2.2. GnRH or LHRHGnRH or LHRH

The lower position the better the success rateThe lower position the better the success rate

Reascent in 25% of patientReascent in 25% of patient

Not indicated in:Not indicated in:

– Ectopic T.Ectopic T.

– Inguinal Hernia Inguinal Hernia

HCG treatment HCG treatment

14-59% success rate14-59% success rate

10,000 IU (1500 Iu/m10,000 IU (1500 Iu/m22 im/2 week – 4 week) im/2 week – 4 week)

Complications:Complications:

GnRHGnRH19-32-65% success rate19-32-65% success rate

1.2 mg/day for 4 weeks. (nasal spray)1.2 mg/day for 4 weeks. (nasal spray)

Overall efficacy of hormonal treatment < 20% Overall efficacy of hormonal treatment < 20%

Surgery remains the Gold standard in the Surgery remains the Gold standard in the management of UDT management of UDT

Surgical management of UDT Surgical management of UDT

Standard orchiopexyStandard orchiopexy

Ancillary techniques for the high UDTAncillary techniques for the high UDT

Reoperative orchiopexy Reoperative orchiopexy

Management of intra- abdominal testis Management of intra- abdominal testis

LaparoscopyLaparoscopy

Fowler- stephenes orchiopexyFowler- stephenes orchiopexy

Microvascular auto transplantation Microvascular auto transplantation

Complications of orchiopexy Complications of orchiopexy

Hydrocele Hydrocele

Simple HydroceleSimple Hydrocele

Communicating HydroceleCommunicating Hydrocele

Hydrocele of the cordHydrocele of the cord

Abdomino scrotal hydroceleAbdomino scrotal hydrocele

Acute scrotum Acute scrotum

Acute scrotal pain – tenderness or swelling Acute scrotal pain – tenderness or swelling

Diff diagnosis Diff diagnosis

Differential diagnosis of the acute Differential diagnosis of the acute subacute scrotum subacute scrotum

Torsion of the spermatic cordTorsion of the spermatic cord

Torsion of the appendix testisTorsion of the appendix testis

Torsion of the appendix epididymisTorsion of the appendix epididymis

EpididymitisEpididymitis

Epididymo-orchitisEpididymo-orchitis

Inguinal herniaInguinal hernia

Communicating hydroceleCommunicating hydrocele

HydroceleHydrocele

Hydrocele of the cordHydrocele of the cord

Trauma/insect biteTrauma/insect bite

Dermatologic lesionsDermatologic lesions

Inflammatory vasculitis (henoch- schönlein purpura)Inflammatory vasculitis (henoch- schönlein purpura)

Idiopathic scrotal edemaIdiopathic scrotal edema

TumorTumor

SpermatoceleSpermatocele

VaricoceleVaricocele

Nonurogenital pathology (e.g., adductor tendinitis)Nonurogenital pathology (e.g., adductor tendinitis)

Torsion of the spermatic cord (intravaginal)Torsion of the spermatic cord (intravaginal)

– Golden time (4 hours)Golden time (4 hours)– Degree of torsionDegree of torsion– Acute or gradual onsetAcute or gradual onset– Severe or minimized painSevere or minimized pain– Nausea & vomiting- the absence of cremasteric reflex Nausea & vomiting- the absence of cremasteric reflex – Manual detorsionManual detorsion– Doppler examination: false positive & false negativeDoppler examination: false positive & false negative– Color doppler: 89% sensitivity 99% specifity?Color doppler: 89% sensitivity 99% specifity?– Radinuclide imaging: sens 90% speci= 89%Radinuclide imaging: sens 90% speci= 89%

Torsion (continued) Torsion (continued)

Explore Both sideExplore Both side

Dartos pouch placement (no sutures)Dartos pouch placement (no sutures)

Sympathetic orchiopathy?Sympathetic orchiopathy?

Intermittent torsionIntermittent torsion

Torsion of the testicular and epididymal Torsion of the testicular and epididymal appendagesappendages

Perinatal torsion of the spermatic cord (extra Perinatal torsion of the spermatic cord (extra vaginal)vaginal)

No surgical explorationNo surgical exploration

Exploration of contralateral T.?Exploration of contralateral T.?

In postnatal torsion: exploration is needed In postnatal torsion: exploration is needed (Bilateral)(Bilateral)