Understanding UNDESCENDED TESTISRasik ShahMBBS, MS (General Surgery), M Ch (Pediatric Surgery)

Paediatric & Laparoscopic Surgeon: Hinduja Hospital, Mahim, Mumbai

President Elect (2012-13): Indian Association of Paediatric Surgeon

Ex Chairman (2011-13): Paediatric Endoscopy Surgeon – India Section of Indian Association of Paediatric Surgeon

Testis

•The testicle is the male gonad

•The primary functions is to produce

▫sperm

▫androgens  (testosterone)

•Two main attachments of testis are

▫Vas Deferens via epididymis

▫testicular vessels

Temperature Regulation

•The testes work best ▫at temperatures slightly less than core

body temperature. ▫The spermatogenesis is less efficient at

lower and higher temperatures. ▫This is presumably why the testes are

located outside the body.

Embryonic Development• Around fourth week ante-natally,the gonadal

rudiments are present adjacent to the developing kidneys.

• Testes follow the "path of descent" from ▫ Lower pole of kidney in the retro-peritoneum

▫ Internal ring

▫ Inguinal canal

▫ Scrotum

• In most cases (97% full-term, 70% preterm), both testesare normallydescended by birth.

• In most of the cases, only one testis fails to descend

What is Maldescended Testicle?

It consists of following conditions.

•Undescended Testicles

•Ectopic Testicles

•Retractile Testicle

•Ascending Testicle

Undescended Testicles

•Arrest of descent along its normal path of descent is termed as Undescended Testicle

•It can have following locations▫High Abdominal near Kidney▫Low Abdominal near groin▫Emergent (Moving in and out of the

abdomen)▫Inguinal▫High Scrotal

Ectopic Testis• It means the testicle has moved away from its

normal path of descent

•After it emerges from the external inguinal ring

•Locations

▫Superficial Inguinal Pouch

▫Pubic

▫Perineal

▫Femoral

Clinical Classification

•Palpable

•Non-Palpable

▫Abdominal

▫Atrophy

▫Absent

• It needs open orchiopexy• Some of the undescended testis descends on

its own in first 2-3 months• If it does not descent in first few months then

it is unlikely to do so • At present the surgery is advocated at the

age of six months• If surgery is delayed then the function of

testis gets affected due to higher temperature in abdomen and chronic trauma to the testicle

Palpable UDT

Retractile Testis

•Testis at rest is located in the scrotum

•However, with stimulus it ascends in the inguinal area

•Usually they don’t need any treatment

Ascending Testicle

•At birth the testis is located in the scrotum

•However, with the growth of the child, the testis fails to remain in the scrotum and ascends in the groin

•These patients needs to be operated to bring the testis in the scrotum

Non-Palpable UDT

•This patients should be subjected to laparoscopy around the age of six months

•Depending upon the findings on laparoscopy further management is carried out

Role of imaging studies like Sonography, CT Scan?

•We don’t advocate as

▫they are not 100 % specific or sensitive

▫they don’t change the plan of management

▫Often confuses parents when the imaging findings don’t match to the operative findings

Lap for Nonpalpable UDT

• If testis is located near the internal ring than the testis can be brought to the scrotum in one operation (65-70 %)

• If testis is located high in abdomen than it needs two operation (8-10%)

• If testis is small in size than it is removed and opposite side is fixed to prevent its loss due to torsion (15-20%)

• If testis is absent or vanished than the opposite side is fixed to prevent its loss due to torsion (4-5%)

What is laparoscopy?

• Small incision is taken near umbilicus

• Trocar is inserted in the incision

• Telescope is inserted trough the trocar

• Inside of the abdomen is visualised

• Then depending upon the findings one or two more trocars are inserted in the abdomen

• Operating instruments are inserted in the abdomen and testis brought in the scrotum in one or two operations

Pre-operative Preparation

•CBC

•Fasting before operation ▫Four hours for breast milk▫Six hours for liquids▫Eight hours for solids

Post operative treatment• Fasting for four hours

• Intravenous fluids continued for 6-8 hours

• Clear fluids started orally after four to six hours and advance to full liquids followed by soft diet

• Oral Analgesics for pain for 48 to 72 hours

• Local antibiotic ointment

▫After dressing is removed or if it comes out

• Discharge either on the same or next day

• Follow up after 5 days and dressing removal

If not operated patient can have• decrease in the function of the testis

• higher incidence of malignancy

• late detection of malignancy

• 70 % incidence of associated patent processus vaginalis

• higher incidence of torsion

• increased incidence of injury

• psychological issues

Investigations

• For Unilateral UDT: CBC (pre operative)

• For Bilateral Nonpalpable UDT

▫ Diagnostic and therapeutic Laparoscopy

▫ HCG Challenge test (presence of testicular tissue)

• In cases suspected to have disorder of sexual

differentiation

▫ Karyotyping

▫ Hormone levels: FSH, LH, AMH

▫ USG: Presence of Uterus: PMDS or CAH

▫ Micro-phallus: Hypopituitarism: Kallamann’s Syndrome

Cancer in UDT• Incidence of malignancy in the undescended testis

▫ 1 in 80 with a unilateral undescended testis

▫ 1 in 40 to 1 in 50 for bilateral undescended testes.

▫ The peak age for this tumor is 15–45 yr.

▫ The most common tumor developing in an UDT is a seminoma (65%)

▫ in contrast, after orchiopexy, seminomas represent only 30% of tumors.

• Self examination of testis after orchiopexy

• Cancer developing in an intra-abdominal testis: late detection

• Recent data: that orchiopexy performed before puberty resulted in a significantly reduced risk of testicular cancer

Fertility after Orchiopexy

•Unilateral UDT: Same as any other couple

•Bilateral UDT: More than 80 %

THANK YOU