abnormalities of the testes and scrotum and their surgical management dr. s. vahidi
TRANSCRIPT
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)