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SURGICAL MANAGEMENT OF UNDESCENDED TESTES

Dr SAMAD ZARE

Shaheed Sadoughi University of Medical SciencesYazd;IranThe anatomical classification of undescendedtestis :

Maldescended testes: lying somewhere along the normal line of descent.

Ectopic testes: lying outside that line.It is recommended that surgical orchidolysis and orchidopexy are performed at the latest by 12-18 months of age.

To date, it seems that pre- or post-operative hormonal treatment may have abeneficial effect on fertility later in life.For the full-term boy under the age of 6 mo, proper managementincludes observation with serial examination because testes maydescend spontaneously during early infancy.

after the age of 2 yr, histologic deterioration of a UDT (and even its contralateral descended mate) can be observed.Treatment for undescended testis before puberty decreases the risk of testicular cancer.

The relative risk of testicular cancer among those who underwent orchiopexy before reaching 13 years of age was 2.23

And

for those treated at 13 years of age or older, the relative risk was 5.40 (15).

Boys with one undescended testis have a lower fertility rate but the same paternity rate as boys with bilateral descended testes.

Boys with bilateral undescended testes have both a lower fertility and paternity rate.Palpable testis:

Surgery for the palpable testis includes orchidofuniculolysis and orchidopexy, via an inguinal approach, with success rates of up to 92%Inguinal orchidopexy:

The majority of undescended testes are amenable to astandard inguinal orchidopexy including:

division of cremasteric fibers ligation and division of the processus vaginalis

retroperitoneal dissection through the internalring with division of lateral fascial bands as required.

A proper skin incision for a standard inguinal pediatric orchidopexy:

The incision extends from a point corresponding with the position of the internalinguinal ring (midway between the ASIS and the pubic tubercle), mediallyand transversely within Langers lines, to a line vertically through the lateralmargin of the scrotum. ASIS, anterior superior iliac spine; PT, pubic tubercle.

An elongated epididymis is commonly found attached to an undescendedtestis, especially with high inguinal or abdominal testes. It is importantto carefully trace the epididymis and vas deferens distally to their most caudalpoints before dividing the gubernaculum to avoid injuring these structures.Note the extremely long epididymal tail (arrow) extending below the scrotumduring this routine inguinal orchidopexy.With regard to sutures, there should either be no fixation sutures or they should be made between the tunica vaginalis and the dartosmusculature.The lymph drainage of a testis that has undergone surgery for orchidopexy has been changed from iliac drainage to iliac and inguinal drainage (important in the event of later malignancy).Impalpable testis:

Some 1020% of undescended testes are impalpable.In approximately 40% of cases of impalpabletestis the gonad lies intra-abdominally;

in 30% it has vanished, with vas and vessels ending blindlydeep to the internal inguinal ring;

in 20% the vas and vessels end blindly within the inguinal canal; nubbin

and in 10% the testis is normal but concealedwithin the inguinal canal.Ultrasound and standard magnetic resonance imaging(MRI) are unreliable for investigating the impalpable testis.

Two different groups of investigators have, however,documented the accuracy of gadolinium (Gd)-enhancedMRI, with sedation, fat supressed and DWI MRI and MR Angiography in localizing intra-abdominal testes, canalicular testes, hypoplastic/atrophic testes, and vanishing testes, with a sensitivity between 96% and 100%

There is a significant chance of finding the testis via an inguinal incision, but in rare cases, it is necessary to search into the abdomen if there are no vessels or vas deferens in the groin.Laparoscopy is the most appropriate way of examining the abdomen for a testisBefore starting diagnostic laparoscopy, it is recommended that the child be examined again under general anaesthesia since aprevious non-palpable testis might now be palpable under anaesthetic conditions.An intra-abdominal testis in a 10-year-old boy or older with a normal contralateral testis should be removed.In bilateral intra-abdominal testes, or in a boy younger than 10 years, a one-stage or two-stage Fowler-Stephens procedure can be performed. Testis lying adjacent to the internal inguinalring such gonads are usually amenable to asingle-stage orchidopexy using a conventionalor a preperitoneal approach. An experiencedlaparoscopist may be able to manipulate thetestis towards the inguinal canal so as to assessthe feasibility of a single-stage procedure.Preperitoneal approach (Jones):

A skin incision at or slightly higher than for astandard inguinal approach is employed and theoblique abdominal muscles are split to gain access tothe peritoneum above the inguinal canal. Thereafter,the testis is mobilised transperitoneally and is passedto the scrotum through the inguinal canal or, if necessary, more directly through the posterior wall ofthe canal medial to the inferior epigastric vessels. Testis located on the posterior abdominalwall or ectopically within the pelvis

this calls for a decision as to whether toremove the gonad (either laparoscopically or asan open procedure) or whether to embark uponorchidopexy. Here the options lie between open or laparoscopically assisted orchidopexy, as either a single or a staged procedure. In the event of a two-stage procedure, the spermatic vesselsare either laparoscopically clipped or coagulated proximal to the testis to allow development of the collateralvasculature . The second-stage procedure, in which the testis is brought directly over the symphysis andnext to the bladder into the scrotum, can also be performed by laparoscopy 6 months later.The testicular survival rate in a one-stage procedure varies between 50% and 60%, with success rates rising up to 90%in a two-stage procedure.

Testicular artery and single vein anastomosed to inferior epigastricvessels (or branches).Microvascular autotransplantation can also be performed with 90% testicular survival rate. However, the procedure requires a very skilful and experienced surgical technique. Vessels ending blindly together at orabove the internal ring such vanished testespresumably result from intrauterine torsion andno further exploration is required.Note that an absent or blind ending vas deferens does not indicate absence of the testis. Vas and vessels seen entering the inguinalcanal here it is impossible to be certainwhether the canal contains a normal testis or anatrophic nubbin of testicular tissue. Opinionvaries on whether inguinal exploration is stillmandatory in this situation.

Alternatively it has been suggested that inguinal exploration is unnecessary if a nubbin is palpable and the contralateral testis is hypertrophied (>1.8 cmpolar length or 2 ml in volume). Failure to visualise blind-ending vesselsor testis in this rare situation, a limitedlaparotomy is indicated in view of the high riskof subsequent malignancy associated with anundetected intra-abdominal testes left in situ.Early postoperative Pain Bleeding Hematoma Local edema Wound separation Wound infection.Late postoperative Testicular malposition or re-ascent Testicular atrophy Torsion of testis Inguinal hernia Hernia alongside peritonealized vas after FowlerStephens orchidopexy rare complication reported onlyas isolated case report Ureteral obstruction due to vasal compression afterFowlerStephens orchidopexy rare complicationreported only as isolated case report Impaired spermatogenesis and infertility Testicular malignancy.COMPLICATIONS:Retractile TestisThe most common form of cryptorchidismand is a normal testis.It has completed the process of descent buttends to pull up out of the scrotum because of the cremasteric reflex,which is particularly strong and universally present in boys between the ages of 2 and 7 yr (3).It can be manipulated intothe scrotum, remains in the scrotum (at least temporarily) after its release,and is normal in size.Retractile testes should be monitored during childhoodbecause they can, on some occasions, become truly undescended.It is not possible to be so confident where thediagnosis lies between high retractile testis andtrue congenital maldescent. In these circumstancesthe history may be more informative than theexamination. Where any doubt exists, regularannual reassessment should be undertaken, and theparents should be advised that the need for surgerycannot be discounted.

If, during follow-up, it becomes apparent that ahigh retractile testis is assuming an increasinglyabnormal position, hormonal manipulation may beconsidered as both a diagnostic and a therapeutictrial. In practice, orchidopexy is generally favoured asthe primary treatment of choice.

In such cases it may be possible to perform this via a scrotal approach.

Ascending testis:

The entity of acquired undescended testis, where a previouslynormal scrotal testis retracts into an ectopic position.There is no consensus on etiology or correct managementfor these cases; although recent data supports a conservative approach ( until puberty ).Spontaneous descent occurred at puberty in 76% of testes(early puberty in 71.4% of these, 26.5% mid puberty,and 2.1% late puberty) and their expectant policy forthe ascending testis has reduced orchidopexy rates intheir hospital by 61.8%Redo orchidopexy:Most papers on repeat orchidopexy include patients whohad initial surgery for inguinal hernia, hydrocele, or cryptorchidismand results for these different groups are oftenamalgamated. A successful result has been documented in92100% of casesRe-ascent of the testis requires a redo orchidopexy,which can be performed via the original inguinal incision or with a scrotal approachRetrograde dissection of the cord structures to gain adequate length. When an inguinal approach is used, a strip of external oblique aponeurosis overlying the cord may be left attached, thus avoiding difficult dissection between the scarred external oblique.

The previously divided hernia sac needs to be separated from the vas and vessels,

the peritoneum swept away and retroperitoneal dissection completed.

If scar tissue around the deep inguinal ring makes dissection problematic, opening the peritoneum above the ring and dissecting down from above may avoid potential vas or vessel injury.

A Prentiss maneuver may be required to achieve adependent scrotal position and good operative exposure,excellent lighting, optical magnification, and tension-freeplacement within a scrotal subdartos pouch are importantin achieving a satisfactory outcome.Ectopic TestisThe most common site of ectopia is the superficial inguinal pouch of Denis Browne, the space between Scarpas fascia and the external oblique fascia above the external inguinal ring.Ectopic descent is thought to result from abnormal development of the gubernaculumor from scrotal inlet obstruction.The accurate diagnosis of an ectopic testis, in contrast to an undescended or retractile testis, is important because the ectopic testis is fixed in position by fibrous attachments.

Because it will not descend either spontaneously or with medicaltherapy, surgery is necessary to place it in the scrotum.Testicular BiopsyThe role of testicular biopsy during routine orchidopexy is controversial.most urologists do not perform testis biopsyduring orchidopexy, except in very unusual circumstances. Such circumstances might include orchidopexy in the older child, to exclude a diagnosis of Sertoli cell only (or carcinoma in situ) within the affected testis.The biopsy results may cause unnecessary stress to thepatient and family and provide little, if any, useful information for improving future fertility.POSTOPERATIVE FOLLOW-UP:

After orchidopexy, the child should be seen in 2 wk to assesswound healing and check testis position.

A second postoperative visit is made 3 mo later to reconfirm testis position and exclude atrophy.

Annual scrotal examinations are then recommended during routine visits withthe primary care physician.

Proper development of secondary sexual characteristics and testicular growth is assessed at puberty, especially for those with a history of bilateral cryptorchidism or delayed surgical correction.

Finally,

patients are seen after puberty at the age of maturity to teach the technique and the importance of testicular self-examination.POTENTIAL PITFALLS:

1. Misdiagnosis of a UDT as a retractile testis, which may result in delayedproper management and histologic deterioration.

2. Failure to examine retractile testes annually, which may result in amissed future ascended testis.

3. Iatrogenic tension or torsion on the spermatic cord during orchidopexy,which may lead to orchidopexy failure resulting from testicular retractionor atrophy.

4. Injury to the spermatic cord structures or epididymis during orchidopexy,which may adversely affect testis and tubular function and caneasily occur in cases in which there is a long-loop vas deferens orepididymis.

5. Inadequate preservation of collateral blood supply during a FSO, whichmay result in testicular atrophy.

6. Incomplete surgical exploration for a nonpalpable testis, which mayleave a testis in the abdominal cavity or lead to the removal of aninaccurately identified vanished testis from the groin or scrotum.THANKS A LOT