CRYPTORCHIDISM

Dr.GOVIND

SRMC & RI

EMBROLOGY

• GONADAL RIDGE – COELOMIC EPITHELIUM

• GERMINAL CELLS- YOLK SAC

• SEMINIFEROUS TUBULE

• SERTOLI CELLS

• TESTOSTERONE & MIS

• GUBERNACULUM & CSL

Descent

• ABDOMINAL PHASE 23 weeks

• INGUINAL PHASE 24-30 weeks

• INFRA INGUINAL PART upto 3 months after birth

• INCIDENCE : 3% general population,30% in preterm

• PRETERM

• SPONTANOUS DECENT : 70% by 3 months….more so in LBW,B/L,normal pathway &developed scrotum

• At 1 year incidence is 1%

CLASSIFICATION

• INTRA ABD…….peeping & ectopic• INTRACANALICULAR• SUPRAPUBIC• INFRAPUBIC• ECTOPIC• RETRACTILE• ASCENDING• Atropic/vanishing

cryptorchidism

20% nonpalpable

20% palpable G/A

35% intra abd

15% Abd vanishing

50% inguinalVanish/present

THEORY OF DECENT OF TESTES

• ENDOCRINE• ANDRIGEN• MIS• ESTROGEN• DECENDIN• GUBERNACULUM (attachments, muscle, morphogenisis)

• GFN & CGRP• EPIDIDYMIS• INTA ABD PRESSURE• DIFFRENTIAL GROWTH

HISTOLOGICAL CHANGES

• After I month: leydig cells

• After 6 months : volume & Ad spermatozoa

• After 1 year : peritubular fibrosis

• After 3 years : leydig cells sertoli cells germ cells

PROBLEMS: FERTILITY

• Same fertility rate upto 1 year of age

• Severe changes at 5 years of age

• Paternity index: B/L crypt corrected ….50% Unilateral……………75% Elevated FSH levels

PROBLEM : HERNIA

• Incidence…………90%

• ? Related to androgen (processes closure)

• Usually closes at least by 3 months of age

• Post Hcg therapy……….

if P.vaginalis closes testis descends in 50% cases

if P,vaginalis doesnot close then testis done not descend at all

PROBLEM : TUMOUR

• Increased incidence ( 40 Vs 14 times)• Puberty tumors• 10% testicular tumor arise form undesended• Higher the testis more chances of

malignancy• Seminoma / yolk sac tumor/embryonal • Relative risk……contralateral desended 3.6 contralateral undesended 15% CIS …………..1.7%

PROBLEM : TORSION

• Increased susceptibility

• Long mesentery / vas

• Related to tumor development

• Related to Hcg therapy

• ?explains vanishing testis

INVESTIGATIONS

• CLINICAL EXAM & EXAM UNDER ANESTHESIA

• USG

• CT

• MRI

• LAPAROSCOPY

CONSERVATIVE

• OBSERVATION

• HCG……..1500IU TWICE WEEKLY

FOR 4 WEEKS

• GNRH……..1.2 mg nasal spray

twice weekly for 4 weeks

Efficacy ………..20%

Hormonal assay

• Basal FSH/LH levels are raise then consider anorchia

• Serum testosterone assay at 2-3 months age

• Hcg stimulation test :

500iu on mon , wed, fri

testosterone levels on Saturday…..

( normal raise > 200ng/dl)

MIS

• Glycoprotein by sertoli cells

• Post puberty MIS synthesis declines

• MIS is a more sensitive marker

• No testicular tissue……..<1ng/ml

• Abnormal testes………….10-15ng/ml

• Normal testes……….35-40ng/ml• Low MIS……………..90% cases absent testis

• Normal MIS……..98% testis present

B/l crypt & normal phallus

MIS normal

orchidopexy

Low levels of MIS

Hcg test: normal

Orchidopexy(r/o pmds)

Hcg test negetive

anorchia

Ambiguous genitalia

MIS assay

Normal: testes +

Male pseudo herma.Androgen resistanceTestosterone syn, defecthypogonadism

Low..

Mixed gonadal dysgenesisTrue hermaph.Testicular regression

undetectable

Female pseudoCAHVanishing testes

UNILATERAL

• USG

• LAPAROSCOPY : DECIDE ON TABLE

SINGLE STAGE ORCHIDOPEXY

TWO STAGED

ORCHIDECTOMY

BILATERAL CRYPTORCHIDISM

• KARYOTYPE

• TESTOSTRONE AT 2-3 MONTHS AGE

• HCG STIMULATION TEST

• MIS ASSAY

• Laparoscopy

• Atleast one side orchidopexy at 9 months

SURGERY

• SIMPLE ORCHIDOPEXY

• ALBERT & PERSKY

• PENTRISS

• KOOP

• STEPHEN FOWLER

• MICROSURGICAL

Standard orchidopexy

• Open tunica vaginalis…eversion

• Dissect internal spermatic fascia,ext.spermatic fascia,cremaster at internal ring

• Fix in dartos pouch

• Tension free

• Pentriss/Albert persky

Fowler-Stephens

• ? Modification of Bevan”s• One staged • Two staged • Identify…collaterals,long loop,large

peritoneal pedicle• Ureter vulnerable • Shortest route to scrotum• Stephen-fowler test• High ligation Vs low ligation

microvascular

• Success rate of 80%• ?procedure of choice in high solitary testis• Gibson incision• safe guard inf.epigastric vessels• Spermatic vessels mobilized upto origin &

ligated based on a wide peritoneal pedicle• Microvascular surgery• Dartos pouch fixation

LAPARASCOPIC SITUATIONS

• BLIND ENDING VAS

• BLIND ENDING VESSELS

• VESSELS ENTERING DEEP RING

• MEDIAL ABDOMINAL TESTIS

• PELIC TESTIS

• SUBHEPATIC/JUXTA SPLENIC