Urology 36 Undescended Testis

Undescended testis
Dr.Santosh Jha
TMU
1
2
A, 5th week Testis begins its
primary descent; kidney
ascends.
B, 8th-9th weeks. Kidney
reaches adult position.
C, 7th month, Testis at
internal inguinal ring;
gubernaculum (in inguinal
fold) thickens and shortens.
D, Postnatal life.
3
4
Introduction
An undescended testis is one which has filed to descend to the scrotum &
is retained at any point along the normal path of descend
Right side: 50%

Left side: 30%
Bilateral: 20%
cryptorchidism
5
Types of undescended testis
Lumbar testis
Iliac testis: testis remains just deep to the deep inguinal ring
Inguinal: testis is in the inguinal canal
At the superficial inguinal ring
Scrotal testis:
the testis lies in the upper part of the scrotum
6
A, Ectopic testes. Perineal
ectopia not shown.
B, Undescended testes.
Percentages of testes
arrested at different stages
of normal descent
7
8
Undescended testis
Scrotal testis:
The testis lies in the upper part of the scrotum
Also known as a retractile testis
Normal scrotal sac & testis
The testis can be brought down
9
Undescended testis: C/F
Symptoms
Underdeveloped scrotum
Infertility
Indirect inguinal hernia
10
Undescended testis: C/F
Signs
Empty scrotum
11
Undescended testis: complications
Torsion of the testis

Epididymo- orchitis
Atrophy
Sterility
Malignancy
12
Undescended testis: management
Hormone therapy
Orchidopexy
Orchidectomy
Laparoscopic surgery
13
14
Undescended testis: hormone therapy
Not used routinely
Indications:
When the surgeon is not sure whether the case is one of retractile
testis or not
Bilateral incomplete descended testis associated with hypogenitalism
& obesity
The hormone mostly used is human chorionic gonadotrophin
15
Undescended testis: orchidopexy
Treatment of choice
Usually should be done by the age of 5 years but it is unnecessary to do

this operation before completion of second birthday of the child
16
Ectopic testis
The testis fails to descend into the scrotum & is deviated from its normal
path of descent
17
Position of the ectopic testis
Superficial inguinal pouch

Pubopenile ectopia
Perineal ectopia
Crural or femoral ectopia
18
Comparison between ectopic & undescended
testis
Undescended testis Ectopic testis
The testis is arrested in its normal The testis deviates from its
path of descent normal path of descent
Usually undeveloped Fully developed testis
Undeveloped & empty scrotum Empty but usually fully developed
on the affected side scrotum
Shorter length of spermatic cord Longer length of spermatic cord
Poor spermatogenesis after 6 yrs Spermatogenesis is perfect
Usually associated with indirect Never associated with indirect
inguinal hernia inguinal hernia
Treatment: surgery & HT Treatment: basically surgical
Associated with a number of Complications: liability to injury
complications
19
Workup
Preterm and maternal history, including the use of
gestational steroids
Perinatal history, including documentation of a

scrotal examination at birth
The child's medical and previous surgical history
Family history of cryptorchidism or syndromes

All boys with nonpalpable testes and normal serum gonadotropin levels must
undergo surgical exploration regardless of the results of the hCG stimulation test.
20
21
Management of Cryptorchidism
Proper identification of the anatomy, position, and viability of the
undescended testis
Identification of any potential coexisting syndromic abnormalities
Placement of the testis within the scrotum in timely fashion to prevent

further testicular impairment in either fertility potential or endocrinologic
function
Attainment of permanent fixation of the testis with a normal scrotal position

that allows for easy palpation
No further testicular damage resulting from the treatment

Definitive treatment of an undescended testis should take
place between 6 and 12 months of age
22
Hormonal Therapy
Exogenous hCG and
Exogenous GnRH or LHRH.
Increases serum testosterone production by stimulation at

different levels of the hypothalamic-pituitary-gonadal cascade
Successful results are more commonly reported in older

groups of children and in testes that were retractile or below
the external inguinal ring. E.g. the lower the pretreatment
position, the better the success rate
23
A transverse skin incision is made in an inguinal skin crease
24
The overall efficacy of hormonal treatment is less
than 20% for cryptorchid testes and is significantly
dependent on pretreatment testicular location.
Therefore, surgery remains the gold standard for the

management of undescended testes.
25
Standard Orchiopexy.
The key steps in this procedure are ---
(1)complete mobilization of the testis and spermatic cord,
(2) repair of the patent processus vaginalis by high ligation of the
hernia sac,
(3) skeletonization of the spermatic cord without sacrificing
vascular integrity to achieve tension-free placement of the
testis within the dependent position of the scrotum, and
(4) creation of a superficial pouch within the hemiscrotum to
receive the testis.
26
A transverse inguinal skin incision is made in the midinguinal canal, usually in a skin
crease in children younger than 1 year
The dermis is opened with electrocautery, and subcutaneous tissue and Scarpa's
fascia are opened sharply.
The skin and subcutaneous tissue are quite elastic in younger children and allow for a
tremendous degree of mobility by retractor positioning for viewing the entire length of
the inguinal canal.
One should be careful to

observe that the testis is
in the superficial
27
A,The external ring is opened.
B, Cremasteric fibers are dissected from the cord

28
A, High ligation of the processus
vaginalis at the internal inguinal ring.
B, The ligated processus and the cord

structures
29
Separation of the internal spermatic fascia
from the cord structures after ligation of the
processus vaginalis 30
Formation of a dartos pouch
31
A, Formation of a
passage to the scrotum.
B and C, Passage of the

testis into the scrotal
pouch
32
Complications of Orchiopexy
Testicular retraction,
Hematoma formation,
Ilioinguinal nerve injury,
Postoperative torsion (either iatrogenic or
spontaneous),
Damage to the vas deferens, and
Testicular atrophy
Devascularization with atrophy of the testis can result from skeletonization
of the cord, from overzealous electrocautery
33

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Undescended testis

Right side: 50%

Indirect inguinal hernia

Torsion of the testis

Not used routinely

The hormone mostly used is human chorionic gonadotrophin

Usually should be done by the age of 5 years but it is unnecessary to do

Superficial inguinal pouch

Perinatal history, including documentation of a

The child's medical and previous surgical history

Family history of cryptorchidism or syndromes

Identification of any potential coexisting syndromic abnormalities

Placement of the testis within the scrotum in timely fashion to prevent

Attainment of permanent fixation of the testis with a normal scrotal position

No further testicular damage resulting from the treatment

Increases serum testosterone production by stimulation at

Successful results are more commonly reported in older

Therefore, surgery remains the gold standard for the

One should be careful to

B, Cremasteric fibers are dissected from the cord

B, The ligated processus and the cord

B and C, Passage of the

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