- 'Normal' testis = scrotal or retractile testis
- 'Abnormal' testis = never been seen low in scrotum and can not be
manipulated to that position
Aetiology and outcome
- Cryptorchidism = testis in abnormal position
- Testis undergoes intra-abdominal descent up to 28 weeks of
intrauterine development
- Normally found in inguinal canal from 28-32 weeks onwards
- Should be expected to be found in scrotum from 30 weeks onwards
- In full-term infants incidence of cryptorchidism is 6%
- By three months incidence has fallen to 2%
- A high incidence of cryptorchidism is seen in premature infants
- In 80% of patients with cryptorchidism the testis is palpable
- 90% of impalpable testes are either high in inguinal canal or
abdomen
- True anorchidism is rare and is due to either primary agenesis or
neonatal torsion
- Cryptorchidism increases the risk of testicular tumours by x10
- 10% of patients with testicular tumours give a history of testicular
maldescent
- Cryptorchidism increases risk of infertility
- Of patients with cryptorchidism - 30% have oligospermia and 10%
azospermia
Undescended testis
- Found in normal path of descent
- Usually found in inguinal canal or abdomen
Maldescended testis
- Has exited via the superficial inguinal ring but is now in an
ectopic position
- Usual sites are the femoral triangle or perineum
Management of the undescended testis
- If testis palpable in inguinal canal or high in scrotum patient
requires orchidopexy
- Should be performed during second year of life
- Usually performed via 'groin and scrotum' incision
- Testis often placed in Dartos pouch
- Early orchidopexy may improve fertility
- No evidence that it reduces risk of malignancy but allows early
identification
- If testis is impalpable laparoscopy is best means of identifying
intra-abdominal testis, vas and vessels.
- If no vas, vessels or testis = primary agenesis
- If vas vessels but no testis = neonatal testis or other vascular
event
- If intra-abdominal testis identified consider staged orchidopexy or
microvascular transfer
- If vas vessels seen entering inguinal canal then explore the groin
- No evidence that hormonal treatment (e.g. LHRH) induces descent
Fowler-Stephen's orchidopexy
- This is a two-staged procedure
- Gonadal vessels are divided at first operation
- This can be achieved laparoscopically
- This encourages a collateral blood supply to develop via cremasteric
and vassal vessels
- Six months late the testis is mobilised on these vessels
- Testis is delivered through abdominal wall medial to inferior
epigastric vessels
Outcome of orchidopexy
- Testis is often smaller and higher in the scrotum than normal testis
- Testis may atrophy and retract to higher position
- Fertility may be reduced
- Following bilateral orchidopexy
- 25% men will have normal sperm counts
- >50% will have azospermia
- Following unilateral orchidopexy
- 50% have subnormal sperm counts
- 50% have normal sperm counts
Bibliography
Bianchi A. The impalpable
testis.
Ann R Coll Surg Eng 1995;
77: 3-6.
Davenport M. Laparoscopic surgery in children. Ann R
Coll Surg Engl 2003; 85: 324-330.
Gill B,
Kogan S.
Cryptorchidism - Current concepts.
Pediatr Clin N Am 1997;
44:
1211-1227. |