Cryptorchidism--(Undescended testis)
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Transcript of Cryptorchidism--(Undescended testis)
CHILD WITH AN EMPTY SCROTUM
A PROBLEM ORIENTED APPROACH
CHILD WITH AN EMPTY SCROTUM
Dr.B.SELVARAJ MS;Mch;FICS;
NEONATAL & PEDIATRIC SURGEON
MELAKA MANIPAL MEDICAL COLLEGE
MELAKA– 75150 MALAYSIA
A PROBLEM ORIENTED APPROACH
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CHILD WITH AN EMPTY SCROTUM
Recognise various conditions
Clinch correct diagnosis
Appropriate investigations
Timely surgical referral
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A PROBLEM ORIENTED APPROACH
OBJECTIVES
CHILD WITH AN EMPTY SCROTUM
UNDESCENDED TESTIS
ECTOPIC TESTIS
RETRACTILE TESTIS
POST-TORSION ATROPHY
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CAUSES
Embryology Of Testicular Descend
Primitive gonad in urogenital ridge turns into testis by gene in short arm of Y chromosome; Early Testis�3 hormones
Testosterone�From Leydig cells CSL regression
Mullerian inhibiting substance from Sertolli cells� Mullerian duct regression
Insulin- like3 hormone �Thickening of caudal gubernaculum� holds testis close to inguinal abdominal wall � Relative descend of testis
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8 to 15 Wks of Gestation- Transabdominal Phase
Embryology Of Testicular Descend
At 25 Wks Processus vaginalis elongates into gubernaculum
Distal end of gubernaculum elongates and reach scrotum between 30- 35 wks
Then testis descend through patent processus vaginalis
Testosterone� GFN� CGRP� Migration of gubernaculum along with testis to scrotum
28 to 35 Wks of Gestation- Inguinoscrotal Phase
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Various Stages Of
Testicular Descend
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Classification Of Cryptorchidism
(Hidden Testis)
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UNDESCENDED TESTIS
ETIOLOGY
Anatomical
Endocrine
Iatrogenic
• Short spermatic
artery
•Retroperitoneal
Adhesion
•Malfunctioning
Gubernaculum
•Narrow inguinal
ring/ canal
• Pituitary
deficiency
•Testosterone
deficiency
•Post Herniotomy
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UNDESCENDED TESTIS
Testicular descend� is arrested in it’s normal path
Rt side�60%; Lt side�30%;Bilateral�10%
Premies�30%; Full term Neonates� 4to5%; 3Month infant�1to2%; 1Yr olds�0.3%
Empty & poorly developed Scrotum
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UNDESCENDED TESTIS
Always associated with patent processus vaginalis� Inguinal Hernia
If testis is palpable in groin do Milking Manuver to R/O Retractile testis
Palpate perineum & upper thigh to R/O Ectopic Testis
If testis is impalpable� needs further workup to localise the testis
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UNDESCENDED TESTIS
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UNDESCENDED TESTIS
Milking Manuver
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UNDESCENDED TESTIS
Complications
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TRAUMA
TORSION
TESTICULAR
MALIGNANCY INFERTILITY
PSYCHOLOGICAL PROBLEMS
UNDESCENDED TESTIS
Postnatal Germ Cell Development
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UNDESCENDED TESTIS
Infertility & Cancer
Scrotum 4*c < than core body temperature� Ideal for spermatogenesis
Transformation of Neonatal gonocyte to type A Spermatogonium is impaired
This transformation occurs at 3to 6 months of age
Dysplastic gonocyte is the cause for malignant transformation in early adulthood & for infertility
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UNDESCENDED TESTIS
Workup
In Bilateral Impalpable Testis: HCG stimulation test to confirm presence of testis
To localise testis the Gold standard is Laparoscopy� Diagnostic & Therapeutic
USG of Groin & Abdomen
CT Scan Groin & Abdomen
MRI of Abdomen
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UNDESCENDED TESTIS
Management
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UNDESCENDED TESTIS
INGUINAL ORCHIDOPEXY
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UNDESCENDED TESTIS
INGUINAL ORCHIDOPEXY
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Algorithm for Impalpable Testis
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UNDESCENDED TESTIS
DIAGNOSTIC LAPAROSCOPY
Vas and Testicular vessels entering the internal inguinal ring
Canalicular UDT
Blind ending Vas and Testicular vessels
Anorchia (Vanishing Testis)
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UNDESCENDED TESTIS
Laparoscopic Fowler Stephens
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UNDESCENDED TESTIS
Laparoscopic Fowler Stephens
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Prentiss Maneuver
UNDESCENDED TESTIS
Complications of Orchidopexy
Damage to Testicular vessels� Testicular Atrophy
Damage to Vas Deferens� Infertility
Retraction of Testis out of Scrotum
Hemorrhage
Wound infection
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ECTOPIC TESTIS
� Testis after coming out of external inguinal ring
has migrated into an abnormal location
� Sites of ectopic testis are
- Superficial inguinal pouch
- Perineum
- Pre penile
- Opposite side scrotum- crossed ectopic
- Femoral triangle
� Diagnosis is obvious & Orchidopexy is easy
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Sites of UDT & Ectopic Testis
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ECTOPIC TESTIS- Perineal
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RETRACTILE TESTIS
Testis can be manipulated into scrotum
Testis is pulled and held high by overactive cremastric muscle
Descends into scrotum whenever child is relaxed/ sleeping
By puberty testis grow in size & remain in scrotum
No intervention is needed
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www.themegaller
y.com
CHILD WITH AN EMPTY SCROTUM
www.themegaller
y.com
CHILD WITH AN EMPTY SCROTUM
TAKE HOME MESSAGE
Child should be operated between 6months to 1year
Undue delay in surgery carries the risk of infertility and malignancy in adult life
Hormone therapy may be tried between 3to 6 months
Retractile testis should not be operated
Intra abdominal testis is best managed with Laparoscopy
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