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Cryptorchidism : Symptoms, Diagnosis and Treatment

  • Posted on- Apr 04, 2018
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Cryptorchidism is a common genital anomaly diagnosed at birth or during childhood. Genetic or environmental factors that alter expression or function of hormones crucial for the testicular descent, insulin-like 3, and testosterone may contribute to cryptorchidism.

When identified at birth, surgical treatment is indicated by 6 months of age if testes fail to descend, or at the time of diagnosis in older children. A laparoscopic approach is preferred for abdominal testes. Early surgical therapy may reduce the risk of sub-fertility and malignancy.

Cryptorchidism or undescended testis is the most common disorder of the male endocrine glands in children. Up to one-third of boys with true cryptorchidism have bilaterally cryptorchid testes.

The main reasons for treatment of cryptorchidism include increased risks of progressive infertility, testicular malignancy, torsion, and or associated inguinal hernia, and because of cosmetic concerns.

However, successful relocation of the testis may reduce but does not prevent these potential long-term sequelae in susceptible individuals.

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Diagnosis of cryptorchidism 

Traditionally, the testicular position at birth was used to determine the presence or absence of undescended testis.

However, in recent decades new evidence supports the concept that some testes that are documented as descended at birth are no longer intra-scrotal at a subsequent time.

This situation is frequently called acquired cryptorchidism, but it more likely represents a primary failure of complete testicular descent and is associated with similar histopathology to that observed in cases discovered at birth.

Although the incidence of acquired mal-descent in the general population of boys with normally positioned testes at birth seems to be low in longitudinal studies, the risk in boys with retractile testes is 7% to 45%.

Treatment of cryptorchidism

Hormonal Therapy

Primary hormonal therapy with hCG or gonadotropin-releasing hormone (GnRH or LH-releasing hormone LHRH) has been used for many years, especially in Europe.

The exact mechanism of action of gonadotropin on the postnatal testicular descent is not known but may involve effects on the spermatic cord and cremaster muscle.

Divergent results have been reported likely because of suboptimal study design, differences in patient age and treatment schedules, possible inclusion of retractile testes, and variable follow-up.

However, several meta-analyses of this published literature suggest that the effectiveness of primary hormonal therapy in cryptorchidism is less than 20%. A recent consensus statement discourages use of hormone therapy for cryptorchidism.

Some data suggest that spermatogonia/tubule (S/T) ratios may improve after treatment with low dose LHRH analogue therapy. However, caution is advised when evaluating these data because of retrospective, nonrandomized study design and patient heterogeneity.

Surgery of cryptorchidism

Palpable testis

Standard inguinal orchidopexy involves several steps after repeat examination under anesthesia to reconfirm testicular location. A transverse inguinal incision is made along Langer lines and Scarpa fascia is incised with care to avoid injury to a testis in the superficial inguinal pouch.

The testis is mobilized after incision of the gubernacular remnant. The cremasteric muscle fibers are transected and the hernia sac isolated, transected, mobilized to the internal inguinal, and ligated.

After the division of lateral fascial bands, the testis is placed in the scrotum in a subcutaneous or subdartos pouch without transcapsular sutures.

A primary scrotal approach to orchidopexy is described in cases in which the testis is palpable and is either close to the scrotum or can be easily drawn into the sac.

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Successful mobilization of the testis and ligation of the hernia sac at the level of the external or internal ring is described alternatively, a secondary inguinal incision is made if needed.

Testicular retraction or atrophy has been reported at 0% to 2%, and postoperative hernia has been noted in 2% to 3% of cases with follow-up in these series ranging from 1 month to 3 years.

Thus, this approach may be a viable option in select cases of cryptorchidism when testes are distal to the external ring.

Further maneuvers may be used to obtain the adequate length of a high inguinal testis. Passing testis behind the inferior epigastric artery and vein after opening the transversalis fascia (the Prentiss maneuver) allows more medial positioning of the cord.

Dividing the internal oblique muscles with lengthening the incision as needed allows further opening of the internal ring and additional dissection of the lateral spermatic fascia in the retroperitoneal space.

A Fowler-Stephens orchiopexy, or division of the internal spermatic artery, can be performed if extensive dissection between the vas and cord has not occurred, as testicular survival then relies on the deferential and external spermatic blood supply.

An alternative for the high testis is microvascular auto transplantation to the ipsilateral inferior epigastric artery and vein.

Rarely, a 2-stage orchidopexy may be used without division of the spermatic vessels when the Prentiss maneuver and cord dissection fail to provide adequate length.

The testis is anchored in its most dependent position or the spermatic cord may be wrapped in a protective sheath for ease of the second stage, generally 6 to 12 months later.

Non-palpable testis

Exploration for a non-palpable testis may occur through an extended inguinal incision, an abdominal incision, or, more commonly, via diagnostic laparoscopy.

At the time of exploration, the most likely findings are intra-abdominal or peeping testis just at the internal ring (25%-50%), vanishing testis most commonly distal to the internal ring (15%-40%) or cord structures (vessels and vas) that enter the internal ring in the presence of a viable testis that is non-palpable because of the size of the testis or patient's body habitus.

The absence of visible spermatic vessels warrants further full exploration of the retroperitoneum to document testicular agenesis, which is extremely rare.

The finding of cord vessels entering the ring warrants inguinal exploration for identification of a distal viable or vanishing testis.

Some surgeons use a primary trans-scrotal approach when a palpable scrotal nubbin is present and confirm the diagnosis of vanishing testis by visualizing a black area containing hemosiderin.

However, if findings are questionable using this approach, laparoscopy is warranted. Although controversial, fixation of the solitary testis should be considered to protect against the theoretic risk of torsion.

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