Presentation on theme: "Abnormalities of the testes and scrotum and their surgical management Dr. S. Vahidi."— Presentation transcript:
Abnormalities of the testes and scrotum and their surgical management Dr. S. Vahidi
Undescended testis Definition: Testes located anywhere between the abdominal cavity and just outside the anatomic scrotum Abnormally position testis –Cryptorchidism = hidden testis UDTEctopic –Un descended testis Multiple etiologies diversity of this congenital disorders
Incidence One of the most common congenital anomalies at birth 3% of full-term male newborns % unilateral 30.3% in prematures –Preterm- low birth weight -twin - small for gestational age 70-77% spontaneously descend, by 3 month. 1% at 1 year of age
Epidemiology Gestational age Birth weight Prematurity Genetic- hormonal- environmental
Classification Variation in testicular size & consistency Epididymial & vassal anomalies Patent processos vaginalis Cryptorctidism: paplable- non palaplable: –Intra abdominal –Absent (vanishing) –Atrophic –Missed on Ph.E.
Cryptorchidism Intra abdominal Intra canalicular Extra canalicular –Supra Pubic –Infra Pubic Ectopic –Denis-browne pouch –Transverse scrotal –Femoral –Perineal –Prepenile
Retractile testis Over active cremasteric reflex Groin 3-7 years of age Infertility? Delayed spontaneous T. Ascent
Theories of Descent & maldescent 3 phase of descending 1.Trans abdominal23 week 2.Trans inguinal 3.Extra canalicular23 week Endocrine factors GubernaculumEpididymis Intra abdominal pressure Histopathology
Endocrine factors Normal hypothalamic- pituitary-gonadal axis testicular descent Androgenes: testosterone & DHT inguinal-scrotal phase of descent Mullerian inhibiting substance (MIS)? Estrogen? Descendin: gubernacular specific growth factor
Gubernaculum Major factor responsible for testicular descent Physiologic mechanism? Testicular descent: –Hormonal factors –Mechanical factors Genito femoral nerve and calcitonin Gene- related peptide?
Epididymis Epididymal abnormalities cryptorchidism Fertility in UDT –Germ cell development –EP. Anomalies
Intra abdominal pressure Defects or agenesis of abdominal wall musculars UDT Significant Role in trans inguinal descent
Histopathology – Leidig cells –Degeneration of sertoli cells –Delayed disappearance of gonocytes –Delayed appearavice of (Ad) spermatogonia –Failure of primary spermatocytes to develop – Germ cells Similar pathology in the contralateral descended testis < 2 years of age
Consequences of UDT InfertilityNeoplasiaHerniaTorsion
Infertility –Bilateral or unilateral UDT –Early or delayed orchiopexy Neoplasia –10% of T. tumors arise from UDTs –T. tumors in UDT: 1/2550 –T. tumors in population: 1/100,000
Neoplasia (continued) Presentation time: puperty Orchiopexy affect the T. tumor? The age of orchiopexy and T. tumor? The location of T. & T. tumor Seminoma is most common T. tumor The cause of increased Risk: temprature or intrinsic pathologic process? Routine T. biopsy during child hood orchiopexy?
Hernia Patent processus vaginalis in >90% of UDT Patent processus vaginalis affect the hormonal treatment of UDT T. Torsion
Work-up of UDT 80% palpable 20% non palpable –20% absent –30% atrophic –50% intra abdominal
Work-up of UDT History –Preterm H. –Perinatal H. –Past medical & surgical H. –Family H. Ph.E –Other birth defect –Genital examination –Contralateral testis Paraclinic –Accuracy of radiologic testing in UDT is 44% Workup in Bilateral UDT –Hormonal workup (HCG stimulation test)- FSH- inhibin B- MIS
Management of UDT Tenets of treatment 1.Proper identification of the Anatomy- position- viability 2.identification of coexisting syndrome 3.Placement of the testis within the scrotum 4.Permanent fixation and easy palpation 5.No further T. damage Definitive treatment should occur before 1 year of age
Indication for orchiectomy in UDT Post pubescent males Contralateral normal T. Anatomically & morphologically abnormal Too far from scrotum
Hormonal therapy 1.HCG 2.GnRH or LHRH The lower position the better the success rate Reascent in 25% of patient Not indicated in: –Ectopic T. –Inguinal Hernia
HCG treatment 14-59% success rate 10,000 IU (1500 Iu/m 2 im/2 week – 4 week) Complications:GnRH % success rate 1.2 mg/day for 4 weeks. (nasal spray) Overall efficacy of hormonal treatment < 20% Surgery remains the Gold standard in the management of UDT
Surgical management of UDT Standard orchiopexy Ancillary techniques for the high UDT Reoperative orchiopexy
Management of intra- abdominal testis Laparoscopy Fowler- stephenes orchiopexy Microvascular auto transplantation Complications of orchiopexy
Hydrocele Simple Hydrocele Communicating Hydrocele Hydrocele of the cord Abdomino scrotal hydrocele
Differential diagnosis of the acute subacute scrotum Torsion of the spermatic cord Torsion of the appendix testis Torsion of the appendix epididymis EpididymitisEpididymo-orchitis Inguinal hernia Communicating hydrocele Hydrocele Hydrocele of the cord Trauma/insect bite Dermatologic lesions Inflammatory vasculitis (henoch- schönlein purpura) Idiopathic scrotal edema TumorSpermatoceleVaricocele Nonurogenital pathology (e.g., adductor tendinitis)
Torsion of the spermatic cord (intravaginal) –Golden time (4 hours) –Degree of torsion –Acute or gradual onset –Severe or minimized pain –Nausea & vomiting- the absence of cremasteric reflex –Manual detorsion –Doppler examination: false positive & false negative –Color doppler: 89% sensitivity 99% specifity? –Radinuclide imaging: sens 90% speci= 89%
Torsion (continued) Explore Both side Dartos pouch placement (no sutures) Sympathetic orchiopathy?
Intermittent torsion Torsion of the testicular and epididymal appendages Perinatal torsion of the spermatic cord (extra vaginal) No surgical exploration Exploration of contralateral T.? In postnatal torsion: exploration is needed (Bilateral)