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CRYPTORCHIDISM Dr.GOVIND SRMC & RI. EMBROLOGY GONADAL RIDGE – COELOMIC EPITHELIUM GERMINAL CELLS- YOLK SAC SEMINIFEROUS TUBULE SERTOLI CELLS TESTOSTERONE.

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Presentation on theme: "CRYPTORCHIDISM Dr.GOVIND SRMC & RI. EMBROLOGY GONADAL RIDGE – COELOMIC EPITHELIUM GERMINAL CELLS- YOLK SAC SEMINIFEROUS TUBULE SERTOLI CELLS TESTOSTERONE."— Presentation transcript:

1 CRYPTORCHIDISM Dr.GOVIND SRMC & RI

2 EMBROLOGY GONADAL RIDGE – COELOMIC EPITHELIUM GERMINAL CELLS- YOLK SAC SEMINIFEROUS TUBULE SERTOLI CELLS TESTOSTERONE & MIS GUBERNACULUM & CSL

3 Descent ABDOMINAL PHASE 23 weeks INGUINAL PHASE weeks INFRA INGUINAL PART upto 3 months after birth

4 INCIDENCE : 3% general population,30% in preterm PRETERM SPONTANOUS DECENT : 70% by 3 months….more so in LBW,B/L,normal pathway &developed scrotum At 1 year incidence is 1%

5 CLASSIFICATION INTRA ABD…….peeping & ectopic INTRACANALICULAR SUPRAPUBIC INFRAPUBIC ECTOPIC RETRACTILE ASCENDING Atropic/vanishing

6 cryptorchidism 20% nonpalpable 20% palpable G/A 35% intra abd 15% Abd vanishing 50% inguinal Vanish/present

7 THEORY OF DECENT OF TESTES ENDOCRINE ANDRIGEN MIS ESTROGEN DECENDIN GUBERNACULUM (attachments, muscle, morphogenisis) GFN & CGRP EPIDIDYMIS INTA ABD PRESSURE DIFFRENTIAL GROWTH

8 HISTOLOGICAL CHANGES After I month: leydig cells After 6 months : volume & Ad spermatozoa After 1 year : peritubular fibrosis After 3 years : leydig cells sertoli cells germ cells

9 PROBLEMS: FERTILITY Same fertility rate upto 1 year of age Severe changes at 5 years of age Paternity index: B/L crypt corrected ….50% Unilateral……………75% Elevated FSH levels

10 PROBLEM : HERNIA Incidence…………90% ? Related to androgen (processes closure) Usually closes at least by 3 months of age Post Hcg therapy………. if P.vaginalis closes testis descends in 50% cases if P,vaginalis doesnot close then testis done not descend at all

11 PROBLEM : TUMOUR Increased incidence ( 40 Vs 14 times) Puberty tumors 10% testicular tumor arise form undesended Higher the testis more chances of malignancy Seminoma / yolk sac tumor/embryonal Relative risk……contralateral desended 3.6 contralateral undesended 15% CIS …………..1.7%

12 PROBLEM : TORSION Increased susceptibility Long mesentery / vas Related to tumor development Related to Hcg therapy ?explains vanishing testis

13 INVESTIGATIONS CLINICAL EXAM & EXAM UNDER ANESTHESIA USG CT MRI LAPAROSCOPY

14 CONSERVATIVE OBSERVATION HCG……..1500IU TWICE WEEKLY FOR 4 WEEKS GNRH……..1.2 mg nasal spray twice weekly for 4 weeks Efficacy ………..20%

15 Hormonal assay Basal FSH/LH levels are raise then consider anorchia Serum testosterone assay at 2-3 months age Hcg stimulation test : 500iu on mon, wed, fri testosterone levels on Saturday….. ( normal raise > 200ng/dl)

16 MIS Glycoprotein by sertoli cells Post puberty MIS synthesis declines MIS is a more sensitive marker No testicular tissue……..<1ng/ml Abnormal testes………….10-15ng/ml Normal testes……….35-40ng/ml Low MIS ……………..90% cases absent testis Normal MIS……..98% testis present

17 B/l crypt & normal phallus MIS normal orchidopexy Low levels of MIS Hcg test: normal Orchidopexy (r/o pmds) Hcg test negetive anorchia

18 Ambiguous genitalia MIS assay Normal: testes + Male pseudo herma. Androgen resistance Testosterone syn, defect hypogonadism Low.. Mixed gonadal dysgenesis True hermaph. Testicular regression undetectable Female pseudo CAH Vanishing testes

19 UNILATERAL USG LAPAROSCOPY : DECIDE ON TABLE SINGLE STAGE ORCHIDOPEXY TWO STAGED ORCHIDECTOMY

20 BILATERAL CRYPTORCHIDISM KARYOTYPE TESTOSTRONE AT 2-3 MONTHS AGE HCG STIMULATION TEST MIS ASSAY Laparoscopy Atleast one side orchidopexy at 9 months

21 SURGERY SIMPLE ORCHIDOPEXY ALBERT & PERSKY PENTRISS KOOP STEPHEN FOWLER MICROSURGICAL

22 Standard orchidopexy Open tunica vaginalis…eversion Dissect internal spermatic fascia,ext.spermatic fascia,cremaster at internal ring Fix in dartos pouch Tension free Pentriss/Albert persky

23 Fowler-Stephens ? Modification of Bevans One staged Two staged Identify…collaterals,long loop,large peritoneal pedicle Ureter vulnerable Shortest route to scrotum Stephen-fowler test High ligation Vs low ligation

24 microvascular Success rate of 80% ?procedure of choice in high solitary testis Gibson incision safe guard inf.epigastric vessels Spermatic vessels mobilized upto origin & ligated based on a wide peritoneal pedicle Microvascular surgery Dartos pouch fixation

25 LAPARASCOPIC SITUATIONS BLIND ENDING VAS BLIND ENDING VESSELS VESSELS ENTERING DEEP RING MEDIAL ABDOMINAL TESTIS PELIC TESTIS SUBHEPATIC/JUXTA SPLENIC


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