1. Franklin Lee Urology R1 Seattle Children’s Hospital

2. Outline 1. Embryology 2. Definition 3. Epidemiology 4. Importance of treatment Fertility Testicular Cancer 5. Age to treat 6. Orchiopexy 7. Nonpalpable Testes

3. Embryology

6. + Androgen Gonad Mullerian Duct CSL Gubernaculum Wolffian Duct + Insl3 + MIS Gubernaculum Testis Wolffian Duct CSL

7. Definitions No good definition Spectrum of disease Retractile testes Gliding Testes Ectopic Absent Nonpalpable testes Testicular ascent

9. Epidemiology One of the most common congenital birth defects 3% of full term males Risk factors Gestational age ~ 30% incidence in premature infants (< 37 weeks) Weight Decreased intraabdominal pressure Prune belly syndrome, omphalocele, gastrochisis Family history 3.6 fold increase risk; 6.9 fold siblings; 4.6 fold father.

10. Importance of treatment: Fertility Cryptorchidism impairs germ cell maturation Treat before onset of histopathologic changes Animal model demonstrating improvement after orchiopexy. 2 key pre-pubertal steps Transformation of fetal stem cell (gonocytes) into adult stem cell pool (Ad spermatogonia) Transformation of Ad spermatogonia into spermatocytes Impact on fertility? Grasso European J Urol 1991: postpubertal orchichiopexy 84% azoospermic or oligospermic. McAleer J Urol 1995: no difference younger than 1 year

14. Testicular Cancer Increased risk of testicular cancer in cryptorchidism 10% testicular tumors arise from cryptorchidism Baseline risk of testicular cancer despite orchiopexy Seminomas more common than non-seminomas

17. Age to treat Should take place between ages 6 months – 1 year Spontaneous descent should have occurred by this age.

22. Nonpalpable Testes Up to 20 % of patients present with Undescended testes Diagnostic laparoscopy Low testicular position < 2 cm from IR High testicular position > 2 cm from IR Open versus laparoscopic repair

23. Low testicle “Peeping testicle” < 2 cm from the internal ring Primary repair Open Laparoscopic

24. High testicle > 2 cm from the internal ring Testicular artery and veins limit mobilization of the testes Fowler-Stephen Orchiopexy Ligation of the spermatic vessels Staged approach 2 stage approach 1 staged approach

25. Controversy Laparoscopic versus open repair 1 stage versus 2 stage Fowler-Stephens repair

26. 1 stage vs 2 stage Fowler Stephens Single Stage Open Fowler Stephens 81.7% Single Stage Lap Fowler Stephens 83.4%

27. Two Stage Open Fowler Stephens 86.0 % Two Stage Lap Fowler Stephens 88.8 %

28. Elyas Et al. 2 stage operation 85% vs 1 stage operation 80% No difference between laparoscopic or open Does not look at complication rate Entirely prospective

29. References McAleer IM, Packer MG, Kaplan GW, et al: Fertility index analysis in cryptorchidism. J Urol 1995; 153:1255-1258 Grasso M, Buonaguidi A, Lania C, et al: Postpubertal cryptorchidism: Review and evaluation of the fertility. Eur Urol 1991; 20:126-128. Lugg JA, Penson DF, Sadeghi F, et al: Prevention of seminiferous tubular atrophy in a naturally cryptorchid rat model by early surgical intervention. J Androl 1996; 17:726-732. Huff DS, Fenig DM, Canning DA, et al: Abnormal germ cell development in cryptorchidism. Horm Res 2001; 55:11-17. Andreas Pettersson, M.D. et al. Age at Surgery for Undescended Testis and Risk of Testicular Cancer. New England J Medicine 2007; 18: 1835-1841 Elyas et al. Is Staging Beneficial for Fowler-Stephens Orchiopexy? A systematic review. J Urol 2010; 183; 2012-2019 Abolyosr, Ahmad. Laparoscopic versus open orchiopexy in the management of abdominal testis: A descriptive study. Int J Urol 2006; 13: 1421-1424. Stillman RJ: In utero exposure to diethylstilbestrol: Adverse effects on the reproductive tract and reproductive performance and male and female offspring. Am J Obstet Gynecol 1982; 142:905-921. Weidner IS, Moller H, Jensen TK, Skakkebaek NE: Risk factors for cryptorchidism and hypospadias. J Urol 1999; 161:1606-1609.

30. Risk factors of Hypospadias: Low birth weight; preeclampsia; Genetics?