1. Management of undescended testes in Gastroschisis
Geolani Dy, MD (PGY-1)
Pediatric Surgery Conference May 23, 2013

2. Introduction
Undescended testes (UDT) most frequent congenital abnormality of male genitalia [1]
UDT more prevalent in newborns with gastroschisis [2]
Management of UDT in babies with gastroschisis debated
1. Scorer & Farrington, 1971
2. Levard G, and Laberge J.M. The fate of undescended testes in patients with gastroschisis. Eur J. Pediatr Surg 7: , 1997.
Photo:
Gauderer JPS 1987 Gastroschisis and extraabdominal ectopic testes
Full term male with gastroschisis, empty L scrotum. Thickened bowel, small liver edge, L testis exteriorized. Adherence noted between cord structures and bowel.
[3] Gauderer, MW. (1987). J Pedatr Surg.

3. Incidence of undescended testes
General Population
Gastroschisis
Occurs in 2-5% of male newborns
Spontaneous descent by age 1 in:
75% full term infants
95% premature [4]
Decreases to <1% beyond age 1
Up to 30-40% male newborns with gastroschisis have UDT [5,6]
Berkowitz, G.S., Lapinski, R.H., Dolgin, S.E., Gazella, J.G., Bodian, C.A., & Holzman, I.R. (1993). Prevalence and natural history of cryptorchidism. Pediatrics, 92(1), 44-9.
Hill S.J., and Durham, M.M. Management of cryptorchidism and gastroschisis. J Pediatr Surg 2011;46(9):
Yardley, I.E., et al. Congenital abdominal wall defects and testicular maldescent—a 10-year single-center experience. J Pediatr Surg 2012;47:

4. Why? Propulsion, involution
Testicular descent related to increased intraabdominal pressure [7]
Absence of forces encouraging testicle migration
Barthold, J.S. Undescended testes: current theories of etiology. (2008). Current Opinions in Urology, 18, 395–40.
A simple way of thinking about factors guiding testicular descent are Propulsion and involution (of gubernaculum). Propulsion is thought ot come from increased intraabdominal pressure, absent in newborns with abdominal wall defects.
A.A. Attah, J.M. Hutson
The role of intra-abdominal pressure in cryptorchidism J Urol, 150 (1993), pp. 994–996

5. Shared pathologic association or confounding variables?
UDT in general population [7]:
Genetic
Environmental
Prematurity
SGA
Low birthweight
Twins
Gastroschisis – similar risk factors
Prematurity
SGA
Low birthweight
5. Barthold 2008
SGA/Prematurity in gastroschisis 40%

6. Two approaches, limited analyses
Primary pexy
One-stage orchiopexy
Testicular anchoring in prepubic area
Berger & Hager (2006), Urology.
“Wait and watch”
Reduction of gastroschisis without manipulation of intraabdominal testes
Placement of extraabdominal testes within abdomen
Hill & Durham (2011), J Pediatric Surgery.
Yardley, et al. (2012), J Pediatric Surgery.
Both gauderer and berger’s studies covered very few

7. Males with gastroschisis: 26
Retrospective
Assess outcomes of different treatment modalities in newborns with UDT, large AWD or diaphragmatic defects
Males with gastroschisis: 26
UDT 27%
Intraabdominal testes: 3
Extraabdominal: 4
In Berger and Hager’s 2006 Study, a retrospective study out of Austria, the authors aim to assess outcomes of different treatment modalities in newborns with UDT and large AWD or diaphragmatic defects.
112 Neonates with large AWD, diaphragmatic hernias

8. Results. Berger & Hager, 2006 Testicle position Intervention Outcome
Intraabdominal (3)
Primary gastroschisis closure,
1 silon pouch
No pexy (unrecognized cryptorchidism in 2)
Atrophy on retroperitoneal exploration  orchiectomy
Extraabdominal (1)
Relocated to inguinal ring (planned second procedure)
Spontaneous descent, normal size
Extrabdominal (2)
1-stage closure and orchidopexy
Normal size, position
Extraabdominal (1) testis adherent to colon, mec ileus, malrotation
Orchiectomy (short testicular vessels, emergent closure)
Death from pneumonia, unrelated to gastroschisis
Atrophy of non-treated intraabdominal testes in 3 gastroschisis patients at retroperitoneal exploration  orchiectomy
Failure of spontaneous descent in 2 gastroschisis patients with intraabdominal testes  atrophy, orchiectomy
Extraabdominal testis relocation to inguinal ring (had planned 2nd procedure)  spontaneous descent, normal size
Extraabdominal testes in 2 patients, 1-stage closure and pexy  normal position, size

9. Results. Berger & Hager, 2006 Conclusions.
Only patients undergoing primary orchidopexy had scrotal testes of normal size at last follow-up
Conclusions.
Orchidopexy with primary closure ideal
Prepubic testicular anchoring better than leaving testis ectopic if one-stage orchiopexy not possible
Testicular anchoring on prepubic area better than leaving testis ectopic if one-stage orchiopexy not possible

10. Retrospective study, 11 years Males with gastroschisis: 63
UDT: 24 (39%)
Mean gestational age, birth weight controlled
Extraabdominal testes into abdominal cavity; intraabdominal not manipulated
Longterm management techniques, outcomes for males with gastroschisis, UDT
Need for surgical intervention
Testicle location, size at follow-up
Surgical approaches
Methods: All neonates with AWDs who presented to Emory tertiary care facility over 10 years identified, for males with gastroschisis, testicle location recorded. Intraabdominal and extraabdominal positioning noted if UDT.
No attempt at positioning into scrotum made at time of gastroschisis closure. Extraabd testes positioned into abd cavity during closure.
169 babies admitted with AWD
80 male
63 gastroschisis
24 UDT (uni/bilat) 38.7%
Mean gestational age 36.3 weeks (SD=1.9), birth weight 2.65kg (SD=0.52) – did not vary between UDT, those with normal testicular descent at birth
16 unilateral, 8 bilateral
4 extraabdominal testes

11. Operative approach. Hill & Durham, 2011
Laparoscopic- assisted orchidopexy
Pneumoperitoneum via umbilical port, Veress needle through hemiscrotum with 10mm step port passageway
Lap assisted orchidopexy. Step port in posisition with testes and cord structures entering port
Final result of orchidopexy with oriented vas and vessels passing through neointernal ring
Pneumoperitoneum via umbilical port and Veress needle through hemiscrotum, with 10mm step port acting as passageway through which testis is gently positioned down into scrotum through neointernal ring. [Photos]

12. Results 31 testes (23 children) were included in the final analysis.
Mean f/u time was 27.3 mos.
Fig. 3 Summary of management and outcomes for male patients treated with gastroschisis and UDT. IAE indicates intraabdominal ectopic testicle at birth; EAE, extraabdominal ectopic testicle at birth.

13. Results
55%
At follow-up, 54.8% testes relocated into scrotum without intervention (n=17)
Fig. 3 Summary of management and outcomes for male patients treated with gastroschisis and UDT. IAE indicates intraabdominal ectopic testicle at birth; EAE, extraabdominal ectopic testicle at birth.

14. Results *
38.7% required orchidopexy (n=12), mean age 16.5 months
The majority underwent surgery after being given mos for testicle to descend without intervention
39%, mean age 16.5 mos
Fig. 3 Summary of management and outcomes for male patients treated with gastroschisis and UDT. IAE indicates intraabdominal ectopic testicle at birth; EAE, extraabdominal ectopic testicle at birth.

15. Hill & Durham, 2011 3-month-old requiring orchidopexy
Of interest, the youngest to undergo orchidopexy was a three month old in the extraabdominal group who was noted to have a very large hernia atfollow-up. This was ultimately discovered to be migration of the undescended testis into the contralateral hemiscrotum, having traveled through an inguinal hernia.

16. Results 6%
2 patients required orchiectomy for atrophy at the time of laparoscopic evaluation.
Fig. 3 Summary of management and outcomes for male patients treated with gastroschisis and UDT. IAE indicates intraabdominal ectopic testicle at birth; EAE, extraabdominal ectopic testicle at birth.

17. Findings. Hill & Durham, 2011
Migrated to appropriate position, no intervention: >50%
Migrated to inguinal canal, no laparoscopy: 43%
Laparoscopy successful – no conversion to open
Orchidopexy successful (n=12)
Orchiectomy for atrophy in 1 patient*
Size mismatch but + growth in 3
Extraabdominal testes less likely to spontaneously migrate into scrotum
Greater incidence of atrophy, need for orchiectomy
Median follow-up time was 27 months.
The most notable finding from Hill and Durham’s paper was that >50% of the undescended testes migrated without intervention to their proper scrotal position. Of those that did not, 43% were able to make it down to the inguinal canal, eliminating the need for laparoscopy or laparotomy.
For those who continued to have nonpalpable testes, laparoscopy was a successful option for localizing, removing and repositioning testes without needing to convert to open.
Only one infant required orchiectomy for atrophy, though this patient was lost to follow-up for stage 2 of a Fowler stephens orchidopexy.
There was a size mismatch but evident growth in three of the pexed testes.
Extraabdominal testes were less likely to spontaneously migrate into scrotum compared with intraabdominal at birth.
Greater incidence of atrophy, need for orchiectomy

18. Conclusions. Hill & Durham, 2011
Watch and wait for gastroschisis and UDT appropriate, especially in intraabdominal testes
More than half will descend during first year without intervention
babies who do not have gastroschisis – spontaneous descent in first year of life almost 70%.

19. Males with gastroschisis: 79
Management techniques, outcomes for males with gastroschisis, omphalocele and UDT
Males with gastroschisis: 79
UDT: 26 (33%)
Need for surgical intervention
Testicle location, size at follow-up
Surgical approaches

20. Nonoperative progress of UDTs. Yardley, et al.
Gastroschisis
Omphalocele

21. Nonoperative progress of UDTs. Yardley, et al.
Gastroschisis
Omphalocele
Primary closure in 20, silo then staged closure in 6.
Like in the prior study, No primary orchidopexy at time of gastroschisis reduction.
Testes were left undisturbed where they presented, except for those that were “prolapsed” or extraabdominal.
In the omphalocele group, 5 underwent primary closure, 1 had giant omphalocele treated with topical therapy, sac epithelialization.
Again, no manipulation of testes unless extraabdominal.
41% descended spontaneously
9% descended spontaneously

22. Side matters. Yardley, et al.
Right UDTs – 10/17 (59%) descend spontaneously
All right-sided in gastroschisis descend
Left UDTs – 9/29 (31%) descend spontaneously

23. Conclusions. Yardley, et al.
Association exists between AWD, UDT
Findings of increased UDT in newborns with AWD not affected by prematurity, gestational age, birth weight
Gastroschisis: nonoperative approach often leads to spontaneous descent
Omphalocele: anticipate orchidopexy
Gastroschisis median age at orchidopexy:
24 months (7-74mos)
Omphalocele median age orchidopexy:
17.5 months (2-61mos)
Median follow-up: 40 months
Gastro 41%, Omphalocele 9%

24. Limitations Selection bias – most studies retrospective
Surgical technique not randomized/controlled
Number of patients small
Extraabdominal UDT rare

25. Two approaches, limited analyses
Primary pexy
Wait and watch
Limits additional procedures
Difficult laparoscopy after gastroschisis closure [8]
Adhesions
Malrotation
Avoids testicular loss
Staged procedure better than none
Spontaneous descent of testes
Delay in relocation advantageous
Fragile blood supply
Other health challenges in early neonatal period
Both gauderer and berger’s studies N smaller
Watch and wait
Delays in testicle relocation may be advantageous wrt long-term outcome. Chowdhary, Lander, Buick et al. 2001
Vascular supply is fragile early – excessive manipulation may compromise blood flow
Gastroschisis babies premature with other health challenges in early neonatal period - low acuity of UDT

26. Conclusions UDT  in neonates with AWD
Not attributable to prematurity, weight alone
Repair before 12 months
Location
Spontaneous descent?
Intraabdominal
More likely
Extraabdominal
Less likely – watch and wait?
Korkorowski, Routh, Graham, & Nelson, 2010
Orchiopexy is recommended in the United States by the age of one year (Korkorowski, Routh, Graham, & Nelson, 2010) if the UDT does not spontaneously descend before 6-12 months of life, with hopes of preserving spermatogonia and minimizing damage to seminiferous tubules.
The European Association of Urology recommends that orchidopexy be performed at the latest by months of age (Tekgül et al., 2011).

27. References
Scorer, C.G., and Farrington, G.H. Congenital deformities of the testis and epididymis. New York: Appleton-Century-Crofts
Levard G, and Laberge J.M. The fate of undescended testes in patients with gastroschisis. Eur J. Pediatr Surg 1997;7:
Gauderer MW. Gastroschisis and extraabdominal ectopic testis: simultaneous repair. J Pedatr Surg 1987;22: (photo)
Berkowitz, G.S., Lapinski, R.H., Dolgin, S.E., Gazella, J.G., Bodian, C.A., & Holzman, I.R. Prevalence and natural history of cryptorchidism. Pediatrics 1993;92(1):44-9.
Hill S.J., and Durham, M.M. Management of cryptorchidism and gastroschisis. J Pediatr Surg 2011;46(9):
Yardley, I.E., et al. Congenital abdominal wall defects and testicular maldescent—a 10-year single-center experience. J Pediatr Surg 2012;47:
Barthold, J.S. Undescended testes: current theories of etiology. Current Opinions in Urology 2008;18:395–40.
Berger, A.P. and Hager, J. Management of neonates with large abdominal wall defects and undescended testis. Urology 2006;68(1):175-9.

28. Thank you!