UDT-UNDESCENDED TESTIS

Introduction:

Undescended testis is one of the common genital anomalies in the genital system of boys, and is high in the premature boys comparing to term new borns.
In the eigh week of intrauterine life, the testis arise in the abdomen cavity, and descend through inguinal canal to the scrotum in the third trimester.[1]
Around 20 % of undescended testis are not palpable[2]. Diagnosis and therapeutic challenges the surgeon and raise the potential of gonads to undergo malignant formation and finally to infertility[3,5]. It is so important to determine the presence or absence of testis,ultra sonography and computer tomography fail to show undescended testis mostly.Radiology images and open surgical exploration have provide to be not reliable in detecting undescended testis[4,3,2] and finally the laparoscopy has become to have the most important roll in both diagnostic and treatment of undescended testis[4,5].

Before laparoscopy was advented, surgical exploration was used often to show undescended testis but then with laparoscopic technique is used widely in both diagnosis and treatment of undescended testis[6].

Sign:
Testicles are the male reproductive organs that produce sperm and the male hormone, testosterone. One or two testicles will not be present in the scrotom during examinations and the testicles might or might not be on the abdominal cavity[2]. In most of boys, undescended testicle descends into the scrotum by itself only. When the testicle doesn't descend, then we recommend surgery after the first year of life
experience with undescended testes has showed that outpatient surgery is safe and effective, with excellent outcomes.
Symptoms:
Usually no symptoms is present other then inability to find the testicle in the scrotum but in adult infertility will be reported due to undescented testis[2,4].

Problems associated with undescended testis includes the following:

Infertility -
Inguinal hernia -
Tumor of testicular -
Cosmetic problems and psychological -
Injury of the undescended testis and torsion or twisting of the testis-






UNDESCENDED TESTIS,gubernaculum and peeping testis seen at entrance of internal ingunal ring

Undescended Testicle
What is an undescended testicle?
Undescended testis or "cryptorchisism" is one of the most common surgical disorders in childhood. Referred to at times, as "empty scrotum" this disorder occurs in 0.8% to 1.1% in male children.

What causes undescended testes?
During the 7th to 8th month of gestation (the location before birth) the testis descend into the scrotum during fetal development. The testes are located on each side of the fetal spine and are drawn downward through the back of the abdomen and pass through the abdominal wall and groin to take its normal position into the scrotum. In some children, particularly those that are born prematurely, this will not occur. In this case, the testicle may be located in a site either high up in the inguinal canal (groin) or in the abdomen.

When a testicle is not in the normal scrotal location several possibilities exist:


There may never have been a testicle (congenital absence/hypoplastic or absent testes)- this is present in 8% of children. The surgeon will need to perform an exploration to verify a true absence rather than a high undescended testis.
The testicle may have atrophied (withered away) before birth due to torsion (twist) or blockage of the testicular blood vessels.
The testicle may have not descended properly, but remains within the abdominal cavity or inguinal canal (see diagram).
In some children the testes may be found in the groin, but can be brought down into the scrotum during examination. These 'retractile' testicles also will be seen to descend when the child is in the bathtub or asleep/relaxed. Retractile testicles are due to overactive "cremasteric" muscles that temporarily pull the testicle into the groin. However, retractile testicles are not believed to injure the testicles and require no treatment.

Why should an undescended testicle be treated?
In humans, the scrotal location of the testicles keeps them cooler than the core body temperature. This lower temperature is important for the development of the testicle as well as for production of normal sperm. Studies have shown that there is an increased risk of infertility in men with a history of undescended testicles. Relocating the testicle into the scrotum may decrease the risk of fertility problems, particularly if done at an early age.

There are other advantages to a location within the scrotum. There is a cosmetic advantage. The scrotal testicle may be less amenable to injury than a testicle outside the scrotum. Finally, and perhaps as important as any other reason, a testicle that has not made it into the scrotum is not accessible to physical examination. Undescended testicles are at increased risk for cancer. Testicular cancer may not occur until after age 40 years. Testicular carcinoma is highly curable, when detected early, and the best way to do this is monthly self-examination, which can only be done if the testicles are within the scrotum.

The major indications for treatment by orchiopexy include:
The scrotal sac is the safest place for the testicle- if it is located above this site it may be prone for more injury.
Enhance fertility
Reduce the likelihood of "torsion" or twisting of the testicle- Testicular torsion is a great risk and twisting of the testicle can lead to decreased blood supply and is a surgical emergency.
An Undescended testicle is associated with a greater risk for testicular cancer
Undescended testicles have an associated hernia sac- and this will need to be corrected as well.
The repair of the undescended testicle will also provide a better cosmetic appearance.
Orchidopexy: How is the surgery done?
Surgery for undescended testicle is performed in an outpatient setting. Your child will have general anesthesia. When a testis is felt in the groin area we usually explore the area through a small incision first. Surgical correction is done by dissecting the spermatic artery and veins and the vas deferens to have adequate length to move the testicle to the correct spot into the scrotum. Most undescended testes are associated with a hernia that must be repaired.(please refer to the hernia handout for more information on this procedure) After this is done, the testis is brought down into the scrotum (secured as low as possible) and anchored in a space created in the scrotum (orchiopexy). This procedure is done with two surgical incisions one in the groin, and one into the scrotum.

See diagram of surgery below:


What to expect after the surgery
Your child will receive a complete set of instructions on wound care after the surgery. He will be uncomfortable for a few days after surgery, and will generally miss 2 to 4 days of school. He most likely should not participate in physical education or sports for at least 2 weeks after surgery. He will be given pain medication for discomfort, and will notice discomfort if he is too active. He will have sutures on his scrotum where the testicle has been brought down. These sutures should have a triple antibiotic ointment placed over the area at least 3 times a day. In general, these sutures will fall out, without the need for suture removal, in the first 7 to 10 days after surgery.

Why is it important to continue to follow up with a physician even after the testicle is placed in a correct position?
Even though the testicle is placed in an anatomically correct position, your child is at risk for two major problems. The first is an increased risk of testicular cancer. This risk involves both testicles even if only one was found to be involved. In general, most children will never develop a cancer, however, the risk is greater than the general population and your child will need follow up. Such cancers usually do not occur before the teenage years, but the risk continues throughout adulthood. Because of this, your child will need to see a physician on a yearly basis for a testicular exam. Additionally, as your child gets older, they should be taught how to perform a monthly testicular examination. This is the best way to detect any abnormal lumps or bumps in the testicle, and get medical treatment as soon as possible.

The second risk is that your child will have a decreased ability to father a child compared to the general population. Although he still has testicles, and he will go through puberty, the testicles may not function as well as normally descended ones. Although he still has a good chance of be able to father, this will be a subject which you will need to make sure he becomes aware of as he enters adulthood.

When should I call to speak with a nurse?
If your child has:

Fever > 100.5 degrees F
Increased tenderness at the surgical site
Increased swelling or redness around the incision
Any unusual drainage or odor from the incision
Unexplained increase in pain
Nausea, vomiting, diarrhea, or constipation which is not improving

Normal migration of the testis



Absent Testis
The testis forms inside the abdomen of the fetus and migrates into the scrotum before birth in 96% of males. It may stop migrating at any stage before it reaches the scrotum, in which case it is referred to as 'undescended'.

A testis should be in the scrotum by the age of 2 years so that it will produce sperm normally in later life. If the undescended testis can be felt in the groin, a small operation can be performed through the groin to fix it in the scrotum. If the testis cannot be felt, it either did not form at all or is still located somewhere in the abdomen. Such a testis has a 2-3% risk of becoming cancerous and needs to be removed.

Although an ultrasound or body scan could be performed to look for a missing testis it is not as accurate as surgery, which has an accuracy of 97% [6]. Laparoscopy minimises the size of the incision and discomfort and allows the patient to leave hospital and return to normal activities earlier. If a testis is present it can be removed laparoscopically