summary of UDT and its management from recent articles and books

1. Recent trends in Management of
Undescended Testes
Dr Awaneesh Katiyar
Institute of Medical Sciences, BHU ,Varanasi

2. Introduction
• Definition:- Failure of the testis to descend into
the scrotum.
• Most common genital disorder identified at birth.
• Premature infants- 33%
• Full term at birth- 2-4%
• At age 1 year- 1%

3. • Unilateral : Bilateral
68% : 32%
• Right : Left
70% : 30%
• Palpable : Nonpalpable Testes
80% : 20%
Left undescended
testis

4. Development of testis
• Early life of
embryo
• Germ cells-
Primordial germ
cells

5. • Coelomic
epithelium
• Medial side of
mesonephros
• Gonadal ridge-
migration of primordial cells(4-6wks)

6. • 7th week – testicular differentiation
• 8th week testis hormonally active
– Sertoli Cell : MIS
– Leydig cell : Testosterone
• 10-15th week external genital differentiation

7. Descent of Testis
• The gubernaculum, the guide for testicular
descent.
• Hormone testosterone and INSL3 peak
between 14 and 17 weeks’ - critical for
testicular descent.

8. Phases of testicular descent
Barteczko and Jacob (2000)
• Phase 1: 5 weeks - The caudal mesonephros contacts
the future gubernaculum at the internal inguinal ring.
• Phase 2: 7 weeks -The genitofemoral nerve
accompanies the newly formed gubernaculum and
processus vaginalis.
• Phase 2a: 8 to 10 weeks - Growth of the gubernaculum.
• Phase 3: 10 to 12 weeks - Gubernaculum remains a
thin cord in both sexes.

9. • Phase 3a: 12 to 14 weeks - The testis overrides the
genital ducts and contacts the gubernaculum.
• Phase 4: 14 to 20 weeks - Migration of the processus
vaginalis produce widening of the inguinal canal
• Phase 5: 20 to 28 weeks - Release of the distal
subcutaneous attachment of the gubernaculum and
transinguinal passage of the testis.
• Phase 5a : after 7th month – Caudal movement of the
testis, regression of the gubernaculum .

10. Factor affecting testicular descent
Mechanical Hormonal
• Gubernaculum
• Cranio-gonadal ligament
• Intra-abdominal pressure
• Inguinal Bursa
• Processus Vaginalis
• Androgen & its receptor
• INSL3 & Its receptor
• Estrogens
• Anti-Mullerian–Inhibiting
Substance
• Calcitonin Gene Related
Peptide
• Epidermal Growth Factor

11. Mechanical Factors
• Gubernaculum – John Hunter(1762) coined term
Gubernaculum.
• Important-
Mechanical Factor
• Mesenchymal band
Lower pole of testis to scrotum

12. • INSL3 Mediates
- Outgrowth phase
• Androgen Mediates
- Regression phase

13. Hormonal Factors
Androgen and its receptor
• Engle (1931) – Intact hypothalmic-pituitary-
testis axis is essential for normal testicular
descent.
• Cryptorchidism associated with
– Hypogonadism
– Androgen insensitivity
– CAIS

14. Estrogens
• Estrogens – Impairs gubernacular development
and to cause persistence of müllerian duct
derivatives.
• Gill and associates – increased incidence of
cryptorchidism in male offspring of women
treated during pregnancy with DES.
• Bernstein and colleagues- male infants born to
mothers with high levels of free estradiol- had
higher frequency of cryptorchidism

15. Testicular ascent
• In past – considered as misdiagnosis caused by an
error in physical examination.
• 32%- 50% - in retractile testis.
• Typically unilateral (77%)
• Identified at mid-childhood.
• Located distal to the inguinal canal.

16. Lockwood theory of Ectopic testis
• Multiple gubernaculum / tails present to
anchor testis from base.
• When scrotal tail gets
ruptured or weakened
at any point,
• Accessory tails act
and pull Ectopic testis

17. Positions of the ectopic testis. The ectopic testis can be identified in various positions, as
shown. The most common location is the superficial inguinal pouch.
Contralateral
scrotum
Perirenal
Peripenile
Superficial
inguinal
Transverse
scrotal
Femoral
Perineal

18. Risk Factors for UDT
• Maternal & Gestational Factors
– Maternal Obesity
– Low birth weight
– Prematurity
(Hakonsen et al, 2014).
Maternal smoking- small-to-moderate increased risk
for cryptorchidism is present in offspring.

19. Genetic Factors
• 14% of cryptorchid boys – have positive
family history.
• Multifactorial pattern transmission
• Father affected – 4%
• Sibiling affected – 6-10 %
• Gene mutation have identified -cryptorchidism
– INSL3
– LGR8
– Androgen receptor polymorphism
– HOXA10
– HOXD13

20. Environmental
• Prenatal exposure - endocrine disrupters
– DES
– Pesticide (DDT)
– Nonylphenol
– Natural phytoestrogens
– Phthalates etc.

21. Syndromes Associated with UDT
• Reduce androgen production and/or action,
such as androgen biosynthetic defects,
• Androgen insensitivity
• Leydig cell agenesis,
• Gonadotropin deficiency disorders.
• Klinefelter syndrome (47,XXY)( 1.8%),
• Down syndrome (trisomy 21),

22. • All cases of classic prune-belly
• 80% of those of spigelian hernia
• 41% - 54% of cerebral palsy
• 15% of myelomeningocele
• 16% - 33% of omphalocele,
• 5% - 15% of gastroschisis
• 19% of imperforate anus
• 12% - 16% of posterior urethral valve
• 6% of umbilical hernia

23. Complications of Undescended Testis
Undescended testis
Torsion
Reduced
fertility
Trauma
Testicular
tumor Epididymo
-orchitis
Inguinal
Hernia

24. Reduced fertility
• Decreased fertility – well known consequence
of cryptorchidism.
• 10-13% boys with – Unilateral UDT
• 33-36% boys with – Bilateral UDT
• Retractile testis – Intrinsically normal.

25. Investigations
• Undescended testis - clinical diagnosis.
• Clinically palpable testis – no role of imaging
• Non palpable testis
– Imaging
– Hormonal assessment
– Laparoscopy

26. Imaging Methods
Ultrasonography
• Most commonly used study
• A meta-analysis of 12 studies
low sensitivity (45 %)
and specificity (78 %).

27. • Other imaging tool like CT scan or MRI is not
recommended.
• Hazard of ionizing radiation- CT scan.
• MRI – overall sensitivity for detection -62%
– 55% - totally intra-abominal
– 86% - for inguinoscotal
• MRI – poor test for atrophied testis

28. Diagnostic Laparoscopy
• Gold Standard for non-palpable testis.
• Possible anatomic finding
– The spermatic vessels enters the inguinal canal
(40%).
– A canalicular or peeping testis (11.2%).
– The Spermatic vessels end blindly (9.8%).
– A Viable intra-abdominal testis (37%).

29. Management of undescended testis
• Cryptorchid testis should be treated – between 6
month to 1 year of age.
• 12-18 months – histological deterioration of the
testis noted.
• Testis rarely descends – after 6 months.
• Surgical advantage to Orchiopexy- within 6
months specially in high undescended testis.

30. Undesceded testis
unilateral
palpable Non palpable
surgery
Refer to 6 months
Low testis
Hormone
therapy
Failure
surgery
Normal external
Genitalia
Hypospadias
or ambigous
genitalia
Diagnostic therapeutic
laparoscopy or open surgery
Pre-op hormone therapy
Hormone
therapy
failure
High
testis Not Intersex
Refer to 6 months
Newborn
Older child

31. Bilateral
Palpable Palpable
Intersexual
Management
by diagnosis
Refer to 6
months
Hormone
therapy
for low
testis
Failure
surgery
surgery Measure LH, FSH,
MIS, hCG
stimulation test
Positive Negative
Laparoscopy or
open surgery
Probable
agonadal
consider
surgery
NonpalpableNonpalpable
Undesceded testis

32. Non-surgical
Only used for
palpable or
unilateral UDT
Surgical
Hormonal therapy
Palpable Nonpalpable
Inguinal / scrotal orchidopexy
evaluate
High inguinal Intra-
abdominal
Laparoscopic
surgery/ open
Management

33. Hormonal therapy
hCG (human Chorionic Gonadotropin)
• Stimulate endogenous secretion of testosterone.
• Therapeutic dose – 1500 U/ m2 body surface area
twice in a week for 4 weeks (FDA approved).
• Total dose should not exceed 15,000 units.
• Testicualar descent rate
– 25% with hCG
– 18 % with GnRH

34. • LHRH- 1.2 mg/ day in divided doses intranasal
for 4 weeks .
• Testicular descent rate –about 20%.
• Not FDA approved
• Boserelin – superanalogue of LHRH
– Small dose- 10µg every other day for 6 months.
– Descent rate – 17%

35. Hormonal assessment for
bilateral Non -palpable testes
Cryptorchidism Anorchidism Female
Pseudohermaphroditism
Karyotype 46,XY 46,XY 46,XX
Serum testosterone
Baseline Normal Low Variable
hCG stimulation test Positive Negative Negative
Gonadotropins Normal incresed Normal
AMH/MIS Positive Negative Negative
Adrenal steroid
precursors
Normal Normal increased

36. Surgical Management
• Palpable testes
• one stage orchidopexy
• Non- palpable testes
• Laparoscopy / open
• High incidence of congenital inguinal hernia (hernia
repair)
• Retractile or ectopic testes
• Cremasterotomy

37. Principles of orchidopexy
(described by Bevan in 1899)
• Adequate exposure
• Herniotomy
• Mobilization of cord
• Fixation of testis

38. Inguinal Orchidopexy
• Most commonaly performed – creation of
subdartos pouch and placing the testis.
• General anesthesia; useful to re-examine the
child- previously nonpalpable testis may become
palpable.
• Groin crease incision is made Careful dissection
to expose the external oblique aponeurosis and
the external ring.

39. (Adapted from Hinman F, Baskin LS. [2009]
Hinman’s atlas of pediatric
urologic surgery. Philadelphia: Elsevier.)

41. • The gubernaculum is divided

42. • A high ligation of the hernia sac is performed, and
the remaining structures are skeletonised

43. • Stephen-Fowler’s technique-
– when cord length is still required
– soft clamp is applied to the testicular artery
– viability of testis is checked.
– If it is viable testis can bring down safely to the
scrotum.

44. Obsolete procedure
• Ombredanne’s operation- when testis is
passed into the opposite scrotum through an
opening on the scrotal septum.
• Ladd and gross procedure - after placing the
testis in the scrotal pouch, it is fixed by a
polypropylene suture into tunica albuginea,
across scrotal skin and into the thigh skin
outside.

45. • Keetley – Torrek procedure - testis is
mobilized and is brought into the scrotal pouch
first. A pouch is created on the medial aspect
of thigh outer to the fascia lata. Testis is
delivered from scrotal pouch is placed into the
thigh pouch.

46. Trans-scrotal Orchidopexy
• Testes that are low in the canal believed to be
ectopic are good candidates
for trans-scrotal approach.
• Incisions
– Superior scrotal
– Low scrotal
– Midline scrotal

47. Surgery for the Non palpable Testis
• Examination under anaesthesia- remains non-
palpable.
• Laparoscopy - Gold standard
Conclusion: Results of open versus laparoscopic orchiopexy procedures (primary or
staged) are fairly comparable. However, laparoscopy provides significantly less
morbidity.

48. • Contraindications to laparoscopy –
– Prior abdominal surgery with potential peritoneal
adhesions.
– A body habitus that will not allow for proper
placement of abdominal wall ports.

49. • Laparoscopy - best means of identifying intra-
abdominal testis, vas and vessels.
• If laparoscopy indicates blind-ending gonadal
vessels and vas deferens, the patient is said to
have vanishing testis syndrome and no further
action is necessary

50. High left testis
Closed
internal ring
Blind-ending
vessels
Vas deferens
High intra-abdominal testis identified on
laparoscopic evaluation. Left testis identified
high in the abdomen is associated with a closed
internal ring.
Vanishing testis noted on laparoscopic
evaluation. Note the blind-ending spermatic
vessels and vas deferens.

51. • If intra-abdominal testis identified consider
staged orchidopexy or microvascular transfer.
• If vas vessels seen entering inguinal canal, the
groin should be explored.
• The length of the gonadal vessels is the
limiting factor to getting the intra-abdominal
testis into the scrotum.

52. Conclusion-
• Vasa and vessels blind ending above the IR as the only finding that
would benefit from laparoscopy only.
• If testis is not visualised and vessels are going into IR , surgical
exloration is mandatory to avoid clinical as well as legal long term
follow up.

53. Laparoscopic procedures
1. Primary one-stage orchiopexy with preservation
of the spermatic vessels
2.Division of the spermatic vessels as the first stage
of a two-stage Fowler-Stephens orchiopexy
The second stage of a two-stage Fowler-Stephens
orchiopexy can also be performed laparoscopically.
3. Orchiectomy.

54. Laparoscopic orchidopexy
Trocar placement

55. • Mobilization of any
structures extending
distal to the internal
ring, including
epididymis/vas and
Gubernacular remnant
testis

56. • Transection of the peritoneum lateral to
the vessels and distal to vas.
• Proximal mobilization of the
vessels while maintaining
collateral blood supply between
the vas and spermatic vessels if
a Fowler-Stephens maneuver
becomes necessary ( short
spermatic cord)
(Adapted from Hinman F, Baskin LS. [2009] Hinman’s atlas of pediatric
urologic surgery. Philadelphia: Elsevier.)

57. • Initial mobilization of the gubernaculum to be used as a
handle for further mobilization of the testis, and
minimal use of cautery during this maneuver.
• Ability to mobilize the testis to the opposite internal
ring has been used as a measure of adequate length for
placement in the scrotum but is not predictable in some
series.
• Once mobilized, the testis is brought through a new
hiatus at the level of the medial umbilical ligament or
through the existing internal inguinal ring.

58. 1. Standard single stage orchidopexy
2. A two-stage Fowler-Stephens orchidopexy
The testicular artery is sacrificed.
• The rationale is that the testicular arterial supply comes
from three sources.
• At a 2nd stage (after 6 months of age, when collaterals
have formed), the testis is brought down on a wide
pedicle of peritoneum containing the remaining vessels.

59. Many recent studies supported that laparoscopic Orchidopexy
better than open for non palpable techniques.

60. Open procedures for
Non- palpable testis
• Abdominal approach
– Transperitonial approach
– Extraperitonial approach
• Inguinal approach
– Extended inguinal approach

61. Microvascular testicular
autotransplantation
• For high intra-abdominal testis
• Reserved for older children with internal
spermatic artery large enough to be
anastomosed to inferior epigastric artery.

62. Autotransplantaion of testes using microvascular technique
(silber and kelly )
principle: cutting of spermatic vessels and re-anastmosis to inf. Epigastric vs using
10/0 sutures under microscopy.

63. Refluo Testicular Autotransplantation
• Provides only venous drainage by
microvascular anastomosis of testicular veins
to inferior epigastric veins
• Based on discovery that failure in Fowler-
Stephens was due to testicular congestion

64. Orchidectomy : Usually reserved for
postpubertal men with a contralateral normally
positioned testis.

65. Postoperative Complications
• Haematoma
• Infection
• Unsatisfactory position (requiring revision),
• Ilioinguinal nerve injury
• Damage to the vas
• Testicular atrophy
• Torsion testis.

66. CONCLUSION
• The etiology of testicular maldescent remains
unknown.
• Knowledge of hormonal correlation with
undescended has improved.
• For palpable testis - Inguinal Orchidopexy
remains gold standard.

67. • Recent advancement in laparoscopic tool has
significantly changes management of UDT.
• Diagnostic Laparoscopy, replaces all imaging
modalities including Ultrasonography & MR.
• Open Orchidopexy to Laparoscopic
Orchidopexy for non palpable testis.