Updated guidelines on the management undescended testis
;
Incidence/ Etiology.
Genes and syndromes.
Retractile Testis.
Laboratory.
Role of imaging.
Hormonal treatment.
Surgery .
Complications.
7. ETIO-PATHOGENESIS
Birth weight is the principal determining
factor, at birth to age one year,
independent of the length of gestation.
8. Genetic syndromes associated with cryptorchidism
• Prune-belly syndrome (100% of patients)
• Noonan syndrome (50% of patients)
• Klinefelter syndrome (27% of patients)
• FG syndrome (24% of patients)
• Down syndrome (6.5% of patients)
• Other syndromes that carry increased risk for disease
include Beckwith-Wiedemann syndrome, Smith-Lemli-
Opitz syndrome, de Lange syndrome, and Prader-Willi
syndrome
9. Syndromic Cryptorchidism
mostly bilat.
reduced androgen production
androgen insensitivity, Leydig cell agenesis, and
gonadotropin deficiency disorders, AMH biosynthesis
or receptor defects.
Diminished intra abd. P.
Prune belly, gastroschisis, omphalocele.
10. Environmental RiskFactors
Exposure to antiandrogenic and/or endocrine-
disrupting chemicals(EDCs) may contribute to
cryptorchidism.
EDCs include phthalates, pesticides, brominated
flame retardants, diethylstilbestrol, and dioxins.
15. Difference between ascending and UDT
• No effect on fertility .
• No predisposition to malignancy
• Responds better to hormonal .
• Scrotal approach.
27. • MRA/MRV 100%
• Expensive
• Needs anesthesia.
• No benefit over Lap.
28. Hormonal treatment for descent
• A meta-analysis of hCG treatment of
cryptorchidism concluded that hCG treatment is no
more effective than placebo. [52]
• American Urological Association guidelines
recommend against the use of hormonal therapy to
induce testicular descent, due to low response rates
and lack of evidence for long-term efficacy. [1]
30. Hormonal treatment for fertility
• European guidelines note that suggest offering
endocrine treatment for bilateral undescended testes,
to possibly improve further fertility potential. [58]
• hadziselimovic et al (1997) suggested that such patients may
benefit from adjuvant hormonal therapy with resultant increased
numbers of germ cells later in life.
• Bilateral.
• low fertility index on biopsy
31. Palpable UDT ; Timing for surgery !
• Definitive surgical therapy should
be performed between ages 6 and
12 months.
34. Our findings confirm that division without
ligation of a patent processus vaginalis is usually
followed by spontaneous peritoneal scarring and
complete closure of the internal inguinal ring.
37. Success vs location
• In a 1995 meta-analysis of orchiopexy by Docimo,
location-based success rates were as follows [60] :
• beyond external ring: 92%
• Canalicular testes: 87%
• Peeping testes: 82%
• Abdominal testes: 74%
38.
39. Conclusions
• In this series, the incidence of post-operative
testicular atrophy
• 5% in the common (low) type
• 9% in the high type.
These numbers and the above risk factors should be
quoted to the caregiver during pre-operative informed
consent
47. Postpubertal presentation
• treatment recommendations for postpubertal men
• Men younger than 32 years with a unilateral
undescended testis and normal contralateral testis
should undergo orchiectomy.
• Men older than 32 years with a unilateral
undescended testis should receive close observation
and physical examination
48. Abd testis with persistent Mullerian remnant
Mullerian
remnant
49.
50. •
• Conclusion: The goal of the approach in PMDS
patients is to preserve testes, as well as carry them to
their natural location.
• Leaving the MR in place is a suitable option for blood
circulation of the testes but the long-term results are
still unknown.
53. Malignancy
• General population : 4.2/100 000
• (RR) UDT X 2.7‒ 8 12‒ 33 / 100 000.
• Contralateral : slightly increased
• Orchiopexy before puberty reduce but
not eliminate the Relative risk from
5.4 to 2.2.
54. Guidelines
• Age at orchiopexy 6-12 months.
• Retractile testis ; yearly FU for
ascending testis.
• No imaging is required .
• Hormonal treatment is not
recommended to induce testicular
descent.
55. Guidelines
• Hormonal treatment may improve
fertility in some bilateral cases with
delayed germ cell maturation.
• Laparoscopy is the gold standard
for diagnosis and treatment of
impalpable testis.