Undescended testis - A condition often ignored by parents

A 2y boy was brought to us with a complaint of absence of rt testis in the scrotum. On examination the rt testis was felt in rt groin. He was taken up for Rt Orchidopexy.

ULTRASOUND report

                

Ultrasound - Smaller rt testis in the inguinal canal

RT GROIN INCISION

Ultrasound - left testis in scrotum

rt testis being mobilised

SOME INFORMATION ON UNDESCENDED TESTIS

                   Normally both the testes are formed in the abdomen and gradually descend into their final position during foetal development. At 1 year of age, nearly 1% of all full-term male infants have cryptorchidism, which is the commonest congenital anomaly affecting the genitalia of newborn male infants . The most useful classification of cryptorchidism is into palpable and non-palpable testes, and clinical management is decided by the location and presence of the testes. 

• Retractile testes require only observation because they may become ascendant. Although they have completed their descent, a strong cremasteric reflex may cause their retention in the groin .
  
• Bilateral, non-palpable testes and any suggestion of sexual differentiation problems (e.g. hypospadias) require urgent, mandatory endocrinological and genetic evaluation.
  
  
  
  
  
  
  
  

  Diagnosis
  Physical examination is the only way of differentiating between palpable or non-palpable testes. There is no benefit in performing ultrasound, computed tomography (CT), magnetic resonance imaging (MRI) or angiography.
  Clinical examination includes a visual description of the scrotum and assessment of the child in both the supine and crossed-leg positions. The examiner should inhibit the cremasteric reflex with his/her non-dominant hand, immediately above the symphysis in the groin region, before touching or reaching for the scrotum. The groin region may be “milked” towards the scrotum in an attempt to move the testis into the scrotum. This manoeuvre also allows an inguinal testis to be differentiated from enlarged lymph nodes that could give the impression of an undescended testis. A retractile testis can generally be brought into the scrotum, where it will remain until a cremasteric reflex (touching the inner thigh skin) retracts it into the groin.
  A unilateral, non-palpable testis and an enlarged contralateral testis suggest testicular absence oratrophy, but this is not a specific finding and does not preclude surgical exploration. An inguinal, non-palpable testis requires specific visual inspection of the femoral, penile and perineal regions to exclude an ectopic testis. Diagnostic laparoscopy is the only examination that can reliably confirm or exclude an intra-abdominal, inguinal and absent/vanishing testis (non-palpable testis) . Before carrying out laparoscopic assessment, examination under general anaesthesia is recommended because some, originally non-palpable, testes become palpable under anaesthetic conditions.
  

  Treatment
  Treatment should be done as early as possible around 1 year of age, starting after 6 months and finishing preferably at 12 months of age, or 18 months at the latest. This timing is driven by the final adult results on spermatogenesis and hormone production, as well as the risk for tumours.
   Medical therapy
  Medical therapy using human chorionic gonadotrophin (hCG) or gonadotrophin-releasing hormone (GnRH) is based on the hormonal dependence of testicular descent, with maximum success rates of 20%. However, it must be taken into account that almost 20% of descended testes have the risk of reascending later.
  Hormonal therapy for testicular descent has lower success rates, the higher the undescended testis is located. A total dose of 6000-9000 U hCG is given in four doses over a period of 2-3 weeks, depending on weight and age, along with GnRH, given for 4 weeks as a nasal spray at a dose of 1.2 mg/day, divided into three doses per day.
  Medical treatment may be beneficial before surgical orchidolysis and orchidopexy (dosage as described earlier) or afterwards (low intermittent dosages), in terms of increasing the fertility index, which is a predictor for fertility in later life. Long-term follow-up data are still awaited. Nonetheless, it has been reported that hCG treatment may be harmful to future spermatogenesis through increased apoptosis of germ cells, including acute inflammatory changes in the testes and reduced testicular volume in adulthood. Therefore, the Nordic Consensus Statement on treatment of undescended testes does not recommend it on a routine basis because there is not sufficient evidence for a beneficial effect of hormonal treatment before or after surgery. However, this statement relied only on data from hormonal treatment using hCG.
  Surgery
  Palpable testis
  Surgery for a palpable testis includes orchidofuniculolysis and orchidopexy, via an inguinal approach, with success rates of up to 92% . It is important to remove and dissect all cremasteric fibres to prevent secondary retraction. Associated problems, such as an open processus vaginalis, must be carefully dissected and closed. It is recommended that the testis is placed in a subdartos pouch. With regard to sutures, there should be no fixation sutures or they should be made between the tunica vaginalis and the dartos musculature. The lymph drainage of a testis that has undergone surgery for orchidopexy has been changed from iliac drainage to iliac and inguinal drainage (important in the event of later malignancy). Scrotal orchidopexy can also be an option in less-severe cases and when performed by surgeons with experience using that approach.
  Non-palpable testis
  Inguinal surgical exploration with possible laparoscopy should be attempted for non-palpable testes. There is a significant chance of finding the testis via an inguinal incision. In rare cases, it is necessary to search into the abdomen if there are no vessels or vas deferens in the groin. Laparoscopy is the best way of examining the abdomen for a testis. In addition, either removal or orchidolysis and orchidopexy can be performed via laparoscopic access .
  For boys aged > 10 years with an intra-abdominal testis, with a normal contralateral testis, removal is an option because of the theoretical risk of later malignancy. In bilateral intra-abdominal testes, or in boys younger than 10 years, a one-stage or two-stage Fowler-Stephens procedure can be performed. In the event of a two-stage procedure, the spermatic vessels are laparoscopically clipped or coagulated proximal to the testis to allow development of collateral vasculature . The second-stage procedure, in which the testis is brought directly over the symphysis and next to the bladder into the scrotum, can also be performed by laparoscopy 6 months later. The testicular survival rate in the one-stage procedure varies between 50 and 60%, with success rates increasing up to 90% for the two-stage procedure. Microvascular autotransplantation can also be performed with a 90% testicular survival rate. However, the procedure requires skilled and experienced surgeons.
  Prognosis

  Although boys with one undescended testis have a lower fertility rate, they have the same paternity rate asthose with bilateral descended testes. Boys with bilateral undescended testes have lower fertility and paternity rates.
  

  Boys with an undescended testis have an increased risk of developing testicular malignancy. Screening both during and after puberty is therefore recommended for these boys. A Swedish study, with a cohort of almost 17,000 men who were treated surgically for undescended testis and followed for ~210,000 person-years, showed that treatment for undescended testis before puberty decreased the risk of testicular cancer. The relative risk of testicular cancer among those who underwent orchidopexy before 13 years of age was 2.23 when compared with the Swedish general population; this increased to 5.40 for those treated at > 13 years . A systematic review and meta-analysis of the literature have also concluded that prepubertal orchidopexy may decrease the risk of testicular cancer and that early surgical intervention is indicated in children with cryptorchidism .

  Boys with retractile testes do not need medical or surgical treatment, but require close follow-up until puberty.