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CRYPTORCHIDISM

BACKGROUND

The incidence of maldescensus testis after the first year of life is 1.8-2%. A distinction is made between abdominal, inguinal or prescrotal testis retention and epifascial, femoral or penodorsal testis ectopy. Sliding and pendulous (retractile) testes are particular variations of cryptorchidism. Sliding testis with a too short spermatic cord relocates into its non-physiological position when pulled into the scrotum and then released. Pendulous (retractile) testis with hypertrophic cremaster muscle fibres is associated with an intermittent retraction of the usually orthotopic testis.

DIAGNOSIS

Maldescensus testis is diagnosed by clinical examination and sonography. Sonography and magnetic resonance imaging (MRI) may help in localizing the impalpable testis; the accuracy of the latter is 90% for intra-abdominal testis. Once abdominal retention is suspected, laparoscopy has been established as a diagnostic and therapeutic procedure. In this procedure, the testis can be localized in its abdominal position and placed scrotally using the technique appropriate to the anatomical conditions. A human chorionic gonadotrophin (HCG) stimulation test, as evidence of testosterone-producing testis tissue, should precede operative exploration for bilaterally impalpable testes.

TREATMENT

The objective of treatment is to achieve an orthotopic scrotal position of the testis, before the child's second birthday, in order to prevent irreversible damage of spermatogenesis in the affected testis. Hormone therapy (optional) is applied for testis retention only. It is ineffective for ectopy, but can be helpful for preparation of local tissue: HCG as an intramuscular injection (9000-30,000 III in different protocols) or luteinizing hormone releasing hormone (LHRH) as a nasal spray (400 ug, three times daily). Both methods are effective in about 20-30% of cases. Follow-up is important because the benefits may fail after a period of time.

Surgical orchidofuniculolysis and orchidopexy are first-line treatment options. Pendulous (retractile) testes are not indicated for surgical repair. Absolute indications for a primary surgical approach are testis retention after failed hormone therapy or after previous inguinal surgery, testis ectopy and all maldescended testes with associated pathology (hernia and/or open processus vaginalis). Inguinal access of the spermatic cord is gained after opening the inguinal canal. Associated pathological conditions (open processus vaginalis, inguinal hernia) are dealt with in the same session. After the spermatic chord and testis have been freed of con­nective tissue and cremaster fibres have been resected, the testis is relocated tension free by pexis in the scrotum. If no testis or spermatic funicle tissue can be found during exploration of the inguinal canal, opening of the peritoneum and intraperitoneal orchidofuniculolysis is performed. If the spermatic funicle is too short, the Fowler-Stephens technique (ligation and dissection of the spermatic vessels) can be applied. Pre-conditions are intact deferent duct and epididymis vessels; these are tested by a temporary clamping of the testicular artery. In rare cases, auto-transplantation by microsurgical anastomosis of the testis vessels with the epigastric vasculature can be considered.

Table 1: Management of cryptorchidism

CRYPTORCHIDISM

Physical examination sonography

Detectable

Unilateral undetectable

Bilateral undetectable

 

MRI (optional)

HCG stimulation

 

v Therapy

Laparoscopy

Intersex?

REFERENCES

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Diagnostic laparoscoy. Curr Opin Pediatr 1998; 10: 323-327