Trakia Journal of Sciences, No 4, pp 379-385, 2016 Copyright©2016 Trakia University Available online at: http://www.uni-sz.bg ISSN 1313-7050 (print) ISSN 1313-3551 (online) doi:10.15547/tjs.2016.04.013 Review SURGICAL TREATMENT OF CRYPTORHIDISM IN CHILDHOOD D. Dinkov, Kr. Kalinova*, K. Georgiev, B. Brahomov, E. Kyazimova, Y. Dimcheva Department of Pediatric Surgery, Medical Faculty, Trakia University, Stara Zagora, Bulgaria ABSTRACT Undescended testis (UDT) or cryptorchidism is the most common genital anomaly seen in boys and can be treated surgically by orchidopexy. Cryptorchidism is best diagnosed clinically, and treated by surgical orchiopexy at age 6-12 months, without a routine biopsy. Timing of orchidopexy must be optimized in order to improve long-term prognosis. Both primary care providers and parents should be educated regarding the advantages of early orchidopexy in UDT. Outcomes of orchiopexy include having a viable, palpable testis in the scrotum, fertility, as measured by paternity rates or semen analysis in adulthood and risk of testicular cancer. Multiple operative techniques have been described and are associated with various success rates. In the past decade, success of orchiopexy for inguinal testes has been >95%. For abdominal testes, success for orchiopexy has been >85-90% in most series with single stage orchiopexy or two stage Fowler-Stephens orchiopexy, both with open surgical or laparoscopic technique. Laparoscopy is the best way of diagnosing and managing intra-abdominal testes. However, having a palpable testis in the scrotum does not assure fertility, as there are iatrogenic factors that may adversely affect the outcome. The risk of testicular carcinoma is increased by a factor of 3.7 to 7.5 times. Key words: cryptorhidism, children, surgery Undescended testis is the commonest genital or undescended testis, is defined as failure of a malformation in boys. Although the testis to descend into a scrotal position, mechanism that regulates prenatal testicular because of the pathological process during descent is still partly obscure, there is embryonic organogenesis (Figure 1A). An persuasive evidence that endocrine, genetic, undescended testis can be located anywhere and environmental factors are involved (1). between the abdominal cavity and the entrance of the scrotum. The treatment of undescended testis should begin after six months and ideally are Different forms of undescended testis completed by the child’s first birthday (2). In Undescended testis can be categorized on the Germany, there is a general consensus about basis of physical examinations (modified from the need to raise awareness of the importance (1, 2): of timely management of undescended testis • Undescended testis. The testicle is (3). Treatment comprises hormonal and/or located intra-abdominally or in the inguinal surgical approaches. Men with untreated canal. It is located in the normal descent bilateral cryptorchidism suffer from impaired pathway and shows normal insertion of the fertility (2). Early treatment can potentially gubernaculum. minimize the risk of infertility, although • Cryptorchidism from the ancient treatment before the age of 13 doesn’t appear Greek "kryptos" (hidden) and "orchis" to lessen the risk of malignancy (4). Scrotal (testicle). The testicle is not palpable and is positioning, however, allows easier located intra-abdominally (retentio testis examination of the testicle—usually by self- abdominalis) or is not present (anorchia). examination—which favors early detection of • Ektopia testis. The testicle is located malignancy (5). The current S2 guidelines beneath the skin superfascially, perineally, on describe in detail a diligent follow up for up to the thigh or shaft of the penis. The testicle one year postoperatively (2) Cryptorchidism, shows abnormal insertion of the ___________________________________ gubernaculum. *Correspondence to: Krasimira Kalinova MD, • Inguinal testicle . The testicle is PhD, Stara Zagora 6003 Bulgaria Trakia palpable in the groin (retentio testis inguinalis). University, Medical faculty, Department of Pediatric surgery, [email protected] • Gliding testicle. The testicle is located at the scrotal entrance or above the scrotum. It Trakia Journal of Sciences, Vol. 14, № 4, 2016 379 DINKOV D., et al. can be drawn down into the scrotum, but located in different levels of canalis immediately slides back into its initial position. inguinalis. (Figures 1A, B, C) (3) • Retractile (hypermobile) testes. The extra-canalicular - superficial inguinal physiological retractile (hypermobile) testicle pouch. is usually present in the scrotum or can be Suprapubic. effortlessly pushed down into the scrotum; it ectopic - the testis get pass from the retracts on induction of the cremasteric reflex external inguinal ring, but it is located in but returns spontaneously into the scrotum. unusual place – outside of the scrotum. Recognizing the retractile (hypermobile) testicle is particularly important because it Non-palpable testes can be: does not require treatment. (5, 6, 7) intra-abdominal - Retentio testis abdominalis – the testis is located We can mark off mainly palpable and non- retroperitoneal before or on the internal palpable testis. To describe the position of the inguinal ring; palpable testis: absent; “peeping” - sliding in and out of the internal Atrophic (that one suffers significant inguinal ring. volume loss after prior inguinal or testicular Canalicular - Retentio testis inguinalis – surgery or due to prolonged location in an uncompleted descend of a testis, which is extrascrotal position or primary developmental failure), (2-4). Figure 1A. Pathological process during embryonic organogenesis (3) Figure 1B. Different levels of retention testis (3). 380 Trakia Journal of Sciences, Vol. 14, № 4, 2016 DINKOV D., et al. Figure 1C. Retentio testis inguinalis – uncompleted descend of a testis (3). Epidemiology bilateral and are caused by an overactive In the neonatal period occurs in 2-4% of cremasteric reflex, which pulls the testis out of reserved for term infants and 33% of the scrotum towards the inguinal canal premature babies, but after 1 year of age only especially when the child is cold. This is a 1% of them have undescended testicles. normal condition.(2) Etiology and pathogenesis In case of bilateral cryptorchidism level of After the 5-th month (Figure 1C) (3) testicle testosterone and gonadotropine are decreased. begins to descend to the inguinal canal and Upon closer examination bimanualno testicle passes through it with the processus vaginalis rolling palpable in the inguinal canal, but peritonei to 7 months. To the 9th month cannot be pushed into the scrotum. The testis is descent has already been completed, but in hypoplastic, with soft consistency. The premature may be completed by the first year external inguinal opening is very narrow or of birth. Destsendus is under the control of obliterans. Abdominal Located testicle maternal gonadotropins violation in this diagnosed with Doppler ultrasonography or balance leads to pathology. In etiopathogenesis scintigraphy. More accurate diagnosis is the allowed and influence factors by the fetus, laparoscopic examination. Hormonal studies in congenital anatomical abnormalities bilateral criptohidismus show decreases in gubernaculum, prematurity or fetal hipotrofics. testosterone and serum gonadotropin. Detained in the inguinal canal is hypoplastic Ultrasound is the most heavily used imaging testicle (Figure 4) and abdominal undeveloped modality to evaluate undescended testes. and atrophic, is impaired and the seminiferous Ultrasound has variable ability to detect its hormonal function. If left in an atypical palpable testes and has an estimated sensitivity position in an area with a higher body and specificity of 45% and 78%, respectively, temperature (in the abdominal cavity body to accurately localize nonpalpable testes. temperature is 2 "C higher than that in the Given the poor ability to localize nonpalpable scrotum), there is a danger of deepening the testes, ultrasound has no role in the routine atrophy and degeneration of malignant, evaluation of boys with cryptorchidism. testicular torsion, and hydrocele. (4, 6) Magnetic resonance imaging has greater sensitivity and specificity but is expensive, not Diagnosis universally available, and often requires The physical examination is still the most sedation for effective studies of pediatric important step in making the diagnosis of UDT patients. Diagnostic laparoscopy has nearly and distinguishing it from a retractile testis. 100% sensitivity and specificity for localizing The most common challenge is to differentiate nonpalpable testes and allows for concurrent a retractile from a true undescended testis. The surgical correction. (4-5) parent should be asked if they have ever seen the testis in the scrotum, for example when There are 6 reasons supporting early bathing the child. Retractile testes are often intervention for UDT, which is now Trakia Journal of Sciences, Vol. 14, № 4, 2016 381 DINKOV D., et al. recommended at 1-2 years of age. These are determine whether a testicle can be located reduced fertility, risk of testicular malignancy, intra-abdominally. If orchiolisis and associated inguinal hernia, risk for testicular orchiopexy would prove inadequate to achieve torsion or trauma, as well as psychological scrotal fixation due to shortness of vasa distress. (2, 3) spermica, auto transplantation with microsurgical technique can be carried out. (7- Treatment