Dr. Bassem W.

Yani ,MD
Diploma of urology, FEBU,FCS,
Cairo, EGYPT
CONSULTANT UROLOGIST
UTH LUSAKA ZAMBIA
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 Gonadal development
• 3-5 weeks gestation, the gonads are
undifferentiated
• 6 weeks gestation , the primordial cells
migration from the wall of yolk sac to the
genital ridge is completed
• 7 weeks gestation, the bipotential gonads will
differentiate to fetal testes under the
influence of SRY protein which is regulated by
SRY gene located on the short arm of Y
chromosome 2
Gonadal development
• 7-9 weeks gestation, sertoli cells secrete
Mullerian inhibiting substances (MIS) which
cause regression of mullerian structures , and
leydig cells secret testesterone which cause
development of wollffian ducts to form
epididymis and vas deference .
• 8-16 weeks gestation, the development of
external genitalia occurs. Canalization of rete
testes and mesonephric ducts begins in week
12 and finished by puberty
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Testicular descending
A, 5th week Testis begins
its primary descent;
kidney ascends.
B, 8th-9th weeks. Kidney
reaches adult position.
C, 7th month, Testis at
internal inguinal ring;
gubernaculum (in
inguinal fold) thickens
and shortens.
D, Postnatal life.
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 Definitions
 Ectopic testis: The
testis fails to descend
into the scrotum & is
deviated from its normal
path of descent
An un-descended testis:
Is one which has failed
to descend to the
scrotum & is retained at
any point along the
normal path of descend. 6
 Incidence of Un-descended testis
• Rang between 3.4% to 5.8% in full term boys
and reach up to 30% in premature boys.
• The incidence will decrease to 0.8% at about 1
year age and remains at this level through out
adulthood
• Right side: 50%, Left side: 30%, Bilateral: 20%
• The spontaneous descent during infancy may
occur owing to normal gonadtropin surge that
occurs around 60 to 90 days of life 7
Types of un-descended testis
Non palpable
 Lumbar testis
 Iliac testis: testis remains
just deep to the deep
inguinal ring
Palpable
 Inguinal: testis is in the
inguinal canal
 At the superficial Inguinal
ring
 Scrotal testis: testis lies in
the upper part of scrotum 8
Position of the ectopic testis
• Superficial
inguinal pouch
• Pubopenile
ectopia
• Perineal ectopia
• femoral ectopia
• Transverse scrotal
ectopia 9
Comparison between ectopic & un-
descended testis
Un-descended testis
• The testis is arrested in its
normal path of descent
• Usually undeveloped
• Undeveloped & empty scrotum
on the affected side
• Shorter length of spermatic cord
• Poor spermatogenesis after 6
yrs
• Usually associated with indirect
inguinal hernia
• Treatment: surgery & HT
Ectopic testis
• The testis deviates from its
normal path of descent
• Fully developed testis
• Empty but usually fully
developed scrotum
• Longer length spermatic
cord
• Spermatogenesis is perfect
• Never associated with
indirect inguinal hernia
• Treatment: basically surgical
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 Why should we diagnose and
treat undescended testis
• 1/increased risk of infertility
• 2/increased risk of testicular tumors
• 3/increased risk of testicular torsion
and injury against the pubic bone
• 4/psychological stigma of empty
scrotum
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Risk factors of un-descended
testis
• 1/advanced maternal age
• 2/maternal obesity
• 3/preterm birth
• 4/positive family history

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 Histology in the undescended testes
• Normally the germ cells differentiate to give
gonocyte
• Some gonocyte attach to the basement membrane
to give foetal spermatogonia which transfer to:
• A spermatogonia during the third to fifth months
of life
• Type B spermatogonia and primary spermatocyte
appear during the fourth year and
spermatogenesis arrest at this stage till puberty
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Histology in the undescended testes
• In undesceded testes the number
of ledig cells are decreased and
appear atrophic. In first 6month of
life ,the total number of germ cells
is within normal range but the
total number of spermatogonia
remains and does not increase with
the age.
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 Aetiology:
• Is well known manifestation of
chromosomal abnormalities and a
component of more than 50 syndromes
of multiple congenital abnormalities but
no consistent chromosomal
abnormalities associated with it.
• Positive Family history ,the risk is 3.6
folds over that of general population
• Effect of the androgen 15
 Aetiology:
• the initial transabdominal descent is controlled
mullerian inhibiting substances,but the
inguinoscrotal descent is androgen dependent
and is mediated indirectly through the release
of calcitonin gene related peptide which is
released from genitofemoral nerve and lead to
rhythmic contraction of the gubernaculum, so
inguino scrotal descent is blocked with
androgen resistant syndrome in which the
androgen receptor has been knocked out
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 Aetiology:
• Boys exposed to diethylstillbesterol
(DES)in utero have an increased
number of congenital anomilies
including undescended testes
• Secondary undescended testes can
occur after inguinal surgery

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 Undescended testis: evaluation
Presentation
 Empty scrotum, Underdeveloped scrotum, Scrotal
swelling
• Infertility
• complications like torsion, tumors, and trauma
History :
You should determine whether the testis was
palpable in the scrotum at the time of birth or within
the first year of life (retractile testis)
Prematurity, Maternal exposure to exogenous hormones
,Previous inguinal surgery, Fertility, Family history 18
 Undescended testis: evaluation
Examination
• The patient should be examined in supine frog leg
position with both legs free, and warm lubricated
hands
• The examination should started on normal contra
-lateral testis (site , size, and texture).
• Then examination of the un-descended testis should
started from anterior superior iliac spine sweeping the
groin from lateral to medial.
• Once the testes is palpated the examiner should grasp
it with the dominant hand and continue to sweep it to
the scrotum with the other hand
 Undescended testis: evaluation
Examination
• If the testis reach the scrotum ,you should
maintain traction on it for one min ,if it
remains in the scrotum , this retractile testes
but if not this is undescended testis
• Once the testis is felt ,you should determine
the site , size ,and consistency.
• You should examine the scrotal and penile
development and the other congenital
anomalies specially hypospadias.
Undescended testis: evaluation
Laboratory tests:
• boys with unilateral or bilateral undescended
testis in whom one of them is palpable , no
need for any lab testis
• Boys with bilateral non palpable undescended
testes or associated with hypospadias specially
the proximal : should do
• chromosomal study
• serum FSH, LH, testesterone
• HCG stimu. Test(after3 months age ) to exclude
bilateral anorchia
Undescended testis: evaluation
 Imaging investigations:
• In palpable undescended, no need for
any imaging test
• Impalpable testis:
• pelvic and scrotal us
• MRA using gadoliuinm enhanced
• diagnostic laparoscopy
 Un-descended testis
management
Hormone therapy
Surgery
both

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 hormone therapy
Indications:
• When the surgeon is not sure whether the
case is undescended testis or retractile testis
• undescended testis associated with
hypogondism
• It is more useful in distal undescended testis
• It is useful in patient with histological
testicular changes.
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hormone therapy
Treatment:
A. Human chorionic gonadotropin
Its action is similar to pituitary LH and have
small dgree of FSH effect, it stimulates the
production of gonadal steroid hormones by
stimulating the leydig cells to produce
androgen
• Dose infant 250 IU twice /week for 5 weeks
• young infant 500 IU twice ,week for 5 weeks
6years 1000 IU twice /week for 5 weeks
hormone therapy
Side effect:
• Increased scrotal rugae ,
pigmentation,pubic hair , and penile
growth which regress after treatment
cessation.
• Epiphyseal plate fusion and retard future
somatic growth if the total dose exceed
1500 IU
hormone therapy
Treatment:
B. Gonadtropin releasing hr analogues
• It stimulates the production of pituitary LH
and FSH, resulting in a temporary increase of
gonadal steroids production.
• Dose ,nasal spray200ug , 6 times/day for 4
wks.
• Side effects ,the same as HCG but it is less
• Some recommended to use HCG in cases
which are not responding to GnRH analogue
Surgical therapy: orchidopexy
Treatment of choice
• Usually should be done by the age of 6
months to 1year and at the maximum
before 5 years old
• Aim of the surgery is to bring the testes
down to its normal position in the
scrotum with proper fixation to prevent
further damage and complications
 Surgical therapy: orchidopexy
• For palpable testes ,the inguinal approach
is the stander
• For non palpable testis, abd. approach or
laparoscopy are recommended. These
options depend on the patient age ,testis
size, condition of the contra lateral testis,
and the skills of the surgeon
• Orchidectomy is still strong option for
undescended testes above the age of 5 ys.
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A transverse skin incision is made in an inguinal skin crease
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 Standard Orchiopexy.
• The key steps in this procedure are ---
(1)complete mobilization of the testis and spermatic cord,
(2) repair of the patent processus vaginalis by high ligation of the hernia sac,
and the cord should be separated from the peritoneum above the internal
ring during this step
Division of distal gubernaculum attachment
Transection of cremastric muscles fiber
Division of lateral spermatic fascia to allow medial movement of the cord
(3) skeletonization of the spermatic cord without sacrificing vascular integrity
to achieve tension-free placement of the testis within the dependent
position of the scrotum, and
(4) creation of a superficial pouch within the hemiscrotum to receive the
testis.

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 A transverse inguinal skin incision is made in the midinguinal canal, usually in a skin
crease in children younger than 1 year
 The dermis is opened with electrocautery, and subcutaneous tissue and Scarpa's
fascia are opened sharply.
The skin and subcutaneous tissue are quite elastic in younger children and allow for a
tremendous degree of mobility by retractor positioning for viewing the entire length of
the inguinal canal.

One should be careful to

observe that the testis is
in the superficial

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A,The external ring is opened.

B, Cremasteric fibers are dissected from the cord

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A, High ligation of the processus
vaginalis at the internal inguinal ring.

B, The ligated processus and the cord

structures

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Separation of the internal spermatic fascia
from the cord structures after ligation of the
processus vaginalis 37
Formation of a dartos pouch
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A, Formation of a
passage to the scrotum.

B and C, Passage of the

testis into the scrotal
pouch

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 Orchidopexy
• Special techniques to add more length to the cord
• 1/prentiss manoeuvre ,the surgeon can divides or passes
the testes under the inferior epigastric vessels and
opening the fascia transversalis
• 2 / the internal inguinal ring can be opened by dividing
the internal oblique and more of lateral spermatic fascia
• 3/Stephen fowler technique , by division of the internal
spermatic artery as high as you can ,and provided that
there is no extensive dissection of the vas and the cord

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• 4/staged orchidopexy
• 5/testicular auto transplantation using
ipsilateral inferior epigastric vessels or median
sacral artery

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 Laparoscopic orchidopexy
• Finding
• 1/ intra abdominal testes
• 2/ blind end spermatic vessles above the internal ring
due to vanishing syndrome ,owing to early prenatal
vascular event (no need for further exploration )
• 3/ cord structure that enter the internal ring ,inguinal
exploration is recommended to exculde testicular
nubbin. Once it is found ,some recommend to explore
and fix the other side

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 Complications of Orchiopexy
• Testicular retraction,
• Hematoma formation,
• Ilioinguinal nerve injury,
• Postoperative torsion (either iatrogenic or
spontaneous),
• Damage to the vas deferens, and
• Testicular atrophy
Devascularization with atrophy of the testis can result from skeletonization
of the cord, from overzealous electrocautery
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