UNDESCENDED TESTIS

DEFINITION

Undescended testis or cryptorchidism is the absence of one or both testes in normal scrotal
position and during initial clinical evalu- ation may refer to palpable or nonpalpable testes,
which are either cryptorchid or absent.
SEX DEVELOPMENT
AND DIFFERENTIATION

Gen-gen lain:
- WT1
- SF1
Anti- Y absence Y influence - SRY
testis (SRY gene) - SOX9
-RSPO1 - DHH
-WNT4 - NR5A1
-DAX1 -WNT4

Sel Sertoli  MIS

No MIS Sel Leydig  T
No androgen

Diamond DA, Yu RN. Disorders of Sexual Development: Etiology Evaluation, and Medical Management. Campbell-Walsh Urology.11th ed 2016
 Y presence
Y absence T DHT
No testosterone Androgen receptor
Phase of testicular decsent
BACKGROUND

Undescended testis or cryptorchidism

• One of the most common congenital malformations of male neonates.
•  1.0-4.6% of full-term neonates
•  1.1-45% of preterm neonates

• May affect both sides (non-palpable)  30% of cases

• In newborn cases with non-palpable any sign of DSDs (concomitant hypospadias)
•  urgent endocrinological and genetic evaluation is required
Incidence UDT

• The cause of UDT is multi-

factorial

• Related to gestational age.

• Related to birth weight.

 Retractile Testis
• Criteria
– Normal size & consistency.
– Remains in scrotum with manipulation.
• Yearly follow- up.
• Hyperactive cremasteric reflex.
• Does not require therapy
 Ectopic Testis

• Lies outside of path of normal descent

• Abnormal gubernacular attachment.
• Similar histology to a cryptorchid
testis.
 ASCENDED TESTIS
• Testis previously in scrotum
• asssociated with decrease tubular fertility index
• 50% patent processus vaginalis
• Does not respond to HCG
• Requires orchiopexy
 Cryptorchid Testis
• Along path of
normal descent.
– Peeping.
– Intracanalicular.
– abdominal.
ETIOLOGY

• Genetic
• Environtmental
• Hromonal defect
 CLASSIFICATION
• The most useful classification of undescended testes is into palpable and non-palpable testes, and
clinical management is decided by the location and presence of the testes.
• Approximately 80% of all undescended testes are palpable.
• Palpable testes include true undescended testes and ectopic testes.
• Non-palpable testes include intra-abdominal, inguinal, absent, and ectopic testes.
 DIAGNOSTIC & MANAGEMENT
DIAGNOSTIC EVALUATION
• History taking and physical examination are key points in evaluating boys with UDT.
• Examining fingers along the inguinal canal towards the pubis region.
• A non-palpable testis in the supine position may become palpable once the child is in a sitting or squatting position.

MANAGEMENT
• Treatment should be started at the age of six months.
• Any kind of treatment leading to a scrotally positioned testis should be finished by twelve months, or eighteen
months at the latest,
 Evaluation of Cryptorchidism
Physical examination:
• Warm room, quiet
child.
• Crossed- leg position.
• Contralateral hypertrophy.
 Fertility Issues
•Most men with unilateral cryptorchidism are
fertile.
– Sperm ct. > 20 million 21- 81%
– Paternity 59- 80%

• Most men with bilateral cryptorchidism are infertile.

– Sperm ct. > 20 million 8- 45%
– Paternity 16- 35%

Kogan, SJ: Eur. J. Pediatr140:

521,1987
 Cryptorchidism & Malignancy
• 10% of GCT are found in patients with a history
of UDT.
• 20- 40 fold increased risk.
• Seminoma is the most common cell type.
 MEDICAL THERAPY
FOR TESTICULAR DESCENT
• Hormonal therapy using hCG or GnRH is based on the hormonal dependence of testicular descent but has a
maximum success rate of only 20%.
• In general, success rates depend on testicular location. The higher the testis is located prior to therapy, the lower the
success rate.
• The Panel consensus is that endocrine treatment to achieve testicular descent is not recommended.
 Hormonal
Treatment of Cryptorchidism
•HCG
– 1500 IU/ m 2 (2x •GnRh
per – 1.2 mg/ day for 4
week for 4 weeks) weeks
– 19% success rate – 21% success rate

10- 25 % REASCEND
Best for low palpable
testis
 SURGICAL TREATMENT
PALPABLE TESTES
• Surgery for palpable testes includes orchidopexy, either via an inguinal or scrotal approach.

NON-PALPABLE TESTES
• For non-palpable testes, surgery must clearly determine whether a testis is present or not. If a testis is found,
the decision must be made to remove it or bring it down to the scrotum.
• For non-palpable testis might be identifiable and subsequently change the surgical approach to standard
inguinal orchidopexy.
• The easiest and most accurate way to locate an intra-abdominal testis is diagnostic laparoscopy.
 Nonpalpable Testis

Location determined laparoscopically:

• Abdominal 40%
• Intracanalicular 28%
• Absent 32%
– Abdominal
– Inguinal
Algoritma tatalaksana UDT
INGUINAL ORCHIDOPEXY

RINCIAN PEMBEDAHAN
2. Mobilisasi testis dan spermatic cord
1. Diseksi inguinal
- Identifikasi testis di dalam tunica vaginalis
- Insisi external oblique fascia. Bebaskan
- Buka tunica vaginalis di bagian anterior dan
fascia dengan berhati-hati agar tidak
lakukan insisi ke arah proximal hingga
memotong N. ilioinguinal.
dasar.
INGUINAL ORCHIDOPEXY
3. Perbaiki defek hernia
- Pegang ujung dari tunica vaginalis di dekat
inguinal ring dengan forcep.
- Pisahkan spermatic cord dari peritoneum
- Pisahkan perlekatan fascia spermatica interna sisi
posterior dan lateral.
- Tutup bagian peritoneum yang terbuka dengan
jahitan purse-string
4. Pembentukan kantung dartos
- Masukkan jari telunjuk ke arah scrotum.
Dilakukan insisi sepanjang 2 cm pada kulit
scrotum
- Bentuk kantung untuk testis dengan
membebaskan kulit dari fascia dartos 1-2
cm. Lebarkan insisi dengan klem.
- Jepit ujung fascia dengan klem Allis
INGUINAL ORCHIDOPEXY

5. Relokasi testis 6. Penutupan

- Masukan jari telunjuk melalui insisi - Jahit m. obliqus internus dengan benang
inguinal ke dalam kanalis inguinalis absorbable 3-0 / 4-0
hingga meraba klem - Tutup m. obliqus eksternus dari arah cephalic ke
caudal untuk membentuk external ring baru.
- Masukan klem mengikuti jari telunjuk
- Rapihkan fascia scarpa, tutup kulit dengan
ke arah cephalic
benang absorbable 3-0 / 4-0
- Jepit tepi tunica albuginea dan tarik
melalui kanal menuju insisi di scrotum.
Perhatikan jangan sampai terpuntir.
LAPAROSCOPIC ORCHIDOPEXY
Rincian pembedahan

1. Inspeksi rongga peritoneum melalui landmark yang telah ditentukan

2. Identifikasi pembuluh darah dan cincin kontralateral, lalu cari cincin pada sisi yang mengalami UDT.
3. Ikuti vas ke arah lateral melalui ligament umbilicalis. Lakukan traksi pada scrotum ipslitateral.
4. Satu dari tujuh penanda mungkin ditemui.
LAPAROSCOPIC ORCHIDOPEXY

Rincian pembedahan

(Hinman 4th Edition)

 LAPAROSCOPIC ORCHIDOPEXY

Rincian pembedahan

5. Bila testis ditemukan, maka dapat dilanjutkan dengan orchidopexy per laparoscopic. Pilih antara tindakan 1
tahap atau 2 tahap
6. Masukkan working port
7. Idenfitifikasi testis, dan gubernaculum.
8. Bila testis dapat ditarik  langsung letakkan ke scrotum ipsilateral
Bila pembuluh darah terlalu pendek  lakukan prosedur bertahap
 FOWLER-STEPHENS

• Dilakukan pemotongan proksimal dan transeksi dari pembuluh darah testikular, dengan
konservasi dari pembuluh darah arteri kolateral, melalui arteri deferensial dan pembuluh darah
kremaster.
• Survival dari testis pada teknik Fowler-Stephens satu tahap bervariasi antara 50% dan 60%,
dengan tingkat keberhasilan mencapai 90% untuk prosedur 2 tahap. .
 FOWLER-STEPHENS

• Tahap Pertama : Ligasi pembuluh darah

1. Pisahkan pembuluh darah spermatic. Clip pembuluh darah setinggi mungkin
2. Letakkan 2 clip 5 mm pada tiap pembuluh darah dan ikat dengan benang non
absorbable.
3. Pemisahan dilakukan pada tahap ke 2.
4. Keluarkan port. Tutup dengan PDS.
 FOWLER-STEPHENS

• Tahap Kedua : Relokasi testis (Dilakukan 6 bulan pasca tindakan pertama)

1. Insisi peritoneum dari internal ring ke gubernaculum.
2. Buat flap triangular dari peritoneum sepanjang 1 cm dari spermatic vessel.
3. Perluas insisi ke arah medial
4. Bebaskan vas deferens secara tumpul
5. Raih testis dengan forsep, nilai mobilitas testis.
6. Pisahkan gubernaculum sejauh mungkin dengan tetap mempertahankan pembuluh darah.
7. Letakkan testis ke dalam scrotum
LAPAROSCOPIC ORCHIDOPEXY
Komplikasi akut pasca Laparoscopic Orchidopexy
LAPAROSCOPIC ORCHIDOPEXY
Komplikasi delayed pasca Laparoscopic Orchidopexy
THANKS