Page 19 - World Journal of Laparoscopic Surgery

Laparoscopic Management of Undescended Testis

CONSEQUENCES OF UNDESCENDED TESTIS

Testicular neoplasm, subfertility, testicular torsion and inguinal
hernia are the known and documented consequences. Of the
neoplasms, testicular germ cell cancers are usually seen. The
incidence among men with an undescended testicle is
approximately one in 1,000 to one in 2,500. 7
Such individuals are found to have lower sperm counts,
poorer quality sperm and lower fertility rates than men whose
testicles descended normally. The likelihood of subfertility
increases with bilateral involvement and increasing age at the
time of orchiopexy.
The incidence of testicular torsion is thought to be higher
in undescended testes than in normal scrotal testes. Torsion of
Fig. 2: Setup in the operation theatre an undescended testicle often occurs with the development of
a testicular tumor, presumably caused by increased weight and
DISCUSSION
distortion of the normal dimensions of the organ. Torsion of an
Most undescended testicles are present at birth. True intra-abdominal testicle may present as an acute abdomen. 10
undescended testicles rarely descend spontaneously after three Most true cases of undescended testicles are associated
months of age. Through surgical examination, about one half of with a patent processus vaginalis. A man with an untreated,
nonpalpable testes are found to be intra-abdominal, while the undescended testicle and an occult inguinal hernia may present
rest represent absent (vanishing) or atrophic testes. The at any time with symptoms and complications typical of any
vanishing testicle is thought to be caused by intrauterine inguinal hernia. 7
testicular torsion. 11
Underlying reasons for cryptorchidism, such as Prader-Willi, HORMONAL THERAPY
Kallmann’s or Laurence-Moon-Biedl syndromes should be Human chorionic gonadotropin (HCG) is used and is adminis-
looked for in these patients. The genitalia should be examined tered intramuscularly. However, the likelihood of success is
for evidence of hypospadias or ambiguity. Concurrence of greatest in the most distal true undescended testicles. In theory,
hypospadias and undescended testis is commonly associated an ectopic testis should not respond to hormone therapy
9
with states of intersexuality, especially mixed gonadal because it is physically prevented from descending. A high
dysgenesis and true hermaphroditism. 10 undescended testis is unlikely to descend completely; if it does,
Treatment for the undescended testis is recommended as it will probably ascend after the hormone stimulation is
early as six months of age and should be completed before age withdrawn. Some side effects of hCG administration can be
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two. Orchidopexy should be done either as a single or multi disturbing for parents. These include enlargement of the penis,
staged procedure, and the testis should be brought down into pubic hair growth, increased testicular size and aggressive
the scrotum. In adults orchidopexy and scrotal placement of behavior during administration. Studies suggest that
the testis gives cosmetic satisfaction to the patient and also gonadotropin-releasing hormone (GnRH) is more effective than
maintains steroid hormonogenesis. However, the patient should HCG in achieving testicular descent. 8
be counseled on the importance of repeated self examination as
the incidence of malignancy in these testicles is higher. If one ROLE OF LAPAROSCOPY
testis is normal and functioning well the option of orchidectomy It is diagnostic and potentially therapeutic. Initially, it is
3
can be given to the patient to avoid the problem of these important to determine whether a testis exists. If the absence of
examinations. a testis is surgically confirmed by identifying blind-ending
testicular vessels, the surgery should be terminated. Sometimes,
CLASSIFICATION OF UNDESCENDED TESTIS the testicular vessels are traced to an abdominal, inguinal or
1. True undescended testicles (including intra-abdominal, scrotal testicular remnant, which is then removed. In about one
peeping at the internal ring and canalicular testes), which half of cases, an intra-abdominal testis is found which is either
exist along the normal path of descent and have a normally brought to the scrotum or removed. 12
inserted gubernaculum. After performing a diagnostic laparoscopy, the inguinal
2. Ectopic testicles, which have an abnormal gubernacular rings are examined, and the status of the processus vaginalis
insertion. (patent or non-patent), wolffian structures and testicular vessels
2
3. Retractile testicles, which are not truly undescended. can be easily identified. The presence of blind-ending spermatic
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