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Surgery.(General 1).Scrotum > 2. Undescended Testis > Flashcards

2. Undescended Testis Flashcards

1
Q

Alternative name for Undescended Testis

A

Arrested testes

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2
Q

INCIDENCE of Undescended Testis

A
  • General INCIDENCE

* Side INCIDENCE

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3
Q

General INCIDENCE in INCIDENCE of Undescended Testis

A
  • It occurs in 3% of full term babies

* but more common in premature babies

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4
Q

Side INCIDENCE in INCIDENCE of Undescended Testis

A

All congenital anomalies of testis common on the right

  • Right testis : 50%
  • Left testis : 30% .
  • Bilateral: 20%.
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5
Q

The reason why right undescended testis is more common than left undescended testis in Side INCIDENCE in INCIDENCE of Undescended Testis

A

due to the later descent of the right testes

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6
Q

ETIOLOGY of Undescended Testis

A

1- Bilateral cases

2- Unilateral cases

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7
Q

Bilateral cases in ETIOLOGY of Undescended Testis

A
  • ETIOLOGY

* Association

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8
Q

ETIOLOGY of Bilateral cases in ETIOLOGY of Undescended Testis

A

Usually due to a hormonal defect in maternal B-HCG.

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9
Q

Association of Bilateral cases in ETIOLOGY of Undescended Testis

A

Usually associated with :

  • hypogonadism
  • slipped upper femoral epiphysis
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10
Q

Etiology of Unilateral cases in ETIOLOGY of Undescended Testis

A

Due to anatomical barrier to normal descent

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11
Q

Anatomical barrier to normal descent in Etiology of Unilateral cases in ETIOLOGY of Undescended Testis

A
  • Short testicular artery “spermatic vessels”: most important factor
  • Associated hernial sac.
  • Inadequate inguinal canal.
  • Retroperitoneal adhesions fixing the testis in higher places.
  • Rupture gubernaculums.
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12
Q

most important Anatomical barrier to normal descent in Etiology of Unilateral cases in ETIOLOGY of Undescended Testis

A

Short testicular artery “spermatic vessels”

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13
Q

PATHOLOGY of Undescended Testis

A
  • The site of undescended testes in order of frequency
  • If bilateral, the condition is known as cryptorchidism.
  • The size and function of the testis
  • Consequences If left in the abdomen:
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14
Q

The site of undescended testes in order of frequency in PATHOLOGY of Undescended Testis

A

1- External ring. most common site

2- Neck of the scrotum.

3- Inguinal canal.

4- Lumbar region (intra-abdominal).

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15
Q

Most common site of undescended testes in order of frequency in PATHOLOGY of Undescended Testis

A

External ring

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16
Q

The size and function of the testis in PATHOLOGY of Undescended Testis

A
  • The size and function of the testis remain normal till the age of 6 months
  • The destruction of the testis starts from 6 months onwards
  • At 2 years, 40% of germ cells are destructed.
  • At 6 years, there is complete atrophy of germ cells.
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17
Q

Consequences If left in the abdomen in PATHOLOGY of Undescended Testis

A

Effects on

  1. Testes
  2. The seminiferous tubules
  3. The interstitial cells are NOT affected
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18
Q

Effects on testes in Consequences If left in the abdomen in PATHOLOGY of Undescended Testis

A

Testes do not grow and becomes atrophic & soft.

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19
Q

Effects on The seminiferous tubules in Consequences If left in the abdomen in PATHOLOGY of Undescended Testis

A

The seminiferous tubules become atrophied because of the higher temperature of the abdomen causing failure of spermatogenesis.

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20
Q

Effects on The interstitial cells in Consequences If left in the abdomen in PATHOLOGY of Undescended Testis

A

The interstitial cells are NOT affected and hence the 2ry sexual characters and erection are normal

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21
Q

Clinical picture of Undescended Testis

A
  • Symptoms

* Examination

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22
Q

Symptoms in Clinical picture of Undescended Testis

A

The mother observes that one side or both side of the scrotum are empty

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23
Q

Examination in Clinical picture of Undescended Testis

A
  • Scrotum
  • Testis Palpation
  • Associations
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24
Q

Scrotum Examination in Clinical picture of Undescended Testis

A

The affected side of the scrotum is empty & not well developed.

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25
Q

Testis Palpation in Examination in Clinical picture of Undescended Testis

A
  1. The testis is palpated if arrested in external ring or neck of the scrotum.
  2. The testis is difficult to be palpated if arrested in inguinal canal.
  3. The testis is not Palpated if intra-abdominal
  4. The testis can be identified as it gives sickening sensation when compressed
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26
Q

Associations in Examination in Clinical picture of Undescended Testis

A

Associated congenital hernia is commonly found in 80-90% of cases

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27
Q

Differential Diagnosis of Undescended Testis

A
  1. Ectopic testis
  2. Testicular agenesis.
  3. Surgically removed testis.
  4. Retractile testis
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28
Q

Retractile testis in Differential Diagnosis of Undescended Testis

A

Definition

Management

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29
Q

Definition of Retractile testis in Differential Diagnosis of Undescended Testis

A

It is a common condition during childhood due to active cremastric reflex on a small mobile testis.

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30
Q

Management of Retractile testis in Differential Diagnosis of Undescended Testis

A
  • In majority of cases
  • In difficult cases
  • Retractile testes require no treatment.
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31
Q

In majority of cases in Management of Retractile testis in Differential Diagnosis of Undescended Testis

A
  • By careful & gentle examination in warm surroundings

* The testis is usually brought by the examiner downwards and medially to scrotum

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32
Q

In difficult cases in Management of Retractile testis in Differential Diagnosis of Undescended Testis

A
  • The “chair test” should be tried.

* The “squatting position test” is an alternative one.

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33
Q

The “chair test” In difficult cases in Management of Retractile testis in Differential Diagnosis of Undescended Testis

A
  • The young patient is asked to sit on a chair and hug his knees to his chest.
  • Pressure thus directed on to the inguinal canal causes a retractile testis to descend into the scrotum
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34
Q

Difference between Retractile testis and Undescended Testis by

A
  • Scrotum Examination

* Pulling down the testis to the scrotum

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35
Q

Scrotum Examination in Retractile testis in Difference between Retractile testis and Undescended Testis by

A

Fully developed

36
Q

Scrotum Examination in Undescended Testis in Difference between Retractile testis and Undescended Testis by

A

Not well developed

37
Q

Pulling down the testis to the scrotum in Retractile testis in Difference between Retractile testis and Undescended Testis by

A

Easily pulled down

38
Q

Pulling down the testis to the scrotum in Undescended Testis in Difference between Retractile testis and Undescended Testis by

A

Cannot be pulled down

39
Q

COMPLICATIONS of Undescended Testis

4 T ( Trauma Torsion Tumour aTrohpy)

A
  1. Liable for trauma and torsion.
  2. Malignant change
  3. Spermatogenesis will be lost if surgery is delayed and if the condition is bilateral, sterility will follow.
  4. Epididymo-orchitis : Extremely rare.
40
Q

Malignant change in COMPLICATIONS of Undescended Testis

A
  • All types of malignancy may occur especially seminoma
  • Increase incidence for malignancy 35 times
  • Due to testicular dysgenesis (histologically abnormal).
41
Q

Investigations of Undescended Testis

A
  • Indications
  • Diagnostic Laparoscopy
  • Radiological investigation
42
Q

Indications of Investigations of Undescended Testis

A

for impalpable testis onty

43
Q

Diagnostic Laparoscopy in Investigations of Undescended Testis

A
  • Investigation of choice.

* Ain shams classification of abdominal undescended testis.

44
Q

Ain shams classification of abdominal undescended testis in Diagnostic Laparoscopy in Investigations of Undescended Testis

A
  • Mechanism

* Types

45
Q

Mechanism of Ain shams classification of abdominal undescended testis in Diagnostic Laparoscopy in Investigations of Undescended Testis

A

According to simplicity of operation

46
Q

Types of Ain shams classification of abdominal undescended testis in Diagnostic Laparoscopy in Investigations of Undescended Testis

A
  • Type I
  • Type II
  • Type III
  • Type IV
47
Q

Type I in Types of Ain shams classification of abdominal undescended testis in Diagnostic Laparoscopy in Investigations of Undescended Testis

A

no testis visualized “vanishing testis” & is thought to be due to intrauterine testicular torsion.

48
Q

Oral Question: Difference between agenesis and vanishing testis

A

Do angiography on testicular artery and vein

In agenesis no blood vessels are found

49
Q

Type II in Types of Ain shams classification of abdominal undescended testis in Diagnostic Laparoscopy in Investigations of Undescended Testis

A

a testis seen at the internal ring with the vas and vessels looping to the internal ring.

50
Q

Type III in Types of Ain shams classification of abdominal undescended testis in Diagnostic Laparoscopy in Investigations of Undescended Testis

A

Testis at the internal ring, with vas and vessels going to the testis directly indicating Short vessels

51
Q

Type IV in Types of Ain shams classification of abdominal undescended testis in Diagnostic Laparoscopy in Investigations of Undescended Testis

A

Intra-abdominal testis not related to the internal ring.

52
Q

Radiological investigation in Investigations of Undescended Testis

A
  1. Abdominal U.S or C.T scan.

2. MRI

53
Q

Indication of MRI in Radiological investigation in Investigations of Undescended Testis

A

done if abdominal U.S and C.T scan fail to localize the testis

54
Q

TREATMENT of Undescended Testis

A

(l) TREATMENT oF INGUINAL UNDESCENDED TESTIS

(lI) TREATMENT oF ABDOMINAL UNDESCENDED TESTIS

(lII) TREATMENT oF patients presented late

55
Q

TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A
  1. Bilateral testes

2. If unilateral or failed medical treatment

56
Q

Bilateral testes in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A

A single course of HCG

57
Q

A single course of HCG in Bilateral testes in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A
  • Therapeutic dose

* Effects of higher dose

58
Q

Therapeutic dose of A single course of HCG in Bilateral testes in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A

500 IU/dose given twice a week for 5 weeks.

59
Q

Effects of higher dose of A single course of HCG in Bilateral testes in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A
  • cause precocious puberty,

* induce epiphyseal plate fusion and retard future somatic growth.

60
Q

If unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A

Orchiopexy (best at 1.5 gears)

61
Q

the reason why Orchiopexy is not done before one year of age in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A

Not before 1 year old to give chance for testis descent

62
Q

Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A
  • Aim
  • Principle
  • In cases of failure to do orchiopexy in one stage
63
Q

Aim of Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A
  1. Mobilize the testis to the scrotum.

2. Retain the testis in the scrotum

64
Q

Principle of Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A
  • The cord and testis are mobilized and freed from the surrounding structures.
  • The associated hernial sac should be excised.
  • The inferior epigastric artery is sometimes divided
  • Retain the testis in the scrotum
65
Q

the reason why The inferior epigastric artery is sometimes divided in Principle of Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A

to abolish the angulation of the vas around it.

66
Q

In cases of failure to do orchiopexy in one stage in Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A

A. Two stage operation :

B. Fowler-Stephens technique :

C. Microvascular technique :

67
Q

Two stage operation In cases of failure to do orchiopexy in one stage in Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A
  • After maximal mobilization, the testis is anchored with prolene suture
  • 2nd stage is done after 6 months.
68
Q

Fowler-Stephens technique In cases of failure to do orchiopexy in one stage in Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A
  • High division of testicular artery

* provided that the anastomosis between the testicular artery and the artery of the vas is intact

69
Q

intact Anastomosis between the testicular artery and the artery of the vas in Fowler-Stephens technique In cases of failure to do orchiopexy in one stage in Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis, is known by

A
  • putting a small vascular clamp (bull dog clamp) on the testicular artery as high as possible for several minutes
  • if the testis does not become ischemic (bluish), the artery is divided
70
Q

Microvascular technique In cases of failure to do orchiopexy in one stage in Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A

Division & re-anastomosis of the testicular vessels at a lower level to the inferior epigastric vessels

71
Q

Retaining the testis in the scrotum in Principle of Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A
  1. Bevan’s Technique

2. Benson’s Technique

72
Q

Bevan’s Technique in Retaining the testis in the scrotum in Principle of Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A
  • Alternative name

* Principle

73
Q

Alternative name for Bevan’s Technique in Retaining the testis in the scrotum in Principle of Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A

Scrotal stitch

74
Q

Principle of Bevan’s Technique in Retaining the testis in the scrotum in Principle of Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A

Fixing the testes to the bottom of the scrotum by a prolene suture, to be removed after 2 weeks

75
Q

Benson’s Technique in Retaining the testis in the scrotum in Principle of Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A
  • Alternative name

* Principle

76
Q

Alternative name for Benson’s Technique in Retaining the testis in the scrotum in Principle of Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A

Extra dartos pouch

77
Q

Principle of Benson’s Technique in Retaining the testis in the scrotum in Principle of Orchiopexy in case of unilateral or failed medical treatment in TREATMENT oF INGUINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A

Placing the testes in a dartos pouch beneath the skin

78
Q

TREATMENT oF ABDOMINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A

The best surgery now is 2 stage laparoscopic orchiopexy

79
Q

2 stage laparoscopic orchiopexy in TREATMENT oF ABDOMINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A
  • 1st stage
  • 2nd stage
  • Disadvantages
80
Q

1st stage in 2 stage laparoscopic orchiopexy in TREATMENT oF ABDOMINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A

laparoscopic clipping of the testicular artery allowing the testis to depend on the blood supply from the artery of vas.

81
Q

2nd stage in 2 stage laparoscopic orchiopexy in TREATMENT oF ABDOMINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A

laparoscopic assisted orchiopexy (LAO) 6 months later

82
Q

Disadvantages of 2 stage laparoscopic orchiopexy in TREATMENT oF ABDOMINAL UNDESCENDED TESTIS in TREATMENT of Undescended Testis

A

Only 15% the testis will be atrophied

So we take consent from parents

83
Q

TREATMENT oF patients presented late in TREATMENT of Undescended Testis

A

a. Cases of late presentation but still before puberty

b. Cases of late presentation after puberty

84
Q

Cases of late presentation but still before puberty in TREATMENT oF patients presented late in TREATMENT of Undescended Testis

A

Orchiopexy and not orchiectomy

85
Q

The reason why we do Orchiopexy and not orchiectomy in Cases of late presentation but still before puberty in TREATMENT oF patients presented late in TREATMENT of Undescended Testis

A
  • For preserving hormonal function.

* Orchiopexy does not diminish the liability for malignancy but improves early diagnosis.

86
Q

Cases of late presentation after puberty in TREATMENT oF patients presented late in TREATMENT of Undescended Testis

A

Orchiectomy for a hopeless atrophic testis

Surgery.(General 1).Scrotum (8 decks)

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