Hear this podcast on Undescended Testis here itself in this embedded audio.
Hear this podcast on Undescended Testis here in this embedded audio.
Transcript for Undescended Testis:
Script for Undescended Testis Podcast
Undescended Testis podcast
1. Host: Welcome to the Surgical Educator Podcast, where we discuss important topics in General & Pediatric surgery. Today we are going to discuss one more cause for groin swellings that is undescended testis. Undescended testis, also known as cryptorchidism, is a common condition that affects many boys. It occurs when one or both testicles fail to descend into the scrotum before birth. Joining us today is Prof. Dr. Selvaraj, a pediatric surgeon who specializes in treating undescended testis. Thank you for joining us, Dr.Selvaraj.
Dr. Selvaraj: Thank you for having me. I'm excited to be here today.
2. Host: So, let's start with the basics. What causes undescended testis doctor?
Dr. Selvaraj: Well, there's no one single cause of undescended testis. It's believed to be a combination of genetic and environmental factors. Some factors that may increase the risk include premature birth, low birth weight, alcohol consumption by the mother during pregnancy and exposure to certain medications especially analgesics during pregnancy. Mutations in androgen receptor (AR) gene is a frequent cause of cryptorchidism. Additionally, there's a higher incidence of undescended testis in boys with certain medical conditions such as Down syndrome and abdominal wall defects like prune belly syndrome.
3. Host: Doctor, Cryptorchidism and Undescended testis are same or different?
Dr.Selvaraj: Good question. Many are using them as synonyms but they are different. Cryptorchidism means the absence of testis in the scrotum- the common complaint with which the male child will be brought to us. Cryptorchidism could be because of 1. Undescended Testis which is arrest of the testis in its normal path of the descend. 2. Ectopic testis where the testis after emerging out of the external inguinal ring, instead of descending into the scrotum will go elsewhere. 3. Retractile testis where testis can be manipulated into scrotum and it is pulled and held high by the overactive cremastric muscle. 4. Post-torsion atrophy where because of fetal torsion of testis during the intra uterine life the testis is either vanished or atrophied. 5. Iatrogenic Cryptorchidism: Where the surgeon forget to place the testis back into the scrotum after inguinal herniotomy surgery.
4.Host: Doctor, can you enlighten us with the embryology of the normal testicular descend?
Dr.Selvaraj: Well, a good understanding of the embryological basis of normal testicular descend is important to understand the spectrum of different defects that can develop. This can be explained in 2 phases 1. Transabdominal phase- 8 to 15 weeks gestation, 2. Inguino-scrotal phase- 28 to 35 weeks of gestation. 1.Trans-abdominal phase-8 to15wks- the primitive gonad which is neither testis nor ovary which develops near the urogenital ridge in posterior abdominal wall will be converted into testis by a signal from a gene from the short arm of Y chromosome. This primitive testis secretes 3 hormones- Testosterone which lyse the cranial suspensory ligament of this gonad, Mullerian inhibiting hormone from Sertoli cells which lyse all mullerian ducts, and the insulin like 3 hormone which cause thickening and foreshortening of caudal gubernaculum causing relative descend of the testis- so now the testis will be just above the internal inguinal ring level.
2. Inguino-scrotal phase- 28 to 35 wks: Around 25 wks Processus vaginalis extend into gubernaculum. Distal end of gubernaculum elongates and reaches scrotum by 30 to 35 Wks which is controlled by testosterone. If this tail of gubernaculum instead of going to scrotum is going elsewhere the ectopic testis results.
5.Host: What are the clinical features of true undescended testis doctor?
Dr.Selvaraj: I told you already the arrest of the testis anywhere in it’s normal path of descend is called the true undescended testis. Rt side 60%, Lt side 30%, Bilateral 10%, Premies 30%, Full term 4to5%, At 1 yr 0.3% . Affected scrotum is poorly developed, always associated with an indirect inguinal hernia, if testis is palpable in the groin do milking manuver to R/O retractile testis, palpate perineum and upper thigh to R/O ectopic testis. If testis is impalpable that needs further workup to localise the testis.
6. Host: Interesting. And what are some of the long-term effects of having an undescended testis?
Dr. Selvaraj: Well, if left untreated, undescended testis can lead to several complications, including the 3 Ts that’s trauma, torsion and tumor. In some cases, it can produce infertility. Testicular carcinoma is because of dysplastic changes in the undescended testis and infertility is because the testicles unlike in scrotum will be subjected to higher body temperature and that’s not conducive for spermatogenesis. Because of absence of testis in scrotum patient can have psychological problems also.
7.Host: What are the investigations to be done in an Undescended testis patient?
Dr.Selvaraj: In bilaterally impalpable testis- we have to do HCG stimulation test to find out testosterone secretion. If there is no increase in testosterone level after this stimulation test that means, there is no testicular tissue in the body and we need not do any other investigation to localise the testis. If the testosterone level increases, then only we must do further investigations to localise the position of the testis. In case of intra-abdominal testis, the gold standard is diagnostic laparoscopy to localise the testis. If there is groin swelling then we can do USG of groin and abdomen, CT or MRI of groin and abdomen.
8.Host: So, what are the treatment options for undescended testis?
Dr. Selvaraj: Treatment options for undescended testis typically involve surgery. But hormonal therapy can be tried from 3 to 6 months age of the child in form of HCG or GnRH or combination of the above two. The goal of surgery is to bring the testis down into the scrotum, where it can develop and function normally. If the testis cannot be brought down into the scrotum, it may need to be removed to prevent the development of testicular cancer.
There are 2 types of UDT. 1. Canalicular 2. Intra-abdominal
For canalicular UDT- Inguinal orchiopexy can be done which consists of herniotomy, orchiolysis-that’s mobilisation of testis and orchiopexy usually done in sub-dartos muscle pouch in scrotum.
For suspected Intra-abdominal testis diagnostic laparoscopy is the gold standard investigation. If you find adequately sized testis with long cord, inguinal or Laparoscopic orchiopexy can be done. If the cord is short, then do Laparoscopic Fowler-stephens orchiopexy either single or staged repair or the other option is microvascular auto transplantation of the testis. If the size of the testis is very small then do Lap orchidectomy.
If no testis found intra-abdominally also then look for Vas deferens and testicular artery. If both are entering the internal inguinal ring do canal exploration and do inguinal orchiopexy. If both Vas and testicular artery are ending blindly, that is a case of post torsion atrophy, and you need not do anything.
9.Host: How successful is surgery for undescended testis?
Dr. Selvaraj: Surgery is usually very successful, especially if it's performed early on. The success rate is typically around 90%. However, it's important to note that even after surgery, boys with undescended testis are still at a slightly higher risk for infertility and testicular cancer compared to boys without the condition.
10.Host: That's good to know. Is there anything else parents of boys with undescended testis should be aware of doctor?
Dr.Selvaraj: Yes, it's important for parents to keep an eye out for signs of complications after surgery, such as swelling, redness, or pain in the scrotum. They can also develop testicular atrophy because of injury to testicular artery or testicular retraction or infertility because of injury to Vas Deferens. Additionally, boys who have had surgery for undescended testis should be monitored regularly by a healthcare provider to ensure that the testis is developing and functioning normally.
11.Host: What is ectopic testis and how to manage this?
Dr.Selvaraj: Ectopic testis is where the testis after emerging out of the external inguinal ring, instead of descending into the scrotum will go elsewhere.There are 5 types of ectopic testis. 1. Superficial inguinal 2. Perineal 3. Prepenile 4. Crossed ectopic 5. Femoral. Diagnosis is obvious and treatment is easy because of presence of long cord.
12.Host: What is retractile testis and how to manage doctor?
Dr.Selvaraj: In retractile testis the testis can be manipulated into scrotum by milking manuver. The testis is pulled and held high by overactive cremastric muscle. When child sleeps testis descends into scrotum. At puberty when testis grow bigger this will be alright and we need not do any treatment, just reassure the parents.
13.Host: Doctor, do you want to tell anything else to the parents?
Dr.Selvaraj: I want to emphasize the following points
1. Child should be operated between 6months to 1year.
2. Undue delay in surgery carries the risk of infertility and malignancy in adult life.
3. Hormone therapy in the form of HcG and GnRH may be tried between 3to6 months.
4. Retractile testis should not be operated
5. Intra-abdominal testis is best managed with Laparoscopy
Host: Well, thank you so much for joining us today, Dr. Selvaraj. It was a pleasure having you on the show.
Dr. Selvaraj: Thank you for having me. It was great to be here.
Host: That's all for today's episode. If you have any questions or suggestions for future topics, feel free to reach out to us on social media or visit our website surgicaleducator.com. And don't forget to subscribe to our podcast for more informative episodes. Thanks for listening!
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