Hinduja hospital conducts regular webinars and tweetinars to help online users get medical advice from expert doctors of hinduja hospital. A similar webinar was conducted by hinduja hospital on undescended testis under guidance of Dr. Rasik Shah. Have you observed a testicular deformation in your infant that doesn't correct itself? Do you know the common problem for which child may need surgery that is related with the descent and final position of testis? Approximately 1% of the children needs surgery for abnormal location of the testis. To know more about Reproductive Deformities in Male Child and its treatment join talk by our expert in Pediatric Surgeon. To know about upcoming webinars sign up at http://www.hindujahospital.com/communityportal/webinar/

1. Understanding UNDESCENDED TESTIS
Rasik Shah
MBBS, MS (General Surgery), M Ch (Pediatric Surgery)
Paediatric & Laparoscopic Surgeon:
Hinduja Hospital, Mahim, Mumbai
President Elect (2012-13):
Indian Association of Paediatric Surgeon
Ex Chairman (2011-13):
Paediatric Endoscopy Surgeon – India Section of Indian Association
of Paediatric Surgeon

2. Testis
• The testicle is the male gonad
• The primary functions is to produce
▫ sperm
▫ androgens (testosterone)
• Two main attachments of testis are
▫ Vas Deferens via epididymis
▫ testicular vessels

3. Temperature Regulation
• The testes work best
▫ at temperatures slightly less than core body
temperature.
▫ The spermatogenesis is less efficient at lower and
higher temperatures.
▫ This is presumably why the testes are located
outside the body.

4. Embryonic Development
• Around fourth week ante-natally,the gonadal rudiments
are present adjacent to the developing kidneys.
• Testes follow the "path of descent" from
▫ Lower pole of kidney in the retro-peritoneum
▫ Internal ring
▫ Inguinal canal
▫ Scrotum
• In most cases (97% full-term, 70% preterm), both
testesare normallydescended by birth.
• In most of the cases, only one testis fails to descend

5. What is Maldescended Testicle?
It consists of following conditions.
• Undescended Testicles
• Ectopic Testicles
• Retractile Testicle
• Ascending Testicle

6. Undescended Testicles
• Arrest of descent along its normal path of
descent is termed as Undescended Testicle
• It can have following locations
▫ High Abdominal near Kidney
▫ Low Abdominal near groin
▫ Emergent (Moving in and out of the abdomen)
▫ Inguinal
▫ High Scrotal

7. Ectopic Testis
• It means the testicle has moved away from its
normal path of descent
• After it emerges from the external inguinal ring
• Locations
▫ Superficial Inguinal Pouch
▫ Pubic
▫ Perineal
▫ Femoral

8. Clinical Classification
• Palpable
• Non-Palpable
▫ Abdominal
▫ Atrophy
▫ Absent

9. Palpable UDT
• It needs open orchiopexy
• Some of the undescended testis descends on its own
in first 2-3 months
• If it does not descent in first few months then it is
unlikely to do so
• At present the surgery is advocated at the age of six
months
• If surgery is delayed then the function of testis gets
affected due to higher temperature in abdomen and
chronic trauma to the testicle

11. Retractile Testis
• Testis at rest is located in the scrotum
• However, with stimulus it ascends in the
inguinal area
• Usually they don’t need any treatment

12. Ascending Testicle
• At birth the testis is located in the scrotum
• However, with the growth of the child, the testis
fails to remain in the scrotum and ascends in the
groin
• These patients needs to be operated to bring the
testis in the scrotum

13. Non-Palpable UDT
• This patients should be subjected to laparoscopy
around the age of six months
• Depending upon the findings on laparoscopy
further management is carried out

15. Role of imaging studies like
Sonography, CT Scan?
• We don’t advocate as
▫ they are not 100 % specific or sensitive
▫ they don’t change the plan of management
▫ Often confuses parents when the imaging findings
don’t match to the operative findings

16. Lap for Nonpalpable UDT
• If testis is located near the internal ring than the
testis can be brought to the scrotum in one
operation (65-70 %)
• If testis is located high in abdomen than it needs two
operation (8-10%)
• If testis is small in size than it is removed and
opposite side is fixed to prevent its loss due to
torsion (15-20%)
• If testis is absent or vanished than the opposite side
is fixed to prevent its loss due to torsion (4-5%)

17. What is laparoscopy?
• Small incision is taken near umbilicus
• Trocar is inserted in the incision
• Telescope is inserted trough the trocar
• Inside of the abdomen is visualised
• Then depending upon the findings one or two more
trocars are inserted in the abdomen
• Operating instruments are inserted in the abdomen and
testis brought in the scrotum in one or two operations

19. Pre-operative Preparation
• CBC
• Fasting before operation
▫ Four hours for breast milk
▫ Six hours for liquids
▫ Eight hours for solids

20. Post operative treatment
• Fasting for four hours
• Intravenous fluids continued for 6-8 hours
• Clear fluids started orally after four to six hours and
advance to full liquids followed by soft diet
• Oral Analgesics for pain for 48 to 72 hours
• Local antibiotic ointment
▫ After dressing is removed or if it comes out
• Discharge either on the same or next day
• Follow up after 5 days and dressing removal

21. If not operated patient can have
• decrease in the function of the testis
• higher incidence of malignancy
• late detection of malignancy
• 70 % incidence of associated patent processus
vaginalis
• higher incidence of torsion
• increased incidence of injury
• psychological issues

22. Investigations
• For Unilateral UDT: CBC (pre operative)
• For Bilateral Nonpalpable UDT
▫ Diagnostic and therapeutic Laparoscopy
▫ HCG Challenge test (presence of testicular tissue)
• In cases suspected to have disorder of sexual
differentiation
▫ Karyotyping
▫ Hormone levels: FSH, LH, AMH
▫ USG: Presence of Uterus: PMDS or CAH
▫ Micro-phallus: Hypopituitarism: Kallamann’s Syndrome

23. Cancer in UDT
• Incidence of malignancy in the undescended testis
▫ 1 in 80 with a unilateral undescended testis
▫ 1 in 40 to 1 in 50 for bilateral undescended testes.
▫ The peak age for this tumor is 15–45 yr.
▫ The most common tumor developing in an UDT is a seminoma (65%)
▫ in contrast, after orchiopexy, seminomas represent only 30% of tumors.
• Self examination of testis after orchiopexy
• Cancer developing in an intra-abdominal testis: late detection
• Recent data: that orchiopexy performed before puberty resulted in
a significantly reduced risk of testicular cancer

24. Fertility after Orchiopexy
• Unilateral UDT: Same as any other couple
• Bilateral UDT: More than 80 %