This document discusses recent trends in the management of undescended testes. It begins with definitions and prevalence rates of undescended testes. It then covers the development of the testes, the phases of testicular descent, and factors that can affect descent. Risk factors for undescended testes like genetics, syndromes, and environmental exposures are outlined. Complications include reduced fertility, torsion, and testicular cancer. Diagnostic tools like ultrasound, CT, MRI, and laparoscopy are discussed. Management includes hormonal therapy or surgical orchiopexy depending on factors like age and palpability. Surgical techniques for orchiopexy like inguinal and trans-scrotal approaches are described.
Rectal prolapse (Surgical anatomy of rectum, pathology and management0sunil kumar daha
Please find the powerpoint on Rectal prolapse. I tried present it on understandable way and all the contents are reviewed by experts and from very reliable references.
Disclaimer: A lot from this slides were taken also from https://www.slideshare.net/babysurgeon/scrotal-swellings-1 (Dr Selvaraj Balasubramani)
This covers only :
ANATOMY
CAUSES
TORSION OF TESTIS
EPIDIDYMO-ORCHITIS
HYDROCELE
EPIDIDYMAL CYST
VARICOCELE
Rectal prolapse (Surgical anatomy of rectum, pathology and management0sunil kumar daha
Please find the powerpoint on Rectal prolapse. I tried present it on understandable way and all the contents are reviewed by experts and from very reliable references.
Disclaimer: A lot from this slides were taken also from https://www.slideshare.net/babysurgeon/scrotal-swellings-1 (Dr Selvaraj Balasubramani)
This covers only :
ANATOMY
CAUSES
TORSION OF TESTIS
EPIDIDYMO-ORCHITIS
HYDROCELE
EPIDIDYMAL CYST
VARICOCELE
OPEN INGUINAL HERNIA REPAIR- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #openinguinalherniarepair #usmle #babysurgeon #surgicaltutor
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• I have already uploaded videos on open and Laparoscopic Appendicectomy, Thyroidectomy, Modified Radical Mastectomy and open and
Laparoscopic Cholecystectomy
• In this video today, I have discussed Open Inguinal Hernia Repair.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful.
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
• Thank you for watching the videos.
POSTERIOR URETHRAL VALVES- Pediatric Surgery
• Dear viewers,
• Greetings from “ Surgical Educator”
• Today I have uploaded one more video in Pediatric Surgery/Pediatric Urology- “ Posterior Urethral Valves”
• Posterior Urethral Valves is the congenital cause for Bladder Outlet Obstruction, resulting in abnormal development of the kidneys as well as the bladder.
• In this video, I talked about the learning outcomes, introduction, etiopathogenesis, clinical features, investigations, differential diagnosis, treatment, follow-up and prognosis of “ Posterior Urethral Valves”
• I hope you will enjoy the video for its educational value.
• You can watch all my teaching videos in the following links
• surgicaleducator.blogspot.com youtube.com/c/surgicaleducator
• Thank you for watching the video.
SIGMOID VOLVULUS- GENERALISED ABDOMINAL PAIN
#surgicaleducator #generalisedabdominalpain #sigmoidvolvuus #usmle #babysurgeon #surgicaltutor
Subscription Link: http://youtube.com/c/surgicaleducator...
Surgical Educator Android App link: https://play.google.com/store/apps/de...
• Dear Viewers,
• Greetings from “Surgical Educator”
• Today I have uploaded a video on Sigmoid Volvulus- a didactic lecture.
• It is one of the life-threatening surgical problems you see in surgical wards.
• I have discussed the various causes for Generalised Abdominal Pain, epidemiology, etiology, pathology, clinical features, investigations, and treatment of Sigmoid volvulus.
• I have also included a mind map, diagnostic algorithm and a treatment algorithm for Sigmoid Volvulus.
• I hope the video will be very useful and you will enjoy it.
• You can watch all my surgical teaching videos in the following link:
• youtube.com/c/surgicaleducator
• Thank you for watching the video.
OPEN INGUINAL HERNIA REPAIR- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #openinguinalherniarepair #usmle #babysurgeon #surgicaltutor
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• I have already uploaded videos on open and Laparoscopic Appendicectomy, Thyroidectomy, Modified Radical Mastectomy and open and
Laparoscopic Cholecystectomy
• In this video today, I have discussed Open Inguinal Hernia Repair.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful.
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
• Thank you for watching the videos.
POSTERIOR URETHRAL VALVES- Pediatric Surgery
• Dear viewers,
• Greetings from “ Surgical Educator”
• Today I have uploaded one more video in Pediatric Surgery/Pediatric Urology- “ Posterior Urethral Valves”
• Posterior Urethral Valves is the congenital cause for Bladder Outlet Obstruction, resulting in abnormal development of the kidneys as well as the bladder.
• In this video, I talked about the learning outcomes, introduction, etiopathogenesis, clinical features, investigations, differential diagnosis, treatment, follow-up and prognosis of “ Posterior Urethral Valves”
• I hope you will enjoy the video for its educational value.
• You can watch all my teaching videos in the following links
• surgicaleducator.blogspot.com youtube.com/c/surgicaleducator
• Thank you for watching the video.
SIGMOID VOLVULUS- GENERALISED ABDOMINAL PAIN
#surgicaleducator #generalisedabdominalpain #sigmoidvolvuus #usmle #babysurgeon #surgicaltutor
Subscription Link: http://youtube.com/c/surgicaleducator...
Surgical Educator Android App link: https://play.google.com/store/apps/de...
• Dear Viewers,
• Greetings from “Surgical Educator”
• Today I have uploaded a video on Sigmoid Volvulus- a didactic lecture.
• It is one of the life-threatening surgical problems you see in surgical wards.
• I have discussed the various causes for Generalised Abdominal Pain, epidemiology, etiology, pathology, clinical features, investigations, and treatment of Sigmoid volvulus.
• I have also included a mind map, diagnostic algorithm and a treatment algorithm for Sigmoid Volvulus.
• I hope the video will be very useful and you will enjoy it.
• You can watch all my surgical teaching videos in the following link:
• youtube.com/c/surgicaleducator
• Thank you for watching the video.
The cause for infertility could be in the male or the female or both or neither-as in ‘Unexplained Infertility.’
Male infertility is usually caused by problems that affect either sperm production or sperm transport.
thoracic aortic injuries are very rare, this presentation will give a brief idea regarding the presentation of Thoracic aortic injury and its management
The Americal Association for the Surgery of Trauma - guidelines for intestinal injury- grading and a brief description of duodenal injury and few Most common Questions
Short eye Examination components - that will tell you the main headings of an eye examination in trauma victims.
drawaneeshkatiyar@gmail.com - for further communication.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
1. Recent trends in Management of
Undescended Testes
Dr Awaneesh Katiyar
Institute of Medical Sciences, BHU ,Varanasi
2. Introduction
• Definition:- Failure of the testis to descend into
the scrotum.
• Most common genital disorder identified at birth.
• Premature infants- 33%
• Full term at birth- 2-4%
• At age 1 year- 1%
3. • Unilateral : Bilateral
68% : 32%
• Right : Left
70% : 30%
• Palpable : Nonpalpable Testes
80% : 20%
Left undescended
testis
7. Descent of Testis
• The gubernaculum, the guide for testicular
descent.
• Hormone testosterone and INSL3 peak
between 14 and 17 weeks’ - critical for
testicular descent.
8. Phases of testicular descent
Barteczko and Jacob (2000)
• Phase 1: 5 weeks - The caudal mesonephros contacts
the future gubernaculum at the internal inguinal ring.
• Phase 2: 7 weeks -The genitofemoral nerve
accompanies the newly formed gubernaculum and
processus vaginalis.
• Phase 2a: 8 to 10 weeks - Growth of the gubernaculum.
• Phase 3: 10 to 12 weeks - Gubernaculum remains a
thin cord in both sexes.
9. • Phase 3a: 12 to 14 weeks - The testis overrides the
genital ducts and contacts the gubernaculum.
• Phase 4: 14 to 20 weeks - Migration of the processus
vaginalis produce widening of the inguinal canal
• Phase 5: 20 to 28 weeks - Release of the distal
subcutaneous attachment of the gubernaculum and
transinguinal passage of the testis.
• Phase 5a : after 7th month – Caudal movement of the
testis, regression of the gubernaculum .
11. Mechanical Factors
• Gubernaculum – John Hunter(1762) coined term
Gubernaculum.
• Important-
Mechanical Factor
• Mesenchymal band
Lower pole of testis to scrotum
13. Hormonal Factors
Androgen and its receptor
• Engle (1931) – Intact hypothalmic-pituitary-
testis axis is essential for normal testicular
descent.
• Cryptorchidism associated with
– Hypogonadism
– Androgen insensitivity
– CAIS
14. Estrogens
• Estrogens – Impairs gubernacular development
and to cause persistence of müllerian duct
derivatives.
• Gill and associates – increased incidence of
cryptorchidism in male offspring of women
treated during pregnancy with DES.
• Bernstein and colleagues- male infants born to
mothers with high levels of free estradiol- had
higher frequency of cryptorchidism
15. Testicular ascent
• In past – considered as misdiagnosis caused by an
error in physical examination.
• 32%- 50% - in retractile testis.
• Typically unilateral (77%)
• Identified at mid-childhood.
• Located distal to the inguinal canal.
16. Lockwood theory of Ectopic testis
• Multiple gubernaculum / tails present to
anchor testis from base.
• When scrotal tail gets
ruptured or weakened
at any point,
• Accessory tails act
and pull Ectopic testis
17. Positions of the ectopic testis. The ectopic testis can be identified in various positions, as
shown. The most common location is the superficial inguinal pouch.
Contralateral
scrotum
Perirenal
Peripenile
Superficial
inguinal
Transverse
scrotal
Femoral
Perineal
18. Risk Factors for UDT
• Maternal & Gestational Factors
– Maternal Obesity
– Low birth weight
– Prematurity
(Hakonsen et al, 2014).
Maternal smoking- small-to-moderate increased risk
for cryptorchidism is present in offspring.
19. Genetic Factors
• 14% of cryptorchid boys – have positive
family history.
• Multifactorial pattern transmission
• Father affected – 4%
• Sibiling affected – 6-10 %
• Gene mutation have identified -cryptorchidism
– INSL3
– LGR8
– Androgen receptor polymorphism
– HOXA10
– HOXD13
21. Syndromes Associated with UDT
• Reduce androgen production and/or action,
such as androgen biosynthetic defects,
• Androgen insensitivity
• Leydig cell agenesis,
• Gonadotropin deficiency disorders.
• Klinefelter syndrome (47,XXY)( 1.8%),
• Down syndrome (trisomy 21),
22. • All cases of classic prune-belly
• 80% of those of spigelian hernia
• 41% - 54% of cerebral palsy
• 15% of myelomeningocele
• 16% - 33% of omphalocele,
• 5% - 15% of gastroschisis
• 19% of imperforate anus
• 12% - 16% of posterior urethral valve
• 6% of umbilical hernia
24. Reduced fertility
• Decreased fertility – well known consequence
of cryptorchidism.
• 10-13% boys with – Unilateral UDT
• 33-36% boys with – Bilateral UDT
• Retractile testis – Intrinsically normal.
25. Investigations
• Undescended testis - clinical diagnosis.
• Clinically palpable testis – no role of imaging
• Non palpable testis
– Imaging
– Hormonal assessment
– Laparoscopy
27. • Other imaging tool like CT scan or MRI is not
recommended.
• Hazard of ionizing radiation- CT scan.
• MRI – overall sensitivity for detection -62%
– 55% - totally intra-abominal
– 86% - for inguinoscotal
• MRI – poor test for atrophied testis
28. Diagnostic Laparoscopy
• Gold Standard for non-palpable testis.
• Possible anatomic finding
– The spermatic vessels enters the inguinal canal
(40%).
– A canalicular or peeping testis (11.2%).
– The Spermatic vessels end blindly (9.8%).
– A Viable intra-abdominal testis (37%).
29. Management of undescended testis
• Cryptorchid testis should be treated – between 6
month to 1 year of age.
• 12-18 months – histological deterioration of the
testis noted.
• Testis rarely descends – after 6 months.
• Surgical advantage to Orchiopexy- within 6
months specially in high undescended testis.
30. Undesceded testis
unilateral
palpable Non palpable
surgery
Refer to 6 months
Low testis
Hormone
therapy
Failure
surgery
Normal external
Genitalia
Hypospadias
or ambigous
genitalia
Diagnostic therapeutic
laparoscopy or open surgery
Pre-op hormone therapy
Hormone
therapy
failure
High
testis Not Intersex
Refer to 6 months
Newborn
Older child
31. Bilateral
Palpable Palpable
Intersexual
Management
by diagnosis
Refer to 6
months
Hormone
therapy
for low
testis
Failure
surgery
surgery Measure LH, FSH,
MIS, hCG
stimulation test
Positive Negative
Laparoscopy or
open surgery
Probable
agonadal
consider
surgery
NonpalpableNonpalpable
Undesceded testis
32. Non-surgical
Only used for
palpable or
unilateral UDT
Surgical
Hormonal therapy
Palpable Nonpalpable
Inguinal / scrotal orchidopexy
evaluate
High inguinal Intra-
abdominal
Laparoscopic
surgery/ open
Management
33. Hormonal therapy
hCG (human Chorionic Gonadotropin)
• Stimulate endogenous secretion of testosterone.
• Therapeutic dose – 1500 U/ m2 body surface area
twice in a week for 4 weeks (FDA approved).
• Total dose should not exceed 15,000 units.
• Testicualar descent rate
– 25% with hCG
– 18 % with GnRH
34. • LHRH- 1.2 mg/ day in divided doses intranasal
for 4 weeks .
• Testicular descent rate –about 20%.
• Not FDA approved
• Boserelin – superanalogue of LHRH
– Small dose- 10µg every other day for 6 months.
– Descent rate – 17%
35. Hormonal assessment for
bilateral Non -palpable testes
Cryptorchidism Anorchidism Female
Pseudohermaphroditism
Karyotype 46,XY 46,XY 46,XX
Serum testosterone
Baseline Normal Low Variable
hCG stimulation test Positive Negative Negative
Gonadotropins Normal incresed Normal
AMH/MIS Positive Negative Negative
Adrenal steroid
precursors
Normal Normal increased
36. Surgical Management
• Palpable testes
• one stage orchidopexy
• Non- palpable testes
• Laparoscopy / open
• High incidence of congenital inguinal hernia (hernia
repair)
• Retractile or ectopic testes
• Cremasterotomy
38. Inguinal Orchidopexy
• Most commonaly performed – creation of
subdartos pouch and placing the testis.
• General anesthesia; useful to re-examine the
child- previously nonpalpable testis may become
palpable.
• Groin crease incision is made Careful dissection
to expose the external oblique aponeurosis and
the external ring.
39. (Adapted from Hinman F, Baskin LS. [2009]
Hinman’s atlas of pediatric
urologic surgery. Philadelphia: Elsevier.)
42. • A high ligation of the hernia sac is performed, and
the remaining structures are skeletonised
43. • Stephen-Fowler’s technique-
– when cord length is still required
– soft clamp is applied to the testicular artery
– viability of testis is checked.
– If it is viable testis can bring down safely to the
scrotum.
44. Obsolete procedure
• Ombredanne’s operation- when testis is
passed into the opposite scrotum through an
opening on the scrotal septum.
• Ladd and gross procedure - after placing the
testis in the scrotal pouch, it is fixed by a
polypropylene suture into tunica albuginea,
across scrotal skin and into the thigh skin
outside.
45. • Keetley – Torrek procedure - testis is
mobilized and is brought into the scrotal pouch
first. A pouch is created on the medial aspect
of thigh outer to the fascia lata. Testis is
delivered from scrotal pouch is placed into the
thigh pouch.
46. Trans-scrotal Orchidopexy
• Testes that are low in the canal believed to be
ectopic are good candidates
for trans-scrotal approach.
• Incisions
– Superior scrotal
– Low scrotal
– Midline scrotal
47. Surgery for the Non palpable Testis
• Examination under anaesthesia- remains non-
palpable.
• Laparoscopy - Gold standard
Conclusion: Results of open versus laparoscopic orchiopexy procedures (primary or
staged) are fairly comparable. However, laparoscopy provides significantly less
morbidity.
48. • Contraindications to laparoscopy –
– Prior abdominal surgery with potential peritoneal
adhesions.
– A body habitus that will not allow for proper
placement of abdominal wall ports.
49. • Laparoscopy - best means of identifying intra-
abdominal testis, vas and vessels.
• If laparoscopy indicates blind-ending gonadal
vessels and vas deferens, the patient is said to
have vanishing testis syndrome and no further
action is necessary
50. High left testis
Closed
internal ring
Blind-ending
vessels
Vas deferens
High intra-abdominal testis identified on
laparoscopic evaluation. Left testis identified
high in the abdomen is associated with a closed
internal ring.
Vanishing testis noted on laparoscopic
evaluation. Note the blind-ending spermatic
vessels and vas deferens.
51. • If intra-abdominal testis identified consider
staged orchidopexy or microvascular transfer.
• If vas vessels seen entering inguinal canal, the
groin should be explored.
• The length of the gonadal vessels is the
limiting factor to getting the intra-abdominal
testis into the scrotum.
52. Conclusion-
• Vasa and vessels blind ending above the IR as the only finding that
would benefit from laparoscopy only.
• If testis is not visualised and vessels are going into IR , surgical
exloration is mandatory to avoid clinical as well as legal long term
follow up.
53. Laparoscopic procedures
1. Primary one-stage orchiopexy with preservation
of the spermatic vessels
2.Division of the spermatic vessels as the first stage
of a two-stage Fowler-Stephens orchiopexy
The second stage of a two-stage Fowler-Stephens
orchiopexy can also be performed laparoscopically.
3. Orchiectomy.
55. • Mobilization of any
structures extending
distal to the internal
ring, including
epididymis/vas and
Gubernacular remnant
testis
56. • Transection of the peritoneum lateral to
the vessels and distal to vas.
• Proximal mobilization of the
vessels while maintaining
collateral blood supply between
the vas and spermatic vessels if
a Fowler-Stephens maneuver
becomes necessary ( short
spermatic cord)
(Adapted from Hinman F, Baskin LS. [2009] Hinman’s atlas of pediatric
urologic surgery. Philadelphia: Elsevier.)
57. • Initial mobilization of the gubernaculum to be used as a
handle for further mobilization of the testis, and
minimal use of cautery during this maneuver.
• Ability to mobilize the testis to the opposite internal
ring has been used as a measure of adequate length for
placement in the scrotum but is not predictable in some
series.
• Once mobilized, the testis is brought through a new
hiatus at the level of the medial umbilical ligament or
through the existing internal inguinal ring.
58. 1. Standard single stage orchidopexy
2. A two-stage Fowler-Stephens orchidopexy
The testicular artery is sacrificed.
• The rationale is that the testicular arterial supply comes
from three sources.
• At a 2nd stage (after 6 months of age, when collaterals
have formed), the testis is brought down on a wide
pedicle of peritoneum containing the remaining vessels.
59. Many recent studies supported that laparoscopic Orchidopexy
better than open for non palpable techniques.
61. Microvascular testicular
autotransplantation
• For high intra-abdominal testis
• Reserved for older children with internal
spermatic artery large enough to be
anastomosed to inferior epigastric artery.
62. Autotransplantaion of testes using microvascular technique
(silber and kelly )
principle: cutting of spermatic vessels and re-anastmosis to inf. Epigastric vs using
10/0 sutures under microscopy.
63. Refluo Testicular Autotransplantation
• Provides only venous drainage by
microvascular anastomosis of testicular veins
to inferior epigastric veins
• Based on discovery that failure in Fowler-
Stephens was due to testicular congestion
64. Orchidectomy : Usually reserved for
postpubertal men with a contralateral normally
positioned testis.
65. Postoperative Complications
• Haematoma
• Infection
• Unsatisfactory position (requiring revision),
• Ilioinguinal nerve injury
• Damage to the vas
• Testicular atrophy
• Torsion testis.
66. CONCLUSION
• The etiology of testicular maldescent remains
unknown.
• Knowledge of hormonal correlation with
undescended has improved.
• For palpable testis - Inguinal Orchidopexy
remains gold standard.
67. • Recent advancement in laparoscopic tool has
significantly changes management of UDT.
• Diagnostic Laparoscopy, replaces all imaging
modalities including Ultrasonography & MR.
• Open Orchidopexy to Laparoscopic
Orchidopexy for non palpable testis.