Cryptorchidism is a condition in which the testicles do not descend into the scrotum, including incomplete testicular descent and testicular ectopia. The majority of cryptorchidism is a clinical condition in which the testes do not descend into the scrotum. The ectopic testis is most often located in the superficial inguinal fossa. 80% of cryptorchid testes are palpable, 20% are not palpable, approximately 20% of the non-palpable testes are testicular agenesis, and 30% are testicular atrophy. Children can retract their testes and usually only need follow-up to demonstrate that the testes are in a normal state and not retracted. The male karyotype must be confirmed when diagnosing bilateral anencephaly, and an endocrinological evaluation is necessary to help determine whether unilateral or bilateral testes are present.
I. Etiology
Cryptorchidism is caused by abnormal testicular descent. There are many factors that cause abnormal testicular descent, and the common ones are
1.Abnormality or absence of the testicular lead belt that introduces the testicle into the scrotum, to the extent that the testicle cannot descend to the scrotum from its original position.
2, congenital testicular hypoplasia makes the testes insensitive to gonadotropins and lose their descending power.
3. Luteinizing hormone-releasing hormone produced by the hypothalamus makes the pituitary gland secrete LH and follicle-stimulating hormone FSH, which can also affect the descending power of the testes. Most of the cases caused by endocrine factors are bilateral cryptorchidism, while most of the cases caused by other factors are unilateral cryptorchidism, and sometimes cryptorchidism can be combined with inguinal hernia.
Clinical manifestations
1.Infertility
Cryptorchidism can lead to damage of germ cells. Early surgical treatment is needed to fix the testicles in the scrotum to reduce the risk of reduced fertility. The earliest postnatal histological abnormality of cryptorchidism is mesenchymal dysplasia that can be observed in the first month after birth. Unilateral cryptorchidism after puberty should be removed because it is prone to malignancy and torsion in the future, and the vast majority of testes lose their fertility.
2.Malignant transformation
Children born with undescended testicles are at risk of testicular malignancy. The incidence of germ cell tumors in men with cryptorchidism is about 40 times higher than that in normal people. The position of the undescended testis influences the relative risk of tumor development in the testis; the higher the position, the greater the risk of malignancy. Half of all intra-abdominal testes develop malignant changes. The most common type of testicular tumor due to cryptorchidism is seminomatous cell tumor. The incidence of carcinoma in situ among patients with cryptorchidism is 1.7%.
3.Hernia
The sphincter is not closed in 90% of patients with undescended testes. The sphincter usually closes after testicular descent and within the first month of life. Sphincter non-closure is associated with a higher risk of epididymal abnormalities. The clinical significance of sphincter non-closure is that it can affect the effectiveness of hormonal therapy for cryptorchidism.
4. Testicular torsion
Cryptorchidism may have abnormal attachment of the testicular levator, levator muscle or abnormal attachment of the testicular sheath, which may predispose to testicular torsion. Although torsion rarely occurs in undescended testes, testicular torsion should be considered in cases of abdominal pain or groin pain with ipsilateral scrotal emptiness.
Examination
1, mainly for the non-palpable testis, in order to determine the presence of the testis and its localization, ultrasound can be used as a routine preoperative examination.
2.CT and MRI have no advantage over B ultrasound in diagnosing cryptorchidism. Testicular arteriogram and spermatic venogram are not recommended. In most cases, the choice of surgery, surgical method and improvement of cryptorchid function do not depend on the imaging results.
3.Laparoscopy is the current “gold standard” for cryptorchidism diagnosis, and treatment can be performed when locating.
4.For bilateral or unilateral cryptorchidism with short penis and hypospadias, HCG stimulation test, androgen, FSH, LH, MIS/AMH measurement, karyotype, genetic genetic measurement, etc. should be performed.
IV. Diagnosis
The diagnosis of this disease is generally not difficult. The differentiation between cryptorchidism, in which the testicles cannot be felt, and testicular agenesis should be taken seriously, and the latter does not require surgery.
V. Treatment
The ideal age for preserving fertility is 12 to 24 months after birth. The spontaneous descent of the testes can be completed within 3 months after birth. The decisive treatment for undescended testes should be completed between 6 and 12 months after birth, and this time is the best time to perform testicular descent fixation.
1.Hormone treatment
Cryptorchidism may be accompanied by hypothalamic-pituitary-gonadal axis abnormalities. Hormone therapy is administered with HCG, LHRH or a combination of both. Guidelines recommend βHCG for preoperative preparation of non-palpable cryptorchidism or some redo cases, which increases blood supply to the testis and facilitates surgery.
2.Surgical treatment
For those whose testicles have not descended to the scrotum even after 6 months of birth, early surgery should be performed. For adolescent patients with cryptorchidism, testicular descent fixation should be performed as soon as it is found. If the testicle is found to be atrophied or cannot descend into the scrotum during surgery, orchiectomy can be performed if necessary.
(1) Open surgery testicular descent and fixation: testicular descent and fixation is performed for those who can palpate the cryptorchid. Generally, an oblique incision is made in the groin to free the spermatic cord, ligate the unclosed sheath or hernia sac, and fix the testicle in the scrotum without tension.
(2) Laparoscopic surgery: indications: all non-palpable testes; diagnosis of suspected interstitial sex; biopsy or intra-abdominal high testicular resection. Contraindications: acute infection, coagulation abnormalities, previous history of abdominal surgery, suspected peritoneal adhesions.
(3) Autologous testicular transplantation: Applicable to high-grade cryptorchidism. The testicular vessels are ligated, the testis is transferred free into the scrotum, and the testicular vessels are anastomosed to the inferior abdominal wall artery. This is not a widely adopted approach and is not recommended as a routine surgical procedure.
VI. Prognosis
Testicular atrophy and necrosis occur in a few cases of unoperated cryptorchidism. Azoospermia can occur in 9% to 15% unilateral and 46% bilateral cryptorchidism in those who have had successful testicular descent fixation. Surgery cannot reduce the risk of tumor, but it can make the testis more accessible for examination.