Cryptorchidism is also a common pediatric surgical condition, so let’s move on to a few of the most talked about issues in pediatric cryptorchidism.
Hey, where are the little balls?
Careful parents may find no testicles or only one testicle inside their child’s scrotum very early after birth, and careless parents will leave it alone until one day when they suddenly become more attentive, or when they are examined by a doctor for other problems.
So where are the little balls (testicles)? To understand this, we have to go back to the embryonic period. During the embryonic period, the testicles are initially in the abdomen, then gradually descend, cross the inguinal canal and normally enter the scrotum before birth. If there is some kind of disturbance (the etiology is not very clear), the testis stays somewhere in this journey, such as the inguinal canal, or the abdominal cavity, and does not enter the scrotum. Other times, the testicle is misdirected by some factor during its descent and goes to an abnormal location such as the perineum or the opposite side. There are also times when the testicles do not develop at all or develop very poorly due to problems with their blood supply during development. All of these cases will manifest as the absence of a testicle or only one testicle in the scrotum, which is what we call cryptorchidism.
On the contrary, the cryptorchidism diagnosed clinically is only the following possibilities: 1) the testicle is absent, there is no testicle at all; 2) the testicle is underdeveloped, too small to be seen and of no use; 3) the testicle is still well developed, hidden in the inguinal canal, or in the abdominal cavity, or in some abnormal location.
In some children, it was very sure that there was a testicle in the scrotum, but after the surgery for hernia or syringomyelia, the testicle on the same side was missing, mostly because the testicle was pulled into the groin, this is called medically induced cryptorchidism. Children who have had testicular surgery or inguinal surgery or whose hernia has been embedded before also have the possibility of testicular atrophy. Although the testicles are still in the scrotum, they will slowly become smaller and cannot even be felt.
In other children, the testicles seem to be very unfaithful, jumping up and down, disappearing one moment and coming back the next, looking in the scrotum one day and disappearing the next. This is called a wandering (retracted) testicle, where the testicle moves back and forth between the scrotum and the groin. Usually, as you get older, after the testicle has grown to a certain size, most of them will stop retracting into the groin and heal on their own; of course, there are a few that may become trapped in the groin and eventually require surgery for cryptorchidism.
Is there any problem with the testicle being in the groin or abdominal cavity?
The testicles have two major roles, one is to produce androgens to maintain male development and sexual characteristics, and the other is to produce sperm to produce the next generation, a well-deserved “family heirloom”.
Just as flowers and plants are suitable for living on balconies rather than in aisles and rooms, the right environment for testicles is the scrotum rather than the groin and abdominal cavity. A spacious scrotum does not restrict the growth of the testicles, while the testicles hidden in the groin are generally smaller than normal; the scrotum also automatically contracts according to the temperature of the environment, always keeping it 2-3 degrees lower than the abdominal cavity, and it is at this relatively cool temperature that the testicles will be able to produce sperm. If the testes are in the groin or abdominal cavity for a long time, even though they still have the ability to produce androgens, the sperm-producing function will most likely be nullified. Moreover, testicles in the abdominal cavity are more prone to torsion, testicles in the groin are more prone to trauma, and even worse: testicles not in the scrotum are more prone to malignancy.
It seems that cryptorchidism is really a problem, especially bilateral cryptorchidism, which is really a big problem!
When is the best time to have surgery?
No more hearsay, many concepts have been updated. It is no longer before the age of five, nor before the age of three, remember: the current domestic textbook clearly states: before the age of two! Surgery done late can do more harm than good. And the latest American Urological Association guidelines are: half to one and a half years old (plus full time if there is prematurity), so hopefully we won’t see any more delayed children.
Is it possible to try hormone shots?
This used to be the more popular approach, and to this day some hospitals are still trying to give Hcg shots to young infants with cryptorchidism, and empirically it seems to work for individual children, but some randomized double-blind studies have shown that the effect is not significant; in other words, individual children may have declining testes without the shots; and there are also studies that show some effects on both cryptorchidism and normal testes after Hcg injections. Therefore, the latest American Urological Association guidelines are that hormone therapy should not be used to induce testicular descent because the evidence suggests that response rates are low and evidence of long-term efficacy is also lacking.
So just observe within the age of half a year, and consider surgery directly after the age of half a year.
What tests are needed for cryptorchidism?
Generally speaking, the experienced hand of a specialist is essential. If you can touch it, it means that it is still developing well and is in the groin or under the skin of the perineum; if you cannot touch it, it means that the testicle is either poorly developed, in the abdominal cavity, or not at all. CT or MR can be useful in finding the testicles, but the accuracy is very limited and there are often misjudgments, so it is not a must.
What about those that cannot be palpated? Laparoscopy! It is different from the old days when the only way to find the testicle was to go into the abdominal cavity and explore it.
Is there anything special about cryptorchidism combined with hypospadias?
Yes, there is. If there is a bilateral cryptorchidism combined with hypospadias, a karyotype analysis must be done to rule out sexual development disorders (hermaphroditism). If necessary, even a biopsy of the gonads is required.
If there is both cryptorchidism and hypospadias, the principle of management is to treat the cryptorchidism first and then the hypospadias.
Is the surgery better lumpectomy or open?
I repeat: I don’t like to call lumpectomy a minimally invasive procedure, as if open is more invasive. Both lumpectomy and open have their own advantages and limitations, so it is better to choose the right one.
For those who can feel the testicles, a small incision is made directly in the groin, the spermatic vessels and vas deferens are fully released, the unclosed sphincter is ligated, and the testicles are placed in the scrotum and fixed. Laparoscopy is not necessary for this type of procedure. It is important to emphasize that the spermatic vessels and vas deferens are adequately freed, otherwise the secondary surgery may be quite difficult.
For those who cannot feel the testicles, laparoscopy is too much of an advantage! The presence or absence of the testes, their position, the condition of the testicular vessels and vas deferens, and the presence or absence of some malformation of the remaining Mullerian ducts can all be seen at a glance. The next step is to decide exactly what surgery is needed. Possible procedures are: stage I or II testicular descent (depending on whether the testicle can be placed in the scrotum in one go), orchiectomy (very poorly developed testicle), testicular biopsy (suspicion of the nature of the testicle), or transfer to open inguinal canal exploration (to see the testicular vessels and vas deferens into the groin).
Should I operate when the best time for surgery has been missed at the time of discovery?
There are various reasons for being delayed, and when the best time is missed, the testes may have lost their ability to produce sperm, but there will still be some ability to produce androgens, and surgery is still necessary. If the development is poor, simply removing it also eliminates the chance of malignancy. Put the testicles into the scrotum, so that even if the testicles become malignant, it will be easy to detect, if the malignancy is in the abdominal cavity is very difficult to be detected.
What should I do if my testicles are still underdeveloped after surgery?
Generally speaking, if the surgery is timely, the testicle after cryptorchidism can continue to grow, but it often cannot catch up with the normal testicle on the opposite side. What the surgeon can do is to move the flowers and plants that were hidden in the room to the balcony, that is, to fix the cryptorchid testicle into the scrotum as much as possible. If there is another normal testicle, it is reasonable to live normally and get married and have children, but if both sides are poorly developed, it will be a problem.
To sum up the treatment of cryptorchidism, it is recommended that if bilateral cryptorchidism is found after birth, especially if there is hypospadias, chromosome karyotype analysis is needed.
If unilateral cryptorchidism is found after birth, there is no need for hormone injection. Wait until half a year old (if there is a month premature birth, then wait until seven months).
Surgery can be done from half to one and a half years of age. For those who can feel the testicles, a small transverse inguinal incision will be performed.
If you can’t feel the testicles, laparoscopic exploration, 1, congenital deficiency, no way; 2, very poor development, removal; 3, development is good, estimated to be a one-time drop, do a phase I surgery, estimated not a one-time drop on the second phase, half a year later to do the drop. 4, found abnormal development of internal genitalia, gonads of suspicious nature, biopsy to determine whether the testicles.
What is needed is close follow-up, and once it is found to affect testicular development or turn into cryptorchidism, timely surgery.