I. Overview
Cryptorchidism, also known as incomplete testicular descent, is a condition in which the testes unilaterally or bilaterally do not descend into the scrotum but remain in a certain position in the descent pathway. In the early embryonic stage, the testes are located in the retroperitoneal space in the subdiaphragmatic plane and gradually descend as the embryo develops. The testis descends into the iliac fossa by the third month, approaches the inguinal ring in the fourth to sixth months, descends into the inguinal canal with the peritoneal sheath in the seventh month, and then descends into the scrotum with the peritoneal sheath in the eighth to ninth months. The proximal segment of the sphincter is atretic and becomes a cord, while the distal end remains open to form the testicular sheath cavity. The testis should descend into the scrotum at birth, but some infants may also descend shortly after birth.
The occurrence of cryptorchidism is associated with abnormal fetal development, which may be caused by maternal endocrine deficiency during the embryonic period, or by mechanical factors that block the testis somewhere during descent. The vast majority of cryptorchid testes are located in the groin, while those that rest in other areas are less common. According to the location of cryptorchidism, it can be divided into high cryptorchidism, low cryptorchidism and sliding testis. High cryptorchidism, i.e., the testis is located in the abdominal cavity from the lower pole of the kidney to above the inguinal ring opening (Figure 1). Low cryptorchid, in which the testis is located above the external inguinal ring orifice but cannot descend into the scrotum. Gliding testis, in which the testis is easily pushed into the upper scrotum or in the inguinal canal at the scrotum.
Cryptorchidism in infants has the possibility of descending on its own, so there is no need to rush to surgery and can be temporarily observed. However, it is generally believed that the possibility of the testicle continuing to descend after 6 months of birth is already very small, and the possibility of descending after 5 years of age is even smaller, so we should not wait blindly, and the best time for treatment is 6 to 18 months after birth.
The objectives of treatment include restoring the normal physiological environment of the testis, preserving the fertility of the patient and avoiding adverse psychological effects; reducing testicular malignancy; repairing the hernia sac associated with cryptorchidism; preventing testicular torsion; and reducing the risk of injury during exercise because the cryptorchidism is located in the groin area.
For low cryptorchidism, extra-scrotal syringomyelia testicular fixation is preferred. However, the treatment options for high and undetected testes are different, with Fowler-Stephens, staged Fowler-Stephens, laparoscopic testicular fixation, and revealed microvascular anastomosis with autograft being the more common approaches. In abdominal type high cryptorchidism, the length of the spermatic cord determines whether a staged testicular descent fixation can be performed. If the length of the spermatic cord is insufficient, the testis and the spermatic cord can be passed posteriorly through the subabdominal vessels, or the subabdominal vessels can be cut and ligated, and the fascia of the inner ring opening inward can be cut to reduce the angular course of the vas deferens. If the above treatment does not allow the testis to be placed into the scrotum or if it is in the scrotum but more tense, then a staged Fowler-Stephens procedure should be chosen. Laparoscopy has been widely used in recent years for the diagnosis and treatment of cryptorchidism, with the advantage of being able to clearly diagnose the location and nature of the testis and its high accuracy rate.
For patients with unilateral cryptorchidism after puberty, especially intra-abdominal cryptorchidism, if the opposite descending testicle is normal, and the epididymis often atrophies due to long-term exposure to high temperature, the chance of malignant transformation is also higher, so cryptorchidectomy is recommended. In principle, testicular prosthesis implantation should be done after orchidopexy regardless of the age.
Fig. 1 Common site of stay of cryptorchid
II. Diagnosis
The judgment of cryptorchidism is not difficult, and the scrotum is found to be empty by palpation (Figure 2). Most of them can be diagnosed by physical examination. During the examination, a warm environment should be provided, and the patient should adopt a lying position with legs slightly bent to relax the levator muscle, and the abdomen, inguinal region, perineum and scrotum should be carefully examined. Cryptorchidism that cannot be palpated in clinical examination accounts for about 20% of patients with cryptorchidism. According to the root statistics, 50% of them are in the inguinal canal, 20%-25% are in the abdominal cavity, 15% are below the external ring, while 10% are testicular agenesis. For these patients, HCG stimulation test should be performed first to identify the presence of testicular tissue, and serum testosterone, FSH and LH basal values should be measured before intramuscular injection of 1000-1500 IU of HCG 3 times a week for 3 weeks. If testosterone increased, the presence of testes was suggested. If the external genitalia of the child had normal morphology, FSH and LH values were elevated before stimulation, and testosterone did not respond after stimulation, the testes were suggested to be atrophied.
Figure 2
The localization of cryptorchidism is difficult, and in the past, we mainly relied on surgical exploration, but it is blind and traumatic, which increases the unnecessary surgical trauma for patients with orchidrosis. Ultrasound is the preferred imaging method for cryptorchidism, which is simple, inexpensive, painless, safe and reliable, and can be repeatedly and regularly examined, especially for young children. Monitoring the changes in size and position of cryptorchidism is of great significance for the clinical application of hormone therapy and the follow-up observation of therapeutic effect and surgical selection. For cryptorchidism that cannot be detected by ultrasound, further imaging diagnosis such as CT and MRI can be made, but it is still difficult for diagnosis and localization because it is difficult to distinguish the density and echogenicity of the testis from other soft tissues, and its accuracy has been a problem. Selective intra-seminogram and hernia capsule imaging method is an invasive examination by transvascular cannulation imaging, which is a more accurate means of examination, but due to the trauma and equipment requirements, the clinical application is limited, and it is more often used for older children. In recent years, laparoscopy has been applied very popularly, and its advantage is that it can clearly diagnose the location and nature of the testis, and it can simultaneously deal with the undescended testis and do one-stage or staged testicular fixation, playing a dual role of diagnosis and treatment. It is usually scheduled to be performed before surgery, and the exploration is centered on the internal ring opening to search for the course of the vas deferens and the spermatic cord structure to determine the presence and location of the cryptorchid. The development of laparoscopic technology not only makes the accuracy rate of localization and diagnosis of high cryptorchidism more than 95%, but also can eliminate the incision in the groin area and fix the testis in the scrotum.
III. Surgical treatment
(I) Descending testicular fixation
1. Indications for surgery
(1) Unilateral cryptorchidism in children.
(2) Children with bilateral cryptorchidism who still have not descended after endocrine treatment.
(3) Ectopic testis, wandering testis or cryptorchidism with inguinal hernia or traumatic testicular ectopic unsuccessfully repositioned by manipulation.
2. Contraindications to surgery
(1) Unilateral cryptorchidism after puberty, whether inguinal or intra-abdominal type, testicular fixation is of no practical significance.
(2) Severe endocrine abnormalities and reproductive defects.
(3) Those with severe mental and intellectual developmental disorders.
(4) Those with abnormal development of epididymis and vas deferens and other accessories that cannot transport sperm, and those with ejaculatory dysfunction.
3.Surgical procedures
(1) Anesthesia: Intraspinal anesthesia, continuous epidural block anesthesia, or local infiltration anesthesia. General anesthesia is used for pediatric patients.
(2) Position: supine position.
(3) Surgical incision: choose an oblique incision in the lower abdomen parallel to the inguinal ligament, and make an incision parallel to the inguinal ligament from 1 to 50 px above the midpoint of the inguinal ligament down to the pubic symphysis.
(4) Exposing the testis: The skin and subcutaneous tissues are incised in turn, and the tendon membrane of the external oblique abdominal muscle is cut to expose the inguinal canal. Most of the cryptorchid testes are located in the inguinal canal. If the testis cannot be found, the inguinal canal can be opened. In patients with combined inguinal hernia, the testis may be in the abdominal cavity, and the testis may enter the inguinal canal with the hernia sac by asking the patient to cough to increase the abdominal pressure.
(5) Release the testis and spermatic cord: cut the testicular tether, cut the testicular sheath, examine the testis, epididymis and vas deferens, remove the excess testicular sheath, and turn the testicular sheath over and suture the edge of the sheath continuously. The spermatic cord sheath is completely peeled off from the spermatic cord so that the spermatic cord is fully free and loosened until the testis can be retracted below the pubic symphysis. If the testis cannot be retracted below the pubic symphysis, the spermatic cord should be continued to be loosened upward from the inner ring to separate it from the extraperitoneal fatty tissue until the testis can be retracted below the pubic symphysis without tension (Figure 3 Figure 4).
(6) Closure of the peritoneal sphincter: If the sphincter is connected to the abdominal cavity, the sphincter should be closed with a circular suture at the inner ring (Figure 5). Be careful not to damage the spermatic vessels and vas deferens. If there is a combined inguinal hernia, a hernia repair should be performed.
(7) Construction of the testicular cavity: The scrotal cavity is gently dilated by separating the scrotum with the index finger through the deep fascia of the abdominal wall of the incision, reaching the base of the scrotum and separating a cavity between the meatus and the skin large enough to accommodate the testis (Figure 6).
(8) Securing the testis: A medium-sized silk thread is passed through the sheath or ligament below the testis without tying a knot, and the two thread tails are then passed outside the skin through the base of the scrotum to pull the testis into the extra-sarcoid cavity at the base of the scrotum. Close the syringomyelia incision, taking care not to twist the spermatic cord.
(9) Closure of the incision: Tighten the traction thread and tie it to the skin of the ipsilateral medial thigh. Close the incision in layers, taking care not to suture too tightly at the outer ring to accommodate one little finger, so as not to affect the blood flow to the testis (Figure 7).
4. Precautions
(1) For cryptorchidism located in the inguinal region or near the external ring, whether unilateral or bilateral, an oblique inguinal incision is used. For cryptorchidism located in the retroperitoneum, an oblique incision of the lower abdomen or an extended incision of the inguinal incision is used for unilateral cases; an arcuate incision of the lower abdomen or a median incision of the lower abdomen is used for bilateral cases.
(2) When releasing the spermatic cord, closing the peritoneal sphincter or performing hernia repair, damage to the spermatic vessels and vas deferens should be avoided.
(3) In some cases where the cryptorchid is high or the spermatic cord is really too short, the spermatic cord should be loosened and straightened and passed through the subcutaneous loop from the retroperitoneum into the scrotum in a straight line to eliminate the bypass length of the walking inguinal canal and increase the effective length of the spermatic cord to improve the chance of successful surgery.
(4) Cryptorchid that cannot be placed into the scrotum by various means can be temporarily left in the subcutaneous tissue of the groin, pending secondary surgery or autologous testicular transplantation. Testes suspected to be malignant or confirmed to be non-functional should be removed.
(ii) Fowler-Stephens testicular fixation
1.Surgical indications High cryptorchidism with long loop vas deferens
2. Contraindications to surgery
(1) The vas deferens is short and it is impossible to put the testis into the scrotum even if the spermatic cord vessels are cut.
(2) Testicular dysplasia.
(3) Segmental atresia or absence of vas deferens.
(4) Absence of the epididymis or separation of the epididymis from the testis.
(5) Bleeding from the testicular incision after blocking the spermatic cord vessels or bleeding stops within 5 minutes.
(6) If the length of the spermatic cord is found to be insufficient after routine freeing of the spermatic cord.
3.Surgical points
(1) Select a suitable incision to expose the cryptorchid in the abdominal cavity, and you can see the connection between the blood vessels in the spermatic cord and the testis, the vas deferens and the accompanying blood vessels like long loops bending downward from the inguinal ring to the hernia sac, and then turning back upward through the inguinal canal to enter the epididymis and the testis above the inner ring.
(2) Before dissecting the spermatic vessels, the internal spermatic artery is clamped with a non-invasive vascular clamp, and a small incision is made in the testicular sheath after 5 min to observe the bleeding situation.
(3) The testis is freed and the retroperitoneum is preserved along the vascular path of the spermatic cord to protect the collateral circulation as much as possible, and then the testis is fixed in the scrotum. In the first stage, the blood vessels in the spermatic cord will be severed only, and then the testis will be released and moved to the scrotum after 6-12 months.
4.Cautions
(1) Sometimes, the epididymis and vas deferens are found during surgery, but the testis cannot be found, i.e. the testis and epididymis are separated. Although the testis is not found after careful intraoperative search, treatment should not end with cutting the spermatic cord at the internal ring unless the testis is completely excluded from the abdominal cavity. However, staged testicular fixation increases the chance of vascular damage to the spermatic cord and postoperative atrophy occurs in 6-17% of testes.
(2) Sometimes the testis cannot be successfully lowered into the scrotum and further freeing of the vessels and allowing the spermatic cord to pass through the vessels is required, by severing the transverse abdominal fascia and crossing the subabdominal vessels to lower the spermatic cord vessels.
(C) Autologous testicular transplantation
1. Indications for surgery
(1) High intra-abdominal cryptorchidism, which is not suitable for testicular descending fixation and staged testicular fixation due to anatomical reasons.
(2) Injury to the spermatic cord due to trauma or surgery that cannot be repaired.
(2) Contraindications to surgery: Adult unilateral cryptorchidism with atrophy.
3.See Chapter 1, Section I. Application of microsurgical techniques in urology.
3.1 Anesthesia: Epidural anesthesia or general anesthesia
3.2 Position: supine position.
3.3 Use ipsilateral inguinal canal incision or paramedian rectus abdominis incision according to the location of the cryptorchid, and explore the cryptorchid from the external ring opening to the inferior pole of the kidney.
3.4 Dissect the inferior abdominal wall artery and vein: after freeing sufficient length, the distal end of the vessel is ligated and the proximal end is blocked with a miniature vascular clip, and heparin procaine solution is dripped around the vessel and saline gauze is used to protect it for anastomosis.
3.5 Freeing the spermatic vessels: the arteries and veins within the proximal spermatic cord are cut off and the vessels are freed, preserving the perivascular strip of retroperitoneum as much as possible. The testicular artery is cut at a high level, the distal testicular end is ligated, the proximal testicular end artery is micro-arterially clamped, the artery and vein are irrigated with heparin solution, and the outer membrane and parietal membrane of the dissected end are trimmed under the microscope.
3.6 Vascular anastomosis: Under the surgical microscope, the internal spermatic artery and vein were anastomosed end-to-end with the subabdominal wall artery and vein respectively using 10-0 nylon thread. The venous clamp was removed first, then the arterial clamp was removed, and the blood flow to the testis was allowed to recover.
3.7 Fixation of the testis: The deep fascia of the abdominal wall is passed through the internal ring to the bottom of the scrotum with fingers to form the descending channel of the testis. The testis scrotum is fixed, and if the vas deferens is not long enough, it can be freed in the direction of the pelvis, taking care not to injure the nutrient vessels, and then the incision is closed in sequence.
4. Precautions
4.1 Rest in bed for 1 week and pad the scrotum to facilitate reflux.
4.2 Closely observe the size, hardness and temperature of the testis. If the testis is obviously enlarged and the scrotum is severely edematous, the pressure should be reduced immediately; if necessary, ultrasound scan should be performed to observe the blood flow.
4.3 Routinely apply low molecular dextran intravenous drip, 500-1000ml/d for 1 week, and discontinue if the oozing is severe.
4.4 Apply small doses of vasodilators, such as 654-2 and poppy bases; anticoagulants, such as pansentin.
4.5 Check testicular blood flow by Doppler ultrasound or radioisotope scan 3 months after surgery.
(iv) Laparoscopic testicular fixation
1. Indications for surgery
(1) The presence or absence of testis and its position cannot be determined by palpation and ultrasound examination.
(2) Intra-abdominal cryptorchidism or bilateral cryptorchidism.
2. Contraindications to surgery
(1) Those who have a history of abdominal surgery.
(2) Those who are extremely obese.
3. Key points of surgery
(1) Anesthesia: general anesthesia.
(2) Position: head low and foot high.
(3) Establish a pneumoperitoneum with a curved incision at the lower edge of the umbilical fossa, 12.5px long, and a transverse incision in the left mid-abdomen and right lower abdomen, 12.5px long, with a 5mm Trocar placed.
(4) The vas deferens can be seen on both sides of the base of the bladder, and the spermatic vessels can be seen on the lateral side of the vas deferens. The intra-abdominal cryptorchid is mostly located between the lateral side of the base of the bladder and the inner ring.
(5) The peritoneum was incised on the lateral side of the spermatic vessels, and then the testis was found along the vessels. Microscopically, the testis was seen to be pink with a smooth surface, and the testis was connected to the testicular lead on one side and to the epididymis and vas deferens on the other side (Figure 8).
(6) A small incision is made in the scrotal skin of the affected side and a space to accommodate the testis is separated under the meatus. The meatus is incised and the testis is entered into the abdominal cavity from the meatus fossa through the external ring of the inguinal canal, the inguinal canal between the medial umbilical fold and the median umbilical fold, and between the suprapubic branch and the rectus abdominis muscle, and the testis is pulled into the scrotal fossa through the inguinal canal with grasping forceps, and the testis is sutured and fixed to the meatus.
Figure 8
4.Cautions
(1) The separation process should be operated carefully, do not damage the spermatic cord vessels and vas deferens, and do not pull excessively to prevent testicular ischemia caused by vascular spasm.
(2) The spermatic cord vessels should be fully free, and there should be enough length to perform one-stage fixation, and the traction of the testis to the scrotum should be tension-free to avoid ischemic atrophy of the testis.
(3) If the testis is found to be hypoplastic or atrophied, orchiectomy should be performed directly under laparoscopy, the spermatic cord vessels should be severed by clamping, and the testis should be removed for biopsy.
(4) An inguinal hernia or unclosed sphincter is found close to the internal ring. If an unclosed sphincter is seen, it suggests that the testis or vestiges may be present distally. If the blind end of the spermatic vessels is seen microscopically or if the vas deferens and spermatic vessels are not developed, testicular agenesis is confirmed. If the blind end is not seen, careful examination of the abdominal cavity up to the lower pole of the kidney may reveal a high gonad.
(5) Intraoperative attention to hemostasis To prevent postoperative scrotal hematoma.
(6) Close the internal ring to prevent leakage of CO2 into the scrotum, which may cause scrotal emphysema.
(E) Surgical complications and management
1. Bleeding: Mostly due to rough intraoperative operation and incomplete hemostasis. Small bleeding in the scrotum can be treated by unobstructed drainage or extraction of blood, cold compresses and pressure on the scrotum. If there is blood flow from the wound drainage or progressive scrotal enlargement after surgery, the sutures should be removed, the hematoma should be cleared, the bleeding should be completely stopped and drainage strips should be placed.
2. Infection: mostly caused by chronic scrotal skin infection, unclean skin cleaning, poor disinfection, more tissue damage during surgery, failure to place drains or poor drainage and improper postoperative care. After infection occurs, anti-infection treatment should be strengthened, local hot compresses or other physical therapy should be applied, and drainage should be kept unobstructed. If there is abscess formation, it should be incised and drained.
3.Vas deferens injury: Mostly caused by the operator’s careless operation. Once the damage is done, a vasovaginal anastomosis should be performed.
4. Testicular retraction: Mostly due to incomplete release of the spermatic cord during the operation, and the testicle is barely pulled into the scrotum without corresponding traction. If it retracts to the upper part of the scrotum, observation can be continued; if it retracts above the external ring, testicular fixation is needed again.
5, testicular ischemic necrosis: mostly due to excessive free spermatic cord and high tension of the spermatic cord, as well as the external ring opening is too small and other reasons. In the early stage, the pressure on the spermatic cord can be lifted by surgery. Once it is clear that the testicle is necrotic, the necrotic testicle should be removed.
6, testicular atrophy: mostly due to intraoperative damage to the spermatic cord vessels, torsion of the spermatic cord and postoperative traction on the testis with excessive force, long-term ischemia of the testis can cause testicular atrophy.