What is cryptorchidism?
Cryptorchidism refers to a malformation in which the testicles of a male infant do not descend from the lumbar region behind the peritoneum to the scrotum in accordance with normal development.
The majority of cryptorchidism is a clinical condition in which the testicle does not descend sufficiently. The ectopic testis is most often located in the superficial inguinal fossa. 80% of cryptorchid testes are palpable, 20% are not, and approximately 20% of the non-palpable testes are testicular agenesis.
Causes
Endocrine factors
Hypothalamic-pituitary-gonadal axis imbalance, androgen, estrogen, anti-Mullerian duct hormone, INSL3 deficiency or insensitivity.
Anatomical factors
Abnormal attachment of the sphincter; abnormal development of the inguinal canal, small opening of the internal ring or mechanical obstruction of the entrance to the scrotum; short spermatic vessels or vas deferens; abnormal development of the testes and epididymis, etc.
Genetic factors
The incidence rate of cryptorchidism is 4.25 times higher in people with family history of cryptorchidism than in those without family history, and some people also found that there is Y chromosome deletion in patients with cryptorchidism through genetic testing.
Environmental factors
Such as some pesticides, insecticides, chemical materials, etc. These substances or their decomposition products can affect humans and produce estrogenic or anti-androgenic effects, thus causing cryptorchidism to occur.
Clinical symptoms
Cryptorchidism can occur unilaterally or bilaterally, unilateral is more common, and the incidence of unilateral is higher in the right side. Children usually have no conscious symptoms. Cryptorchidism is often accompanied by unclosed sphincter, which can be manifested as syringomyelia or inguinal hernia. The scrotum on the affected side is obviously dysplastic, asymmetrical on the left and right side in unilateral scrotum, small and flat in bilateral scrotum, lack of skin folds, light pigmentation, and empty scrotum on the lesioned side, and the testicles cannot be found during examination. (In children, because the testicular reflex is relatively active, after stimulation such as cold or fright, the contraction of the testicular muscle can lift the testicle into the inguinal canal. Hot tub baths can help to distinguish retractable testes from true cryptorchidism. Retractable testes can often descend to the scrotum after hot tub baths, while true cryptorchidism cannot.
Decreased fertility or sterility – The temperature of the scrotum is lower than body temperature and the testes are in the abdomen or groin, where the temperature is higher for the development of germ cells and can cause irreversible damage.
Testicular injury – Testicles located in the inguinal canal or near the pubic tubercle are superficially located, fixed, and vulnerable to direct injury from external forces.
Cryptorchid malignant transformation – the chance of malignant transformation into testicular tumor is more than ten times or tens of times higher than that of normal testis.
Cryptorchidism with abnormalities – often accompanied by deformities of the vas deferens and epididymis.
Mental damage – often causes low self-esteem in older children.
Ancillary tests
Ultrasonography – Ultrasound is easy to perform and non-invasive, and is currently the main imaging method for patients with cryptorchidism.
Examination – Cryptorchidism appears on CT as an ovoid soft tissue mass shadow of about 1 to 3 cm at the site of normal testicular migration, varying in size, with clear borders, bright outline, uniform density, and mild enhancement after enhancement.
Laparoscopy is safer and more accurate, especially for patients of all ages, and it can also free and release the testes and spermatic vessels under the microscope at the same time, and fix the testes in the scrotum in one stage, that is, the diagnosis and treatment of cryptorchidism can be completed in one stage.
Treatment principle
After the diagnosis of cryptorchidism is clear, treatment should be done as soon as possible to lower the abnormal position of the testis to the normal scrotal position. （If the testicle does not descend 6 months after birth, there is very little chance that it will descend on its own. 6 months later, it can cause irreversible damage to the function of the testicle, so it is recommended to have surgery at the earliest possible time. (Treatment of cryptorchidism must be completed before 2 years of age.)
Compared to the side effects of hormones, surgery is currently a reliable treatment for cryptorchidism.
Basic procedure: For cryptorchidism in which the testicles can be palpated in the groin, the traditional way is to use an oblique inguinal incision, fully free the spermatic cord and testicles, ligate the hernia sac at the inner ring of the inguinal canal, and fix the cryptorchid at the scrotum.
In our hospital, we use transverse inguinal incision or Bianchi incision at the edge of scrotum, which is beautiful and difficult to see the scar after healing.
Laparoscopic treatment: It is suitable for high cryptorchidism whose testicles cannot be reached in the groin. If the blind end of the blood vessel is seen along the spermatic cord, the testis can be identified as a testicular defect, and if there is a nodule at the blind end, it should be removed and sent for pathological examination.
Surgery: sever the spermatic cord vessels and relocate the testis. It is suitable for some high intra-abdominal cryptorchid and those with long vas deferens and curved in the inguinal canal.