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CRYPTORCHIDISM

CRYPTORCHIDISM. Dr.GOVIND SRMC & RI. EMBROLOGY. GONADAL RIDGE – COELOMIC EPITHELIUM GERMINAL CELLS- YOLK SAC SEMINIFEROUS TUBULE SERTOLI CELLS TESTOSTERONE & MIS GUBERNACULUM & CSL. Descent. ABDOMINAL PHASE 23 weeks INGUINAL PHASE 24-30 weeks

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CRYPTORCHIDISM

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  1. CRYPTORCHIDISM Dr.GOVIND SRMC & RI

  2. EMBROLOGY • GONADAL RIDGE – COELOMIC EPITHELIUM • GERMINAL CELLS- YOLK SAC • SEMINIFEROUS TUBULE • SERTOLI CELLS • TESTOSTERONE & MIS • GUBERNACULUM & CSL

  3. Descent • ABDOMINAL PHASE 23 weeks • INGUINAL PHASE 24-30 weeks • INFRA INGUINAL PART upto 3 months after birth

  4. INCIDENCE : 3% general population,30% in preterm • PRETERM • SPONTANOUS DECENT : 70% by 3 months….more so in LBW,B/L,normal pathway &developed scrotum • At 1 year incidence is 1%

  5. CLASSIFICATION • INTRA ABD…….peeping & ectopic • INTRACANALICULAR • SUPRAPUBIC • INFRAPUBIC • ECTOPIC • RETRACTILE • ASCENDING • Atropic/vanishing

  6. cryptorchidism 20% nonpalpable 50% inguinal Vanish/present 20% palpable G/A 15% Abd vanishing 35% intra abd

  7. THEORY OF DECENT OF TESTES • ENDOCRINE • ANDRIGEN • MIS • ESTROGEN • DECENDIN • GUBERNACULUM (attachments, muscle, morphogenisis) • GFN & CGRP • EPIDIDYMIS • INTA ABD PRESSURE • DIFFRENTIAL GROWTH

  8. HISTOLOGICAL CHANGES • After I month: leydig cells • After 6 months : volume & Ad spermatozoa • After 1 year : peritubular fibrosis • After 3 years : leydig cells sertoli cells germ cells

  9. PROBLEMS: FERTILITY • Same fertility rate upto 1 year of age • Severe changes at 5 years of age • Paternity index: B/L crypt corrected ….50% Unilateral……………75% Elevated FSH levels

  10. PROBLEM : HERNIA • Incidence…………90% • ? Related to androgen (processes closure) • Usually closes at least by 3 months of age • Post Hcg therapy………. if P.vaginalis closes testis descends in 50% cases if P,vaginalis doesnot close then testis done not descend at all

  11. PROBLEM : TUMOUR • Increased incidence ( 40 Vs 14 times) • Puberty tumors • 10% testicular tumor arise form undesended • Higher the testis more chances of malignancy • Seminoma / yolk sac tumor/embryonal • Relative risk……contralateral desended 3.6 contralateral undesended 15% CIS …………..1.7%

  12. PROBLEM : TORSION • Increased susceptibility • Long mesentery / vas • Related to tumor development • Related to Hcg therapy • ?explains vanishing testis

  13. INVESTIGATIONS • CLINICAL EXAM & EXAM UNDER ANESTHESIA • USG • CT • MRI • LAPAROSCOPY

  14. CONSERVATIVE • OBSERVATION • HCG……..1500IU TWICE WEEKLY FOR 4 WEEKS • GNRH……..1.2 mg nasal spray twice weekly for 4 weeks Efficacy ………..20%

  15. Hormonal assay • Basal FSH/LH levels are raise then consider anorchia • Serum testosterone assay at 2-3 months age • Hcg stimulation test : 500iu on mon , wed, fri testosterone levels on Saturday….. ( normal raise > 200ng/dl)

  16. MIS • Glycoprotein by sertoli cells • Post puberty MIS synthesis declines • MIS is a more sensitive marker • No testicular tissue……..<1ng/ml • Abnormal testes………….10-15ng/ml • Normal testes……….35-40ng/ml • Low MIS……………..90% cases absent testis • Normal MIS……..98% testis present

  17. B/l crypt & normal phallus Low levels of MIS MIS normal Hcg test negetive Hcg test: normal Orchidopexy (r/o pmds) orchidopexy anorchia

  18. Ambiguous genitalia MIS assay undetectable Normal: testes + Low.. Mixed gonadal dysgenesis True hermaph. Testicular regression Male pseudo herma. Androgen resistance Testosterone syn, defect hypogonadism Female pseudo CAH Vanishing testes

  19. UNILATERAL • USG • LAPAROSCOPY : DECIDE ON TABLE SINGLE STAGE ORCHIDOPEXY TWO STAGED ORCHIDECTOMY

  20. BILATERAL CRYPTORCHIDISM • KARYOTYPE • TESTOSTRONE AT 2-3 MONTHS AGE • HCG STIMULATION TEST • MIS ASSAY • Laparoscopy • Atleast one side orchidopexy at 9 months

  21. SURGERY • SIMPLE ORCHIDOPEXY • ALBERT & PERSKY • PENTRISS • KOOP • STEPHEN FOWLER • MICROSURGICAL

  22. Standard orchidopexy • Open tunica vaginalis…eversion • Dissect internal spermatic fascia,ext.spermatic fascia,cremaster at internal ring • Fix in dartos pouch • Tension free • Pentriss/Albert persky

  23. Fowler-Stephens • ? Modification of Bevan”s • One staged • Two staged • Identify…collaterals,long loop,large peritoneal pedicle • Ureter vulnerable • Shortest route to scrotum • Stephen-fowler test • High ligation Vs low ligation

  24. microvascular • Success rate of 80% • ?procedure of choice in high solitary testis • Gibson incision • safe guard inf.epigastric vessels • Spermatic vessels mobilized upto origin & ligated based on a wide peritoneal pedicle • Microvascular surgery • Dartos pouch fixation

  25. LAPARASCOPIC SITUATIONS • BLIND ENDING VAS • BLIND ENDING VESSELS • VESSELS ENTERING DEEP RING • MEDIAL ABDOMINAL TESTIS • PELIC TESTIS • SUBHEPATIC/JUXTA SPLENIC

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