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Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,CRYPTORCHIDISM,Dr.GOVIND,SRMC & RI,1,EMBROLOGY,GONADAL RIDGE ,COELOMIC EPITHELIUM,GERMINAL,CELLS- YOLK SAC,SEMINIFEROUS TUBULE,SERTOLI CELLS,TESTOSTERONE & MIS,GUBERNACULUM & CSL,2,Descent,ABDOMINAL PHASE 23 weeks,INGUINAL PHASE 24-30 weeks,INFRA INGUINAL PART upto 3 months after birth,3,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%,4,CLASSIFICATION,INTRA ABD.peeping & ectopic,INTRACANALICULAR,SUPRAPUBIC,INFRAPUBIC,ECTOPIC,RETRACTILE,ASCENDING,Atropic/vanishing,5,cryptorchidism,20% nonpalpable,20% palpable G/A,35% intra abd,15% Abd vanishing,50% inguinal,Vanish/present,6,THEORY OF DECENT OF TESTES,ENDOCRINE,ANDRIGEN,MIS,ESTROGEN,DECENDIN,GUBERNACULUM,(attachments, muscle, morphogenisis),GFN & CGRP,EPIDIDYMIS,INTA ABD PRESSURE,DIFFRENTIAL GROWTH,7,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,8,PROBLEMS: FERTILITY,Same fertility rate upto 1 year of age,Severe changes at 5 years of age,Paternity index:,B/L crypt corrected .50%,Unilateral75%,Elevated FSH levels,9,PROBLEM : HERNIA,Incidence90%,? 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,10,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 riskcontralateral desended 3.6,contralateral undesended 15%,CIS .1.7%,11,PROBLEM : TORSION,Increased susceptibility,Long mesentery / vas,Related to tumor development,Related to Hcg therapy,?explains vanishing testis,12,INVESTIGATIONS,CLINICAL EXAM & EXAM UNDER ANESTHESIA,USG,CT,MRI,LAPAROSCOPY,13,CONSERVATIVE,OBSERVATION,HCG.1500IU TWICE WEEKLY,FOR 4 WEEKS,GNRH.1.2 mg nasal spray,twice weekly for 4 weeks,Efficacy .20%,14,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),15,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,16,B/l crypt & normal phallus,MIS normal,orchidopexy,Low levels of,MIS,Hcg test: normal,Orchidopexy,(r/o pmds),Hcg test,negetive,anorchia,17,Ambiguous genitalia,MIS assay,Normal: testes +,Male pseudo herma.,Androgen resistance,Testosterone syn, defect,hypogonadism,Low.,Mixed gonadal dysgenesis,True hermaph.,Testicular regression,undetectable,Female pseudo,CAH,Vanishing testes,18,UNILATERAL,USG,LAPAROSCOPY : DECIDE ON TABLE,SINGLE STAGE ORCHIDOPEXY,TWO STAGED,ORCHIDECTOMY,19,BILATERAL CRYPTORCHIDISM,KARYOTYPE,TESTOSTRONE AT 2-3 MONTHS AGE,HCG STIMULATION TEST,MIS ASSAY,Laparoscopy,Atleast one side orchidopexy at 9 months,20,SURGERY,SIMPLE ORCHIDOPEXY,ALBERT & PERSKY,PENTRISS,KOOP,STEPHEN FOWLER,MICROSURGICAL,21,Standard orchidopexy,Open tunica vaginaliseversion,Dissect internal spermatic fascia,ext.spermatic fascia,cremaster at internal ring,Fix in dartos pouch,Tension free,Pentriss/Albert persky,22,Fowler-Stephens,? Modification of Bevan”s,One staged,Two staged,Identifycollaterals,long loop,large peritoneal pedicle,Ureter vulnerable,Shortest route to scrotum,Stephen-fowler test,High ligation Vs low ligation,23,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,24,LAPARASCOPIC SITUATIONS,BLIND ENDING VAS,BLIND ENDING VESSELS,VESSELS ENTERING DEEP RING,MEDIAL ABDOMINAL TESTIS,PELIC TESTIS,SUBHEPATIC/JUXTA SPLENIC,25,
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