Lanciano 25.11.2006

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Lanciano 25.11.2006
CATTEDRA DI CHIRURGIA PEDIATRICA UNIVERSITA
DEGLI STUDI G. DANNUNZIO CHIETI-PESCARA

• ANOMALIE DI DISCESA
• DEL
• TESTICOLO

N. Pappalepore
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ANOMALIE DI DISCESA DEL TESTICOLO
T.RITENUTO Endoaddominale (criptorchidia) Intracanalicolare Emergente Scrotale alto (gliding testis) T.ECTOPICO Inguinale superficiale Femorale Pre-penieno Perineale Crociato T.RETRATTILE (mobile) (in ascensore) (fluttuante)
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TESTICOLO RITENUTO EMERGENTE
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TESTICOLO ECTOPICO PERINEALE
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LINCIDENZA DI TESTICOLO RITENUTO ALLA NASCITA È
CORRELATA AL PESO
PESO ALLA NASCITA IN GRAMMI INCIDENZA DI TESTICOLO RITENUTO ()
da 451 a 910 da 911 a 1810 da 1811 a 2040 da 2041 a 2490 da 2491 a 2720 da 2721 a 3630 da 3631 a .. 100 62 25 17 12 3,3 0,7
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ANOMALIE DI DISCESA DEL TESTICOLO DIAGNOSTICA
TESTICOLO PALPABILE Diagnosi
clinica Diagnosi clinica
Ecografia RMN LAPAROSCOPIA
TESTICOLO NON PALPABILE
In caso di bilateralità test di stimolo con HCG
alla ricerca di tessuto testicolare
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Testicolo endocanalicolare
Testicolo endoscrotale
Test. Endoaddominale alto
Vanishing testis
Testicolo allanello ing. Int.
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ANOMALIE DI DISCESA DEL TESTICOLO QUALE
TRATTAMENTO ?
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ANOMALIE DI DISCESA DEL TESTICOLO TERAPIA

• TESTICOLO RITENUTO
• Terapia ormonale, quando non controindicata
• Successo terapeutico nel 20-25 dei casi
• Intervento chirurgico (orchidopessi)
• TESTICOLO ECTOPICO
• Intervento chirurgico di elezione, indicato al
  momento della
• diagnosi
• TESTICOLO RETRATTILE
• Nessuna terapia

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Hormonal cryptorchidism therapy systematic
review with metanalysis of randomized clinical
trials. Henna MR, Del Nero RG, Sampaio CZ,
Atallah AN, Schettini ST, Castro AA, Soares
BG The importance of cryptorchidism treatment
concerns the possibility of diminishing risk of
malignant degeneration and improving fertility.
Success rates of hormonal treatment vary 0-55
with human chorionic gonadotropin (hCG) and 9-78
with gonadotropin-releasing hormone (GnRH). Due
to uncertainties regarding the effectiveness of
this treatment, a systematic review and
meta-analysis of randomized controlled trials
(RCTs) on hormonal cryptorchidism treatment was
done using the methodology of Cochrane
Collaboration. Two studies compared hCG with
GnRH, with a testicular descent rate of 25 vs.
18, respectively. Nine trials compared
intranasal LHRH with placebo, with complete
testicular descent rates of 19 vs. 5. Two other
studies comparing doses and administration
intervals could not be pooled together due to
heterogeneity. With the information analyzed
until the present, the evidence for the use of
hCG vs. GnRH shows advantages for hCG, and this
review also shows that there is evidence that
luteinizing hormone releasing hormone (LHRH) is
more effective than placebo. But because this
evidence is based on few trials, with small
sample sizes and moderated risk of bias, this
treatment cannot be recommended for everyone, and
there is no evidence that supports hCG's use in
larger doses and larger intervals. Results from
this systematic review are important for
developing better RCTs that may decrease the
uncertainty of cryptorchidism treatment.
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Structural evidence against hormonal therapy for
cryptorchid testis abnormal gubernacular
attachment Han WK, Kim JH, Hong CH, Han
SW.Departments of Urology and Brain Korea 21
Project for Medical Science, Yonsei University
College of Medicine, Seoul, Korea .PURPOSE
Various factors are involved in testicular
descent, and no single factor is elucidated as
the cause of cryptorchidism. We prospectively
observed the locations of gubernacular
attachments in the cryptorchid testis. MATERIALS
AND METHODS From April 1996 to June 2002, 639
boys underwent surgical correction of cryptorchid
testis. Those with complete records of testicular
locations and gubernacular attachments were
analyzed. RESULTS A total of 639 boys underwent
732 surgical corrections of inguinal testis (425,
58), high scrotal testis (165, 23) and
impalpable abdominal testis (142, 19).
Impalpable abdominal testes had gubernacular
attachment to either the lateral or upper scrotum
in 36 cases (25) or around the inguinal ring in
83 (58). The gubernaculum was attached to the
bottom of the scrotum in 21 inguinal testes (5),
to the lateral or upper scrotum in 132 (31) or
around the inguinal ring in 268 (63). In cases
of high scrotal testis the gubernaculum was
attached usually to the bottom of the scrotum
(28, 17), to the lateral or upper scrotum (109,
66) or around the inguinal ring (26, 16).
CONCLUSIONS The locations of distal gubernacular
attachments in the cryptorchid testis were
usually abnormal (93). In these cases the
possible testicular descent induced by hormonal
therapy may either be insufficient or unable to
prevent future ascent. Thus, early surgical
correction rather than hormonal therapy is
warranted in boys with cryptorchid testis.
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TESTICOLO RITENUTO CONTROINDICAZIONI ALLA TERAPIA
ORMONALE
ERNIA INGUINALE CLINICAMENTE EVIDENTE
TESTICOLO ECTOPICO TESTICOLO RITENUTO IATROGENO
(dopo intervento per e.inguinale) _______________
__________________________________________________
___________
Children presenting with a concomitant
inguinal hernia should have immediate
orchidopexy done at same time that the inguinal
herniotomy performed.
HUTSON, 1998
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ORCHIDOPESSI Testicolo palpabile

• Intervento di piccola chirurgia per lo
  specialista chirurgo pediatra
• Anestesia generale /- locoregionale
• Può essere eseguito in regime di Day Surgery
• Controlli dopo la dimissione dopo 7-10
  giorni
• 
  dopo 6-12 mesi

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ORCHIDOPESSI Tempi chirurgici

1. Mobilizzazione del testicolo e degli
   elementi del funicolo nel canale inguinale
2. Trattamento delleventuale ernia associata
3. Posizionamento e fissazione del testicolo in
   sede scrotale

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ORCHIDOPESSI Tempi chirurgici
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ORCHIDOPESSI fissazione della gonade in sede
scrotale

• Tecnica di Torek (1909)
• fissazione alla coscia
• Tecnica di Ombredanne (1927)
• fissazione controlaterale trans-settale
• Tecnica di Shoemaker (1931)
• tasca scrotale extra-dartoica

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TRANSSCROTAL ORCHIDOPEXY (Bianchi e Squire, 1989)
Rationale We found testicular undescent to be
largely due to a short processus vaginalis, the
vascular pedicle being long enough for the testis
to be placed in the scrotum without
tension. Indicazioni Testicoli palpabili al di
fuori del canale inguinale T. ritenuto
prescrotale e scrotale alto T. ectopico
inguinale soprafasciale
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The influence of orchiopexy on serum inhibin B
level relationship with histology Irkilata HC,
Yildirim I, Onguru O, Aydur E, Musabak U, Dayanc
M. From the Departments of Urology (HCI, IY, EA,
MD), Pathology (OO) and Immunology (UM), Gulhane
Military Medical Academy, School of Medicine,
Ankara, Turkey.PURPOSE Since inhibin B is the
endocrine marker of spermatogenesis, basal
inhibin B levels may reflect germ cell status in
children. The aims of this study were to
determine the changes in endocrine parameters
after orchiopexy in patients with cryptorchidism
and to compare these findings with testicular
biopsy parameters. MATERIALS AND METHODS A
total of 27 boys with undescended testis were
included in this study. Inguinal orchiopexy was
performed in all patients and 15 underwent
testicular biopsy at orchiopexy. Spermatogonia
per tubular transverse section and fertility
index values were determined. Before and 6 months
after orchiopexy serum basal inhibin B and other
serum hormone levels were measured in all
patients. RESULTS Mean serum basal inhibin B
levels significantly increased 6 months after
successful orchiopexy (p 0.001). However,
inhibin B level did not increase in patients who
had a low testicular biopsy score. Other
reproductive hormone levels did not change after
orchiopexy. CONCLUSIONS Basal inhibin B level
could be used as a follow-up parameter after
orchiopexy. If basal inhibin B level does not
increase in the postoperative period, the amount
of germ cells in the testis may be too low or the
orchiopexy might not have been implemented
appropriately. 
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RITENZIONE TESTICOLARE TRATTAMENTO A CHE ETA ?
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Le alterazioni a carattere degenerativo delle
cellule germinali sono evidenti già alla fine del
secondo anno di vita.
Hadziselimovic, 1981
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TESTICOLO RITENUTO

• Alterazioni ultrastrutturali degenerative
• irreversibili oltre i 2 anni di vita
• ? DIAMETRO TUBULI SEMINIFERI
• ATROFIA CELLULE DI LEYDIG
• ? n SPERMATOGONI

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Letà ottimale per la terapia del testicolo
ritenuto (terapia ormonale o orchidopessi) va
individuata tra il primo ed il secondo compleanno.
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Current status of cryptorchidism Leung AK,
Robson WL.The University of Calgary, Pediatric
Consultant, Alberta Children's Hospital, Calgary,
Alberta, Canada. Cryptorchidism is present at
birth in 3 to 5 of term male infants. The
incidence is higher in preterm and low birth
weight infants. The two most important possible
sequelae are infertility and testicular tumor.
Diagnostic studies are usually not necessary if
the undescended testis is palpable. Laparoscopy
has replaced imaging studies for localization of
a nonpalpable testis and might also obviate the
need for exploration of the groin. The
recommended age for treatment has progressively
decreased as our understanding of the problem has
improved. Current information suggests that the
placement of the testis in the scrotum should be
accomplished by 1 year of age to maximize the
potential for fertility. Treatment options
include surgical relocation or hormonal therapy.
The lower the pretreatment position of the
testis, the better the success rate for either
method.

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When orchidopexy is done in a Pediatric
Surgical Center, a younger age does not increase
the risk of complications
HUTSON, 1998
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RITENZIONE TESTICOLARE E FERTILITÀ
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  Etiology of azoospermia in 100 consecutive
nonvasectomized men Fedder J, Cruger D,
Oestergaard B, Petersen GB. History was taken
systematically for 100 azoospermic,
nonvasectomized men referred consecutively to a
Danish fertility clinic. The men were examined by
ultrasound, and their blood samples were analyzed
for karyotype, Y microdeletions, and cystic
fibrosis transmembrane conductance regulator gene
mutations. In 29 of patients, the condition
could be explained by genetic abnormalities in
22, by diseases or external influence and in
27, by former cryptorchidism. The azoospermic
condition remained unexplained in only 22.
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The relationship of cryptorchidism to
fertility. Trussell JC, Lee PA.Penn State
College of Medicine, The Milton S. Hershey
Medical Center, 500 University Drive, Hershey, PA
17033-0850, USA. Cryptorchidism is the most
common genitourinary disorder of childhood,
resulting in 27,000 surgical cases each year in
the United States. Of the 3 of full-term infants
affected, most will have testes that will descend
normally within a few months. The remaining 1,
who have a cryptorchid condition that persists,
should consider medical or surgical intervention.
In addition, although the effect of
cryptorchidism on testicular development and
fertility has been studied extensively, the only
fact of certainty is that untreated men with
bilateral abdominal testes will be infertile. The
remaining scenarios (unilateral, inguinal,
gliding, and medically or surgically treated
conditions) offer unpredictable levels of
fertility. Fortunately, based on recent research,
the correlation between testis maldescent and
infertility may not be as prevalent as previously
reported.
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FERTILITY AFTER ORCHIDOPEXY
Authors N of pz Average age at operations (Ys) Fertility test FERTILITY FERTILITY
Authors N of pz Average age at operations (Ys) Fertility test Unilateral Bilateral
Puri ODonnell(85) 142 7 13 Semen analysis 74 30
Kinger (88) 25 6.2 Semen analysis 70 40
Cendron (89) 40 7.0 Paternity 87 33
Kumar (89) 56 7 18 Paternity 84 60
Okuyama (89) 167 2 5 Semen analysis 95 24
43 9 12 Semen analysis 86 20
Mandar (94) 135 8.9 Semen analysis 53 26
Lee (93) 51 7.1 Paternity 78 60
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All current studies suggest that the incidence
of paternity is similar between the normal
patient and the patient with unilateral
cryptorchidism irrespective of the age of the
orchidopexy. In the child with bilateral
cryptorchidism, patients with testes found in the
pre-scrotal space will usually have normal or
near normal semen analysis while individuals with
bilateral intra-abdominal testes will usually
either be azoospermic or have poor semen
quality
Husmann D.A., 2002
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TESTICOLO RITENUTO DISSOCIAZIONE EPIDIDIMO -
DIDIMO
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RITENZIONE TESTICOLARE E NEOPLASIA TESTICOLARE
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RITENZIONE TESTICOLARE E NEOPLASIA
Nei testicoli criptorchidi il rischio di
degenerazione carcinomatosa è 22 volte superiore
rispetto ai testicoli normalmente discesi.
Cromie, 1983
Il rischio di degenerazione carcinomatosa del
testicolo ritenuto endoaddominale è 6 volte
superiore a quello delle altre forme di
ritenzione testicolare.
Martin, 1982
The life time risk of developing testicular
cancer in men from the general population is
approximately 0,3-0,7 .... The risk of a man
with a history of cryptorchidism developing
testicular cancer is 3-5, i.e. a 4-7 fold
increased risk.
Husmann D.A., 2002
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GRAZIE PER LA VOSTRA ATTENZIONE !
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ORCHIDOPESSI Complicanze intraoperatorie

• Sezione del dotto deferente e/o dei
  vasi spermatici interni
• Sezione del nervo ileo- inguinale
• Emorragia da lesioni vascolari
• Perforazione della vescica

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ORCHIDOPESSI Complicanze precoci

• Ematoma
• Infezione della ferita
• Necrosi testicolare

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ORCHIDOPESSI Complicanze tardive

• Ipotrofia/ atrofia
• Orchidopessi sotto tensione
• Lesione dei vasi spermatici
• Torsione del testicolo
• Orchidopessi in due tempi
• Plastica del canale inguinale sotto tensione
• Ritenzione testicolare recidiva
• Infertilità

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