隐睾的诊治教学课件

1、Cryptorchidism:Pathogenesis,Diagnosis, TreatmentRichard A. Ashley, Julia S. Barthold, Thomas F. Kolon. Urol Clin North Am. 2010 May;37(2):183-93. Normal testicular descent: a testis that remains stationary within the dependent portion of the scrotum. Cryptorchidism : a developmental defect in which

2、the testis fails to descend completely into the scrotumDefinitions Cryptorchidism =undescended testis “hidden testis” the abdominal cavity testis outside the anatomic scrotum main reasons for treatment to cryptorchidism infertility(不育), testicular malignancy, testicular torsion, inguinal hernia(腹股沟斜

3、疝 ), cosmetic concerns.EPIDEMIOLOGY/PATHOGENESISIsolated cryptorchidism is one of the most common congenital anomalies found at birth affects upward of 1% to 4% in full-term newborns and in up to 45% of preterm male babiespossiblerisk factors for cryptorchidismAdvanced maternal age, maternal obesity

4、(肥胖症 ),maternal diabetes(糖尿病 ), family history of cryptorchidism,preterm birth, low birth weight, small for gestational age（孕龄）, breech presentation(臀先露), consumption of cola-containing drinks during pregnancyAs a result of the normal gonadotropin surge(LH and FSH)approximately 70% to 77% of cryptor

5、chid testes will spontaneously descend, usually by 3 months of age. Only 6.9% of cryptorchid testes descended spontaneously beyond 6 months of age low birth weight, bilateral cryptorchidism, normal scrotal anatomy, testis that are positioned lower along the normal path of descent a small or poorly r

6、ugated scrotum with hypospadias（尿道下裂） Risk ratios for cryptorchidism（ 1 million male births were reviewed ） 10.1 in twins,3.5 in brothers, 2.3 in offspring of fathers compared with patients with no family history of the disordera 5-fold increased risk in offspring of affected fathers a 7- to 10-fold

7、 increased risk in those with an affected brotherBirth weight may be the principal determinant of cryptorchidism at birth and at 1 year of life；independent of the length of gestation（妊娠）. Classification palpable nonpalpable (Excluding atrophic or vanishing testes).palpable testes have descended beyo

8、nd the abdomen (internal ring（内环口）)nonpalpable testes are intra-abdominal. Cryptorchid testicular position is most simply described at the time of exploration intra-abdominal intracanalicular（腹股沟管内 ） extracanalicular (suprapubic or infrapubic（耻骨上、耻骨下） ), ectopic（异位）. Eighty percent of undescended te

9、stes are palpable and 20% are nonpalpable. The most common ectopic location is within a superficial pouch between the external oblique fascia and Scarpas fascia “peeping” testes because they can move between the abdominal cavity and inguinal canal. Rarely, a testis is found in ectopic intra-abdomina

10、l positions such as in the perihepatic（肝周） and perisplenic（脾周） regions. The terms “nonpalpable testis” and “retractile testis” are ubiquitous. “nonpalpable testis” intra-abdominal, absent (vanishing), atrophic, missed on physical examination. The anatomic hallmark of a vanishing testis blind-ending

11、spermatic vessels（输精管） that are found just proximal to the internal inguinal ring. A “retractile testis” withdraws spontaneously out of the scrotum toward the inguinal canal by an active cremasteric reflex but can easily be brought down into a dependent position within the scrotum and remains there

12、after traction has been released. Ascent probably represents an undescended testis that is almost completely descended. children with retractile testes should be monitored regularly (yearly), at least up to puberty, until the testes are no longer retractile and remain intrascrotal. testicular descen

13、t occurs in two phases transabdominal and inguinoscrotal （经腹腔） （经腹股沟阴囊）most cases testicular descent is complete between the 30th and 32nd weeknormal hypothalamic-pituitary-gonadal axis prerequisite testicular descentandrogens do not mediate the first phase of testicular descentimpaired androgen bio

14、synthesis or action can impede the second phase of testicular descen In utero（子宫的） testosterone deficiency can be caused by decreased LH, by impaired function of gonadotropinreleasing hormone (GnRH) or LH receptors, or by loss-of-function mutations in the proteins involved in testosterone biosynthes

15、is（生物合成）. Estrogens are thought to impair gubernacular（引带的） development and to cause persistence of mllerian duct derivatives（衍生物）. All evidence implicates the gubernaculum as the major factor responsible for testicular descent. in cases of nonpalpable testis is controversial.Ultrasound (US), comput

16、ed tomography (CT)scan magnetic resonance imaging (MRI)The accuracy of these studies in identifying intraabdominal testes may be low. the most reliable mode of examination is the physical examinationby a pediatric urologist (84%) a referring physician (53%). The accuracy of imaging studies in this s

17、eries was 44% imaging did not influence decisions in any of the cases. Examination for the undescended testis performed with warm hands and soapy water on the fingertips to reduce skin friction. The examiners fingers are swept down from just above the internal ring along the inguinal canal into the

18、scrotum. The clinician should feel either a testis moving back under the fingertips against the direction of palpation. Check the size, location, texture of the contralateral descended testis. Management of Cryptorchidism Proper identification of the anatomy, position, and viability of the undescend

19、ed testis Identification of any potential coexisting syndromic abnormalities Placement of the testis within the scrotum in timely fashion to prevent further testicular impairment in either fertility potential or endocrinologic function Attainment of permanent fixation of the testis with a normal scr

20、otal position that allows for easy palpation No further testicular damage resulting from the treatment Definitive treatment of an undescended testis should take place between 6 and 12 months of age. Hormonal Therapy Two types of medical treatment of an undescended testis exogenous hCG exogenous GnRH

21、 or LHRH. the lower the pretreatment position, the better the success rate Hormonal treatment is not indicated with previously operated testes with prior surgery that would result in inguinal scar tissue formation with ectopic testes with an inguinal hernia. Typical treatment scheduleHCG 1500 IU/m2

22、intramuscular twice a week for 4 weeks. A downside of hCG treatment is that it must be given parenterally on a frequent basis. Side effects of hormonal treatmentincreased rugation pigmentation of the scrotum. an increase in size of the penis the development of pubic hair which regresses after cessat

23、ion of therapy. the overall efficacy of hormonal treatment is less than 20% for cryptorchid testes and is significantly dependent on pretreatment testicular location. surgery remains the gold standard for the management of undescended testes. Surgical Treatment It is very useful to examine the child

24、 after induction of general and regional anesthesia to reaffirm testicular position or attempt to establish testicular position in the case of a previously nonpalpable testis. success rate 92% for testes below the external ring, 89% for inguinal testes, 84% for microvascular orchiopexy, 81% for stan

25、dard abdominal orchiopexy, 77% for staged Fowler-Stephens orchiopexy, 67% for standard Fowler-Stephens orchiopexy. standard abdominal orchiopexy(1) complete mobilization of the testis and spermatic cord, (2) repair of the patent processus vaginalis by high ligation of the hernia sac, (3) skeletoniza

26、tion of the spermatic cord without sacrificing vascular integrity to achieve tension-free placement of the testis within the dependent position of the scrotum, (4) creation of a superficial pouch within the hemiscrotum to receive the testis.If anatomic conditions prevent adequate spermatic vessel le

27、ngth from being achieved during primary orchidopexy or if, under unusual circumstances, a two-stage procedure is undertaken with planned preservation of the spermatic vesselsThe testis is anchored to the external ring or pubic symphysis after maximal mobilization in the first stage, and a second pro

28、cedure is performed 6 to 12 months later. Fowler-Stephens OrchiopexyLigation of the testicular vessels occasionally becomes a necessary consideration, especially in the management of a high inguinal or intra-abdominal testis. the vascular anatomy of the testis and devised a means to repair a high un

29、descended testis and preserve its blood supply via collateral circulation. When the spermatic vessels are divided, blood supply to the testis is dependent on collateral circulation from the deferential artery, a branch of the inferior vesical artery, and the cremasteric system, a branch of the inferior epigastric artery. Laparoscopic Management of an Undescended Testis the advantag