Cryptorchidism: an overview of information

Cryptorchidism (from the Greek kryptos - hidden, orchis - testicle) is a congenital urological disease in which one or both testicles did not descend into the scrotum at the time of birth.

[1], [2], [3], [4]

Epidemiology

The urgency of this disease is due to the high frequency of infertile marriages in patients with various forms of cryptorchidism, which is 15-60%. According to various authors, cryptorchidism occurs in newborn full-term boys in 3% of cases, in preterm infants - up to 30% of cases.

According to the literature, right-sided cryptorchidism occurs in 50% of cases, bilateral cryptorchidism - in 30%, and left-sided cryptorchidism - in 20% of cases.

The process of ovulation is a completely unexplored aspect of sexual differentiation, both with respect to the nature of the forces that cause the movement of the testicles, and the hormonal factors that regulate this process.

It is accepted to distinguish five stages of egg migration:

• Bookmark the gonad;
• migration of the testicle from the place of formation of the gonad to the entrance to the inguinal canal;
• formation of an opening in the inguinal canal (vaginal process), through which the testicle leaves the abdominal cavity;
• passage of testicles through the inguinal canal into the scrotum;
• obliteration of the vaginal process of the peritoneum.

[5], [6], [7], [8], [9], [10], [11], [12]

Causes of the cryptorchidism

The process of ovulation is a completely unexplored aspect of sexual differentiation, both with respect to the nature of the forces that cause the movement of the testicles, and the hormonal factors that regulate this process.

It is accepted to distinguish five stages of egg migration:

• Bookmark the gonad;
• migration of the testicle from the place of formation of the gonad to the entrance to the inguinal canal;
• formation of an opening in the inguinal canal (vaginal process), through which the testicle leaves the abdominal cavity;
• passage of testicles through the inguinal canal into the scrotum;
• obliteration of the vaginal process of the peritoneum.

The process of the migration of the testicles from the abdominal cavity to the scrotum begins with the 6th week of the intrauterine development of the fetus. Eggs reach the inner ring of the inguinal canal approximately to the 18-20th week, and at the time of the birth of the fetus the gonads are located on the bottom of the scrotum. If the transabdominal route of testicular migration does not depend on the level of androgens, and possibly mediated by intraabdominal pressure and the paracrine effect of growth peptides of local or testicular origin, the passage of the testicle through the inguinal canal depends to a sufficient extent on the concentration of androgens produced by the embryonic testicle. However, the leading role at this stage belongs to LH, actively produced by the pituitary gland of the fetus in the last trimester of pregnancy.

Many congenital anomalies associated with a defect in testosterone biosynthesis, a violation of the function of Sertoli cells, secreting antimulylerov factor, deficiency of gonadotropin production, are accompanied by cryptorchidism (Kalman, Kleinfelter syndrome, Prader-Willi, Noonan, etc.). In addition, cryptorchidism is one of the symptoms of genetic disorders that cause multiple developmental anomalies (Carnelia de Lange syndromes, Smith-Lepley-Opits syndrome, etc.). However, in some patients with cryptorchidism, primary abnormalities of gonadotropic and gonadal functions are not detected, especially in its unilateral form. Apparently, cryptorchidism is a consequence of multifactorial disorders, in which hormonal deficiency does not always play a major role. The leading role in the development of cryptorchidism is played, possibly, by genetic disorders that lead to a lack of paracrine factors, produced both by testicles, and by the cells of the vessels, the vas deferens, and the inguinal canal.

The main consequence of cryptorchidism is a violation of the germinal function of the testicle. Histological examination in the testicles reveals a decrease in the diameter of the spermatic ducts, a decrease in the number of spermatogonia and foci of interstitial fibrosis. Similar violations in undescended testicles were detected in 90% of children over 3 years old. In the literature, there is information about structural changes in Leydig and Sertoli cells in cryptorchidism in older boys. The question remains whether these changes will be the result of cryptorchism or its cause. Opinions are expressed that changes in the testicle with cryptorchidism are primary. This is confirmed by the fact that patients with unopened testes do not undergo pathological changes in the tubular epithelium with age. Fertility disorders even with the timely reduction of testicles are noted in 50% of patients with bilateral and in 20% of patients with unilateral cryptorchidism.

The risk of developing testicular neoplasia in patients with cryptorchidism is 4-10 times higher than in men in the general population. Of the total number of seminoma diagnosed, 50% are found in undescended testicles. Eggs located in the abdominal cavity are more intensively subjected to malignancy (30%) than, for example, located in the inguinal canal. The lowering of the testicle does not reduce the risk of malignancy, but it allows timely diagnosis of the neoplasm. In 20% of cases, tumors in patients with unilateral cryptorchidism develop in the contralateral testicle. In addition to the seminoma, men with cryptorchidism have a high incidence of gonocyte and carcinoma. The fact that this type of tumor develops can also confirm the theory of the primary dysgenesis of an undescended testicle.

Currently, most researchers suggest dividing patients with cryptorchidism into two groups. The first group includes patients with short spermatic cord. The main causes of the disease include genetic, hormonal, receptor and paracrine causes. The second group includes patients with different forms of ectopias of the male gonad (inguinal, perineal, femoral, pubic and heterolateral), which are based on a mechanical theory of the violation of testicular migration.

The division into different groups according to the pathogenesis is due to a fundamentally different approach to the tactics of treating patients with this disease. In the first group, where the problem is initiated by testicular retention (delay of the gonad on the way to migration to the scrotum), preoperative preparation using gonadotropins is necessary. The purpose of hormonal therapy is lengthening of the vascular bundle of the male gonad, which allows the testicle to be lowered into the scrotum with minimal tension. Tension of the vascular bundle leads to a decrease in the diameter of the gonadal feeding vessels and, consequently, to a worsening of the trophism of the organ. Vessels, which feed the walls of the main vessels of the spermatic cord, also suffer, causing edema of the vessel wall, decreasing its diameter, which again negatively affects the blood flow, contributing to ischemia of testicular tissue.

At present, the negative effect of short-term ischemia on testicular tissue has been proven. After three hours of gonadal ischemia, when the seminal cord is twisted, diffuse necrosis occurs in the testicle tissue. After 6-8 hours from the moment of torsion necrosis is subjected to almost the entire gonad.

Thus, one of the most important tasks facing the surgeon is the minimization of ischemia of testicular tissue during the operative correction of cryptorchidism. Accordingly, the entire arsenal of known operational aids should be used taking into account the pathogenesis of secondary infertility associated with a violation of the gonadal trophism.

[13], [14], [15], [16], [17]

Symptoms of the cryptorchidism

When examining a patient with a presumptive diagnosis of cryptorchidism, it must be remembered that in some cases it is possible to identify children with false cryptorchidism or with an increased cremaster reflex. In such children, the scrotum is usually well developed. When palpation in the groin, in the direction from the inner ring of the inguinal canal to the outer ring, the gonad can be reduced to the scrotum. Parents of such a child often remark that during a bath in warm water the testicles descend independently into the scrotum. Symptoms of cryptorchidism in children with a true form consist in the fact that the testicle can not be lowered into the scrotum. 

In this case, one or both halves of the scrotum are hypoplastic, and the gonad is palpated in the inguinal, in the femoral, pubic, perineal or in the opposite half of the scrotum. Of particular interest is the testicle palpable in the inguinal region, since in this case there is a need for differential diagnosis of inguinal ectopy of the gonad with inguinal retention. With any form of ectopy of the gonad, there is practically no need for hormonal preoperative preparation, since the elements of the spermatic cord are well defined and have a sufficient length for free descent into the scrotum in an operative way.

However, in case of inguinal retention, the gonad is located in the inguinal canal, and the testicles do not have sufficient length for a free descent. That is why patients with inguinal retention of the gonad require preoperative hormonal therapy.

Unfortunately, it should be noted that hormone therapy is not always successful. According to one of the versions, the cause may be a blockade of androgen receptors of the testicles, which may be complete or partial. Perhaps this can explain the effectiveness of hormone therapy for a certain group of patients, a slight effect in patients with partial blockade of receptors and a complete lack of dynamics - with their complete blockade. It should be noted that hormone therapy is least effective in patients whose testicles are located in the abdominal cavity. Presumably, the degree of dysgenesis and receptor activity directly depends on the severity of the pathological process.

It is often possible to differentiate the inguinal ectopia from inguinal retention by performing a palpation study. In those cases when the palpable gonad in the inguinal region is displaced exclusively along the course of the canal, repeating its anatomical course, i.e. Is limited by the walls of the inguinal canal, it is possible to ascertain with a high degree of reliability the testicle retention. And, on the contrary, the displacement of the gonad in virtually all directions indicates inguinal ectopia.

The most severe group is patients with abdominal retention, both from the point of view of diagnosis and from the position of treatment. First of all, in a patient with the syndrome of the "non-palpable testicle" it is necessary to determine the sex identity, excluding the violation of the chromosomal sex. In this case, first of all, differential diagnosis should be carried out with mixed gonadal dysgenesis.

Mixed gonadal dysgenesis is a condition in which phenotypic men or women have an egg on one side, and on the other, a fallopian tube, a staple (connective tissue cord), and sometimes a rudimentary uterus. Heavier (strek) is a thin, pale, elongated formation, more often oval in shape, located either in a broad ligament or on the pelvic wall, consisting of an ovary stroma.

In karyotyping, in 60% of patients with this anomaly 45XO / 46XY mosaicism is detected, and in 40% of male patients, 46XY. Most often the genitals of a patient with this anomaly have a bisexual structure. In those cases where the male phenotype predominates, the patients are diagnosed with one of the forms of hypospadias and, as a rule, infertility.

In such cases, the patient is assigned a female sex and performs feminizing operations with the removal of vestigial internal genital organs. Much less often, usually for social reasons, sex is left male. To this end, laparoscopic removal of the uterus, uterine tube and arrow is performed, and the testicle is either removed by transferring the child to hormone replacement therapy in the future, or reduced to the scrotum, and the parents of the child are warned about the high likelihood of malignant gonads, whose frequency in patients with mixed gonadal dysgenesis reaches 20-30%.

The algorithm for examining patients with the syndrome of the "non-palpable testicle" includes ultrasound scanning of the abdominal cavity, but this method of diagnosis, unfortunately, does not always prove to be reliable.

Modern high medical technologies make it possible to use radioisotope methods, angiography, CT MRT, etc. For diagnosing severe forms of cryptorchidism. However, laparoscopic examination is the most objective and reliable method of diagnosing this disease at present. It allows you to assess the state of the vessels of the gonad, accurately determine the localization of the testicle and assess the state of the gonad by external signs. With severe dysplasia of the testicle, orhifunicullectomy is produced. In doubtful cases, a biopsy of the gonad is performed.

Hormonal treatment using gonadotropins does not always allow you to get the desired result, but some patients still achieve lengthening of the testicles. The determining sign of the effectiveness of the therapy is the displacement of the gonad to the opposite ring of the inguinal canal during the re-diagnostic laparoscopy.

Repeated laparoscopy is performed 1-3 weeks after the course of hormonal treatment. In those cases when it is possible to achieve a positive effect to a greater or lesser extent, immediately after evaluating the length of the vessels, the gonads pass to the open method of operative egg reduction.

[18]

Treatment of the cryptorchidism

Medication for cryptorchidism

Treatment of cryptorchidism is carried out with preparations of chorionic gonadotropin. Despite the fact that hormone therapy cryptorchidism is widely used for more than 30 years, information about its effectiveness is extremely contradictory. From the point of view of endocrinologists, the effectiveness of hormonal therapy is determined in that group of patients where the testicles were previously located in the scrotum. In the treatment of true cryptorchidism, the efficacy does not exceed 5-10%. Efficiency refers to the movement of the gonad in the scrotum under the influence of hormonal therapy, but it does not produce an estimate of the length of the testicle vessels.

There are different dosing regimens and the frequency of administration of human chorionic gonadotropin in the treatment of cryptorchidism, but there are no significant differences in the results of the various treatment regimens. The standard scheme for the administration of human chorionic gonadotropin preparations: injections 2 times a week for 5 weeks intramuscularly. The treatment should be started after the child reaches one year of age using the following doses of human chorionic gonadotropin: 1.5 2 years 300 units for injection; 2.5 6 years - 500 units; 7-12 years old 1000 units. For the treatment of cryptorchidism, analogues of the luteinizing hormone releasing hormone (LHRH), which are administered in the pulsed mode, are also used. The effectiveness of this treatment does not differ from the effectiveness of treatment with human chorionic gonadotropin.

Operations

Despite the great clinical experience of treating such a disease as cryptorchidism. Operations are conducted without adhering to any specific deadlines. Most clinicians recommend starting treatment at the earliest possible date: W. Issendort and S. Hofman (1975). R Petit and Jennen (1976, S. Waaler (1076) - at the age of 5, AG Pugachev and AM Feldman (1079) - at 3, NL Kush (1970) - at 2 years, T V. Semenova And A. Tulpanov, A. P. Erokhin, S. I. Volozhin, A. K. Faieulina, Berku, Donahoe, Hadziselimovic (2007) - in the 1st year, S. Herker (1977) - on the 4th-5th day life.

Long-term results of the operation show that infertility develops in 50-60% of patients operated on for cryptorchidism over the age of 5 years. In the era of conservative treatment of cryptorchidism with the use of hormone therapy, it was widely believed that this treatment is quite effective without surgery. However, in 90% of cases, cryptorchidism is not accompanied by infection of the vaginal process of the peritoneum. In such patients after migration of the testicle to the scrotum, it is necessary to perform operations that prevent the development of inguinal hernia and dropsy.

Clinicians often face a situation where, after several months, after hormonal therapy, the gonad is again pulled up to the level of the inguinal canal. This circumstance once again proves the need for an operation in cryptorchidism with the aim of tying the vaginal process of the peritoneum and performing orchiopexy.

All known operations for cryptorchidism are divided into two groups: one-stage and two-stage. One-step methods include operations that allow you to separate and bandage the vaginal process of the peritoneum from the inner ring of the inguinal canal, to mobilize the elements of the spermatic cord, to lower the testicle into the scrotum, and to perform temporary or permanent fixation of the gonad. Two-step methods, in turn, can also be divided into two subgroups:

• operations with cryptorchidism, performed with a moderate shortage of the length of the vessels of the gonad;
• operations with cryptorchidism, performed with a pronounced shortage of the length of the vessels of the gonad.

The first operation about cryptorchidism was made by Koch from Munich in 1820. On the advice of Cheliusoii, he opened the scrotum, passed the ligature through the vaginal membrane, and applied the pelot in the expectation that by subsequent traction for the ligature it would be possible to lower the testicle into the scrotum. This operation resulted in the death of the patient as a result of developing peritonitis. The first successful operation with cryptorchidism in 1879 was made by Annandale to a boy of three years with perineal ectopia to the right. Annandale stitched the testicle to the bottom of the scrotum with a subcutaneous catgut suture.

Of the most common treatment methods, the methods of the first group include the methods Petriwalasky (1932), Schoemaker (1931), Ombredanne (1910), Welch (1972), Perrone, Signorelli (1963). Recently, the most widely used method is Schoemaker-Petriwalask, which allows to optimally lower the gonad in the scrotum and fix it in the subcutaneous pocket on the bottom of the scrotum.

Interesting is the idea of Ombredanne, Welch, Perrone, Signorelli, which is based on the fixation of the lowered gonadal to the intermuscular septum. Methods differ only in the ratio of the gonad to the septum. The disadvantage of the method in cryptorchidism is the impossibility of performing this intervention as a result of a pronounced shortage in the length of the spermatic cord.

The principal advantage of these technologies is the direct directionality of the vascular bundle of the testicle without artificially created kinks. This technique allows to minimize the degree of ischemia of the gonad, caused by the inflection of the spermatic cord.

The method of Kitli-Bail-Torek-Herzen is referred to the first subgroup of two-stage technologies. The first stage of the method with cryptorchidism is based on the dressing of the vaginal process of the peritoneum, mobilization of the vascular bundle and fixation of the gonad to a wide hip joint with the creation of the femoral-scrotal anastomosis. Three months later, the separation of the femoral-scrotal anastomosis, the separation of the gonad and cutting it off from a broad ligament with immersion in the scrotum is performed. Disadvantages of the method:

• cases with a pronounced deficiency in length of the spermatic cord, when this technology is not feasible;
• the inflection of the spermatic cord at the level of the outer ring of the inguinal canal (may contribute to the disturbance of hemodynamics in the gonad);
• cicatricial process that occurs perifokalno in the field of implantation of the testicle, with a high degree of probability leads to irreversible changes in the gonad.

The second subgroup includes operations with cryptorchidism, in which a pronounced shortage in the length of the spermatic cord does not allow the gonad to be reduced to the scrotum. In these cases, a gradual reduction is carried out. During the first stage, the vaginal process of the peritoneum is processed and the testicle is fixed at the point of maximum descent. Subsequently, after 3-6 months after the first stage of the operation, cryptorchidism produces a gonadal discharge from the surrounding tissues and its reduction into the scrotum. The disadvantage of the method is a pronounced cicatricial process, which is formed around the lowered gonad after the first stage of the operation, which can negatively influence the organ function in the future.

This group includes the operation with cryptorchidism of the "long loop of the duct" developed and implemented by R. Fowler and FD Stephens in 1963. The principle of operation is the intersection of the testicles with the preservation of the collateral branches and vessels of the vas deferens.

The frequency of fertility decline in patients with cryptorchidism does not always depend on the degree of gonadal dysgenesis. Often the cause of infertility can be a pathogenetically unjustified method of the operation of cryptorchidism, leading to ischemia of testicular tissue.

To the operation with cryptorchidism using the principle of temporary fixation of the testicle, the method developed by Mikster (1924) is referred to. The operation is started from the same incision as in hernia repair. The aponeurosis of the external oblique muscle is stratified. Dissect the anterior wall of the inguinal canal and conduct its revision. Most often, the testicle is located along the groin canal or near its outer ring. In some cases, with inguinal retention of the testicle, it can wander, being in the abdominal cavity or in the inguinal canal. This is why it is not always possible to palpably determine the gonad in the inguinal canal. In those cases where the testicle is located in the abdominal cavity, it is previously withdrawn, then a hernial sac is excreted.

When using microsurgical instruments and optical magnification, the vaginal process is optimally isolated using an open method. It is possible to use hydro-preparation of tissues. The allocated hernial sac is stitched and bandaged at the inner ring of the inguinal canal, after which they begin to mobilize the elements of the spermatic cord.

An important moment in the operation with cryptorchidism of the testicle descent is the maximum isolation of the elements of the spermatic cord with the dissection of the fibrous cords accompanying the vessels, which makes it possible to significantly increase the length of the neurovascular bundle. If necessary, mobilization is performed zabrjayusnno until the moment when the testicle does not reach the scrotum. Sometimes, despite the pre-operative hormonal preparation, the testicles still remain short. In this situation, the lower epigastric vessels are dissected. This option was proposed by Prentiss (1995). The principle of this manipulation is to reduce the distance from the beginning of the testicles to the scrotum by decreasing the angle in the scheme of the surgical triangle. Eggs can also be carried out in a shorter way, saving the epigastric vessels. For this purpose, a curved clamp of the type of Billroth bluntly creates an opening in the back wall of the inguinal canal. The clamp is carried under the epigastric vessels, seized by the shells or by the remnants of the hunter thread and guided through the newly formed opening in the back wall of the inguinal canal.

The principle of fixation of the lowered testicle in the scrotum according to Miexter consists in the imposition of a piercing ligature, derived through the skin of the scrotum and fixed to the skin of the thigh. The fixing ligature is carried out in the region of the transition of the belly to the testicle, at the lower pole. The choice of the distal fixation point is determined by a preliminary "fitting" in order to prevent the pronounced tension of the elements of the spermatic cord. Then the inguinal canal is sewn from the top down. The outer ring of the inguinal canal should not squeeze the elements of the spermatic cord. For this purpose, the last seam on the anterior wall of the inguinal canal is superimposed under the control of the fingertip. The wound is sutured layer by piece tightly. The fixing ligature and skin seams are removed on

7th day after surgery. Operation with cryptorchidism Keetley-Torek differs from this technology by fixing the testicle to the wide fascia of the thigh by creating a femoral-scrotal anastomosis. After treatment of the vaginal process of the peritoneum and mobilization of the gonad, a ligature-leash is applied for the remains of the hunter's strand. The scrotum is dissected in the lowest place, making a 2-3 cm long incision. A clamp of the type of Billroth is passed through the incision, the ligature is seized and the egg is taken out. The method of "fitting" determines the level of fixation of the gonad to the inner surface of the thigh. Then a transverse incision similar to the incision on the scrotum is performed on the femur.

According to the Keetley technology, the testicle is not removed from the scrotum, but is sealed by separate sutures for the remains of the hunter thread to the wide fascia of the thigh. The edges of the skin of the scrotum are sewn with the edges of the cut of the skin of the thigh, forming a femoral-scrotal anastomosis. According to the Torek method, a testicle bed is created on the scrotum and then the gonad is fixed to the wide fascia of the thigh, after which a femoral-scrotal anastomosis is applied. The wound in the groin area is sutured according to the method described above.

After 6-8 weeks, the anastomotic separation is performed, the testicle is immersed in the scrotum.

The method of Fowler (1972) is considered one of the attempts to abandon the methods of rigid fixation of the gonad to the thigh. The principle of operation with cryptorchidism is to hold the fixation ligature through the lower part of the scrotum and superimpose the seam in the back of the scrotum so that when tying it there is no pronounced traction for the testicular vessels. When Fowler fixes, the testicle is always somewhat drawn to the posterior surface of the scrotum, not giving a characteristic protrusion of its contours. The fixing ligature and cutaneous sutures are removed on the 7th day.

The principle of fixing the gonad according to the method of Bevan (1899) is that both ends of the fixing ligature are removed through the skin of the scrotum and tied up on the tube. The tube and thread are removed on the 7th day.

The perforation of the fixation ligature through the skin of the scrotum is a feature of orchopexy according to the method of Sokolov. Then the ligature is tightened and tied on the platen, and the ends of the thread are tied to the rubber end attached to the langete on the opposite thigh. Ligature and cutaneous sutures are removed on the 7th day.

In those cases when it is not possible to reduce the testicle to the scrotum in one stage, the principle of the staged movement of the gonad is used. During the first stage, the testicle is fixed under the skin, in the pubic region, to the inguinal ligament or the upper part of the scrotum. A mandatory condition is a minimum tension of the testicle vessels in order to prevent ischemia of the testicular tissue. Attempt to move the gonad in the scrotum is performed after 6-12 months.

Operations with cryptorchidism using the principle of permanent fixation. The operation of Schoemaker (1931) and Petriwalsky (1931) was widely used throughout the world for the original way of fixing the gonad in the scrotum. Unlike many of the above methods, this technology allows you to perform "gentle" traction of the gonad.

The operation with cryptorchidism is performed from the inguinal access, the inguinal canal is opened, the vaginal process of the peritoneum is processed and the elements of the spermatic cord are mobilized according to the technology described above. The method of fixing the gonad in the scrotum is fundamentally different. For this purpose, the index palei is carried to the bottom of the scrotum, creating a tunnel through which, in the future, a gonad is conducted. In the middle third of the scrotum, a transverse incision of about 10 mm in length is produced at the height of the fingertip. The depth of the cut must not exceed the thickness of the skin of the scrotum itself. Then, using a "mosquito" type bent in the sagittal plane, a cavity is created between the skin and the fleshy shell of the scrotum. The volume of the cavity formed should correspond to the volume of the reduced gonad.

Then, a "mosquito" clamp is made from the wound in the scrotum to the inguinal surgical wound, the gonad envelopes are captured and outwardly through the scrotal incision, so that the opening in the fleshy shell freely passes the elements of the spermatic cord. This technique allows you to create an additional retention mechanism for the testicle, being a dampener with a moderate tension of the gonad. The testicle is fixed with two or three sutures for the remains of the vaginal process to the fleshy shell.

The next step is removing the hydatids and placing the testicle into the vaginal sac, which is sutured to the spermatic cord. Gonadu is immersed in the formed bed, the skin of the scrotum is sutured with a nodular or continuous suture. The wound in the groin is sutured layer by layer. When forming the outer ring of the inguinal canal, it is necessary to remember the possible compression of the elements of the spermatic cord.

Operation with cryptorchidism Ombredanna

A cut in the inguinal region opens the anterior wall of the inguinal canal and mobilizes the spermatic cord. The index finger passes through the lower corner of the wound into the scrotum and through the septum pulls the skin on the opposite side. Then the skin is dissected and a septum of the scrotum is cut over the tip of the finger. For the ligature, pre-stitched through the remains of the hunter's strand, the testicle is taken out through the incision outwards. The incision in the septum is sutured to the spermatic cord, and the testicle is immersed in the scrotum. The inguinal canal is sutured, as in hernia repair. The wound of the scrotum is tightly closed.

Operation with cryptorchidism Chukhrienko-Lyul'ko

Make an incision, as in hernia repair. After mobilization of the spermatic cord, the vaginal process is dissected in the transverse direction. The proximal part of the appendage leading to the abdominal cavity is stitched with a sutured suture and tied with a continuous lavsan suture. Then on the front surface of the corresponding half of the scrotum make a superficial cutaneous incision up to 6 cm long. From the skin of the scrotum, the fleshy shell is bluntly separated. In the upper corner of the scrotum in the fleshy shell make a cut through which the testicle is carried. The wound of the fleshy shell is sewn with lavsan sutures. In addition, the fleshy membrane is fixed with a lavsan suture to the opposite wall of the scrotum, starting from the spermatic cord and to the bottom of the scrotum. To the dense wall formed in this way, the testicle is fixed with the free ends of the threads, with which the distal part of the vaginal process is sewn. The inguinal canal and the wound of the scrotum are sutured. As a result, the testis is fixed in the lowest part of the scrotum between her skin and the double wall of the fleshy shell.

Operation with Vermuth cryptorchidism

The bed for the testicle is not created by expanding the scrotum, but with the help of a clamp. The threads with which the remains of the hunter thread are stitched, with the help of straight needles through the formed bed of the scrotum, are removed and tied. Adjust the elastic traction to the inner surface of the opposite thigh, as in the operation on Gross, or on the side of the operation, as in orchio-therapy with Sokolov. The testicle is fixed in the lowest part of the scrotum between the fleshy membrane and the skin of the scrotum.

At present, operations with cryptorchidism - funiculopexia - are becoming more common.

Ejaculation of the testicle in the scrotum with the formation of a new arteriovenous stalk (autotransplantation of the testicle according to Kirpatovsky). It is carried out by crossing the testicular vascular pedicle, but, unlike the method of Fowler and Stephens, a new vascular pedicle is formed. To do this, the vessels are connected to a new source of blood supply, which is usually chosen by the lower epigastric vessels, due to which the elongation of the newly formed vascular pedicle takes place. From a typical transplantation, this operation with cryptorchidism is distinguished only by the fact that the vas deferens do not cross and do not form vaso-vasal anastomoses, since its length proves sufficient to lower the testicle. Transplantation of the testis on the arteriovenous stalk is used in the most severe forms of cryptorchidism in conditions of high abdominal retention. When the testicle is located at the lower pole of the kidney on a short trunk vascular pedicle, or instead of the main vessel there is only an arterial network.

Operation in cryptorchidism in this case is reduced to the intersection of the testicular artery and vein, and the vas deferens mobilize all the way to the entrance to the small pelvis. The eggs are removed from the abdominal cavity through an artificially created opening in the region of the medial inguinal fossa and immersed in the scrotum through the surface opening of the inguinal canal. In the inguinal canal, the lower epigastric vessels are distinguished - the artery and vein, which are crossed, and their central ends are transposed into the inguinal canal. Blood supply in the lowered testicle is restored by connecting the testicular artery and vein with the lower epigastric vessels using microsurgical techniques.

The use of microsurgical techniques allows the testicle to be lowered into the scrotum by autotransplantation in cases when the insufficient length of the vascular pedicle of the testicle excludes the possibility of orchidopexy. More preferably, the compound of the testicular artery and vein with the lower epigastric artery and vein, respectively. A. Haertig et al. (1983) recommend limiting the application of arterial anastomosis, considering sufficient venous outflow through v. Deferentialis. T.I. Shioshvili considers this a forced measure, for example, in the case of an anomaly of v. Testicularis, since in this case, periorhitis may develop in the postoperative period.

Van Kote (1988) believes that autotransplantation of the testicle is promising only in 20% of patients with abdominal cryptorchidism. Optimal age is considered two years, but this operation with cryptorchidism has so far been successfully performed only in two boys at the age of 2 years. Microsurgical autotransplantation of the testicle, which is in the abdominal cavity before the age of two, is hampered by the small size of testicular vessels with a diameter of 0.4 to 0.6 mm.

In addition, it is necessary to remember the anatomical features of trophic testis. Apparently, it is no coincidence that the ovarian artery departs from the renal artery to the left and from the abdominal aorta on the right, and immediately before the entry into the gonad the testicular artery has a convoluted course. The long main way and multiple crimp of the vessel is a kind of damper, which allows maintaining the optimal temperature regime of the gonad. At present, it is not known how the artificial change in blood flow affects the functional significance of the gonad.

In recent years, there have appeared works in which endoscopic methods of orchiopexy are described. The operation is performed by laparoscopic method in children with abdominal form of cryptorchidism.

Most often use the endoscopic method of orchiopexy by Fowler-Stephens. Perform it with a high abdominal testicle and the absence or inferiority of the contralateral testicle. These operations in cryptorchidism are performed in two stages. An anatomical prerequisite for the success of orchpexia in cryptorchidism according to Fowler-Stephens is the long loop of the vas deferens and a short vascular bundle.

After the test for laparoscopy, the localization of the testicle and its condition is determined by hemostatic clips, ligating the inner family vessels at a distance. This completes the first stage of the operation. JA Pascuale et al (1989) in the experiment found that when dressing the spermatic blood vessels to the testicle in the first hour is reduced by 80%, but by the 30th day it is normalized. Six months after the laparoscopic clipping of the vessels, the patient undergoes the second stage of orchiopexy. Seed vessels are ligated and separated from the clips proximally. Then a broad cuff is extracted from the peritoneum of the testicle and the vas deferens and this complex is reduced to the scrotum after mobilization. An important aspect is the wide allocation of the parathesic leaf of the peritoneum. Firstly, this method allows you to exclude the torsion of the gonad in the process of bringing it back to the scrotum; secondly, the probability of blood supply to the gonad on the single artery of the vas deferens remains. With the atrophy of the testicle located in the abdominal cavity, laparoscopic orchiectomy is performed.

Preventing the birth of children with cryptorchidism remains the emphasis on the exclusion of disruptors from the diet of pregnant women and the development of strict indications for the use of hormone therapy during pregnancy.