Cryptorchidism - Information Overview

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

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Epidemiology

The relevance 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 3% of cases in full-term newborn boys, and up to 30% of cases in premature babies.

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

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

It is customary to distinguish five stages of testicular migration:

• gonad bookmark;
• migration of the testicle from the site 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 the testicles through the inguinal canal into the scrotum;
• obliteration of the vaginal process of the peritoneum.

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Causes cryptorchidism

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

It is customary to distinguish five stages of testicular migration:

• gonad bookmark;
• migration of the testicle from the site 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 the testicles through the inguinal canal into the scrotum;
• obliteration of the vaginal process of the peritoneum.

The process of testicular migration from the abdominal cavity to the scrotum begins in the 6th week of intrauterine fetal development. The testicles reach the internal ring of the inguinal canal by approximately the 18th to 20th week, and by the time of birth the gonads are located at the bottom of the scrotum. If the transabdominal route of testicular migration does not depend on the level of androgens, and is possibly mediated by intra-abdominal pressure and paracrine influence of growth peptides of local or testicular origin, then 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, dysfunction of Sertoli cells secreting anti-Müllerian factor, and insufficient gonadotropin production are accompanied by cryptorchidism (Kallmann, Klinefelter, Prader-Willi, Noonan syndromes, etc.). In addition, cryptorchidism is one of the symptoms of genetic disorders causing multiple developmental anomalies (Carnelius de Lange, Smith-Lepley-Opitz syndromes, etc.). However, some patients with cryptorchidism do not have primary disorders of gonadotropic and gonadal functions, 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 probably played by genetic disorders leading to a deficiency of paracrine factors produced by both the testicles and the cells of the vessels, vas deferens, and inguinal canal.

The main consequence of cryptorchidism is a violation of the germinal function of the testicle. Histological examination of the testicles reveals a decrease in the diameter of the seminal ducts, a decrease in the number of spermatogonia and foci of interstitial fibrosis. Similar disorders in undescended testicles are found in 90% of children over 3 years old. The literature contains information on structural changes in the Leydig and Sertoli cells in cryptorchidism in older boys. The question of whether these changes are a consequence of cryptorchidism or its cause remains a subject of discussion. There are opinions that changes in the testicle in cryptorchidism are primary. This is confirmed by the fact that in patients with undescended testicles, pathological changes in the tubular epithelium do not occur with age. Impaired fertility, even with timely descent of the testicles, is noted in 50% of patients with bilateral and 20% of patients with unilateral cryptorchidism.

The risk of testicular neoplasia in patients with cryptorchidism is 4-10 times higher than in men in the general population. Of all the diagnosed testicular seminomas, 50% are found in undescended testicles. Testicles located in the abdominal cavity are more susceptible to malignancy (30%) than, for example, those located in the inguinal canal. Lowering the testicle does not reduce the risk of malignancy, but allows for timely diagnosis of the neoplasm. In 20% of cases, tumors in patients with unilateral cryptorchidism develop in the contralateral testicle. In addition to seminomas, men with cryptorchidism have a high incidence of gonocytomas and carcinomas. The fact that this type of tumor develops may also support the theory of primary dysgenesis of the undescended testicle.

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

The division into groups with different pathogenesis is due to a fundamentally different approach to the treatment tactics for patients with this disease. In the first group, where the problem is initiated by testicular retention (gonad delay on the way to migration to the scrotum), preoperative preparation with gonadotropins is necessary. The purpose of hormonal therapy is to lengthen 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 vessels feeding the gonad and, accordingly, to a deterioration in the trophism of the organ. The vessels feeding the walls of the main vessels of the spermatic cord also suffer, causing edema of the vessel wall, reducing its diameter, which again negatively affects the blood flow, contributing to ischemia of the testicular tissue.

The negative impact of short-term ischemia on testicular tissue has now been proven. After three hours of gonadal ischemia, diffuse necrosis occurs in testicular tissue during torsion of the spermatic cord. After 6-8 hours from the moment of torsion, almost the entire gonad undergoes necrosis.

Thus, one of the most important tasks facing the surgeon is to minimize testicular tissue ischemia during surgical correction of cryptorchidism. Accordingly, the entire arsenal of known surgical techniques should be used taking into account the pathogenesis of secondary infertility associated with impaired trophism of the gonad.

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Symptoms cryptorchidism

When examining a patient with a presumptive diagnosis of cryptorchidism, it is necessary to remember that in some cases it is possible to identify children with false cryptorchidism or with an increased cremasteric reflex. In such children, the scrotum is usually well developed. When palpating in the groin area, in the direction from the inner ring of the inguinal canal to the outer ring, the gonad can be lowered into the scrotum. Parents of such a child often note that during bathing in warm water, the testicles descend into the scrotum on their own. Symptoms of cryptorchidism in children with the true form are that the testicle cannot 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, femoral, pubic, perineal region, or in the opposite half of the scrotum. Of particular interest is the testicle palpated in the inguinal region, since in this case there is a need for differential diagnosis of inguinal ectopia of the gonad with inguinal retention. With any form of ectopia of the gonad, there is practically no need for hormonal preoperative preparation, since the elements of the spermatic cord are well defined and have sufficient length for free lowering into the scrotum by surgery.

However, with inguinal retention, the gonad is located in the inguinal canal, and the testicular vessels are not long enough for free descent. This is why patients with inguinal retention of the gonad require preoperative hormonal therapy.

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

Often, it is possible to differentiate inguinal ectopia from inguinal retention by conducting a palpatory examination. In cases where the gonad palpated in the inguinal region shifts exclusively along the canal, repeating its anatomical course, i.e. is limited by the walls of the inguinal canal, it is possible to state testicular retention with a high degree of certainty. And, on the contrary, the shiftability of the gonad in almost all directions indicates inguinal ectopia.

The most severe group is patients with abdominal retention, both from the diagnostic and treatment perspectives. First of all, it is necessary to determine the sex of a patient with the "non-palpable testicle" syndrome, excluding chromosomal sex disorders. In this case, differential diagnostics should be carried out primarily with mixed gonadal dysgenesis.

Mixed gonadal dysgenesis is a condition in which phenotypic males or females have a testicle on one side and a fallopian tube, a ligament (connective tissue cord), and sometimes a rudimentary uterus on the other. The cord (ligament) is a thin, pale, elongated structure, often oval in shape, located either in the broad ligament or on the pelvic wall, consisting of ovarian stroma.

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

In such cases, the patient is assigned the female gender and feminizing surgeries are performed with the removal of rudimentary internal genitalia. Much less often, usually for social reasons, the gender is left male. For this purpose, a laparoscopic removal of the uterus, fallopian tube and scrotum is performed, and the testicle is either removed, transferring the child to hormone replacement therapy in the future, or lowered into the scrotum, and the child's parents are warned about the high probability of gonadal malignancy, the frequency of which in patients with mixed gonadal dysgenesis reaches 20-30%.

The examination algorithm for patients with the "non-palpable testicle" syndrome includes ultrasound scanning of the abdominal cavity, but this diagnostic method, unfortunately, is not always reliable.

Modern high medical technologies allow using radioisotope methods, angiography, CT MRI, etc. to diagnose severe forms of cryptorchidism. However, laparoscopic examination is the most objective and reliable method for diagnosing this disease at present. It allows assessing the condition of the gonadal vessels, accurately determining the location of the testicle and assessing the condition of the gonad by external signs. In case of severe testicular dysplasia, orchifuniculectomy is performed. In doubtful cases, a gonadal biopsy is performed.

Hormonal treatment with gonadotropins does not always provide the desired result, but in some patients it is still possible to achieve elongation of the testicular vessels. The determining sign of the effectiveness of the therapy is the displacement of the gonad to the opposite ring of the inguinal canal during repeated diagnostic laparoscopy.

Repeat laparoscopy is performed 1-3 weeks after the course of hormonal treatment. In cases where a positive effect is achieved to a greater or lesser extent, immediately after assessing the length of the gonadal vessels, an open method of surgical lowering of the testicle is used.

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Treatment cryptorchidism

Drug treatment of cryptorchidism

Treatment of cryptorchidism is carried out with chorionic gonadotropin preparations. Despite the fact that hormonal therapy of cryptorchidism has been 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 the group of patients where the testicles were previously located in the scrotum. In the treatment of true cryptorchidism, the effectiveness does not exceed 5-10%. Effectiveness means the movement of the gonad into the scrotum under the influence of hormonal therapy, but at the same time, the length of the testicular vessels is not assessed.

There are various dosage regimens and frequencies of administration of human chorionic gonadotropin in the treatment of cryptorchidism, but there are no reliable differences in the results of using various treatment regimens. The standard regimen for the administration of human chorionic gonadotropin preparations: injections 2 times a week for 5 weeks intramuscularly. 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 IU per injection; 2.5 6 years - 500 IU; 7-12 years 1000 IU. Analogues of luteinizing hormone-releasing hormone (LHRH), administered in a pulsed mode, are also used to treat cryptorchidism. The effectiveness of this treatment is no different from the effectiveness of treatment with human chorionic gonadotropin.

Operations

Despite the vast clinical experience in treating such a disease as cryptorchidism, operations are performed without adhering to any specific time frame. Most clinicians recommend starting treatment as early as possible: W. Issеndort and S. Hofman (1975). R. Petit and Jennen (1976, C. Waaler (1976) - at 5 years; A.G. Pugachev and A.M. Feldman (1979) - at 3 years; N.L. Kush (1970) - at 2 years; T.V. Semenova, A.N. Tyulpanov, A.P. Erokhin, S.I. Volozhin, A.K. Faieulin, Berku, Donahoe, Hadziselimovic (2007) - in the 1st year; C. Herker (1977) - on the 4th-5th day of life.

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

Clinicians often encounter a situation where, after several months of hormonal therapy, the gonad is again pulled up to the level of the inguinal canal. This circumstance once again testifies to the need for surgery for cryptorchidism in order to ligate the vaginal process of the peritoneum and perform orchiopexy.

All known operations for cryptorchidism are divided into two groups: one-stage and two-stage. One-stage methods include operations that allow for the isolation and ligation of the vaginal process of the peritoneum at the internal ring of the inguinal canal, mobilization of the elements of the spermatic cord, lowering the testicle into the scrotum and performing temporary or permanent fixation of the gonad. Two-stage methods, in turn, can also be divided into two subgroups:

• operations for cryptorchidism, performed with moderate deficiency in the length of the gonadal vessels;
• operations for cryptorchidism, performed in cases of severe deficiency in the length of the gonadal vessels.

The first operation for cryptorchidism was performed by Koch from Munich in 1820. On the advice of Cheliusoii, he opened the scrotum, passed a ligature through the vaginal membrane and applied a pellot in the hope that subsequent traction on the ligature would lower the testicle into the scrotum. This operation resulted in the death of the patient as a result of peritonitis. The first successful operation for cryptorchidism was performed in 1879 by Annandale on a three-year-old boy with perineal ectopia on the right. Annandale sutured the testicle to the bottom of the scrotum with a subcutaneous catgut suture.

Among the most common treatment methods, the first group includes the methods of Petriwalasky (1932), Schoemaker (1931), Ombredanne (1910), Welch (1972), Рerrone, Signorelli (1963). Recently, the most widely used method is the Schoemaker-Petriwalasky method, which allows the gonad to be optimally lowered into the scrotum and fixed in a subcutaneous pocket at the bottom of the scrotum.

The idea of Ombredanne, Welch, Perrone, Signorelli remains interesting, based on fixation of the lowered gonad to the interscrotal septum. The methods differ from each other only in the relationship of the gonad to the septum. The disadvantage of the method in cryptorchidism is the impossibility of performing this intervention as a result of the pronounced deficiency in the length of the spermatic cord.

The fundamental advantage of these technologies is the direct orientation of the vascular bundle of the testicle without artificially created kinks. This technique allows minimizing the degree of ischemia of the gonad caused by the kinking of the spermatic cord.

The first subgroup of two-stage technologies includes the Keatley-Baile-Torek-Gertsen method. The first stage of the method for cryptorchidism is based on ligation of the vaginal process of the peritoneum, mobilization of the vascular bundle and fixation of the gonad to the broad ligament of the thigh with the creation of a femoroscrotal anastomosis. After three months, the femoroscrotal anastomosis is divided, the gonad is isolated and cut off from the broad ligament with immersion in the scrotum. Disadvantages of the method:

• cases with a pronounced deficiency in the length of the spermatic cord, when this technology is not feasible;
• kink of the spermatic cord at the level of the outer ring of the inguinal canal (may contribute to a violation of hemodynamics in the gonad);
• The cicatricial process that occurs perifocally in the area of testicular implantation is highly likely to lead to irreversible changes in the gonad.

The second subgroup includes operations for cryptorchidism, in which a pronounced deficiency in the length of the spermatic cord does not allow the gonad to be lowered into the scrotum. In these cases, a step-by-step lowering is performed. During the first stage, the vaginal process of the peritoneum is treated and the testicle is fixed at the point of maximum lowering. Subsequently, 3-6 months after the first stage of the operation for cryptorchidism, the gonad is isolated from the surrounding tissues and lowered into the scrotum. The disadvantage of this method is the pronounced cicatricial process that forms around the lowered gonad after the first stage of the operation, which can negatively affect the function of the organ in the long term.

The same group should include the operation for cryptorchidism "long loop of the duct" developed and implemented by R. Fowler and FD Stephens in 1963. The principle of the operation consists of crossing the vessels of the testicle while preserving the collateral branches and vessels of the vas deferens.

The incidence of decreased fertility in patients with cryptorchidism does not always depend on the degree of gonadal dysgenesis. Often, the cause of infertility may be a pathogenetically unjustified method of cryptorchidism surgery, leading to testicular tissue ischemia.

The method developed by Mixter (1924) is related to the operation for cryptorchidism using the principle of temporary fixation of the testicle. The operation begins from the same incision as for herniotomy. The aponeurosis of the external oblique muscle is exposed layer by layer. The anterior wall of the inguinal canal is dissected and its revision is performed. Most often, the testicle is located along the inguinal canal or at its outer ring. In some cases, with inguinal retention of the testicle, it can wander, being either in the abdominal cavity or in the inguinal canal. This is why it is not always possible to palpate the gonad in the inguinal canal. In cases where the testicle is located in the abdominal cavity, it is first brought out, then the hernial sac is isolated.

When using microsurgical instruments and optical magnification, the vaginal process is optimally isolated by an open method. It is possible to use tissue hydropreparation. The isolated hernial sac is stitched and ligated at the internal ring of the inguinal canal, after which they begin to mobilize the elements of the spermatic cord.

An important point in the operation for cryptorchidism of testicular descent is the maximum isolation of the spermatic cord elements with dissection of the fibrous strands accompanying the vessels, which allows to significantly increase the length of the vascular-nerve bundle. If necessary, mobilization is performed retroperitoneally until the testicle reaches the scrotum. Sometimes, despite the preoperative hormonal preparation, the testicular vessels still remain short. In this situation, dissection of the inferior epigastric vessels is performed. This type of intervention was proposed by Prentiss (1995). The principle of this manipulation is to reduce the distance from the beginning of the testicular vessels to the scrotum by reducing the angle in the scheme of the spermatic surgical triangle. The testicle can also be passed a shorter way, preserving the epigastric vessels. For this purpose, an opening is created in the posterior wall of the inguinal canal using a curved Bilroth clamp in a blunt manner. The clamp is passed under the epigastric vessels, grasped by the membranes or by the remains of Hunter's cord and passed through the newly formed opening in the posterior wall of the inguinal canal.

The principle of fixation of the reduced testicle in the scrotum according to Mikster consists of applying a suture ligature brought out through the skin of the scrotum and fixed to the skin of the thigh. The fixing ligature is carried out in the area of transition of the protein coat into the proper coat of the testicle, at the lower pole. The choice of the distal fixation point is determined by a preliminary "try-on" in order to prevent pronounced tension of the elements of the spermatic cord. Then the inguinal canal is sutured from top to bottom. The outer ring of the inguinal canal should not compress the elements of the spermatic cord. For this purpose, the last suture on the anterior wall of the inguinal canal is applied under the control of the fingertip. The wound is sutured tightly in layers. The fixing ligature and skin sutures are removed at

Day 7 after surgery. The Keetley-Torek cryptorchidism operation differs from this technology by fixing the testicle to the broad fascia of the thigh by creating a femoroscrotal anastomosis. After treating the vaginal process of the peritoneum and mobilizing the gonad, a leash ligature is applied to the remains of the Hunter's cord. The scrotum is dissected at the lowest point, making a 2-3 cm long incision. A Bilroth clamp is passed through the incision, the ligature is grasped and the testicle is brought out. The "try-on" method determines the level of fixation of the gonad to the inner surface of the thigh. Then a transverse incision is made on the thigh, similar to the incision on the scrotum.

According to the Keetley technique, the testicle is not removed from the scrotum, but is fixed with separate sutures to the remains of the Hunter's cord to the broad fascia of the thigh. The edges of the scrotal skin incision are sutured to the edges of the thigh skin incision, forming a femoroscrotal anastomosis. According to the Torek method, a bed for the testicle is created on the scrotum and then the gonad is fixed to the broad fascia of the thigh, after which a femoroscrotal anastomosis is applied. The wound in the groin area is sutured using the method described above.

After 6-8 weeks, the anastomosis is separated and the testicle is placed into the scrotum.

The Fowler method (1972) is considered one of the attempts to abandon the methods of rigid fixation of the gonad to the thigh. The principle of the operation for cryptorchidism is to pass a fixing ligature through the lower part of the scrotum and apply a perineal suture behind the scrotum so that when tying there is no pronounced traction on the testicular vessels. When fixing according to Fowler, the testicle is always slightly pulled to the back surface of the scrotum, without giving a characteristic protrusion of its contours. The fixing ligature and skin sutures are removed on the 7th day.

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

The through passage of the fixing ligature through the skin of the scrotum is a feature of orchiopexy using the Sokolov method. The ligature is then pulled up and tied on a roller, and the ends of the thread are tied to a rubber end attached to a splint on the opposite thigh. The ligature and skin sutures are removed on the 7th day.

In cases where it is not possible to lower the testicle into the scrotum in one stage, the principle of staged gonad transfer is used. During the first stage, the testicle is fixed under the skin, in the pubic area, to the inguinal ligament or in the upper part of the scrotum. A mandatory condition is minimal tension of the testicular vessels in order to prevent testicular tissue ischemia. An attempt to move the gonad into the scrotum is performed after 6-12 months.

Operations for cryptorchidism using the principle of permanent fixation. The Schoemaker (1931) and Petriwalsky (1931) operation has become widespread throughout the world for its original method of fixing the gonad in the scrotum. Unlike many of the above methods, this technology allows for "gentle" traction of the gonad.

The operation for cryptorchidism is performed through the inguinal approach, the inguinal canal is opened, the vaginal process of the peritoneum is treated and the elements of the spermatic cord are mobilized using the technology described above. The method of fixing the gonad in the scrotum is fundamentally different. For this purpose, the index finger is passed to the bottom of the scrotum, creating a tunnel through which the gonad is subsequently passed. In the middle third of the scrotum, at the height of the tip of the finger, a transverse incision of about 10 mm in length is made. The depth of the incision should not exceed the thickness of the scrotum skin itself. Then, using a mosquito clamp curved in the sagittal plane, a cavity is created between the skin and the fleshy membrane of the scrotum. The volume of the cavity formed should correspond to the volume of the gonad being brought down.

Then a mosquito-type clamp is passed from the wound in the scrotum to the inguinal surgical wound using a finger, the membranes of the gonad are grasped and brought out through the scrotal incision, so that the opening in the dartos freely passes the elements of the spermatic cord. This technique allows for the creation of an additional retaining mechanism for the testicle, acting as a damper with moderate tension on the gonad. The testicle is fixed with two or three sutures for the remains of the vaginal process to the dartos.

The next step is to remove the hydatids and place the testicle in the vaginal sac, which is sutured to the spermatic cord. The gonad is immersed in the formed bed; the skin of the scrotum is sutured with a nodal or continuous suture. The wound in the inguinal region is sutured layer by layer. When forming the outer ring of the inguinal canal, it is necessary to remember about the possible compression of the elements of the spermatic cord.

Surgery for cryptorchidism Ombredanna

The anterior wall of the inguinal canal is opened by an incision in the groin area and the spermatic cord is mobilized. The index finger is passed through the lower corner of the wound into the scrotum and the skin on the opposite side is pulled through its septum. The skin is then cut and the scrotal septum is cut above the tip of the finger. The testicle is brought out through the incision using a ligature previously stitched through the remains of Hunter's cord. 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 herniotomy. The scrotal wound is sutured tightly.

Surgery for cryptorchidism Chukhrienko-Lyulko

An incision is made as in herniotomy. After mobilization of the spermatic cord, the vaginal process is dissected transversely. The proximal part of the process leading to the abdominal cavity is stitched with a purse-string suture and tied with a continuous lavsan suture. Then, on the anterior surface of the corresponding half of the scrotum, a superficial skin incision up to 6 cm long is made. The dartos is bluntly separated from the skin of the scrotum. In the upper corner of the scrotum, an incision is made in the dartos, through which the testicle is passed. The wound of the dartos is sutured with lavsan sutures. Additionally, the dartos 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. The testicle is fixed to the dense wall thus formed with the free ends of the threads with which the distal part of the vaginal process is stitched. The inguinal canal and the scrotal wound are sutured. As a result, the testicle is fixed in the lowest part of the scrotum between its skin and the double wall of the dartos.

Surgery for cryptorchidism Vermuten

The bed for the testicle is created not by expanding the scrotum, but by means of a clamp. The threads with which the remains of the Hunter's cord are stitched are brought out through the formed bed of the scrotum using straight needles and tied. Elastic traction is established to the inner surface of the opposite thigh, as in the Gross operation, or on the side of the operation, as in the Sokolov orchiopexy. The testicle is fixed in the lowest part of the scrotum between the fleshy membrane and the skin of the scrotum.

Currently, operations for cryptorchidism - funiculopexy - are becoming increasingly widespread.

Lowering the testicle into the scrotum with the formation of a new arteriovenous pedicle (testicular autotransplantation according to Kirpatovsky). It is performed by cutting the testicular vascular pedicle, but, unlike the Fowler and Stephens method, a new vascular pedicle is formed. For this, the vessels are connected to a new source of blood supply, which is usually the lower epigastric vessels, due to which the newly formed vascular pedicle is lengthened. The only difference between this operation and a typical transplant for cryptorchidism is that the vas deferens is not cut and vaso-vasal anastomoses are not formed, since its length is sufficient for lowering the testicle. Transplantation of the testicle on an arteriovenous pedicle 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 main vascular pedicle, or instead of a main vessel there is only an arterial network.

In this case, the operation for cryptorchidism is reduced to the intersection of the testicular artery and vein, and the vas deferens is mobilized along its entire length to the entrance to the small pelvis. The testicle is removed from the abdominal cavity through an artificially created opening in the area of the medial inguinal fossa and immersed into the scrotum through the superficial opening of the inguinal canal. In the inguinal canal, the lower epigastric vessels are isolated - an 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 to 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 where the insufficient length of the vascular pedicle of the testicle excludes the possibility of orchidopexy. It is more preferable to connect the testicular artery and vein with the inferior epigastric artery and vein, respectively. A. Haertig et al. (1983) recommend limiting the procedure to the imposition of an arterial anastomosis, considering venous outflow through v. deferentialis to be sufficient. T.I. Shioshvili considers this a forced measure, for example, in the case of anomaly of v. testicularis, since periorchitis 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. The optimal age is considered to be two years, but such an operation for cryptorchidism has so far been successfully performed only in two boys aged 2 years. Microsurgical autotransplantation of the testicle located in the abdominal cavity up to the age of two is difficult due to the small size of the testicular vessels with a diameter of 0.4 to 0.6 mm.

In addition, it is necessary to remember the anatomical feature of the testicle trophism. Apparently, it is no coincidence that the testicular artery departs from the renal artery on the left and from the abdominal aorta on the right, and immediately before entering the gonad, the testicular artery has a tortuous course. The long main path and multiple tortuosity of the vessel are a kind of damper that allows maintaining the optimal temperature regime of the gonad. At present, it is unknown how artificial changes in blood flow affect the functional significance of the gonad.

In recent years, works have appeared that describe endoscopic methods of orchiopexy. The operation is performed laparoscopically in children with abdominal cryptorchidism.

The most commonly used endoscopic method is orchiopexy by Fowler-Stephens. It is performed when the testicle is located high in the abdominal cavity and the contralateral testicle is absent or incomplete. These operations for cryptorchidism are performed in two stages. The anatomical prerequisite for the success of orchiopexy for cryptorchidism by Fowler-Stephens is a long loop of the vas deferens and a short vascular bundle.

After determining the localization of the testicle and its condition during laparoscopy, hemostatic clips are installed, ligating the internal spermatic vessels at a distance. This completes the first stage of the operation. JA Pascuale et al. (1989) found in an experiment that when ligating the spermatic vessels, the blood flow to the testicle decreases by 80% in the first hour, but normalizes by the 30th day. Six months after laparoscopic clipping of the vessels, the patient undergoes the second stage of orchiopexy. The spermatic vessels are ligated and separated proximally from the clips. Then a wide cuff is isolated from the peritoneum of the testicle and the vas deferens, and this complex, after mobilization, is lowered into the scrotum. An important aspect is the wide isolation of the paratesticular sheet of the peritoneum. Firstly, this technique allows us to exclude torsion of the gonad in the process of lowering it into the scrotum; secondly, the possibility of blood supply to the gonad on the single artery of the vas deferens is preserved. In case of atrophy of the testicle located in the abdominal cavity, laparoscopic orchiectomy is performed.

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