Cryptorchidism Rapid Fire Session: Update Course 2015

OK, the next rapid fire, going down the road, we'll talk a little bit about cryptorchism. Here's our case study. A 4 year old, uh, noted to have an empty scrotum. Parents says that she's seen previously both testicles in the scrotum, but for a while now she hasn't seen the other one. Otherwise, uh, the child has a negative history. So what do we know about crystal Thoicism? It's one of the most common pediatric disorders of the male endocrine glands. It's the most common genital disorder identified at birth. Um, there are two types, congenital, found at birth, and then acquired, um, which you can have children who have had normally descended testicles and the parents have seen them. It's been documented, and then for some reason, uh, they are not just merely retractile, but they can no longer be brought down without discomfort into a normal position within the scrotum. So why do we even care? Well, we care because treatment of cryptoricism reduces the risks, such as impaired fertility, testicular malignancy. Risk of torsion and treats the associated inguinal hernia. What are the controversies associated with the management of cryptorchism? There are 3 areas the use of hormones in the treatment of this condition, the use of imaging. And the management of intraabdominal testicles, there's probably other ones, but those are the three that I'm going to focus on in this brief talk. So hormonal therapy is usually with various different agents that they've all been tried. Um, the mechanism, the actual mechanism of action of each of these agents is um frankly unknown. Um, the studies that have been published included multiple treatment strategies, different ways, different approaches, different doses, different intervals of the doses, um, and none of them have good response rates. Um, and there are no, uh, demonstrable long-term benefits of treatment with hormone therapy. So the conclusion. Is that hormonal therapy should not be used to induce testicular descent, as evidence shows low response rates and lack of evidence for long-term efficacy. The second question is imaging. 70% of undescended testicles are palpable. They may not be palpable during the examination while the child is awake, but they are usually palpable under anesthesia. However, you must need, you, we are required to confirm the tester's presence and the location prior to considering uh the type of uh operative management we're going to do. Ultrasound has a sensitivity of only 45% and a specificity of only 78% in determining the location, the size, uh, and other, you know, um, um, uh, types of documentation that are required in order to precisely confirm the presence of the testicle and its exact location. So, and an ultrasound cannot identify intraabdominal testicles. So imaging, um, using other modalities are expensive, require an anesthesia, or they themselves irradiate the tissues. And there's no radiologic test that is 100% accurate to determine whether a testicle is absent. So the conclusion is a surgical exploration such as a diagnostic laparoscopy or open exploration must be performed on all on all non-palpable, unilateral, and many bilateral crypt orchid patients. Imaging should not be performed since it's really helpful, can actually delay uh uh treatment. The management of the intradominal testicle, there is no advantage for laparoscopic versus open exploration. If the vessels are, uh, terminate. In other words, there is no testicle, that's the end of the procedure. If the testicles are salvageable, you have a choice of three operations a primary, uh, orchidopexy, a one-stage Fowler-S Stevens, or a two-stage Fowler-S Stevens. The idea, the the the the the way to do uh uh your uh decision tree is that you try to spare the testicular vessels if possible, um. If not, there is no apparent advantage of a one-stage versus a two-stage Fowler-Steveen procedure. An orchiectomy may be prudent in the presence of a normal contralateral descended testicle. Great, thank you. Real quick. Single stage or or a one or a two-stage follower, Steven, Witt? Uh, I actually prefer two stage, but others in our group do one stage, so I think it's, it's surgeon preference. I think it's, I think in this day and age, most of the time you can get the testes down without needing to divide the testicular vessels, but if you do, I think it's dealer's choice. 12 year old with an undescended test. I would, well, if it's prepubertal, that's a tough 12 year old's hard. 10 year old, I think you try to do an orchopexy, 14 year old, you'd probably take it out, but the teaching is if it's prepubertal, you can try to do an orchopexy, but if they're going through puberty, then you ought to take it out, OK. Any other comments or questions? Very good. Uh, last one. Cool, lumps and bumps. We're ready. All right, so, uh, you know, Todd was kind enough to give me this subject called lumps and bumps, which horrified me because, I mean, it's certainly one of the most common things that we have to deal with, but the, the, the, the process and the, the, the, the amount of pathology is just, I think, insurmountable. OK, so since I.