"Clinical study and management of children with imperfect descent of testis".
It affect all races, and there does not seem to be a geographic propensity, although undescended testis may be associated with a number of chromosomal and hereditary disorders in which specific defect can be identified, at the present time the majority of the cases appear to be isolated. This is probably due to the fact that relatively little is known about what causes the testis to migrate from the abdomen in to the scrotum.
At age 2 years, a testis residing outside the scrotum and in the high temperature zones in the abdomen or inguinal canal would start to deteriorate and this becomes established at age of 5 years.
Early surgical correction helps to avert this and reduce the risk of complication. The undescended testis has greater risk of leading to infertility and tumerogenesis.
Thus it is important to follow mobilization, cord dissection, isolation of patent processes vaginalis and relocation of the testis to the scrotum.
Many terms including cryptorchidism, undescended testis, imperfect descent of testis, maldescent of testis are used. But all terms refer to any testis which is deviated from the normal path of descent from abdomen to scrotum.
We have studied the different locations presented, its associated anomalies and complications and management of imperfect descent of testis.
MATERIAL AND METHODS: children admitted in to the pediatric surgery wardswith the history of absence of testis in the scrotumare included in this study.
This Hospital equipped with the facilities to carry out all necessary investigations to arrive at an accurate pre-operative clinical diagnosis.
Study design: Descriptive study
Sample size: 50
Sample design: Purposive sampling
Study period: Dec 2011 to May 2013
INCUSION CRITERIA: Children of age from day 1 of birth to 18 years who presented with absent testis in scrotum since birth.
EXCLUSION CRITERIA: Children who had intersex disorder and retractile testis. In thisstudy patient's, detailed history was taken, routine investigations like TC, DC, Hb and systemic examination were done in all patients. Ultrasound examination of the abdomen was done in all cases.
All patients were treated surgically after taking proper consent from the patient's parents, open and lap orchidopexy were the surgeries performed.
If the cases are bilateral, patients were advised to undergo surgery later for the other side,every patient was advised for follow upregularly once a month at the time discharge from the hospital.
1. AGE INCIDENCE
The average age of presentation in the study is 6 years.
2. SIDE OF INVOLVEMENT
Right side is the most common side of involvement i.e 21 cases,
The commonest symptom in all cases was absence of testis in the scrotum. Groin swelling was present in 8 cases (16%). Pain in the swelling was also present in 3(06%).
4. Palpable Testis
Most common site where testis was found is superficial pouch 12(29.26%) followed by inguinal region 11(26.82%).
5. Ectopic testis
6. Impalpable Testis
Most common site of impalpable testis was canalicular 5(62.5%) followed by intra-abdominal 2(25%).
7. Location of improper descent of testis
Most common site found was in superficial pouch.
8. Anomalies associated
8.1. Anomalies associated with imperfect descend of testis with respect to age
Most abnormalities found were of gubernaculums
8.2 Anomalies associated with imperfect descent of testis with respect to location of the testis
Most common abnormality was of gubernaculum in mid-scrotal region
1. Ultrasound of abdomen was done in 50 cases. In 5 cases testis was present in the root of scrotum, 6 patients external ring, 12 patients in the superficial pouch, 11 patients inguinal canal, 8 cases are intra-abdominal (in 8 intra-abdominal cases) one case testis was present in the lumbar region, in one case it was present in right iliac fossa. One case in the pelvis and 5 are canalicular absent testis in 1 case.
2. Blood and urine examination was done routinely in all the cases for preoperative assessment of the patient.
3. Screening chest was also done in all the patients. Other relevant investigations were also done.
We did 41 cases of open orchidopexy and 8 cases of lap orchidopexy and for 1 absent testis in abdomen, only diagnostic lap was done.
Post-operative period: Was uneventful.
FOLLOW UP: we only followed up for any ascent of testis after orchidopexy, any atrophy of testis, and wound infection. But due to lack of time in our study, we were not able to study regarding fertility of patients
ASSOCIATED SYNDROMES: We got 2 cases of beck with- Weidman syndrome
ASSOCIATED COMPLICATIONS: 2 cases with obstructed hernia
1. PRESENTING AGE GROUP:
In the present study of 50 patients
* 7 patients were below 2 years of age (14%).
* 28 patients were between 2 to 5 years of age (56%).
* 11 Patients were between 5 to 10 years of age (33.34%).
* 4 patients were between 10 to 18 years of age (36.67%).
This series is compared with M.B. Jackson et al series in which 60 boys were included in the study, as shown in below.
The present series has shown that the majority of the patients were detected in 2-5 yrs age group, compared to Jackson et al series. Few of the patients were detected in the school health check up and were referred to our hospital.
2. SIDE OF INVOLVEMENT
Right is the most common side of involvement in our study.
3. FAMILY HISTORY
4 patients had family history of imperfect descent of testis in our study.
4. TYPES OF UNDESCENDED TESTIS
Kaplan(1993) proposed the most popular system, which categorizes imperfect descent of testes as either palpable or impalpable.
The subject nature of the physical examination confounds the accurate classification of testicular position. A more accurate assessment occurs at the time of surgery.
We have got less cases in upper scrotum compared to Hutson& Baker studies (57a, 57b)
(Found intra operatively)
5. ASSOCIATED ABNORMALITY
6. ASSOCIATION OF NEOPLASIA WITH UNDESCENDED TESTIS
7. FERTILITY AND UNDESCENDED TESTIS
Orchidopexy was done before reproductive age group in many of our patients. Long term follow-up could not be done because of lack of time in the study period.
We didn't do orchidectomy for any cases.
CONCLUSION: Undescended testis is most common in right side.In palpable Undescended testis, superficial pouch is the most common site where the testis is found. In ectopic, femoral is the most common site. In impalpable testis most common is canalicular.
Open orchidopexy for palpable and lap orchidopexy for impalpable testis is most common operation performed.
Many of the undescended testis descend within one year of age, hence we should wait till one year of age.
Orchidopexy for undescended testis should be done within 2 years of age as histopathological changes start around 2 years of age till 16 years where irreversible histopathological changes takes place.
Routine pre-operative imaging for undescended testis is neither necessary nor helpful. Ultrasound or MRI do not accurately localizes a true non palpable testis and hence does not alter the surgical management. Laparoscopy directly should be used for evaluation of children with impalpable undescended testis.
SUMMURY: Imperfect descent of testis is the most common problem encountered in pediatric surgery OPD. Many theories have been proposed for imperfect descent of testis, but till today the exact etiology still unknown.
In this descriptive study 50 children of age from day 1 of birth to 18 years, who presented with the complaints of absent testis were selected on the basis of purposive sampling.
This study was conducted between Dec 2011 to May 2013, all of the 50 children fulfilling the inclusion and exclusion criteria after detailed examination underwent abdominal and scrotal scanning. And for palpable testis open orchidopexy was done and for impalpable testis lap orchidopexy was done.
In our study:
* 56% incidence is present in 2-5 years of age.
* 42% of undescended testis were present on right side
* 82% cases are palpable in undescended testis
* In palpable testis 30% cases are present in superficial pouch followed by inguinal canal(26%)
* In impalpable testis 77% of cases present in canalicular region followed by intra abdominal(22%).
* 2 children who presented with impalpable testis were found to have of Beck-with weidmann syndrome.
* We got 2 cases presented with obstructed inguinal hernia and on examination were found to have undescended testis
* We did 41 cases of open orchidopexy and 8 cases of lap orchidopexy and for 1 absent in abdomen, only diagnostic laparoscopy was done.
* Orchidopexy carries 98% of success rate
* Follow up was done for any ascent, atrophy of testis and wound infection.
* We did not get any complications, but due to lack of time in our study we were not able to study regarding the fertility of the patient.
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Sathyanarayana B.A , Ramachandra J 
[1.] Sathyanarayana B.A.
[2.] Ramachandra J.
PARTICULARS OF CONTRIBUTORS:
[1.] Professor, Department of General Surgery, Kempegowda Institute of Medical Sciences, Bangalore.
[2.] Professor, Department of General Surgery, Kempegowda Institute of Medical Sciences, Bangalore.
NAME ADRRESS EMAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Sathyanarayana B.A., Professor, Department of General Surgery, Kempegowda Institute of Medical Sciences, V.V. Puram, Bangalore.
Date of Submission: 22/11/2013.
Date of Peer Review: 23/11/2013.
Date of Acceptance: 02/12/2013.
Date of Publishing: 14/12/2013
Table. 1 shows the age incidence of imperfect descent of testis. Age in years NO. Of cases Percentage < 2 years 7 14% 2-5 years 28 56% 5-10 years 11 22% 10-18 years 4 8% Table. 2 shows the side of involvement Side of involvement NO. of cases Percentage Right side 21 42% Left side 18 36% bilateral 11 22% Table. 3 showing symptoms Symptom No of cases Percentage Absence of testis in scrotum 39 78% with underdeveloped scrotum Groin swelling 8 16% Pain in the swelling 3 6% Table 4: Location of the palpable testis Position Patients Percentage Mid-Scrotal 7 17.07% Root of scrotum 5 12.19% Superficial pouch 12 29.26% External ring 6 16.63% Inguinal canal 11 26.82% Total 41 100.00% Table 5: Showing location of the Ectopic testis Site No of cases Transverse scrotal 0 Femoral 0 Perineal 0 Prepenileectopia 1 Total 1 Table 6: Showing location of the impalpable testis Site No of cases Percentage Canalicular 5 62.50% Intra-abdominal 2 25.00% Absent 1 12.50% Total 8 100.00% Table 7: location of improper descent of testis Location n Percentage Mid-Scrotal 7 14.58% External Ring 6 12.50% Superficial Pouch 12 25.00% Root of Scrotum 5 10.42% Inguinal Canal 11 22.92% Canalicular 5 10.42% Intra-Abdominal 2 4.17% Absent 1 2.00% Pre-penile 1 2.00% Total 50 100.00% Table 8.1: Anomalies associated with respect to age. Anomalies Age group Total <2 Yrs 2-5 yrs >5-10 yrs >10yrs Hernia 2 10 3 1 16 Epididymal 2 6 2 0 10 Gubernaculum 3 17 8 0 28 Vas Deferns 1 2 0 0 3 ProcessusVaginalis 3 12 6 1 22 Total 6 24 9 1 40 Table 8.2: Anomalies associated with respect to location of the testis Anomalies Location Mid-Scrotal External ring Superficial Pouch Hernia 0 2 3 Epididymal 2 2 2 Gubernaculum 7 6 6 Vas Deferns 0 0 2 ProcessusVaginalis 6 5 4 Total 7 6 10 Location Anomalies Root of Inguinal Total Scrotum canal Hernia 2 7 14 Epididymal 1 2 9 Gubernaculum 5 2 26 Vas Deferns 0 0 2 ProcessusVaginalis 4 2 21 Total 5 8 36 Table 9.1: Results of surgery SURGERY No of patients percentage Orchidopexy 49 98% Orchidectomy 0 0% success 49 98% Table 9.2: Type of surgery underwent (* As testis is absent just diagnostic laparoscopy was done). SURGERY N percentage OPEN ORCHIDOPEXY 41 82% LAP ORCHIDOPEXY 8 16% None * 1 2% Total 50 100% Table.10: Comparison of age Distribution between two studies. Study M.B.Jackson et al N-60 Present series N-50 Age in years No of patients(%) No of patients(%) <2 yrs 9(15%) 7(14%) >2-5 yrs 24(40%) 28(56%) >5-10 yrs 25(41.7%) 11(22%) >10-18 yrs 11(18.3%) 4(8%) Table.11: Comparison of side of involvement between two studies Author Right Left Bilateral M.B.Jackson et al 38.30% 43.30% 18.30% Lange 45% 30% 25% Present series 42% 36% 22% Table.12: Family history of undescended testis in different studies. Author Percentage Bishop 15 Brimblecom 15 Whniles 15 Present series 4 Table.13.1: Number of palpable and impalpable testis in different studies. Author Palpable Impalpable M.B.Jackson 86.80% 13.20% Jacks S Elder 80% 20% Present series 82%(42) 18%(8) Hutson& Baker 80% 20% Table.13.2: Location of palpable testis in different studies. Palpable testis Hutson & Baker Present series Superficial pouch 30% 29.26% Inguinal 20% 26.82% Upper scrotum 45% 30% Table.13.3: Location of impalpable testis in different studies Author Absent testis Canalicular Intra abdominal Jacks S Elder 10% 65% 25% Hutson & Baker 0% 0% 20% Present series 77.77%(5) 22.22%(2) Table.14: Associated abnormalities in different studies. Abnormality M.B.Jackson Scorer Present series Abnormality of gubernaculums 79% 56%(28) Patency of processusvaginalis 44% 46%(23) Epididymal abnormality 14.70% 46% 20%(10) Abnormal position of vas 5.90% 06%(3) deferense Hernia sac 51.50% 55 % 33%(16) Table.15: Association of neoplasia with undescended testis in different studies. Name of author percentage Canadian series 16 American series 6.6 to 13.4 Taylor and wydham 13 present series 0 Table.16: results of surgery. Study Stanley Kogan Present series Orchidopexy 90% 98% Orchidectomy 10% 0% Success 90% 98%
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|Title Annotation:||ORIGINAL ARTICLE|
|Author:||Sathyanarayana, B.A.; Ramachandra, J.|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Dec 16, 2013|
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