This article will touch upon the importance of testes, classification of undescended testes, their diagnosis and treatment methods. We will emphasize the importance of descending testes at early age despite the fact that in our country, patients still apply at late ages. We will explain the surgical techniques applied to patients, whose previous testis descending surgeries failed, and applied to cases where the surgery for undescended testis (intra-abdominal testis) is even more difficult.
Function of Testis?
The male egg (testis) that is located in the sac called Scrotum has two main functions: to secrete testosterone and generate reproduction cells (sperm). Testosterone is responsible for sexual desire, male type hairing and muscle development. The human body temperature is 37 degrees. The temperature in the scrotum is 3-4 degrees lower than normal. The sacs preserve 33-35 degree temperature by expanding & sagging under heat and shrinking under cold. Sperm cells are produced due to this low temperature in sacs. When the testes don’t descend to the sacs, temperatures above 37 degrees prevent the production of sperms. They should be descended.
What is Undescended Testis?
During child’s development in mother’s womb, the testes began to form at the waist region and at the rear abdominal wall. They descend down during further stages of pregnancy. They descend to the sacs (scrotum) by passing through the groin channel. As the testes form in the kidney region, the blood vessels and nerves of the descending testis, which are called pedicle (stem), come from above. If any halt occurs during this descending for any reason, one talks about an “undescended testis”. The testis is not felt within the scrotum. 2% of the newly born male babies have undescended testis. This ratio is higher in prematurely born babies. Descending continues for 6-8 months following birth. The ratio of testes that have not descended after the 8th month is 1 percent. This ratio is higher if there is undescended testis in the father, brother or twin. If there is undescended testis in one twin, the ratio of undescended testis in the other twin is 10 percent.
Undescended testes may simultaneously exist with inguinal hernia. Undescended testes should be descended by surgery within 6 months - 1 year at the latest due to risks of infertility, testis torsion and testis cancer. 80 percent of undescended testes can be understood by hand with a simple physical examination on the groin. 20 percent cannot be understood by examination (non-palpable). 90 percent of undescended testes are single-sided and 10 percent thereof is double-sided.
As the testis is an important organ, the blood vessel that feeds the testes (testicular artery) is directly fed from the main blood vessel called aorta that is located at the kidney level. It is also fed by two substitute blood vessels from the groin region. As surgeries for undescended testes are performed at the infancy age, they require rigor and precision. The anatomy is miniature. We recommend that pediatric urologists perform it.
Diagnosis of Undescended Testis
Diagnosis for undescended testis is mainly made by physical examination. Ultrasonography, tomography, MR and diagnostic laparoscopy can also be used. But tomography may be harmful for the child due to high radiation. MR is not practical is it requires anesthesia and takes longer. Diagnostic laparoscopy may be required for 15 percent of undescended testes that are located in the higher abdomen (very high in the abdomen). Genetic (karyotype) research, hormone analysis and diagnostic laparoscopy are mandatory for patients with both testes undescended in order to clarify hermaphrodism (dual gender). Undescended Testis can exist simultaneously with hypospadias.
If the testes cannot be detected manually during examination, the presence or absence of testes can be observed by special telescopes inserted into the abdominal cavity (laparoscopy). The absence of organ at the edge of testis blood vessels shows that no testes were present during birth. Or a very small testis remnant is determined at the edge of these blood vessels.
Laparoscopy for Undescended Testis
Laparoscopic diagnosis is entering the abdomen from a small hole and examining it with a camera. The location of undescended testis is sought by camera. 88 percent of undescended testes are diagnosed by simple physical examination and ultrasonography. These testes have been jammed inside the groin channel and can be felt by hand. All of these are descended to their locations by a standard undescended testis surgery. On the other hand, 12 percent of undescended testes are located higher in the abdomen. Laparoscopy is used for diagnosing such testes. We confirm the absence of any testis during laparoscopic diagnosis and no additional procedure is required. Only 6-7 percent of all undescended testes are real intraabdominal undescended testis (testis left at a very high distance). Testis in normal development has stayed inside the abdomen. The higher the testis stays in the abdomen, the harder and riskier its surgery becomes. Inter-abdominal testis operation is amongst the harder operations of pediatric urology.
Due to cremasteric reflex reaction of children between 3-7 years of age during examination for undescended testis (child’s involuntary reflex against examination), the testis skips upwards and cannot be felt in the scrotum. It therefore gives the impression of undescended testis. That is because the testis is mobile in the scrotum during this period. Wrong diagnosis of undescended testis can occur. Such cases don’t require surgery. The patient should be checked at certain intervals. These patients are unnecessarily operated for undescended testis. But these testes skip upwards due to timidity and they descend to their original location over time.
Testis Not Felt By Hand
There are several reasons when testes cannot be felt by hand during physical examination.
First reason: 20 percent of undescended testes are not felt by hand during examination. Although 40 percent of them are present in the groin, they cannot be detected owing to causes such as obesity etcetera. They can be identified by ultrasonography.
Second reason: 45 percent of testes, which cannot be felt manually, either never formed or formed but later shrank due to miscellaneous reasons (digenetic, vanishing testis). The general belief is that during the development of testis in the mother womb, the testis swivels, decays due to the jamming of blood vessels and therefore disappears. It can be understood by a 3 cm incision or laparoscopy.
Third reason: 15 percent of testes that cannot be felt manually are present but were stuck in any location within the zone that is between the kidneys and the scrotum. These represent real intra-abdominal undescended testes. Testes remaining high inside the abdomen represent one of hardest surgeries of pediatric urology. In theory, they may be located anywhere alongside the distance between the kidney region and the scrotum. In practice however, all of intraabdominal testes are located at a maximum distance of 3-4 cm above the interior outlet of the groin channel. No testes were ever seen at higher distances.
Why is Undescended Testis Descended?
Descending undescended testes is important for 3 reasons.
Infertility in Undescended Testes
The temperature in the scrotum (testis sac) is 2-4 degrees lower than normal. This temperature is very important for the production of sperms. The sperm producing cells of the testes are damaged by excessive temperature when testes remain under normal body temperature (37 degrees). But the cells of the testes that secrete testosterone are not damaged.
90 percent of undescended testes are single-sided and 10 percent thereof is double-sided. Although the number of sperms is lower than normal in single-sided undescended testes, it has been shown that pregnancy rate is same as normal males, no infertility occurs. But infertility is inevitable in the adult age if double-sided undescended testes are not descended by surgery.
Cancer Risk in Undescended Testes
It is known that cancer rate is higher than normal in undescended testes. For this reason, the earlier they are descended, the better precaution is taken against cancer risk. The general opinion is that testes should be removed for patients that are diagnosed with undescended testes after 12 years of age. This will prevent potential testis cancer risks. Our opinion is that even after 12 years of age, the testis should be descended to its normal position for the sake of testosterone function. That is because removing the testis, which secretes testosterone, creates psychological and physical problems. And the testis should be followed-up by ultrasonography on an annual basis against the low risk of cancer. Thus, the testis can be removed if any suspicion arises.
Testis cancers are amongst the rarely seen ones. They are entirely treated if detected early. One should therefore avoid any unnecessary removal of testis. The cancers of testes in normal position can be detected and treated immediately due to the growth occurring in the testis. But undescended intraabdominal testes cannot be diagnosed with cancer. They can be diagnosed after cancer advances and their treatment can be difficult. For this reason, they should be descended always.
Testis Torsion (Turning) in Undescended Testis
When testis descends to its location, it is fixed onto the sac base with a bond called gubernaculum. As there is no immobilization in undescended testis, the testis may rotate one or several times around its blood vessel stem. It is therefore deprived of blood, suffers necrosis, shrinks and loses its function. The testis should be descended because of this probability.
Surgeries for Undescended Testes
Is Drug Treatment Possible for Undescended Testes?
Drug treatment (hormone) is harmful and has no place for treating undescended testes. Hormone application may be beneficial for diagnosing testes that cannot be felt by hand. That’s because hormone enables one to feel the testis by hand. Surgical treatment is primary.
Standard Surgery for Undescended Testis (Orchiopexy)
Simple undescended testes can felt by hand at the groin region during physical examination. Standard surgery is applied for patients that have simple undescended testes (orchiopexy). This technique frees testis’ blood vessel stem (pedicle) from the peripheral adhesions above. When the testis is freed and descends downwards, it is placed on a nest created at the base of the scrotum.
Fowler-Stephens Surgery in Undescended Testes
Intraabdominal testes are those have stuck above the groin region, inside the abdomen. Surgery for such testes above is even more difficult. Single or two-phase Fowler-Stephens surgery is applied for intraabdominal undescended testes. The main blood vessel that feeds the testis is incised during the single-phase technique of the Fowler-Stephens surgery. The testis is placed inside the scrotum with the hope that two substitute blood vessels will feed the testis. It was seen that pursuant to this surgery, testis shrank due to insufficient feeding. It is two-phase version therefore became popular. During the first phase of this two-stage technique, the main blood vessel of the testis is incised again. The testis is descended to the scrotum during the second phase with the hope that 6 months later, secondary blood vessels will expand further and better feed the testis as the testis was not descended. But this two-phase Fowler-Stephens technique doesn’t yield the desired success rate. The reason is incising the blood vessel that feeds the testis.
Testis Descending Surgery without Incising the Blood vessel Stem
In the method favored by us and other international competent authorities of medicine, the main blood vessel of the testis isn’t incised as opposed to the Fowler-Stephen method. Even in highly-located intraabdominal testes, we gain distance by extending the blood vessel stem with precise maneuvers without incising the main blood vessel of the testis (radical proximal dissection of blood vessel structures) and the testis is descended to its normal location. This is called Radical Proximal Testicular Blood Vessel Pedicle Dissection Surgery.
With consideration of this principle, we use the flexibility of the blood vessel stem, free it from its periphery, use a shortcut within the body, therefore extend the blood vessel stem until the scrotum and place the testis in its location. We enter the abdominal cavity by a 4 cm incision made to the groin region prior to surgery. We find the testis. It is freed from peripheral peritoneum adherences. We free the blood vessel structures and vasa efferentia (the cordon that conveys sperms to seminal vesicles). One should pay attention to vasa efferentia during surgery. Because its damage may lead to infertility. Using special retractors (tissue brackets), the main blood vessel structure of the testis in the rear abdomen is entirely freed until the kidney zone.
In cases where the blood vessel stem cannot be extended, a second 3 cm skin incision is made from the lateral wall of the abdomen close to the kidney region. The abdominal wall consists of 3 layers of muscles that intercross each other. Incision doesn’t disrupt the integrity of these muscles. They are separated alongside the direction of their tendons. We reach the blood vessel stem from the 2nd incision. The blood vessel that the groin incision couldn’t free enough is further freed by the lateral abdomen incision. With this method, testes that have remained within the abdomen can be placed in their normal locations within the scrotum.
As this distance is shorter in low-age patients, their surgeries are easier. This surgery can also be applied on patients at advanced ages. As this open surgical method doesn’t incise muscles, it inflicts almost no damages to the patient (minimal invasive open surgery) and the patient can be discharged the following day. The patient is called for examination one week later. Success of surgery is checked by ultrasonography at the end of 1st, 2nd, 6th and 12th months.
How Do We Descend Undescended Testes with Prior Unsuccessful Surgeries?
Re-Do Undescended Testis Surgery
The operation for descending undescended testes, for which purpose previous surgeries failed, are called RE-DO Undescended Testis Surgery. This is the majority of the patient portfolio applying to us. The cause for failure in the first surgery is that the blood vessel stem of the testis wasn’t freed enough from the peripheral tissues. During its voyage in the mother’s womb, the testis pushes the peritoneum and descends to the scrotum from the groin channel. The cause for failure during the first surgery is that although the blood vessel stem is long enough for descending the testis to its normal location, it isn’t sufficiently freed from the peripheral adherences and especially from the peritoneum sac. For this reason, the testis remains above the scrotum or inside the groin channel and therefore cannot descent to the scrotum. The surgical failure here owes to technical error.
Second operation is harder and riskier as there are also adherences (scar tissue) that formed after the first operation. The testis has adhered to the peripheral tissues by a stiff scar tissue (a filling tissue produced by the body). During the second surgery, it is important not to damage the testis inside this adhered mass. One should free the testis as a whole with the scar tissue, find the blood vessel structure and also free the peritoneum sac. The testis can be descended to its normal location entirely. Re-Do Undescended Testis Surgery performed by experienced surgeons can be successfully applied and the testes can be descended to their locations.
Are There Any Testes that Cannot be Descended by Surgery?
Any undescended but healthy testis, which is diagnosed by imaging methods and laparoscopy, can be successfully descended to the scrotum, inclusive of the ones that couldn’t be descended during a previous unsuccessful operation.