Study and Management of Undescended Testes

Incidence of testicular cancers in cryptorchid patients is estimated to be 3-5 times higher than in the general population. About 20 percent of testicular tumors in men with unilateral cryptorchidism occur on the side with the normally descended testicle; this finding supports the argument against indiscriminate removal of undescended testes. Although there is no proof that orchiopexy reduces the risk of testicular cancer, it is performed to ease detection through testicular selfexamination.2


Introduction
Isolated cryptorchidism is the most common congenital anomaly of the male genitalia , affecting almost 1% of the full term infants at the age of 1 year.
The abnormality assumes particular importance in cases of bilateral undescended testis,. In unilateral cases treatment is directed to prevent complications known to be associated with undescended testis (UDT) Cryptorchidism is a rare condition, occuring between 0.7% and 2% of children over one year of age 1 .
Incidence of testicular cancers in cryptorchid patients is estimated to be 3-5 times higher than in the general population. About 20 percent of testicular tumors in men with unilateral cryptorchidism occur on the side with the normally descended testicle; this finding supports the argument against indiscriminate removal of undescended testes. Although there is no proof that orchiopexy reduces the risk of testicular cancer, it is performed to ease detection through testicular selfexamination. 2 Sonography is simple to perform, rapid, non-invasive relatively inexpensive, easily reproducible, widely available and does not involve irradiation of gonads.
Diagnostic laparoscopy has gained wide acceptance as a diagnostic procedure for identifying the exact anatomy of impalpable testes and adnexae 3 .
Surgery for undescended testis is indicated to increase the chances of fertility, to reduce the chances of malignant degeneration or at least increases the chances of early detection of malignancy, Besides this it may also prevent psychological problems associated with an empty scrotum in later life. 4 The current study is being carried out to identify the various clinical presentations of undescended testis, to analyze the reliability of Ultrasonography in identification of undescended testis and the efficacy of various surgical modalities for management of undescended testes.

Material and Method
This present study was carried out at Jawaharlal Nehru Medical College and Acharya Vinoba Bhave Rural Hospital, Sawangi ( Meghe ), Wardha, Maharashtra, India, between August 2011 to August 2013 . Patients from nearby district hospital, primary health centers and private healthcare facilities are often referred to this hospital. Most patients seeking healthcare at the institute come from neighborhood villages and small towns.
Total 43 patients cases of Undescended Testes were studied prospectively . In these 43 cases , there were 6 cases having bilateral undescended testes , this means total 49 undescended testes were included in this study . Most of the patients were referred to this hospital under child health programme.
Written informed consent was taken from the adult patient. In case of children, the parent's consent was taken. All patients were examined in a systematic order as mentioned in the proforma. The study was undertaken after the Institutional Ethical Committee's approval.

Inclusion criteria
Patients coming to A.V.B.R.H. above the age of six months with history of absent testes in the scrotum either unilateral or bilateral.

Exclusion criteria
• Patients of undescended testes of age less than 6 months

Study design
After detailed history and complete general and systemic examination and local examination of genitelia and scrotum, diagnosis of undescended testes was done.
After detailed clinical examination patients were subjected for ultrasonography of scrotum and inguinal canal to know the location and size of testes.
Along with Ultrasonography of scrotum patient were subjected to various routine investigations like haemogram , liver function test , kidney function tests blood sugar , urine analysis to know the condition of patient and feasibility of surgery.
• Patients having palpable unilateral undescended testes were subjected to orchiopexy directly • Patients having bilateral palpable undescended testes were subjected to orchiopexy directly • Patients having impalpable unilateral or bilateral testes were thoroughly examined by described clinical method of palpation and evaluated by ultrasonography to locate the testes and if the testes located in inguinal canal, orchiopexy was done.
• In patients where testes was not located by ultrasonography , were subjected for palpation under general anaesthesia to locate the testes . If testes were not located under anaesthesia patients were subjected for diagnostic laparoscopy and appropriate surgical procedure was done .
• Patients in whom testes were found flabby and small were subjected for orchidectomy otherwise in all the other patients having testes normal in size and consistency orchidopexy was done.

Age distribution of patients of undescended testes
In this study maximum number of cases were in the age group of 5 to 15 yrs i.e. fourteen (32.59 %) and seventeen cases were between age group of 10 to 15 yrs ( 39.5%) n=43  Out of fourty nine undescended testes twenty nine ( 59.2%) testes were located in inguinal canal . 100 Out of total fourty nine undescended testes that were included in present study, fourty (81.63%) were subjected for orchidopex as they were normal in consistency In five (10.21%) undescended testes orchidectomy was done as these were found small amd flabby intraoperatively.

Surgical procedure for undescended testes (n=49)
In four (8.16%) undescended testes which were not palpable on described clinical examination and not located on ultrasonography, diagnostic laparoscopy was done . In all diagnostic laparoscopies vas and vessels were entering in deep ring so inguinal canal exploration was done . Small nibbus were found on inguinal exploration which were excised .

Discussion
Total of 43 cases of undescended testes were studied in the present study . out of 43 cases 6 were of bilateral undescended testes that means total 49 undescended testes were studied in the present study A wide range of age was seen in the present study of 43 cases. one case(2.33%) was in between 6 months to 2 years of age, and 2 yrs to 5 yrs of age each .fourteen (32.59 %) cases were between 5years to 10 years of age, and seventeen (39.5 %) cases between 11 years to 15years of age. There were total ten cases (23.25%) cases between 15 yrs to 35 yrs of age group.
In 2010 according to Paul J et al noticed undescended testis in patients between 0 to 6 months of age are nil, 43% cases between 6 months to 2 years of age, 26% between 2 years to 5 years of age, 19% cases between 5years to 15 years of age, and 12% cases between 15years and above age 5 . In 2010 Khalid noticed undescended testis in patients below age of one year i.e up to 49.2% and patients above the age of one year i.e 45% and 5.8% between 2 years to 5 years of age 6 . Seyyed Mostafa et al concluded that late diagnosis by physician and lack of insight of parents are the main reasons in delayed diagnosis and treatment of undescended testis. Therefore education of parents and careful physical examination of the babies at birth and regular follow up until 18 months can prevent delay in diagnosis 7 . In the present study age of presentation is late as compaired to other studies as this study was carried out in rural area where there was significant delay in the referral of patients with an undescended testes either because the condition was not identified early on, or the doctor gave false reassurance that the testicle may descend by itself even after the age of 6 months, or the parents of the patient failed to seek proper surgical advice because they feared surgery and didn't appreciate its importance. One of the reason for late presentation is Home deliveries done in maximum number. Of cases In the present study fourty four (89.8 %) undescended testes were palpable and five (10.2%) testes were non palpable . All cases were examined by described clinical method of palpation . In all the above studies maximum number of undescended testes were palpable. In the present study also maximum number of testes were palpable We studied, the side on which undescended testis get arrested during its descent, more frequently. In the present study we had 21 (48.8%) cases of right sided undescended testis, 16 (37.2%) cases of left sided undescended testis and 6 (14%) cases IJBAR (2013) 04 (11) www.ssjournals.com of bilateral undescended testis.
In 2007 according to Sinha et al of the 250 cases under study 202 (80.8%) were unilateral in that cases of right sided undescended testis were 110 (54.5%) and 92 (45.5%) cases of left sided undescended testis and 48 (19.2%) cases of bilateral undescended testis were present 10 According Christofer , the right testis is affected in 50% of cases, the left testis is affected in 30% of cases, and double arrest occurs in 20% of cases 11 .
According to Ajmer ,he studied 313 cases of undescended testis the right testis is affected in 119 ( 39% ) of cases, the left testis is affected in 92 ( 30% )of cases, and double arrest occurs in 51 ( 31% ) of cases 12 In all the above studies right sided undescended testes is more common than left sided undescended testes and bilateral undescended testes are less in number. In the present study also maximum cases were of right sided undescended testes.
In our study Ultrasonography was performed in all patients who presented with undescended testis. We studied the role of Ultrasonography in localizing the testis. we performed Ultrasonography in 43 patients out of 43.
In our study, amongst 43 patients, who underwent Ultrasonography, testes were located in 41 patients . In five patients testes were not located on ultrasound also .
According to Bjerklund et al ultrasonography was performed in 119 patients of undescended testis. In 113 patients the testis was demonstrated as an echo-poor oval structure i.e 95% localisation identified 13 K Wolverson et al stated localisation of undescended testis was attempted in 23 instances USG resulted in 88% sensitivity, 100% specificity and 91% accuracy. The authors recommend high resolution real time USG as a modality of choice for this procedure because it is simple, accurate ,and avoids the use of ionizing radiation 14 .
Dartos pouch orchidopexy is commonly done surgery. It has success rate of 95.2% and lesser hospital stay 15 . Ameh et al concluded that following orchiopexy fertility after treatment for unilateral undescended testis is about 84%, bilateral 60%, and over all 79% 16 . In 2006 Irina Taran et al concluded the success of orchiopexy for inguinal testis has been more than 95% where as tumours that occur following orchiopexy are much more likely to be nonseminomatous 17 . According to Fabio et al (2012) orchidectomy should not be a rule for unilateral undescended testes in adults and if testicular preservation is feasible it should be offered to patients with relatively normal organs . . They have preserved 68.4% of testes through laparoscopy depending upon size , position and contralateral testicular status . In midterm follow up testicular tumour was not the concerrn , unfortunately fertility may not be preserved in bilateral undescended testes 18 Mahmoudreza et al in 2011 had done orchiopexy in adults and recommend the patients to do self examination periodically after orchiopexy and scheduled routine examination by urologist . They preferred this over testicular biopsy. 19 We have done orchiopexy in adults also as patient can self examine testes for malignancy changes in follow up period and can also be examined by surgeon clinically In adults psychological satisfaction is also one of the reason for doing orchiopexy

Conclusions
In our study the maximum number of cases were recorded between five years to fifteen years of age In the present study we concluded that there is need of coordinated campaign between surgeons , pediatricians, general practitioners and community Workers for timely intervention of undescended testes .Right sided undescended testis is common presentation.