V870: Management of cryptorchidism in adults
VideoIntroduction and Objectives
Although cryptorchidism should be diagnosed at birth and treated in early childhood, in many parts of the world it is first diagnosed in adulthood, often incidentally. This video presents data on 58 men over the age of 18 years who underwent surgery for cryptorchidism, with an illustrative case of an apparently atrophic inguinal testis.
A 31-year old man presented with a painful swelling 5x5 cm in the right inguinal area and an empty right hemiscrotum. Ultrasound and computed tomography suggested malignancy in an undescended inguinal testis, or inflammatory lymphadenitis. Surgical exploration of the inguinal canal revealed a spermatic cord-like structure apparently attached to a severely atrophic inguinal testis. The peritoneum was opened and an intraperitoneal testis was found. Orchidectomy was performed because the testicular vessels were very short and the patient had completed his family. Histology of the testis showed atrophy of the seminiferous tubules with no germ cells, and the excised inguinal mass showed acute lymphadenitis.
We treated 58 men over the age of 18 years (mean 26, range 18 to 41) diagnosed with cryptorchidism in the period February 1999 to December 2010. The undescended testis was on the right side in 43% of cases, on the left in 35% and bilateral in 22%. The testis was palpable in the inguinal canal in 60% and non-palpable in 40%. At surgery the testis was inguinal in 69%, intraperitoneal in 29% and absent in only 2%. The procedure performed was orchidopexy in 61% and orchidectomy in 39%. Histology showed atrophic testicular tissue in 89% and no testicular tissue in only 11%.
The presence of an apparent testicular remnant (“nubbin”) in the inguinal canal should not be accepted as evidence of testicular atrophy or agenesis. Surgical exploration of the inguinal area and retroperitoneum is not sufficient to exclude the presence of an undescended intra-abdominal testis, which is always intraperitoneal, not retroperitoneal. Laparoscopy or surgical exploration of the peritoneal cavity is essential. The vas deferens, epididymis and blood vessels may descend in an open processus vaginalis, creating the impression of an atrophic inguinal testis, while the testis itself remains intraperitoneal.