infant with empty scrotum

INFANT WITH EMPTY SCROTUM: 

INFANT WITH EMPTY SCROTUM Under Supervision of: Prof.Dr . Saber M.Waheeb

PowerPoint Presentation: 

Anatomy and embryology Undescended testis, or failure of the testis to drop into the scrotum, is one of the most common surgical disorders in childhood Most of the time, children's testicles descend by the time they are 9 months old. This problem occurs in approximately in about 3 - 4% of full-term infants

PowerPoint Presentation: 

- The testes originate in the abdomen and descends through the inguinal canal and into the scrotum during the eighth and ninth months of gestation. -This normal movement of the testicle is caused by hormonal influences and another anatomic structure called the gubernaculum

PowerPoint Presentation: 

Blood supply and lymphatic drainage of the testes and scrotum are distinct The paired testicular arteries arise directly from the abdominal aorta - The testis has collateral blood supply from * the cremasteric artery * artery to the ductus deferens - Lymphatic drainage of the testes follows the testicular arteries back to the paraaortic lymph nodes , while lymph from the scrotum drains to the inguinal lymph nodes

PowerPoint Presentation: 

Mechanisms of testicular descent Traction of the testis by gubernaculum and cremasters . - Intraabdominal pressure pushes the testis through the inguinal canal . - Development and maturation of the epididymis contributing to descent . - Endocrine factors probably play a major role in descent . * Testosterone induces testis descent in humans - Androgens affect the nuclei of the genitofemoral nerve to release modulating factors for gubernacular development

Testicular maldescent: 

Testicular maldescent Arrested testicles: Etiology -Mechanical factors -Hormonal factors -Intrinsic testicular defect

Sites of arrest: 

Sites of arrest - Intraabdominal : lumbar region or Iliac fossa -Extra abdominal Intracanalicular testis Extracanalicular testis (Superficial inguinal pouch) Pathology Macroscopic Microscopic

Ectopic testes: 

Ectopic testes Etiology : (Lockwood theory ) Ectopic sites :

PowerPoint Presentation: 

Ascending testes Retractile testes Retractile testis indicated for orchiopexy After bringing the testis down, it immediately goes up. Syndrome of atrophy of normally descended testes : Unilateral hidden impalpable testes Previous history of normal descent Equal well-developed both scrotal halves Contralateral oversized testes

PowerPoint Presentation: 

Vanishing testis syndrome Surgically removed testicle Can be associated with other abnormalities : Prune belly syndrome Common in infants with abdominal wall defects

Complications: 

C omplications

Complications: 

C omplications Temperature effect Endocrine effects Germ cell development Fertility Malignancy Inguinal hernia Trauma Epididymoorchitis torsion

Temperature effects: 

Temperature effects

Endocrine effects: 

Endocrine effects

Diagnosis: 

Diagnosis 1- History: If the testes were ever palpable in the scrotum at the time of birth or within the first year of life. Previous inguinal surgery . prematurity f amily history of cryptorchidism and other congenital anomalies, neonatal deaths, precocious puberty, infertility, and consanguinity .

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2- physical examination: inspection: Appearance of the scrotum: Inguinal swelling:

PowerPoint Presentation: 

Determine the exact testicular position: Identify the lowest position that it will sit comfortably without undue tension: possible associated findings such as hernia, hydrocele, penile size, and urethral position

PowerPoint Presentation: 

D . D . of palpable testis in SIP Retractile testis Ectopic testis Arrested testis History of scrotal descent Yes No No Scrotum Well developed Well developed Ipsilateral hypoplastic half of the scrotum Bimanual traction of the testis Can bring the testis down the scrotum Never Never Raising up testis More prominent More prominent Impalpable Lateral displacement No change No change Disappearance into DIR Inguinal hernia Never Never Associated with hernia

Investigations 1)Imaging studies: 

Investigations 1)Imaging studies

2)Invasive laparoscopy : : 

2)Invasive laparoscopy :

3)Serum studies and karyotyping :: 

3)Serum studies and karyotyping :

PowerPoint Presentation: 

E ither : *2 Stage operation : Fixations the testes to pubic tubercle for 6 months then the second stage to bring it down to scrotum. * Fowler_- Stevens procedure : Principle : cutting of vascular pedicle and leave testicle in place intaabdominal for 6 months to accommodate vascularity from the surroundings to ischemic testicle then second stage transform the testicle to scrotum..

Autotransplantaion of testes using microvascular technique (silber and kelly ) priciple: cutting of spermatic vessels and re-anastmosis to inf. Epigastric vs using 10/0 sutures under microscopy.: 

Autotransplantaion of testes using microvascular technique ( silber and kelly ) priciple : cutting of spermatic vessels and re- anastmosis to inf. Epigastric vs using 10/0 sutures under microscopy.

Fixation in the scrotum: 

*Formation of a dartos pouch *A, Formation of a passage to the scrotum. * B and C, Passage of the testis into the scrotal pouch Fixation in the scrotum

Types of fixations: 

A.Subdartos pouch (De Netto): the commonest B.Transseptal fixation (Ombredanne ) C.scrotal neck plication (Bevan ) D . Scrotal stitch Types of fixations

PowerPoint Presentation: 

**Complications of orchiopexy : Scrotal swelling . Inadequate testis position . Accidental division of vas deference and blood supply of testis testicular atrophy. Bleeding . Infection .

PowerPoint Presentation: 

Role of laparscoy in treatment ** has important role in diagnosis as well as in management . non-palpable testes (lap ..) Absent or present Low or high abdominal & healthy freeing vascular supply Another incision 2 nd operation In scrotum after 6 months. ( Fowler_Stephens ) Bring testes down

Laparoscopic assisted orchiopexy (lao): 

Advantages 1- low risk 2- excellent diagnostic 3- the best tool for the  management of undescended testis ,with excellent imaging which does not need costly investigations like computerized tomography and MR 4- Laparoscopy has been reported as the safest procedure for management of undescended testis Laparoscopic assisted orchiopexy ( lao )

he: 

he **Indicated: bilateral arrested testicle with hypogonadis and obesity . Human chorionic gonadotropin HCG . Given IM in adose 1000 Iu / twice weekly / 8hrs . Disadvantage: precocious puberty & short stature . Success rate < 10% Not recommended nowadays. Hormonal therapy

PowerPoint Presentation: 

** pathological retractile testes ??? ** incomlete descent by age of puberty . unilateral ** reduced size & consistency . Retractile testicles Assurance & follow up Orchidopexy only if :

PowerPoint Presentation: 

Surgical replacement of the testis into scrotum +/- fixation according to the length of the cord .. Orchiectomy : We totally remove undescended Testes if it was atrophied and send It for pathological study . Ectopic testes

THANK YOU: 

THANK YOU Students : 779 780 781 782 783 784 785