What is an undescended testis?
Testicle (eggs) starts to develop while the baby is in the mother’s womb and moves downwards as well as developing. At the end of the 7th month in the mother’s womb, it passes through the abdomen into the inguinal canal, 7-8. It continues to progress in the inguinal canal in the last 6 months, and generally at the end of the 9th month, they complete their migration in the inguinal canal and descend into the scrotum (the bag in which the testicles are located). The descent of the testicles continues in the first 3 months after birth. If there is a pause in the descent of the testicles for any mechanical, hormonal or self-induced reason, the testis is stuck at a point on the migration path and an undescended testis occurs.
Which babies do they have?
Since the testicular migration is completed in 9 months, the incidence in premature babies is naturally high. While this rate has been reported as 30% in premature babies, it has been reported as 2-3% in term babies. However, the fact that this rate was reported as 0.8% at the age of 1 after the babies were followed up suggested that the testicles continued to migrate after birth.
Unilateral undescended testis is 60% right, 30% left, 10% bilateral.
Why won’t it go down?
It is thought that the structure called the gubenaculum, which is accepted as a guide during the migration of the testis, is not fully developed or that this structure has developed but is attached to another place instead of the scrotum (bag), and it is thought that the testis cannot reach the bag. Although there is no consensus on why the testicles do not descend, it is thought to be caused by hormonal reasons.
How can it be understood that the testicle has not descended?
When the eggs are examined by hand, it can be understood that they are not in the bag. For an ideal examination, the room should be warm, the child should be treated kindly, the feet should be crossed towards the abdomen (frog position), and the testicles should be tried to be found by stroking the inguinal canal. Sometimes it is also helpful to sit in hot water.
What kind of tests are done?
In general, manual inspection is sufficient. Sometimes the testis is not palpable, in this case, help can be obtained from ultrasonography. The presence and location of the testis can be determined with 80% accuracy, but the experience of the person performing the ultrasound is very important. Magnetic Resonance Imaging (MR) can be applied if it cannot be detected on USG. This method gives nearly 100% information. Hormone studies can be done, but this only gives information about the existence of the testis, we cannot have an idea about its location and structure. Laparoscopy is the most reliable method in cases of nonpalpable undescended testis. In the laparoscopic examination, an idea can be obtained about the presence, location, size and structure of the testis, and the process of lowering the testis into the scrotum can be performed in the same session.
If the testis is not in the bag (not palpable) where is it?
If we consider that the testis starts to develop in the area where the kidney is located and migrates downwards while in the mother’s womb, the testis can be located in the lower part of the kidney as well as in the inguinal canal or just outside the inguinal canal.
Apart from this, the testis has descended, but just before or just after birth, as a result of its rotation (torsion), the vessels may be affected and the testicles may melt (atrophy), in these cases there is no palpable testis.
If the testis is sometimes not in the bag and sometimes it is not in the bag, it is called shy (retractile) testis. It is easily brought into the bag during the examination and remains in the bag for a while. Similarly, if the testicle, which can be brought into the bag with difficulty, does not remain in the bag and immediately goes up, it is called gliding.
If the testis is oriented to a different route during its normal migration, it is called ectopic testis. The testis may be towards the root of the penis outside the bag, towards the outer edge of the bag, towards the leg, and in the perineum (close to the anus), but in its most common form, it has come out of the canal, however, it is located at the top of the bag and cannot be brought to the bottom of the bag in any way.
What happens if undescended testis is not treated?
Infertility: It is more important especially in untreated patients who have passed the age of 2 years. Because the changes in the testis begin after the 6th month, but important changes occur after the 1st year, these changes become irreversible after the 2nd year. While the probability of having a child was found to be 85% in the normal population, this rate was reported as 84% in unilateral undescended testes who had undergone surgery, and 53% in cases with timely treated bilateral undescended testicles. On the other hand, the chance of having a child in untreated bilateral testicles is close to 0%.
Malignancy (risk of cancer): The incidence of cancer in undescended testicles is 1%. The reason is that the facility has been exposed to high heat and pressure since the time it was in the mother’s womb. It is 15 times higher in unilateral patients and 33 times more in bilateral cases. It is known that surgical removal of the testis does not reduce the risk of cancer, but it still helps in making the diagnosis in the early period.
Inguinal Hernia: With undescended testicles, there is 80% inguinal hernia. Hernia-related problems occur.
Testicular Torsion: In undescended testicles, the rate of blood circulation deterioration by turning around the testicles is higher than in normal testicles.
Risk of Trauma: In the inguinal canal, the testis is more open to physical trauma and can be crushed more easily. Since it can move freely in the bag, it recovers from trauma more easily.
Psychological Effects: To protect against the psychological effects of testicular absence.
Does it improve if hormone is given in the treatment of undescended testis?
Hormone therapy has no place in true undescended testis. However, it is used in some centers in retractile testicles and testicles located close to the bag. For this purpose, hormones such as HCG and LHRH were used, and they were abandoned because their long-term effectiveness was not seen to be very high. In addition, there are some side effects related to HCG. Premature closure of growth plates in bones, increased hair growth, temporary growth in testes and penis size, and restlessness in children are the most common of these side effects. No significant difference was observed in patients receiving hormone therapy compared to placebo.
When should undescended testis surgery be performed?
If an undescended testicle is detected, the testicle should be surgically placed into the scrotum. The ideal age range for this job is 6-18 months. It is known that in cases with undescended testis after the age of 2 years, the cells forming the testis are affected and lost.
What will we encounter after the operation?
It is generally performed as a daily operation. Children are discharged 2-3 hours after the operation. However, there may be inflammation, bleeding, hematoma at the surgery site, albeit at a small rate. The testis, the nerves and vessels of the testis, the sperm-carrying duct can be damaged.
