정류고환의 수술정류고환의 수술

가톨릭의대

한 창 희

• 용어의 정의와 분류

•진단

•고환고정술 방법

•복강경 하 고환고정술

ContentsContents

Clinical ClassificationClinical Classification

• Palpable 80% True undescended (intra, extra-canalicular) Ectopic Retractile Gliding

Ascended

• Nonpalpable 20% Intra-abdominal Absent(vanishing) Atrophic(testicular nubbin) Missed on P/E

TerminologyTerminology

• Spontaneously descending testis• True undescended testis• Ectopic testis• Retractile testis• Gliding testis• Ascended testis

Clinical Pediatric Urology, 4thed.

True Undescended True Undescended TestisTestis

• Intra-abdominal• Proximal intracanalicular• Distal intracanalicular• Prescrotal (Superficial inguinal pouch)

Prognostic significance?

Ectopic TestisEctopic Testis• Outside of path of normal descent• Distal to the external ring• Abnormal gubernacular attachment• Femoral, pubic, perineum, contralateral scrotum, • Superficial inguinal pouch ?

Retractile TestisRetractile Testis

Cremasteric Reflex 자극

• Remains in scrotum with manipulation

• Hyperactive cremasteric reflex

• Normal size & consistency

• Follow-up• Operation indicated in

testicular atrophy• DDx with gliding testis

Gliding TestisGliding Testis

잡아당기면놓으면

• Manipulated into upper scrotum with tension

• Immediately retracts into inguinal region

• Pathologic changes similar to true undescended testis

Ascended TestisAscended Testis• Testis previously in scrotum• Etiology - Patent processus vaginalis - Muscle spasticity (cerebral palsy) - Iatrogenic (after hernia, hydrocele repair) • 50% patent processus vaginalis• Decreased tubular fertility index• Does not respond to HCG• Requires orchiopexy

Descent of TestisDescent of Testis• Transabdominal descent

– 1st trimester – Urogenital ridge to internal ring– Androgen independent

• Transinguinal descent – 7-9 months of gestational age– Androgen dependent

• Postnatal descent – 70% of cryptorchid descend at

3 mo of age

Testicular descent: Testicular descent: the current hypothesisthe current hypothesis

• Gubernaculum– Jelly-like mass– embryonic mesenchyme– Lies within inguinal canal– Connecting testis and scrotum

•Swelling inguinal canal formation (24wks)

•Regression testicular descent (24-32 wks)

IncidenceIncidence

• Premature infants 30.3%• Full term infants 3.4%• 1 year 0.7-0.8%• School age 0.76-0.95%• Adult 0.7-1.0%

Evaluation of Evaluation of Cryptorchidism: Cryptorchidism:

LocalizationLocalization• Imaging study: Ultrasonography, CT scan,

MRI – High false-negative rates– Very little value

• P/E by pediatric urologist: more valuable• HCG Stimulation Test:– Unilateral : Ectopic vs. Retractile– Ascended testis– Bilateral nonpalpable testes

• Laparoscopy

Evaluation of Evaluation of Cryptorchidism: Cryptorchidism:

Physical ExaminationPhysical Examination– Warm room, relaxed child– Observation prior to examination– Relaxed position : frog-leg, crossed-leg,

sitting, leaning forward– Milk down, palpating from iliac crest to scrotum – Scrotum : hypoplastic, bifid, rugae, transposition,

pigmentation– Contralateral hypertrophy– Presence of hypospadias/chordee, penile length – Serial examinations, if equivocal

정류고환의 치료 목적정류고환의 치료 목적

•Possible improved fertility

•Self-examination for testis mass (cancer)

•Correction of associated hernia

•Prevention of testicular torsion

•Avoidance of injury against pubic bone

•Psychological effects of empty scrotum

Cryptorchidism Cryptorchidism HistologyHistology

• Normal at 6 months• Decreased at 2 years• Age at 3 years 1/3 normal 1/3 decreased 1/3 markedly diminished

Orchiopexy: Effect of Orchiopexy: Effect of AgeAge

• Surgery < 2 years:– Higher inhibin B levels– Lower FSH profiles

• Suggests an overall beneficial effect of early orchiopexy.

J Urol. 162: 986, 1999

정류고환의 치료 시기정류고환의 치료 시기• 조기화 되는 추세

– 6 세 (1975), 2 세 (1984), 1 세 (1986-), 최근 6개월 ~1 세

• 생후 6 개월 ~15 개월이 바람직1.생후 3-4 개월 (6 개월 ) 이후 자연 하강은 드물다 .2.생식세포의 변성

12 개월부터 심해진다 . 후천적 , 진행성이며 비가역적

3.생후 6 개월이면 마취의 위험도 및 수술 술기에 큰 차이가 없다 .

Management of UDTManagement of UDT

Surgery for Palpable Surgery for Palpable UDT:UDT:Inguinal OrchiopexyInguinal Orchiopexy

Inadequate Cord Inadequate Cord LengthLength

• Patent processus dissected completely free of the cord?• Internal ring incision and retroperitoneal cord

mobilization?• Lateral peritoneal attachment divided?• Inguinal floor or transverse fascia divided(Prentis)?• Deep epigastric vessel divided?• Opposite testis normal ? Single stage Fowler-Stephens• Opposite testis undescended ? staged orchiopexy, unilateral F-S and delayed op

Surgical Techniques: Surgical Techniques: Lengthening of Cord Lengthening of Cord

lat. spermatic fascia

Prentis maneuver

internal spermatic fascia

processus vaginalis

Prescrotal Orchiopexy Prescrotal Orchiopexy (Bianchi)(Bianchi)

Success Rate of Success Rate of Orchiopexy: Inguinal Orchiopexy: Inguinal

TestisTestis

World J Urol. 24: 231-9, 2006

Nonpalpable TestisNonpalpable Testis

• Location determined laparoscopically• Abdominal 40%• Intracanalicular 28%• Absent 32%

- Abdominal- Inguinal

LaparoscopyLaparoscopy

Abdominal TestesAbdominal Testes

Peeping

Iliac Vessel

Inguinal Ring

High Intraabdominal

BA

C D

Management of Management of Unilateral Nonpalpable Unilateral Nonpalpable

UDTUDTLaparoscopy

Abdominal vanishing testis

Abdominal testis

Vas & ISV into inguinal ring

Laparoscopicorchiectomy

Laparoscopic orchiopexy

Laparoscopic staged orchiopexy

Inguinal explore

No further surgery

Jones technique

Management of Management of Bilateral Nonpalpable UDTBilateral Nonpalpable UDT

Evaluate for intersex

HCG Stimulation test

Bilateral vanishing testes?Laparoscopy

Laparoscopic orchiopexy

Neg. Pos.

Jones TechniqueJones Technique

Jones TechniqueJones Technique

Jones TechniqueJones Technique

Standard Fowler-Stephens

Laparocopic OrchiopexyLaparocopic Orchiopexy

Laparocopic OrchiopexyLaparocopic Orchiopexy

Sequential Approach Sequential Approach in Laparoscopic in Laparoscopic OrchiopexyOrchiopexy

Success Rate of Success Rate of Orchiopexy: Abdominal Orchiopexy: Abdominal

& Peeping Testis& Peeping Testis

World J Urol. 24: 231-9, 2006