What is the best option for an adolescent who had bilateral undescended testicles, and at open surgery detected atrophic at the inguinal canal?; what to do; orchidectomy, or orchidopexy and follow up?
Thank you for a very interesting and controversial issue but highly important for the concerned patient. Please consider the following points b4 making a decision on table. I presume it on table intraoperatively.
1. Our estimation of said "atrophic testyicle" is just a presumption but not surity of "atrophy". There are historical records of such cases of "presumed" atrophic testicle visually (by naked eye estimation) but were noted to be having some functional tissue. Hence, these testicles can be preserved on first instance to be given a chance and followed up carefully with taking the parents in confidence.
2. Preceding decision is safe presuming that the patient shall be complying our follow up protocol.
3. If follow up protocol is not possible or reliable due to literacy or geographical locations, then one side is subjected to orchiectomy and wait for histological report before proceeding for surgery on other side. Or alternatively, a biopsy is taken and wound closed on first sitting and histological report should guide us for next step surgery. Until then, patient is kept under surgical supervision before dismissing home.
4. Orchiectomy is a final irreversible step that must be very carefully evaluated and conducted. Preservation must be warned and weighed for future possibility of malignancy and the parents or guardians must be adequately counselled for.
Om Prakash Sudrania@
Om Prakash Sudrania
Thanks Dear, what you mentioned suits my opinion since long time, I get relieved by your wise statements, unfortunately most of the pediatric surgeons know little about such situations, and usually seeing one aspect of the truth.
@ Mohamed A Baky Fahmy Thank you for your sweet words for my observation. Kindly also peruse the following observations. Every undescended testicle is reckoned to be of subliminal standard in its embryological, hence physiological development. This determines its irate course in descent. This is practically irreversible but can be arrested from deterioration if its normal position is restored at its earliest.
Briefly, physiology of testicles need three major considerations:
1. Masculity depends upon production of testosterone that can be generated by even residual testicular tissues.
2. Fertlity depends upon proper spermatogenesis which is a very complex function but depends upon good histological generation of spermatozoa. This is a very sensitive matter and depends upon lot of factors and needs a fully healthy testes. Lot of immunological factors are also involved.
3. Transformation into malignant tissues. Yes, longer these testes remain outside scrotum and also upon the age of patient. Every passing year of the child increases the potential for malignancy. Longer the testes remain outside scrotum, more the chances for malignancy. But the percentage of such malignancy varies and certainly a proper supervision must be kept. Unfortunately the malignant degeration does not completely abate even after orchiopexy. Because such testicles are regarded as basically defectice in their structural development de novo that leads to their loss of descent from their abdominal position ab initio. Thus the surgeon must remain vigilant even after their orchidopexy in normal position. Such defect is better slowed or improved when these testicles are restituted in normal position sooner but never completely eliminated.
Anyone interested in more details must pderuse the relevant literature. Ethnicity may be another factor that should be studied by the surgeons in their locality. Western studies may be mere guiding force but must be tallied in their own population.
In bilateral cases of undescended testicles, both sides should never be operated in one sitting and let one side be operated first and biopsy must be done though csarefully to minimise further damage to already defective testes. This should also determine the guidelines for next surgery.
Thanks Dear, are you doing Fowler Stephen even for an atrophic one?
Orchidectomy on one side and orchidopexy on the other side to preserve endocrine function whilst keeping the testis under surveillance for cancer
Zuhair Kamal
Do you will try a hormonal manipulation?
I think even if it is atrophic, orchidopexy and follow up is my preferable choice.
I can recall a case report quoted in Bailey & Love's Textbook of Surgery. In a surgical class, a teacher stated that anyone having bilateral undescended testicles shall nevber be able to father his children. In that classroom, one student had the same issue of bilateral undescended testicles, who following that lecture went out and committed suicide. Unfortunately, his postmortem report later reported that his both testicles were full of active and motile sperms. Sad though but we cannot predict the biological behaviour of any individual.
Message: One should be careful in imputing decisions based on some generalised observations because there can alwahys be exceptions and it more so when it comes to the biological characteristics in different individuals.
If both testes are atrophic. I will be reluctant to do orchidectomy at that point.
I will consider biopsy and orchidopexy, constant follow up and patient to regurlay palpate the testes for Malignancy.
Testosterone levels+/_ consider hormonal therapy.
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