CRYPTORCHISM (cryptorchismus; Greek kryptos hidden + orchis small egg; synonym retentio testis) — the system anomaly of development which is characterized by a delay (not omission) of a small egg on the natural way of the following from the lower pole of a kidney to the bottom of a scrotum of edge is externally shown by absence in a scrotum one (monorchism) or both testicles. Inborn lack of testicles, usually one, is called anarchism. By the time of the birth To. it is observed at 20 — 30% of children, at the age of 1 year — at 2%, 13 — 14 years — at 1%, after 20 — 21 — at 0,2 — 0,3% of adult persons.
Among patients of a surgical profile there is a frequency To. makes 0,2 — 0,6%. According to E. S. Shakhbazyana, right-hand To. occurs at 50,8%, left-side — at 35,3%, bilateral — at 13,9% of patients.
the Majority of the offered classifications To. consider only forms which are an independent disease, but not secondary display of endocrine pathology, a dysgenesis of gonads etc. In a wedge, the relation S. L. Gorelik and Yu. D. Mirlesa (1968's) classification, according to a cut is most successful To. it is subdivided on inborn and acquired (result of an injury of a pla of operation), into one - and bilateral, and on location of a small egg — into belly and inguinal forms. The bilateral belly Cryptorchism S. Ya. Doletsky et al. (1976) is considered manifestation of insufficiency of a masculinization.
Inguinal form true To. it is necessary to distinguish from false To. (Xing: the psevdoretention, the migrating small egg), at Krom normally fallen small egg can is long or periodically be out of a scrotum under the influence of reduction of the muscle lifting a small egg. False To. it is observed at 1/3 children directed to the doctor concerning absence in a scrotum of a small egg. At a palpation such small egg is easily reduced on the place.
Close to To. a state is the ectopia of a small egg. Having passed the pakhovy channel, the small egg falls not to a scrotum. and is located under skin in any of adjacent sites. Seldom both small egg can be in one half of a scrotum.
According to Skorer (G. G. Scorer, 1964), normal process of formation and lowering of testicles in a scrotum comes to the end during the period from 6 months of an antenatal life to 6th post-natal week. All process, beginning from the correct laying of a floor of a germ, is defined by the set of chromosomes, hormones of cortical substance of adrenal glands and gonads of a fruit, a chorionic gonadotrophin of mother and luteinizing hormone of a fruit emitted in certain proportions.
Etiol, factors To. various teratogenic influences during pregnancy leading to disturbance of chromosomal information, an imbalance of hormones of mother, and then and a fruit and as a result — to an abnormal differentiation of embryonal fabrics, first of all a mesenchymal origin are.
the Pathogeny is defined by an arrest of development of the directing (gyunterovy) linking of a small egg playing a role of the main conductor of the falling small egg and also development of connective tissue fibrous obstacles in the course of its migration. The role of a connective tissue barrier at an entrance to a scrotum is especially important. Narrowing of this so-called third abdominal ring creates an obstacle for advance of a small egg and leads to its retraction to the pakhovy canal. At the same time the underdevelopment of a yaichkovy artery and shortening of a vulval shoot of a peritoneum takes place.
Disturbance of gonadotropic function of gipotalamo-pituitary system results in deficit of the differentiating hormones and to a dysgenesis of gonads. Further in the course of post-natal development dysplasticly - the dystrophic phenomena in the neostarted-up small egg progress. Disturbance of a temperature schedule and a perversion of enzymatic processes in fabric of testicles, their constant traumatization become accessory factors at the same time that leads to accumulation in blood of antibodies and an autoaggression. The autoimmune conflict aggravates defeat of a parenchyma of a small egg.
Studying patomorfol, structures of testicles at To., according to an intravital biopsy, showed that their development until hearth maturing happens poorly, and then completely stops. In the next years in a small egg the irreversible phenomena of an atrophy progress. Differentiation spermatogoniyev and prespermatid is absent, the quantity of seed tubules is sharply reduced, considerable growth of connecting fabric and development of a hyalinosis is observed. Patol, changes are noted at the age of two years. Progressing of dystrophic changes of glandulotsit of a small egg (cells of Leydiga) begins with 5-year age. Extent of reproductive (spermatogenic) function depends on a stage of development patol, changes. At bilateral To. only at 10% of men existence of spermatozoa is observed. Also androgenic function decreases. Since 10 years decrease in level 17 of ketosteroids is observed, especially at bilateral To.
A clinical picture
At premature newborns and babies To. usually consider physiological, considering that aged till 1 year spontaneous lowering of testicles happens in 70 — 80%. Lack of testicles in a scrotum in the prepubertatny period (at their existence on site before) is characteristic for false, seldom traumatic, To. Impotence, pains or unpleasant feelings at physical happen the main complaints of adults. tension, during the sexual intercourse that is observed at 60 — 70% of patients.
True To. it is always characterized by an underdevelopment of one of half or all scrotum. This symptom is described by Hamilton (W. Hamilton, 1937). A certain skill and observance of a number of rules is necessary for establishment of lack of testicles in a scrotum. Hasty palpation of a scrotum not warmed hands of the doctor or in the presence of strangers can lead to reflex reduction of the muscle lifting a small egg, and the small egg can highly escape to the pakhovy canal or out of its limits. It is especially important in cases when the symmetric underdevelopment of a scrotum is followed by a hypogonadism, and then it is difficult to probe the testicles which are in the place because of their small size and a pasty consistence.
The form and the sizes of superficial abdominal rings are determined by a palpation through a scrotum. When one or both abdominal rings represent a narrow crack or are not defined at all, it testifies to an underdevelopment of inguinal area, the obliteration of a superficial opening of the inguinal channel excluding a possibility of lowering of a small egg in a scrotum.
At To. processes can develop various patol. To. the cut can be followed by inguinal hernia, premises to emergence not obliterated vulval shoot of a peritoneum is (that takes place at 90% of patients To.).
Torsion of the neostarted-up small egg because of its free situation arises more often than torsion of a healthy small egg. Infringement of a small egg at To. arises usually at a prelum its walls of the inguinal channel at the time of passing through deep or superficial inguinal openings, and also at a prelum contents of a hernial bag. Torsion and infringement of a small egg at To. arise sharply, are shown by symptoms of restrained inguinal hernia (see) or acute abdomen (see). The acute disorder of blood circulation leads to the necrosis of a small egg which is quickly arising at torsion more slowly at infringement.
The neostarted-up small egg has predisposition to emergence in it malignant tumors of a disembrnogenetichesky origin; their frequency makes 6 — 12%, and in relation to all malignant tumors of a small egg — apprx. 9 — 15%. Treat the most malignant types of tumors seminomas (see), horionepitelioma (see. Trophoblastic disease ) and teratoblastomas (see), characterized by early innidiation in regional limf, nodes, lungs, a pleura and other internals.
Tumors in the neostarted-up small egg arise at the age of 20 — 40 years more often. Operational bringing down of a small egg does not reduce the frequency of their malignancy, but promotes early recognition of a tumor.
the Diagnosis in typical cases comes easy. Differential diagnosis To. with anarchy (see) it is possible by means of stimulation horiogoniny glandulotsit of a small egg. In 3 days of daily intramuscular introduction of a horiogonin (from 500 to 1500 PIECES) investigate urine on contents in it 17 ketosteroids. Normal their level increases by 1,5 — 2 times in comparison with initial, decrease testifies to an underdevelopment of gonads, and lack of dynamics — to lack of gonads. The specified test is especially important at a combination To. with hypospadias (see), at Klaynfelter and Turner's syndromes (see. Klaynfeltera syndrome , Turner syndrome ).
In hard diagnostic cases sometimes use pelvigrafiya (see), at a cut it is possible to konturirovat highly located neostarted-up small egg. With the same purpose apply pelvic angiography (see), the location of the neostarted-up small egg, the extent of its development and feature of blood supply allowing to establish. Diagnosis is promoted by a stsintigrafiya of testicles with the help 99mTc — a pertekhnetata. On stsintigramma localization of gonads, and is determined by intensity of accumulation of marked drug — extent of their development.
Exists two directions: conservative and operational.
Conservative treatment, or hormonal therapy, apply at inguinal and belly forms K., but taking into account indicators of excretion of the luteinizing hormone (LH). The chorionic gonadotrophin is appointed if the LG level does not exceed 124,8 ME/l; enter intramusculary on 500 ME 2 time a week within one month. In the absence of effect the course is repeated in a month. Method of the choice is local introduction of a chorionic gonadotrophin to fabrics of the inguinal channel to the location in it of a small egg or to the level of a deep abdominal ring. Injections make daily within 3 days, and at bilateral To. 3 more days to the counterlateral area. At the correct definition of indications to hormonal therapy the effect is reached at 51,5 — 90% of patients. To babies enter within 1,5 — 2 months vitamin E (oil solution of tocopherol of acetate on 5 — 10 mg a day); it exerts the stimulating impact on gipotalamo-pituitary system and improves exchange processes in seed plants. At the same time treatment is combined with introduction to a diet of the nursing mother of A, B1, C, D, E vitamins. To children at the age of 1 — years would appoint vitamin E in combination with ascorbic to - that. At obesity and decrease in standard metabolism — repeated 2 — 3 weeks courses of Thyreoidinum on 0,001 — 0,005 g for normalization of functions thyroid and gonads. With 6 — 12-year age to lay down. the complex is supplemented with vitamin A (15 — 20 thousand ME a day) for the purpose of normalization of formation of nuclear structures of a spermatogenic epithelium and activation of cellular proliferation in seed plants. At androgenic insufficiency appoint to 3 — 5 weeks Nerobolum in the increasing doses (2 — 5 mg a day); the course is repeated in 1,5 — 2 months. With 12 — 15-year age treatment is supplemented with the serumal gonadotrophin in tablets (to 200 PIECES a day) strengthening a spermatogenesis.
The adult appoint methyltestosterone in injections or inside for up to 3 weeks.
According to some authors, the greatest efficiency of hormonal therapy is reached when testicles are located in the inguinal channel or out of it — at an entrance to a scrotum i.e. when they most often fall to a scrotum independently in the prepubertatny period.
The main method of treatment is operation, to-ruyu carry out at patients aged from 7 up to 10 years though some authors recommend to perform operation at the age of 1 — 3 years. It is proved by the fact that secondary dystrophic changes of a spermatogenic epithelium at To. arise at the age of 1 — 2 years, and in sustentsita (Sertoli's cells) and glandulotsita of a small egg — from 5 — 6 years and by 12 — 14 years become irreversible.
In rare instances, when To. remained at adults, indications to operation shall be limited since there is a danger of a malignancy of a small egg under the influence of its bringing down after puberty.
Orkhipeksiya — operation of bringing down and fixing of a small egg — is made under the general anesthesia. Most often full mobilization and bringing down of a small egg is interfered by a short seed cord, as a result of the shortened yaichkovy artery. Lengthening is possible by straightening of its course, carrying out a small egg and a seed cord under the lower epigastriß vessels or under a back wall of the inguinal channel as S. Ya. Doletsky and A. B. Okulov recommend (1975). Straightening of a vessel and medial movement of a cord lead to its lengthening.
Numerous methods of operations can be divided into 2 groups: 1) single-step bringing down and fixing (funiculopexy) to fabrics of the corresponding half or other half of a scrotum, to a periosteum of a pubic hillock etc.; 2) double-stage bringing down with temporary fixing of a small egg under or for skin of the respective or opposite side of a hip, to a plaster or adhesive bandage, etc.
Basic distinction of these two groups of operations is the element of traction of quickly reduced small egg provided at double-stage ways than and indications to the choice of a method of operation are defined. At the low provision of a small egg (the distal site of the inguinal canal, below a superficial abdominal ring) it can be reduced by single-step operation. At higher position preference is given to double-stage operation, at a cut during temporary fixing of a small egg by the «physiological» traction dosed by the patient the noticeable additional lengthening of a yaichkovy artery excluding postoperative retraction of a small egg and its atrophy owing to an acute disorder of blood circulation in it is reached. These techniques allow to carry out bringing down of a small egg in a scrotum. In those exceptional cases, when at a belly form K. it does not manage to be reached, the small egg is not subject to removal: it is fixed to surrounding fabrics at the level of the successful mobilization, and in 1 — 2 years aim to reduce it finally in a scrotum.
The most rational method of single-step operation is Petrivalsky's way — Shemakera, at Krom the mobilized small egg is moved to a scrotum and fix in the bed formed between her skin and a dartos.
The combination of ways of Kitli, Torek, Herzen (fig.) is the cornerstone of two-stage operational bringing down of testicles. The Pakhovy channel is opened on all its extent. The small egg with a seed cord and a vulval shoot of a peritoneum is allocated with the uniform block to a deep abdominal ring. After their division the peritoneal funnel is tied up and cut as a hernial bag. By stupid preparation will mobilize a vascular bundle in retroperitoneal space. If necessary in addition cross oblique and cross muscles of a stomach, destroy a deep abdominal ring, cut a cross fascia to the lower epigastriß vessels that allows to make mobilization of a small egg up — to the lower pole of a kidney and down — to a bladder. The mobilized small egg is reduced in a tunnelizirovainy scrotum. Further do cuts at the bottom of a scrotum and on the medial surface of a hip with an exposure of a wide fascia. Sew the rear edges of skin wounds of a hip and a scrotum among themselves. The small egg for the remains of covers of a vulval shoot is fixed to a wide fascia of a hip. Sew front edges of a skin wound. For the purpose of the maximum providing food of a small egg and weakening of a tension of an artery the leg on the operated party would be stacked on Beler's tire on — 7 days on Versilova, Vorokhobov and Derzhavin's way (1964).
The second stage of operation — separation of a skin cuff, movement and fixing of a small egg in a scrotum are carried out in 6 — 12 months. These operations allow to achieve permanent moving of a small egg to a scrotum from 95 — 97% of patients.
Operational treatment of separate forms K. has some features. At bilateral To. in the beginning reduce more low located small egg since its favorable hormonal impact on other small egg is possible. At false To. with high mobility of a small egg operational treatment for the purpose of prevention of its torsion or infringement is sometimes shown. At total absence of one of testicles imitation of bringing down of a small egg by the room in the corresponding half of a scrotum of a hypodermic fatty tissue, a skin rag, an alloplastichesky prosthesis is recommended. At total absence of both testicles I. D. Kirpatov-sky developed an arterial leg operation of transplantation of a cadaveric small egg, the successful attempt a cut in 1977 was made also at the child.
From the moment of identification To. patients shall be on the dispensary account. Them the surgeon and the endocrinologist shall carry out overseeing. At a number of patients hormonal treatment in the postoperative period before final recovery is necessary. See also Small egg .
Bibliography Versilova E. B., Vorokhobov L. A. and Derzhavin V. M. Treatment of a cryptorchism at children, Vestn, hir., t. 92, No. 4, page 117, 1964; Gorelik S. L. imirles Yu. D. Kriptorkhizm and his surgical treatment, M., 1968, bibliogr.; Diagnosis and treatment of a cryptorchism at children (A method, recommendations), sost. S. Ya. Doletsky, etc., M., 1976; D oletsky S. Ya. and Isakov Yu. F. Children's surgery, p. 2, page 890, M., 1970; Zhukovsky M. A. Children's endocrinology, page 391, M., 1971 *; Fundamentals of children's urology and nephrology, under the editorship of S. D. Go-ligorsky, page 354, Kiev, 1973; Starkova H. T. Fundamentals of clinical andrology, page 126, M., 1973; Shakhbazyan. S. Kriptorkhizm and his treatment, M., 1957; With h and p at Page W. a. W about 1 g i n W. Cryp-torchism, N. Y., 1957; Keetley C. B. Temporary fixation of testis to thigh, Lancet, v. 2, p. 279, 1905; Scorer C. G. a. Farrington G. H. Congenital deformities of the testis and epididymis, N. Y., 1971; T o r e k F. The technique of orcheo-pexy, N. Y. med. J., v. 90, p. 948, 1909.
B. S. Gusev, V. M. Derzhavin.