Cryptorchidism

CRYPTORCHIDISM (from Greek kryptos - hidden, secret and orchis - testicle), a developmental anomaly in which one or both testicles do not descend into the scrotum but are arrested somewhere along the path from their place of formation (at the lower pole of the kidneys) to the external opening of the inguinal canal. Arrest at any point within the abdominal part of this path (before the internal opening of the inguinal canal) is designated as retentio abdominalis, while arrest in the inguinal canal is designated as retentio inguinalis. If the testicle is found anywhere outside its usual path (for example in the pelvis, under the skin of the perineum, etc.), it is referred to as ectopia testis. In exceptionally rare cases, a testicle arrested in the abdominal cavity descends downward and penetrates under the skin of the thigh along the typical course of femoral hernias (ectopia cruralis). Cases of testicles found in the perineal region have been described (ectopia perinaealis). Unilateral cryptorchidism occurs significantly more often than bilateral cryptorchidism. The process of testicular descent begins at the time of their final formation, i.e., at the 3rd month of embryonic life, and is mostly completed by the time of the child's birth, but sometimes later. Due to this latter circumstance, cryptorchidism in newborns is encountered much more frequently than in adults. Thus, according to Hansemann, on average out of 11 cases of cryptorchidism in newborns, in 10 cases the testicles subsequently descend. According to modern views, testicular descent occurs passively, under the influence, on one hand, of the arrest in development of the gubernaculum, and on the other hand, of the continuing growth of the trunk. The gubernaculum (gubernaculum Hunteri) in the embryo with one end (cranial) connects to the gonad (more precisely - to the lower end of the Wolffian body, which transforms into the epididymis), while its other end (caudal) passes through the anterior abdominal wall at the site of the future inguinal canal and attaches under the outer coverings in the area of the so-called genital swelling, from which in males the scrotum subsequently forms. Since the arrest in development of this ligament occurs at a time when its length does not exceed several millimeters, it is understandable that with the growth of the trunk, the movable testicle must gradually move to the site of attachment of its caudal end (see vol. VIII, art. 313, fig. 2). As for the mechanism of arrests in the process of testicular descent leading to one or another form of cryptorchidism, at present it cannot be considered sufficiently clarified. Previously, an explanation for this phenomenon was sought in intra-abdominal adhesions or in abnormal narrowness of the inguinal canal. Now the greatest importance in this respect is attributed to the underdevelopment of art. spermaticae internae, which due to its shortness can hinder the proper displacement of the gonad. Some attribute the atrophy of germinal elements in cryptorchidism to the same hypoplasia of a. spermaticae and the resulting insufficient blood supply to the organ. They are usually small, dense, the lumen of their tubules is narrowed, while the walls, on the contrary, are thickened and hyalinized; the germinal epithelium is almost or completely absent; in the interstitium, focal proliferations of interstitial Leydig cells are often observed. However, as has already been said, this picture is only usual but not obligatory, and sometimes even in elderly people, atrophic changes in the arrested testicle turn out to be weakly expressed. Some authors attribute great importance to the influence of temperature in the development of atrophy of germinal elements in cryptorchidism, the optimum of which for the multiplication and maturation of sperm-forming cells apparently lies significantly lower than the temperature of the abdominal cavity. Indeed, in the slit-like space between the visceral and parietal layers of the tunica vaginalis of the testicle, as shown by special measurements made during operations, the temperature is 3-7° lower than the temperature in the abdominal cavity. On the other hand, experiments on moving testicles into the abdominal cavity in animals also establish the unfavorable effect of this procedure on the development of spermatozoa. Finally, the mechanical stress to which testicles are subjected in retentio inguinalis can also not be without influence on the development of atrophic processes. In unilateral cryptorchidism, the loss of spermatogenic function has no practical significance, since the activity of the healthy testicle completely replaces the atrophic one. It must be kept in mind that cryptorchid testicles, even those not possessing spermatogenic function, retain their internal secretion, and therefore castration, which was previously used in cryptorchidism, is inadmissible. It must also be noted that in arrested testicles, especially when the arrest occurs in the inguinal canal, there is a greater tendency to develop tumors. Sarcoma, carcinoma, and choriocarcinoma are most frequently encountered here. According to Kocher, malignant tumors occur in arrested testicles in approximately 1:1,000 cases, while in normal testicles they occur 25 times less frequently. A common companion of cryptorchidism is hernia, which particularly easily occurs with inguinal cryptorchidism due to the fact that the processus vaginalis peritonei remains open; according to Uffreduzzi, it occurs in 90%, according to Schönholzer in 93%. In inguinal cryptorchidism, sometimes due to abnormally increased mobility of the testicle, sudden twisting of the cord with subsequent strangulation of the testicle is observed. In individuals with bilateral cryptorchidism, if atrophy of the testicles occurs early, underdevelopment of secondary sexual characteristics is usually observed. Attempts exist (Moszkowicz) to represent the essence of cryptorchidism as a phenomenon of intersexuality (see).

M. Skvortsov. In a number of cases, cryptorchidism was observed in several members of the same family, which indicates its connection with hereditary predisposition. Often in cryptorchids, a number of developmental disorders of other organs are observed. Aronovich, Ufretuzzi and others, when examining mentally retarded children and adults in shelter-hospitals, found among them from 3% to 18% cryptorchids (in normal people this figure does not exceed 0.2-0.4%). At the same time, other developmental defects of the genital organs were found in these same individuals: hypospadias, epispadias, false hermaphroditism, as well as hernias and skull anomalies. The etiology of cryptorchidism is thus heterogeneous and can apparently be of both genotypic and paratypic nature. - Symptoms. The most characteristic symptom is the absence of one or both testicles in the scrotum. It is easy to detect a retained testicle if it is located at the external inguinal ring or in the lower part of the inguinal canal. In this case, a soft cord of the processus vaginalis is palpated and in it a slightly reduced, round-shaped testicle. When the latter is compressed, the patient experiences characteristic pain sensations. When the testicle is retained behind the internal inguinal ring, or even deeper in the pelvis, it cannot be palpated through the abdominal coverings. Treatment. The most common reason that causes people suffering from cryptorchidism to consult a doctor is the accompanying hernia. Pain sensations in abdominal cryptorchidism are completely absent; in inguinal cryptorchidism, ze in patients, pulling pains are observed, especially after great muscular exertions. Abdominal cryptorchidism does not require treatment measures; one should only observe the patient in order to be able to promptly remove a malignant tumor if it appears. In children, as they grow, inguinal cryptorchidism may resolve on its own, and therefore up to the age of 10-12, in the absence of a hernia, one should be content with applying a truss with a pelote pressing the testicle downward and which can cause obliteration of the processus vaginalis. Surgical intervention in inguinal cryptorchidism has as its objective the displacement of the testicle into the scrotum in order to create conditions for its normal position and eliminate the traumatic effects to which it is subjected in the inguinal canal. The operation for cryptorchidism consists of two moments: 1) elongation of the spermatic cord by mobilization of its elements, 2) fixation of the displaced testicle to prevent its retraction and return to the inguinal canal. If cryptorchidism is accompanied by a hernia, then it is best to perform the operation simultaneously. For inguinal cryptorchidism alone, the operation is performed as follows: an incision of the skin and subcutaneous tissue along the course of the inguinal canal, starting from the external inguinal ring. The inguinal canal is opened as far upward as possible, and the testicle together with the spermatic cord is isolated. If the testicle can be easily pulled down to the bottom of the scrotum, it is fixed there with several silk sutures, capturing the tunica albuginea and the edges of the wound on both sides. The wound in the inguinal canal area is closed in layers (Schiller's method). In a number of cases, with the above method, it is impossible to bring the testicle down even to the upper part of the scrotum. To⁵ elongate the cord, Kustner and others, considering that the main obstacle to bringing down the testicle is the vessels, recommend their transection. Numerous observations, however, show that this intervention puts the very existence of the testicle at serious risk, which usually dies after this. Due to the unsatisfactory and traumatic nature of methods for permanent fixation of the brought-down testicle, many authors resort to the method of prolonged traction of the spermatic cord by temporarily securing the testicle in the area of the thigh skin. The most rational method is that of Katzenstein with the passage of the testicle through the scrotum and covering it with a skin flap from the anterior surface of the thigh. Herzen, using this method, places the testicle under the skin of the thigh, but sews together with several sutures the edges of the thigh, forming a scrotal-femoral anastomosis (see figure). The cord located inside this last channel is thus protected from external harmful influences. After a month and a half to two months after the first operation

"between the uncut scrotum"

the testicle is removed from under the skin of the thigh and placed in the scrotum. The skin wound is closed. In those cases where the mobilization of the elements of the spermatic cord is associated with great trauma, it is best to abandon wide mobilization of the cord and forced traction of the testicle and, following the advice of Kronlein, place the testicle together with a part of the processus vaginalis into the preperitoneal tissue of the abdominal wall. In case of torsion of the testicle, immediate surgery is necessary. In ectopia in the thigh area, the usual methods for femoral hernia operation are applied. Retained testicles that have undergone malignant degeneration must be removed. In case of degeneration of inguinal testicles, orchidectomy must be followed by laparotomy for revision of the abdominal cavity for the removal of lymph glands affected by the neoplasm.

ya. Bruskin.