Undescended Testicle

Drs. Mikael Petrosyan and Hans Pohl discuss undescended testes and what parents need to know

Transcript

Opening 0:08

This is Surgucation, surgical education for parents. We are here to inform, inspire, connect and heal. Undescended testicle. Surgucation episode 10, D r. Hans Pohl, Chief of Urology, Children's National Hospital.

Dr. Mikael Petrosyan 0:31

Hi, welcome to SURGUCATION. This is Mikael Petrosyan I'm your host today. We have Dr. H ans Pohl, our visiting g uests. He is a chief of urology at Children's National Hospital, and we're going to talk about undescended testicle today. Also used to be called cryptorchidism, but the term is a little bit too complex to pronounce and understand. So I think most of us understand this topic as it is testicle that hasn't descended t o t he scrotum,

Dr. Pohl 0:57

That's right but a few of us speak Greek anymore.

Dr. Mikael Petrosyan 0:58

So that that's true. Welcome to SURGUCATION. Thanks for being with us today.

Dr. Hans Pohl 1:02

It's a pleasure to be back.

Dr. Mikael Petrosyan 1:03

I have some questions for you, and hopefully we'll be able to clarify this , for , many parents that are listening or have kids who have undescended testicle.

Dr. Hans Pohl 1:11

And I have the answers to all of your questions.

Dr. Mikael Petrosyan 1:14

What is the undescended testicle, and how do you know that your child has undescended testicle? So , uh, first , uh, for people to understand what generally happens in , in just about the last , uh , four to six weeks of development, is that the testicles which are forming in the abdomen actually close to the kidneys , uh, will begin to descend into the scrotum. And , uh, they do so by , uh , following a pathway , uh, through the inguinal canal or the groin, and , uh , make their way into the scrotum. And once they arrive there, that canal is closed. Uh, the testis is supposed to stay in the scrotum , uh, from basically birth , uh, and , uh, in some , uh , few boys , uh , that process stops part of the way and the testicle , um , will be either in the belly or in the groin , uh , and does not complete its descent. So the child would understand a testicle comes to clinic to you to visit you guys. How do you diagnose it? And is there any tests that you need to do besides physical examination?

Dr. Hans Pohl 2:27

Generally? Um, it's pretty easy if the boy has two testicles in the scrotum, then pretty much , uh, you know, that , uh, there's no problem there, right? Uh , but if the boy has one or both of the testicles, not in the scrotum , uh, then , uh, that child is going to need some kind of exploration or surgery to , uh, look for find, and then bring the , the testicles down. So as a result, there is not much imaging at all that's required. Uh , so at this point in time, it's a generally a made by physical examination. Um, there may be a couple of circumstances where a sonogram can be of help. Um, and my , um, practice now is that I would use it in a boy who , uh, is perhaps a very overweight and , uh , it makes it difficult for me to , uh , locate the testis , um , in , in the groin. But , uh , short of those circumstances , uh, even the American urological association has , uh , said that. So sonography has no real role anymore in the diagnosis of undescended testis.

Dr. Mikael Petrosyan 3:33

So what if you don't treat the undescended testicle, you just happened to not notice it and it goes untreated .

Dr. Hans Pohl 3:39

Well, the problem with not treating an undescended testis is that , uh, the testis is supposed to be in the scrotum in order for the , uh , cells that are ultimately going to , uh , become sperm forming cells to actually mature properly. And so if the testis is located in an abnormal position, those cells will slowly die over the course of the 12 years. And by the time the boy enters puberty a few, if any of those cells remain and that test us will not make sperm. So,

Dr. Mikael Petrosyan 4:12

So you let you diagnose on the set of testicle. How do you actually treat the undescended testicle?

Dr. Hans Pohl 4:17

As I, as I mentioned before, it's a surgical condition. So the only way to treat the undescended testis is to , uh , perform an incision , uh, loosen the tissues around the core of the testicle and the testicle that are holding the testis in its high place. And by removing , uh , that tissue, the cord relaxes, and it allows the testis to naturally fall into the scrotum. Uh, we , we usually put a suture or a stitch in place , uh , to make sure that the test is stays there while it's all healing. And all of the sutures we use are dissolvable. So after about six weeks, the testis has just essentially glued itself into proper location.

Dr. Mikael Petrosyan 4:57

I'm going to go a little bit of complex . Maybe some parents have kids who have tests as are in the abdomen. I know there's t wo s tage procedures as well. What happens when the c hild's testicle are actually in the abdomen, t hey're haven't descended yet

Dr. Hans Pohl 5:11

So it's relatively straightforward to make an inguinal decision for a testis that is in the inguinal or the groin, a canal, but when the test is, has not exited the abdomen , uh , then , uh , we need to use a laparoscopy, which includes a camera and two other instruments to , uh, loosen , uh, the attachments , uh , between the test descent and the inside of the abdomen. And then to push the testicle down. There is some debate in , um, uh , pediatric urology community as to whether that should be done as a two-step or a single step , uh , procedure. Uh, the , um , large studies have found that if it is performed in a two step operation, the success rate slightly higher for being able to bring the test to stout and having it , um, uh, survive it's , uh , it's descent . But the , um, the increased , uh, success rate , uh, is only perhaps about 10%. And so it becomes then a , I think a conversation that one needs to have with the parents as to whether , uh , they would prefer to have two separate surgical procedures , uh, for a very slight increase in success.

Dr. Mikael Petrosyan 6:25

I know reading the literature on internet, as well as looking back where I did my medical school, we used to get told that if you have an undescended testicle, the cancer incidence of cancer is much higher in those kids. I know that has changed. Uh , why don't you tell those parents who have kids with uncertain testicle , what are the incidents of cancer? So the first thing I tell parents is any boy that has testicles has a risk of cancer because by virtue of having testicles, you have a risk of cancer. And so the question is , is if that test us is in a slightly abnormal position, what is the increased , uh , risk over that baseline risk? We used to be taught , uh , that , uh, the end of send a test as has a 30 or 40 times greater risk of testicular cancer, which was really kind of a scary number , uh, when one thinks about it from that perspective, having done this now for 22 or so years, I have never taken care of a testicular cancer and a previously undescended testis. So it's unclear exactly where those old numbers came from in a more , uh, modern series , uh, out of Sweden. Uh , they reported their rate of only about two to three times greater. Uh, and , um, and I think that those , uh, those numbers are probably more real. Uh, so I think that there is a concern, but I don't think the concern is as great as we once thought it was. Let's say the parents have a child who with unscented testicle, how do they prepare for the operation at what , uh , what is the age they should normally get that surgery done? Well , uh , if the testis is not descended, it should be brought down as soon as possible. Now, I don't want parents to leave thinking that it's an emergency and they need to go to the operating room the next day after the diagnosis, we clearly have enough time to prepare the family and the child to undergo the general anesthesia and the surgical procedure. Uh, so what I would say is that if the testes are not in the scrotum, by the time the child is six months old, then you know, that those testes are that testis is not going to come down , uh, by itself. And the child is a candidate for surgery. Uh, so , uh, they should seek either a general surgeon or a , uh , or a urologist who's capable doing that kind of surgery, and then bring those testes down , um , as soon as is practical. So what are the expectations of parents after the operation? So they expect Pain-wise, activity-wise,

Dr. Hans Pohl 9:09

What's really incredible is that , uh, as you know, as being a skilled pediatric surgeon yourself, that we can do all sorts of procedures on tiny children and they recover extremely well. And undescended testis surgery is, is one of those , uh, most of the parents that , um, come back to see me a couple of weeks after surgery will report that their child , um, goes back to normal activity by the day after the operation. I think that's, that's generally true. Uh, for instance, if it's a baby under one year of age , um, you know, they're not playing tennis or golf. So generally they're basically doing their normal little baby thing the day after surgery. And if it's an older child , uh , usually they're already in the position to, you know, want to jump off rooftops. Uh , and so we actually have to tell parents to just keep the kid calm for a couple of weeks to ensure proper healing. So kids recover extremely quickly.

Dr. Mikael Petrosyan 10:02

Great , awesome. So I guess the lessons learned from parents would be the undescended testicle is a surgical problem. It can be easily fixed. It should be done by six months of age increased risk of cancer twofold , but not 30 or 60 that could used to be, and that's all. And on internet, some of the information internet as well. That's correct. Be careful where you get your information these days. True . Alright . Well, thank you very much. That was awesome. Hopefully many parents will learn from this podcast and you're welcome to come back and tell us more about urology. I'm always happy to come back. Thank you very much.