정류고환의 수술
DESCRIPTION
정류고환의 수술. 가톨릭의대 한 창 희. Contents. 용어의 정의와 분류 진단 고환고정술 방법 복강경 하 고환고정술. Clinical Classification. Palpable 80% True undescended (intra, extra-canalicular) Ectopic Retractile Gliding Ascended Nonpalpable 20% Intra-abdominal - PowerPoint PPT PresentationTRANSCRIPT
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