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정류고환의 수술

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

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정류고환의 수술

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  1. 정류고환의 수술 가톨릭의대 한 창 희

  2. Contents 용어의 정의와 분류 진단 고환고정술 방법 복강경 하 고환고정술

  3. Clinical 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

  4. Terminology • Spontaneously descending testis • True undescended testis • Ectopic testis • Retractile testis • Gliding testis • Ascended testis Clinical Pediatric Urology, 4thed.

  5. True Undescended Testis • Intra-abdominal • Proximal intracanalicular • Distal intracanalicular • Prescrotal (Superficial inguinal pouch)  Prognostic significance?

  6. Ectopic Testis • Outside of path of normal descent • Distal to the external ring • Abnormal gubernacular attachment • Femoral, pubic, perineum, contralateral scrotum, • Superficial inguinal pouch ?

  7. Retractile Testis • Remains in scrotum with manipulation • Hyperactive cremasteric reflex • Normal size & consistency • Follow-up • Operation indicated in testicular atrophy • DDx with gliding testis Cremasteric Reflex 자극

  8. Gliding Testis • Manipulated into upper scrotum with tension • Immediately retracts into inguinal region • Pathologic changes similar to true undescended testis 잡아당기면 놓으면

  9. Ascended 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

  10. Descent 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

  11. Testicular descent: the 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)

  12. Incidence • 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%

  13. Evaluation of Cryptorchidism: Localization • 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

  14. Evaluation of Cryptorchidism: Physical 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

  15. 정류고환의 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

  16. Cryptorchidism Histology • Normal at 6 months • Decreased at 2 years • Age at 3 years 1/3 normal 1/3 decreased 1/3 markedly diminished

  17. Orchiopexy: Effect of Age • Surgery < 2 years: • Higher inhibin B levels • Lower FSH profiles • Suggests an overall beneficial effect of early orchiopexy. J Urol. 162: 986, 1999

  18. 정류고환의 치료 시기 • 조기화 되는 추세 • 6세(1975), 2세(1984), 1세(1986-), 최근 6개월~1세 • 생후 6개월~15개월이 바람직 • 생후 3-4개월(6개월)이후 자연 하강은 드물다. • 생식세포의 변성 • 12 개월부터 심해진다 . • 후천적, 진행성이며 비가역적 • 생후 6개월이면 마취의 위험도 및 수술 술기에 큰 차이가 없다.

  19. Management of UDT

  20. Surgery for Palpable UDT: Inguinal Orchiopexy

  21. Inadequate Cord Length • 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

  22. Surgical Techniques: Lengthening of Cord processus vaginalis lat. spermatic fascia internal spermatic fascia Prentis maneuver

  23. Prescrotal Orchiopexy (Bianchi)

  24. Success Rate of Orchiopexy: Inguinal Testis World J Urol. 24: 231-9, 2006

  25. Nonpalpable Testis • Location determined laparoscopically • Abdominal 40% • Intracanalicular 28% • Absent 32% • Abdominal • Inguinal

  26. Laparoscopy

  27. Abdominal Testes A B Inguinal Ring Peeping D C Iliac Vessel High Intraabdominal

  28. Management of Unilateral Nonpalpable UDT Laparoscopy Abdominal vanishing testis Vas & ISV into inguinal ring Abdominal testis No further surgery Inguinal explore Laparoscopic orchiectomy Laparoscopic orchiopexy Jones technique Laparoscopic staged orchiopexy

  29. Management of Bilateral Nonpalpable UDT Evaluate for intersex HCG Stimulation test Neg. Pos. Bilateral vanishing testes? Laparoscopy Laparoscopic orchiopexy

  30. Jones Technique

  31. Jones Technique

  32. Jones Technique

  33. LaparocopicOrchiopexy Standard Fowler-Stephens

  34. LaparocopicOrchiopexy

  35. Sequential Approach in Laparoscopic Orchiopexy

  36. Success Rate of Orchiopexy: Abdominal & Peeping Testis World J Urol. 24: 231-9, 2006

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