86 M.C. Large and M.S. Gundeti

8.3  Treatment of Undescended Testis

1.Hormonal therapies have poor success rates as a high local concentration is required to induce descent.11

2.Surgical repair may be scrotal, inguinal, abdominal, laparoscopic or robotic-assisted. The approach is dictated by the location of the testis and surgeon’s preference (e.g., an inguinal testicle may be repaired through an inguinal or high-scrotal incision).

3.Occasionally, nonpalpable testes that are visualized intraabdominally are not able to be placed intrascrotally, in which the testicular artery and vein are ligated and the child is reexplored in 6 months in hope that collateral supply will allow increased mobilization.

4.Blind-ending vessels indicate absence of the testis (a testis may be present in spite of a blind-ending vas deferens).

5.The treatment of small testicular nubbins is debatable: some surgeons remove them citing rare reports of CIS developing, while others will leave them in situ.7

8.4  Indications for Referral

1.Examination by a urologist should be performed by age 3–6 months, with repair indicated at age 6 months if spontaneous descent has failed to occur.

2.Presence of ambiguous genitalia or severe hypospadias alongside undescended testes mandates a karyotype and multi-disciplinary workup with urologic involvement. Elevation of LH and FSH with absence of Müllerian inhibiting substance strongly suggests absence of testes.

References

1.Berkowitz GS, Lapinski RH, Dolgin SE, et al. Prevalence and natural history of cryptorchidism. Pediatrics. 1993;92:44-9.

2.Wenzler DL, Bloom DA, Park JM.What is the rate of spontaneous testicular descent in infants with cryptorchidism? J Urol. 2004;171:849-51.

Chapter 8.  Disorders of Male External Genitalia

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3.Kogan SJ. Fertility in cryptorchidism. An overview in 1987. Eur J Pediatr. 1987;146(Suppl 2):S21-S24.

4.Wilkerson ML, Bartone FF, Fox L, et al. Fertility potential: a comparison of intra-abdominal and intracanalicular testes by age groups in children. Horm Res. 2001;55:18-20.

5.Friedman RM, Lopez FJ, Tucker JA, King LR, Negro-Vilar A. Fertility after cryptorchidism: a comparative analysis of early orchiopexy with and without concomitant hormonal therapy in the young male rat. J Urol. 1994;151:227-33.

6.Swerdlow AJ, Higgins CD, Pike MC. Risk of testicular cancer in cohort of boys with cryptorchidism. BMJ. 1997;314:1507-11 [Published erratum appears in BMJ 1997;315:1129].

7.Wood HM,Elder JS.Cryptorchidism and testicular cancer:Separating fact from fiction. J Urol. 2009;181:452-61.

8.Elder JS. Cryptorchidism: Isolated and associated with other genitourinary defects. Pediatr Clin North Am. 1987;34:1033-53.

9.Schultz KE, Walker J. Testicular torsion in undescended testes. Ann Emerg Med. 1984;13:567-9.

10. Dessireddi NV, Liu DB, Maizels M, et al. Magnetic resonance arteriography/venography is not accurate to structure management of the impalpable testis. J Urol. 2008;180(4 Suppl):1808-9.

11.Rajfer J, Walsh PC. Hormonal regulation of testicular descent: experimental and clinical observations. J Urol. 1977;118:985-90.

Chapter 9

Disorders of Male External

Genitalia: Circumcision

Garrett Pohlman and Duncan Wilcox

Key Points

››The majority of boys will have a fully and easily retractable foreskin by physical maturity.

››Benefits of circumcision include lower risk of UTI’s in male infants, a protective affect against invasive penile cancer, and reduced incidence of STD’s.

››Circumcision should not be performed in newborns with hypospadias, epispadias, ambiguous genitalia, hidden penis, chordee without hypospadias, webbed penis, micropenis, or dorsal hood deformity.

››The complication rate for newborn circumcision ranges from 0.2% to 3%.

9.1  Natural History of the Prepuce

The prepuce is apparent prenatally at 8 weeks of gestation as a ridge of thickened epithelium. The prepuce grows forward over the glans to completion by 16 weeks of gestation. Early in gestation there is no separation between the epithelium lining the prepuce and glans. Preputial adhesions

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Surgery in Clinical Practice, DOI: 10.1007/978-1-84996-366-4_9,

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