MINISTRY OF

MINISTRY OF DEFENCE

EDUCATION AND TRAINING
VIETNAM MILITARY MEDICAL UNIVERSITY
=======

NGUYỄN MẠNH THẮNG

THE STUDY ON MORPHOLOGY, FUNCTION,
HISTOPATHOLOGY AND SURGERY RESULTS OF
CRYPTORCHIDISM

Speciality

: Surgery

Code

: 9720104

ABSTRACT OF THE THESIS FOR MEDICAL DOCTOR

HA NOI - 2019


THE THESIS WAS COMPLETED
IN VIETNAM MILITARY MEDICAL UNIVERSITY

Scientific Supervisors:

Nguyễn Mạnh Thắng, Trần Quán Anh, Nguyễn Quang
(2018), “Testosterone and gonadotropins in adult male with
cryptorchidism: Compare pre and post orchidopexy”, Journal of
military pharmaco-medicine, page196-198.


1
INTRODUCTION
Cryptorchidism is a popular sequela in reproduction – urology
system in male baby. The proportion of cryptorchidism accounted for 24% in full-term full-term infant and 20-30% in preterm infant.
Cryptorchidism is a long-term risk factor that cause many
complications such as infertility, testicle cancer, change of hormone…
Some studies showed that cryptorchidism cause alters of testicle’s
structure and function, and it is believed as a cause of infertility.
Nowaday, some scientists concerned that relationship between
decreasing competence of sperm and unilateral cryptorchidism and alter
of the other normal testicle in scrotum.
Cryptorchidism related closedly to testicle cancer and suffer from
cancer higher than from 4 to 40 times in normal testicle in scrotum in
many studies.
Guideline of many Association of Urology also showed that early
operation help to prevent complications, the latest age of operation was
18 months old. However, in fact there were many patients that were
operated late. In Vietnam, the proportion of puberty surgery was 3040%. So that there were many male adult with cryptorchidism.
Besides, removing cryptorchidism in adult is popular in Vietnam.
It maybe affect to psycholory, hormone, decrease competemce of
reproduction. So there is a question that orchiopexy in male adult bring
to effectiveness? Our study assess outcome of orchiopexy in male adult.
Objectives of our study were:
1. Studying few characteristics of

Androgen receptors. Estrogen could affect the movement of testes.
1.2.3. Mechanical factor:
Malformation of scrotum-testis ligament, epididymis disorder,
lower intra-abdominal pressure.
1.2.4. The disorders related to cryptorchidism
Hypospadias, feminized testes …
1.3. The anatomy of testis and the related components
- The cryptorchidism testis is smaller and more round-shaped than
the normal one. The cryptorchidism testis has the semilunar-shaped
epididymis.
- The testicular vessels normally had connection between the
testicular and ductus deferens artery, and testicular parenchymal.
In the cryptorchidism, the artery is smaller. The testicular artery
branches into two, one for testicular, other for epididymis without
connection.
1.4. LH, FSH, Testosterone and the effect to congenital physiology
According to Ramaswamy S. and Weinbauer G.F.: LH/testosterone
and FSH are the necessary hormones to maintain the normal semen
production.
Babu S.R.et al. the gonadal hormones (LH, FSH) and testosterone
are the basic factors of semen production.


3
Meeker J.D. et al. showed the role of FSH, LH is negative with
density, shape and mobility.
1.5. The sperm test in cryptorchidism patients
The deficiencies appear in both unilateral and bilateral
cryptorchidism groups
1.5.1. Bilateral cryptorchidism

The histology change fits in the age, the older, the more fibrosis.


4
1.6.3. The malignancy of spermatogenesis cells
The high temperature leads to abnormal development
spermatogenesis cells, reaction of oxydation and temperature shock
made to injury cells.
1.7. The complication of cryptorchidism
1.7.1. Infertility
1.7.1.1. Infertility caused by bilateral cryptorchidism
+ Untreated bilateral cryptorchidism: it is believed as a cause of
infertility
+ Treated bilateral cryptorchidism before adulthood: according to
Chung E, it was higher prevalence of infertility than unilateral
cryptorchidism.
+ Treated bilateral cryptorchidism after adulthood: it was showed
the mobility improvement in many researches.
1.7.1.2. Infertility caused by unilateral cryptorchidism
Recently, some authors concern on the relation between infertility
and reduce spermatogenesis in unilateral cryptorchidism after
adolescence.
1.7.1.3. Infertility and time of operation
The infertility could be prevented if the operation is performed
before 18 months of age
1.7.2. Testis cancer
1.7.2.1. The characteristics of testis cancer
The prevalence of testis cancer is 1% among male. In
cryptorchidism, the risk could increase 5-10 times. In Green R, the
prevalence could increase 35 times. The higher risk in case of

Isolation of testicular vessels is performed by the peritoneal
approach.
1.8.2.4. Bianchi and Squire technique
Approaching from the scrotum, the midline in case of bilateral, and
horizontal incision at the lowest point with unilateral is performed.
1.8.2.5. Kỹ thuật Walther-Ombredane
In case of inguinal testis: Isolation each components of inguinal
cord, tighten the hydrocele at the proximal
1.8.2.6. Fowler – Stephens
- The research of Fowler and Stephen (FS): the blood supply for
testis is ductus deferens artery, scrotum muscle, gubernaculum,
therefore testicular artery could be dissected to pull down the testis.
FS technique 1 stage: Clamp the testicular artery, assessment the
supplies after some minutes, then dissection.
FS technique 2 stages: Clamp but no dissection. After 3-6 months
for correlation circulation, then dissection.
1.8.2.7. Itself testis graft
Artery-Vein testis were cut nearly in root and connected to Arteryvein espigastria later-inferior. Bukowski T.P. showed that patient with
two testes of cryptorchidism was high position, they have to at least one
testis was vessel graft.


6
1.8.3. Techniques of orchidopexy by laparoscope
Techniques were popularly applied to non-palpble testis
cryptorchidism.
1.8.3.1. Orchidopexy by standard laparoscope techniques
Techniques were used to abdomial testis cryptorchidism with longstem vessel to take testis down scrotum.
1.8.3.2. Laparoscope to ochidopexy by Fowler Stephens
Laparoscope to ochidopexy with one or two stages by FS was applied


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2.2.2. Design of the study
2.2.2.1. Studying on characteristics of morphology, function,
hispathology of cryptorchidism in male adult
- Age of patient: divided age groups as following:
+ Noting changes of hormone, sperm test. Comparing the
characteristics before and after to define restoring of testis.
- Re-test of antibody sperm
Outcome of orchidopexy
Verygood results:
- Testis was entirely in scrotum, volume of testis after operation
was similar to or bigger than its before operation.
- Improving clearly to density of testis: azoospermic before
operation but cryptospermia after operation. Cryptospermia before
operation but oligozoospermia after operation. Oligozoospermia before
operation, normozoospermia after operation.
Good results:
- Testis was entirely in scrotum, volume of testis after operation
was similar to or bigger than its before operation.
- Improving unclearly to density of testis or only improve of sperm
movement
- Improving clearly to hormones (increasing testosteron, decreasing
LH and FSH)


9
Average results:
- Testis was entirely in scrotum, volume of testis after operation
was similar to or bigger than its before operation.
- No improving to hormones.
- No improving to spermiogram.
Bad results:
- Testis was led to high position or in scrotum but atrophy testis.
- No improving or decline of hormones and spermiogram.
2.2.3. Operating techinique

Graph 3.1: Distribution of aging group in patients with
cryptorchidisms: Minimum age was 15 years old. Maximum age was
43 years old. Mean age was 25.69±5.7 years old.
Graph 3.2: Chief complaint: No testis in scrotum was the best
popular reason (63.4%), infertility reason accounted for 23.2%.
Table 3.1: History of marriage and having baby: the proprotion of
single and no information for having baby was 65.1%, the proprotion
of over one-year-marriaged patient with no baby was 24.1%.
Table 3.2: History of sexuality: The proportion of patient with
normal sexuality was the hihgest (59.8%). The proprotion of erectile
dysfunction was 14.3%.
Graph 3.3. Unilateral or two bilateral cryptorchidism were
respectively 67.9% and 32.1%
Graph 3.4: Unilateral or bilateral cryptorchidism and chief
complaint for infertility
Unilateral cryptorchidism, chief complaint for infertility 11/76 BN
(14.5%)
Bilateral cryptorchidism, the proportion of being admitted hospital
for infertility accounted for 15/36 patients (41.7%)
Graph 3.5: Unilateral or bilateral cryptorchidism and erectile
dysfunction
- The proprotion of erectile dysfunction in bilateral accounted for
12/36 patients (33.3%).
- The proprotion of erectile dysfunction in unilateral cryptorchidism
accounted for 4/76 patients (5.3%)
Table 3.3. Normal physical development in unilateral
cryptorchidism were 73/76 patients (96.1%), in bilateral cryptorchidism
were 24/36 patients (66.7%).
Table 3.4: Morbidity in groin-scrotum: No disease accounted for
95/112 patients (84.8%), number of groin-hernia were 12/112 patients


Number of Mean±SD
testis
(cm3)
35
4.7+ 2.4
33
6.4 + 2.3
39
4.3+ 1.8
36
4.4 + 2.1

p
0.250
0.790

Table 3.10: Comparing mean volume of undescended testes in
unilateral cryptorchidism and normal testis in the other scrotum
Volume of testis
The right undescended
testes/Unilateral
The left normal testis
The left undescended
testes/Unilateral
The right normal testis

Number
of testis


5.1 + 2.1
The right undescended testes /Bilateral
34
4.5 + 2.3
The left undescended testes /Unilateral
40
4.2 + 1.7
The left undescended testes / Bilateral
36
4.6 + 2.0

p
0.669
0.414


12
Table 3.12. Palpable undescended testes: The proportion of soft
density was 69.1%, of normal density was 29.1%
Table 3.13: Density of testis in operation: There were two testes
having vestige, 146 remain testes were assessed denssity in which the
proportion of soft density accounted for the highest was 74.7%.
Graph 3.7: Adhesion of epididymis and testis
47.3% normal, 45.9% part-adhension of epididymis and testis, 6.8%
undefiend adhension of epididymis
Graph 3.8: Characteristics of spermatic cord vessel after operation
The proportion of stretchy vessels was 56.8%, of non-stretchy
sperm vessels 41.1% There were 3/146 testes (2.1%) with stretchy sperm
vessels so short that take down in scrotum.
Table 3.14: Location of undescended testes and characteristics of

Table 3.16: Spermiogram analysis in unilateral cryptorchidism
Unilateral
cryptorchidism
Normal
(n=44)
proprotion by
Spermiogram analysis
WHO 1999
Mean±SD
(Min-Max)
Vitality (%)
49.7±12.8 (15-80)
≥75%
Rapid progressive motility (A) (%)
14.3±10.4 (0-40)
≥25%
Total of motility (A+B) (%)
37.3±12.8 (5-50)
≥50%
Normal morphology (%)
37.8±17.8 (0-70)
≥ 30%


13
Table 3.17: Abnormality of spermiogram in unilateral
cryptorchidism.
44 unilateral patients who have oligozoospermia and
normozoosperm:Asthenozoospermia 72.7%, Teratozoospermia 27.3%.
Table 3.18: There were 35 patients that were tested antibody of sperm.

cell only
syndrome

maturation
arrest

hypospermatogenesis

Table 3.20: Spermatogenesis and location of undescended testes
before operation


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In impalpable undescended testes group, maturation arrest was the most
popular accounted for 15/26 patients (57.7%). In palpable undescended
testes group, hypospermatogenesis was the most popular 50%
Table 3.21: The other changes of histology: one testis with
calcification, 97.8% testes with no other changes of histology.
3.4. Results of taking down testis
Average following-up time 14,3 ± 2,3 months (12 - 20 months).
Table 3.22: Location of undescended testet after ochidopexy, reexamination: The proportion of testis in scrotum was 80.1%, of in scrotum
root was 19.2%, of in shallow groin hole was 0.7%.
Table 3.23: Comparing volume of testis by ultrasound before and
after surgery
Volume of testicle
(cm3)
The right undescended testes /Unilateral
The left undescended testes/ Unilateral
The right undescended testes / Bilateral
The left undescended testes / Bilateral

(n=36)
LH (IU/l)
5.8±2.0
8.4±3.6


LH (IU/l)

11.6±6.0

8.4±3.6


Table 3.31: The success of operation
Operation outcome
Very Good
Good
Average
Bad
Total

Unilateral
cryptorchidism
n
%
8
15.1
30
56.6
15
28.3
0
0
53
100

Bilateral
cryptorchidism
n
%
4
11.1
7

in unilateral and 43.4% in bilateral cryptorchidism group. This result is
consistent with many domestic and foreign studies that do not suggest
that complications of cryptorchidism are erectile dysfunction.


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Table 3.3: Normal physical development was 96,1% (unilateral
cryptorchidism), 66,7% (bilateral cryptorchidism). This result fits in
Thai Minh Sam research.
Table 3.4: Comorbidities : inguinal herniation 10,7%; cyst of
epididymis 4,5%. According to Le Minh Trac, 26,7% patients with other
malformation, cordless cysts (19,1%) and inguinal herniation (2,7%).
4.2. Characteristics of cryptorchidism morphology
and function
4.2.1. Location
Graph 3.6: The proportion of palpable undescended testes was
37,2%, non-palpable was 62,8%. In other studies the proportion of nonpalpable was 20%.
Table 3.5: Undetectable of 5 testes (3,4%) in ultrasound. The
American Urology association, the ultrasound had the low specificity
and sensitivity in term of diagnosis of non-palpable undescended testes.
The difference could be explained by the clear anatomy of adult
patients, and the more large volume of testis. The prevalence of testis in
abdominal and inguinal was 23,6% and 25%. This results are different
with Le Minh Trac study, non-palpable testis was 37,7%,and the authors
conclude generally that most of the testicles are palpable
Table 3.6: CT scanner showed the same result in comparison with
ultrasound: The prevalence of abdominal testis was 33,9%; in the
inguinal was 30,4%. According to Tasian G.E., CT scanner had no role
in term of diagnosis.
Table 3.7: In comparison with ultrasound, the prevalence of

74,7%. This result differed than the Le Minh Trac study, in infants (1-2
years old): 92% normal density, 5% soft and fibrosis. It was supposed
that delay treatment lead to size down the testis.
4.2.4. The characteristics of epididymis in operation
Graph 3.7: 67 testes (45,9%) had epididymis with semilunar shape.
The normal connection of epididymis in Le Minh Trac study was
95,7%, the higher undescended testis was, the more abnormal exist.
4.2.5. The characteristics of testicular vessels
Graph 3.8: The stressed of testicular vessels was 56,8%, there were
2,1% testes only pulled down into proximal scrotum. It was caused by the
high of undescended testis, it was characterized with testis in adulthood.
There were difference with Thai Minh Sam study, the object was older and
not count on the age, hence 95,8% wasn’t tender, 4,2% slight tender.
Table 3.14: Almost stressed testicular vessels were high
undescended testes
4.2.6. Male hormone before operation
Table 3.15 There was a decrease of testosterone in bilateral
cryptorchidism affected than unilateral group affected (14,5±7,3
mmol/l, 17±5,9 mmol, respectively, p = 0,049). Thai Minh Sam also
showed the same result.


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According to many researched, LH and FSH in the unilateral
affected group was rarely changed. In contrast with bilateral affected,
even if testosterone changes or not. In unilateral affected group, LH
concentration was 6,7±2,6 IU/l (normal range), meanwhile FSH was
8,8±6,9 IU/l. In bilateral affected group, LH, FSH concentration
increased (11,6±5,9 IU/l and 22±13,7 IU/l) meanwhile testosteron was
normal (14,5±7,3 mmol/l).



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Table 3.19: 46 undescended testes were biopsy during operation in
which 20 testes were palpable and 26 impalpable testes. According to
Ho Minh Nguyet et al. showed that the histologic changes of
undescended testis had no realtionship to location of testis.
4.3.2. The spermatogenesis of undescended testes
Graph 3.11: The syndrome which only Sertoli cell, non spermatic
cell in seminiferous tubules 10,9% had the optimist prediction after
operation. Chung E. concluded that non spermatocyte at the operation
point was important prediction of infertility.
Maturation arrest was 50% testes in study. These patients could
have a good outcome if early operation.
The same outcome also happens in the group full of
spermatogenesis stage, but lower spermatocyte count (39,1%).
Table 3.20: The abnormal spermatogenesis happens same in both
low and high undescended testis group. This could be a characteristic of
undescended testis in adult, the change of histology appears no change
in the position of testis. Therefore, the result of this study showed the
difference that the different age leads to different the number of ductus
deferens and primary spermatocyte.
4.3.3. The histologic change of cryptorchidism testis
Table 3.21: One testis with calcification, no testis with malignancy change.
4.4. Assessing results of orchiopexy
4.4.1. Time of observation:
Average 14,3±2,3 months (12 - 20 months).
4.4.2. The location of undescended testes after
ochidopexy
Table 3.22: The prevalence of testes in scrotum was 80,1%, 19,2%

the above author because this is a group of patients in adulthood, a lot
of undescended testis high, short vessel, risk of nourishing testicles
After surgery, the failure of shrinking testicles after surgery is also a
success.
4.4.4. Male hormones after orchidopexy
Table 3.24: There are differences between the two groups of
unilateral and bilateral cryptorchidism patients of the three hormonal
indicators. The average LH, FSH in the bilateral groups were higher
(LH: 8.4 ± 3.6 IU / l and 5.8 ± 2.0 IU / l, p