Incidence at birth and natural history of cryptorchidism: a study of 10,730 consecutive male infants

Prevalence of congenital cryptorchidism in China: A nationwide population-based surveillance study, 2007-2021

BACKGROUND

Despite cryptorchidism being a common genital abnormality in male newborns with significant prevalence variations globally, there is a notable scarcity of epidemiological data on this condition in China.

OBJECTIVE

This study aimed to delineate the prevalence pattern of cryptorchidism in Chinese population over the past 15 years using nationwide surveillance data.

MATERIALS AND METHODS

Data from the China National Population-based Birth Defects Surveillance System (2007-2021) were analyzed to calculate the prevalence rates of cryptorchidism, stratified by birth year, maternal age, maternal residence, and geographic region. Adjusted prevalence rate ratios were computed using Poisson regression, while trends in prevalence and average annual percent change (AAPC) were assessed using the joinpoint regression model.

RESULTS

During the study period, a total of 1,833 cases of cryptorchidism were identified among 2,565,964 full-term male births, resulting in prevalence rates of 7.14, 5.60, and 1.54 per 10,000 births for overall, isolated, and associated cryptorchidism, respectively. The overall prevalence increased from 3.86 to 11.20 per 10,000 births, with an AAPC of 7.9% (95% confidence interval: 5.5-11.0). Significant variations were observed across maternal age (< 20 years, 7.62/10,000; 20-24 years, 6.14/10,000; 25-29 years, 6.96/10,000; 30-34 years, 7.48/10,000; ≥35 years, 9.22/10,000), maternal residence (urban vs. rural, 10.99/10,000 vs. 2.86/10,000), and geographic region (eastern, 12.38/10,000; central, 2.36/10,000; western, 2.63/10,000). Approximately one-third of cryptorchidism cases were bilaterally, while two-thirds were unilateral. Commonly observed associated abnormalities included congenital hydrocele testis, as well as anomalies in the genital organs, circulatory system, and musculoskeletal system.

CONCLUSION

Despite lower rates compared to other countries, the increasing trend in prevalence of cryptorchidism necessitates further investigation and intervention.

Expanded phenotype and cancer risk in patients with Beckwith-Wiedemann spectrum caused by CDKN1C variants

Beckwith-Wiedemann spectrum (BWSp) is caused by genetic and epigenetic alterations on chromosome 11 that regulate cell growth and division. Considering the diverse phenotypic landscape in BWSp, the characterization of the CDKN1C molecular subtype remains relatively limited. Here, we investigate the role of CDKN1C in the broader BWSp phenotype. Notably, patients with CDKN1C variants appear to exhibit a different tumor risk than other BWSp molecular subtypes. We performed a comprehensive literature review using the search term "CDKN1C Beckwith" to identify 113 cases of patients with molecularly confirmed CDKN1C-BWSp. We then assessed the genotype and phenotype in a novel cohort of patients with CDKN1C-BWSp enrolled in the BWS Research Registry. Cardinal and suggestive features were evaluated for all patients reported, and tumor risk was established based on available reports. The most common phenotypes included macroglossia, omphalocele, and ear creases/pits. Tumor types reported from the literature included neuroblastoma, acute lymphocytic leukemia, superficial spreading melanoma, and intratubular germ cell neoplasia. Overall, this study identifies unique features associated with CDKN1C variants in BWSp, enabling more accurate clinical management. The absence of Wilms tumor and hepatoblastoma suggests that screening for these tumors may not be necessary, while the neuroblastoma risk warrants appropriate screening recommendations.

Testicular volume at puberty in boys with congenital cryptorchidism randomised to treatment at different ages

AIM

To assess testicular volume at puberty for boys who underwent orchidopexy at 9 or at 36 months compared to boys with spontaneous postnatal descent.

METHODS

At age 6 months, boys with congenital unilateral cryptorchidism were randomised to surgery at 9 or 39 months of age and followed to 16 years in parallel with boys with spontaneous postnatal descent. Ultrasound was done at 11 and 16 years to determine testicular volume. The ratio of the initially undescended testis to its scrotal counterpart was used to assess testicular growth.

RESULTS

At age 16, the ratio was lower (p < 0.00) in the late group compared to the early group. At 16 years, the spontaneously descended testes were significantly smaller than their scrotal counterparts but larger than the operated groups (early p < 0.01 and late p < 0.00).

CONCLUSION

Our data at 16 years show that orchidopexy at 9 months results in better testicular growth compared to 3 years but did not reach the corresponding volumes of their scrotal counterparts. This indicates that earlier surgery is beneficial to testicular growth. At age 16, the postnatally descended testes were not only larger than the surgically treated testes but also exhibited impaired testicular growth.

The epidemiology of cryptorchidism and potential risk factors, including endocrine disrupting chemicals

Congenital cryptorchidism, also known as undescended testis, is the condition where one or both testes are not in place in the scrotum at birth and is one of the most common birth defects in boys. Temporal trends and geographic variation in the prevalence of cryptorchidism from 1% to 9% have been reported in prospective cohort studies. The testes develop in the abdominal cavity and descend to the scrotum in two phases, which should be completed by gestational week 35. Thus, the risk of cryptorchidism is higher in preterm boys. In many cases a spontaneous descent occurs during the first months of life during the surge of gonadotropins and testosterone. If not, the testis is usually brought down to the scrotum, typically by surgery, to increase future fertility chances and facilitate cancer surveillance. The increasing frequency of impaired semen quality and testicular cancer, with which cryptorchidism is associated, represents a concern for male reproductive health in general and a need to understand its risk factors. The risk of cryptorchidism is closely related to gestational factors (preterm birth, low birth weight and intrauterine growth restriction), and especially maternal smoking seems to be a risk factor. Evidence is accumulating that the increasing prevalence of cryptorchidism is also related to prenatal exposure to environmental chemicals, including endocrine disrupting compounds. This association has been corroborated in rodents and supported by ecological studies. Conducting human studies to assess the effect of endocrine disrupting chemicals and their interactions is, however, challenged by the widespread concomitant exposure of all humans to a wide range of chemicals, the combined effect of which and their interactions are highly complex.

CAG and GGN repeat polymorphisms in the androgen receptor gene of a Chilean pediatric cohort with idiopathic inguinal cryptorchidism

BACKGROUND

Cryptorchidism is one of the most common congenital disorders in boys and it is associated with a higher risk of sub-fertility and testicular cancer. Testicular descent occurs during embryo-fetal development in two phases, transabdominal and inguino-scrotal. In the latter process, androgens play a leading role. The androgen receptor has in its N-terminal domain, two aminoacidic repeats encoded by polymorphic nucleotide repetitions: (CAG)nCAA and GGN. The number of repetitions of these trinucleotides has been associated with different transactivation capacities and sensitivities of the androgen receptor response.

OBJECTIVE

To determine whether pediatric Chilean individuals with idiopathic inguinal cryptorchidism have a different number of CAG and/or GGN repeats polymorphisms compared with controls.

MATERIALS AND METHODS

A total of 109 cases with idiopathic inguinal cryptorchidism (26 bilateral and 83 unilateral) were studied by polymerase chain reaction amplification from DNA extracted from peripheral blood, followed by fragment size analysis by capillary electrophoresis, which were compared with 140 controls.

RESULTS

The CAG26 repeats allele was increased in the total cases (8.3% vs. 1.4%; p = 0.012; odds ratio = 6.21, 95% confidence interval 1.31-29.4), and in bilateral cases compared to controls (11.5% vs. 1.4%; p = 0.028; odds ratio = 9 CI 95% 1.43-56.8). Similarly, CAG > 22 alleles were increased in the total cases (62.4% vs. 49.3%, p = 0.041), and more significantly in bilateral cases (73.1% vs. 49.3%; p = 0.032; odds ratio = 2.79, 95% confidence interval 1.1-7.1). In addition, CAG < 18 alleles were not observed among cases, but were present in 5.7% of controls (p = 0.01). Regarding the GGN repeats, no differences were observed between cases and controls either when analyzing separately unilateral and bilateral cryptorchidism. The joint analysis of the distribution of CAG and GGN alleles showed that the CAG26 allele was present with GGN23, hence the combination CAG26/GGN23 alleles was equally increased in bilateral cases compared with controls (11.5% vs. 1.4%). In contrast, CAG < 18 was preferably observed in the combination CAG < 18/GGN≠23 and was absent in the total cases (4.3% vs. 0%; p = 0.037).

DISCUSSION

These results suggest that greater lengths of CAG alleles may contribute to a diminished androgen receptor function. The CAG26 allele alone or in combination with GGN23 was associated with a higher risk of bilateral cryptorchidism. On the other hand, CAG < 18 and the CAG < 18/GGN≠23 allele combination may reduce the probability of cryptorchidism.

Association between maternal use of spray formulations and offspring urological anomalies: The Japan Environment and Children's Study

OBJECTIVE

Concerns exist regarding the effects of maternal inhalation of household products on fetal health. This study aimed to clarify the impact of maternal exposure to household products, including spray formulations, on urological anomalies in offspring up to the age of 1 year.

METHODS

This study included data from 84 237 children from the Japan Environment and Children's Study, an ongoing nationwide cohort study. Using maternal self-report questionnaires, information on the use of organic solvents, waterproof sprays, insect-repellent sprays, insecticide sprays, and herbicides from implantation until the second or third trimester of pregnancy and data on urological anomalies were collected 1 year after delivery.

RESULTS

Urological anomalies occurred in 799 infants. Multivariate logistic regression analysis adjusted for maternal age, pregnancy body mass index, gestational diabetes, pre-existing maternal kidney disease, and preterm birth revealed no association between maternal exposure to organic solvents and the prevalence of offspring urological anomalies. Nevertheless, we observed significant associations between waterproof spray use during pregnancy and urological anomalies in boys (odds ratio [OR]: 1.28, 95% confidence interval [CI]: 1.03-1.59) and between the use of insecticide spray during pregnancy and urological anomalies in girls (OR: 1.48, 95% CI: 0.98-2.22). Sub-analysis revealed significant associations between waterproof spray use during pregnancy and vesicoureteral reflux in boys (OR: 2.14, 95% CI: 1.02-4.49) and between the use of insecticide spray during pregnancy and hydronephrosis in girls (OR: 2.23, 95% CI: 1.11-4.47).

CONCLUSION

Spray formulation use during pregnancy might increase the risk of urological anomalies in the offspring.

Mapping of referral patterns for undescended testes - Risk factors for referral of children with normal testes

BACKGROUND

Accurate referral of boys with suspected undescended testes (UDT) is of importance to preserve fertility and reduce risk of future testicular cancer. While late referral is well studied, there is less knowledge about incorrect referrals, hence, referral of boys with normal testes.

OBJECTIVE

To evaluate the proportion of UDT referrals that did not lead to surgery or follow-up, and to assess risk factors for referral of boys with normal testes.

STUDY DESIGN

All UDT referrals to a tertiary center of pediatric surgery during 2019-2020 were retrospectively assessed. Only children with suspected UDT in the referral (not suspected retractile testicles) were included. Primary outcome was normal testes at examination by a pediatric urologist. Independent variables were age, season, region of residence, referring care unit, referrer's educational level, referrer's findings, and ultrasound result. Risk factors for not needing surgery/follow-up were assessed with logistic regression and presented as adjusted odds ratios with a 95% confidence interval (aOR, [95% CI]).

RESULTS

A total of 378 out of 740 included boys (51.1%) had normal testes. Patients >4 years (aOR 0,53, 95% CI [0,30-0,94]), referrals from pediatric clinics (aOR 0.27, 95% CI [0.14-0.51]) or surgery clinics (aOR 0.06, 95% CI [0.01-0.38]) had lower risk of normal testes. Boys referred during spring (aOR 1.80, 95% CI [1.06-3.05]), by a non-specialist physician (aOR 1.58, 95% CI [1.01-2.48]) or referrer's description of bilateral UDT (aOR 2.34, 95% CI [1.58-3.45]), or retractile testes (aOR 6.99, 95% CI [3.61-13.55]) had higher risk of not needing surgery/follow-up. None of the referred boys that had normal testes had been re-admitted at the end of this study (October 2022).

DISCUSSION

Over 50% of boys referred for UDT had normal testes. This is higher or equal to previous reports. Efforts to reduce this rate should in our setting probably be directed towards well-child centers and training in examination of testicles. The main limitation of this study is the retrospective design and the rather short follow-up time, which however should have very modest effect on the main findings.

CONCLUSION

Over 50% of boys referred for UDT have normal testes. A national survey regarding the management and examination of boys testicles has been launched and directed at well-child centers to further evaluate the findings of the current study.

Cryptorchidism: The dog as a study model

Cryptorchidism (CO) or undescended testicle is an abnormality of male gonadal development that can generate long-term repercussions in men, such as infertility and germ cell neoplasia in situ (GCNIS). The origin of these alterations in humans is not completely clear, due to the absence of an animal model with similar testicular development as in humans with CO. This work intends to describe the testicular histological development of dogs with congenital CO, and determine whether the species could adequately serve as a study model for this pathology in humans. The study was carried out with 36 dogs, equally distributed in two groups: healthy control (CTRL) and CO groups. The contralateral testis to the undescended one in CO group of the animals was considered and analyzed. Each group was subdivided in three stages of development: (1) peripubertal stage (6–8 months), (2) young adult (9–48 months) and (3) senile (49–130 months). Histological development, the presence of cells with gonocyte morphology, cell proliferation, testicular lipoperoxidation and hormonal concentrations of testosterone, estradiol, FSH and LH were evaluated and described. In the cryptorchid testes, the first histological alterations appeared from the first stage of development and were maintained until the senile stage. A pronounced testicular lipoperoxidation occurred only in the second stage of development. The histological alterations due to CO were markedly evident in the young adult stage. Testosterone concentrations witnessed a decrease starting from in the second stage and kept on until the last stage. The contralateral testes of the CO animals showed alterations that positioned them between the control and CO testes. Testicular development of dogs with CO is similar to that of humans. The results of the study suggest that this species could serve as a suitable model for the study of CO in humans.

Association of PFKM gene polymorphisms and susceptibility to cryptorchidism in a Chinese Han population

BACKGROUND

Cryptorchidism is one of the most common congenital anomalies in newborn boys. There are various risk factors that have been verified to have relationship with cryptorchidism, including exogenous and genetic, but the pathogenesis of cryptorchidism remains unclear. PFKM gene is a critical gene encodes for a regulatory enzyme, which limits the rate in the pathway of glycolysis. We assumed that cryptorchidism risk may associated with PFKM gene single-nucleotide polymorphisms (SNPs). Thus we selected three tag SNPs in the PFKM gene and aimed to investigate the possible association between PFKM gene polymorphisms and cryptorchidism risk.

METHODS

The SNPs were genotyped using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis. 140 cases and 227 controls were enrolled in this study, including 105 unilateral cryptorchidism and 35 bilateral cases. The testis position was decided by the higher one in bilateral cases.

RESULTS

The frequency of allele G of SNP rs2228500 is increased in cryptorchidism patients compared to that in controls (p < 0.05). Genotypic frequencies of rs2228500 are associated with the susceptibility of cryptorchidism in the codominant model (p < 0.05). And compared with G/G genotype in the dominant model, notable decreased frequencies of A carriers (A/G-A/A genotypes) were observed in cryptorchidism patients (p = 0.0069, OR = 1.80, 95% CI  1.17-2.75).

CONCLUSIONS

This research first revealed that PFKM gene polymorphisms were associated with cryptorchidism in a Chinese Han population. We have offered primary evidence that the G allele and the G/G genotype of rs2228500 SNP in the PFKM gene are more frequent in patients with cryptorchidism than healthy controls.

Prevalence, management, and outcome of cryptorchidism associated with gastroschisis: A systematic review and meta-analysis

PURPOSE

Cryptorchidism associated with gastroschisis has been poorly investigated. We aimed to assess the prevalence of this association, and to address the management and outcome of cryptorchidism in this context.

MATERIALS AND METHODS

In this systematic review, we searched electronic databases (PubMed, Web of Science, and Google Scholar), without language restrictions from inception to March 31, 2021, for studies on cryptorchidism and gastroschisis co-occurrence. Random effects meta-analysis was used to calculate pooled prevalence estimates of cryptorchidism in gastroschisis and spontaneous testicular descent in this population.

RESULTS

Twenty-five studies were included for the systematic review. All were retrospective case reports or series for a total of 175 patients. Pooled prevalence estimate for cryptorchidism in gastroschisis was 19% (95% CI 13-26). Complete data sets for management and outcome analysis were available in 94 patients, involving 120 undescended testes [63 (52.5%) nonpalpable, 34 (28.3%) prolapsed outside the abdominal wall defect, and 23 (19.2%) palpable]. Fifty-five descended spontaneously, with a pooled prevalence estimate of 50% (95% CI 31-69). Twelve testes/remnants were primarily removed or absent, while 49 testes underwent orchiopexy (success rate, 63%). Excluding 4 testes still awaiting orchiopexy, 30 of the remaining 116 (25.8%) testes had a dismal outcome, including testicular loss (19), hypoplasia (8) or recurrent cryptorchidism (3).

CONCLUSION

Cryptorchidism in gastroschisis appears to occur more frequently than in the normal population. The overall mediocre testicular outcome seems to reflect the most unfavorable presentation of cryptorchidism in gastroschisis, which is represented by originally intrabdominal or prolapsed testis in the majority of cases.

LEVEL OF EVIDENCE

IV.

Masculinizing surgery in disorders/differences of sex development: clinician- and participant-evaluated appearance and function

OBJECTIVES

To report the long-term follow-up outcomes of masculinizing surgery in disorders/differences of sex development (DSD), including both physicians' and patients' perspectives on appearance and functional outcome, including sexuality.

PATIENTS AND METHODS

In total, 1040 adolescents (age ≥16 years) and adults with a DSD took part in this multicentre cross-sectional clinical study in six European countries in 2014/2015. Of those, 150 living in other than the female gender had some kind of masculinizing surgery: hypospadias repair, orchidopexy, breast reduction and/or gonadectomy. The study protocol included medical data collection, an optional genital examination, and patient-reported outcomes including satisfaction with appearance and current sexual functioning.

RESULTS

Diagnoses included partial and mixed gonadal dysgenesis (45,XO/46,XY; n = 38), Klinefelter syndrome/46,XX males (n = 57), and various 46,XY DSDs (n = 42; e.g. partial androgen insensitivity syndrome, severe hypospadias) and 13 with other diagnoses. Of the participants, 84 underwent hypospadias surgery, 86 orchidopexy, 52 gonadectomy and 32 breast reduction (combinations possible). Physicians evaluated anatomical appearance at genital examination as poor in approximately 11% of patients. After hypospadias surgery, 38% of participants reported that they were (very) dissatisfied with anatomical appearance and 20% with function. The physician and patient evaluations were moderately correlated (r = 0.43).

CONCLUSION

The majority of participants were neutral to satisfied with the appearance and function in the long-term after masculinizing surgery. Given the initial severe phenotype and a risk of unsatisfactory results after masculinizing surgery in DSD, treatment should be handled by experienced multidisciplinary teams in order to optimize the postoperative results.

The fat anchor orchiopexy technique: results and outcomes from 150 cases surgical experience

PURPOSE

The purpose of the study is to evaluate results and outcomes in a long-time follow-up period, by performing a novel testicular fixation procedure, known as "fat anchor orchidopexy" (FAO), for the treatment of palpable low inguinal undescended testis.

MATERIALS AND METHODS

We retrospectively reviewed all patients who underwent scrotal orchiopexy technique, from May 2013 to May 2019, at the Pediatric Surgery Division of Department of Surgical Pathology, University of Pisa (Italy). FAO (Spinelli's technique) consists in anchoring the testicles to sub-scrotal fat with a single trans-scrotal incision. All the patients enrolled had history of unilateral or bilateral undescended testis. Data collected included patient's age, operative times and complications.

RESULTS

A total of 150 children with cryptorchidism were treated using a single trans-scrotal orchiopexy. Of them, 130 patients (86.7%) had unilateral undescended testis and 20 (13.3%) bilateral cryptorchidism. Mean patient's age was 21 months (range: 14-28 months). All the procedures were planned in a day-surgery setting. Trans-scrotal orchiopexy was successful in all cases and no patients required an additional groin incision. No intraoperatively and postoperatively major complications were observed. Patients' post-operative pain was mild (mean pediatric visual analog scale = 2). In all cases, the healing process was rapid and no surgical wounds infections were reported during the post-operative period, referring excellent cosmesis results. During a mean 48-month follow-up period, no testicular retraction, recurrence or testis atrophy was reported.

CONCLUSION

The original Spinelli's technique (FAO) proves to be a safe and effective method for the treatment of palpable or distal-to-external-inguinal-ring testes. No immediate and delayed post-surgery complications were reported. In all cases, the anchored testicle remained in the scrotal position with normal vascularization. This novel surgical technique could give better options for scrotal fixation in case of low-lying cryptorchid testes.

Current concepts surrounding neonatal hormone therapy for boys with congenital hypogonadotropic hypogonadism

INTRODUCTION

Congenital hypogonadotropic hypogonadism (CHH) is a genetic disorder of reproduction and development, characterized by deficient gonadotropin-releasing hormone (GnRH) secretion or action, affecting 1-in-4,000-15,000 males. Micropenis and undescended testes are cardinal features of antenatal GnRH deficiency and could indicate absent minipuberty in the first postnatal months. In this review, we outline the pathophysiology and clinical consequences of absent minipuberty and its implications for optimal approaches to the endocrine management of affected boys.

AREAS COVERED

Deficient GnRH activity during fetal development and neonatal-infancy phase of minipuberty accounts for the diminished mass of Sertoli cells and seminiferous tubules among CHH males, enduring impairment of reproductive function even during gonadotropin replacement in adult life. In overcoming this obstacle, several clinical studies of neonatal gonadotropin replacement have consistently shown positive results in inducing testicular development and correcting cryptorchidism.

EXPERT OPINION

A high index of clinical suspicion, combined with hormonal testing undertaken in the postnatal period of 1-4 months, can reliably confirm or refute the diagnosis of CHH. Timely identification of CHH in affected male infants (having characteristic "red flag' developmental anomalies) opens up the possibility for gonadotropin replacement as a targeted therapy to restore the normal hormonal milieu of minipuberty. Further work is necessary in formulating optimal gonadotropin treatment regimens to be more widely adopted in clinical practice.

Recent advancement in the treatment of boys and adolescents with hypogonadism

Clinical manifestations and the need for treatment varies according to age in males with hypogonadism. Early foetal-onset hypogonadism results in disorders of sex development (DSD) presenting with undervirilised genitalia whereas hypogonadism established later in foetal life presents with micropenis, cryptorchidism and/or micro-orchidism. After the period of neonatal activation of the gonadal axis has waned, the diagnosis of hypogonadism is challenging because androgen deficiency is not apparent until the age of puberty. Then, the differential diagnosis between constitutional delay of puberty and central hypogonadism may be difficult. During infancy and childhood, treatment is usually sought because of micropenis and/or cryptorchidism, whereas lack of pubertal development and relative short stature are the main complaints in teenagers. Testosterone therapy has been the standard, although off-label, in the vast majority of cases. However, more recently alternative therapies have been tested: aromatase inhibitors to induce the hypothalamic-pituitary-testicular axis in boys with constitutional delay of puberty and replacement with GnRH or gonadotrophins in those with central hypogonadism. Furthermore, follicle-stimulating hormone (FSH) priming prior to hCG or luteinizing hormone (LH) treatment seems effective to induce an enhanced testicular enlargement. Although the rationale for gonadotrophin or GnRH treatment is based on mimicking normal physiology, long-term results are still needed to assess their impact on adult fertility.

Genetics of cryptorchidism and testicular regression

Cryptorchidism, i.e., undescended testis, is one of the most common genital malformations in newborn male babies. The birth rate of cryptorchidism varies from 1.6 to 9.0 %. Etiology of disrupted testicular descent is complex and predisposing causes include genetic, hormonal, environmental, lifestyle and maternal factors. Testicular descent occurs in two major steps and testicular hormones and normal function of hypothalamic-pituitary-testicular axis are important for normal descent. Several gene mutations are associated with syndromic cryptorchidism but they are rarely found in boys with isolated undescended testis. Testicular regression can also cause an empty scrotum. Normal male genital phenotype indicates that the boy has had functioning testis during development. Torsion of the testis can cause testicular regression but in many cases the reason for vanishing testis remains elusive. In this narrative review we discuss genetics of cryptorchidism and testicular regression.

Prevalence of congenital cryptorchidism in Estonia

BACKGROUND

Cryptorchidism is one of the most common urogenital malformations. Cryptorchidism prevalence varies greatly in different countries and populations. The aim of the current study was to determine and analyse cryptorchidism prevalence in Estonia.

MATERIALS AND METHODS

During 2012-2015, all consecutively born 5014 boys at Tartu University Hospital were examined for cryptorchidism. All the subjects with cryptorchidism were followed up for at least 6 months to assess spontaneous testicular descent.

RESULTS

Note that 2.1% cases had one or both testicles undescended at birth, 1.6% cases at expected date of birth, 1% cases at 3 months of age, and 0.8% cases at the age of 6 months had cryptorchidism. Cryptorchidism prevalence at birth was higher in preterm boys (11.9%), boys of low birth weight (16.7%) and boys small for gestational age (14%) but was lower in full-term newborn boys (1.1%). During follow-up, testes descended spontaneously in 61.6% of boys, more commonly in prematurely born boys (92%) and boys with low gestational weight (93%) as compared to full-term cryptorchid boys (29.2%) and cryptorchid boys with normal birth weight (34%). At the age of 6 months, cryptorchidism prevalence was equalized in preterm boys (0.9%) and boys with low birth weight (1%) as compared to full-term boys (0.7%) and boys with normal birth weight (0.7%). Boys SGA required surgical intervention more commonly than boys with normal birth weight. Ethnically, cryptorchidism prevalence at birth was similar among Estonians and non-Estonians.

CONCLUSION

Our data revealed that cryptorchidism prevalence, especially in full-term boys, is lower in Estonia than reported in the other Nordic-Baltic countries and worldwide.

Usefulness of clinical factors for diagnosing and differentiating types of testicular malposition in boys: A retrospective study

OBJECTIVE

To investigate useful objective variables and factors supporting the diagnosis of retractile testis and cryptorchidism by primary care providers, including urologists.

METHODS

This retrospective study included 512 boys diagnosed with retractile testis or cryptorchidism at our institute. Boys with retractile testis were followed up and underwent orchiopexy once the testis became undescended, while boys with cryptorchidism underwent orchiopexy immediately. We investigated trends in the prevalence of testicular malposition and explored useful diagnostic factors for retractile testis and cryptorchidism.

RESULTS

Of 512 boys, 199 were diagnosed with retractile testis and 313 were diagnosed with cryptorchidism. Comparison of clinical information between retractile testis and cryptorchidism showed that age at diagnosis, laterality, and location of the testis were significantly different between the groups (P < 0.0001, P < 0.0001, and P < 0.0001, respectively). The comparison of surgical information also showed that epididymal abnormality and state of processus vaginalis is patency or closure were significantly different between the groups (P = 0.0088 and P = 0.0003, respectively). Multivariate analysis showed that diagnosis at age 0-1 years, unilaterality, and canalicular testis were predictive factors for cryptorchidism (P = 0.001, P < 0.0001, and P < 0.0001, respectively).

CONCLUSIONS

Age at diagnosis, laterality, and location of the testis could be factors to aid the diagnosis of retractile testis and cryptorchidism.

Referrals for Cryptorchidism: Analyzing for Quality from a Pre-COVID Dataset

OBJECTIVE

To identify risk factors associated with an inaccurate diagnosis, delayed referral, and/or inappropriate ultrasound in consecutive referrals for an undescended testicle (UDT).

METHODS

This study was approved by the institutional review board. Data was prospectively collected for all children referred to University of Oklahoma's pediatric urology service from August 2019 to February 2020. The data was imported into SAS vs 9.4 for analysis. We categorized the "quality" of referral by a point system using 3 factors (no previous ultrasound, ≤18 months, correct location). An optimal referral had an accurate testicular examination, was referred by 18 months of age, and no diagnostic ultrasound.

RESULTS

We collected 75 referrals. Thirty-nine (52.0%) had confirmed UDT, requiring surgery. Twenty-seven (69.2%) had an accurate initial examination. Forty-one (54.7%) were outside the optimal age. Thirty-four were considered low quality (0-1 qualities) and 41 were high quality (2-3 qualities). Seven (9.3%) were optimal (3/3 qualities). Referrals that needed intervention were statistically more likely to be higher quality.

CONCLUSION

Increased quality of UDT referrals directly correlated with the likelihood for treatment. This study reveals a need for more education on UDT referral in the community. By improving referring provider knowledge and skills, we can minimize unnecessary referrals.

Postnatal germ cell development in cryptorchid boys

Cryptorchidism is associated with infertility in adulthood. Early orchiopexy is suggested to reduce the risk. Information is lacking on the potential link between infant germ cell maturation and the risk of future infertility. The objective of the study was to evaluate age-related germ cell development in cryptorchidism. Immunostaining for markers of germ cell development (octamer-binding transcription factor 3/4 [OCT3/4], placental alkaline phosphatase [PLAP], KIT proto-oncogene [C-KIT], podoplanin [D2-40], Lin-28 homolog A [LIN28], and G antigen 7 [GAGE-7]) was performed in testicular biopsies from 40 cryptorchid boys aged 4-35 months. Germ cell numbers and distributions were evaluated in cross sections of seminiferous tubules, with and without immunostaining. OCT3/4, D2-40, and LIN28 were generally expressed in the early stages of germ cell development, as shown by positive expression in germ cells in the central region of seminiferous tubules. In contrast, PLAP and GAGE-7 were expressed in both central and peripheral parts of the tubules in the early stages of development and expressed mainly in a peripheral position with advancing age. Germ cell maturation was delayed in this study population as compared with that observed in our previous study on germ cell markers in a healthy population. The number of GAGE-7-positive germ cells per tubular cross section obtained by immunostaining was significantly higher than that obtained by standard hematoxylin and eosin staining. Double immunostaining revealed heterogeneity in germ cell development in cryptorchid testes. These results shed light on the pathophysiology of germ cell development in boys with cryptorchidism.

A narrative review of the history and evidence-base for the timing of orchidopexy for cryptorchidism

INTRODUCTION

Consensus recommendations for surgical management of cryptorchidism recommend orchidopexy between 6 and 18 months of age. The COVID-19 pandemic has impacted elective surgical scheduling.

OBJECTIVE

In response to the COVID-19 pandemic, we sought to review the available data regarding the natural history, surgical management, and infertility- and cancer-related risks associated with cryptorchid testes. The purpose of this review is to provide parents, referring providers, and surgeons with information to inform their decisions to proceed with or delay orchidopexy.

METHODS

A retrospective review and analysis of all available articles relevant to the natural history, surgical management, and infertility- and cancer-related risks of cryptorchidism present on PubMed, SCOPUS, and Cochrane Library was conducted.

RESULTS

The quality of historic literature pertaining to the effect of cryptorchidism on fertility and malignancy differ, with poorer data available on fertility. Cryptorchid testes may show histologic differences as early as birth, and some of these changes may have prognostic value in future fertility. Formerly unilateral cryptorchid men have slightly but not significantly reduced paternity rates compared to the general population. Cryptorchid testes have an increased risk of germ cell carcinogenesis, and robust data suggest the risk for malignancy in cryptorchid testes increases substantially after puberty.

CONCLUSION

The current body of evidence regarding the risks for future infertility and testicular cancer support the consensus recommendations for surgical correction of cryptorchidism between 6 and 18 months of age. During the uncertain time of the COVID-19 pandemic, decision for orchidopexy is a shared-decision between physician and parent. For an infant or young boy with a unilateral undescended testes, delaying orchidopexy several months until a time of decreased exposure risk is unlikely to result in substantial or sustained fertility or malignant risks.

Ambulatory Orchidopexy Is a Potential Solution to Improve the Rate of Timely Repair in Cryptorchid Boys: An 8 Year Retrospective Study of 4,972 Cases

Background: Cryptorchidism is the most common congenital anomaly in pediatric urology. Although early surgery on cryptorchid boys is recommended by pediatric urologists worldwide, the actual age at orchidopexy is often older than the recommended age. Our medical center has started performing ambulatory orchidopexy since March 2016 at the ambulatory surgery center. We aimed to investigate whether ambulatory orchidopexy can improve the timely repair rate. Methods: A retrospective analysis was conducted from 2012 to 2019 at our medical center. Ambulatory orchidopexy was started at our medical center on March 24, 2016. Boys born on or after September 24, 2015 were classified into the "with ambulatory medical resource" group, and boys born before September 24, 2014, were classified into the "without ambulatory medical resource" group. The timely repair rates were calculated and compared. Results: A total of 4,972 cryptorchidism cases were included in the final study. Approximately 33.0% of cryptorchid boys received timely surgery (orchidopexy by the age of 18 months), and only 6.8% of all cryptorchid boys underwent surgery before the age of 1 year. After the performance of ambulatory orchidopexy, the timely repair rate increased from 25.7 to 37.0% (P < 0.001), and the percentage of patients receiving surgery before the age of 1 year increased significantly from 3.5 to 8.6% (P < 0.001). The proportion of timely repair in patients with ambulatory medical resources was significantly higher than that in patients without ambulatory medical resources (15.6% vs. 58.2%, P < 0.001). Significant changes in the rate of surgery before 12 months of age were also found between the two groups (2.4% vs. 14.8%, P < 0.001). Conclusions: After the performance of ambulatory orchidopexy in our medical center, the rates of both timely repair and receiving surgery before the age of 1 year increased significantly. Ambulatory orchidopexy is a potential solution to improve the rate of timely repair in cryptorchid boys, and it is worthy of promotion in developing countries and regions.

Cytogenetic assessment of Iranian infertile men with undescended testis: A retrospective study

Objective:

Undescended testis (UDT) is a urogenital disease that affects fertility. This study looked into the cytogenetic abnormalities of Iranian infertile patients with UDT.

Methods:

Our study included 522 infertile patients with UDT (case group) and two control groups, one with 300 infertile men without UDT and another with 268 fertile men.

Results:

Chromosomal abnormalities were found in 45 patients with UDT (8.62%). Seven of the alterations were considered as normal features. Klinefelter syndrome and mosaicism were the most common anomalies. Chromosomal abnormalities were found in 31 infertile men in the control group (10.33%), 13 of which deemed normal and 18 (6%) anomalous. Nine chromosomal abnormalities were found in the second control group with fertile men (3.35%), six deemed normal and three (1.11%) anomalous.

Conclusion:

Despite the high rate of abnormalities in infertile controls (6%) and the higher rate seen in infertile individuals with UDT indicate a significant prevalence of chromosomal abnormalities in the Iranian population, particularly when the literature suggests that the normal rate of abnormal karyotypes should be within the 0.7-1% range in the general population. The incidence of abnormal karyotypes increased when infertile patients had additional conditions such as UDT.

Trends in the Treatment Outcomes and Features of Cryptorchidism in Boys: A Single-Institute Experience

Purpose

Cryptorchidism is one of the most common congenital abnormalities in pediatric urology, and orchiopexy is performed for the prevention of testicular damage and malignant transformation. We examined the distribution and outcomes of cryptorchidism under a single investigator at our institute.

Patients and Methods

This retrospective study included 283 boys diagnosed with cryptorchidism at our institute. Cryptorchidism was diagnosed based on the medical history and physical examination findings. Boys without spontaneous resolution after 6 months of age were indicated for orchiopexy. We investigated the 12-year trend in the distribution and outcomes of cryptorchidism at the institute.

Results

The mean age at diagnosis, gestational age, and birth weight were 2 years, 37 weeks, and 2740 g, respectively. A total of 170 boys underwent orchiopexy under 2 years of age, and 136 boys underwent orchiopexy under the age of 1 year, while 62 boys underwent orchiopexy over the age of 3 years. Abnormalities of the epididymis and disclosure of the processus vaginalis were observed in 44 (25%) and 72 boys (41%), respectively. Comparison of boys with or without hypospadias showed that the age at orchiopexy was higher in boys with hypospadias than in those without hypospadias (P=0.028). In addition, boys without hypospadias had a higher rate of abnormality of the epidermis than those with hypospadias (P=0.024).

Conclusion

Our findings suggest that most boys with cryptorchidism are treated under the age of 2 years and the incidence of epididymal abnormality is relatively high, especially in boys with hypospadias. An understanding of the natural features of cryptorchidism could lead to better management and outcomes. Further research is warranted to develop an appropriate treatment timeline in boys with cryptorchidism.

[German guideline on undescended testis-what is relevant in daily routine?]

With an incidence of 0.7-3% in male infants, undescended testicles is one of the most common congenital anomalies. In the first 6 months of life, the testicles may spontaneously descend in up to 70% of individuals. If the testicle is not in a scrotal position afterwards, fertility can gradually be reduced and the risk of a testicular tumor increases. Therefore, the current German guideline for undescended testis recommends that therapy should be take place between 6 and 12 months of life. After extensive information on the advantages and disadvantages, hormone therapy with the aim of a descensus or in those with bilateral anomaly with the aim of improving the germ cell pool can be offered. After the first year of life, hormone therapy is obsolete. Otherwise, surgical intervention is the treatment of choice. In the case of gliding or deep inguinal testis via scrotal or inguinal access, in the case of nonpalpable and sonographically undetectable testis, laparoscopy is carried out for diagnosis and simultaneous therapy. In the first postoperative year, adequate follow-up should be done to detect a re-ascensus and/or insufficient growth. Regular self-examinations from the age of 15 serve for the early detection of a testicular tumor that occurs only very rarely (approximately 0.003%).

["Uncomplicated" inguinal testis : How practicable are the guidelines?]

It has been known for more than 20 years that early treatment of maldescended testicles can have a positive effect on fertility and a negative effect on the development of tumors. In certain circumstances, hormone therapy is still recommended in German-speaking countries. However, its benefit is still controversially discussed. Therapy is usually initiated by the pediatrician, who is usually the first to detect undescended testicles. Since therapy may involve early hormone therapy as well as surgery, acceptance among pediatricians and also the parents may be reduced. The question also arises as to how far the implementation is practicable. In patients with nonpalpable testis, there are many controversies concerning the value of ultrasound investigations. In the following two case studies, the treatment decisions for undescended testes in infancy are exemplified. Furthermore, the available evidence from the literature and guidelines is presented to provide assistance for daily routine care and to critically discuss potential fields of application and limitations of existing guidelines.

Urologic conditions associated with malignancy

INTRODUCTION

Recent advances in cancer research have highlighted the role of genetics in malignancy. Genetic dysregulation of core cellular functions similarly influences benign conditions. These common genetic factors have led researchers to identify an association between certain urologic conditions and malignancy. The objective of this review is to evaluate the literature linking benign urologic conditions including male infertility, Peyronie's disease, cryptorchidism, and hypospadias, to malignancy.

METHODS

A search of PubMed was performed using the following search terms and their combinations: male infertility, female infertility, cancer, malignancy, mortality, male urologic conditions, azoospermia, Peyronie's disease, cryptorchidism, hypospadias, and genetics. Studies were assessed for quality and included or excluded based on study design and relevance to the topic of urologic conditions and malignancy.

RESULTS

A total of 52 studies were evaluated, of which 38 were included. Associations between male infertility and testicular cancer, prostate cancer, and other cancers including melanoma, bladder cancer, and thyroid cancer were examined. Several genetic alterations were found to be common in the pathogenesis of both male infertility and carcinogenesis. Associations between female infertility and breast, ovarian, and endometrial cancer are also assessed, as are the relationships between Peyronie's disease, cryptorchidism, and hypospadias and malignancy.

CONCLUSIONS

Recent work has identified associations between a number of malignancies and benign urologic conditions including male infertility, Peyronie's disease, cryptorchidism, and hypospadias. Molecular and genetic mechanisms have been proposed, but no definitive causal relationships have been identified to date. Future work will continue to better define the links between malignancy and benign urologic conditions and ultimately facilitate risk stratification, screening, and treatment of affected men.

Congenital Hypogonadotrophic Hypogonadism: Minipuberty and the Case for Neonatal Diagnosis

Congenital hypogonadotrophic hypogonadism (CHH) is a rare but important etiology of pubertal failure and infertility, resulting from impaired gonadotrophin-releasing hormone secretion or action. Despite the availability of effective hormonal therapies, the majority of men with CHH experience unsatisfactory outcomes, including chronic psychosocial and reproductive sequelae. Early detection and timely interventions are crucial to address the gaps in medical care and improve the outlook for these patients. In this paper, we review the clinical implications of missing minipuberty in CHH and therapeutic strategies that can modify the course of disease, as well as explore a targeted approach to identifying affected male infants by integrating clinical and biochemical data in the early postnatal months.

Cryptorchidism after the Fukushima Daiichi Nuclear Power Plant accident:causation or coincidence?

Cryptorchidism (undescended testes) is among the most common congenital diseases in male children. Although many factors have been linked to the incidence of cryptorchidism, and testicular androgen plays a key role in its pathogenesis, the cause remains unknown in most cases. Recently, a Japanese group published a speculative paper entitled, "Nationwide increase in cryptorchidism after the Fukushima nuclear accident." Although the authors implicated radionuclides emitted from the Fukushima accident as contributing to an increased incidence of cryptorchidism, they failed to establish biological plausibility for their hypothesis, and glossed over an abundance of evidence and expert opinion to the contrary. We assessed the adequacy of their study in terms of design setting, data analysis, and its conclusion from various perspectives. Numerous factors must be considered, including genetic, environmental, maternal/fetal, and social factors associated with the reporting of cryptorchidism. Other investigators have established that the doses of external and internal radiation exposure in both Fukushima prefecture and the whole of Japan after the accident are too low to affect testicular descent during fetal periods;thus, a putative association can be theoretically and empirically rejected. Alternative explanations exist for the reported estimates of increased cryptorchidism surgeries in the years following Japan's 2011 earthquake, tsunami, and nuclear crisis. Data from independent sources cast doubt on the extent to which cryptorchidism increased, if at all. In any case, evidence that radionuclides from the Fukushima Daiichi Nuclear Power Plant could cause cryptorchidism is lacking.

Use of ultrasound for the palpable undescended testis: a wasteful practice

BACKGROUND

Many primary care physicians order an ultrasound (US) before referral to specialist care for suspected undescended testis; however, the value of this practice is questionable.

OBJECTIVE

To determine the proportion of boys referred for suspected undescended testis who had accompanying US, the cost of this practice and the accuracy of US for testis localization when compared with physical examination by a pediatric urologist.

METHODS

This was a retrospective chart review at a pediatric urology service, including all patients referred for suspected undescended testis from 2008 to 2012. We determined the cost of US ordered, and calculated Cohen's kappa, sensitivity and specificity, and positive and negative predictive value.

RESULTS

We identified 894 eligible patients; 32% (289/894) were accompanied by US. In 77% (223/289), the urologist was able to palpate the testis: 51% (147/289) had a normal/retractile testis and 26% (76/289) had a palpable undescended testis. At a cost of 71.10 CAD per US, 20 547.90 CAD was expended on this practice. Of the 223 patients with palpable testes, we were able to gather detailed US and physical examination results for 214 patients. Cohen's kappa was 0.06 (95% CI -0.005, 0.11; P = 0.10). US had 92.8% sensitivity (95% CI 84.1, 96.9%) and 15.2% specificity (95% CI 10.2, 21.9%) to detect an undescended testis. The positive predictive value was 34.2% (95% CI 27.8, 41.3%), while the negative predictive value was 81.5% (95% CI 63.3, 91.8%).

CONCLUSIONS

Referral of patients for suspected undescended testis should not be accompanied by an US study as US is not useful in these cases.

Anti-Müllerian Hormone and Testicular Function in Prepubertal Boys With Cryptorchidism

INTRODUCTION

The functional capacity of the testes in prepubertal boys with cryptorchidism before treatment has received very little attention. The assessment of testicular function at diagnosis could be helpful in the understanding of the pathophysiology of cryptorchidism and in the evaluation of the effect of treatment. Anti-Müllerian hormone is a well-accepted Sertoli cell biomarker to evaluate testicular function during childhood without the need for stimulation tests.

OBJECTIVE

The aim of the study was to assess testicular function in prepubertal children with cryptorchidism before orchiopexy, by determining serum anti-Müllerian hormone (AMH). We also evaluated serum gonadotropins and testosterone and looked for associations between testicular function and the clinical characteristics of cryptorchidism.

MATERIALS AND METHODS

We performed a retrospective, cross-sectional, analytical study at a tertiary pediatric public hospital. All clinical charts of patients admitted at the outpatient clinic, and recorded in our database with the diagnosis of cryptorchidism, were eligible. The main outcome measure of the study was the serum concentration of AMH. Secondary outcome measures were serum LH, FSH, and testosterone. For comparison, serum hormone levels from a normal population of 179 apparently normal prepubertal boys were used.

RESULTS

Out of 1,557 patients eligible in our database, 186 with bilateral and 124 with unilateral cryptorchidism were selected using a randomization software. Median AMH standard deviation score was below 0 in both the bilaterally and the unilaterally cryptorchid groups, indicating that testicular function was overall decreased in patients with cryptorchidism. Serum AMH was significantly lower in boys with bilateral cryptorchidism as compared with controls and unilaterally cryptorchid patients between 6 months and 1.9 years and between 2 and 8.9 years of age. Serum AMH below the normal range reflected testicular dysfunction in 9.5-36.5% of patients according to the age group in bilaterally cryptorchid boys and 6.3-16.7% in unilaterally cryptorchid boys. FSH was elevated in 8.1% and LH in 9.1% of boys with bilateral cryptorchidism, most of whom were anorchid. In patients with present testes, gonadotropins were only mildly elevated in less than 5% of the cases. Basal testosterone was mildly decreased in patients younger than 6 months old, and uninformative during childhood.

CONCLUSION

Prepubertal boys with cryptorchidism, especially those with bilaterally undescended gonads, have decreased AMH production. Although serum AMH may fall within the normal range, there is a considerable prevalence of testicular dysfunction during childhood in this frequent condition.

Risk factors for cryptorchidism

Undescended testis - known as cryptorchidism - is one of the most common congenital abnormalities observed in boys, and is one of the few known risk factors for testicular cancer. The key factors that contribute to the occurrence of cryptorchidism remain elusive. Testicular descent is thought to occur during two hormonally-controlled phases in fetal development - between 8-15 weeks (the first phase of decent) and 25-35 weeks gestation (the second phase of descent); the failure of a testis to descend permanently is probably caused by disruptions to one or both of these phases, but the causes and mechanisms of such disruptions are still unclear. A broad range of putative risk factors have been evaluated in relation to the development of cryptorchidism but their plausibility is still in question. Consistent evidence of an association with cryptorchidism exists for only a few factors, and in those cases in which evidence seems unequivocal the factor is likely to be a surrogate for the true causal exposure. The relative importance of each risk factor could vary considerably between mother-son pairs depending on an array of genetic, maternal, placental and fetal factors - all of which could vary between regions. Thus, the role of causative factors in aetiology of cryptorchidism requires further research.

Age at Surgery and Outcomes of an Undescended Testis

BACKGROUND

Undescended testis (UDT) is the most common genital anomaly in boys. Current guidelines recommend surgery before 12 months of age to maximize fertility and potentially reduce the risk of future malignancy. We investigated the prevalence of UDT and examined rates of surgery and age at surgery in an Australian population.

METHODS

UDT was identified from all live-born infants in New South Wales, Australia, from 2001 to 2011 using routinely collected record-linked birth and hospital data. The prevalence of UDT, surgery rates, age at surgery, postsurgical outcomes, and risk factors for surgery performed later than the recommended age were evaluated.

RESULTS

There were 10 875 (2.1%) boys with a recorded diagnosis of UDT. Corrective surgery was performed in 4980 (45.8%), representing a cumulative prevalence of 9.6 per 1000 male births. Five percent of surgeries were orchidectomies, and 9% of boys had revision surgery. Median age at surgery was 16.6 months (interquartile range 11.8 to 31.0 months), decreasing from 21 months for boys born in 2001 to 13 months for boys born in 2010. Among those boys having surgery before 36 months (n = 3897), 67% had corrective surgery after the recommended 12 months of age; socioeconomic disadvantage, regional/remote area of residence, and lack of private health insurance were risk factors for having corrective surgery after 12 months.

CONCLUSIONS

One in 50 boys born are diagnosed with UDT; two-thirds had no report of corrective surgery. The age at surgery is decreasing; however, two-thirds of surgeries are performed after 12 months of age.

Laparoscopic treatment for inguinal hernia combined with cryptorchidism: Totally extraperitoneal repair with orchiectomy under the same operative view

•

We treated two patients with right indirect inguinal hernias and cryptorchidism.

•

Both patients underwent TEP repair with orchiectomy under the same operative view.

•

TEP repair with orchiectomy could be safely performed.

•

This procedure could be an option for the treatment of such adult patients.

Introduction

Approximately 7% of child patients with inguinal hernias also present with cryptorchidism. On the other hand, combined adult cases are uncommon. Here we report two adult cases of inguinal hernia combined with intra-canalicular cryptorchidism who underwent totally extraperitoneal (TEP) repair with orchiectomy under the same operative view.

Presentation of cases

We treated two patients (49- and 38-year-old men) with right indirect inguinal hernias and cryptorchidism. Both patients underwent TEP repair with orchiectomy. In operative findings, an atrophic testis was drawn out with a hernia sac from the internal inguinal ring. After the testis was separated from the sac and cord structure was sheared, it was removed. The procedure did not require special techniques and devices. In both patients, the postoperative courses were satisfactory.

Discussion

To our knowledge, there has been only one such reported case till date which demonstrated the feasibility of TEP repair accompanied by orchiectomy.

Conclusions

TEP repair with orchiectomy under the same operative view could be safely performed in adults with an inguinal hernia combined with extra-abdominal cryptorchidism. This procedure could be an option for the treatment of such adult patients.

Association between levels of persistent organic pollutants in adipose tissue and cryptorchidism in early childhood: a case-control study

BACKGROUND

Congenital cryptorchidism, i.e. failure of the testicular descent to the bottom of the scrotum, is a common birth defect. The evidence from epidemiological, wildlife, and animal studies suggests that exposure to mixtures of endocrine disrupting chemicals during fetal development may play a role in its pathogenesis. We aimed to assess the association between cryptorchidism and prenatal exposure to polychlorinated biphenyls (PCBs), polychlorinated dibenzo-p-dioxins and furans (PCDD/Fs), and polybrominated diphenyl ethers (PBDEs).

METHODS

We conducted a case-control study consisting of 44 cryptorchid cases, and 38 controls operated for inguinal hernia, umbilical hernia, or hydrocele at the Turku University Hospital or Rigshospitalet, Copenhagen in 2002-2006. During the operation a subcutaneous adipose tissue biopsy was taken. Samples were analysed for 37 PCBs, 17 PCDD/Fs and 14 PBDEs by gas chromatography-high-resolution mass spectrometry. Chemical concentrations were adjusted for postnatal variation introduced by differences in duration of breastfeeding, age at the operation, and country of origin with a multiple linear regression. Association between adjusted and unadjusted chemical concentrations and the risk of cryptorchidism were analysed with logistic regression to get an estimate for odds ratio (OR) of cryptorchidism per multiplication of chemical concentrations with ca. 2.71 (Napier's constant).

RESULTS

Total-TEq i.e. the WHO-recommended 2,3,7,8-TCDD equivalent quantity of 17 dioxins and 12 dioxin-like PCBs and sum of PCDD/Fs were positively associated with cryptorchidism [OR 3.21 (95% CI 1.29-9.09), OR 3.69 (95% CI 1.45-10.9), respectively], when adjusting for country of origin, the duration the child was breastfed, and age at operation. The association between the sum of PCBs and cryptorchidism was close to significant [OR 1.92 (95% CI 0.98-4.01)], whereas the association between the sum of PBDEs and cryptorchidism was not [OR 0.86 (95% CI 0.47-1.54)]. There were no associations between unadjusted chemical concentrations and the risk of cryptorchidism.

CONCLUSIONS

Prenatal exposure to PCDD/Fs and PCDD/F-like PCBs may be associated with increased risk for cryptorchidism. Our finding does not exclude the possibility of an association between the exposure to PBDEs and cryptorchidism.

Effects on normalized testicular atrophy index (TAIn) in cryptorchid infants treated with GnRHa pre and post-operative vs surgery alone: a prospective randomized trial and long-term follow-up on 62 cases

PURPOSE

The aim of this study was to investigate the effects of gonadotropin releasing hormone analog (GnRHa) therapy on normalized testicular atrophy index (TAIn) using gonadorelin before and after orchiopexy.

METHODS

62 infants with 87 undescended testes (UDT) were prospectively assigned to two homogeneous groups according to age, position of UDT and TAIn. The patients were randomized to receive either orchiopexy alone or orchiopexy combined with GnRHa as nasal spray at 1.2 mg daily for 4 weeks before surgery and 4 weeks after surgery. Surgical approaches were relative to the position of the UDT: Shoemakers technique in proximal-UDT and Bianchi technique in distal-UDT. All the patients were evaluated clinically and sonographically 1 month before surgery, at the time of surgery, 1 month, 6 months and 5 years after surgery.

RESULTS

Ultrasound data in our study have shown a statistically significant decrease of TAIn in children given additional HT only after 5 years of follow-up, in unilateral cases and in the entirety of treated patients; in bilateral cases this difference was not statistically significant.

CONCLUSION

Patients with a TAIn >20% treated with preoperative and post-operative GnRHa therapy have a significant increase in testicular volume after 5 years of follow-up, as shown by the relative reduction of TAIn values.

The timing of surgery for undescended testis - a retrospective multicenter analysis

BACKGROUND

n Germany, it is recommended that the surgical treatment of an undescended testis should be carried out between the ages of 6 months and 1 year to lower the risks of subfertility and testicular carcinoma. Although this recommendation has appeared in the German guidelines from 2007 onward, orchidopexy is still frequently performed at later ages.

METHOD

We retrospectively analyzed data from seven pediatric surgical services in the German state of Baden-Württemberg on all boys who underwent orchidopexy from 2009 to 2012. We classified the timing of surgery as Age Group I (before the first birthday), Age Group II (between the first and second birthdays), and Age Group III (after the second birthday). We determined whether preoperative hormonal treatment was given and distinguished primary from secondary undescended testis.

RESULTS

Among 2213 boys who underwent orchidopexy, 1850 had primary and 363 had secondary undescended testis. Of those with primary undescended testis, the percentages of boys who underwent surgery in Age Groups I, II, and III were (respectively, with 95% confidence intervals): 18.7% (17-20.6%), 24.4% (22.5-26.5%), and 57% (54.6-59.2%). A small percentage of boys in each group also received preoperative hormonal treatment. From 2009 to 2012, there was a secular trend favoring earlier orchidopexy. In 2012, 28 boys (14.2% [9.7-20.0%]) had orchidopexy in outpatient pediatric surgery practices before their first birthday, while 68 did on hospital inpatient services (40.7% [33.2-48.6%]).

CONCLUSION

Most of the patients studied had surgery at a later age than recommended. Adherence to the guidelines in this respect is nonetheless relatively good in Germany compared to other countries, as studies from abroad have yielded findings that are just as bad or worse.

Epididymal-testicular fusion anomalies in cryptorchidism are associated with proximal location of the undescended testis and with a widely patent processus vaginalis

Past studies documented the presence of epididymal/testicular fusion anomalies and persistence of a patent processus vaginalis in a small case-series of cryptorchid and/or hydrocele patients. The primary aim of this study was to determine the prevalence of the epididymal/testicular anomalies in a series of more than 1000 cryptorchid patients compared with controls. Secondary aims were: (i) to investigate the association between the cryptorchidism and the patency of p. vaginalis; and (ii) to correlate the epididymal/testicular fusion anomalies with the position of the testis and with the patency of the p. vaginalis. The clinical and surgical data of 1002 cryptorchid patients and 230 controls were retrospectively retrieved and analysed. Epididymal/testicular fusion anomalies were classified as: (i) normal anatomy; (ii) minor anomalies; and (iii) major anomalies. Statistical analysis was performed using the Student's t-test and Chi-square tests. The prevalence of the epididymal/testicular fusion anomalies was higher in the cryptorchid group compared with that of the control group (minor and major anomalies in cryptorchids vs. controls, respectively: 42.2 vs. 5.6% and 9.3 vs. 1.6%, P < 0.0001). Moreover, we documented a correlation of these anomalies with a more proximal localization of the testis (minor and major anomalies in proximal vs. distal location of the testis, respectively: 62.5 vs. 34.8% and 19.1 vs. 6.3%, P < 0.0001) and with the persistence of a widely patent p. vaginalis (minor and major anomalies in widely patent p. vaginalis vs. narrow duct, respectively: 51.7 vs. 42.2 and 11.9% vs. 7.8%, P < 0.001). In conclusion, the epididymal/testicular fusion anomalies were strongly associated with cryptorchidism and the persistence of a widely patent peritoneal vaginal duct. Although it remains unclear whether these anomalies cause non-descent of the testis or, conversely, result from the cryptorchidism or from the persistence of a widely patent duct, our data re-enforce this association.

Cryptorchidism in Egyptian neonates

Cryptorchidism is one of the most common genital malformations in newborn males, but its etiology remains largely unknown. The observation of geographical variability in the prevalence of cryptorchidism suggests a role for environmental factors. The aim of this study was to determine the prevalence of this condition among Egyptian neonates.

METHODS

The initial study population comprised 1000 neonates recruited from El Galaa maternity teaching hospital. To determine the risk factors for cryptorchidism in Egypt, 40 healthy full term infants were selected randomly during the same time period as a control group.

RESULTS

Twenty-nine cases of cryptorchidism per 1000 newborn males were detected, i.e. a frequency of 2.9%; 10 (34.5%) had bilateral cryptorchidism while 19 (65.5%) had a unilateral lesion. Other congenital anomalies were detected in 5 (17.2%) of the cryptorchid newborns. Five factors were significantly associated with higher risk of cryptorchidism: gestational age of 37 weeks or less, birth weight equal to or less than 2.75 kg, cesarean delivery, steroid therapy and twin pregnancy. Using logistic regression, birth weight ≤ 2.75 kg was the only independent factor predicting cryptorchidism, with an odds ratio of 10.3 and 95% confidence interval of 2.9-36.4.

CONCLUSION

These results highlight low birth weight as the cardinal risk factor for cryptorchidism. A larger scale multi-centric study is needed to clearly identify all the risk factors for cryptorchidism in Egyptian neonates.

Shorter anogenital distance correlates with undescended testis: a detailed genital anthropometric analysis in human newborns

STUDY QUESTION

Are the anogenital distance (AGD) and stretched penile length (SPL) shorter in human newborn males with cryptorchidism?

SUMMARY ANSWER

AGD is significantly shorter in boys with undescended testis (UDT) and this correlation may indicate that both have a common antecedent early in gestation.

WHAT IS KNOWN ALREADY

Animal studies have reported a critical time period during early gestation termed the male programming window (MPW) where androgen deficiency results in reduced AGD and penile length, as well as cryptorchidism and hypospadias. Two pilot human studies have explored this association but these studies were small and heterogeneous with regard to age, race and had selection bias.

STUDY DESIGN, SIZE, DURATION

A prospective descriptive study involving measurement of AGD and SPL at birth in a racially homogenous sample of 1154 consecutive newborns was performed over a period of 6 months. All measurements were taken by a single trained observer (V.J.).

PARTICIPANTS/MATERIALS, SETTING, METHODS

All consecutively born male infants at a community hospital were classified as having descended and or UDT. Testicular position in the undescended group was graded as high scrotal, inguinal or non-palpable. AGD (from the centre of anus to the junction of the smooth and rugated skin of scrotum) and SPL were measured. The AGD index (AGDi) was calculated by dividing AGD by cube root of birthweight.

MAIN RESULTS AND THE ROLE OF CHANCE

Of the 1154 infants examined, 624 were males and 71 had UDT. AGD was significantly shorter in infants with UDT when compared with infants with descended testis (mean ± SD; 2.21 ± 0.36 versus 2.56 ± 0.31 cm; P < 0.001). AGDi was also significantly shorter in infants with UDT (mean ± SD; 1.68 ± 0.27 versus 1.81 ± 0.20 cm/kg⁻³; P < 0.001). Significance was maintained even when preterm (P < 0.001) and low birthweight boys (LBW) (P < 0.001) were excluded. SPL was also significantly shorter in infants with UDT (Mean ± SD; 3.08 ± 0.52 versus 3.31 ± 0.38 cm; P < 0.001) but the significance was not maintained when preterm (P = 0.119) and LBW boys (P = 0.666) were excluded. Birthweight, gestational age and length adjusted regression models showed significantly shorter AGD in infants with UDT, but SPL was not different. Infants with higher position of testis appeared to have a shorter AGD and SPL but the correlation did not reach statistical significance. No difference in AGD or SPL was noted between boys with unilateral and bilateral UDT.

LIMITATIONS, REASONS FOR CAUTION

The present study did not include data pertaining to maternal or newborn health status. Also parental drug exposure or occupational exposures to endocrine-disrupting chemicals was not studied. These may possibly affect genital anthropometric measurements.

WIDER IMPLICATIONS OF THE FINDINGS

The study strengthens the hypothesis of existence of MPW in humans. Shorter AGD in cryptorchid infants may reflect the effect of androgen disruption or deficiency during MPW. AGD may be a more reliable non-invasive marker of androgen action during MPW than SPL to predict reproductive outcomes in humans.

Management of undescended testis: a decision analysis

BACKGROUND

Undescended testis (UDT) or cryptorchidism is the most common genital anomaly seen in boys and can be treated surgically by orchidopexy. The age at which orchidopexy should be performed is controversial for both congenital and acquired UDT.

METHODS

A decision analysis is performed in which all available knowledge is combined to assess the outcomes of orchidopexy at different ages.

RESULTS

Without surgery, unilateral congenital UDT and bilateral congenital UDT are associated with average losses in quality-adjusted life-years (QALYs) of 1.53 QALYs (3% discounting 0.66 QALYs) and 5.23 QALYs (1.91 QALYs), respectively. Surgery reduces this QALY loss to on average 0.84 QALYs (0.21 QALYs) for unilateral UDT and 1.66 QALYs (0.40 QALYs) for bilateral UDT. Surgery at detection will lead to the lowest QALY loss of 0.91 (0.34) and 1.73 (0.60) QALYs, respectively, for unilateral and bilateral acquired UDT compared with surgery during puberty and no surgery. No sensitivity analysis is able to change the preferences for these strategies.

CONCLUSIONS

Based on our decision analytic model using societal valuations of health outcomes, surgery for unilateral UDT (both congenital and acquired) yielded the lowest loss in QALYs. Given the modest differences in outcomes, there is room for patient (or parent) preference with respect to the performance and timing of surgery in case of unilateral UDT. For bilateral UDT (both congenital and acquired), orchidopexy at any age provides considerable benefit, in particular through improved fertility. As there is no strong effect of timing, the age at which orchidopexy is performed should be discussed with the parents and the patient. More clinical evidence on issues related to timing may in the future modify these results and hence this advice.

Vitamins e and C alleviate the germ cell loss and oxidative stress in cryptorchidism when administered separately but not when combined in rats

The antioxidant effects of vitamins C and E on cryptorchidism-induced oxidative stress were investigated in male Sprague-Dawley rats. Forty rats (200-250 g) were randomly divided in a blinded fashion into five groups (n = 8). Group 1 was sham operated and treated with vehicle (corn-oil, 10 mL/kg). Groups 2, 3, 4, and 5 were rendered unilaterally cryptorchid and treated with vehicle (10 mL/kg), vitamin E solution (75 mg/kg), vitamin C solution (1.25 g/kg), and combination of vitamin E (75 mg/kg) and vitamin C (1.25 g/kg) solutions, respectively. Germ cell count, superoxide dismutase (SOD), total protein (TP), and testicular weight (TW) were lower, but malondialdhyde (MDA) was higher in the cryptorchid rats than the sham-operated rats. When administered separately, vitamins C and E increased germ cell count, SOD, TP, and TW but did not reduce MDA in the cryptorchid rats when compared to the vehicle-treated cryptorchid rats. However, there was no significant difference in these parameters between vehicle-treated and combined vitamins C- and E-treated rats. This suggests that vitamins E and C alleviate the germ cell loss and oxidative stress in cryptorchidism when administered separately but not when combined in rats.