Results of orchiopexy for the undescended testis

The role of the resistive index in predicting testicular atrophy after orchiopexy in unilateral undescended testis

PURPOSE

One of the most important complications of undescended testis (UDT) surgery is testicular atrophy (TA). We aimed to investigate the factors associated with TA in children who underwent orchiopexy for unilateral UDT.

METHODS

The data of 215 patients aged < 15 years who underwent orchiopexy for unilateral UDT between November 2019 and September 2022 were analyzed retrospectively. Clinical, radiological, surgical, and follow-up findings were recorded.

RESULTS

TA was observed in 29 (13.5%) patients. Mean resistive index (RI) values were 0.44 ± 0.06, 0.54 ± 0.09 and 0.69 ± 0.1 in low, middle and high testicular locations, respectively, and intratesticular RI increased significantly as the testis location raised (p < 0.001). After orchiopexy, the mean testis volume ratio (TVR) increased significantly (0.63 ± 0.13 vs. 0.77 ± 0.15, p < 0.001). Besides, the mean RI values decreased significantly in the postoperative follow-up (0.53 ± 0.12 vs. 0.47 ± 0.13, p < 0.001). In multivariate regression analysis, testicular high location (OR 4.332, 95% CI 2.244-6.578, p = 0.002), deferens-epididymal anomaly (OR 3.134, 95% CI 1.345-7.146, p = 0.021), TVR ≤ 0.5 (OR 5.679, 95% CI 2.953-12.892, p < 0.001) and RI ≥ 0.6 (OR 7.158, 95% CI 3.936-14.569, p < 0.001) were independent predictive factors for TA after orchiopexy.

CONCLUSION

Higher testis location, deferens-epididymis anomaly, preoperative TVR and RI were independent predictive factors for TA after orchiopexy in unilateral UDT. The results of the study will help surgeons to predict TA before orchiopexy.

Open Versus Laparoscopic Gubernaculum-Sparing Second-Stage Fowler-Stephens Orchiopexy for Intra-Abdominal Testis: A Long-Term Study

Background:

The benefits of performing open versus laparoscopic gubernaculum-sparing second-stage Fowler–Stephens orchiopexy (FSO) remain unclear. We compared the two techniques to answer this question.

Methods:

We retrospectively studied a cohort of patients who underwent laparoscopic first-stage FSO and open versus laparoscopic gubernaculum-sparing second-stage FSO at our institution between September 2004 and June 2020 (all patients underwent surgery by a single surgeon). We evaluated both procedures based on the incidence of testicular atrophy, testicular ascent, and other complications.

Results:

The age at initial surgery was 45.7 ± 28.2 months (median, 39). One hundred nine cases were treated with open second-stage gubernaculum-sparing FSO (OFSO), and 96 cases were treated with laparoscopic second-stage gubernaculum-sparing FSO (LFSO). The mean follow-up period was 59.8 months (median, 54; standard deviation, +35). The overall testicular atrophy rate was 1.5%. Atrophy was observed in 2 and 1 patient in the OFSO and LFSO groups, respectively (1.8% versus 1.0%, P > .05). There was no significant difference in the incidence of testicular ascent between both groups (2.8% versus 3.1%). Five and four complications were noted in the OFSO and LFSO groups, respectively (P > .05).

Conclusions:

Second-stage gubernaculum-sparing FSO achieved high testicular survival rates and satisfactory testicular positions. Neither the open nor laparoscopic approach appeared superior, because the overall testicular survival rates and incidence of testicular ascent and other complications were equivalent between both groups.

Testicular Germ Cell Tumours and Proprotein Convertases

Simple Summary

Despite the high survival rate of the most common neoplasia in young Caucasian men: Testicular Germ Cell Tumors (TGCT), the quality of life of these patients is impaired by the multiple long-term side effects of their treatment. The study of molecules that can serve both as diagnostic biomarkers for tumor development and as therapeutic targets seems necessary. Proprotein convertases (PC) are a group of proteases responsible for the maturation of inactive proproteins with very diverse functions, whose alterations in expression have been associated with various diseases, such as other types of cancer and inflammation. The study of the immune tumor microenvironment and the substrates of PCs could contribute to the development of new and necessary immunotherapies to treat this pathology.

Abstract

Testicular Germ Cell Tumours (TGCT) are widely considered a “curable cancer” due to their exceptionally high survival rate, even if it is reduced by many years after the diagnosis due to metastases and relapses. The most common therapeutic approach to TGCTs has not changed in the last 50 years despite its multiple long-term side effects, and because it is the most common malignancy in young Caucasian men, much research is needed to better the quality of life of the many survivors. Proprotein Convertases (PC) are nine serine proteases responsible for the maturation of inactive proproteins with many diverse functions. Alterations in their expression have been associated with various diseases, including cancer and inflammation. Many of their substrates are adhesion molecules, metalloproteases and proinflammatory molecules, all of which are involved in tumour development. Inhibition of certain convertases has also been shown to slow tumour formation, demonstrating their involvement in this process. Considering the very established link between PCs and inflammation-related malignancies and the recent studies carried out into the immune microenvironment of TGCTs, the study of the involvement of PCs in testicular cancer may open up avenues for being both a biomarker for diagnosis and a therapeutic target.

The Management of Intraabdominal Testis: A Survey of the World Federation of Associations of Pediatric Surgeons (WOFAPS) Practices

BACKGROUND AND OBJECTIVE

The optimal treatment protocol of intraabdominal testis is still a matter of debate and until now there are a lot of areas of controversy as regards this challenging subtype. The aim of this report is to document current practice patterns among surgeons from different continents through an online Redcap survey supervised the World Federation of the Association of Pediatric Surgeons (WOFAPS).

METHODS

A 16-question-survey related to the management of intraabdominal testis was created and administered via RedCap. The WOFAPS headquarters sent an email to all members inviting voluntary survey participation. Data were entered using Microsoft EXCEL spreadsheet and analyzed. Descriptive statistics were performed for each survey item.

RESULTS

There were 436 WOFAPS members who participated in this study with a response rate of 29%, and the vast majority were pediatric surgeons. Only 13% tried to use hormone therapy aiming to induce testicular descent or to improve future fertility. The choices of various surgical techniques were noted. During laparoscopy, if vessels and cord structure were seen entering the ipsilateral internal inguinal ring, most respondents chose to explore the groin. On the other hand, should there was an absent or atrophic testis, the respondents were split on whether to perform a contralateral orchiopexy.

CONCLUSION

This survey describes the current practices of a sample of pediatric surgeons and urologists in the management of intraabdominal testis. The use of hormonal treatment, timing of fixation and management in case of passing through vas and vessels through DIR were undisputable. However, management of low-lying and peeing testis together with the management of contralateral testis were still debatable.

Testicular blood supply and growth in children with high cryptorchidism treated with gubernaculum preserving vs. cutting laparoscopic orchiopexy: A pilot trial

INTRODUCTION

It is still controversial whether the frenum of testis should be retained in laparoscopic testicular fixation.

MATERIALS AND METHODS

It is a prospective experiment to study testicular preservation on testicular growth in children with high cryptorchidism.

RESULTS

From January 2018 to June 2020, 120 children with high cryptorchidism in Inner Mongolia Maternal and Child Health Care Hospital and The Fourth Hospital of Baotou were randomly divided into retention group (60 cases in group P, aged 1-3 years, average 1.85 ± 0.58) and cutting group (60 cases in group C, aged 1-3 years, average 1.75 ± 0.66) (P = 0.52). PSV, EDV, RI and testicular volume were measured by color Doppler ultrasound before operation and 1,3,6,12 months after operation. No, there was significant difference between the two groups (P > 0.05).

CONCLUSIONS

There is no significant difference in testicular blood supply and growth between laparoscopic testicular fixation and frenulum amputation in children with high cryptorchidism.

A prediction model for risk factors of testicular atrophy after orchiopexy in children with undescended testis

BACKGROUND

There have been limited studies with small sample sizes about risk factors of testicular atrophy. Thus, we aimed to investigate the risk factors for testicular atrophy after orchiopexy in male children with undescended testes and develop a prediction model based on clinical variables.

METHODS

We performed a retrospective review of data on children who underwent orchiopexy for undescended testes from 2013 to 2017. The variables assessed included age, laterality, testicular location, preoperative testicular volume ratio, deferens and epididymis anomaly, hormonal treatment, comorbidities, type of surgical procedure, operating time, and complications as the outcome of testicular atrophy. A nomogram was constructed to predict the probability of testicular atrophy. We also validated our model based on a prospective cohort of patients who underwent orchiopexy from January 2018 to December 2018.

RESULTS

A total of 1,608 patients undergoing orchiopexy were included in the training cohort. The median age was 2.8 years (range, 0.5-11.3 years). After follow-up for 12 to 18 months (median, 14 months), 228 (14.2%) cases of atrophic testes were recorded. The independent predictors of testicular atrophy were preoperative testicular volume ratio [odds ratio (OR) 0.001, P=0.001], testicular location (OR 1.903, P=0.001), deferens and epididymis anomaly (OR 6.470, P=0.001), and two-stage Fowler-Stephens orchiopexy (OR 2.613, P=0.04). Successful validation was achieved, and a receiver operating characteristic (ROC) curve was constructed. The sensitivity and specificity of the prediction model were 78.1% and 77.5%, respectively. The area under the ROC curve was 0.851.

CONCLUSIONS

In patients with undescended testes, excluding those with chromosomal abnormalities and testicular nubbin, the incidence of testicular atrophy after orchiopexy is higher in patients with a lower testicular volume ratio, higher testicular location, deferens and epididymis anomaly, and in two-stage Fowler-Stephens orchiopexy. Therefore, this prediction model provides useful evidence for surgeons to choose an appropriate surgical procedure for undescended testes and predict the probability of testicular atrophy.

Quality improvement assessment of a bianchi-technique pediatric orchiopexy perioperative pain management pathway

BACKGROUND

Surgical correction of undescended testes is a common surgical procedure which can be performed via a two-incision technique or a single high scrotal incision (Bianchi technique). The Bianchi technique requires less surgical time and may be associated with less pain in the initial postoperative period, however it has been adopted slowly due to a lack of familiarity and perceived technical challenges of the technique. Traditionally postoperative orchiopexy pain is managed with a caudal or ilioinguinal/iliohypogastric nerve block. As urologists at our site adopted the Bianchi technique, the anesthesiologists stopped performing caudals or ilioinguinal/iliohypogastric nerve blocks as local infiltration appeared sufficient. Therefore, this quality improvement (QI) project endeavoured to assess Alberta Children's Hospital's care pathway in its effectiveness to control pain in the first 24 h following pediatric orchiopexy using the Bianchi technique.

METHODS

We completed a prospective QI project examining a care pathway for patients undergoing orchiopexy using the Bianchi technique. Eligible patients were healthy and aged 6 months to 12 years. A multimodal analgesic approach including local anesthetic surgical infiltration was used. Pain scores (FLACC) were recorded for up to 2 h postoperatively and a PPPM was completed at 24 h postoperatively.

RESULTS

Sixty-four patients were included in the final analysis. The median discharge FLACC score was 0 (range 0-2) (Table 2). Median intraoperative morphine administered was 0.09 mg/kg with no significant correlations between the amount of morphine administered and postoperative pain measures. Median PPPM scores were 4 and 3.5 for unilateral and bilateral procedures, respectively.

CONCLUSIONS

We have demonstrated that orchiopexies repaired using the Bianchi technique following the care pathway established at Alberta Children's Hospital are associated with minimal pain scores. Our QI project suggests that combining a Bianchi technique with a simple multimodal analgesic approach including local infiltration, negates the need for regional anesthesia techniques, yet still provides adequate analgesia.

A history of cryptorchidism is associated with impaired testicular function in early adulthood: a cross-sectional study of 6376 men from the general population

STUDY QUESTION

Is there a difference in testicular function in early adulthood between men born with cryptorchidism and men born with normally descended testes?

SUMMARY ANSWER

In men from the general population, a history of cryptorchidism was associated with lower total testis volume and impaired semen quality as well as altered serum levels of reproductive hormones.

WHAT IS KNOWN ALREADY

The association between cryptorchidism and testicular function is well documented in studies based on sub-fertile or infertile men recruited from a clinical setting. However, the association has not previously been investigated in men from the general population, who were unselected regarding fertility status.

STUDY DESIGN, SIZE, DURATION

This is a cross-sectional population-based study of 6376 young Danish men examined from 1996 to 2017.

PARTICIPANTS/MATERIALS, SETTING, METHODS

This study is based on young men from the greater Copenhagen area, Denmark (median age of 19 years) who were unselected regarding fertility status and semen quality. The young men delivered a semen sample, had a blood sample drawn and underwent a physical examination including assessment of testis volume. Participants completed a questionnaire regarding cryptorchidism at birth, current lifestyle and their mother’s pregnancy, after consulting their mother. The differences in markers of testicular function, including testis volume, semen parameters and reproductive hormones between men with and without a history of cryptorchidism were investigated with multiple linear regression analyses.

MAIN RESULTS AND THE ROLE OF CHANCE

The participation rate was 24% for the entire study period. Overall, a history of cryptorchidism was associated with reduced testicular function. In the adjusted models, a history of cryptorchidism was associated with a 3.5 ml lower total testis volume, determined by orchidometer (P &lt; 0.001), 28% lower sperm concentration (95% CI: −37 to −20) and 26% lower inhibin B/FSH ratio (95% CI: −50 to −22) compared to men without a history of cryptorchidism, suggesting a reduced spermatogenetic capacity. Men with a history of cryptorchidism also had a slightly reduced Leydig cell function expressed as a 6% lower testosterone/LH ratio (95% CI: −12 to −0.7). The significant effect sizes and different markers of testicular function pointing in the same direction across the different models based on a large sample size support that the results are not chance findings.

LIMITATIONS, REASONS FOR CAUTION

Information on cryptorchidism at birth and treatment modus was obtained by retrospective self-report, and each participant only delivered one semen sample.

WIDER IMPLICATIONS OF THE FINDINGS

The results suggest that men with a history of cryptorchidism could be at increased risk of experiencing fertility problems. However, among these men there is a wide variation in semen quality and further research is needed in order to identify the subgroup of boys born with cryptorchidism who are at the greatest risk of impaired semen quality when reaching adulthood.

STUDY FUNDING/COMPETING INTEREST(S)

The study received financial support from the Research fund of Rigshospitalet, Copenhagen University Hospital; the European Union (Contract numbers BMH4-CT96-0314, QLK4-CT-1999-01422, QLK4-CT-2002-00603. FP7/2007-2013, DEER Grant agreement no. 212844); the Danish Ministry of Health; the Danish Environmental Protection Agency; A.P. Møller and wife Chastine McKinney Møllers Foundation; and Svend Andersens Foundation. None of the founders had any role in the study design, collection, analysis or interpretation of data, writing of the paper or publication decisions. The authors have nothing to declare.

TRIAL REGISTRATION NUMBER

N/A.

The impact of primary location and age at orchiopexy on testicular atrophy for congenital undescended testis

In this study, we investigated post-orchiopexy testicular growth of undescended testes (UDTs) at different primary locations and determined the risk factors for testicular atrophy (TA). We conducted a retrospective chart review of boys who had undergone orchiopexy for UDTs during January 2001–December 2013. Patient profile, age at operation, primary UDT location, and testicular volume were noted. TA was defined as ≥50% loss of volume after orchiopexy. The primary endpoints were testicular growth and TA after orchiopexy. The secondary endpoint was risk factors for TA. In total, 182 boys had undergone regular ultrasonography; the median follow-up period was 34 months. Among 230 UDTs, 18 (7.8%) atrophic testicles were identified within a median interval of 13 months after orchiopexy. TA rates were 3.3% (1/30), 6.9% (12/173), and 18.5% (5/27) in primary suprascrotal, canalicular, and above-inguinal UDTs, respectively. The survival probability of UDT was 91%, 92% and 100% when orchiopexy was performed in age ≤1 year, 1 < age ≤2 years, and 100% in age >2 years, respectively. Multivariate analysis revealed that inguinal and above-inguinal UDTs (hazard ratio [HR] 11.76, 95% confidence interval [CI] 1.55–89.33, p = 0.017) and genetic or endocrine disorders (HR 3.19, 95% CI 1.19–8.56, p = 0.021) were the risk factors for TA, but not age at operation, premature birth, and laterality. Thus, TA incidence was higher when patients had high primary testicular locations. Early orchiopexy before two years of age may be associated with higher TA risk, while most testicles have promising growth after orchiopexy.

Surgical Management of Undescended Testis - Timetable and Outcome: A Debate

Around 1.4-3.8% of boys in the Western world are operated because of cryptorchidism. This means that orchidopexy remains one of the most common surgical procedures performed in boys. As a consequence, several consensus reports, guidelines, and reviews dealing with the management of cryptorchidism have been published recently. Based on our research and 30 years' experience with the management of cryptorchidism, the intention of the present publication is to advise on the surgical management and comment on the expected outcome, especially with focus on the controversies related to guidelines and reviews. Except for late referral and waiting lists, which may be practical problems, there is no reason to postpone orchidopexy for nonsyndromic congenital cryptorchid testes beyond 6 months. There is good evidence that such strategy improves the fertility potential and decreases the risk of testicular cancer. In cases with genuine gonadotropin insufficiency, early surgical correction is not enough and adjuvant LH-RH treatment should be implemented to improve the fertility potential. Cryopreservation may be an option in case of treatment failure of adjuvant LH-RH. A prerequisite for such management includes serum hormone assessment and evaluation of testicular biopsies at orchidopexy. Ascended testes contribute to 20-60% of operative cases and should be treated when diagnosed.

Fertility in males after childhood, adolescent, and adult inguinal operations

BACKGROUND/PURPOSE

Inguinal hernia repair and orchidopexy are among the most common operations in boys. The impact on future fertility has not been conclusively defined. This study evaluates sperm quality after previous inguinal surgery.

METHODS

Spermiograms of men with a desire to conceive children were analyzed. History of previous inguinal surgery (hernia repair, orchidopexy, varicocele ligation) was correlated with sperm quality. Other influential factors (age, BMI, chronic medication, tobacco use) were also tested.

RESULTS

A total of 333 patients were included. Overall, 12.6% of the subjects had undergone previous inguinal surgery. Of these, 17 (43%) were inguinal hernia repairs, 8 (20%) orchidopexies, and 6 (15%) varicocele ligations, while 9 (22%) could not give an exact history. Abnormal spermiograms were found in 60% (n = 24) of those with previous inguinal surgery versus 48% in controls (p = 0.16). On multivariate analysis, pathologic spermiogram parameters were associated with previous inguinal surgery, orchidopexy, use of chronic medication, and smoking, but NOT with inguinal hernia or varicocele repair alone.

CONCLUSIONS

Previous inguinal hernia or varicocele repair does not seem to impact negatively on quality of sperm later in life. Orchidopexy, smoking, and use of chronic medication, however, were all associated with pathologic sperm quality parameters.

TYPE OF STUDY

Prospective comparative study.

LEVEL OF EVIDENCE

Level II.

Altered miRNA profile in testis of post-cryptorchidopexy patients with non-obstructive azoospermia

BACKGROUND

Cryptorchidism is one of the most common causes of non-obstructive azoospermia (NOA) leading to male infertility. Despite various medical approaches been utilised, many patients still suffer from infertility. MicroRNAs (miRNAs) play vital roles in the progress of spermatogenesis; however, little is known about the miRNA expression profile in the testes. Therefore, the miRNA profile was assessed in the testis of post-cryptorchidopexy patients.

METHODS

Three post-cryptorchidopexy testicular tissue samples from patients aged 23, 26 and 28 years old and three testis tissues from patients with obstructive azoospermia (controls) aged 24, 25 and 36 years old were used in this study. Next-generation sequencing (NGS) was used to perform the miRNA expression profiling. Quantitative real-time reverse transcription polymerase chain reaction (qRT-PCR) assays were subsequently used to confirm the results of several randomly-selected and annotated miRNAs.

RESULTS

A series of miRNAs were found to be altered between post-cryptorchidopexy testicular tissues and control tissues, including 297 downregulated and 152 upregulated miRNAs. In the subsequent qRT-PCR assays, the expression levels of most of the selected miRNAs (9/12, P < 0.05) were consistent with the results of NGS technology. Furthermore, signal transduction, adaptive immune response and biological regulation were associated with the putative target genes of the differentially-expressed miRNAs via GO analysis. In addition, oxidative phosphorylation, Parkinson's disease and ribosomal pathways were shown to be enriched using KEGG pathway analysis of the differentially-expressed genes.

CONCLUSIONS

This study provides a global view of the miRNAs involved in post-cryptorchidopexy testicular tissues as well as the altered expression of miRNAs compared to control tissues, thus confirming the vital role of miRNAs in cryptorchidism.

Association between RNA-binding protein Ptbp2 and germ cell injury in an experimentally-induced unilateral cryptorchidism murine model

RNA binding protein polypyrimidine tract binding protein 2 (Ptbp2) as a key alternative splicing regulator for male germ cell development is well established. However, its expression levels and role in cryptorchidism testes tissues has not been explored. Additionally, the molecular mechanism of heat stress impacts the correct proliferation and differentiation of germ cells is unclear. To investigate whether changes in Ptbp2 expression are correlated with heat stress-induced germ cell injury in testicular tissue, we used a murine model of intraperitoneal cryptorchidism with surgical operation. Here we present compelling evidence that germ cells are severely damaged in mice with unilateral cryptorchidism, with non-obstructive azoospermia. And the Ptbp2 and Pgk2 mRNA levels were significantly decreased in parallel, leading us to conclude that the negative correlation between Ptbp2 levels and germ cell injury in unilateral cryptorchidism murine model. We hypothesize that Ptbp2 is susceptible to heat stress and its disruption has resulted in stability decline of germ cell transcripts Pgk2 mRNA, which consequently lead to germ cell injury in cryptorchidism testes. Thus, we confirm that Ptbp2 is an essential factor in heat stress-induced sperm cell injury and non-obstructive azoospermia.

The Nonpalpable Testis: A Narrative Review

PURPOSE

While the nonpalpable testis represents a small portion of all cryptorchid testes, it remains a clinical challenge for pediatric urologists. Controversy exists surrounding the best evaluation and management of this entity. In this review we update what is known about the nonpalpable testis, including the etiology, preoperative evaluation and best surgical management as well as novel techniques and ongoing controversies.

MATERIALS AND METHODS

We searched PubMed® and MEDLINE® from January 2000 to January 2017 using relevant key terms. Of 367 articles 115 were considered for inclusion based on a priori design. Using a narrative review format, an update on the evaluation and management of the nonpalpable testis including novel concepts and techniques was synthesized.

RESULTS

The nonpalpable testis should be evaluated by physical examination only. Imaging is not indicated for routine cases. The optimal surgical approach and technique remain debatable but several novel techniques have been described. Due to the rarity of the nonpalpable testis, randomized controlled trials and other quality comparisons are difficult. Therefore, management remains controversial.

CONCLUSIONS

Evaluation and management of the nonpalpable testis remain difficult, and some aspects are still debated. Future research should focus on multi-institutional collaborative trials to determine the optimal operative management.

General paediatric surgery for patients aged under 5 years: a 5-year experience at a district general hospital

Introduction The gradual shift of general paediatric surgery (GPS) provision from district general hospitals (DGH) to specialised units is well recognised in the UK. The consequences of centralisation include a reduction in exposure to GPS for current surgical trainees. The GPS practice of a DGH is examined here. Methods All operations performed on children aged under 5 years over a 5-year period were identified using the local electronic operation database. Electronic hospital records and clinic letters were accessed to collect data on demographics, operations performed and outcome measures. Results 472 GPS operations were performed on children between the age of 22 days and 5 years between 2009 and 2014, of which 43 were on an emergency basis and 105 were performed on patients aged less than 1 year. Three patients were admitted following day case surgery. Six patients were readmitted within 30 days. Complication rates for all procedures and the four most common procedures were similar to those found in published literature. Conclusions GPS for patients aged less than 5 years is comparatively safe in the DGH setting. The training opportunities available at DGHs are invaluable to surgical trainees and vital for sustaining the future provision of GPS by such hospitals.

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.

Putting the pieces together: cryptorchidism - do we know everything?

Cryptorchidism is one of the most common birth defects in male children, and it has a potential impact on future health. It is the best-characterized risk factor for reduced fertility and testicular cancer. However, the etiology of cryptorchidism remains largely unknown. In the literature, we find different opinions and theories on this topic. Probably, the etiology is multifactorial, and hormonal, genetic and environmental factors may regulate testicular development and descent from intra-abdominal location into the bottom of the scrotum. The descent of the testis is a complex, two-stage process. A critical role in testicular descent has been attributed to androgens, insulin-like hormone 3 (insl3) and anti-Müllerian hormone. It is believed that interaction between Leydig and Sertoli cells may cause impaired spermatogenesis. Based on recent knowledge of germ cell development, it is believed that the best treatment for undescended testis is orchiopexy between 6th and 12th month of life. Long follow-up studies are needed to focus on the effect of this recommendation.

Cryptorchidism --disease or symptom?

Testes descend to the scrotum normally before birth. When they fail to do so, the boy is cryptorchid and has an increased risk for testicular germ cell cancer and subfertility later in life. Early correction of maldescent by orchiopexy operation improves the spermatogenetic capacity of the testis but does not return the testicular cancer risk to the control level. Testicular descent is regulated by testis-derived hormones testosterone and insulin-like peptide 3. Cryptorchidism can therefore be considered a symptom of impaired testicular function that may also be linked to other testicular diseases, such as germ cell cancer and subfertility. Early orchiopexy can alleviate the effects of cryptorchidism on spermatogenesis, but alertness for testicular cancer should be maintained. In searching the genetic and environmental reasons for these diseases, it is useful to consider their connection with each other.

Testicular atrophy after attempted pediatric orchidopexy for true undescended testis

BACKGROUND/PURPOSE

A normal testis in the scrotum is the most important outcome of the attempted pediatric orchidopexy for a true undescended testis. The reports of post-orchidopexy testicular atrophy in the literature have ranged from non-existent to unclear. Our purpose in this study was to estimate the incidence of and associated risk factors for post-orchidopexy testicular atrophy.

METHODS

We performed a retrospective review of data from children who had an attempted orchidopexy for a true undescended testis from 1969 to 2003 inclusive. REB approval 1000011987.

RESULTS

There were 1400 attempted orchidopexies involving common (low) type (n=1135), ectopic type (n=174), and high type testes (n=91). There were a total of 111/1400 (8%) atrophic testes, mostly right-sided. 66/111 (59%) were MADE atrophic, and 45 (41%) were FOUND atrophic. Of the 1135 common type, 56 (5%) were MADE atrophic. In the ectopic and high types, the incidence of post-operative testicular atrophy was 1% and 9%, respectively. The most significant risk factors associated with testes MADE atrophic were high testicle, vas problems, and pre-operative torsion.

CONCLUSIONS

In this series, the incidence of post-operative testicular atrophy that was MADE was 5% in the common (low) type and 9% in the high type. These numbers and the above risk factors should be quoted to the caregiver during pre-operative informed consent.

The fate of spermatogonial stem cells in the cryptorchid testes of RXFP2 deficient mice

The environmental niche of the spermatogonial stem cell pool is critical to ensure the continued generation of the germ cell population. To study the consequences of an aberrant testicular environment in cryptorchidism we used a mouse model with a deletion of Rxfp2 gene resulting in a high intra-abdominal testicular position. Mutant males were infertile with the gross morphology of the cryptorchid testis progressively deteriorating with age. Few spermatogonia were identifiable in 12 month old cryptorchid testes. Gene expression analysis showed no difference between mutant and control testes at postnatal day 10. In three month old males a decrease in expression of spermatogonial stem cell (SSC) markers Id4, Nanos2, and Ret was shown. The direct counting of ID4+ cells supported a significant decrease of SSCs. In contrast, the expression of Plzf, a marker for undifferentiated and differentiating spermatogonia was not reduced, and the number of PLZF+ cells in the cryptorchid testis was higher in three month old testes, but equal to control in six month old mutants. The PLZF+ cells did not show a higher rate of apoptosis in cryptorchid testis. The expression of the Sertoli cell FGF2 gene required for SSC maintenance was significantly reduced in mutant testis. Based on these findings we propose that the deregulation of somatic and germ cell genes in the cryptorchid testis, directs the SSCs towards the differentiation pathway. This leads to a depletion of the SSC pool and an increase in the number of PLZF+ spermatogonial cells, which too, eventually decreases with the exhaustion of the stem cell pool. Such a dynamic suggests that an early correction of cryptorchidism is critical for the retention of the SSC pool.

Epidemiology, classification and management of undescended testes: does medication have value in its treatment?

Genetic, hormonal, and anatomical factors are believed to be involved in the etiology of undescended testes. Due to increased risk of infertility, testicular cancer, torsion and/or accompanying inguinal hernia (>90%) as well as cosmetic concerns, all these patients require treatment. In this review paper, we aimed to evaluate the success rates of treatment modalities used in undescended testes, beginning from 1930 to the present, and to draw attention to the possible risks and benefits and also the efficacy of hormonal therapy in the management of the disorder, which is still a controversial issue. Hormonal therapy may lead to penile growth, painful erection, and behavioral changes while on treatment. In recent years, it has been reported that human chorionic gonadotropin (hCG) treatment was associated with interstitial edema due to increased vascular permeability, inflammation-like changes, and several adverse effects on germ cells by increasing pressure and apoptotic process. It has also been reported that LHRH analogues have positive effects on germ cells by increasing fertility in patients undergoing unilateral or bilateral orchiopexy. In some studies, the success rate of hCG treatment was reported to be higher following buserelin. In some other studies, hCG treatment was recommended before orchiopexy to reduce the risk for surgical ischemia. There are a limited number of randomized controlled studies, so evidence showing the efficacy of hormonal therapy is insufficient. According to the 2007 Consensus Report of Nordic countries, it is recommended that surgery is the first-line treatment modality in undescended testes and that it should be performed by pediatric surgeons and urologists at the age of 6-12 months.

Post-orchidectomy retroperitoneal seminoma: A case report

Between 2 and 5% of malignant germ cell tumors in males arise at extragonadal sites. The origin of extragonadal retroperitoneal germ cell tumors remains controversial. Whether these develop primarily in the retroperitoneum or are metastases of a primary testicular tumor has long been debated. We report a 38-year-old male who presented with abdominal pain and was diagnosed with retroperitoneal seminoma. The patient gave a history of having undergone a right orchidectomy for an undescended testis via the inguinal route 10 years previously with a reported histology of benign inflammatory mass.

Expression of estrogen receptors α and β in paratesticular tissues in boys operated on for unilateral cryptorchidism between the 1st and 4th years of life

BACKGROUND

The aim of this study was to assess the expression of estrogen receptors alpha and beta in paratesticular tissues in a group of boys with and without cryptorchidism, and evaluation of karyotypes, localization, morphology and the major length of the undescended testes.

MATERIAL/METHODS

Fifty boys (1-4 years old) with unilateral cryptorchidism were evaluated. Fifty healthy boys within the same age range, with inguinal hernia, served as a control group. Measurements concerning expression of ERalpha ERbeta receptors were preformed using monoclonal mouse antibodies against human receptor alpha and beta.

RESULTS

In the mesothelial layer, the expression of ERalpha was higher in the patients group with undescended testes and it was statistically significant (p=0.04). There was no difference in the expression of ERbeta in this layer between groups. In the stromal cell layer there was statistically significant higher expression of ERbeta (p<0.05) in the group of patients with undescended testes.

CONCLUSIONS

There was no difference between expressions of ERalpha in stromal cell layer. In the endothelial layer there was no difference in expression of ERalpha and ERbeta. In the smooth muscle layer there was no expression of ERalpha in either group. The expression of ERbeta in the smooth muscle layer was nearly identical in both groups. Undescended testes were generally found in the superficial inguinal pouch (n=46). The major lengths of the undescended testes were smaller in comparison to the testes positioned normally. In 9 of the cases the testes had different shape, and turgor deficit, and epididymides were smaller, dysplastic and separated from the testis.

Serum AMH concentration as a marker evaluating gonadal function in boys operated on for unilateral cryptorchidism between 1st and 4th year of life

The aim of this study was to measure the serum AMH (anti-Mullerian hormone) concentrations in a group of boys with or without cryptorchidism, evaluation of karyotypes, testicular position, morphology, and major length of the undescended testes. Fifty boys who were 1-4 years old (median = 2.4 years) with unilateral cryptorchidism were evaluated. All of them underwent orchidopexy in 2010. Prior to the procedure, all of the subjects had undergone karyotyping to exclude chromosomal abnormalities. Fifty healthy boys within the same age range (median = 2.1 years) admitted for planned inguinal hernia repair in 2010, served as controls. Blood samples were collected, while obtaining blood for standard laboratory tests routinely performed before the surgeries. Medians of AMH in boys with cryptorchidism were lower than in boys with inguinal hernia and differed significantly between two groups. Undescended testes were generally found in superficial inguinal pouch (n = 46), in two cases were noted to be in the external ring of the inguinal canal, and in another two instances, in the abdominal cavity. The major lengths of the undescended testes were smaller in comparison to the testes positioned normally (mean of 1 cm vs. a mean of 1.5 cm, respectively). In nine of the cases, the testes had turgor deficit, a drop shape, with epididymides that were small, dysplastic, and separated from the testis. The authors found that AMH was lower in boys with unilateral cryptorchidism (also found to have smaller testis) when compared with the control group.

Spermatogenesis in cryptorchidism

Cryptorchidism or undescended testis is the most frequent congenital abnormality in newborn boys. The process of testicular descent to the scrotum is controlled by hormones produced in Leydig cells, insulin-like3, and androgens. Variation in genetic and environmental factors might affect testicular descent. A failure of spermatogenesis and germ cell apoptosis resulting in infertility as well as an increased risk of neoplastic transformation of germ cell are the direct consequences of cryptorchidism in adulthood.

Are general paediatric surgery outcomes comparable between district general hospital and regional referral centres?

INTRODUCTION

This study recorded the complication rates for general paediatric surgery undertaken in our district general hospital (DGH) and compared them with the limited amount of data published in this field. There has been a gradual diminution in the numbers of general paediatric surgeons throughout the UK. The Royal College of Surgeons of England has produced guidelines to safeguard the provision of paediatric surgery in DGHs. There are minimal data on the acceptable outcomes and complication rates for elective general paediatric operations.

METHODS

The following operations undertaken by the paediatric urologist in our unit between November 2006 and May 2010 were scrutinised: orchidopexy, laparoscopy for undescended testes, herniotomy and circumcision. The results were compared to those in the literature and current guidelines. Complications were recorded via audit records, clinic letters or records of attendance at the accident and emergency department.

RESULTS

A total of 306 paediatric operations (125 orchidopexies, 28 laparoscopies, 41 herniotomies and 51 circumcisions) were undertaken over the 42-month study period. Only 4.5% of cases experienced post-operative complications. The majority of these were testicular atrophy and infection. There were no intra-operative complications.

CONCLUSIONS

In our DGH the complication rates for general paediatric operations compare favourably with those set out by the literature and guidelines, which support the training and delivery of general paediatric surgery within DGHs.

The concordance of testicular anatomic location in bilateral cryptorchidism

OBJECTIVE

To determine the frequency of concordance of testicular anatomical location between both undescended testes based on surgical findings.

BACKGROUND

Cryptorchidism occurs in approximately 1% of boys over one year of age, and in 10-20% of these cases, the condition is bilateral. We report a series of 168 patients with a preoperative diagnosis of bilateral undescended testes who underwent surgical exploration and in whom two testes were surgically identified.

METHODS

The testicular location of both testes was stratified according to six anatomic regions. For each patient the anatomic site of each testis, both palpable and impalpable, and the surgical procedure required for orchidopexy were recorded.

RESULTS

The mean age was 59.3 months (2.5 months-21 years). In 90% of the cases the surgical technique was identical for both sides. Approximately two thirds of the patients were found to have both testes in concordant anatomical locations and in 88% the location of one testis was predictive within one anatomic "step" of the location of the contralateral gonad.

CONCLUSION

These findings may have significant implications for counseling families and anticipating the necessary surgical approach required when only one undescended testis has been localized preoperatively.

The challenge of early surgery for cryptorchidism

OBJECTIVE

In congenital cryptorchidism, a recent Nordic Consensus report recommends surgical correction at 6-12 months of age to prevent male infertility. In published series of orchiopexies the median age at surgery is often 3 years or more. The aim of this study was to evaluate whether early surgery is technically safe.

MATERIAL AND METHODS

The study included 356 boys with 418 orchiopexies and median 1 year of follow-up.

RESULTS

At follow-up 367 testes were in the scrotum without iatrogenic atrophy. Eight testes were atrophied and in 43 cases a redo operation was performed to achieve a scrotal position of the testis. All acquired undescended testes had a successful result. The age at operation for the group with congenital undescended testes in the intracanalicular position or in a position close to the external inguinal annulus was 4 months to 14.5 years. In the latter group the median age at operation for the 41 failures was 2 years and 4 months, which is significantly younger than the median age for the more successful operations (3 years and 9 months).

CONCLUSION

The standard orchiopexy is technically demanding in small boys. Focus on successful operative results in specialist centres is important when treating cryptorchidism with early surgery, otherwise the positive beneficial biological impact on fertility potential may be lost due to treatment failure.

What is new in cryptorchidism and hypospadias--a critical review on the testicular dysgenesis hypothesis

It has been hypothesized that poor semen quality, testis cancer, undescended testis, and hypospadias are symptoms of one underlying entity--the testicular dysgenesis syndrome--leading to increasing male fertility impairment. Though testicular cancer has increased in many Western countries during the past 40 years, hypospadias rates have not changed with certainty over the same period. Also, recent studies demonstrate that sperm output may have declined in certain areas of Europe but is probably not declining across the globe as indicated by American studies. However, at the same time, there is increasing recognition of male infertility related to obesity and smoking. There is no certain evidence that the rates of undescended testes have been increasing with time during the last 50 years. In more than 95% of the cases, hypospadias is not associated with cryptorchidism, suggesting major differences in pathogenesis. Placental abnormality may occasionally cause both cryptorchidism and hypospadias, as it is also the case in many other congenital malformations. The findings of early orchidopexy lowering the risk of both infertility and testicular cancer suggest that the abnormal location exposes the cryptorchid testis to infertility and malignant transformation, rather than there being a primary abnormality. Statistically, 5% of testicular cancers only are caused by cryptorchidism. These data point to the complexity of pathogenic and epidemiologic features of each component and the difficulties in ascribing them to a single unifying process, such as testicular dysgenesis syndrome, particularly when so little is known of the actual mechanisms of disease.

Natural history and long-term testicular growth of acquired undescended testis after spontaneous descent or pubertal orchidopexy

OBJECTIVE

To assess prospectively the natural history and long-term testicular growth of acquired undescended testis (UDT) after spontaneous descent or pubertal orchidopexy in case of nondescent.

PATIENTS AND METHODS

From 1996 until 2008, 391 boys with 464 acquired UDT were included in the study. In accordance with Dutch consensus on non-scrotal testes, spontaneous descent at puberty was awaited; if this did not take place, orchidopexy was performed at puberty. Acquired UDT was defined as a testis previously residing in the scrotum that can no longer be manipulated into a stable scrotal (high scrotal) or nonscrotal (inguinal, impalpable) position. After referral, testis position, testis volume and puberty stage were monitored annually until adolescence. Testis volume was assessed using an orchidometer and compared with the Dutch standard. All investigations were carried out by the same physician (W.H.). Of these boys, 84 (mean age 12.9 years, range 6.4-21.3) were also clinically assessed by a second physician (J.G.), unaware of the results of the first examination. In addition, these boys were assessed with testicular ultrasonography, carried out by both physicians.

RESULTS

Currently the mean (range) follow-up is 4.7 (0.1-12.0) years, and 253 acquired UDT have reached the scrotum. In 196 of these 253 cases (77.5%), there was spontaneous descent at puberty (mean age at descent 12.9 years, range 9.8-16.9); in the other 57 cases (22.5%), pubertal orchidopexy was required due to nondescent; five cases required orchidectomy. Of the 494 testis volume measurements after spontaneous descent, 458 (92.7%) were at ≥10th centile for age, of which 311 (63.0%) were ≥50th centile, and 107 (21.7%) ≥90th centile. After pubertal orchidopexy for nondescent, of the 85 measurements, 79 (92.9%) were at ≥10th centile, 53 (62.4%) ≥50th centile and 12 (14.1%) ≥90th centile. In unilateral cases, after spontaneous descent 174 of the 294 (59.2%) retained testes were found to be smaller than their counterpart and 90 of 294 (30.6%) were equal in size. After pubertal orchidopexy in unilateral cases, 40 of the 51 (78.4%) testes were smaller, and nine (17.6%) were equal in size. There was a strong correlation between both investigators for the measurement of testicular volume by orchidometer, and for the main investigator (W.H.) between his measurements by ultrasonography and the Prader orchidometer.

CONCLUSION

Acquired UDT has a 77.5% tendency of spontaneous descent at puberty. In nearly all cases, after spontaneous descent as well as after pubertal orchidopexy, long-term testicular growth is within the normal range.

Open versus laparoscopic staged Fowler-Stephens orchiopexy: impact of long loop vas

PURPOSE

There is a paucity of literature on factors associated with testicular atrophy following second stage laparoscopic Fowler-Stephens orchiopexy. We hypothesized that dissection of a long looping vas during this procedure could compromise testicular blood supply, leading to testicular atrophy.

MATERIALS AND METHODS

Following an initial laparoscopic testicular vessel ligation, a second stage Fowler-Stephens orchiopexy was performed in 73 testes (laparoscopic in 61, open in 12). The presence of a long looping vas was noted from the first stage operative notes. Doppler ultrasound was performed postoperatively to confirm testicular atrophy.

RESULTS

Atrophy rate at a mean followup of 13.5 months was 20.5% (15 of 61 in laparoscopic and 0 of 12 in open orchiopexy). None of the 5 long looping vas testes atrophied following open orchiopexy, compared to 5 of 6 (83%) following laparoscopic orchiopexy (p = 0.03). Analyzing the laparoscopic group alone, a long looping vas was significantly associated with risk of atrophy (p <0.01).

CONCLUSIONS

The presence of a long looping vas was associated with a higher atrophy rate following laparoscopic second stage Fowler-Stephens orchiopexy. Laparoscopic management of the long looping vas may be more challenging and, therefore, in such cases open Fowler-Stephens orchiopexy may result in better success rates by preserving the integrity of the collateral vessels.

Economic analysis of infant vs postpubertal orchiopexy to prevent testicular cancer

OBJECTIVES

To use decision analysis to determine the economic benefits of early vs late orchiopexy, specifically with respect to testicular cancer development and management. Studies have suggested that prepubertal orchiopexy might confer additional protection from the development of testicular cancer compared with postpubertal orchiopexy. Infant surgery is often performed by pediatric subspecialists and hence might be more costly. Although rare, testicular cancer can require significant medical expenditures.

METHODS

We examined the resource index (RI) (physician charges and hospital costs) from the medical establishment's perspective. Economic modeling was performed to determine whether early or late orchiopexy minimized the RI. The stage- and histologic-specific costs of subsequent testicular cancer were incorporated into our models. The variables were tested over realistic ranges in the sensitivity analysis to determine the threshold values.

RESULTS

In the base case analysis, the RI for infant and postpubertal orchiopexy was $7500 and $10,928 per patient, respectively. The sensitivity analysis demonstrated that the costs for operating room time, physicians' fees, operative times, and baseline cancer risk were important parameters. However, only the surgeons' fees demonstrated threshold values. The RI for treating cancer and the cancer risk reduction after early orchiopexy did not significantly affect our models.

CONCLUSIONS

Our models of orchiopexy for prevention of testicular cancer showed that infant orchiopexy is less costly than later surgery, provided that the surgeons' fees are not excessive. It appears that early surgery might significantly reduce the treatment costs of testicular cancer for cryptorchid boys and supports the current standard of care in the United States.

An old technique for surgery of 'high' undescended testis revisited

INTRODUCTION

Most undescended testes resolve spontaneously in the first year of life. If the testis remains undescended by the second year, the most probable means of scrotal placement is orchiopexy. After the first successful operation for orchiopexy, many surgical modifications were described. This study presents our limited experience with Prentiss' maneuver in six boys with high undescended testes.

PATIENTS AND METHODS

Two left, two right and two bilateral testes, in six patients, were operated. Five patients were admitted with the complaint of unilaterally or bilaterally 'empty scrotum'. The sixth patient previously had a right high undescended testis which had been placed in a high scrotal position. Following the standard steps of inguinal orchiopexy Prentiss' maneuver were performed and yielded adequate distance to place the testes mid scrotum.

RESULTS

On follow-up, Doppler ultrasound examination revealed normal sized testes with normal blood flow in all patients with dimensions correlated with age.

CONCLUSION

Although perhaps only useful in orchiopexy for high undescended testis, incision of the transversalis fascia preserves testicular blood flow by relieving tension on the testicular vessels.

Management of boys with nonpalpable undescended testis

Cryptorchidism is one of the most common genitourinary disorders in young boys. Although the management of boys with palpable testis is standardized, there are no formal guidelines for the management of boys with nonpalpable testis. In this Review we look at the current trends in the diagnosis and treatment of this disorder, as well as the indications for therapy and surgical procedures. On the basis of current evidence, we find that there is no optimum orchidopexy technique for the treatment of intra-abdominal testis, although it is preferable to adopt techniques that preserve the spermatic vessels. We also briefly examine the follow-up of patients with this disorder and its common complications. As yet, there are no data that assess the potential of laparoscopic orchidopexy being a risk factor for impaired fertility later in life.

The frequency of undescended testis from birth to adulthood: a review

We performed a systematic review and critique of the literature on the frequency of undescended testis (UDT) among boys from birth to adolescence. Special attention was given to whether previous testicular position was taken into account to distinguish between congenital and acquired UDT. We searched Medline, Embase, Cinahl and the Cochrane Library. Any study reporting on the frequency of UDT was included. Study population age, number of boys studied, period of examination, primary examiner, area of study, study design, ethnicity, definitions used and previous testicular position were analysed. A total of 46 studies met the inclusion criteria. Twenty-three of the 46 (50%) studies involved newborns. Definitions were described in half of the studies; however, the definitions used were heterogeneous. Previous testis position was described in 11% (5/46) of the studies. At birth, in term and/or birth weight >2.5 kg infants, the UDT rate ranged from 1.0 to 4.6%, and in premature and/or birth weight <2.5 kg infants from 1.1 to 45.3%. At the age of 1 year UDT in term and/or birth weight >2.5 kg infants was seen in 1.0-1.5%, at 6 years in 0.0-2.6%, at 11 years in 0.0-6.6% and at 15 years in 1.6-2.2% of boys. The frequency of UDT shows variable figures in the literature. The actual frequency of acquired UDT essentially remains unclear because of the shortage of studies performed at an older age, and of studies reporting on previous testicular position.