Ideal timing of orchiopexy: a systematic review

Mini-Puberty, Physiological and Disordered: Consequences, and Potential for Therapeutic Replacement

There are 3 physiological waves of central hypothalamic-pituitary-gonadal (HPG) axis activity over the lifetime. The first occurs during fetal life, the second-termed "mini-puberty"-in the first months after birth, and the third at puberty. After adolescence, the axis remains active all through adulthood. Congenital hypogonadotropic hypogonadism (CHH) is a rare genetic disorder characterized by a deficiency in hypothalamic gonadotropin-releasing hormone (GnRH) secretion or action. In cases of severe CHH, all 3 waves of GnRH pulsatility are absent. The absence of fetal HPG axis activation manifests in around 50% of male newborns with micropenis and/or undescended testes (cryptorchidism). In these boys, the lack of the mini-puberty phase accentuates testicular immaturity. This is characterized by a low number of Sertoli cells, which are important for future reproductive capacity. Thus, absent mini-puberty will have detrimental effects on later fertility in these males. The diagnosis of CHH is often missed in infants, and even if recognized, there is no consensus on optimal therapeutic management. Here we review physiological mini-puberty and consequences of central HPG axis disorders; provide a diagnostic approach to allow for early identification of these conditions; and review current treatment options for replacement of mini-puberty in male infants with CHH. There is evidence from small case series that replacement with gonadotropins to mimic "mini-puberty" in males could have beneficial outcomes not only regarding testis descent, but also normalization of testis and penile sizes. Moreover, such therapeutic replacement regimens in disordered mini-puberty could address both reproductive and nonreproductive implications.

National survey of physicians in Swedish child health centres finds insecurity and unawareness regarding management of undescended testicles

AIM

To investigate underlying factors for previously reported shortcomings in child health centres' (CHC) referral process of boys with undescended testicles.

METHODS

A total of 386 physicians working at Swedish CHCs were surveyed regarding their knowledge about undescended testicles and their clinical management. Multivariate regression analyses were performed to identify risk factors of non-adherence to guidelines and self-reported lack of clinical skills.

RESULTS

The overall knowledge of the health benefits of undescended testicle surgery was high (89%), while two-thirds were unaware of surgery being recommended <1 year of age. One-fifth of respondents had never received guidance on examination techniques. Male gender (adjusted odds ratio [aOR] 0.51, 95% confidence interval [95% CI] 0.31-0.86), education in paediatrics (aOR 0.37, 95% CI 0.18-0.76) and more experience (aOR 0.02, 95% CI 0.01-0.09) significantly decreased the risk of unfamiliarity with examinations. More experience decreased the risk of stating the incorrect indications for undescended testicle surgery (aOR 0.17, 95% CI 0.03-0.95) and finding examinations difficult (aOR 0.22, 95% CI 0.07-0.72). Medical education outside Nordic countries was a risk factor for unawareness of guidelines (aOR 2.06, 95% CI 1.21-3.51).

CONCLUSION

The knowledge and confidence level of the study population varied widely. The results indicate a need for further theoretical and practical education among Swedish CHC physicians.

Relationship between preoperative nutritional status assessed using anthropometric measures and postoperative complications in pediatric surgical patients

AIM

To determine the relationship between preoperative nutritional status assessed using anthropometric measures and postoperative complications in pediatric surgical patients.

METHODOLOGY

This prospective observational cohort study included 650 patients from 6 months to 18 years undergoing elective surgery at our institution. Elective surgery included procedures such as herniotomy, orchidopexy, urethroplasty, cystoscopy, PUV fulguration, pyeloplasty, ureteric reimplantation, stoma formation/closure, anorectoplasty, pull-through, choledochal cyst excision and repair, VP shunt insertion, lipomyelomeningocele repair, diastematomyelia excision and repair, and cyst excision. Nutritional status was standardized using Z scores for weight, length, and BMI. Patients were monitored for a month following surgery to detect any complications, and they were classified into five grades using the Clavien-Dindo classification. The duration of hospital stays and readmission within 30 days following discharge were secondary outcomes.

RESULTS

There were 627 patients of both sexes involved in the study: 350 patients aged 6 months to 5 years (Group A), while 277 were aged between 5 and 18 years (Group B). Wasting status was 47.71% in Group A and 41.52% in Group B. In Group A, 40% of patients were stunted, while 83.75% were in Group B. Group A had 57.14% underweight patients. The complication rate was 39.14% in Group A and 38.99% in Group B. The incidence of postoperative complications was not significantly different in malnourished patients. The patients with prolonged duration of surgery (> 2 h) developed more complications in both groups (Group A-67.2%, Group B-82.6%; p < 0.0001). In addition, the patients who experienced complications had lengthier hospital stays (p < 0.001 in both groups) and increased readmission rates (p = 0.016 in Group A and p = 0.008 in Group B).

CONCLUSION

In our study, half of the patients in Group A and nearly two-third in Group B were malnourished. The preoperative poor nutritional status based on anthropometric parameters is not associated with increased postoperative complications. Randomized control trials linking preoperative malnutrition based on anthropometric measures and clinical outcomes in pediatric surgery patients are necessary to provide more robust information on this subject.

The Safety and Effectiveness of Single-Stage, Vessel-Preserving, Laparoscopic Orchiopexy for Intra-Abdominal Testes in Pediatric Patients: A 10-Year Single-Center Experience

Objectives: Intra-abdominal testes are located in a variety of intra-abdominal positions, most less than 2 cm from the internal ring. Various surgical techniques of laparoscopic orchiopexy have been described to date. The aim of this study was to evaluate the safety and long-term efficacy of a single-stage, vessel-preserving, laparoscopic orchiopexy for intra-abdominal testes in pediatric patients. Methods: A retrospective search of the medical records of 32 children (34 testes) who underwent single-stage, vessel preserving, laparoscopic orchiopexy for intra-abdominal testes between 1 January 2014 and 31 December 2023 was performed. Single-stage laparoscopic orchiopexies were performed in all patients for whom sufficient length of the spermatic cord was achieved during the procedure. The volume of each patient's testes was measured using ultrasound before and 6 months after laparoscopic orchiopexy. The main outcome of this study was testicular volume before and after the procedure. The secondary outcomes were the occurrence of early and late complications, the duration of surgery, and the length of hospital stay. Results: The median age at the time of surgery was 10 months (interquartile range-IQR 9, 13). The majority of the children (n = 24; 75%) were less than 12 months old at the time of surgery. A normal testis was found in 24 patients (70.6%), while a hypotrophic testis was visible in 10 cases (29.4%). The majority of the testes were located near the internal ring (n = 19; 55.9%), while in the remaining cases, the testes were located near the iliac blood vessels. The median duration of the surgical procedure was 37.5 min (IQR 33, 42.5). The duration of hospitalization was one day for all the children. No intraoperative complications were observed. One child had a wound infection at the site of the umbilical trocar, which was treated conservatively. In two cases (5.5%), testicular atrophy was detected during long-term follow-up. In three cases, the testis was found in a higher position in the scrotum during the follow-up period, but in two cases, the position was normal during the follow-up period, while in one case, the position in the scrotum remained unchanged. At long-term follow-up with a median of 35 months (IQR 19, 60.5), the overall success rate was 94.5%. The median testicular volume at 6-month follow-up increased from 0.31 mL (IQR 0.28, 0.43) to 0.40 mL (IQR 0.33, 0.53) (p = 0.017). Conclusions: Single-stage, vessel-preserving, laparoscopic orchiopexies for intra-abdominal testes are safe and effective in pediatric patients in whom adequate spermatic cord length can be achieved during the procedure.

Outcomes and experiences of adults with congenital hypogonadism can inform improvements in the management of delayed puberty

Patients with congenital hypogonadism will encounter many health care professionals during their lives managing their health needs; from antenatal and infantile periods, through childhood and adolescence, into adult life and then old age. The pubertal transition from childhood to adult life raises particular challenges for diagnosis, therapy and psychological support, and patients encounter many pitfalls. Many patients with congenital hypogonadism and delayed or absent puberty are only diagnosed and treated after long diagnostic journeys, and their management across different centres and countries is not well standardised. Here we reconsider the management of pubertal delay, whilst addressing problematic diagnostic issues and highlighting the limitations of historic pubertal induction protocols - from the perspective of both an adult and a paediatric endocrinologist, dealing in our everyday work with the long-term adverse consequences to our hypogonadal patients of an incorrect and/or late diagnosis and treatment in childhood.

Immediate Versus Delayed Surgical Management of Infant Cryptorchidism With Inguinal Hernia

INTRODUCTION

Cryptorchidism is commonly treated with orchiopexy at 6-12 months of age, often allowing time for undescended testicle(s) (UT) to descend spontaneously. However, when an inguinal hernia (IH) is also present, some surgeons perform orchiopexy and inguinal hernia repair (IHR) immediately rather than delaying surgery. We hypothesize that early surgical intervention provides no benefit for newborns with both IH and UT.

METHODS

The Nationwide Readmissions Database was used to identify newborns with diagnoses of both IH and UT from 2010 to 2014. Patients were stratified by management: IHR performed on initial admission (Repair) or not (Deferral). Demographics, outcomes, and complications were compared. Results were weighted for national estimates.

RESULTS

We analyzed 1306 newborns (64% premature) diagnosed with both IH and UT. IHR was performed at index admission in 30%. Repair was more common in premature babies (43% vs. 8% full-term, p < 0.001) and patients with congenital anomalies (33% vs. 27% without congenital anomaly, p = 0.012). There was no difference in readmission rates. Repair patients had higher rates of orchiectomy than did Deferral. No Deferral patients were readmitted for bowel resection, and <1% were readmitted for orchiectomy or hernia incarceration.

CONCLUSION

In newborns with UT and IH, immediate repair is not associated with improved outcomes. Even with incarceration on initial presentation, rates of readmission with incarceration or bowel compromise for patients who undergo Deferral of surgery are minimal. Moreover, Repair newborns have higher rates of orchiectomy. We found no benefit to early operative intervention; thus, we recommend waiting until 6-12 months of age to reassess for surgery.

LEVEL OF EVIDENCE

Level III TYPE OF STUDY: Retrospective Comparative Study.

Bibliometric analysis of scientific publications on cryptorchidism: Research hotspots and trends between 2000 and 2022

Background

Cryptorchidism is defined as failure of unilateral or bilateral testicular descent, which increases the risk of infertility and testicular carcinoma. Although there is much research on cryptorchidism, few studies have used the bibliometric analysis method. The purpose of this study was to conduct a comprehensive analysis of cryptorchidism from muti-dimensional perspectives to summarize the research hotspots and trends in cryptorchidism research.

Methods

Relevant studies on cryptorchidism were retrieved from the Web of Science Core Collection (WoSCC) database from 2000 to 2022. A comprehensive bibliometric analysis of cryptorchidism was performed by using the CiteSpace, Tableau Public, and VOSviewer software, including the annual distributions of publications, countries, authors, institutions, journals, references, and keywords.

Results

From January 1st, 2000 to May 17th, 2022, a total of 5023 papers concerning cryptorchidism were identified for analysis. The USA contributed the most publications (n = 1193) in this field, and the annual number of publications rose rapidly in China. The University of Melbourne published the largest number of papers (n = 131). "Hutson, John M." was the most core author ranked by publications (n = 51), and "Skakkebaek, Niels E." enjoyed the largest number of citations (4441). The JOURNAL OF UROLOGY published the largest number of papers (n = 225), while the average citations per publication of the 75 papers in HUMAN REPRODUCTION reached 62.38. Additionally, burstness analysis of references and keywords showed that cryptorchidism research was mainly focused on the exploration of the optimal mode of treatment for cryptorchidism, including hypogonadism such as Kallmann syndrome and Klinefelter syndrome.

Conclusion

Cryptorchidism has attracted continuous attention from the scientific community concerned. International collaboration in the field has witnessed significant growth in recent years and remains essential to further enhance collaborative efforts between scholars from different countries. In addition, the exploration of the optimal treatment modality for cryptorchidism, especially in the prevention of adult infertility, remains a major focus of future research. High-quality follow-up studies are also needed in the future. The pathogenesis (especially at the genetic level) and treatment of hypogonadism such as Kallmann syndrome and Klinefelter syndrome have attracted increasing attention recently, which may usher in some breakthroughs in coming years.

Diagnosis, Classification, and Contemporary Management of Undescended Testicles

This article provides a comprehensive review regarding undescended testicles and other related conditions. We have included background information summarizing variable clinical presentations, epidemiology, and the implications of undescended testis (UDT) on fertility and malignancy risk. This article has an emphasis on the approach to diagnosis and surgical management for the UDT. The purpose of this review is to provide readers with useful clinical tools for assessing and treating patients with cryptorchidism.

A dual-center study of predictive factors for sperm retrieval through microdissection testicular sperm extraction and intracytoplasmic sperm injection outcomes in men with non-mosaic Klinefelter syndrome

PURPOSE

This study evaluated the predictors of sperm retrieval (SR) in non-mosaic Klinefelter syndrome (KS) patients undergoing microsurgical testicular sperm extraction (mTESE). The cutoff values of the predictors of SR and overall pregnancy rates after intracytoplasmic sperm injection (ICSI) were analyzed for the positive SR (PSR) cases.

MATERIALS AND METHODS

The study was a dual-center retrospective study. Overall 118 patients with KS underwent mTESE between January 2011 and July 2021. Clinicopathological factors including comorbidities, endocrine profiles, and testicular volumes were analyzed.

RESULTS

A total of 58 patients showed PSR (49.2%) and 60 patients (50.8%) had negative SR (NSR). The mean overall age of the patients was 32.5 years. The NSR patients had a significantly greater prevalence of obesity, diabetes mellitus, and cerebrovascular disease. The PSR group had a significantly higher left testis mean volume (p=0.039). The differences between the two study groups regarding follicular-stimulating hormone, luteinizing hormone, and testosterone variations at 1 and 3 months after mTESE were insignificant. Preoperative mean neutrophil-to-lymphocyte ratio was significantly greater in the NSR group (p=0.011), but the platelet-to-lymphocyte ratio showed no significant difference between the two study groups. A live child birth was achieved in 53.4% of the PSR patients. Multivariate logistic analysis showed that total testicular volume >3.93 mL, left testis volume >1.79 mL, and neutrophil-to-lymphocyte ratio ≤1.82 were significantly associated with PSR.

CONCLUSIONS

mTESE-ICSI is a feasible method for KS patients to have a child, and total testicular volume, left testis volume, and neutrophil-to-lymphocyte ratio might be predictors of successful SR.

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.

Society for Endocrinology guidelines for testosterone replacement therapy in male hypogonadism

Male hypogonadism (MH) is a common endocrine disorder. However, uncertainties and variations in its diagnosis and management exist. There are several current guidelines on testosterone replacement therapy that have been driven predominantly by single disciplines. The Society for Endocrinology commissioned this new guideline to provide all care providers with a multidisciplinary approach to treating patients with MH. This guideline has been compiled using expertise from endocrine (medical and nursing), primary care, clinical biochemistry, urology and reproductive medicine practices. These guidelines also provide a patient perspective to help clinicians best manage MH.

Case Report: Orchiopexy in Two Poodle Dogs and Its Effect on Their Sperm Quality Parameters

Cryptorchidism is a common congenital abnormality encountered in veterinary clinics. The treatment of choice for this condition is a surgical procedure named orchiectomy or orchidectomy, where the retained testicle is removed. Surgical placement and fixation of the cryptorchid testicle into the scrotum, referred to as orchiopexy, is used in humans. However, due to the hereditary nature of cryptorchidism in dogs, this treatment option has not been proposed in veterinary clinics. Two adult Poodle dogs were referred to our research facility for a sperm parameter evaluation check. The two dogs were unilateral cryptorchid dogs treated with orchiopexy before the age of 6 months. Their sperm kinematics and morphology were within normal ranges, and their libido and testicles sizes were normal. Treatment of unilateral cryptorchidism by orchiopexy in dogs before the age of 6 months successfully restored spermatogenic function and sperm quality-related parameters. However, due to the nature of this condition, orchiectomy remains the treatment of choice.

[Health care reality of selected pediatric urologic surgeries in Germany from 2006 to 2019]

BACKGROUND

The conservative and surgical treatment of children is a fundamental pillar of the urological specialist training program and represents one of the core competencies within urological healthcare. The loss of this expertise has been a reoccurring topic within urologic occupational policy. The aim of this study is to analyse actual case numbers and to compare the distribution and dynamics of pediatric urologic surgeries between the specialist departments of urology and pediatric surgery in Germany.

MATERIALS AND METHODS

We defined the surgical treatments of maldecensus testis, hypospadias, and vesicoureteral reflux (VUR) as index interventions. Using the tool reimbursement.INFO (RI Innovation GmbH, Hürth, Germany) we analysed publicly available quality report data of German hospitals between 2006 and 2019.

RESULTS

While orchidopexy was more commonly performed in the field of urology, the correction of hypospadias and the surgical treatment of VUR showed higher case numbers in the field of pediatric surgery. Proportionally, there was no relevant shift between urologic and pediatric surgical clinics for orchidopexy and surgical VUR therapy during the study period. For hypospadias corrections, the proportion of surgeries performed in pediatric surgical units is increasing (p < 0.0001). In pediatric surgery 84-93% of the analyzed procedures are performed in high-volume units, while this proportion is 56-73% in urology. In particular, a high proportion of VUR therapy in urology is performed as an occasional procedure (30% very low volume).

CONCLUSIONS

The quality report data enable the compilation of case numbers and the analysis of the distribution between urology and pediatric surgery in Germany. Merely the correction of hypospadias has shown a relevant shift towards pediatric surgery. The causes and possible consequences for professional policy of this preliminary investigation are complex and require further analysis.

Management of high inguinal undescended testis: a review of literature

Background

Undescended testis is one of the most common paediatric surgical diagnoses. A lot of research has been done to date, to standardise the surgical management of intra-abdominal and extra-abdominal undescended testis. High inguinal undescended testis is a unique clinical encounter which demands additional surgical measures over conventional orchidopexy for better surgical results.

Main body of abstract

Open inguinal orchidopexy is a routine and quite straightforward operation for the majority of extra-abdominal undescended testis. However, there are instances in which the testis, even though situated in the inguinal region, poses a challenge for surgeons, to bring it in the scrotum by routine open inguinal orchiopexy. High inguinal testis can be defined as “any intra-canalicular testis present higher up in the inguinal canal and cannot be brought down easily to the scrotum by routine surgery as in standard orchiopexy (open or laparoscopy) and require additional lengthening manoeuvres”. It needs additional surgical lengthening manoeuvres like Prentiss, along with the steps of routine orchiopexy to bring it down in the scrotum. This review article describes the various nomenclatures of undescended testis, appropriate investigations and also various additional surgical measures in the management of difficult high inguinal testis.

Conclusion

High inguinal undescended testis poses a unique technical challenge even to well-experienced surgeons. It is very important that surgeons dealing with this condition are well aware of the anatomy in this region and also various different manoeuvres described to date to bring the testis down in the scrotum.

The outcome of laparoscopic assisted orchidopexy in very young children: A single hospital experience

INTRODUCTION

Early orchidopexy has been linked to improved long term outcomes of fertility and reduced malignancy rates. However, the optimal age of intervention has been subject to change over the years.

OBJECTIVE

This study aims to study males aged 6 months or less who undergo laparoscopic assisted orchidopexy for intraabdominal testes to establish the safety, efficacy, and benefit in the defined age group.

STUDY DESIGN

We prospectively assessed 19 boys at or below 6 months of age, who had laparoscopic assisted orchidopexy for intraabdominal undescended testes at Salmaniya Medical Complex in Bahrain between January 2014 and December 2018. We examined: demographics, laterality, testicular locations, testicular volumes, operative time, complications, and durations of hospitalization and follow-up. Ultrasound-derived testicular volumes were assessed before and after orchidopexy. They were calculated using the Hansen formula (Testicular volume = 0.52 × length [L] × width [W]² [1]. They were then compared with reference ranges from a Dutch cohort study of 769 healthy boys. Successful outcomes were correct intrascrotal position with minimal complications and normal testicular volumes.

RESULTS

A total of 19 males were operated at a mean age of 5.6 months and followed for a mean of 2.35 years. Of these, 7 had left-sided and 12 had right-sided cryptorchidism. Testicular locations were noted intra-operatively; 10 were above the internal ring, 5 near the iliac vessels, and 4 close to the kidney. The mean operative time was 59.58 minutes. Only 2 minor complications occurred and no cases of testicular atrophy. None of the patients required hospital-stay beyond 24 hours. The success rate was 89.46% in achieving correct scrotal position. Testicular volumes were normal before and after orchidopexy. They significantly increased after orchidopexy (P ≤ 0.05). The testicular growth rate after 24 months was slightly higher than normal.

DISCUSSION

In line with previous studies we were 89.46% successful in re-positioning testes [2]. In contrast to studies intervening at older ages which associated intra-abdominal testes with greater risks of complications, we found few minor complications and no testicular atrophy [3,4]. Testicular volumes in the affected testes were normal, contrary to decreased volumes found by other researchers [5]. Limitations of this study are the small number of patients and short follow-up which limits assessment of long-term outcomes.

CONCLUSION

Early orchiopexy is safe and effective. Laparoscopic assisted orchidopexy at an early age was beneficial and resulted in normal testicular volumes before and after surgery.

Correlation between testicular volume and histological findings in children with unilateral cryptorchidism: Potential impact on future fertility

OBJECTIVES

Our aim is to assess the correlation between testicular volume and histological findings in children with unilateral cryptorchidism.

METHODS

From September 2016 to August 2018, from 60 patients surgically treated for cryptorchidism, 45 children were enrolled in this single-center prospective study. Depending on the degree of testicular volume reduction, patients were divided into Group 1 with <20% reduction and Group 2 with reduction ⩾20%. Patients underwent unilateral orchidopexy and simultaneous biopsy of the undescended testis. Tanner stage was assigned. Tubular Fertility Index was measured.

RESULTS

Group 1 included 20 patients (44.4%) and Group 2 included 25 patients (55.5%). Mean age was 2.10 years (range 12 months-3.8 years) in Group 1 and 2.8 years (range 18 months-4.41 years) in Group 2. Although there is a positive correlation between testicular volume and Tubular Fertility Index, no significant association was found between groups (p-value = 0.29). Furthermore, histological patterns did not differ significantly among groups.

CONCLUSIONS

The degree of volume reduction in undescended testis does not seem to correlate significantly with the severity of histological changes that accompany cryptorchidism. Tubular Fertility Index could serve as objective tool for the assessment of future fertility.

Frequent azoospermia in patients with testicular germ cell cancer and a history of cryptorchidism: a report of nine cases and review of the literature

This study analyzed semen parameters in patients with testicular germ cell cancer and a history of cryptorchidism. Among testicular cancer patients referred for sperm cryopreservation, the semen of 9 patients with a history of cryptorchidism, including three cases of bilateral cryptorchidism and one case of cryptorchidism with bilateral metachronous tumor, was analyzed. Eight patients underwent orchidopexy during childhood. The tumor was observed on the contralateral side of the undescended testis, except in the bilateral metachronous tumor and cryptorchidism cases. Five patients, including the one who developed a metachronous testicular tumor on the undescended testis, showed azoospermia even though in three of them, semen was collected before undergoing orchiectomy. Clinical urologists should recognize that spermatogenesis is severely impaired in these patients and consider cryopreservation before orchiectomy or onco-TESE.

Timing of orchidopexy and its relationship to postoperative testicular atrophy: results from the ORCHESTRA study

Background

In 2011 a consensus statement from the British Association of Paediatric Urologists recommended lowering the age at orchidopexy to under 1 year. There are concerns that a younger age at operation may increase postoperative testicular atrophy. The ORCHESTRA study aimed to establish the current age at orchidopexy in a multicentre, international audit and to see whether testicular atrophy was affected by age at operation.

Methods

The study was undertaken over a 3-month period in 28 centres in boys undergoing orchidopexy for unilateral, palpable undescended testes. Data collection was done using a standardized, predetermined protocol. The primary outcome was postoperative testicular atrophy. Secondary outcomes were wound infections, reoperations, and unplanned hospital stays related to anaesthetic events.

Results

A total of 417 patients were included, of whom only 48 (11.5 per cent) underwent orchidopexy before 1 year of age. There was no difference in anaesthetic complications in boys aged less than 1 year versus older patients: 0 of 48 (0 per cent) versus 6 of 369 (1.6 per cent) (P = 0.999). Complete follow-up was available for 331 patients (79.4 per cent). There was no difference in atrophy rate between those aged less than 1 year and older boys: 1 of 37 (3 per cent) versus 9 of 294 (3.1 per cent) (P = 0.999). Reoperation rates were 0 of 37 (0 per cent) and 7 of 294 (2.4 per cent) respectively (P = 1.000). There were more wound infections in boys under 1 year of age: 4 of 37 (11 per cent) versus 7 of 294 (2.4 per cent) (P = 0.025).

Conclusion

Only 11.5 per cent of boys underwent surgery before the age of 1 year. There was no increased risk of postoperative testicular atrophy with early surgery, although there was a higher rate of wound infection. Further study is required to demonstrate that early orchidopexy is not inferior to orchidopexy undertaken in boys aged over 1 year.

Time response of rat testicular alterations induced by cryptorchidism and orchiopexy

Cryptorchidism is one of the main risk factors for infertility and testicular cancer. Orchiopexy surgery corrects cryptorchidism effects. Different models of cryptorchidism developed in the rat include surgery. We assessed testicular alterations in rats submitted to surgical cryptorchidism and examined their potential for reversibility at different time points in order to verify time dependency effect(s) on the recovery of the undescended testes. Cryptorchidism was induced in 3-week-old rats. Animals were euthanized 3, 6 or 11 weeks after surgery to evaluate the morphological progression of cryptorchidism-induced germinative epithelial alterations. Other groups underwent orchiopexy 3, 5 or 9 weeks after surgical cryptorchidism, before or after puberty. Animals were euthanized 3 or 8 weeks after orchiopexy. Controls underwent sham surgery at the same time points as the surgical groups. Cryptorchid testes showed decreased weight, germinative epithelial degeneration, apoptosis and vacuolation, corresponding to impairment of spermatogenesis and of Sertoli cells. Some tubules has a Sertoli cell-only pattern and atrophy. The intensity of damage was related to the duration of cryptorchidism. After orchiopexy, spermatogenesis completely recovered only when testicular relocation occurred before puberty and the interval for recovery was extended. These results indicate that age, sexual maturity and extension of germ cell damage were relevant for producing germ cell restoration and normal spermatogenesis. We provide original observations on the time dependency of testicular alterations induced by cryptorchidism and their restoration using morphologic, morphometric and immunohistochemical approaches. It may be useful to study germ cell impairment, progression and recovery in different experimental settings, including exposure to exogenous chemicals.

A Case to Overcome the Stigma of Testicular Cancer

Testicular cancer is seen commonly in young males and has a high cure rate if diagnosed and treated early. It clinically presents with painless testicular swelling. We discuss the case of a young previously healthy male with an aggressive testicular cancer which started with a testicular swelling but the primary site underwent necrosis secondary to its own vascular demand thus giving the false impression of resolution, but not before metastasizing to the rest of the body. With this case, we aim to highlight the importance of increasing awareness of testicular cancer and its presenting symptoms in young males and the need to overcome the stigma around the evaluation of testicular swellings.

Waiting time for short-stay surgery in a paediatric surgery department

AIM

The aim of this study was to assess the waiting time (WT) for a short-stay surgery and determine its possible determinant factors.

PATIENTS AND METHODS

This was a retrospective study conducted in the Department of Paediatric Surgery at the National Hospital of Lamordé of Niamey, Niger. It included patients aged 0-15 years who benefitted from a short-stay surgery (24-48 h of hospitalisation) during a period of 19 months (1st January 2017 - 31st July 2018). Patient, diagnosis and surgical treatment data were gathered. WT was the time elapsed between the indication of a surgical operation and its realisation. The Kruskal-Wallis test was used with a threshold statistical significance of < 0.05.

RESULTS

Short-stay surgery constituted 25.4% of all operating activities (n = 271). Inguinal or inguinoscrotal hernia was the most frequent pathology at 31.38% (n = 85). The mean WT was of 116.6 days (range: 4-491 days) and the median was 114 days. WT was greater than or equal to 3 months for 63.9% of the patients (n = 173). Based on pathology, the mean WT varied between 57.5 days (ovarian hernia) and 163.6 days (5.8 months) for epigastric hernia. A significantly longer WT was observed with the presence of a comorbidity (P = 0.0352) but was not associated with patient residence (P = 0.0951).

CONCLUSION

A long WT for a short-stay surgery should be improved upon by different interventions with respect to the supply and demand of care and the setting of priorities.

Comparison of diagnostic and treatment guidelines for undescended testis

Cryptorchidism or undescended testis is the single most common genitourinary disease in male neonates. In most cases, the testes will descend spontaneously by 3 months of age. If the testes do not descend by 6 months of age, the probability of spontaneous descent thereafter is low. About 1%-2% of boys older than 6 months have undescended testes after their early postnatal descent. In some cases, a testis vanishes in the abdomen or reascends after birth which was present in the scrotum at birth. An inguinal undescended testis is sometimes mistaken for an inguinal hernia. A surgical specialist referral is recommended if descent does not occur by 6 months, undescended testis is newly diagnosed after 6 months of age, or testicular torsion is suspected. International guidelines do not recommend ultrasonography or other diagnostic imaging because they cannot add diagnostic accuracy or change treatment. Routine hormonal therapy is not recommended for undescended testis due to a lack of evidence. Orchiopexy is recommended between 6 and 18 months at the latest to protect the fertility potential and decrease the risk of malignant changes. Patients with unilateral undescended testis have an infertility rate of up to 10%. This rate is even higher in patients with bilateral undescended testes, with intra-abdominal undescended testis, or who underwent delayed orchiopexy. Patients with undescended testis have a threefold increased risk of testicular cancer later in life compared to the general population. Self-examination after puberty is recommended to facilitate early cancer detection. A timely referral to a surgical specialist and timely surgical correction are the most important factors for decreasing infertility and testicular cancer rates.

Challenges to delivering pediatric surgery services in the midst of COVID 19 crisis: experience from a tertiary care hospital of Pakistan

Covid-19 pandemic has significantly challenged the healthcare delivery across the world. Surgery departments across the country responded to this challenge by halting all non-emergency procedures. This delay in diagnosis and management of surgical disease could result in significant mortality and morbidity among the most vulnerable population-the children. In this manuscript, we discuss the measures adopted as well as the challenges faced by the pediatric surgery department at Aga Khan University Hospital, Karachi (AKUH), Pakistan, which is a private, not-for-profit entity and providing optimum surgical care to the patients. We also underscore the need for global strategies for tackling such crisis.

Timing of paediatric orchidopexy in universal healthcare systems: international administrative data cohort study

BACKGROUND

International guidelines in 2008 recommended orchidopexy for undescended testis at 6-12 months of age to reduce the risk of testicular cancer and infertility. Using administrative data from England, Finland, Ontario (Canada), Scotland and Sweden (with data from Victoria (Australia) and Iceland in supplementary analyses), the aim of this study was to investigate compliance with these guidelines and identify potential socioeconomic inequities in the timing of surgery before 1 and 3 years.

METHODS

All boys born in 2003-2011 with a diagnosis code of undescended testis and procedure codes indicating orchidopexy before their fifth birthday were identified from administrative health records. Trends in the proportion of orchidopexies performed before 1 and 3 years of age were investigated, as were socioeconomic inequities in adherence to the guidelines.

RESULTS

Across all jurisdictions, the proportion of orchidopexies occurring before the first birthday increased over the study period. By 2011, from 7·6 per cent (Sweden) to 27·9 per cent (Scotland) of boys had undergone orchidopexy by their first birthday and 71·5 per cent (Sweden) to 90·4 per cent (Scotland) by 3 years of age. There was limited evidence of socioeconomic inequities for orchidopexy before the introduction of guidelines (2008). Across all jurisdictions for boys born after 2008, there was consistent evidence of inequities in orchidopexy by the first birthday, favouring higher socioeconomic position. Absolute differences in these proportions between the highest and lowest socioeconomic groups ranged from 2·5 to 5·9 per cent across jurisdictions.

CONCLUSION

Consistent lack of adherence to the guidelines across jurisdictions questions whether the guidelines are appropriate.

Embryonal carcinoma of an intraabdominal testicular tumor on an undescended testicle: a case report

Cryptorchidism, as a singular pathology or associated with other dysgenesis syndromes, is one of the main factors of risk for the development of the testicular tumors. Although there are a great number of cases of undescended testicles that are diagnosed and treated during the first 6-12 months of life, there are rare cases of adults who are undiagnosed and untreated from this anomaly, which can present a high risk of malignancy. In this study we present the case of a 36-year-old patient, diagnosed at puberty with left cryptorchidism, untreated, who also hadevidenced a large intraabdominal tumoral mass associated with it. The tumoral mass had its origin in the undescended left testicle. Surgical excision of the tumor and retroperitoneal lymphadenectomy was performed. The histological result revealed embryonal carcinoma, without lymphnode metastasis. Adult patients with untreated cryptorchidism should be thoroughly investigated, as they have a high risk of developing testicular cancer.

Age at Surgery and Outcomes of Undescended Testes at King Salman Armed Forces Hospital, Tabuk, Saudi Arabia

Objective The aim of this study was to investigate the age at diagnosis and surgery of undescended testes and patients' outcomes. Methods This is a retrospective study that reviewed the files of patients who underwent orchidopexy at the King Salman Armed Forces Hospital (KSAFH), Tabuk, Saudi Arabia (SA), between January 1, 2015, and March 30, 2019. All children from birth until 13 years old who were admitted within the specified time frame and underwent orchidopexy were included in this study. The gathered data were analyzed through the Statistical Package for Social Sciences software (SPSS, version 23; SPSS Inc., Chicago, IL, USA). Results  A total of 175 patients were included in this study. The rate of orchidopexy at our institution was 12.2%. The median ages at diagnosis and surgery were 12 and 24 months, respectively. The median duration between diagnosis and surgery was eight months. The most common site of undescended testis was inguinal (80.6%). Bilateral undescended testes were recorded in 24.6% of cases, and 25.7% of cases were impalpable. The size of the undescended testis was average in half the cases, small in 44.6% and atrophic in 6.4% of cases. Postoperative complications were reported in 4.0% of cases. Cox regression analysis revealed that the age at diagnosis was a significant risk factor affecting the time of surgery. Conclusion The findings of this study revealed that most cases of undescended testes in Tabuk were operated beyond the age recommended by international guidelines. The age at diagnosis seems to significantly affect the time of surgery.

Surgery for no palpable testis before the age of one year: a risk for the testis?

INTRODUCTION

Surgery for undescended testis is now commonly recommended before the age of one year. However, the risk of testicular atrophy or miss location after surgery at a young age has not been clearly evaluated.

OBJECTIVE

The objective of this study is to evaluate the rate of testicular atrophy after surgery for non-palpable testis before the age of one year.

MATERIALS

Fifty-five patients operated between 2005 and 2014 for non-palpable testes were reviewed for clinical and ultrasound (US) evaluation. Median follow-up after surgery was of 68.5 months (range 26-130 months). The median age at surgery was of months (5-12 months). Eight patients (14.5%) had bilateral non-palpable testis; thus, 63 testes were evaluated. At surgery, 38 (60%) testes were located in the high inguinal canal; 25 (40%), in the abdominal cavity. Orchiopexy was performed with preservation of the testicular vessels for 58 testes. Fowler-Stephens (FS) procedure was performed for 5 testes. Testicular location was clinically evaluated, and testicular volume was measured using a standard sonogram technique in our pediatric radiology department. Ratio comparing the volume of the descended testis to the spontaneously scrotal located testis was calculated in unilateral forms.

RESULTS

After surgery, testes had scrotal location in 62 cases and inguinal location in one case. Seven cases of atrophy were confirmed after US control (11%), more frequently (odds ratio, OR 11.68 [1.9-72.5]) in abdominal testis (24%) than in inguinal testis (2.6%). Atrophy testicular was more frequent with FS technique (OR 7.1 [1.3-40.1]), but the population was weak (N = 5). Median volume ratio for unilateral form was 0.88 [0-1.8]; 14 patients presented a ratio greater than 1.

DISCUSSION

The influence of the young age at surgery and the risk of post operative testicular atrophy had not been clearly evaluated. The term of 'no palpable testis' supports an heterogeneous group mixing abdominal and extra-abdominal testis sharing a uniform clinical presentation. Our rate of atrophy in the group of abdominal testes (24%) and inguinal testes (2.6%) is similar to the literature, which concerns older patients. The long-term sonogram assessment demonstrated a good development of the testis after surgery, especially in inguinal cases.

CONCLUSION

Surgery for no palpable testis before the age of one year does not lead to a superior risk of testicular atrophy compared with surgery at an older age and allows a good development of the testis.

Phenotype evolution and health issues of adults with Beckwith-Wiedemann syndrome

BACKGROUND

Beckwith-Wiedemann syndrome (BWS) phenotype usually mitigates with age and data on adulthood are limited. Our study aims at reporting phenotype evolution and health issues in adulthood.

METHODS

34 patients (16 males), aged 18-58 years (mean 28.5) with BWS were enrolled.

RESULTS

26 patients were molecularly confirmed, 5 tested negative, and 3 were not tested. Final tall stature was present in 44%. Four patients developed Wilms' Tumor (2, 3, 5, and 10 years, respectively); one hepatoblastoma (22 years); one acute lymphoblastic leukemia (21 years); one adrenal adenoma and testicular Sertoli cell tumor (22 and 24 years, respectively); and three benign tumors (hepatic haemangioma, uterine myoma, and mammary fibroepithelioma). Surgery for BWS-related features was required in 85%. Despite surgical correction several patients presented morbidity and sequelae of BWS pediatric issues: pronunciation/swallow difficulties (n = 9) due to macroglossia, painful scoliosis (n = 4) consistent with lateralized overgrowth, recurrent urolithiasis (n = 4), azoospermia (n = 4) likely consequent to cryptorchidism, severe intellectual disability (n = 2) likely related to neonatal asphyxia and diabetes mellitus (n = 1) due to subtotal pancreatectomy for intractable hyperinsulinism. Four patients (two males) had healthy children (three physiologically conceived and one through assisted reproductive technology).

CONCLUSIONS

Adult health conditions in BWS are mostly consequent to pediatric issues, underlying the preventive role of follow-up strategies in childhood. Malignancy rate observed in early adulthood in this small cohort matches that observed in the first decade of life, cumulatively raising tumor rate in BWS to 20% during the observation period. Further studies are warranted in this direction.

[Dental-craniofacial manifestation and treatment of rare diseases in China]

Rare diseases are genetic, chronic, and incurable disorders with relatively low prevalence. Thus, diagnosis and management strategies for such diseases are currently limited. This situation is exacerbated by insufficient medical sources for these diseases. The National Health and Health Committee of China recently first provided a clear definition of 121 rare diseases in the Chinese population. In this study, we summarize several dental-craniofacial manifestations associated with some rare diseases to provide a reference for dentists and oral maxillofacial surgeons aiming at fast-tracking diagnosis for the management of these rare diseases.

Dental-craniofacial manifestation and treatment of rare diseases

Rare diseases are usually genetic, chronic and incurable disorders with a relatively low incidence. Developments in the diagnosis and management of rare diseases have been relatively slow due to a lack of sufficient profit motivation and market to attract research by companies. However, due to the attention of government and society as well as economic development, rare diseases have been gradually become an increasing concern. As several dental-craniofacial manifestations are associated with rare diseases, we summarize them in this study to help dentists and oral maxillofacial surgeons provide an early diagnosis and subsequent management for patients with these rare diseases.

Gonadotropin-Induced Spermatogenesis in CHH Patients with Cryptorchidism

Congenital hypogonadotropic hypogonadism (CHH) patients with cryptorchidism history usually have poor spermatogenesis outcome, while researches focusing on this population are rare. This study retrospectively evaluated gonadotropin-induced spermatogenesis outcome in CHH patients with cryptorchidism (n = 40). One hundred and eighty-three CHH patients without cryptorchidism were served as control. All patients received combined gonadotropins therapy (HCG and HMG) and were followed up for at least 6 months. The median follow-up period was 24 (15, 33) months (totally 960 person-months). Sperm (>0/ml) initially appeared in semen at a median of estimated 24 months (95% confidence interval (CI) 17.8-30.2). Twenty (20/40, 50%) patients succeeded in producing sperms, and the average time to produce first sperm was 19 ± 8 months. Five pregnancies were achieved in 9 (5/9, 56%) couples who desired for children. Compared with CHH patients without cryptorchidism (n = 183), cryptorchid patients had longer median time for sperm appearance in semen (24 months vs. 15 months, P < 0.001), lower rate of spermatogenesis (50% vs. 67%, P=0.032), and lower mean sperm concentration (1.9 (0.5, 8.6) million/ml vs. 11.1(1.0, 25.0) million/ml, P=0.006) at the last visit. In conclusion, CHH patients with cryptorchidism require a longer period for gonadotropin-induced spermatogenesis. The successful rate and sperm concentration were lower than patients without cryptorchidism.

Systematic reviews and meta-analytic techniques

Systematic reviews (SRs) are a form of research methodology that addresses a specific research question by collecting, appraising and summarising all empirical evidence that fits pre-specified eligibility criteria. Systematic reviews have grown exponentially since their emergence in the late 1970 s as evidence-based medicine permeated medical culture. With several key advantages and limitations inherent to their design, all health care providers should be familiar with their basic structure, how to critically appraise them, and how to incorporate their findings into clinical practice. This review will contextualise systematic reviews within the broader framework of other review types, and outline the steps in conducting or appraising a systematic review. This includes the framing of an appropriate question, the search strategy, appraisal of included studies, as well as synthesis and analysis of the acquired data. A focus on SRs in the context of pediatric surgical practice will be emphasized. A concise primer on meta-analytic techniques is also provided, with resources highlighted for further reading.

Guideline implementation for the treatment of undescended testes: Still room for improvement

BACKGROUND

Early orchidopexy (OP) around the age of 1 year is recommended in boys with congenital undescended testis (UDT) worldwide since decades. Former retrospectives studies did not distinguish congenital from acquired UDT with a consecutive negative bias concerning the age at surgery.

METHODS

In a retrospective analysis, data of all boys who underwent OP in eight pediatric surgery institutions from 2009 to 2015 were analyzed. Congenital or acquired UDT were differentiated. Patients were categorized into 3 groups of age at surgery: (1) <12 months, (2) 12-24 months, (3) >24 months. Data of one institution were analyzed in detail: exact age of first referral, exact age at surgery, intraoperative findings.

RESULTS

Out of 4448 boys, 3270 boys had congenital UDT. In 81% (2656 cases) surgery was performed beyond the age of 1 year, in 54.4% (1780) beyond the age of 2 years. chi-Square statistics showed a higher rate of early operations in hospitals compared to outpatient services and in Germany compared to Switzerland. In 694 congenital detailed cases, median age at referral was 13 months [range 0-196], median age at surgery was 15 months [range 0-202].

CONCLUSION

Delayed referral is the main reason for guideline non-conform delayed surgery in UDT.

TYPE OF STUDY

Clinical Research paper.

LEVEL OF EVIDENCE

Level III: Treatment Study.

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.

Timing of orchidopexy at a tertiary center in Saudi Arabia: reasons for late surgery

BACKGROUND

Orchidopexy should be performed during the first 18 months of life to decrease the risk of infertility and tumor formation. In our center, the timing of surgical correction varies depending on the availability of an operating room.

OBJECTIVES

Evaluate whether orchidopexy performed for patients referred to our center is done within the recommended time period and to determine causes for delay.

DESIGN

Retrospective descriptive study.

SETTING

Pediatric urology department of a tertiary care center.

SUBJECTS AND METHODS

We retrospectively reviewed the charts of patients charts who underwent orchidopexy at our center from 2000 to 2010. We assessed referral time and waiting list time, which were subdivided as follows: from referral to first visit and from first visit to surgery. We included patients younger than 14 years and excluded pa.tients with comorbidities that affected the timing of referral and surgi.cal treatment.

MAIN OUTCOME MEASURES

Referral time period and waiting list time for surgical correction of patients presented with undescended testis.

SAMPLE SIZE

128 RESULTS: After exclusion of 32 patients because of comorbidities, we describe 128 who underwent surgery for cryptorchidism at our center. The median (interquartile range, minimum-maximum) for age at sur.gery was 46.7 months (24.4-83.4, 3.1-248.6]). The median (IQR) referral occurred at an age of 25.3 months (4.1-65.5). The median (IQR) waiting list time was 15.2 months (8.1-23.3). The median (IQR) waiting time from referral to the first visit was 4.1 months (1.0-8.2). The median wait.ing time from the first visit to surgery was 8.1 months (3.8-17.5).

CONCLUSIONS

The age at the time of surgery at our center was far from ideal because of late referrals. A structured program offered by our National Health Service to educate referring physicians is necessary. Community health initiatives must emphasize prompt referral to reduce the impact of delayed surgery.

LIMITATIONS

Lack of data on the type of referring physician (i.e., general practitioner, pediatrician, surgeon, urologist).

CONFLICT OF INTEREST

None.

Cryptorchidism in Sweden: A Nationwide Study of Prevalence, Operative Management, and Complications

OBJECTIVES

To review the cumulative prevalence, operative management, and complications of treatment for cryptorchidism in Sweden.

STUDY DESIGN

A nationwide observational study from longitudinal register data of all Swedish-born boys 0-18 years of age, diagnosed with cryptorchidism from 2001 to 2014. Primary outcomes were occurrence and age at primary surgery. Secondary outcomes included type of procedure and surgical site infection.

RESULTS

Of 20 375 boys diagnosed with cryptorchidism in 2001-2014, 12 766 were surgically treated. The cumulative childhood prevalence was 1.8% (95% CI, 1.5-2.0), with a higher prevalence in boys born prematurely, small for gestational age, or with low birth weight. The median age at treatment decreased from 6.2 years in 2001 to 3.4 years in 2014 (P < .001). Still, 94.1% (95% CI, 92.7-95.6) had surgery after the recommended 1 year of age in 2014. Variations in age at surgery between Swedish counties were great (range, 2.9-5.9 years of age). There were no deaths within 30 days after surgery and the frequency of surgical site infection was low (1.4%; 95% CI, 1.1-1.6).

CONCLUSIONS

The cumulative childhood prevalence of cryptorchidism was high, and complications were rare. Few boys underwent surgery in a timely manner according to clinical guidelines, and standards of care varied considerably across the country. Further research and collective actions are needed to improve the detection and management of congenital cryptorchidism.

Systematic review and meta-analysis comparing outcomes following orchidopexy for cryptorchidism before or after 1 year of age

Background

Current guidelines recommend orchidopexy for cryptorchidism by 12 months of age, yet this is not universally adhered to. The aim of this systematic review and meta‐analysis was to compare outcomes between orchidopexies performed before and after 1 year of age.

Methods

MEDLINE and Embase were searched (September 2015) using terms relating to cryptorchidism, orchidopexy and the outcomes of interest. Studies were eligible for inclusion if they compared orchidopexy at less than 1 year of age (early) with orchidopexy at 1 year or more of age (delayed) and reported the primary outcome (testicular atrophy) or one of the secondary outcomes (fertility potential, postoperative complication, malignancy). Studies were excluded when more than 50 per cent of infants had intra‐abdominal testes, or the population included infants with disorders of sexual differentiation. Additional studies were identified through reference list searching. Unpublished data were sought from the ORCHESTRA study investigators.

Results

Fifteen eligible studies were identified from 1387 titles. There was no difference in atrophy rate between early orchidopexy and delayed orchidopexy (risk ratio 0·64, 95 per cent c.i. 0·25 to 1·66; 912 testes). Testicular volume was greater (mean difference 0·06 (95 per cent c.i. 0·01 to 0·10) ml; 346 testes) and there were more spermatogonia per tubule (mean difference 0·47 (0·31 to 0·64); 382 testes) in infants undergoing early orchidopexy, with no difference in complication rate (risk ratio 0·68, 0·27 to 1·68; 426 testes). No study reported malignancy rate.

Conclusion

Atrophy and complication rates do not appear different between early and delayed orchidopexy, and fertility potential may be better with early orchidopexy. Imprecision of the available data limits the robustness of these conclusions.

Advances in paediatric urology

Paediatric urological surgery is often required for managing congenital and acquired disorders of the genitourinary system. In this Series paper, we highlight advances in the surgical management of six paediatric urological disorders. The management of vesicoureteral reflux is evolving, with advocacy ranging from a less interventional assessment and antimicrobial prophylaxis to surgery including endoscopic injection of a bulking agent and minimally invasive ureteric reimplantation. Evidence supports early orchidopexy to improve fertility and reduce malignancy in boys with undescended testes. A variety of surgical techniques have been developed for hypospadias, with excellent outcomes for distal but not proximal hypospadias. Pelvi-ureteric junction obstruction is mostly detected prenatally; indications for surgery have been refined with evidence, and minimally invasive pyeloplasty is now standard. The outlook for patients with neurogenic bladder has been transformed by a combination of clean intermittent catheterisation, algorithms of diagnostic investigations, and innovative medical and surgical therapies. Posterior urethral valves are associated with considerable mortality; fetal diagnosis allows stratification of candidates for intervention, but ongoing bladder dysfunction in patients after valve ablation remains a cause of long-term morbidity.

The management of boys under 3 months of age with an inguinal hernia and ipsilateral palpable undescended testis

AIMS

The optimal management for boys under 3 months of age with an indirect inguinal hernia (IIH) and ipsilateral palpable undescended testis (IPUDT) is unknown. We aimed to: 1) determine the current practice for managing these boys across the UK, and 2) compare outcomes of different treatment strategies.

METHODOLOGY

We undertook two studies. Firstly, we completed a National Survey of all surgeons on the British Association of Paediatric Surgeons email list in 2014. Subsequently, we undertook a multi-centre, retrospective, 10-year (2005-2015) review across 4 pediatric surgery centers of boys under 3months of age with concomitant IIH and IPUDT. Primary outcome was testicular atrophy. Secondary outcomes included need for subsequent orchidopexy, testicular ascent and hernia recurrence. Data are presented as median (range). Chi-squared test and multivariate binomial logistic regression analysis were used for analysis; p<0.05 was considered significant.

RESULTS

Survey: Consultant practice varies widely across the UK, with a tendency towards performing concurrent orchidopexy at the time of herniotomy under 3 months of age. Concurrent orchidopexy is favored less in cases where the hernia is symptomatic. Case Series Review: Forty-one boys with 43 concomitant IIH and IPUDT were identified, and all included. 32 (74%) hernias were reducible, 11 (26%) were symptomatic requiring urgent or emergency repair. Post-conceptual age at surgery was 45weeks (36-65). Primary operations included: 29 (67%) open hernia repair and standard orchidopexy, 8 (19%) open hernia repair with future orchidopexy if required, 4 (9%) laparoscopic hernia repair with future orchidopexy if required, 2 (5%) open hernia repair and suturing of the testis to the inverted scrotum without scrotal incision. Variation in atrophy rate between different surgical approaches did not reach statistical significance (p=0.42). Overall atrophy rate was 18%. If hernia repair alone was undertaken (8 open and 4 laparoscopic), the testis did not descend in 8 patients, requiring subsequent orchidopexy (67%); if orchidopexy was undertaken at the time of hernia repair, 1 in 29 required a repeat orchidopexy (3%) (p=0.0001). No hernia recurred.

CONCLUSION

This study suggests that orchidopexy at the time of inguinal herniotomy does not increase the risk of testicular atrophy in boys under 3months of age.

Evaluation of Pediatric Undescended Testes with Elastosonography

Background

Undescended testes, which are defined as the failure of testes to descend to scrotum, are the most common developmental defect in male infants. Indirect evaluation of histologic damage can be performed with the help of palpation during operation. Hard texture of testes tissue is likely related with histological damage. Real-time elastography is an emerging technology of ultrasonic imaging of soft tissue strain and elasticity, it aims at providing information regarding the mechanical properties of tissues, such as their hardness or stiffness. This study aim was to investigate the changes in strain and elasticity of testes tissue by using elastography technique.

Materials and methods

A total of 32 patients, who had undescended testes were included in this study. Only two patients had bilateral undescended testes, other patients had unilateral. The age of the patients were recorded according to the time of ultrasonographic (USG) examination. The undescended testes was displayed in the elastographic box with the neighbouring subcutaneous fat tissues. The strain ratios were measured as the ratios of the elasticities of the subcutaneous fat tissue to the elasticities of the undescended testes.

Results

A total of 32 patients with 34 testes were included in the study. The mean age of the patients with undescended testes was 32.6 months (range 7-60 months). The mean strain ratios were 0.67 (range 0.12-1.41) for the undescended testes and there were no significant differences in undescended testes strain ratios related to patient age (p = 0.453).

Conclusion

This preliminary study showed that there were no significant fibrosis which can be demonstrated with elastosonography before the age of 5 years old. Additional studies with his-topathological results are needed to identify sensitivity and specificity of elastosonography in undescended testis and in planning optimal operation time for these patients.

A systematic review of the quality of conduct and reporting of systematic reviews and meta-analyses in paediatric surgery

OBJECTIVE

Our objective was to evaluate quality of conduct and reporting of published systematic reviews and meta-analyses in paediatric surgery. We also aimed to identify characteristics predictive of review quality.

BACKGROUND

Systematic reviews summarise evidence by combining sources, but are potentially prone to bias. To counter this, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was published to aid in reporting. Similarly, the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) measurement tool was designed to appraise methodology. The paediatric surgical literature has seen an increasing number of reviews over the past decade, but quality has not been evaluated.

METHODS

Adhering to PRISMA guidelines, we performed a systematic review with a priori design to identify systematic reviews and meta-analyses of interventions in paediatric surgery. From 01/2010 to 06/2016, we searched: MEDLINE, EMBASE, Cochrane, Centre for Reviews and Dissemination, Web of Science, Google Scholar, reference lists and journals. Two reviewers independently selected studies and extracted data. We assessed conduct and reporting using AMSTAR and PRISMA. Scores were calculated as the sum of reported items. We also extracted author, journal and article characteristics, and used them in exploratory analysis to determine which variables predict quality.

RESULTS

112 articles fulfilled eligibility criteria (53 systematic reviews; 59 meta-analyses). Overall, 68% AMSTAR and 56.8% PRISMA items were reported adequately. Poorest scores were identified with regards a priori design, inclusion of structured summaries, including the grey literature, citing excluded articles and evaluating bias. 13 reviews were pre-registered and 6 in PRISMA-endorsing journals. The following predicted quality in univariate analysis:, word count, Cochrane review, journal h-index, impact factor, journal endorses PRISMA, PRISMA adherence suggested in author guidance, article mentions PRISMA, review includes comparison of interventions and review registration. The latter three variables were significant in multivariate regression.

CONCLUSIONS

There are gaps in the conduct and reporting of systematic reviews in paediatric surgery. More endorsement by journals of the PRISMA guideline may improve review quality, and the dissemination of reliable evidence to paediatric clinicians.