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

Management of the undescended testis in children: An American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee Systematic Review

PURPOSE

Management of undescended testes (UDT) has evolved over the last decade. While urologic societies in the United States and Europe have established some guidelines for care, management by North American pediatric surgeons remains variable. The aim of this systematic review is to evaluate the published evidence regarding the treatment of (UDT) in children.

METHODS

A comprehensive search strategy and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were utilized to identify, review, and report salient articles. Five principal questions were asked regarding imaging standards, medical treatment, surgical technique, timing of operation, and outcomes. A literature search was performed from 2005 to 2020.

RESULTS

A total of 825 articles were identified in the initial search, and 260 were included in the final review.

CONCLUSIONS

Pre-operative imaging and hormonal therapy are generally not recommended except in specific circumstances. Testicular growth and potential for fertility improves when orchiopexy is performed before one year of age. For a palpable testis, a single incision approach is preferred over a two-incision orchiopexy. Laparoscopic orchiopexy is associated with a slightly lower testicular atrophy rate but a higher rate of long-term testicular retraction. One and two-stage Fowler-Stephens orchiopexy have similar rates of testicular atrophy and retraction. There is a higher relative risk of testicular cancer in UDT which may be lessened by pre-pubertal orchiopexy.

Comparative study of testicular volume in children with unilateral cryptorchidism of different ages in the tropical province of China

OBJECTIVE

To assess the testicular volume in children with unilateral cryptorchidism of different ages in Hainan Province, China.

METHODS

The study included 424 children (ranging in age from 0 month to 4 years) with unilateral cryptorchidism or normal who were treated from 2017 to 2021 at our institution. They were divided into different groups according to age. We evaluated the correlation of testicular volume between the children with cryptorchidism and the normal children among different groups.

RESULTS

There was a significant difference in testicular volume between the affected side and the healthy side. There was no difference in testicular volume between the left side and the right side of each control group. There were significant differences between the affected side of cryptorchid groups and the same side of the control groups. There were no significant differences between the healthy side of cryptorchid groups and the same side of the control groups. There were no significant differences between the affected side of left cryptorchid groups and right cryptorchid groups. There were no significant differences between the healthy side of left cryptorchid groups and right cryptorchid groups. There were significant differences in testicular volume among different age groups of the control group, while there were no differences in the cryptorchid groups.

CONCLUSIONS

The development of testicular volume in children with unilateral inguinal cryptorchidism is affected in earlier age, and there was no compensatory testicular adaptation in the healthy testis.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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.

Abdominal cocoon with bilateral cryptorchidism and seminoma in the right testis: a case report and review of literature

BACKGROUND

Abdominal cocoon is a rare peritoneal lesion and is difficult to diagnose because of its lack of special clinical manifestations. Until now, there is no case report of abdominal cocoon combined with cryptorchidism and seminoma.

CASE PRESENTATION

A case of abdominal cocoon with cryptorchidism and seminoma was diagnosed and treated in our hospital. The patient had no symptoms except occasional abdominal pain. He underwent laparoscopy because of bilateral cryptorchidism and seminoma in the right testis. During the surgery, he was diagnosed with abdominal cocoon due to the thick fibrous tissues which was tightly adhered and encased part of intestine like a cocoon. Enterolysis and bilateral cryptochiectomy were performed after the diagnosis and nutritional and symptomatic support was provided after the surgery. The patient recovered well and was discharged soon. The postoperative pathological examination confirmed the presence of bilateral cryptorchidism and seminoma in the patient's right testis.

CONCLUSION

There are only a handful of cases where a patient has both abdominal cocoon and cryptorchidism. Since the etiologies of both diseases remain unknown, further research is required to investigate effective diagnosis and treatment for the diseases and explore the potential connection between the two diseases.

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.

Histopathology of Unilateral Cryptorchidism

Defective mini-puberty inducing insufficient gonadotropin secretion is one of the most common causes of nonobstructive azoospermia in men suffering from congenital isolated unilateral or bilateral cryptorchidism. The aim of our study was to determine the risk for azoospermia by histologic criteria in a cohort of unilateral cryptorchid boys undergoing orchidopexy and bilateral testicular biopsy. We performed a retrospective analysis of data available in the library of the Cryptorchidism Research Institute, Liestal, Switzerland. Complete histological evaluations were available for 319 boys operated on for unilateral cryptorchidism with simultaneous biopsy of the contralateral descended testicle. The median age was 39 (5-192) months and 58 patients were <18 months of age. Forty-eight percent of undescended testis (UDT) and 21% of contralateral testis had no A dark (Ad) spermatogonia. Furthermore, in 11% of boys Ad spermatogonia were lacking in both testes. Positive correlation was found between the spermatogonia/tubule ratio of the UDT and contralateral testis (Spearman rank order correlation is 0.16, P = .003). The extent of alteration in the UDT correlated with the contralateral descended testis, indicating that unilateral cryptorchidism is a bilateral disease. Observed impaired transition from gonocytes into Ad spermatogonia indicates defective mini-puberty, providing one of explanations for azoospermia and infertility development in unilateral cryptorchid men.

Delayed treatment of undescended testes may promote hypogonadism and infertility

CONTEXT

Undescended testes at birth may be caused by testosterone deficiency during fetal development. It is unclear whether the process of failed descent contributes to permanent endocrine impairment.

OBJECTIVES

To evaluate the impact of age at treatment of undescended testes on endocrine and spermatogenic testicular function in middle-aged men.

PATIENTS AND METHODS

Reproductive hormone and semen data of 357 men with previously undescended testes were evaluated with respect to age at correction of testicular position and compared to those of 709 controls with eutopic testes at birth and normozoospermia.

RESULTS

Men with undescended testes had higher mean Luteinizing Hormone levels (p < 0.0001) and lower mean testosterone levels (p = 0.003) compared to controls. They also had lower bi-testicular volumes, higher Follicle Stimulating Hormone levels, and lower sperm concentrations (all p < 0.0001). Lowest mean sperm concentrations were found in subjects with bilateral undescended testes. Normal sperm concentrations were found in 21 % of cases (in 27 % of men with unilateral and in 12 % with bilateral undescended testes), while oligozoospermia was diagnosed in 44 %, and azoospermia in 35 % (in 28 % with unilateral, 46 % with bilateral undescended testes). Subjects with reduced semen quality had higher gonadotropin levels than those with normozoospermia. Age at correction (median: 6 years (1-39)) was inversely correlated with bi-testicular volumes and sperm concentrations, and positively correlated with FSH and LH, but not with serum testosterone.

CONCLUSION

Latent, rarely decompensated hypogonadism is a potential long-term consequence of undescended testes, besides infertility and testicular cancer, preferentially affecting subjects with delayed or unsuccessful correction of testicular position. Impaired Leydig cell function is likely to contribute to compromised fertility. These observations support correction of cryptorchidism during early infancy.

Undescended testes: an update

PURPOSE OF REVIEW

This article summarizes the latest evidence on the risk factors, management and outcomes of undescended testes (UDTs).

RECENT FINDINGS

UDTs remain common, with increasing evidence that acquired UDT or the ascending testis syndrome should be considered part of the spectrum of this disease. Prompt diagnosis and early referral for surgical evaluation and treatment would seem most likely to result in an optimal functional and cosmetic outcome. Hormonal treatment, rather than orchidopexy, remains popular in some centers, despite a lack of good evidence to support its efficacy, although it may have an important adjunct role in optimizing fertility. Although often performed, ultrasound does not generally assist in the diagnosis and management of UDT, with enhanced education of primary care physicians more likely to facilitate early referral. The testis, rather than quiescent, appears biologically active in the male infant, with increasing evidence of an adverse impact on future spermatogenesis and fertility in men with a UDT.

SUMMARY

Male infants with a UDT should be diagnosed and referred early for surgical evaluation. It seems likely that the optimal timing for surgery should be before the boy's first birthday. There remains a need for high-quality, long-term outcomes data to guide optimal management.

Operative management of cryptorchidism: guidelines and reality--a 10-year observational analysis of 3587 cases

Background

Undescended testis (UDT) is the most common disorder in pediatric surgery and one of the most important risk factors for malignancy and subfertility. In 2009 local guidelines were modified and now recommend treatment to be completed by the age of 1. Aim of this study was to analyze age distribution at the time of orchidopexy, whether the procedure is performed according to guideline recommendations and to assess primary care pediatricians’ attitude regarding their treatment approach.

Methods

We retrospectively analyzed 3587 patients with UDT regarding age at orchidopexy between 2003 and 2012 in 13 German hospitals. Furthermore, we conducted an anonymized nation-wide survey among primary care pediatricians regarding their attitude toward management of UDT.

Results

Before modification of the guideline 78 % (n = 1245) of the boys with UDT were not operated according to guideline recommendations. After the modification that number rose to 95 % (n = 1472). 42 % of the orchidopexies were performed on patients aged 4 to 17 years. 46 % of the primary care pediatricians were not aware of this discrepancy and 38 % would only initiate operative management after the first year of life. In hospitals with pediatric surgery departments significantly more patients received orchidopexy in their first year of life (p < .001).

Conclusion

The guideline for UDT in Germany has not yet been implemented sufficiently. Timing of orchidopexy must be optimized in order to improve long-term prognosis. Both primary care providers and parents should be educated regarding the advantages of early orchidopexy in UDT. Prospective studies are needed to elucidate the high rate of late orchidopexies.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-015-0429-1) contains supplementary material, which is available to authorized users.