Surgical findings in acquired undescended testis

Diagnoses and Treatment of Acquired Undescended Testes: A Review

Acquired undescended testes were once considered a sporadic disease. In recent years, reports suggest that they are not uncommon, with an incidence rate about 3 times that of congenital undescended testes. The etiology of acquired undescended testes remains inconclusive, clinical diagnostic standards are unclear, and treatment approaches are still controversial. There is ongoing debate about the mechanism of testicular ascent. The prevailing view is that acquired undescended testes occur due to the partial absorption of the gubernaculum, which forms part of the parietal peritoneum. The residual gubernacular fibers continuously pull on the spermatic cord, preventing the spermatic cord from elongating proportionately to somatic growth, leading to a re-ascent of the testis. Acquired undescended testes may increase the risk of testicular cancer, but this is still debated. The preferred treatment method is also controversial. However, surgical fixation has an immediate effect; no studies have proven that early surgery improves fertility in patients. The etiology of acquired undescended testes is closely related to the continuous pull of the residual gubernacular fibers on the spermatic cord, which prevents the cord from extending proportionately to body growth. There are no clear diagnostic standards for acquired undescended testes yet, and spontaneous descent is possible, so testicular fixation surgery may not be the preferred treatment method.

Cryptorchidism and puberty

Cryptorchidism is the condition in which one or both testes have not descended adequately into the scrotum. The congenital form of cryptorchidism is one of the most prevalent urogenital anomalies in male newborns. In the acquired form of cryptorchidism, the testis that was previously descended normally is no longer located in the scrotum. Cryptorchidism is associated with an increased risk of infertility and testicular germ cell tumors. However, data on pubertal progression are less well-established because of the limited number of studies. Here, we aim to review the currently available data on pubertal development in boys with a history of non-syndromic cryptorchidism-both congenital and acquired cryptorchidism. The review is focused on the timing of puberty, physical changes, testicular growth, and endocrine development during puberty. The available evidence demonstrated that the timing of the onset of puberty in boys with a history of congenital cryptorchidism does not differ from that of non-cryptorchid boys. Hypothalamic-pituitary-gonadal hormone measurements showed an impaired function or fewer Sertoli cells and/or germ cells among boys with a history of cryptorchidism, particularly with a history of bilateral cryptorchidism treated with orchiopexy. Leydig cell function is generally not affected in boys with a history of cryptorchidism. Data on pubertal development among boys with acquired cryptorchidism are lacking; therefore, more research is needed to investigate pubertal progression among such boys.

Late ascended testes: is non-orthotopic gubernacular insertion a confirmation of an alternative embryological etiology?

INTRODUCTION

Re-ascended testes account for a proportion of all undescended testes (UDTs); one main hypothesis relating to their etiology relates to a patent processus vaginalis peritonei. The aim was to investigate gubernacular insertion points in boys with late ascended testis as a possible guide to an alternative embryological etiology.

PATIENTS AND METHODS

Patients with proven ascended testes were recruited from four different pediatric urology centers between May 2016 and September 2017. All patients were evaluated regarding their gubernacular insertion during orchidopexy. The presence of accompanying patent processus vaginalis and the association between the epididymis and testis were also documented.

RESULTS

Seventy-seven children (mean age = 73.1 ± 41.2 months [range 18-176]) were enrolled into the study. A non-orthotopic gubernacular insertion point was found in 96.1% (n = 74); 34.2% (n = 26) of these were located in the groin and 63.2% (n = 48), high within the scrotum. Figure A. An open processus vaginalis peritonei was found in 35.1%. Twelve patients (15.6%) had small, dysplastic appearing testis with testis-epididymis dissociation. Boys with a higher insertion of the non-orthotopic gubernaculum (n = 48, groin) were operated earlier (mean age at surgery, 62.3 months) compared with those with a gubernacular insertion at a high scrotal site (mean age at surgery, 90.5 months; p = 0.004). Figure B.

DISCUSSION

This study revealed that non-orthotopic gubernacular insertion is found in the vast majority of the ascending testis cases. Patent processus vaginalis was accompanying only 35.1% of all children and might be the cause of the ascending testis in this small subgroup of patients in line with the earlier reports [1]. In boys with ascending testes, in this population, the gubernaculum was very likely to insert non-orthotopically. In concordance with previous reports [2] and regarding the finding of a an earlier age at surgery in boys with higher inserting gubernacula, this could provide a logical explanation as to how these testes are initially palpable in the scrotum and then, during body growth are retracted to the groin.

CONCLUSION

In 96.1% of the patients, a non-orthotopic gubernacular insertion was found. This points to embryologic etiology, complying well with earlier reports and further underlining the critical importance of timely diagnosis and treatment for this group of patients.

Contralateral metachronous undescended testis: Is it predictable?

INTRODUCTION

Metachronous undescended testis (mcUDT), an acquired UDT after contralateral orchiopexy, can occur in some boys. If one were able to predict its occurrence, one might consider a proactive approach or at least one would be able to counsel the parents accordingly. Our hypothesis was there may be characteristics evident at the time of initial orchiopexy which could predict the development of contralateral mcUDT.

OBJECTIVE

The aim was to Identify factors present at initial orchiopexy that predict development of subsequent mcUDT.

STUDY DESIGN

Subjects were identified using the Current Procedural Terminology code for inguinal orchiopexy (54640). We included patients from January 1997 to October 2015. We included patients who underwent orchiopexy for unilateral UDT (uUDT). The study population consisted of patients who had undergone metachronous orchiopexies; controls were patients who were 17 years at time of data collection with a single orchiopexy. Cox proportional hazard regression was used to model the relationship between possible predictors of subsequent UDT using PROC PHREG with SAS Software 9.4.

RESULTS

From 1035 eligible patients we identified 38 with mcUDT and 207 controls (uUDT). Median age at the first orchiopexy of mcUDT patients was 2.5 years (min/max, 0.50/10.4 years) and 8.2 years (min/max 0.70/12.8 years) for uUDT, p < 0.0001. Subjects with a contralateral retractile testis on preoperative exam had a 4.2 times higher rate of subsequent UDT than patients with a contralateral descended testis (95% CI 2.077-8.353). The rate of mcUDT was 6.7 times higher if the testis was a retractile testis under anesthesia (95% CI 2.7-16.5) (Table).

DISCUSSION

Contralateral retractile UDT was a significant predictor of mcUDT. We believe patients with a contralateral retractile testis at time of orchiopexy should be counseled on bilateral orchiopexy. The risks of complications with orchiopexy should be weighed against risks of a subsequent surgery and anesthesia event.

CONCLUSION

A discussion of risks and benefits regarding bilateral orchiopexies should be undertaken with the parents prior to surgery in the setting of an UDT with contralateral retractile testis.

[Congenital undescended testis: Should open processus vaginalis have any impact on the elected surgical approach?]

PURPOSE

Compare the position of the undescended testis at clinical examination and under general anesthesia with the patency of an open processus vaginalis.

PATIENTS AND METHODS

We included children from 2 to 18 years of age operated for a unilateral or bilateral undescended testis between January 2006 and April 2014 at the Annecy Genevois hospital, France. The analysis was conducted considering that the individual was the testis. Testicular position before surgery, under general anesthesia and patency of open processus vaginalis as a surgical finding were prospectively recorded.

RESULTS

Three hundred and six children were included. The analysis was conducted over 401 testes. The position at clinical examination was significantly linked to a persistent open processus vaginalis (P=0.0045). Over the 282 testes considered as candidate for Bianchi's procedure, as to say intra- or supra-scrotal under general anesthesia, 154 had a persistent processus vaginalis (55%).

CONCLUSION

There is a link between a persistent processus vaginalis and the location of the undescended testis which should encourage us not to neglect the inguinal approach, and eventually to question the relevance of Bianchi's procedure.

LEVEL OF EVIDENCE

4.

Long-term testicular position and growth of acquired undescended testis after prepubertal orchidopexy

PURPOSE

The aim of the study was to determine long-term testicular position and growth of acquired undescended testis (UDT) after prepubertal orchidopexy.

METHODS

Patients who had undergone prepubertal orchidopexy for acquired UDT at our hospital between 1986 and 1999 were recruited to assess long-term testicular position and volume. Testis position was assessed by physical examination. Testis volume was measured with Prader orchidometry and ultrasound and was compared with normative values reported in the literature.

RESULTS

A total of 105 patients (aged 14.0-31.6 years) were included with 137 acquired UDT (32 bilateral, 33 left sided, and 40 right sided). All but 1 of the orchidopexied testes (99.3%) were in low scrotal position. The mean volume of the orchidopexied testes in unilateral UDT (n = 73, 10.57 ± 3.74 mL) differed significantly from the size of the testes at the contralateral side (14.11 ± 4.23 mL) (P = .000). The operated testes (10.28 ± 3.45 mL) were smaller than the mean adult testis volume reported in the literature (13.4-13.6 mL; cutoff, 13.2 mL).

CONCLUSION

Testis position after prepubertal orchidopexy for acquired UDT was nearly always low scrotal. The volume of the orchidopexied testes was smaller than both the volume of the contralateral testes and the normative values reported in the literature.

Acquired cryptorchidism in a boy with disorder of sex development

Recently, it has been reported that boys with severe hypospadias are at increased risk for acquired cryptorchidism. The reports suggested that prenatal and postnatal androgen disruption might be correlated with this condition. We experienced a case of ovotesticular disorder of sex development (DSD), which was ultimately diagnosed at surgery for acquired cryptorchidism. Ascent of the scrotal contents of the left side was detected in a 7-yr-old boy with the 46, XX karyotype, who had a history of perineal hypospadias repair. Intraoperative findings revealed the left gonad consisted of 2 segments, and this was histologically diagnosed as ovotestis by biopsy specimen. Resection of the ovarian segment was performed simultaneously. Exploration of the contralateral gonad showed the same findings. This is the first report of acquired cryptorchidism observed in a patient with DSD presenting with ambiguous genitalia.

Perioperative surgical findings in congenital and acquired undescended testis

PURPOSE

Perioperative surgical findings in congenital and acquired undescended testis (UDT) were prospectively assessed.

METHODS

We included all boys with congenital or acquired UDT who underwent orchidopexy at our hospital between January 2006 and August 2009. Perioperatively, we scored the position and volume of the testis, the insertion of the gubernaculum, the patency of the processus vaginalis, and the obtained position.

RESULTS

We included 69 boys (aged 0.9-14.6 years) with 76 congenital UDT and 28 boys (aged 2.2-18.5 years) with 30 acquired UDT. In the congenital group, the testis was in intracanalicular position in 55 cases (72%), whereas in the acquired UDT group, this was in 11 cases (37%; P < .001). The insertion of the gubernaculum was at the bottom of the scrotum in 13 cases (17%) of the congenital UDT group and in 12 cases (40%) of the acquired UDT group (P < .05). The processus vaginalis was open in 63 cases (83%) of the congenital and in 9 cases (30%) of the acquired UDT group (P < .001).

CONCLUSION

Compared to congenital UDT, acquired UDT are more likely to be situated in the superficial inguinal pouch, to have a normal insertion of the gubernaculums, and to have a closed processus vaginalis.

Relevance of herniography for accurate diagnosis of patent processus vaginalis in cryptorchidism

OBJECTIVE

To clarify the role of peritoneography in assessing the patency of processus vaginalis (PV) in pediatric patients diagnosed with cryptorchidism.

MATERIALS AND METHODS

We designed a prospective clinical trial to evaluate the patency of PV in boys presenting cryptorchidism. Herniography was performed in 310 prepubertal boys. Data about the morphology of PV was compared with operative findings in those surgically treated patients. Retractile and ectopic testes were excluded from the study.

RESULTS

Of the 376 undescended testes (310 patients), 281 cases were associated with an obliterated PV. Herniography revealed 95 cases of open PV in cryptorchid boys. The 244 normally descended testes had associated patent processus vaginalis in only 31 cases.

CONCLUSIONS

Herniography is the most relevant procedure for accurate diagnosis of persistent PV. The persistence of PV was significantly more frequent when the position of the testes is more cranial. The incidence of an open PV decreases with age.

The nomad testis

Perspective on the paper by Hack et al(see page 17)