Testicular hypertrophy as a predictor for contralateral monorchism: Retrospective review of prospectively recorded data

Does the contralateral testicular volume decide the need for diagnostic laparoscopy in cases of unilateral impalpable undescended testis?

BACKGROUND

This study aimed the evaluation of the value of the calculated volume of a normal testis to predict the status of its contralateral impalpable side and hence decide the importance of laparoscopic exploration.

METHODS

Patients with unilateral impalpable undescended testis - as confirmed by clinical and sonographic examination- were enrolled in our prospective interventional study between November 2018 and August 2022 at Elshatby University Hospital, Faculty of Medicine, Alexandria University. The volume and three-dimensional diameter of the normal contralateral testis were measured by the pre-operative US using the formula: Volume = L x W x H x π/6, where L is the length, W is the width, H is the height, and was correlated with the intra-operative laparoscopic findings.

RESULTS

Seventy-six patients were included in our study. The age of the studied patients ranged between 6 months and 4 years with a mean of 2.17 ± 1.30 years; most of them were between one and three years old. Forty-six patients (60.5%) have left-sided impalpable testis and 30 patients (39.5%) have right-sided impalpable testis. The calculated volume of the contralateral normal testis was significantly larger in those patients who had both blind ending vas and vessels (0.89 ± 0.16) and in those who had an atrophic testis passing through the deep inguinal ring (DIR) -which was excised through the inguinal region- (0.83 ± 0.20) than in those patients who had their testes intra-abdominal (0.53 ± 0.18) or passing through the DIR to the inguinal region (0.80 ± 0.19). (Kruskal Wallis test; p < 0.001*).

CONCLUSIONS

The calculated sonographic volume of a normal testis can predict the status of its contralateral impalpable side significantly with sensitivity & specificity of 75.0% & 88.89% respectively and a cut-off point of ≤ 0.674; hence, helps in parent counselling preoperatively.

TRIAL REGISTRATION

Name of the registry: Clinicaltrials.gov PRS.

TRIAL REGISTRATION NUMBER

NCT05933811. Date of registration: 10-7-2023 (retrospectively registered). URL of trial registry record: https://clinicaltrials.gov .

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.

The optimum cut-off value of contralateral testis size in the prediction of monorchidism in children with nonpalpable testis: A systematic review

BACKGROUND

Contralateral Testis Hypertrophy (CTH) is a clinical marker that could be used to guide the choice of the main surgical strategy. In patients with a Non-palpable Testis (NPT), the degree of CTH as measured by testicular length or volume has been shown to be able to predict whether the undescended testis will survive.

OBJECTIVE

The purpose of this study was to establish the proper cut-off for identifying non-viable testes based on the current literature.

DESIGN

We systematically searched several medical databases as well as Google Scholar search engines for references and citations. All the studies that reported CTH as a result of NPT in prepubertal boys were included. Data from the included articles was gathered by two independent reviewers. The checklist developed by the Joanna Briggs Institute (JBI) was used to evaluate the methodological quality of the studies that were included. Due to the incredibly high degree of heterogeneity among the studies, no meta-analysis was done.

RESULTS

The current systematic review included 17 studies that assessed the cut-off point to detect non-viable testis. The size and length of the testes were taken into consideration based on our findings. We found that different studies reported various ideal cut-off values for predicting non-viable testes, which can be brought on by various measuring techniques, evaluation ages, and patient groupings. The difference in testis volume was greater than the difference in its length, which can be attributable to the fact that some studies used an orchidometer to measure the testis's length directly or indirectly.

CONCLUSION

According to the results of our study, it seems that defining a cut point for diagnosis of CTH based on the size of the testis, cannot demonstrate the absence of a non-palpable testis.

Abdominal Cryptorchidism with Complete Dissociation between the Testis and Deferent Duct Mimicking Testicular Regression Syndrome

Complete separation of the deferent duct from the epididymis in cryptorchid testes residing in the abdomen is an extremely rare variant of developmental disorders of the testis and epididymis. Available sources mention only three clinical cases similar to our observations. The unique anatomic aspects of this disorder hamper the correct diagnosis of an intra-abdominal cryptorchid testis. Two boys with nonpalpable left-sided cryptorchidism underwent diagnostic laparoscopy, revealing an intra-abdominally located testis. The epididymis was completely separated from the deferent duct, and the epididymis and testis were supplied by testicular vessels. Exploration of the inguinal canal revealed blind-ending deferent ducts. The testis was brought down through the inguinal canal and fixed in the scrotum in both boys. The follow-up examination at 6 months revealed no signs of testicular atrophy or malposition of the testis in either patient. With our observations in mind, the exclusive use of a transscrotal or transinguinal approach as the initial surgical exploration in the treatment of patients with nonpalpable forms of cryptorchidism may be inappropriate. Careful laparoscopic examination of the abdominal cavity is indispensable in children with suspected testicular regression syndrome or nonpalpable forms of cryptorchidism.

Diffusion‐weighted imaging and conventional magnetic resonance imaging for detection of non-palpable undescended testis

Background

MRI is noninvasive imaging tool and does not imply ionizing radiation and applies multiplanes images, but it is sometimes less efficient in locating intraabdominal functioning testicles and it fails to locate most of the atrophied testicles. Our aim in this study was to assess the value of the combined conventional MR imaging and DWI in the detection of non-palpable undescended testes in pediatric patients and correlate the results with the laparoscopic finding.

Results

This prospective study was carried out from January 2020 to February 2022 on 60 pediatric patients with 68 non-palpable undescended testes referred from Urology department to the radiodiagnosis and medical imaging department at our institute for MR imaging evaluation of clinically diagnosed non-palpable undescended testis, and their age ranged from 6 months to 17 years with mean age of 4.24 ± 4.67 years. The conventional MRI sensitivity was 85.71%, specificity was 100%, NPV was 60%, and PPV was 100% with accuracy of 88.23%. The combined DWI and MRI sensitivity was 92.86%, specificity was 100%, NPV was 75%, and PPV was 100% with accuracy of 94.12%. DWI was able to detect all viable abdominal testes, while only detecting 26 (out of 28) inguinal testes. Combined assessment was able to detect all viable abdominal and inguinal testes.

Conclusions

Combined DWI with a high b value and conventional MRI including T1WI, T2WI and fat-suppression T2WI showed considerable diagnostic performance compared to conventional MRI alone improving the preoperative sensitivity and accuracy of detection of non-palpable undescended testes.

Contralateral testicular hypertrophy is associated with a higher incidence of absent testis in children with non-palpable testis

BACKGROUND AND OBJECTIVE

The objective of our study is to examine the impact of monorchism on contralateral testicular size in children with non-palpable testis (NPT). Enhanced contralateral testicular volume or longitudinal diameter (length) serves as a predictor of monorchism. In the present study, we assessed the ability of ultrasound measured enlarged contralateral testicular length for predicting monorchism (and hence a testicular nubbin) in children with NPT. Furthermore, we evaluated the general prevalence of viable versus non-viable testes in patients referred to our institution with unilateral undescended testis between 2005 and 2020.

STUDY DESIGN

We analysed the records of 54 patients who underwent diagnostic laparoscopy for NPT between 2005 and 2020 in a European tertiary care centre. Testicular lengths (longitudinal diameter) and testicular volume of the contralateral testis, as well as surgeon (surgeon 1 vs surgeon 2 vs others) and age at surgery (months) were assessed and stratified according to intraoperative findings (presence or absence of a testicular nubbin). Testicular length and volume were evaluated by ultrasound examination in office prior to surgery. Chi-square and t-test for descriptive analyses as well as uni- and multivariable logistic regression analyses were performed using R Version 3.1.0 (R Project for Statistical Computing, www.R-project.org).

RESULTS

A total of 15 children presented with viable testes and 39 patients with testicular nubbin. Mean age was 20.5 months in the overall cohort and 22.6 vs 19.7 months in children with viable testis vs testicular nubbin (p = 0.4). In patients with presence of a testicular nubbin, the contralateral testis was larger (median length 17 mm (16-19.2)) as compared to patients with a viable testis (median length 15 mm (14-17), p = 0.001). Similarly, contralateral testicular volume was lower in patients with a present viable testis (0.6 ccm vs 0.8 ccm; p < 0-001). This effect remained statistically significant when logistic regression analyses were adjusted for age and weight at surgery, year of surgery, surgeon, and laterality. OR (odds ratio) for presence of a testicular nubbin was 1.6 (per mm) [95% CI (confidence interval) 1.13-2.17; p = 0.007].

CONCLUSION

Patients with preoperative increased length and volume of the contralateral testis in the ultrasound examination are at significantly higher risk of monorchism than their counterparts with lower testicular length. This should be emphasized during counselling of the parents prior to surgery. In our experience parents cope more easily with the diagnosis of monorchism, once this has already been discussed and explained thoroughly prior to surgery.

In Which Patients and Why Is Laparoscopy Helpful for the Impalpable Testis?

Since laparoscopy has been proposed in the management of the nonpalpable testis (NPT), this technique has been widely diffused among pediatric surgeons and urologists, but its application is still debated. We conducted a retrospective review to highlight how diagnostic and surgical indications for laparoscopy are selective and should be targeted to individual patients. From 2015 to 2019, 135 patients with NPT were admitted to our surgical division. Of these, 35 were palpable on clinical examination under anesthesia and 95 underwent laparoscopy. The main laparoscopic findings considered were: intra-abdominal testis (IAT), cord structures that are blind-ending, completely absent, or entering the abdominal ring. The patients' mean age was 22 months. In 48 cases, an IAT was found, and 42 of these underwent primary orchidopexy while 6 had the Fowler-Stephens (FS) laparoscopic procedure. Of the first group one patient experienced a testicular atrophy while two a reascent of the testis. In the FS orchidopexy group, one patient had testicular atrophy. Cord structures entering the internal inguinal ring were observed in 35 children, and all were surgically open explored. In 3 cases of these, a hypotrophic testis was revealed and an open orchidopexy was executed. In the remaining the histological examination revealed viable testicular cells in four patients and fibrosis, calcifications, and hemosiderin deposits in the others. Eleven patients presented with intrabdominal blind-ending vessels and one a testicular agenesia. A careful clinical examination is important to select patients to submit to laparoscopy. Diagnostic laparoscopy, and therefore, the anatomical observation of the testis and cord structures are strictly related to develop a treatment plan. In IAT, many surgical strategies can be applied with good results. Laparoscopy offers a concrete benefit to the patient.

Diagnosis and treatment of the intra-abdominal gonad in the pediatric population: Testes, ovaries, dysgenetic gonads, streaks, and ovotestes

BACKGROUND/PURPOSE

Pediatric surgical specialists are often confronted with the difficult task of identifying, diagnosing and managing intra-abdominal gonads in children. Ranging from the intra-abdominal cryptorchid testis to normal or pathologic ovaries and gonads in disorders of sexual development, all intra-abdominal gonads in the pediatric population pose different diagnosis and management challenges. Understanding the hormonal and fertility potential of the gonad and knowing its potential cancer risk is essential when deciding how to manage these patients. In addition, the ideal surgical management for each one of these patients is often debated.

METHODS

Descriptive literature review.

RESULTS/CONCLUSION

Herein, we reviewed gonadal formation, common etiologies, diagnosis and management of intra-abdominal testes, pathologic ovaries and gonads in disorders of sexual development. Fertility potential and cancer risk for each were also reviewed and how both affect surgical management of the gonad.

TYPE OF STUDY/LEVEL OF EVIDENCE

Review Article, Level V.

Testicular hypertrophy as predictor of contralateral nonpalpable testis among Chinese boys: An 18-year retrospective study

OBJECTIVE

To assess the accuracy of contralateral testis hypertrophy for predicting the fate of nonpalpable testis in Chinese boys at different ages.

METHODS

The data of patients who presented with unilateral impalpable testis and who underwent laparoscopy at the Children's Hospital of Chongqing Medical University between January 1, 2000 and January 1, 2018 were reviewed. The boys were divided into four groups: age-matched volunteers with no testicular abnormalities represented the control group (group I), boys with palpable undescended testis (group II), boys with nonpalpable testis (NPT)/viable testis (VT) (group III), and boys with NPT/non-viable testis (NVT) group (group IV). Scrotal testes were prospectively measured by ultrasonography for volume and size, and diagnostic laparoscopy was performed to determine the state of the cryptorchid testis.

RESULTS

The mean contralateral testicular volume and length in the boys with an absent testis was 0.78mL and 17mm compared with 0.67mL and 15mm in the boys with a testis present and 0.63mL and 15mm in the controls, respectively (P<0.05). The predictive accuracy, sensitivity, and specificity for an absent testis were 64.9%, 75%, and 49%, respectively, for volume and 64.2%, 56.3%, and 76.4%, respectively for length at the optimal cutoff value of 0.65mL volume and 16.55mm length. Contralateral testis volume was the most accurate in predicting monorchism in 0-2-year-olds (sensitivity: 75%, specificity: 70%, accuracy: 73.1%) and the contralateral testicular length was most accurate for 4-6-years-old (sensitivity: 68.6%; specificity: 77.8%; accuracy: 72.2%). We also included 29 patients with bilateral undescended testis (UDT) and with unilateral nonpalpable. Cutoff values for testicular volume and length were 0.6mL (sensitivity: 81.8%, specificity: 88.9%, accuracy: 86.2%) and 13.5mm (sensitivity: 63.6%, specificity: 77.8%, accuracy: 77.8%).

CONCLUSION

The present results exclusively obtained from laparoscopic exploration suggest that a testis volume of>0.65mL or a testis length of>16.55mm could predict monarchism with an accuracy of about 65%. In younger patients aged 0-2 years and 4-6 years, the overall predictive accuracy increases to about 73% but laparoscopic exploration is still required.

Detection of monorchidism in boys with unilateral undescended testes: clinical benefits and limitations of contralateral testicular size

INTRODUCTION

Contralateral testicular size was recommended as an effective measurement in prediction of monorchidism in some previous studies but a few argued it as invalid. Further investigation was demanded.

OBJECTIVES

To investigate the effectiveness of contralateral testicular size in prediction of monorchidism in patients with unilateral non-palpable undescended testes (NPT) aged between 9 and 48 months.

MATERIALS AND METHODS

Total of 707 patients aged between 9 and 48 months and diagnosed with unilateral undescended testes (UDT) between January 2016 and December 2018 at the study department were enrolled. In accordance with physical examinations and surgical findings, patients were divided into three groups: palpable UDT (group A, n = 609), non-palpable but viable testes (group B, n = 57) and monorchidism (group C, n = 41). Contralateral testicular length and volume were evaluated with ultrasonography. Comparison of contralateral testicular size between three groups and calculation of optimal cut-off value and diagnostic performance of it among NPT were performed.

RESULTS

The length and volume of contralateral testes of group C were larger than of group A (P < 0.01) and group B (P < 0.01), whereas these differences between groups were small. Among patients with NPT, a receiver operating characteristic curve was used to determine the optimal cut-off value. It revealed that both a testicular length of 17.5 mm and a volume of 1.05 ml provided the highest Youden's index for prediction of monorchidism. The sensitivity and specificity for testicular length were 34.1% and 94.7%, and volume were 34.1% and 93%, respectively. The predictive accuracy for testicular length and volume were 69.4% and 65.7%, respectively. Even though the negative predictive value was merely 66.6% (54/81) and 66.2% (53/80), the positive predictive value (PPV) reaches to 82.3% (14/17) and 77.7% (14/18) for testicular length and volume.

DISCUSSION

Several factors including choosing of measurement tools, age range, ethnicity, and selection bias of cohorts may be accounted for the huge differences among cut-off values and predictive accuracy. The diagnostic performance of contralateral testicular size in prediction of monorchidism in patients with NPT was poor. But the PPV was relatively promising. Contralateral testicular hypertrophy can provide information for surgical planning.

CONCLUSION

The overall diagnostic performance of contralateral testicular size in prediction of monorchidism in poatients with UDT aged between 9 and 48 months was poor. But the efficiency of cut-off value predicting absence of viable testes was relatively higher. This value should be objectively applied but only as a reference which would not be a complete replacement of laparoscopy exploration.

Impact of Preoperative Ultrasonographic Evaluation for Detection of a Viable Testis in Patients With a Unilateral Nonpalpable Testis

OBJECTIVES

To investigate the impact of preoperative ultrasonography (US) for detecting a viable testis in patients with a unilateral nonpalpable testis.

METHODS

Patients with a unilateral nonpalpable testis or unilateral palpable undescended testis who underwent preoperative US were enrolled. Patients were divided into 3 groups as follows: nonpalpable testis/no testis (n = 27), which included patients who had a unilateral nonpalpable testis with no viable testis detected at surgery; nonpalpable testis/viable testis (n = 10), which included patients who had a unilateral nonpalpable testis with a viable testis identified at surgery; and palpable undescended testis (n = 63), which included patients who had a unilateral palpable undescended testis. Preoperative US findings were compared among each group.

RESULTS

The testicular volume on the contralateral descended side in the nonpalpable testis/no testis group was significantly greater than that in the nonpalpable testis/viable testis and palpable undescended testis groups. When a testicular volume of 0.54 mL was used as the cutoff value, the sensitivity, specificity, positive predictive value, and negative predictive value for the presence of the affected testis were 75.3%, 100%, 100%, and 60.0%, respectively. The testis on the affected side was detected in none of the nonpalpable testis/no testis group, 7 of the nonpalpable testis/viable testis group, and all of the palpable undescended testis group. When a visible testis on the affected side and a testicular volume of 0.54 mL or less were defined as positive, all patients in the nonpalpable testis/viable testis and palpable undescended testis groups had positive findings versus none in the nonpalpable testis/no testis group.

CONCLUSIONS

Preoperative US provides valuable information for predicting the presence of a viable testis in patients with a unilateral nonpalpable testis by estimating both the unaffected testis and the affected side.

Scrotal testis size in unilateral non-palpable cryptorchidism, what it can and cannot tell: Study of a Middle Eastern population

BACKGROUND

Predicting the fate of a unilateral non-palpable testis based on its scrotal counterpart has been recommended by some, yet disputed by others, and the question remains open.

OBJECTIVE

To investigate the accuracy of contralateral testis hypertrophy in predicting the absence of a unilateral non-palpable testis in a Middle Eastern population.

STUDY DESIGN

This retrospective study included all patients referred to the present institution with unilateral non-palpable testis between June 2010 and August 2014, who had undergone laparoscopy. The scrotal testis was examined by sonography for size and volume, and diagnostic laparoscopy was utilized to determine the state of the cryptorchid testis.

RESULTS

Of the 135 referred patients, 64 were aged ≤8 years, 29 were 9-18 years, and 42 were >18 years old. Diagnostic laparoscopy revealed 63 intra-abdominal testes, 20 small intra-inguinal testes, 32 vanished testes, and 20 nubbins or aplasia (Summary fig.). Scrotal testis volume was only a modest predictor for absence of the contralateral gonad in adult patients in whom a 22 ml cut-off yielded 64.3% sensitivity and 92.9% specificity. For those aged <18 years, overall accuracy was poor and dropped below 60%. Relative enlargement of contralateral testis in decreasing order of size was observed in patients with primary monorchism, followed by those with secondarily atrophic or nubbin testis, and then those with normal sized inguinal or abdominal testis.

DISCUSSION

Unlike some previous series, which based their conclusions upon open exploration and mostly studied pre-pubertal subjects, the present results exclusively from laparoscopic exploration suggested that contralateral testis volume is a poor and inconsistent predictor of monorchism in children, and marginally predictive for young adults with unilateral non-palpable testis. This study comprised a reasonably large overall sample size compared with preceding reports; however, the number of patients within in each age group was limited. Greater numbers could allow for statistical comparison stratified by age group, for which this study was not powered.

CONCLUSION

Contralateral testis volume predicts, with modest accuracy, monorchism in adults with unilateral non-palpable testis. In younger patients, the overall predictive accuracy of scrotal testis size is poor and not consistently dependable.

The Nonpalpable Testis: A Narrative Review

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Can Hypertrophy of the Contralateral Testis Predict the Absence of a Viable Testis in Infancy with Cryptorchidism: A Prospective Analysis

This prospective study aimed to evaluate whether Contralateral compensatory testicular hypertrophy (CTH) is valid as a predictive tool for a non-viable testis in children aged between 6 and 18 months, and whether CTH is affected by mini-puberty. Seventy-two testes from 60 boys aged between 6 and 18 months were categorized into three groups: 24 testes contralateral to surgically removed non-viable testes (NVTs), 24 testes contralateral to surgically corrected undescended testes (UDTs), and 24 testes from a normal controls. Contralateral testicular length and volume were measured with ultrasonography and compared among the groups. Group 1 (NVT) had a significantly longer length and larger volume than group 2 (UDT). The length and volume of each group among three developmental periods (6-10, 10-14, and 14-18 months) were also analyzed. In the controls, the length was significantly larger at 6-10 months than at 10-14 months in accordance with previously reported changes in testicular size due to the effect of "mini-puberty." The volume of controls showed a similar pattern, though without statistical significance. However, this pattern was not observed in the NVT and UDT groups. A receiver operating curve revealed that a testicular length of 16.1 mm or a volume of 0.59 ml had the highest sensitivity and specificity for predicting NVTs. The CTH was also found to be valid as a predictive tool for a NVT in children of ages 6 to 18 months, as the effect of mini-puberty appeared to be absent in the NVT and UDT groups. However, the cut-off values were less than those of previous reports. The proper cut-off level according to the age and measurement method should be applied in this developmental period.