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Echeverría Sepúlveda MP, Yankovic Barceló F, López Egaña PJ. The undescended testis in children and adolescents part 2: evaluation and therapeutic approach. Pediatr Surg Int 2022; 38:789-799. [PMID: 35307748 DOI: 10.1007/s00383-022-05111-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2022] [Indexed: 11/26/2022]
Abstract
Undescended testis (UDT) is defined as failure of a testis to descend into the scrotum and it is a common reason for consultation in pediatric urology. As extensively discussed in "The undescended testis in children and adolescents: part 1", the failure of a testis to descend alters testicular germ-cells development, increasing the risk of infertility and testicular cancer in adulthood. Here, we present the second part of our review and analysis of this topic with the aim to propose an updated and well-informed approach to UDT together with a treatment flow chart that may be useful to guide pediatric surgeons and urologists in the care of these patients. The main goal of the management of patients with UDT is to diminish the risk of infertility and tumor development and is based on the clinical findings at the time of diagnosis.
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Affiliation(s)
- María Pilar Echeverría Sepúlveda
- Pediatric Urology Service, Hospital Dr. Exequiel González Cortés and Clinica Alemana, Barros Luco, San Miguel, 3300, Santiago, Chile
- Departments of Pediatrics and Pediatric Surgery, Universidad de Chile, Santiago, Chile
| | - Francisca Yankovic Barceló
- Pediatric Urology Service, Hospital Dr. Exequiel González Cortés and Clinica Alemana, Barros Luco, San Miguel, 3300, Santiago, Chile
- Pediatric Urology Service, Clinica Santa Maria, Santiago, Chile
- Departments of Pediatrics and Pediatric Surgery, Universidad de Chile, Santiago, Chile
| | - Pedro-Jose López Egaña
- Pediatric Urology Service, Hospital Dr. Exequiel González Cortés and Clinica Alemana, Barros Luco, San Miguel, 3300, Santiago, Chile.
- Pediatric Urology Service, Clínica Alemana, Santiago, Chile.
- Departments of Pediatrics and Pediatric Surgery, Universidad de Chile, Santiago, Chile.
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Outcomes following emergency fixation of torted and non-torted testes. J Pediatr Urol 2021; 17:538.e1-538.e8. [PMID: 34103229 DOI: 10.1016/j.jpurol.2021.05.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 04/26/2021] [Accepted: 05/13/2021] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Scrotal exploration is a frequently performed emergency procedure in children. It is a subject of debate as to whether and how a non-torted testis should be fixed, with a wide variation in practice across the UK. This study aims to ascertain whether the method of testicular fixation (if any) impacts on patient outcomes. METHODS A review of all emergency scrotal explorations performed in children under the age of 18 between 2008 and 2018 in a tertiary Paediatric Surgery unit was undertaken. Patients were categorised by initial fixation method, chi squared analysis was used to compare complication and reoperation rates. RESULTS 522 boys were taken to theatre, 424 had a unilateral procedure and 98 had bilateral; after 35 orchidectomies, 585 testes were left in situ. The most frequent diagnosis at operation was torted testicular appendage (n = 278, 53%), followed by testicular torsion (n = 79, 15%). The number of testes by category of fixation were: 72 no documented fixation, 130 dartos pouch only, 34 absorbable sutures, 346 non-absorbable sutures and 3 unspecified sutures. There was no difference in the reattendance rate between groups after outliers were removed (p = 0.72). Thirty-seven patients experienced complications, most commonly ongoing pain. Nine patients required an ipsilateral reoperation, 25 underwent a contralateral operation at a later date. The complication rate appeared to be higher in the no fixation group compared to the dartos (p = 0.02) and sutured groups (p = 0.048). Testes in the no fixation group had a higher reoperation rate compared to the sutured group (p = 0.002). CONCLUSIONS The present study is a detailed analysis of a wide variety of emergency testicular fixation methods in a large cohort, including the routine fixation of non-torted testes. Whilst there appears to be a benefit to using sutured or dartos fixation, this merits cautious interpretation. It is likely that influences on complications and reoperations are multifactorial and cannot be attributed solely to the method of testicular fixation. Adoption of a standardised approach to emergency fixation of testes within or across institutions may be a potential avenue for future studies.
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Transparenchymal testicular suture: A systematic review and meta-analysis highlighting the impact of additional fixation suture during routine orchiopexy. J Pediatr Urol 2021; 17:183-189. [PMID: 33478901 DOI: 10.1016/j.jpurol.2020.12.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/11/2020] [Accepted: 12/15/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Orchiopexy for cryptorchidism is one of the common day-care surgeries performed by pediatric surgeons across the globe. Although majority of the surgeons reposition the testis into a sub-dartos pouch, the practice of taking an additional transparenchymal anchoring suture is often debated. The potential risks include impaired spermatogenesis and sub-fertility. Also, a consensus statement regarding the superiority of suture fixation over no suture fixation, in terms of prevention of recurrence of cryptorchidism, is lacking. This systematic review and meta-analysis aims to compare the outcomes of orchiopexy between the two groups i.e. without (Group A) and with the transparenchymal suture fixation (Group B). METHOD The authors systematically searched the databases PubMed, EMBASE, Web of Science and Scopus through October, 2020 for comparative studies. Statistical analysis was performed using a fixed-effects model; and pooled risk ratio (RR) and heterogeneity (I2) were calculated. The methodological quality of the studies was assessed utilizing the Downs and Black scale. RESULT Five comparative studies, comprising a total of 734 and 1002 children within the groups A and B respectively, were recruited in this study. As compared to the children belonging to group A, a significantly higher incidence of recurrence of cryptorchidism (RR 1.75; 95% CI 1.10-2.80, p = 0.02) was observed among the children of group B. However, the difference in the incidence of testicular atrophy could not reach statistical significance (RR 1.56; 95% CI 0.23-10.50, p = 0.65). The average Downs and Black scale scores ranged from 15 to 21.5, with all the studies having moderate to high-risk of bias. CONCLUSION The present meta-analysis revealed superiority of orchiopexy performed without transparenchymal suture fixation in terms of recurrence of cryptorchidism. Although, the incidence of testicular atrophy was higher among the children belonging to the suture group, no statistically significant difference was observed among the two groups. However, the level of evidence of the published comparative studies is limited. Therefore, it is recommended to focus on adequate mobilization of the testis and its positioning in the sub-dartos with minimal tension rather than over-reliance on futile adjuncts like taking transparenchymal testicular suture.
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Hirner L, Rübben I, Lax H, Hirner C, Panic A, Darr C, Krafft U, Hadaschik B, Niedworok C, Rehme C. The value of an additional scrotal suture during orchidopexy. J Pediatr Urol 2021; 17:82.e1-82.e5. [PMID: 33191101 DOI: 10.1016/j.jpurol.2020.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/12/2020] [Accepted: 10/15/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Undescended testes present in 3-5% of male infants at birth. Orchidopexy is indicated to improve fertility and reduce the risk of testicular tumors. Guidelines recommend orchidopexy as early as six months of age, treatment should be finished within the age of 18 months. So far, no unequivocal proof demonstrated the superiority of one of the different surgical techniques. OBJECTIVE To evaluate the value of an additional scrotal suture between the tunica albuginea and the dartos fascia during orchidopexy in an outpatient setting. It is yet unclear, whether the suture influences the incidence of secondary cryptorchidism or recurrence. STUDY DESIGN This is a retrospective cohort study. Between 2010 and 2018 two experienced surgeons performed 561 inguinal orchidopexy-procedures in an open technique (375 boys). In group 1 (2010-2014) they managed 234 IOP (156 boys) without an additional scrotal suture. Since 2014, in group 2 an additional suture has been performed in 327 IOP (219 boys). Statistically, we compared both groups over a period of consecutive 4 years after the model of a life table analysis (Logrank). RESULTS The numbers of boys with complete follow-up were 118 of 156 in group 1 and 154 of 219 in group 2, demonstrating 7 (5.9%) and 7 (4.5%) recurrences, respectively. There was no statistically significant difference in recurrences between group 1 and group 2 (Logrank-Test, p = 0.97). Orchidopexie failure was detected between 0.9 and 23.1 months after the IOP in group 1 and between 3.2 and 17.7 months in group 2. Mean age in months at the operation in both groups was significantly higher than the recommended 6-18 months in the EAU/AUA-guidelines. Both groups showed similar rates of postoperative complications. DISCUSSION Orchidopexy is a safe procedure in an outpatient setting. So far there is no evidence that performing an additional scrotal suture decreases the operative failure rate in inguinal standard orchidopexy procedures.
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Affiliation(s)
- L Hirner
- Department of Urology, University Hospital Essen, University of Duisburg-Essen, Duisburg, Hufelandstraße 55, 45147, Essen, Germany; Department of Urology and Urologic Oncology, Alfried Krupp Krankenhaus, Hellweg 100, 45276, Essen, Germany.
| | - I Rübben
- Department of Urology, University Hospital Essen, University of Duisburg-Essen, Duisburg, Hufelandstraße 55, 45147, Essen, Germany; Department of Pediatric Urology, Helios Hospital Duisburg, An der Abtei 7-11, 47166, Duisburg, Germany
| | - H Lax
- Institute for Medical Informatics, Biometry, and Epidemiology, University Hospital Essen, Zweigertstraße 37, 45130, Essen, Germany
| | - C Hirner
- Department of Urology, University Hospital Essen, University of Duisburg-Essen, Duisburg, Hufelandstraße 55, 45147, Essen, Germany
| | - A Panic
- Department of Urology, University Hospital Essen, University of Duisburg-Essen, Duisburg, Hufelandstraße 55, 45147, Essen, Germany
| | - C Darr
- Department of Urology, University Hospital Essen, University of Duisburg-Essen, Duisburg, Hufelandstraße 55, 45147, Essen, Germany
| | - U Krafft
- Department of Urology, University Hospital Essen, University of Duisburg-Essen, Duisburg, Hufelandstraße 55, 45147, Essen, Germany
| | - B Hadaschik
- Department of Urology, University Hospital Essen, University of Duisburg-Essen, Duisburg, Hufelandstraße 55, 45147, Essen, Germany
| | - C Niedworok
- Department of Urology, University Hospital Essen, University of Duisburg-Essen, Duisburg, Hufelandstraße 55, 45147, Essen, Germany; Department of Urology, Hermann-Josef-Hospital Erkelenz, Tenholter Str. 43, 41812, Erkelenz, Germany
| | - C Rehme
- Department of Urology, University Hospital Essen, University of Duisburg-Essen, Duisburg, Hufelandstraße 55, 45147, Essen, Germany
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Cancian M, Ellsworth P, Caldamone A. Contralateral metachronous undescended testis: Is it predictable? J Pediatr Urol 2017; 13:504.e1-504.e5. [PMID: 28434636 DOI: 10.1016/j.jpurol.2017.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 03/09/2017] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Madeline Cancian
- Department of Urology, Warren Alpert Medical School, Brown University, Providence, RI, USA.
| | - Pamela Ellsworth
- Division of Urology, Nemours Children's Hospital, Orlando, FL, USA
| | - Anthony Caldamone
- Department of Urology, Warren Alpert Medical School, Brown University, Providence, RI, USA
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Alam A, Delto JC, Blachman-Braun R, Wayne G, Mittal AG, Castellan M, Kozakowski K, Labbie A, Gosalbez R. Author Reply. Urology 2017; 101:109-110. [DOI: 10.1016/j.urology.2016.09.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Kehoe JE, Christman MS. To ‘Pex or Not to ‘Pex: What to Do for the Contralateral Testis When a Nubbin Is Discovered. Curr Urol Rep 2017; 18:9. [DOI: 10.1007/s11934-017-0657-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Radmayr C, Dogan HS, Hoebeke P, Kocvara R, Nijman R, Silay S, Stein R, Undre S, Tekgul S. Management of undescended testes: European Association of Urology/European Society for Paediatric Urology Guidelines. J Pediatr Urol 2016; 12:335-343. [PMID: 27687532 DOI: 10.1016/j.jpurol.2016.07.014] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 07/14/2016] [Indexed: 10/21/2022]
Abstract
CONTEXT Undescended testis is the most common endocrinological disease in the male newborn period. Incidence varies between 1.0% and 4.6% in full-term neonates, with rates as high as 45% in preterm neonates. Failure or delay of treatment can result in reduced fertility and/or increased testicular cancer risk in adulthood. OBJECTIVE To provide recommendations for the diagnosis and treatment of boys with undescended testes which reduce the risk of impaired fertility and testicular cancer in adulthood. EVIDENCE ACQUISITION Embase and Pubmed were searched for all relevant publications, from 1990 to 2015 limited to English language. Data were narratively synthesized in light of methodological and clinical heterogeneity. The risk of bias of each included study was assessed. EVIDENCE SYNTHESIS There is consensus that early treatment, by 18 months at the latest, for undescended testes is mandatory to avoid possible sequelae regarding fertility potential and cancer risk. The current standard therapy is orchidopexy, while hormonal therapy is still under debate. However, in some individuals the successful scrotal placement of previously undescended testes may not prevent potential negative long-term outcomes regarding fertility and testicular malignancy. CONCLUSIONS There is good evidence for early placement of undescended testes in the scrotal position to prevent potential impairment of fertility and reduce the risk of testicular malignancy. No consensus exists on the various forms of hormonal treatment, which are assessed on an individual basis.
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Affiliation(s)
- Christian Radmayr
- Paediatric Urology, Medical University of Innsbruck, Innsbruck, Austria.
| | - Hasan S Dogan
- Hacettepe University, Faculty of Medicine, Department of Urology, Division of Paediatric Urology, Ankara, Turkey
| | - Piet Hoebeke
- Department of Urology, Ghent University Hospital, Gent, Belgium
| | - Radim Kocvara
- Department of Urology, General Teaching Hospital in Praha, and Charles University 1st Faculty of Medicine, Praha, Czech Republic
| | - Rien Nijman
- Department of Urology, Division of Paediatric Urology, University of Groningen, Groningen, The Netherlands
| | | | - Raimund Stein
- Division of Paediatric Urology, Department of Urology, Mainz University Medical Centre, Johannes Gutenberg University, Mainz, Germany
| | - Shabnam Undre
- Department of Paediatric Urology, Great Ormond Street Hospital for Sick Children, London, UK
| | - Serdar Tekgul
- Hacettepe University, Faculty of Medicine, Department of Urology, Division of Paediatric Urology, Ankara, Turkey
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This Month in Pediatric Urology. J Urol 2015. [DOI: 10.1016/j.juro.2015.09.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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