A new management algorithm for impalpable undescended testis with gadolinium enhanced magnetic resonance angiography

Abnormal descent of the testis and its complications: A multimodality imaging review

Cryptorchidism refers to an absence of the testis in the scrotal sac. Testicular descent occurs in two stages: transabdominal and gubernacular. The descent of the testis can be arrested in its usual path of descent (true undescended testis) or can migrate from the usual path of descent (ectopic testis). Localising the missing testis is important for surgical planning, as well as for identification of complications that are more common with cryptorchidism. Ultrasound is the initial imaging modality to visualise, as well as localise the testis in cryptorchidism. However, ultrasound imaging is limited in visualising testes that are not superficial in location. This article highlights various examples of abnormal descent of the testis in usual as well as unusual locations and complications of undescended testes. Further evaluation with computed tomography scan or magnetic resonance imaging is needed in indeterminate cases and for identification of complications. We have highlighted the role of specific modalities with imaging findings in this pictorial review for the appropriate selection of each modality in clinical practice.

Bilateral low origin of testicular artery: a case report

The testicular artery is frequently subjected to radiographic imaging techniques such as angiography for diagnosis and treatment of conditions like epididymitis, testicular torsion, tumor, hematoma, and hydrocele and in cases of undescended testis. Radiologists and surgeons should therefore be aware of testicular artery variants. Although there are numerous studies and case reports that mention testicular artery variants, this is probably the first case, reporting a bilateral low origin of the testicular artery and discussing its probable embryological etiology.

The undescended testis: Clinical management and scientific advances

Undescended testes (UDT), where one or both testes fail to migrate to the base of the scrotum, can be congenital (2-5% of newborn males) or acquired (1-2% of males). The testis may be found in any position along its usual line of descent. Cryptorchidism affects the developing testicular germ cells and increases the risk of infertility and malignancy. Clinical management aims to preserve spermatogenesis and prevent the increased risk of seminoma. Examination to document the testicular position will guide the need for imaging, medical management and the surgical approach to orchidopexy.

Diagnostic imaging in cryptorchidism: utility, indications, and effectiveness

BACKGROUND

Cryptorchidism (undescended testis) is the most common genitourinary anomaly in male infants.

METHODS

We reviewed the available literature on the diagnostic performance of ultrasound, computed tomography, and magnetic resonance imaging (MRI) in localizing undescended testes.

RESULTS

Ultrasound is the most heavily used imaging modality to evaluate undescended testes. Ultrasound has variable ability to detect palpable testes and has an estimated sensitivity and specificity of 45% and 78%, respectively, to accurately localize nonpalpable testes. Given the poor ability to localize nonpalpable testes, ultrasound has no role in the routine evaluation of boys with cryptorchidism. Magnetic resonance imaging has greater sensitivity and specificity but is expensive, not universally available, and often requires sedation for effective studies of pediatric patients. Diagnostic laparoscopy has nearly 100% sensitivity and specificity for localizing nonpalpable testes and allows for concurrent surgical correction.

CONCLUSIONS

Although diagnostic imaging does not have a role in the routine evaluation of boys with cryptorchidism, there are clinical scenarios in which imaging is necessary. Children with ambiguous genitalia or hypospadias and undescended testes should have ultrasound evaluation to detect the presence of müllerian structures.

Cryptorchidism: pathogenesis, diagnosis, treatment and prognosis

Cryptorchidism is a common genital anomaly diagnosed at birth or during childhood. Genetic and/or environmental factors that alter expression or function of hormones crucial for testicular descent, insulin-like 3, and testosterone, may contribute to cryptorchidism. When identified at birth, surgical treatment is indicated by 6 months of age if testes fail to descend, or at the time of diagnosis in older children. A laparoscopic approach is preferred for abdominal testes. Early surgical therapy may reduce the risk of subfertility and/or malignancy.

Cryptorchidism and testicular cancer: separating fact from fiction

PURPOSE

We dissected prevailing assumptions about cryptorchidism and reviewed data that support and reject these assumptions.

MATERIALS AND METHODS

Five questions about cryptorchidism and the risk of testicular cancer were identified because of their implications in parent counseling and clinical management. Standard search techniques through MEDLINE were used to identify all relevant English language studies of the questions being examined. Each of the 5 questions was then examined in light of the existing data.

RESULTS

The RR of testicular cancer in a cryptorchidism case is 2.75 to 8. A RR of between 2 and 3 has been noted in patients who undergo orchiopexy by ages 10 to 12 years. Patients who undergo orchiopexy after age 12 years or no orchiopexy are 2 to 6 times as likely to have testicular cancer as those who undergo prepubertal orchiopexy. A contralateral, normally descended testis in a patient with cryptorchidism carries no increased risk of testis cancer. Persistently cryptorchid (inguinal and abdominal) testes are at higher risk for seminoma (74%), while corrected cryptorchid or scrotal testicles that undergo malignant transformation are most likely to become nonseminomatous (63%, p <0.0001), presumably because of a decreased risk of seminoma.

CONCLUSIONS

Orchiectomy may be considered in healthy patients with cryptorchidism who are between ages 12 and 50 years. Observation should be recommended in postpubertal males at significant anesthetic risk and all males older than 50 years. While 5% to 15% of scrotal testicular remnants contain germinal tissue, only 1 case of carcinoma in situ has been reported, suggesting that the risk of malignancy in these remnants is extremely low.

Management of boys with nonpalpable undescended testis

Cryptorchidism is one of the most common genitourinary disorders in young boys. Although the management of boys with palpable testis is standardized, there are no formal guidelines for the management of boys with nonpalpable testis. In this Review we look at the current trends in the diagnosis and treatment of this disorder, as well as the indications for therapy and surgical procedures. On the basis of current evidence, we find that there is no optimum orchidopexy technique for the treatment of intra-abdominal testis, although it is preferable to adopt techniques that preserve the spermatic vessels. We also briefly examine the follow-up of patients with this disorder and its common complications. As yet, there are no data that assess the potential of laparoscopic orchidopexy being a risk factor for impaired fertility later in life.

Current management of the undescended testicle

Cryptorchidism, where either one or both testes fails to migrate to the base of the scrotum, affects 4% to 5% of full-term and 9% to 30% of premature males at birth. The testis can be found in any position along its usual line of descent; however, approximately 80% will be located in the inguinal region, just outside the inguinal canal. Early correction, from 3 to 6 months of age, is currently advised. The preferred means of investigation and subsequent surgical intervention are dependent on the position of the cryptorchid testis. Risks associated with cryptorchidism include infertility and malignancy. The aim of appropriate management is to minimize these, and any other, associated complications.

Qu'attendre de l'échographie dans les anomalies de la migration testiculaire ?

OBJECTIVE

To evaluate the accuracy of ultrasonographic examination in boys with an undescended testis.

MATERIAL AND METHODS

All patients who were referred to the paediatric surgeon after detection of an undescended testis were evaluated prospectively between November 2001 and November 2004. Among these 377 patients, 87 were referred with an ultrasonogram previously prescribed by the referring primary physician. The results of the ultrasonogram were compared to the results of the clinical examination of the paediatric surgeon and, in cases of no palpable testis, to the surgical findings.

RESULTS

Ultrasonography did not detect the retractile testes. Ultrasonography detected 67% of the palpable undescended testes. In cases of no palpable testis, the ultrasonographic examination missed the abdominal testes and sometimes other structures were falsely interpreted as a testis.

CONCLUSION

Sonography has no place in the diagnosis of undescended testis.

MAGNETIC RESONANCE ANGIOGRAPHY FOR THE NONPALPABLE TESTIS: A COST AND CANCER RISK ANALYSIS

PURPOSE

For the unilateral nonpalpable testis standard management is open surgical or laparoscopic exploration. An ideal imaging technique would reliably identify testicular nubbins and safely allow children to forgo surgical exploration without compromising future health or fertility. Our goal was to perform a cost and risk analysis of magnetic resonance angiography (MRA) for unilateral nonpalpable cryptorchid testes.

MATERIALS AND METHODS

A search of the English medical literature revealed 3 studies addressing the usefulness of MRA for the nonpalpable testicle. We performed a meta-analysis and applied the results to a hypothetical set of patients using historical testicular localization data. Analysis was then performed using 3 different management protocols-MRA with removal of testicular nubbin tissue, MRA with observation of testicular nubbin tissue and diagnostic laparoscopy. A cancer risk and cost analysis was then performed.

RESULTS

MRA with observation of testicular nubbin tissue results in 29% of patients avoiding surgery without any increased cost of care. Among the 29% of boys with testicular nubbins left in situ and observed the highest estimated risk was 1 in 300 of cancer developing, and 1 in 5,300 of dying of cancer.

CONCLUSIONS

A protocol using MRA with observation of inguinal nubbins results in nearly a third of boys avoiding surgical intervention at a similar cost to standard care without any significant increased risk of development of testis cancer.

Cryptorchidism: diagnosis, treatment, and long-term prognosis

Cryptorchidism is a common anomaly treated by every pediatric urologist. The etiology is multifactorial and includes hormonal and molecular factors. Diagnostic abilities may be enhanced by radiologic advances. Hormonal and surgical treatment modalities are discussed herein, as well as the identification and prevention of long-term sequelae.

Bimanual digital rectal examination for the evaluation of the nonpalpable testis

PURPOSE

In the evaluation and treatment of the nonpalpable testis open surgical exploration and laparoscopy are methods used to differentiate abdominal, infrainguinal (below the internal ring) and atrophic or absent testes. We sought to evaluate the use of bimanual digital rectal examination as an additional tool to localize the nonpalpable testis.

MATERIALS AND METHODS

Forty-one consecutive patients with 45 nonpalpable testes were evaluated in a prospective fashion. Bimanual digital rectal examination was performed with the patients under general anesthesia just before diagnostic laparoscopy or open inguinal exploration. Palpability, location, length and contralateral testicular length were recorded.

RESULTS

Twenty-five gonads or spermatic cords (56%) were palpable using the bimanual technique. All positive examinations were confirmed laparoscopically or by open exploration, and the majority of gonads were intra-abdominal (17 of 25, 68%). Seventeen normal appearing gonads underwent orchiopexy and 8 were removed secondary to atrophy, dysgenesis or poor position. Twenty testes (44%) were not palpated using this method. Of these gonads 10 normal appearing testes were found at exploration and underwent orchiopexy. Of the 10 remaining gonads 6 atrophic testes were removed, and 4 hemosiderin laden remnants were thought to represent "vanished testes." Overall, 26 gonads or remnants were intra-abdominal, 10 were "peeping" or canalicular and 9 were infrainguinal. The overall specificity was 100%, with a sensitivity of 60%. The positive predictive value was 100%.

CONCLUSIONS

Bimanual digital rectal examination is a valuable tool in the evaluation of the nonpalpable testis, and identified the presence and position of the testis in the majority of our cases. Although sensitivity is low, when the testis is palpated by this method, diagnostic laparoscopy to localize the testis may be avoided.

Using gadolinium-infusion MR venography to show the impalpable testis in pediatric patients

OBJECTIVE; This study evaluated the adjunctive value of gadolinium-infusion MR venography to locate the impalpable testis.

SUBJECTS AND METHODS

Routine MR imaging and MR venography were performed in 34 patients presenting with impalpable testis. MR venography was performed by dynamic injection of gadopentetate dimeglumine bismethylamide with images taken at delayed venous phases. The site of the testis was determined by detection of the contrast-enhanced pampiniform venous plexus.

RESULTS

A total of 44 impalpable testes were examined. Twenty-six hypoplastic canalicular testes, two testes at pelvic skinfold, four atrophic testes in the scrotum, and five intraabdominal testes were detected on both routine MR imaging and MR venography. Five "vanishing" testes in the scrotum and two at the groin region were detected by MR venography but not on MR imaging.

CONCLUSION

Gadolinium-infusion MR venography is superior to MR imaging in the detection of atrophic testes. The method is a useful adjunct in patients with negative MR imaging findings.