The use of computerized tomography scanning to localize the impalpable testis

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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.

Ultrasonography is unnecessary in evaluating boys with a nonpalpable testis

OBJECTIVE

An inguinal sonogram often is obtained in boys with a nonpalpable testis to "localize" the testis, ie, determine whether the testis is present. The results of ultrasonography in boys with a nonpalpable testis were analyzed.

METHODS

The records of boys who were referred to a pediatric urology center with a diagnosis of nonpalpable testis and who had undergone inguinal sonography were reviewed. The results of sonography were compared with findings in the office as well as surgical findings.

RESULTS

A total of 62 boys who were referred with a diagnosis of a nonpalpable testis and who had undergone a sonogram were reviewed. The sonogram was ordered by the primary care physician in 51 boys (82%) and by a general urologist in 11 cases (18%). The testis was identified by sonography in 12 (18%) of 66 cases, and all were localized to the inguinal canal. Physical examination by a pediatric urologist showed that 6 were in the scrotum and 6 were in the inguinal canal or perineum. Of the 54 testes that were not localized by the sonogram, 33 (61%) were palpable and 21 (39%) were nonpalpable. Of the truly nonpalpable testes, laparoscopy and abdominal/inguinal exploration identified the testis as abdominal in 10 cases and atrophic secondary to spermatic cord torsion in 11 cases.

CONCLUSION

Sonography is unnecessary in boys with a nonpalpable testis, because it rarely if ever localizes a true nonpalpable testis, and it does not alter the surgical approach in these patients.

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

PURPOSE

We evaluated the diagnostic accuracy of preoperative localization of impalpable undescended testis using ultrasound and gadolinium (Gd) enhanced magnetic resonance angiography (MRA).

MATERIALS AND METHODS

Ultrasound and Gd-MRA were performed prospectively in 21 boys (23 impalpable testes) with cryptorchidism before laparoscopy and surgical exploration. Gd-MRA was done using a 1.5 Tesla magnetic resonance scanner with a turbo field echo technique after bolus intravenous injection of 0.4 mmol./kg. body weight of Gd diethylenetriaminepentaacetic acid. A total of 10 dynamic scans were acquired during 15 minutes after Gd injection to cover the early arterial and delayed venous phases. All patients subsequently underwent diagnostic laparoscopy and definitive surgery.

RESULTS

Ultrasound correctly localized 9 of 10 intracanalicular testes but failed to reveal any intra-abdominal or vanishing testes. In contrast, Gd-MRA correctly localized 4 intra-abdominal, all 10 intracanalicular and 8 canalicular vanishing testes. In 1 patient with an intra-abdominal vanishing testis ultrasound and Gd-MRA failed to make the diagnosis. When correlated with the findings of subsequent laparoscopy and surgical exploration, Gd-MRA had a diagnostic sensitivity of 96% and a specificity of 100% for localizing impalpable undescended testes. Based on Gd-MRA and ultrasound findings laparoscopy could have been avoided in 18 of 23 cases (78%). No adverse effect was associated with Gd use in this study.

CONCLUSIONS

Gd-MRA accurately diagnoses vanishing testes and reliably differentiates intraabdominal from intracanalicular impalpable testes, allowing definite preoperative planning of the surgical approach and avoiding unnecessary laparoscopy. A new management algorithm for impalpable testis in patients with cryptorchidism is proposed based on ultrasound and Gd-MRA findings.

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

PURPOSE

We evaluated the diagnostic accuracy of preoperative localization of impalpable undescended testis using ultrasound and gadolinium (Gd) enhanced magnetic resonance angiography (MRA).

MATERIALS AND METHODS

Ultrasound and Gd-MRA were performed prospectively in 21 boys (23 impalpable testes) with cryptorchidism before laparoscopy and surgical exploration. Gd-MRA was done using a 1.5 Tesla magnetic resonance scanner with a turbo field echo technique after bolus intravenous injection of 0.4 mmol./kg. body weight of Gd diethylenetriaminepentaacetic acid. A total of 10 dynamic scans were acquired during 15 minutes after Gd injection to cover the early arterial and delayed venous phases. All patients subsequently underwent diagnostic laparoscopy and definitive surgery.

RESULTS

Ultrasound correctly localized 9 of 10 intracanalicular testes but failed to reveal any intra-abdominal or vanishing testes. In contrast, Gd-MRA correctly localized 4 intra-abdominal, all 10 intracanalicular and 8 canalicular vanishing testes. In 1 patient with an intra-abdominal vanishing testis ultrasound and Gd-MRA failed to make the diagnosis. When correlated with the findings of subsequent laparoscopy and surgical exploration, Gd-MRA had a diagnostic sensitivity of 96% and a specificity of 100% for localizing impalpable undescended testes. Based on Gd-MRA and ultrasound findings laparoscopy could have been avoided in 18 of 23 cases (78%). No adverse effect was associated with Gd use in this study.

CONCLUSIONS

Gd-MRA accurately diagnoses vanishing testes and reliably differentiates intraabdominal from intracanalicular impalpable testes, allowing definite preoperative planning of the surgical approach and avoiding unnecessary laparoscopy. A new management algorithm for impalpable testis in patients with cryptorchidism is proposed based on ultrasound and Gd-MRA findings.

Pediatric testicular problems

Testicular problems in children may be both congenital and acquired. These problems are often difficult to diagnose and carry significant sequelae if untreated. Early surgical consultation is often needed for correction of the problem. This article reviews the pathophysiology of the most common pediatric testicular abnormalities with emphasis on the diagnostic modalities employed and current treatment alternatives.

Laparoscopic assessment and orchidectomy for the undescended testis

Cryptorchidism is the most common disorder of male sexual differentiation. Pre-operative assessment and localization of undescended testes by various investigatory modalities have been of limited clinical value. The recent use of diagnostic and therapeutic laparoscopy for undescended testis peri-operatively has been shown to be safe and informative in the planning of appropriate surgical management. The authors' initial experience with this procedure, for five patients with unilateral undescended testis, is presented.

Extraperitoneal inguinal pelviscopy: diagnostic tool for nonpalpable testes

In patients with nonpalpable testes, intraperitoneal laparoscopy is not a direct approach to the tissues in which the gonad is likely to be located. Accordingly, the technique may be time-consuming and accompanied by complications. In 23 patients, the retropubic space was insufflated with carbon dioxide through a suprapubic puncture, and a pelviscope was advanced beyond the deep inguinal ring into the extraperitoneal pelvic cavity using the vas deferens as a guide. The nonpalpable testis was located in all patients, being deep to the inguinal ring in 17 and in the iliac fossa in 4. In the two patients with bilateral nondescent, three testes were deep to the inguinal ring, and one was lying over the psoas muscle. No complications were encountered. Extraperitoneal pelviscopy is simple, easy, and safe and provides a direct approach to the pelvic and abdominal extraperitoneal tissues.

The limited role of imaging techniques in managing children with undescended testes

We studied the usefulness of radiography for localization of cryptorchid testes. A total of 23 radiographic studies ordered by referring physicians was done for testis localization in 18 boys. Two patients had retractile testes and were followed expectantly. Ultrasonography failed to detect palpable testes in both cases. A total of 16 boys (19 undescended testes) underwent operative exploration and the findings were compared. Ultrasonography correlated with the operative findings in 7 of 12 cryptorchid testes (58%), while computerized tomography and magnetic resonance imaging correlated in only 4 of 12 (33%) and 0 of 1 (0%), respectively. The overall accuracy of radiological testing was 44%. Physical examination was 53% accurate when performed by the referring physician and 84% accurate when done by the attending pediatric urologist. In no case did radiographic assessment influence the decision to operate, the surgical approach or the viability/salvageability of the involved testes. Preoperative radiography for undescended testes is neither necessary nor helpful.

CT and MR imaging of malignant germ cell tumor of the undescended testis

Preoperative localization of the impalpable undescended testis is necessary to facilitate proper surgical planning. There is an increased incidence of malignant change in the undescended testis; demonstration of malignancy before surgery will significantly alter the treatment. We describe the computed tomographic (CT) and magnetic resonance (MR) findings in 2 patients with malignant change in an intraabdominal testis. The CT scan revealed lesions with areas of low density, 1 of which had focal calcifications; MR revealed lesions of predominantly low or intermediate signal intensity on both long and short TR/TE images, with some areas of very high signal on both sequences. After initial management with chemotherapy, the residual tumor was surgically resected. In neither instance was residual normal testis demonstrated. Both CT and MR are ideal methods of examining malignant transformation of the undescended testis, because of their ability to characterize the internal structure of the organ and, in the case of MR, its capacity for multiplanar imaging. They are almost of equal value except for the ability of CT to identify calcification and of MR to diagnose hemorrhage.

The undescended testis. Hormonal and surgical management

Cryptorchidism is the most common disorder of sexual differentiation in males, with an incidence of 3.4 per cent in the term newborn, decreasing to 0.8 per cent at 1 year of age. The mechanisms of normal testicular descent are multifactorial and include an intact hypothalamic-pituitary-testicular axis, as well as a normal gubernaculum and epididymis. In boys with cryptorchidism, the testes demonstrate degenerative changes histologically as early as 1 to 2 years of age. Both testes may be affected, even with a unilateral undescended testis. The most important long-term complications of cryptorchidism include infertility and testicular cancer. The risk of malignancy is 10 to 40 times higher in men with cryptorchidism than in normal men and is highest in men who have had an intra-abdominal testis and in certain intersex conditions. Orchiopexy does not appear to lessen this risk. In clinical trials in the United States, hormonal therapy with hCG or GnRH has not been effective in causing testicular descent; therefore, orchiopexy remains standard treatment. However, hCG is recommended if the clinician suspects that a testis is retractile. Orchiopexy should be performed between 12 and 18 months of age to prevent the degenerative changes that are demonstrable by 2 years.

Laparoscopy in adults and children with nonpalpable testes

Laparoscopy was performed in 31 patients presenting 36 nonpalpable testes. Sixteen adults had a chronological age of 15 to 33 years (average 21 years) and fifteen children had a chronological age of 2 to 13 years (average 6 years). Among 20 investigated testes in 16 adults, 11 (55%) were sighted in the abdominal cavity. Vessels and deferens were seen entering the inner inguinal ring in 5 cases (25%). Vascular and gonadal structures were not found in four cases (20%). Among 16 investigated testes in 15 children, 10 (62,5%) were sighted in the abdominal cavity. Vessels and deferens entering the inner inguinal ring were sighted in 2 cases (12,5%). Nothing was found in two cases (12,5%). Blind ending vas sighted in 1 case (6,25%) and one exam was not conclusive because of intestinal adherence in 1 case (6,25%). The laparoscopy proved to be an accurate diagnosis method in 34 (94,5%) of 36 cases of nonpalpable examined testes.

Cryptorchidism: isolated and associated with other genitourinary defects

Cryptorchidism is the most common disorder of sexual differentiation in male children, with an incidence of 3.4 per cent in the term newborn, decreasing to 0.8 per cent at 1 year of age. The mechanisms of normal testicular descent are multifactorial and include an intact hypothalamic-pituitary-testicular axis, as well as a normal gubernaculum and epididymis. In boys with cryptorchidism, the testes demonstrate degenerative changes histologically as early as 1 to 2 years of age. Both testes may be affected, even with a unilateral undescended testis. The most important long-term complications of cryptorchidism include infertility and testicular cancer. The risk of malignancy is approximately 40 times higher in male subjects with cryptorchidism than in normal men, and is highest in male subjects who have had an intra-abdominal testis and in certain intersex conditions. Orchiopexy does not appear to lessen this risk. Hormonal therapy with HCG or LH-RH has remained unproven in clinical trials in the United States; therefore, orchiopexy remains standard treatment. HCG is recommended if the clinician suspects that a testis is retractile, however. Orchiopexy should be performed between 12 and 18 months of age to prevent the degenerative changes that are demonstrable by 2 years.

Hyperplasia of spermatic cord nerves: a sign of testicular absence

The comparative histologic study of the spermatic cord in the absence of testis, epididymis-testis separation, and normal development of both testis and epididymis, revealed that there is nerve trunk hyperplasia and hypertrophy in absence of the testis. This finding may greatly aid the diagnosis of testicular absence in the management of impalpable testes.

Magnetic resonance imaging of the cryptorchid testis

Magnetic resonance imaging was used to evaluate seven patients with undescended testes. In six patients the presence or absence of testicular tissue was predicted correctly prior to surgery. Spermatic cord structures, if present, were accurately visualized in all patients.