Cryptorchidism: isolated and associated with other genitourinary defects

Investigating the effect of sudden occlusion of the testicular vessels on the testicular tissue in rat models

One of the ways to treat undescended testicles is to use orchiopexy surgery, which is modified into the two-stage Fowler-Stephens technique in cases of short or immobile testes. The disadvantage of using this technique is the probability of testicular ischaemia following the sudden closure of the testicular artery; although the collateral arteries prevent atrophy, the testis loses its germ cells during this stress and may no longer be functional. Therefore, this study aims to examine the changes in testicular tissue regarding necrosis and infarction after the occlusion of the vessels.

METHODS AND MATERIALS

In this experimental study 15 male rats weighing 200-250 g were prepared and first, one of the rats was sacrificed and testicles on both sides were used for pathology control. After general anaesthesia vascular ligature was performed with the left testes undergoing both venous and arterial occlusion and the right testes only arterial occlusion. After 1 month, all specimens were killed and the testes were completely removed and sent for histopathological evaluation.

RESULTS

A total of 14 rats and 28 testes were studied in two equal groups of case and control. There was no significant difference between the case and control groups in terms of testicular volume, consistency, and viability. Microscopic findings revealed that necrosis, infarction, and state of inflammation were significantly higher in the case group than in the control group.

CONCLUSION

The results of this study show that abrupt closure of the testicular artery in rats is associated with necrosis and infarction, decreased spermatogenesis, and more inflammation. However, no significant differences were found in terms of macroscopic findings including volume, consistency, and viability.

Could increased expression of aquaporin-1 be an etiological cause in childhood noncommunicating hydroceles that do not regress spontaneously?

BACKGROUND

Aquaporins are membrane water channel proteins that are expressed in the epithelium and endothelium. Their primary function is to control the flow of water in the membranes of the cells.

OBJECTIVE

In this study, we investigated whether there is increased expression of aquaporin-1 in the tunica vaginalis of hydrocele patients in childhood that do not regress spontaneously an whether it has an effect on the etiology of hydrocele.

STUDY DESIGN

Boys who were diagnosed with hydrocele and scheduled for surgery were included and formed the hydrocele group. Boys in the same age range who underwent surgery for inguinal hernia or undescended testicles were included as a control group. Aquaporin-1 expression was evaluated by immunohistochemical examination of capillaries in tissue samples taken from the tunica vaginalis during the operation. Aquaporin-1-positive vessels were counted by selecting 5 unrelated areas with the highest vascular density, and the average number of vessels was calculated for each case.

RESULTS

A total of 48 male patients were included in the study. Of these, 27 constituted the hydrocele group (mean age 3.51 ± 2.59 years), and 21 constituted the control group (inguinal hernia, n = 17; undescended testicle, n = 4) (mean age 3.95 ± 3.80 years). The mean ages of both groups were statistically similar (p = 0.32). The mean numbers of aquaporin-1-positive vessels at the capillaries in the tunica vaginalis of the patients were 20.74 ± 7.10 in hydrocele group and 17.23 ± 4.07 in the control group. The expression of aquaporin-1 in the hydrocele group was significantly higher (p = 0.037).

DISCUSSION

It was shown that aquaporin-1 expression was higher in adult cases with hydrocele. Also an increase in aquaporin-1 expression was detected in tunica vaginalis of children with hydrocele in our study.

CONCLUSION

It was thought that aquaporin-1 overexpression may play a role in non-communicating hydroceles in children.

Ambulatory Orchidopexy Is a Potential Solution to Improve the Rate of Timely Repair in Cryptorchid Boys: An 8 Year Retrospective Study of 4,972 Cases

Background: Cryptorchidism is the most common congenital anomaly in pediatric urology. Although early surgery on cryptorchid boys is recommended by pediatric urologists worldwide, the actual age at orchidopexy is often older than the recommended age. Our medical center has started performing ambulatory orchidopexy since March 2016 at the ambulatory surgery center. We aimed to investigate whether ambulatory orchidopexy can improve the timely repair rate. Methods: A retrospective analysis was conducted from 2012 to 2019 at our medical center. Ambulatory orchidopexy was started at our medical center on March 24, 2016. Boys born on or after September 24, 2015 were classified into the "with ambulatory medical resource" group, and boys born before September 24, 2014, were classified into the "without ambulatory medical resource" group. The timely repair rates were calculated and compared. Results: A total of 4,972 cryptorchidism cases were included in the final study. Approximately 33.0% of cryptorchid boys received timely surgery (orchidopexy by the age of 18 months), and only 6.8% of all cryptorchid boys underwent surgery before the age of 1 year. After the performance of ambulatory orchidopexy, the timely repair rate increased from 25.7 to 37.0% (P < 0.001), and the percentage of patients receiving surgery before the age of 1 year increased significantly from 3.5 to 8.6% (P < 0.001). The proportion of timely repair in patients with ambulatory medical resources was significantly higher than that in patients without ambulatory medical resources (15.6% vs. 58.2%, P < 0.001). Significant changes in the rate of surgery before 12 months of age were also found between the two groups (2.4% vs. 14.8%, P < 0.001). Conclusions: After the performance of ambulatory orchidopexy in our medical center, the rates of both timely repair and receiving surgery before the age of 1 year increased significantly. Ambulatory orchidopexy is a potential solution to improve the rate of timely repair in cryptorchid boys, and it is worthy of promotion in developing countries and regions.

Clinical and socioeconomic factors associated with delayed orchidopexy in cryptorchid boys in China: a retrospective study of 2423 cases

We investigated the associations of clinical and socioeconomic factors with delayed orchidopexy for cryptorchidism in China. A retrospective study was conducted on cryptorchid boys who underwent orchidopexy at Children's Hospital at Chongqing Medical University in China from January 2012 to December 2017. Of 2423 patients, 410 (16.9%) received timely repair by 18 months of age, beyond which surgery was considered delayed. Univariate analysis suggested that the laterality of cryptorchidism (P = 0.001), comorbidities including inguinal hernia/scrotal hydrocele (P < 0.001) or urinary tract disease (P = 0.016), and whether patients lived in a poverty county (P < 0.001) could influence whether orchidopexy was timely or delayed. Logistic regression analysis suggested that the following factors were associated with delayed repair: unilateral rather than bilateral cryptorchidism (odds ratio [OR] = 1.752, P < 0.001), absence of inguinal hernia or hydrocele (OR = 2.027, P = 0.019), absence of urinary tract disease (OR = 3.712, P < 0.001), and living in a poverty county (OR = 2.005, P < 0.001). The duration of postoperative hospital stay and hospital costs increased with the patient's age at the time of surgery.

Health Disparities in the Appropriate Management of Cryptorchidism

OBJECTIVE

To assess regional practices in management of cryptorchidism with regard to timely fixation by the current recommended age of 18 months.

STUDY DESIGN

A retrospective study was performed. Charts of all patients who underwent surgical correction for cryptorchidism by a pediatric general surgeon or urologist within a tertiary pediatric hospital in an urban setting were systematically reviewed.

RESULTS

We identified 1209 patients with cryptorchidism. The median age of surgical correction was 3.7 years (IQR: 1.4, 7.7); only 27% of patients had surgical correction before 18 months of age. Forty-six percent of our patients were white, 40% were African American, and 8% were Hispanic. African American and Hispanic patients were less likely to undergo timely repair (P?=?.01), as were those with public or no insurance (P?<?.0001). A majority (72%) of patients had no diagnostic imaging prior to surgery. A majority of patients had palpable testes at operation (85%) and underwent inguinal orchiopexy (76%); 82% were operated on by a pediatric urologist. Only 35 patients (3%) experienced a complication; those repaired late were significantly less likely to develop a complication (P?=?.03). There were no differences in age at time of surgery by surgeon type.

CONCLUSIONS

A majority of our patients were not referred for surgical intervention in a timely manner, which may reflect poor access to care in our region. Public and self-pay insurance status was associated with delayed repair. Education of community physicians and families could be potentially beneficial.

A rare emergency: testicular torsion in the inguinal canal

Objectives. To report our experience and present the largest series of testicular torsion cases in the inguinal canal. Material and Methods. The clinical data of 13 patients with testicular torsion in the inguinal canal treated between 2005 and 2013 were reviewed. Recorded patient age, whether the testes were palpable or not, side of the affected testes, the presence of hernia, ischemia time, and operation outcomes were assessed. Results. Patient age ranged from 8 to 70 months (29.15 ± 20.22). Mean ischemia time was 16.5 ± 21.3 hours. Accompanying inguinal hernia was present in 92% of the cases (12/13). Four of the thirteen patients (30.8%) were treated by orchiectomy because the necrosis was present after prolonged ischemia time. Nine patients (69.2%) were treated by single session orchidopexy. Conclusion. Torsion of testes in the inguinal canal is a rare disease, but with rapid diagnosis, affected testes can be salvaged, but the key factor is to keep this condition in mind.

[Cryptorchidism: from physiopathology to infertility]

Cryptorchidism is a defect of testicular descent. Hormonal, genetic and environmental factors might also contribute to the aetiology of cryptorchidism and its increased incidence in recent years in industrialised countries. Cryptorchidism itself might be considered a complex disease. This testicular pathology represents the best-characterized risk factor for reduced fertility and testicular cancer. The purpose of this review is to better understand physiopathology and mechanisms of infertility in men with history of cryptorchidism.

The undescended testis: diagnosis, treatment and long-term consequences

BACKGROUND

The late descent of a testicle into the scrotum may impair its development. Reduced fertility is the main risk of primary cryptorchidism even after timely treatment, as histopathological changes (Leydig cell hypoplasia) already become apparent in the first few months of life. There is evidence, however, that treatment is often delayed. Hormonal and surgical treatments complement each other and should be provided before the child's first birthday.

METHODS

Selective literature search in PubMed (January 2008) based on the following keywords: "cryptorchidism", "maldescensus testis", "etiology", "therapy", "semen quality", "testicular cancer". Particular attention was paid to the current S2 guidelines on cryptorchidism.

RESULTS/DISCUSSION

Hormone therapy is the best initial treatment in most cases, with a few exceptions. If this is unsuccessful, surgery should be performed without delay. The success of treatment depends on the initial position of the testicle. Treatment does not lessen the risk of malignancy. Parents must be informed about this risk. The undescended testicle is the most common genital malformation in boys. When diagnosed, it should be treated hormonally and/or surgically before the child's first birthday to minimize the risk of impaired fertility. Successful treatment before age 13 appears not to lessen the risk of testicular cancer, but it does facilitate early detection by enabling physical examination of the testicle.

Two-Stage Fowler-Stephens Orchidopexy Preserving The Gubernacular Vessels And A Purely Laparoscopic Second Stage

PURPOSE

We describe a modification of the two-stage laparoscopic Fowler-Stephens technique in which the gubernacular vessels are preserved and the testis is brought down the canal via the internal ring. A purely laparoscopic second stage is performed. We report our outcomes with this technique.

MATERIALS AND METHODS

All laparoscopic Fowler-Stephens orchidopexies undertaken at our hospital from 1996 to July 2004 were identified from a prospectively collected database of all surgical procedures undertaken in the unit. A retrospective case-note review was undertaken.

RESULTS

We identified 21 patients, 4 bilateral and 17 unilateral, giving a total of 25 intra-abdominal testes. Mean age at presentation was 21 months (range, 0-56 months). Mean age at the first stage was 36 months (range, 11-68 months). The testis position at initial laparoscopy was high in 5, close to the internal inguinal ring in 9, peeping in 6, and pelvic in 5. The testis size at this stage was either normal, good sized, or reasonable sized in 15, small or dysplastic in 5, and in 5 the size was not commented upon. The testicular vessels were mainly divided by diathermy at the first stage, but in 6 the vessels were clipped. The second stage was undertaken 6 months after the first, in order to allow the collateral blood supply to adapt. Twelve testes had changed position category during this interval, 2 having ascended to a higher position and 10 descended to a lower position; 12 were in the same position at both stages; and in 1 case the position was not commented upon at the second stage. A purely laparoscopic second stage technique was used in 21 cases; an assisted-open second stage was undertaken in 1 case. In 3 cases the testis was palpable in the groin at examination under anesthesia and so an open second stage orchidopexy was performed. Follow-up was at 6 and 18 months after the second stage. Eighteen of the 21 testes that underwent a purely laparoscopic second stage survived at 6 months, giving a success rate with this technique of 86%. The overall testis survival rate in the entire group at 6 months was 88% (22/25). Findings in those patients reviewed at 18 months were unchanged.

CONCLUSION

The two-stage laparoscopic Fowler-Stephens orchidopexy, with preservation of the gubernacular vessels and predominantly using a purely laparoscopic second stage, provided a very good testis survival rate, approaching 90%.

MIS/AMH in the assessment of cryptorchidism and intersex conditions

Mullerian inhibiting substance (MIS), also known as anti-Mullerian hormone (AMH), causes Mullerian duct involution during male sexual differentiation and also has a postnatal regulatory role in the gonads. Serum MIS/AMH has a gonad specific pattern of expression and its concentrations are sexually dimorphic in children; hence measurement of serum MIS/AMH helps in the evaluation of children with gonadal disorders. In boys with cryptorchidism (non-palpable gonads), serum MIS/AMH correlates with testicular tissue. A measurable value is predictive of undescended testes while an undetectable value is highly suggestive of anorchia. In minimally virilized phenotypic females, MIS/AMH helps differentiate between gonadal and non-gonadal causes of virilization. In children with intersex conditions, MIS/AMH values assist differential diagnosis: a value above the normal female range is predictive of testicular tissue, while an undetectable value is suggestive of absent testicular tissue. Thus, MIS/AMH is useful for delineating gonadal pathology and facilitates the differential diagnosis and management of children with diverse gonadal disorders.

Prenatal measurement of testicular diameter by ultrasonography: development of fetal male gender and evaluation of testicular descent

Prenatal ultrasonography has evolved through advancements in imaging technology and observer experience. The purpose of the present study was to evaluate fetal testicular descent and diameter in relation to gestational age. A prospective cross-sectional study on 331 fetuses from an unselected population underwent a detailed assessment of testicular descent and diameter at 20-40 weeks' gestation by means of transabdominal sonography (91.2%) and transvaginal sonography (8.8%) when necessary. Fetal gender was identified in the transverse and sagittal planes and maximum testicular diameter was measured. The mean testicular diameter (in millimeters) per week and the 95% confidence interval (CI) were defined. Testicular descent was not observed prior to 23 weeks' gestation, with 6.6% of the fetuses having one testis descended at 23 weeks and 98.2% after 32 weeks. A linear relationship between testicular diameter and gestational age was observed. The present results chart the time course for testicular descent and provide a centile chart for fetal testicular diameter from 25 to 40 weeks' gestation. These findings may aid prenatal diagnosis of associated abnormal conditions as well as investigations into the clinical finding of abnormal testicular size.

Scrotal pathology in pediatrics with sonographic imaging

Scrotal pathology in pediatrics ranges from the more benign hydrocele and varicocele to acute testicular torsion requiring emergent surgery. Malignant testicular tumors can be insidious in onset or may present acutely when trauma brings a swollen scrotum to the patient's or physician's attention. Three common conditions can present as an acute scrotum, all of which can suggest testicular torsion clinically. Epididymitis often has a less acute onset than testicular torsion, although it does not always present with a straightforward diagnosis. Although it is generally an inflammatory process affecting males from 9 to 14 years of age, it can be seen in younger males with Henoch-Schonlein purpura and Kawasaki disease. Torsion of the appendix of the testis and epididymis can present acutely and mimic acute testicular torsion and generally occurs from 6 to 12 years of age. Testicular torsion itself usually occurs from 12 to 18 years of age and usually results from the anatomical "bell-and-clapper" deformity. Infarction of the testis can occur within as early as 4 to 6 hours after torsion, depending on the duration of symptoms and degree of twist of the spermatic cord. Advances in ultrasound technology in recent years have made ultrasound the examination of choice for imaging scrotal pathology, whether acute or chronic in nature. Doppler technology has tremendously increased the radiologist's ability to assess flow within the prepubertal testicle, which allows assessment of viability in the undescended testis as well as in neonatal torsion. The ability of ultrasound to diagnose the pathogenesis of the acute scrotum is unsurpassed by any other imaging modality. Ultrasound is a readily available, noninvasive examination without radiation that provides excellent anatomic detail and serves as an important and tremendously helpful imaging modality in all types of pediatric scrotal pathology.

Individual and associated effects of length of inguinal canal and caliber of the sac on clinical outcome in children

PURPOSE

The caliber of processus vaginalis is accepted to define the clinical outcome to be an inguinal hernia or hydrocele not based on any evaluation. The caliber of sacs and length of inguinal canals of boys and girls were evaluated to define the relation of sex, age, and the diagnosis with caliber of the sac and the length of inguinal canal.

METHODS

A total of 217 inguinal canals in 24 girls and 112 boys with inguinal hernia, 30 boys with hydrocele or hydrocele of the cord, and 31 boys with undescended testis have been evaluated. Twenty patients had bilateral involvement. The length of inguinal canal, and the circumference of the sac were measured. A formula was developed to predict the length of inguinal canal according to the age and sex. The circumferences of the sacs, length of inguinal canals, and the ratios of the circumference to the length were compared according to the clinical pictures.

RESULTS

The regression model of the relationship between the age and the length of the inguinal canal is an equation of third degree (inguinal canal in millimeters) = 0.0000119 x age 3 (months) - 0.00292 x age 2 (months) + 0.3168 x age (months) + 19.979 (r2 = 0.47). Inguinal canal is longer in boys (25.133 and 27.996 mm; P = .018), and length does not differ among diagnoses but differs according to age showing a linear growth after 24 months. Although the circumference as a sole parameter could classify only 55.3% of boys correctly, the ratio of length of inguinal canal to circumference of the sac has been the significant parameter in classifying boys into 1 of 3 groups including inguinal hernia, undescended testis, and hydrocele with a 70.2% success rate.

CONCLUSIONS

Inguinal canal that shows a linear growth after 24 months of age is longer in boys. Caliber is not the unique factor that determines the clinical outcome. Although the ratio of length of inguinal canal to the circumference of the sac defines the clinical picture best, even this parameter cannot classify the cases correctly. Therefore, some factors in addition to the caliber and length of inguinal canal might have roles in determining the clinical outcome.

Management of undescended testis

The term cryptorchidism indicates a testis, which has failed to descend to the scrotum and is located at any point along the normal path of descent or at an ectopic site. Hormones play a pivotal role in testicular descent except during the migration to the level of internal inguinal ring. Cryptorchidism is present in about 4.5% of newborns with a higher incidence in preterms. The incidence decreases to 1.2% by the first year. It is classified as palpable and impalpable. The most common site of an ectopic testis is superficial inguinal pouch. Retractile testis is often bilateral and most common in boys between 5 and 6 years of age. Hypospadias and inguinal hernias are the most common associated anomalies seen with undescended testis. A thorough clinical examination helps in arriving at the etiology. A short hCG stimulation test helps to exclude anorchia. Different imaging techniques are of little help in diagnosis and require the help of an experienced radiologist. Laparoscopy has an important role in the diagnosis and management of undescended testis. The common complications include torsion and atrophy of testis. Infertility is seen in about 40% of unilateral and 70% of bilateral cryptorchidism. Undescended testis is 20 to 40 times more likely to undergo malignant transformation than normal testis. Both hCG and GnRH have been used with limited success in these children. All boys with cryptorchidism should be referred to a pediatric surgeon before 2 years of age. These children should be followed up every year after surgery to identify testicular tumors.

Scrotal imaging

Scrotal ultrasonography has many indications. Evaluation of testis masses, hydroceles, and extratesticular structures are the most common indications. Color Doppler ultrasound has made assessment of scrotal blood flow possible. This enables the sonographer to make specific diagnoses in cases of acute scrotal pain. Other indications include evaluating infertile men, searching for an undescended testis, and evaluating the traumatized scrotum.

The effects of pre- and postnatal exposure to the nonsteroidal antiandrogen flutamide on testis descent and morphology in the Albino Swiss rat

Exposure of male Albino Swiss rats to the nonsteroidal antiandrogen flutamide during the period from gestational day (d) 10 to birth resulted in feminisation of the external genitalia and the suppression of growth of the male reproductive tract. In adulthood, testes were found to be located in diverse positions. True cryptorchidism occurred in 10% of cases, whereas 50% of testes descended to the scrotum and 40% were located in a suprainguinal ectopic region. Varying degrees of tubule abnormality were seen in the testes of flutamide-treated animals, ranging from completely normal tubules with full spermatogenesis (and the expected frequency of the stages of spermatogenesis) to severely abnormal tubules lined with Sertoli cells only. For each individual testis, the overall severity of tubule damage was strongly correlated with its adult location, with intra-abdominal testes worst affected and scrotally-located testes least; only the latter contained normal tubules. Similarly, intra-abdominal testes were the smallest in weight and contained the least testosterone. By contrast, postnatal treatment of male rats with flutamide from birth to postnatal d 14 did not impair development of the external genitalia, the process of testicular descent or adult spermatogenesis. These findings confirm that androgen blockade during embryonic development interferes with testicular descent but also demonstrate that (1) prenatal flutamide treatment per se has a detrimental effect on adult testis morphology but (2) the degree of abnormality of the testes is strongly influenced by location.

Current Diagnostic Possibilities in Cryptorchidism

From a review of Literature on the subject, the Authors have followed developments in diagnosing cryptorchidism. The objective examination is still fundamental, but nowadays ultrasound, NMR, CT, phlebography and laparoscopy can be used. Surgical exploration remains a valid method for completing the above examinations.

Retroperitoneal germ cell neoplasm: MR and CT

A case of germ cell neoplasm in an undescended retroperitoneal testicle is reported. CT revealed a large mass most consistent with a chronic hematoma. MRI demonstrated findings typical for neoplasm, and this was confirmed on biopsy.

Hormonal therapy in undescended testes

A clinical study trial of HCG therapy in 78 selected prepubertal cryptorchids (40 unilateral and 38 bilateral) having a total of 116 undescended gonads revealed that complete descent occurred in 12.5% gonads (13% in unilateral and 12% in bilateral group). Good response was observed in only those gonads which were located in the inguinal canal and at the external ring, irrespective of it being right or left sided gonad. In patients with impalpable testes, though there was no complete descent, yet partial descent was noted in 18% (21/116 gonads). The response was better in the older children.

Minor morphological aberrations in children with isolated urinary tract malformations

The prevalence of 54 minor morphological aberrations (MMAs) (mild malformations, dysplasias, deformities and phenogenetic variants) was determined in 138 children with isolated malformations of the urinary tract and in 32 patients with multiple major birth defects including renal malformations. Children with infectious diseases matched to each patient by sex, age and ethnic origin served as controls. The overall prevalence of MMAs--expressed as MMA/subject ratio--proved to be significantly higher in patients with multiple malformations (2.50) than in those with isolated renal abnormalities (0.80) and in controls (0.76). The difference between the latter two groups was not significant. Apart from characteristic patterns of well-defined syndromes, the only specific association found was the higher prevalence of supernumerary nipples in patients with isolated (and hidden) urinary tract abnormalities of various types (9.4% versus 1.8% in controls; P less than 0.005).

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.