Early orchiopexy: prepubertal intratubular germ cell neoplasia and fertility outcome

Testis tissue cryopreservation may be considered in boys with cryptorchidism

ABSTRACT

This study assessed the feasibility of testis tissue cryopreservation (TTC) for fertility preservation in prepubescent boys with cryptorchidism. From January 2014 to December 2022, the University Hospital of Copenhagen (Rigshospitalet, Copenhagen, Denmark) implemented TTC for 56 boys with cryptorchidism to preserve their reproductive potential. Testis tissue samples were collected during orchiopexy (32 cases) or at subsequent follow-up procedures (24 cases), necessitated by an increased risk of infertility as indicated by hormonal assessments and/or findings from initial surgical biopsies. Testis samples were procured for TTC and pathological analysis. The cohort had an average age of 1.3 (range: 0.3-3.8) years at the time of orchiopexy, with 91.1% presenting bilateral cryptorchidism. The study revealed a median germ cell count of 0.39 (range: 0-2.88) per seminiferous tubule, with germ cells detected in 98.0% of the bilateral biopsies and 100% of the unilateral, indicating a substantial potential for fertility in these immature tissues. A dark spermatogonia (Ad) was detected in 37 out of 56 patients evaluated, with a median Ad spermatogonia count of 0.027 (range: 0.002-0.158) per seminiferous tubule. A total of 30.2% of the samples lacked Ad spermatogonia, indicative of potential gonadotrophin insufficiency. The median hormone levels measured were as follows: follicle-stimulating hormone (FSH) at 0.69 (range: 0.16-2.5) U l-1, luteinizing hormone (LH) at 0.21 (range: 0.05-3.86) U l-1, and inhibin B at 126 (range: 17-300) pg ml-1. Despite early orchiopexy, 20%-25% of boys with cryptorchidism remain at risk for future infertility, substantiating the necessity of TTC as a precaution. The study highlights the need for refined predictive techniques to identify boys at higher risk of future infertility.

Undescended testis: A roundtable discussion based on clinical scenarios - Part 2

Undescended testis (UDT, cryptorchidism) is the most frequent genital anomaly in boys. However, its treatment varies widely throughout the world. This second part of our roundtable discussion aims to continue to ask global experts to express their attitudes towards several case scenarios of UDT in order to explore the rationale for their clinical decisions. As the European Association of Urology - Young Academic Urologists Pediatric Urology Working Group, we believe that this roundtable series will facilitate colleagues all over the world to reflect and improve their practices regarding the treatment of UDT.

National survey of physicians in Swedish child health centres finds insecurity and unawareness regarding management of undescended testicles

AIM

To investigate underlying factors for previously reported shortcomings in child health centres' (CHC) referral process of boys with undescended testicles.

METHODS

A total of 386 physicians working at Swedish CHCs were surveyed regarding their knowledge about undescended testicles and their clinical management. Multivariate regression analyses were performed to identify risk factors of non-adherence to guidelines and self-reported lack of clinical skills.

RESULTS

The overall knowledge of the health benefits of undescended testicle surgery was high (89%), while two-thirds were unaware of surgery being recommended <1 year of age. One-fifth of respondents had never received guidance on examination techniques. Male gender (adjusted odds ratio [aOR] 0.51, 95% confidence interval [95% CI] 0.31-0.86), education in paediatrics (aOR 0.37, 95% CI 0.18-0.76) and more experience (aOR 0.02, 95% CI 0.01-0.09) significantly decreased the risk of unfamiliarity with examinations. More experience decreased the risk of stating the incorrect indications for undescended testicle surgery (aOR 0.17, 95% CI 0.03-0.95) and finding examinations difficult (aOR 0.22, 95% CI 0.07-0.72). Medical education outside Nordic countries was a risk factor for unawareness of guidelines (aOR 2.06, 95% CI 1.21-3.51).

CONCLUSION

The knowledge and confidence level of the study population varied widely. The results indicate a need for further theoretical and practical education among Swedish CHC physicians.

Role of Anti-Müllerian Hormone in Male Reproduction and Sperm Motility

Anti-Müllerian hormone (AMH) is secreted by Sertoli cells and is responsible for the regression of Müllerian ducts in the male fetus as part of the sexual differentiation process. Serum AMH concentrations are at their lowest levels in the first days after birth but increase after the first week, likely reflecting active Sertoli cell proliferation. AMH rises rapidly in concentration in boys during the first month, reaching a peak level at ∼6 months of age, and it remains high during childhood, then they will slowly decline during puberty, falling to low levels in adulthood. Serum AMH measurement is used by pediatric endocrinologist as a specific marker of immature Sertoli cell number and function during childhood. After puberty, AMH is released especially by the apical pole of the Sertoli cells toward the lumen of the seminiferous tubules, resulting in higher levels in the seminal plasma than in the serum. Recently, AMH has received increasing attention in research on male fertility-related disorders. This article reviews and summarizes the potential contribution of serum AMH measurement in different male fertility-related disorders.

The fate of germ cells in cryptorchid testis

Cryptorchidism in males constitutes a notable risk factor for both infertility and testicular cancer. Infertility in adulthood is closely linked to the germ cell status in childhood. Furthermore, the significance of germ cell status is important as more than 95% of all reported testicular malignancies are germ cell tumors. The review aims to elucidate the pathogenesis of germ cells in cryptorchid testes concerning their association with infertility and testicular malignancies. Impaired germ cell numbers are evident in cryptorchid testes even during antenatal and neonatal stages. In cryptorchidism there is a rapid decline in germ cell number within the first year of life, partially attributed to physiologic gonocyte apoptosis. Additionally, germ cells fail to differentiate normally during mini-puberty leading to reduced germ cell proliferation and delayed clearance of gonocytes from the seminiferous epithelium. Absence of germ cells in testicular biopsies occurs already 10 months of age and germ cell deterioration progressively worsens with approximately 50% of persisting cryptorchid testes lacking germ cells during puberty. The deficient germ cell maturation and proliferation leads to later infertility. Elevated temperature in the cryptorchid testes and also hormonal deficiency contribute to this phenomenon. Germ cell neoplasia in situ (GCNIS) originating during fetal development may manifest in rare cases associated with disorders of sexual development, chromosomal abnormalities in boys, specific syndromes, and teratomas that include cryptorchidism. In adults, the presence of GCNIS predominantly represents a new histology pattern before invasive germ cell cancer is demonstrated and is neither congenital nor related to abnormal gonocyte transformation.

The role of the resistive index in predicting testicular atrophy after orchiopexy in unilateral undescended testis

PURPOSE

One of the most important complications of undescended testis (UDT) surgery is testicular atrophy (TA). We aimed to investigate the factors associated with TA in children who underwent orchiopexy for unilateral UDT.

METHODS

The data of 215 patients aged < 15 years who underwent orchiopexy for unilateral UDT between November 2019 and September 2022 were analyzed retrospectively. Clinical, radiological, surgical, and follow-up findings were recorded.

RESULTS

TA was observed in 29 (13.5%) patients. Mean resistive index (RI) values were 0.44 ± 0.06, 0.54 ± 0.09 and 0.69 ± 0.1 in low, middle and high testicular locations, respectively, and intratesticular RI increased significantly as the testis location raised (p < 0.001). After orchiopexy, the mean testis volume ratio (TVR) increased significantly (0.63 ± 0.13 vs. 0.77 ± 0.15, p < 0.001). Besides, the mean RI values decreased significantly in the postoperative follow-up (0.53 ± 0.12 vs. 0.47 ± 0.13, p < 0.001). In multivariate regression analysis, testicular high location (OR 4.332, 95% CI 2.244-6.578, p = 0.002), deferens-epididymal anomaly (OR 3.134, 95% CI 1.345-7.146, p = 0.021), TVR ≤ 0.5 (OR 5.679, 95% CI 2.953-12.892, p < 0.001) and RI ≥ 0.6 (OR 7.158, 95% CI 3.936-14.569, p < 0.001) were independent predictive factors for TA after orchiopexy.

CONCLUSION

Higher testis location, deferens-epididymis anomaly, preoperative TVR and RI were independent predictive factors for TA after orchiopexy in unilateral UDT. The results of the study will help surgeons to predict TA before orchiopexy.

Factors which delay surgery for undescended testis in Ontario: A retrospective population based cohort study on timing of orchidopexy between 2006 and 2012

BACKGROUND

Delays in performing orchidopexy (OP) for undescended testis (UDT) result in loss of germ cells. Despite practice guidelines recommending OP by 18 months of age, significant delays in OP occur. This delay may impact fertility and increase the risk of testicular malignancy in boys with UDT.

OBJECTIVE

The objective of this study is to identify factors associated with delayed OP with the goal of identifying modifiable risk factors.

STUDY DESIGN

A population-based, retrospective cohort study was conducted using linked databases held at ICES to evaluate factors associated with timing of OP in Ontario for 4339 male newborns undergoing their first OP between 2006 and 2012. Primary outcome was delayed OP (>18 months). Multivariable logistic regression analysis was performed to identify patient, physician, and hospital risk factors for delayed OP.

RESULTS

Median age at OP was 24 months, while median age at first surgical consult was 20 months (IQR 10-60 months). Older age at first surgical consult (>12 months vs. <9 months, OR 17.83) was identified as the primary risk factor for delayed OP, besides ICU hospitalization (OR 3.42), associated hypospadias (OR 2.30), higher hospital OP volume (OR 1.91), more healthcare visits in first year of life (OR 1.05), and older surgeon age (OR 1.02).

DISCUSSION

Our findings support reports that OP is often performed past guideline recommendations. Interventions that result in earlier referral for UDT (<6 months) may result in timely OP. Limitations for this study include potential misclassification or missing data within the utilized databases.

CONCLUSION

The most important barrier to timely OP is delay in first surgical consultation. Aiming for an earlier referral through guideline modifications or education to referring providers may help achieve the goal of timely OP.

An investigation of the reliability of YouTube videos on undescended testis

INTRODUCTION AND OBJECTIVE

There are thousands of patient information videos published on YouTube, the most watched video sharing platform; however, most of these videos contain incomplete or incorrect information. Interestingly, some videos with incomplete or incorrect information have a higher view rate. This study aimed to evaluate the quality of patient information videos on 'undescended testis' published on YouTube.

MATERIAL AND METHOD

A search was conducted on YouTube using the keywords 'undescended testis' and 'cryptorchidism', and a total of 373 videos were found. Among these, 122 patient information videos presented in the English language were examined. Four different scoring systems were used to evaluate the quality of the videos: Patient Education Materials Assessment Tool for Audiovisual Materials, Global Quality Score, Journal of American Medical Association score, and modified DISCERN scoring system. Whether the videos contained accurate and sufficient information was evaluated using a scoring system developed based on the patient information booklet prepared by the European Association of Urology (EAU) on undescended testis.

RESULTS

The median duration (sec), number of views and number of likes of the videos were 269 (11-2484), 589 (6-1.563561) and 7 (0-4.200), respectively. According to the EAU-patient information scoring (EAU-PIS), while 32 (26.2%) of the total 122 videos contained a good level of informativeness (score: 8-10), the view rate of these videos was only 4.1% among all videos. When the top 10 most watched videos were evaluated, their mean EAU-PIS was 5.9 ± 2.81, and these videos contained a moderate level of informativeness. On the positive side, 90% of all the videos recommended surgery as a treatment option.

DISCUSSION

Although YouTube is a widely used video-sharing platform, it is also a website where people or institutions can easily upload non-standardized videos due to the absence of regulations. Therefore, although it is an easily accessible source of information, it has many gaps in terms of reliability. As shown in our study, the rate of videos with accurate information was very low. It would be beneficial for viewers to be aware of this and accept YouTube as a source where they can have a general idea about a subject in which they are interested rather than using it as a reference information site. In future, YouTube can become a reference source in the medical field, especially with the standardization of medical videos through the collaboration of various organizations.

European Association of Urology Guidelines on Male Sexual and Reproductive Health: 2021 Update on Male Infertility

CONTEXT

The European Association of Urology (EAU) has updated its guidelines on sexual and reproductive health for 2021.

OBJECTIVE

To present a summary of the 2021 version of the EAU guidelines on sexual and reproductive health, including advances and areas of controversy in male infertility.

EVIDENCE ACQUISITION

The panel performed a comprehensive literature review of novel data up to January 2021. The guidelines were updated and a strength rating for each recommendation was included that was based either on a systematic review of the literature or consensus opinion from the expert panel, where applicable.

EVIDENCE SYNTHESIS

The male partner in infertile couples should undergo a comprehensive urological assessment to identify and treat any modifiable risk factors causing fertility impairment. Infertile men are at a higher risk of harbouring and developing other diseases including malignancy and cardiovascular disease and should be screened for potential modifiable risk factors, such as hypogonadism. Sperm DNA fragmentation testing has emerged as a novel biomarker that can identify infertile men and provide information on the outcomes from assisted reproductive techniques. The role of hormone stimulation therapy in hypergonadotropic hypogonadal or eugonadal patients is controversial and is not recommended outside of clinical trials. Furthermore, there is insufficient evidence to support the widespread use of other empirical treatments and surgical interventions in clinical practice (such as antioxidants and surgical sperm retrieval in men without azoospermia). There is low-quality evidence to support the routine use of testicular fine-needle mapping as an alternative diagnostic and predictive tool before testicular sperm extraction (TESE) in men with nonobstructive azoospermia (NOA), and either conventional or microdissection TESE remains the surgical modality of choice for men with NOA.

CONCLUSIONS

All infertile men should undergo a comprehensive urological assessment to identify and treat any modifiable risk factors. Increasing data indicate that infertile men are at higher risk of cardiovascular mortality and of developing cancers and should be screened and counselled accordingly. There is low-quality evidence supporting the use of empirical treatments and interventions currently used in clinical practice; the efficacy of these therapies needs to be validated in large-scale randomised controlled trials.

PATIENT SUMMARY

Approximately 50% of infertility will be due to problems with the male partner. Therefore, all infertile men should be assessed by a specialist with the expertise to not only help optimise their fertility but also because they are at higher risk of developing cardiovascular disease and cancer long term and therefore require appropriate counselling and management. There are many treatments and interventions for male infertility that have not been validated in high-quality studies and caution should be applied to their use in routine clinical practice.

The outcome of laparoscopic assisted orchidopexy in very young children: A single hospital experience

INTRODUCTION

Early orchidopexy has been linked to improved long term outcomes of fertility and reduced malignancy rates. However, the optimal age of intervention has been subject to change over the years.

OBJECTIVE

This study aims to study males aged 6 months or less who undergo laparoscopic assisted orchidopexy for intraabdominal testes to establish the safety, efficacy, and benefit in the defined age group.

STUDY DESIGN

We prospectively assessed 19 boys at or below 6 months of age, who had laparoscopic assisted orchidopexy for intraabdominal undescended testes at Salmaniya Medical Complex in Bahrain between January 2014 and December 2018. We examined: demographics, laterality, testicular locations, testicular volumes, operative time, complications, and durations of hospitalization and follow-up. Ultrasound-derived testicular volumes were assessed before and after orchidopexy. They were calculated using the Hansen formula (Testicular volume = 0.52 × length [L] × width [W]² [1]. They were then compared with reference ranges from a Dutch cohort study of 769 healthy boys. Successful outcomes were correct intrascrotal position with minimal complications and normal testicular volumes.

RESULTS

A total of 19 males were operated at a mean age of 5.6 months and followed for a mean of 2.35 years. Of these, 7 had left-sided and 12 had right-sided cryptorchidism. Testicular locations were noted intra-operatively; 10 were above the internal ring, 5 near the iliac vessels, and 4 close to the kidney. The mean operative time was 59.58 minutes. Only 2 minor complications occurred and no cases of testicular atrophy. None of the patients required hospital-stay beyond 24 hours. The success rate was 89.46% in achieving correct scrotal position. Testicular volumes were normal before and after orchidopexy. They significantly increased after orchidopexy (P ≤ 0.05). The testicular growth rate after 24 months was slightly higher than normal.

DISCUSSION

In line with previous studies we were 89.46% successful in re-positioning testes [2]. In contrast to studies intervening at older ages which associated intra-abdominal testes with greater risks of complications, we found few minor complications and no testicular atrophy [3,4]. Testicular volumes in the affected testes were normal, contrary to decreased volumes found by other researchers [5]. Limitations of this study are the small number of patients and short follow-up which limits assessment of long-term outcomes.

CONCLUSION

Early orchiopexy is safe and effective. Laparoscopic assisted orchidopexy at an early age was beneficial and resulted in normal testicular volumes before and after surgery.

A prediction model for risk factors of testicular atrophy after orchiopexy in children with undescended testis

BACKGROUND

There have been limited studies with small sample sizes about risk factors of testicular atrophy. Thus, we aimed to investigate the risk factors for testicular atrophy after orchiopexy in male children with undescended testes and develop a prediction model based on clinical variables.

METHODS

We performed a retrospective review of data on children who underwent orchiopexy for undescended testes from 2013 to 2017. The variables assessed included age, laterality, testicular location, preoperative testicular volume ratio, deferens and epididymis anomaly, hormonal treatment, comorbidities, type of surgical procedure, operating time, and complications as the outcome of testicular atrophy. A nomogram was constructed to predict the probability of testicular atrophy. We also validated our model based on a prospective cohort of patients who underwent orchiopexy from January 2018 to December 2018.

RESULTS

A total of 1,608 patients undergoing orchiopexy were included in the training cohort. The median age was 2.8 years (range, 0.5-11.3 years). After follow-up for 12 to 18 months (median, 14 months), 228 (14.2%) cases of atrophic testes were recorded. The independent predictors of testicular atrophy were preoperative testicular volume ratio [odds ratio (OR) 0.001, P=0.001], testicular location (OR 1.903, P=0.001), deferens and epididymis anomaly (OR 6.470, P=0.001), and two-stage Fowler-Stephens orchiopexy (OR 2.613, P=0.04). Successful validation was achieved, and a receiver operating characteristic (ROC) curve was constructed. The sensitivity and specificity of the prediction model were 78.1% and 77.5%, respectively. The area under the ROC curve was 0.851.

CONCLUSIONS

In patients with undescended testes, excluding those with chromosomal abnormalities and testicular nubbin, the incidence of testicular atrophy after orchiopexy is higher in patients with a lower testicular volume ratio, higher testicular location, deferens and epididymis anomaly, and in two-stage Fowler-Stephens orchiopexy. Therefore, this prediction model provides useful evidence for surgeons to choose an appropriate surgical procedure for undescended testes and predict the probability of testicular atrophy.

Clinical Applications of Serum Anti-Müllerian Hormone Measurements in Both Males and Females: An Update

Infertility is one of the most common non-communicable diseases, affecting both men and women equally. Ovarian reserve, the number of primordial follicles in the ovaries is believed to be the most important determinants for female fertility. Anti-Müllerian hormone (AMH) secreted from granulosa cells of growing follicles is recognized as the most important biomarker for ovarian reserve. Ovarian reserve models have been developed using AMH and other hormonal indicators, thus childbearing plans and reproductive choices could be arranged by women. In assisted reproductive technology cycles, measurement of AMH helps to predict ovarian response and guide recombinant follicle-stimulating hormone dosing in women. Serum AMH level is increasingly being recognized as a potential surrogate marker for polycystic ovarian morphology, one of the criteria for diagnosis of polycystic ovarian syndrome. AMH is also secreted by Sertoli cells of testes in men, and AMH measurements in the prediction of surgical sperm recovery rate in men have also been investigated. AMH levels are significantly higher in boys than in girls before puberty. Therefore, serum levels of AMH in combination with testosterone is used for the differential diagnosis of disorders of sex development, anorchia, non-obstructive azoospermia, and persistent Müllerian duct syndrome. Recently, serum AMH measurements have also been used in fertility preservation programs in oncofertility, screening for granulosa cell tumors, and prediction of menopause applications. In this review, we will focus on clinical application of AMH in fertility assessments for healthy men and women, as well as for cancer patients.

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Anti-Müllerian hormone (AMH) plays a key role in models assessing ovarian reserve

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AMH is used for the differential diagnosis of disorders of sex development

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AMH provides a molecular marker for related fertility and infertility disorders

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An international standard will aid in the development of various AMH assays

Trends in treatment outcomes for retractile testis in Japanese boys: A single-center study

OBJECTIVES

To investigate the natural course of retractile testis by analyzing its prevalence and outcomes.

METHODS

This retrospective study included 215 boys in whom retractile testis was diagnosed after reviewing the medical history and physical examinations of the patients. Orchiopexy was performed once the testis became undescended. We investigated the trends in the prevalence and outcomes of retractile testis and compared clinical factors between cases that resolved spontaneously and those that required orchiopexy.

RESULTS

Of 215 boys, 145 were finally evaluated. The mean age at diagnosis was 2 years, and 100 boys were aged ≤2 years when they were hospitalized. Seventy-three boys were referred to our institution through health examinations as babies. The condition improved spontaneously in 89 boys, while 43 boys underwent orchiopexy, and 13 boys remained under follow-up. The follow-up period between diagnosis and resolution was significantly longer in the spontaneous resolution group than in the surgical intervention group (P = 0.011). Bilateral retractile testis improved spontaneously in significantly more boys compared to unilateral retractile testis (P = 0.0010). Spontaneous resolution was observed in boys of all ages, but those diagnosed at ≤3 years of age had a significantly higher rate of spontaneous resolution compared to those who were diagnosed at >3 years of age (P = 0.0019).

CONCLUSIONS

Our findings suggest that retractile testis cannot be affirmed as a variant of normal testis. Performing examinations at a young age is critical for preventing misdiagnosis, screening failures, and unnecessary surgery.

How boys and testicles wander to surgery: a nationwide cohort study of surgical delay in Sweden

BACKGROUND

Early orchidopexy is recommended for cryptorchidism and the surgery is increasingly centralised. The objectives were to determine the incidence, risk factors and if distance to treating hospital impacted on timely treatment of cryptorchidism.

METHODS

In this observational study, all boys born in Sweden from 2001 to 2014 were followed in national registers to determine the incidence of cryptorchidism by levels of birth-related risk factors and social determinants. Travel time to hospital was used as the primary exposure in multivariable survival analysis, with age at surgery as main outcome.

RESULTS

Of 748 678 boys at risk for cryptorchidism, 7351 were treated and evaluated for timing of surgery (cumulative childhood incidence 1.4%, 95% CI 1.3% to 1.5%). The incidence was clearly associated with prematurity and overdue pregnancy (HR for <32 weeks 2.77 (95% CI 2.39 to 3.21); 32-36 weeks HR 1.36 (95% CI 1.24 to 1.49); >41 weeks HR 1.19 (95% CI 1.10 to 1.29)), low birth weight (<1000 g HR 3.94 (95% CI 3.15 to 4.92); 1000-1499 g HR 3.70 (95% CI 3.07 to 4.46); 1500-2500 g HR 1.69 (95% CI 1.52 to 1.88)) and intrauterine growth restriction (small for gestational age HR 2.38 (95% CI 2.14 to 2.65); large for gestational age HR 1.26 (95% CI 1.13 to 1.42)), but not with smoking or maternal age. Each 30 min increase in travel time was associated with a reduced probability of timely treatment (HR for being treated by age 3 adjusted for risk factors and socioeconomic determinants: 0.91 (95% CI 0.88 to 0.95)). Lower income and financial support were also associated with treatment delays (adjusted HR for lowest income quintile 0.82 (95% CI 0.72 to 0.93) and for families with financial support 0.85 (95% CI 0.73 to 0.97)).

CONCLUSIONS

Travel distance to treating hospital was associated with delayed treatment. 'Not all those who wander are lost', but these findings suggest a trade-off between centralisation benefits and barriers of geography also in elective paediatric surgery.

Regulation of anti-Müllerian hormone (AMH) in males and the associations of serum AMH with the disorders of male fertility

Anti-Müllerian hormone (AMH) is a functional marker of fetal Sertoli cells. The germ cell number in adults depends on the number of Sertoli cells produced during perinatal development. Recently, AMH has received increasing attention in research of disorders related to male fertility. This paper reviews and summarizes the articles on the regulation of AMH in males and the serum levels of AMH in male fertility-related disorders. We have determined that follicle-stimulating hormone (FSH) promotes AMH transcription in the absence of androgen signaling. Testosterone inhibits the transcriptional activation of AMH. The undetectable levels of serum AMH and testosterone levels indicate a lack of functional testicular tissue, for example, that in patients with anorchia or severe Klinefelter syndrome suffering from impaired spermatogenesis. The normal serum testosterone level and undetectable AMH are highly suggestive of persistent Müllerian duct syndrome (PMDS), combined with clinical manifestations. The levels of both AMH and testosterone are always subnormal in patients with mixed disorders of sex development (DSD). Mixed DSD is an early-onset complete type of disorder with fetal hypogonadism resulting from the dysfunction of both Leydig and Sertoli cells. Serum AMH levels are varying in patients with male fertility-related disorders, including pubertal delay, severe congenital hypogonadotropic hypogonadism, nonobstructive azoospermia, Klinefelter syndrome, varicocele, McCune-Albright syndrome, and male senescence.

Plasma concentration of MMP-1 and MMP-2 in boys with cryptorchidism and its lack of correlation with INSL3 and inhibin B

The matrix metalloproteinases are enzymes capable of remodeling of extracellular matrix, and modulate the behavior of cells. Maturation of gubernaculum and spermatogenesis demand proper equilibrium of metalloproteinases and their inhibitors. The aim of this survey was to investigate the levels of matrix metalloproteinase type 1 (MMP-1) and matrix metalloproteinase type 2 (MMP-2) in the plasma of children with unilateral cryptorchidism along with levels of Insulin-like Peptide 3 (INSL3) and inhibin B. INSL3 have a role in gubernaculum development. Inhibin B is produced by Sertoli cells, and its levels reflect the status of the testis germinative epithelium. Fifty boys with an undescended testicle, aged 1-4 years (median = 2.4 years) were enrolled into the study. Fifty boys with inguinal hernia aged 1-4 years, served as controls (median age = 2.1 years). Investigators assessed the MMP-1 and MMP-2 concentrations using Surface Plasmon Resonance Imaging. The levels of INSL-3 and inhibin B were assessed using commercial enzyme-linked immunosorbent assay ELISA. The median concentration of MMP-1 and MMP-2 in the blood plasma of patients with unilateral cryptorchidism, was nearly 2-folds higher than in controls. The great area under the ROC curve with the cut off value of 0.865 for MMP-1, and 0.819 for MMP-2, indicates the high clinical sensitivity and specificity of the test of plasma levels of MMP-1 and MMP-2 for boys with cryptorchidism. The increased plasma levels of MMP-1 and MMP-2, probably reflect the level of apoptosis of the germ cells in undescended testicles, in response to the heat stress during the period of prepubertal testis development. In the group of cryptorchid boys, we found slightly lower concentrations of INSL3, without statistical significance and without correlation with MMP-1 and MMP-2 levels. There were no significant differences in the levels of inhibin B in the group of boys with cryptorchidism and boys with inguinal hernia and it also did not correlate with MMP-1 and MMP-2 concentrations.

Trans-scrotal Incision Approach versus Traditional Trans-scrotal Incision Orchiopexy in Children with Cryptorchidism: A Randomized Trial Study

Background:

Although undescended testis (UDT) is the most prevalent malformation in male neonates, the best mode of UDT treatment remains controversial. This study aimed to compare trans-scrotal incision approach with traditional trans-scrotal incision orchiopexy in children suffering from cryptorchidism.

Materials and Methods:

This single-blind randomized clinical trial was done on 100 children with UDT who needed surgery. The participants were alternately undergoing trans-scrotal incision orchiopexy (Group I) and traditional inguinal incision orchiopexy (Group II). The success rate and incidence of postoperative complications were evaluated 1 week and 1 month and 6 months after the operation in the two groups.

Results:

Both the groups were similar in baseline characteristics including age and laterality (P > 0.05). There was no significant difference between the two groups in terms of the incidence of wound infection, testicular atrophy, testicular hypotrophy, and relapse (P > 0.05). In addition, the success rates were 98% in Group I and 94% in Group II (P > 0.05).

Conclusion:

Both surgical methods have a high success rate, and there is no significant difference in the incidence of complications; however, in terms of beauty, satisfaction, and shortening the duration of surgery and the duration of hospitalization, trans-scrotal approach was more successful than the traditional method.

Selecting Infants With Cryptorchidism and High Risk of Infertility for Optional Adjuvant Hormonal Therapy and Cryopreservation of Germ Cells: Experience From a Pilot Study

INTRODUCTION

Orchiopexy for congenital cryptorchid testes is recommended between ½ and 1 year of age to preserve testicular germ cell maturation. Early operation is not enough to preserve fertility in 22 and 36% of cases. Aim of this study was to set up a protocol for optional adjuvant hormonal therapy after orchiopexy and thereafter cryopreservation of testicular biopsies from infants with bilateral cryptorchidism and high infertility risk.

MATERIALS AND METHODS

We included 17 boys with bilateral cryptorchidism, normal FSH, and impaired germ cell number per tubular transverse section (G/T) in testicular biopsies at orchiopexy, 7 months to 3½ years old. Postoperatively, optional adjuvant LHRH (kryptocur^®) 0.2 mg/0.1 mL 2× every second day in 16 weeks were offered. Ten boys were applicable for age matching according to parent's choice of treatment regime and G/T. Five of them had kryptocur^®, and five were controls. Repeat bilateral testicular biopsy evaluation and cryopreservation were offered to all boys 12 months after primary orchiopexy. For cryopreservation, tissue pieces were incubated with a cryoprotectant with a slow program freezing.

RESULTS

Two out of five kryptorcur^®-treated boys normalized both the average G/T and the number of adult dark spermatogonia (Ad-S). Another kryptocur^®-treated boy with initial low G/T and no Ad-S increased the G/T and achieved normal number of Ad-S at time of cryopreservation. In the control group, two patients reached only normal lower range regarding the G/T and the number of Ad-S. None of boys with less than average 0.2 G/T improved significantly, whether they were kryptocur^®-treated or not.

CONCLUSION

Based on literature and the present results, we recommend adjuvant LHRH treatment to boys with cryptorchidism and insufficient genuine gonadotropin stimulation at time of surgery, as these patients have high infertility risk. Cryopreservation should be an option in case of treatment failure of adjuvant LHRH. However, to avoid repeat surgery with biopsy, some parents may choose biopsy for cryopreservation at time of the initial bilateral orchiopexy, well informed that the procedure may only be truly indicated in 22 and 36% of the cases.

Sperm DNA damage measured by sperm chromatin structure assay in men with a history of undescended testes

The aim of this study was to compare sperm DNA damage between men with a history of congenital undescended testis (UDT) and men with a history of acquired UDT. A long-term follow-up study of men with previous UDT was performed. Fifty men with congenital UDT who had undergone orchiopexy at childhood age, 49 men with acquired UDT after a 'wait-and-see'-protocol (e.g. awaiting spontaneous descent until puberty and perform an orchiopexy in case of non-decent), and 22 healthy proven fertile men were included. The DNA fragmentation index (DFI) using sperm chromatin structure assay (SCSA) was used to express the level of sperm DNA damage. Decreased fertility potential was considered if DFI was above 30%. Sperm DNA damage was not statistically different between cases of congenital and acquired UDT. DFI was significantly more often >30% in the complete group of men with congenital UDT (9/50; 18%) and in the subgroup with bilateral congenital UDT (3/7; 43%) in comparison with the controls (none) (p-value 0.049 and 0.01, respectively). Age at orchiopexy in congenital UDT had no statistical effect on DNA damage. In men with acquired UDT, DFI did not statistically differ between those having undergone orchiopexy and those experiencing spontaneous descent. This study supports the hypothesis that UDT is a spectrum representing both congenital UDT and acquired UDT. Sperm DNA damage at adult age is not influenced by age at orchiopexy in congenital UDT cases and by orchiopexy or spontaneous descent in acquired UDT cases.

Evaluation of Pediatric Undescended Testes with Elastosonography

Background

Undescended testes, which are defined as the failure of testes to descend to scrotum, are the most common developmental defect in male infants. Indirect evaluation of histologic damage can be performed with the help of palpation during operation. Hard texture of testes tissue is likely related with histological damage. Real-time elastography is an emerging technology of ultrasonic imaging of soft tissue strain and elasticity, it aims at providing information regarding the mechanical properties of tissues, such as their hardness or stiffness. This study aim was to investigate the changes in strain and elasticity of testes tissue by using elastography technique.

Materials and methods

A total of 32 patients, who had undescended testes were included in this study. Only two patients had bilateral undescended testes, other patients had unilateral. The age of the patients were recorded according to the time of ultrasonographic (USG) examination. The undescended testes was displayed in the elastographic box with the neighbouring subcutaneous fat tissues. The strain ratios were measured as the ratios of the elasticities of the subcutaneous fat tissue to the elasticities of the undescended testes.

Results

A total of 32 patients with 34 testes were included in the study. The mean age of the patients with undescended testes was 32.6 months (range 7-60 months). The mean strain ratios were 0.67 (range 0.12-1.41) for the undescended testes and there were no significant differences in undescended testes strain ratios related to patient age (p = 0.453).

Conclusion

This preliminary study showed that there were no significant fibrosis which can be demonstrated with elastosonography before the age of 5 years old. Additional studies with his-topathological results are needed to identify sensitivity and specificity of elastosonography in undescended testis and in planning optimal operation time for these patients.

Management of undescended testes: European Association of Urology/European Society for Paediatric Urology Guidelines

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.

Perspectives in Pediatric Pathology, Chapter 14. Natural History of Undescended Testes

Cryptorchidism is one of the most frequent problems encountered in pediatric urology. Its causes, associated lesions, and prognosis in terms of fertility have been a source of interest and discrepancies for pediatric pathologists and urological surgeons.

Cryptorchidism and Fertility

Congenital cryptorchidism, that is, undescended testis, is one of the most common urogenital abnormalities observed in newborn boys. In addition to the congenital form, there is also acquired form of cryptorchidism. Fertility potential of patients with cryptorchidism has been evaluated by testicular histology and volume, semen quality, reproductive hormone levels, time to conception, and paternity rates. Cryptorchidism is associated with abnormalities in testicular development, and early treatment is recommended to optimize the fertility potential of the patients.

Fertility potential in a cohort of 65 men with previously acquired undescended testes

PURPOSE

To evaluate testicular function in men with previously acquired undescended testes (AUDT) in whom spontaneous descent was awaited until puberty followed by orchiopexy in case of nondescent.

METHODS

Andrological evaluation including paternity, scrotal ultrasound, reproductive hormones, and semen analysis was performed in three groups: men with AUDT, healthy controls, and men with previously congenital undescended testes (CUDT).

RESULTS

In comparison with controls, men with AUDT more often had significantly abnormal testicular consistency, smaller testes, lower sperm concentration, and less motile sperm. Except for more often a normal testicular consistency in men with AUDT, no differences were found between men with AUDT and men with CUDT. Also, no differences were found between men with AUDT which had spontaneously descended and men who underwent orchiopexy.

CONCLUSIONS

Fertility potential in men with AUDT is compromised in comparison with healthy controls, but comparable with men with CUDT. This suggests that congenital and acquired UDT share the same etiology. No significant difference was found between men who had spontaneous descent and men needing orchiopexy. However, fertility potential is unknown for men after immediate surgery at diagnosis, and this should be a subject for future studies.

Ideal timing of orchiopexy: a systematic review

The ideal management of cryptorchidism is a highly debated topic within the field of pediatric surgery. The optimal timing of orchiopexy is particularly unclear, as existing literature reports mixed recommendations. The aim of this study was to determine, based on a systematic review, the most favorable age at which orchiopexy should be performed. We conducted a systematic search of MEDLINE, Embase, CINAHL, and the Cochrane Library to find relevant articles. Two researchers quality assessed each study using the following tools: AMSTAR (systematic reviews), Jadad (RCTs), and MINORS (non-RCTs). We developed a conclusion based on the highest quality studies. We found one relevant systematic review, one RCT, and 30 non-RCTs. Fertility potential was greatest when orchiopexy was performed before 1 year of age. Additionally, orchiopexy before 10–11 years may protect against the increased risk of testicular cancer associated with cryptorchidism. Orchiopexy should not be performed before 6 months of age, as testes may descend spontaneously during the first few months of life. The highest quality evidence recommends orchiopexy between 6 and 12 months of age. Surgery during this timeframe may optimize fertility potential and protect against testicular malignancy in children with cryptorchidism.

The regulation of testicular descent and the effects of cryptorchidism

The first half of this review examines the boundary between endocrinology and embryonic development, with the aim of highlighting the way hormones and signaling systems regulate the complex morphological changes to enable the intra-abdominal fetal testes to reach the scrotum. The genitoinguinal ligament, or gubernaculum, first enlarges to hold the testis near the groin, and then it develops limb-bud-like properties and migrates across the pubic region to reach the scrotum. Recent advances show key roles for insulin-like hormone 3 in the first step, with androgen and the genitofemoral nerve involved in the second step. The mammary line may also be involved in initiating the migration. The key events in early postnatal germ cell development are then reviewed because there is mounting evidence for this to be crucial in preventing infertility and malignancy later in life. We review the recent advances in what is known about the etiology of cryptorchidism and summarize the syndromes where a specific molecular cause has been found. Finally, we cover the recent literature on timing of surgery, the issues around acquired cryptorchidism, and the limited role of hormone therapy. We conclude with some observations about the differences between animal models and baby boys with cryptorchidism.

Serum AMH in Physiology and Pathology of Male Gonads

AMH is secreted by immature Sertoli cells (SC) and is responsible for the regression of Müllerian ducts in the male fetus as part of the sexual differentiation process. AMH is also involved in testicular development and function. AMHs are at their lowest levels in the first days after birth but increase after the first week, likely reflecting active SC proliferation. AMH rises rapidly in concentration in boys during the first month, reaching a peak level at about 6 months of age, and then slowly declines during childhood, falling to low levels in puberty. Basal and FSH-stimulated levels of AMH, might become a useful predictive marker of the spermatogenic response to gonadotropic treatment in young patients with hypogonadotropic hypogonadism. After puberty, AMH is released preferentially by the apical pole of the SC towards the lumen of the seminiferous tubules, resulting in higher concentrations in the seminal plasma than in the serum. Defects in AMH production and insensitivity to AMH due to receptor defects result in the persistent Müllerian duct syndrome. A measurable value of AMH in a boy with bilateral cryptorchidism is predictive of undescended testes, while an undetectable value is highly suggestive of anorchia or ovaries, as would be the case in girls with female pseudohermaphroditism and pure gonadal dysgenesis. Lower serum AMH concentrations in otherwise healthy boys with cryptorchidism, who were compared with their age-matched counterparts with palpable testes, have been reported previously. AMH levels are higher in prepubertal patients with varicocele than in controls. This altered serum profile of AMH in boys with varicoceles may indicate an early abnormality in the regulation of the seminiferous epithelial function. Serum AMH is known to be valuable in assessing gonadal function. As compared to testing involving the administration of human chorionic gonadotropin, the measurement of AMH is more sensitive and equally specific. Measurement of AMH is very useful in young children, because serum gonadotropin concentrations in those who are agonadal are nondiagnostic in midchildhood and serum testosterone concentrations may fail to increase with provocative testing in children with abdominal testes.

Fertility potential in men with a history of congenital undescended testes: a long-term follow-up study

Men with a history of congenital undescended testes (UDT) have an increased risk of fertility problems. Despite no definitive proof, current guidelines recommend early surgical intervention because this may have a positive effect on future fertility potential by preventing degenerative changes of the testes in early life. Also surgical intervention facilitates observability of the testes in view of possible malignancy. We evaluated testicular function in adult men with previous UDT treated at different ages before puberty. A long-term follow-up study of men with previous UDT was performed. Andrological evaluation included medical history taking, physical examination, scrotal ultrasound, determination of reproductive hormones, and semen analysis. Findings were compared with those of a control group of men with normal testicular descent. The influence of age at orchiopexy on future fertility parameters was evaluated in a multivariate regression analysis. 62 men were included of whom seven had had bilateral UDT. Twenty-four patients had had their orchiopexy before the age of 24 months of whom eight men had it before 12 months of age. Forty-eight men had had unsuccessful luteinizing-hormone-releasing-hormone (LHRH) nasal spray treatment during childhood, whereas 14 of 24 men operated before 24 months of age had not received LHRH treatment before orchiopexy. Fertility potential in men with a history of UDT is compromised in comparison with controls. We could not detect any influence of age at orchiopexy on fertility parameters. However, the number of patients operated before the age of 12 months is limited. This study does not support the assumption that early orchiopexy results in better fertility potential.

Practice variation and clinical confusion regarding undescended testes and retractile testes among primary care respondents: a multi-regional survey study in the United States

PURPOSE

Although previous studies have looked at referral patterns and indications for orchiopexy, this is the first attempt at quantifying the primary care provider knowledge base of cryptorchidism and its implications in a large multi-state setting in the United States.

METHODS

Primary care providers (PCPs) (n = 3,000) were invited to complete a web-based survey regarding cryptorchidism. We evaluated: practice setting; training; knowledge of cryptorchidism; relationship to pediatric urologists and surgeons; understanding of the relationship between cryptorchidism, infertility and testis cancer.

RESULTS

Seventeen percent (n = 453) of PCPs responded to the survey. Fifty-three percent indicated that they had minimal to no exposure to pediatric urology during training. Two-thirds refer patients with retractile testes to surgical specialists. Practice setting was associated with the type of information families received about the impact of UDT on fertility and malignancy with rural practices being more likely to counsel that unilateral UDT imparted a high risk of malignancy (RR 1.5; 95 % CI 1.2, 1.9) and bilateral UDT resulted in likely infertility (RR 2.1; 95 % CI 1.5, 2.8).

CONCLUSIONS

This study underscores the need for increased evidence-based recommendations, as well as improved training and education of PCPs in the US who deal with disorders of testicular descent.

Difficult differential diagnoses in testicular pathology

CONTEXT

Although relatively rare, testicular cancer is the most common solid organ malignancy in young men and remains a leading cause of cancer death in this population. Different types of testicular tumors are treated differently, with an overall very high cure rate with proper management. Pathologists must, therefore, be familiar with important diagnostic pitfalls in testicular pathology, particularly those that result in different treatments or prognoses.

OBJECTIVE

To summarize key diagnostic features and useful ancillary tools for the most frequently encountered problems in testicular tumor pathology.

DATA SOURCES

Current texts, PubMed (National Library of Medicine) articles, and archives at Indiana University School of Medicine and Beth Israel Deaconess Medical Center were all reviewed.

CONCLUSIONS

Problematic differential diagnoses include seminoma versus nonseminomatous germ cell tumors, germ cell tumors versus non-germ cell tumors, intratubular germ cell neoplasia versus atypical germ cells with maturation arrest, pseudolymphovascular invasion versus real lymphovascular invasion in germ cell tumors, and macroscopic Sertoli cell nodules versus Sertoli cell tumors. In almost all cases, awareness of the differential diagnostic possibilities based on routine light microscopic features permits application of either additional, directed observations or immunohistochemical studies that lead to an accurate diagnosis.

Serum AMH concentration as a marker evaluating gonadal function in boys operated on for unilateral cryptorchidism between 1st and 4th year of life

The aim of this study was to measure the serum AMH (anti-Mullerian hormone) concentrations in a group of boys with or without cryptorchidism, evaluation of karyotypes, testicular position, morphology, and major length of the undescended testes. Fifty boys who were 1-4 years old (median = 2.4 years) with unilateral cryptorchidism were evaluated. All of them underwent orchidopexy in 2010. Prior to the procedure, all of the subjects had undergone karyotyping to exclude chromosomal abnormalities. Fifty healthy boys within the same age range (median = 2.1 years) admitted for planned inguinal hernia repair in 2010, served as controls. Blood samples were collected, while obtaining blood for standard laboratory tests routinely performed before the surgeries. Medians of AMH in boys with cryptorchidism were lower than in boys with inguinal hernia and differed significantly between two groups. Undescended testes were generally found in superficial inguinal pouch (n = 46), in two cases were noted to be in the external ring of the inguinal canal, and in another two instances, in the abdominal cavity. The major lengths of the undescended testes were smaller in comparison to the testes positioned normally (mean of 1 cm vs. a mean of 1.5 cm, respectively). In nine of the cases, the testes had turgor deficit, a drop shape, with epididymides that were small, dysplastic, and separated from the testis. The authors found that AMH was lower in boys with unilateral cryptorchidism (also found to have smaller testis) when compared with the control group.

Single scrotal incision orchiopexy for children with palpable low-lying undescended testis: early outcome of a prospective randomized controlled study

Purpose

We prospectively evaluated the surgical outcomes of single scrotal incision orchiopexy in children with a palpable undescended testis compared with the traditional two incision orchiopexy.

Materials and Methods

A total of 398 orchiopexies (292 children) were included and randomly assigned to the single scrotal incision orchiopexy group (Group I, 147 children, 201 testes) or the traditional inguinal incision orchiopexy group (Group II, 145 children, 197 testes). The final number of patients enrolled (excluding those lost to follow-up) was 107 children (146 testes) in group I and 105 children (141 testes) in group II. Success was defined as no complications, postoperative intrascrotal location of the testis, and no conversion to the traditional inguinal approach. Surgical outcomes and complications were compared between the two groups. Testicular location, complications, and subjective satisfaction rate were assessed at the follow-up evaluation at least 12 months postoperatively.

Results

The overall success rate in group I was 92.5% in 135 of 146 testes; the remaining 9 testes required conversion to traditional two incision orchiopexy. In group II, orchiopexy was successful in 136 of 141 testes (96.5%). The operation time and hospital stay were significantly shorter in group I (40.5±25.9 minutes, 2.1±0.8 days) than in group II (62.3±35.6 minutes, 2.5±0.7 days), respectively (p<0.001, p=0.03). Postoperative complications were found in two cases (hematoma, wound dehiscence) in group I and in one case (wound dehiscence) in group II; all cases with complications recovered with conservative care. The subjective rate of satisfaction with the cosmetic result was 96.6% in group I and 96.5% in group II (p=0.97).

Conclusions

We conclude that single scrotal incision orchiopexy is a simple technique that is associated with a shorter operation time and hospital stay than the traditional method and that is more feasible cosmetically.

Testicular catch up growth: the impact of orchiopexy age

OBJECTIVE

To compare the long-term follow-up growth of congenital, unilaterally palpable, undescended testes after orchiopexy according to age at the time of surgery. The optimal age for surgical treatment remains controversial.

MATERIALS AND METHODS

A total of 86 patients (108 testes) between the ages of 1 and 9 years underwent orchiopexy. Patients were divided according to age at the time of surgery: group I, <2 years (n = 43); group II, 2 ≤ age < 5 years (n = 35); and group III, ≥5 years (n = 30). The boys were then followed for more than 2 years after surgery. Ultrasonography was used for determination of testicular volume. Testicular volume percentage was compared by the equation of (operated testis volume/normal testis volume × 100%).

RESULTS

Testicular location was the inguinal canal in 92 (85.2%) and lower to the external inguinal ring in 16 (14.8%). Only group I, which received orchiopexy within two years from birth, showed significant recovery of testicular volume at follow-up (P <.05), compared with groups II and III.

CONCLUSIONS

Orchiopexy performed at less than 2 years from birth was a significant factor for recovery of delayed cryptorchid testicular growth. This result suggests that early orchiopexy improves subsequent testicular catch-up growth.

[Cryptorchidism and infertility from the perspective of interdisciplinary guidelines]

Cryptorchidism is the most common genital disorder in boys. Early-born boys are affected in up to one third of the cases, while about 2-5% of full-term newborns suffer from at least one undescended testicle. As a result of short-term endogenous testosterone secretion after birth the prevalence decreases to 1-2% after 3 months. According to most studies, watchful waiting after 6 months is not justified because after this time spontaneous testicular descent only very rarely occurs. Even though the effects of testicular development and fertility in undescended testis have been extensively examined, the only fact that remains certain is that approximately 90% of untreated men with bilateral cryptorchidism develop azoospermia. The remaining scenarios of cryptorchidism (unilateral, ectopic, inguinal, treated or not treated) exhibit unpredictable fertility and likelihood of fatherhood.

Screening of testicular descent in older boys is worthwhile: an observational study

BACKGROUND

Testicular descent in boys is now routinely screened only once, at 6-8 weeks of age. Early surgery for undescended testes is recommended.

AIM

To assess the value of screening for testicular descent at 6-8 weeks, 8-9 months, and 39-42 months of age.

DESIGN OF STUDY

Observational study.

SETTING

Royal Hospital for Sick Children, Glasgow and the Scottish community-based Child Health Surveillance Programme.

METHOD

Screening data for boys undergoing surgery for abnormal testicular descent between April 2006 and September 2007 was reviewed. The main outcome measure was median age at first operation for abnormal testicular descent comparing attendance at screening with non-attendance.

RESULTS

Boys who attended screening underwent surgery at a significantly younger median age than boys who did not attend screening at 6-8 weeks (2.7 versus 7.7 years; P<0.001); 8-9 months (4.5 versus 9.7 years; P<0.001); and 39-42 months (7.8 versus 10.8 years; P = 0.014). A new diagnosis was made in 33% (42 of 128 boys) at 6-8 weeks, 28% (21/74) at 8-9 months, and 39% (15/38) at 39-42 months. Detection on screening did not always trigger referral. Referral was triggered by screening in 48% (62/128) of cases, and by incidental examinations in 27% (34/128).

CONCLUSION

The previous screening regimen was effective, but checks at 8-9 months and 39-42 months have recently been abolished. Reinstatement of screening for testicular descent in older boys is advocated because screened boys underwent surgery at a younger age. Doctors should be encouraged to check testicular descent in boys throughout childhood, and refer promptly when there is any concern.

Cryptorchidie: influence sur la fertilité de l’âge au moment de l’orchidopexie, du siège et de la taille du testicule et de l’existence d’anomalies épididymaires

Malgré le traitement chirurgical, la cryptorchidie reste la cause la plus fréquente de stérilité. À travers une revue de la littérature, les auteurs relatent les données actuelles concernant l’influence de l’âge au moment de l’orchidopexie, de la taille du testicule, du siège du testicule et de l’existence d’une indépendance épididymotesticulaire sur la fertilité ultérieure.

What is new in cryptorchidism and hypospadias--a critical review on the testicular dysgenesis hypothesis

It has been hypothesized that poor semen quality, testis cancer, undescended testis, and hypospadias are symptoms of one underlying entity--the testicular dysgenesis syndrome--leading to increasing male fertility impairment. Though testicular cancer has increased in many Western countries during the past 40 years, hypospadias rates have not changed with certainty over the same period. Also, recent studies demonstrate that sperm output may have declined in certain areas of Europe but is probably not declining across the globe as indicated by American studies. However, at the same time, there is increasing recognition of male infertility related to obesity and smoking. There is no certain evidence that the rates of undescended testes have been increasing with time during the last 50 years. In more than 95% of the cases, hypospadias is not associated with cryptorchidism, suggesting major differences in pathogenesis. Placental abnormality may occasionally cause both cryptorchidism and hypospadias, as it is also the case in many other congenital malformations. The findings of early orchidopexy lowering the risk of both infertility and testicular cancer suggest that the abnormal location exposes the cryptorchid testis to infertility and malignant transformation, rather than there being a primary abnormality. Statistically, 5% of testicular cancers only are caused by cryptorchidism. These data point to the complexity of pathogenic and epidemiologic features of each component and the difficulties in ascribing them to a single unifying process, such as testicular dysgenesis syndrome, particularly when so little is known of the actual mechanisms of disease.

Advances in molecular genetics of cryptorchidism

Cryptorchidism is the most common congenital disorder in boys; one major complication of this disorder is male infertility. Androgens are key hormones to complete testicular descent; therefore, impaired fetal androgen action can result in this anomaly; its molecular etiology, however, remains unknown. Recent molecular approaches might provide an opportunity to identify not only candidate genes but also several predictive markers of future fertility. The purpose of this review is to summarize the recent insight into the genetic pathway of testicular descent and the molecular etiology of isolated cryptorchidism, and discuss the prospects of treatment to achieve future fertility in such patients.

Age at orchiopexy and testis palpability predict germ and Leydig cell loss: clinical predictors of adverse histological features of cryptorchidism

PURPOSE

We determined the relationship between clinical variables and testicular histopathological changes associated with decreased fertility potential in children with cryptorchidism.

MATERIALS AND METHODS

Testis biopsies of 274 children who underwent orchiopexy and concurrent testicular biopsy between 1991 and 2001 were analyzed for germ and Leydig cell loss, and testicular fibrosis. Multivariable logistic regression was used to determine if age at orchiopexy (analyzed as continuous and ordinal variables), preoperative testis palpability, unilateral vs bilateral disease and/or side of undescended testis was predictive of these pathological outcomes.

RESULTS

Age at orchiopexy was associated with germ and Leydig cell depletion. Each month of testis undescent was associated with development of moderate/severe germ cell depletion (OR 1.02 for each month of age, p <0.005) and Leydig cell loss (OR 1.01 for each month of age, p <0.02). Nonpalpable testes were associated with severe germ cell depletion. Children with palpable testes had lower odds of germ cell depletion than those with nonpalpable testes (OR 0.46, p <0.005). This finding corresponds to a significant 2% risk per month of severe germ cell loss and 1% risk per month of Leydig cell depletion for each month a testis remains undescended, and a 50% greater risk of germ cell depletion in nonpalpable relative to palpable cryptorchid testes.

CONCLUSIONS

Testes that remain undescended are associated with progressive loss of germ and Leydig cells, and nonpalpable testes predict severe germ cell loss.

Review of the extent to which orchidopexy is performed at the optimal age: implications for health services

BACKGROUND

In recent decades, the recommended age for orchidopexy for primary undescended testes has decreased, in the expectation that this might improve subsequent fertility. The aim of this study was to investigate whether this is reflected in a reduction in the age at which orchidopexies are carried out, and the implications for child health services.

METHODS

All boys who underwent an orchidopexy for an undescended testis carried out by the Christchurch-based paediatric surgical service between January 1997 and December 2007 were identified through a prospectively collected database. They were analysed according to the age at time of operation and year of surgery to determine whether there was any trend over time. The proportions of children younger than 2 years and between 2 and 5 years of age were calculated for each year.

RESULTS

In total, 788 boys underwent orchidopexies for primary undescended testes, with 335 (42.5%) boys having surgery before the age of 2 (mean age 54.3 months, median 31.1 months). During the whole 11-year period, there was no significant change in age at orchidopexy, whereas from 2003, a significant trend towards lower age at operation (Spearman's rank -0.1112, P = 0.0071) and a significant increase in the proportion of boys having surgery before the age of 2 (Spearman's rank 0.9000, P = 0.0374) were seen.

CONCLUSIONS

Although there has been a modest reduction in the mean age of orchidopexy since 2003, overall, the mean age at orchidopexy remains well above the recommended optimal age, implying that more attention should be paid towards earlier diagnosis and referral for primary undescended testes.