1
|
Nepal P, Kumar D, Ojili V. Abnormal descent of the testis and its complications: A multimodality imaging review. SA J Radiol 2018; 22:1374. [PMID: 31754510 PMCID: PMC6837786 DOI: 10.4102/sajr.v22i1.1374] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 07/31/2018] [Indexed: 12/13/2022] Open
Abstract
Cryptorchidism refers to an absence of the testis in the scrotal sac. Testicular descent occurs in two stages: transabdominal and gubernacular. The descent of the testis can be arrested in its usual path of descent (true undescended testis) or can migrate from the usual path of descent (ectopic testis). Localising the missing testis is important for surgical planning, as well as for identification of complications that are more common with cryptorchidism. Ultrasound is the initial imaging modality to visualise, as well as localise the testis in cryptorchidism. However, ultrasound imaging is limited in visualising testes that are not superficial in location. This article highlights various examples of abnormal descent of the testis in usual as well as unusual locations and complications of undescended testes. Further evaluation with computed tomography scan or magnetic resonance imaging is needed in indeterminate cases and for identification of complications. We have highlighted the role of specific modalities with imaging findings in this pictorial review for the appropriate selection of each modality in clinical practice.
Collapse
Affiliation(s)
- Pankaj Nepal
- St. Vincent's Medical Center, Connecticut, United States
| | | | - Vijayanadh Ojili
- Department of Radiology, University of Texas Health, San Antonio, United States
| |
Collapse
|
2
|
Ismail KA, Ashour MHM, El-Afifi MA, Hashish AA, El-Dosouky NE, Negm M, Hashish MS. Laparoscopy in the management of impalpable testis (Series of 64 Cases). Afr J Paediatr Surg 2017; 14:65-69. [PMID: 30688280 PMCID: PMC6369599 DOI: 10.4103/ajps.ajps_103_08] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The undescended testis represents one of the most common disorders of childhood. Laparoscopy has been widely used both in the diagnosis and treatment of non-palpable testis. In this study, we investigated and evaluated the usefulness of laparoscopy in the diagnosis and treatment of no palpable testis. PATIENTS AND METHODS From January 2003 to January 2008, we used laparoscopy in the management of 64 patients with 75 impalpable testes. Their ages varied from 1 to 15 years (median age = 4.6 years). The site and the size of the testes were localised by abdominopelvic ultrasonography in all 64 children for accurate diagnosis. One stage laparoscopic orchiopexy was performed in 26 testes, staged Fowler-Stephens orchiopexy was underwent in 17 testes, while laparoscopic orchidectomy was done in 5 testes. Follow-up by clinical examination and colour Doppler ultrasound was performed in every patient who underwent orchiopexy. RESULTS There were 11 patients with bilateral non-palpable testes. The overall diagnostic agreement of ultrasound with laparoscopy was seen in only 16 out of 75 testes (21.3%). The results of diagnostic laparoscopy were varied and showed various pathological. Conditions and positioned of the testes, such as 20 low intra-abdominal testes (26.6%), 17 testes were high intra-abdominal (22.7%), and 18 testes (24%) entered the inguinal canal. Associated inguinal hernia was present in 4 patients. After a mean follow-up period of 26 months (6 months - 5 years), all testes were in the bottom of the scrotum except 3 testes were retracted to the neck of the scrotum and atrophy of the testis occurred in 2 patients (2.7%). CONCLUSION Laparoscopy has proven to be the only diagnostic modality where the findings provide a clear dependable direction for the definitive management of impalpable testes, so it allows an accurate diagnosis and definitive treatment in the same sitting.
Collapse
Affiliation(s)
- Khalid A Ismail
- Department of General Surgery, Section of Pediatric Surgery, Tanta University Hospital, Tanta, Egypt
| | - Mohamed H M Ashour
- Department of General Surgery, Section of Pediatric Surgery, Tanta University Hospital, Tanta, Egypt
| | - Mahmoud A El-Afifi
- Department of General Surgery, Section of Pediatric Surgery, Tanta University Hospital, Tanta, Egypt
| | - Amel A Hashish
- Department of General Surgery, Section of Pediatric Surgery, Tanta University Hospital, Tanta, Egypt
| | - Nagay E El-Dosouky
- Department of General Surgery, Section of Pediatric Surgery, Tanta University Hospital, Tanta, Egypt
| | - Mohamed Negm
- Department of General Surgery, Section of Pediatric Surgery, Tanta University Hospital, Tanta, Egypt
| | - Mohamed S Hashish
- Department of General Surgery, Section of Pediatric Surgery, Tanta University Hospital, Tanta, Egypt
| |
Collapse
|
3
|
Hartigan S, Tasian GE. Unnecessary diagnostic imaging: a review of the literature on preoperative imaging for boys with undescended testes. Transl Androl Urol 2016; 3:359-64. [PMID: 26816791 PMCID: PMC4708136 DOI: 10.3978/j.issn.2223-4683.2014.11.05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Cryptorchidism or undescended testis is one of the most common pediatric disorders of the male endocrine glands and the most common genital disorder identified at birth. Ultrasound is commonly ordered for boys with undescended testes prior to referral to a surgical specialist, but its sensitivity and specificity is insufficient to reliably localize non-palpable testes and thus confers unnecessary costs to the patient and the healthcare system. We review the ability of ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) to reliably locate undescended testes and emphasize whether diagnostic imaging should change the decision to operate or the surgical approach for boys with cryptorchidism.
Collapse
Affiliation(s)
- Siobhán Hartigan
- 1 Department of Surgery, Division of Urological Surgery, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA ; 2 Division of Pediatric Urology, 3 Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Gregory E Tasian
- 1 Department of Surgery, Division of Urological Surgery, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA ; 2 Division of Pediatric Urology, 3 Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| |
Collapse
|
4
|
Krishnaswami S, Fonnesbeck C, Penson D, McPheeters ML. Magnetic resonance imaging for locating nonpalpable undescended testicles: a meta-analysis. Pediatrics 2013; 131:e1908-16. [PMID: 23690512 PMCID: PMC4074662 DOI: 10.1542/peds.2013-0073] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Preoperative imaging techniques may guide management of nonpalpable, cryptorchid testicles. We evaluated conventional MRI for identifying and locating nonpalpable testicles in prepubescent boys via meta-analysis. METHODS Databases including Medline were searched from 1980 to February 2012. Eligible studies included ≥10 boys with cryptorchidism/suspected cryptorchidism and reported data on testicular presence/absence and position (abdominal, inguinal, or scrotal) as determined by imaging and surgery. Two investigators independently reviewed studies against inclusion criteria. We captured the number of testicles that were correctly and incorrectly identified and located, relative to surgically verified status, and estimated sensitivity and specificity by using a random-effects model. RESULTS Eight unique prospective case series included 171 boys with 193 nonpalpable testicles (22 with bilateral testicles). Surgery identified 158 testicles (81.9%) present and 35 absent. MRI correctly identified testicles with an estimated median sensitivity of 0.62 (95% Bayesian credible interval [BCI]: 0.47-0.77) and a specificity of 1.0 (95% BCI: 0.99-1.0). MRI located intraabdominal testicles with a sensitivity of 0.55 (95% BCI: 0.09-1.0) and inguino-scrotal testicles with a sensitivity of 0.86 (95% BCI: 0.67-1.0). We were not able to obtain estimates for MRI sensitivity or specificity for locating atrophied testicles. The estimated specificity for location-specific testicles reached almost 100%. CONCLUSIONS Conventional MRI has low sensitivity for estimating the population sensitivity for identifying the presence of nonpalpable cryptorchid testicles. When testicles are identified, MRI is poor at locating both atrophied and intraabdominal testicles but performs modestly well in locating those in the inguino-scrotal regions.
Collapse
Affiliation(s)
| | | | - David Penson
- Center for Surgical Quality and Outcomes Research, Institute for Medicine and Public Health, and,Departments of Urology and
| | - Melissa L. McPheeters
- Vanderbilt Evidence-based Practice Center and,Obstetrics and Gynecology, Vanderbilt Medical Center, Nashville, Tennessee; and
| |
Collapse
|
5
|
Abacı A, Çatlı G, Anık A, Böber E. Epidemiology, classification and management of undescended testes: does medication have value in its treatment? J Clin Res Pediatr Endocrinol 2013; 5:65-72. [PMID: 23748056 PMCID: PMC3701924 DOI: 10.4274/jcrpe.883] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Genetic, hormonal, and anatomical factors are believed to be involved in the etiology of undescended testes. Due to increased risk of infertility, testicular cancer, torsion and/or accompanying inguinal hernia (>90%) as well as cosmetic concerns, all these patients require treatment. In this review paper, we aimed to evaluate the success rates of treatment modalities used in undescended testes, beginning from 1930 to the present, and to draw attention to the possible risks and benefits and also the efficacy of hormonal therapy in the management of the disorder, which is still a controversial issue. Hormonal therapy may lead to penile growth, painful erection, and behavioral changes while on treatment. In recent years, it has been reported that human chorionic gonadotropin (hCG) treatment was associated with interstitial edema due to increased vascular permeability, inflammation-like changes, and several adverse effects on germ cells by increasing pressure and apoptotic process. It has also been reported that LHRH analogues have positive effects on germ cells by increasing fertility in patients undergoing unilateral or bilateral orchiopexy. In some studies, the success rate of hCG treatment was reported to be higher following buserelin. In some other studies, hCG treatment was recommended before orchiopexy to reduce the risk for surgical ischemia. There are a limited number of randomized controlled studies, so evidence showing the efficacy of hormonal therapy is insufficient. According to the 2007 Consensus Report of Nordic countries, it is recommended that surgery is the first-line treatment modality in undescended testes and that it should be performed by pediatric surgeons and urologists at the age of 6-12 months.
Collapse
Affiliation(s)
- Ayhan Abacı
- Dokuz Eylül University Faculty of Medicine, Department of Pediatric Endocrinology, İzmir, Turkey.
| | - Gönül Çatlı
- Dokuz Eylül University Faculty of Medicine, Department of Pediatric Endocrinology, İzmir, Turkey
| | - Ahmet Anık
- Dokuz Eylül University Faculty of Medicine, Department of Pediatric Endocrinology, İzmir, Turkey
| | - Ece Böber
- Dokuz Eylül University Faculty of Medicine, Department of Pediatric Endocrinology, İzmir, Turkey
| |
Collapse
|
6
|
Abstract
Undescended testis is one of the common surgical disorders in childhood and twenty percent of the undescended testes are nonpalpable. Surgical management is required in almost all cases for the repositioning or removal of the undescended testes and early intervention is preferred for optimal outcome. Use of imaging studies for accurate preoperative localisation of the nonpalpable testis is a wide prevalent practice. However, available evidences have questioned the need of such studies.
Collapse
Affiliation(s)
- Manas Ranjan Pradhan
- Department of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India
| | | |
Collapse
|
7
|
Tasian GE, Copp HL, Baskin LS. Diagnostic imaging in cryptorchidism: utility, indications, and effectiveness. J Pediatr Surg 2011; 46:2406-13. [PMID: 22152893 PMCID: PMC3712862 DOI: 10.1016/j.jpedsurg.2011.08.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Revised: 08/18/2011] [Accepted: 08/19/2011] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cryptorchidism (undescended testis) is the most common genitourinary anomaly in male infants. METHODS We reviewed the available literature on the diagnostic performance of ultrasound, computed tomography, and magnetic resonance imaging (MRI) in localizing undescended testes. RESULTS Ultrasound is the most heavily used imaging modality to evaluate undescended testes. Ultrasound has variable ability to detect palpable testes and has an estimated sensitivity and specificity of 45% and 78%, respectively, to accurately localize nonpalpable testes. Given the poor ability to localize nonpalpable testes, ultrasound has no role in the routine evaluation of boys with cryptorchidism. Magnetic resonance imaging has greater sensitivity and specificity but is expensive, not universally available, and often requires sedation for effective studies of pediatric patients. Diagnostic laparoscopy has nearly 100% sensitivity and specificity for localizing nonpalpable testes and allows for concurrent surgical correction. CONCLUSIONS Although diagnostic imaging does not have a role in the routine evaluation of boys with cryptorchidism, there are clinical scenarios in which imaging is necessary. Children with ambiguous genitalia or hypospadias and undescended testes should have ultrasound evaluation to detect the presence of müllerian structures.
Collapse
Affiliation(s)
| | - Hillary L. Copp
- Department of Urology, University of California, San Francisco
| | | |
Collapse
|
8
|
Tasian GE, Copp HL. Diagnostic performance of ultrasound in nonpalpable cryptorchidism: a systematic review and meta-analysis. Pediatrics 2011; 127:119-28. [PMID: 21149435 PMCID: PMC3010084 DOI: 10.1542/peds.2010-1800] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
CONTEXT Ultrasound is frequently obtained during the presurgical evaluation of boys with nonpalpable undescended testes, but its clinical utility is uncertain. OBJECTIVE To determine the diagnostic performance of ultrasound in localizing nonpalpable testes in pediatric patients. METHODS English-language articles were identified by searching Medline, Embase, and the Cochrane Library. We included studies of subjects younger than 18 years who had preoperative ultrasound evaluation for nonpalpable testes and whose testis position was determined by surgery. Data on testis location determined by ultrasound and surgery were extracted by 2 independent reviewers, from which ultrasound performance characteristics (true-positives, false-positives, false-negatives, and true-negatives) were derived. Meta-analysis of 12 studies (591 testes) was performed by using a random-effects regression model; composite estimates of sensitivity, specificity, and likelihood ratios were calculated. RESULTS Ultrasound has a sensitivity of 45% (95% confidence interval [CI]: 29-61) and a specificity of 78% (95% CI: 43-94). The positive and negative likelihood ratios are 1.48 (95% CI: 0.54-4.03) and 0.79 (95% CI: 0.46-1.35), respectively. A positive ultrasound result increases and negative ultrasound result decreases the probability that a nonpalpable testis is located within the abdomen from 55% to 64% and 49%, respectively. Significant heterogeneity limited the precision of these estimates, which was attributable to variability in the reporting of selection criteria, ultrasound methodology, and differences in the proportion of intraabdominal testes. CONCLUSIONS Ultrasound does not reliably localize nonpalpable testes and does not rule out an intraabdominal testis. Eliminating the use of ultrasound will not change management of nonpalpable cryptorchidism but will decrease health care expenditures.
Collapse
Affiliation(s)
- Gregory E. Tasian
- Department of Urology, University of California, San Francisco, California
| | - Hillary L. Copp
- Department of Urology, University of California, San Francisco, California
| |
Collapse
|
9
|
Abstract
BACKGROUND The undescended testis represents one of the most common disorders of childhood. Laparoscopy has been widely used for the diagnosis and treatment of non-palpable testis. In this study, we investigated and evaluated the usefulness of laparoscopy in the diagnosis and treatment of the non-palpable testis. METHODS From January 2003 to January 2008, we used laparoscopy in the management of 64 patients with 75 impalpable testes. The patients' ages varied from 1 to 15 years (median 4.6 years). The sites and sizes of the testes were localized by abdominopelvic ultrasonography (US) in all 64 children. One-stage laparoscopic orchiopexy was performed for 26 testes, staged Fowler Stephens orchiopexy for 17 testes, and laparoscopic orchidectomy for five testes. Follow-up by clinical examination and color Doppler US was performed in every patient who underwent orchiopexy. RESULTS There were 11 patients with bilateral non-palpable testes. The overall diagnostic agreement of US with laparoscopy was seen for only 16 of 75 testes (21.3%). The results of diagnostic laparoscopy were varied and showed various pathologic conditions and positions of the testes, such as 20 low intraabdominal testes (26.6%), 17 high intraabdominal testes (22.7%), and 18 testes (24%) that had entered the inguinal canal. Associated inguinal hernia was present in four patients. After a mean follow-up period of 26 months (6 months-5 years) all testes were seen to be located in the bottom of the scrotum, with the exception of three testes that had retracted to the neck of the scrotum and two testes that had atrophied (2.7%). CONCLUSIONS Laparoscopy has proven to be the only diagnostic modality where the findings provide a clear, dependable direction for definitive management of impalpable testes. It allows an accurate diagnosis and simultaneous definitive treatment.
Collapse
|
10
|
Corvin S, Sturm W, Anastasiadis A, Kuczyk M, Stenzl A. Laparoscopic Management of the Adult Nonpalpable Testicle. Urol Int 2005; 75:337-9. [PMID: 16327302 DOI: 10.1159/000089170] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2005] [Accepted: 07/14/2005] [Indexed: 11/19/2022]
Abstract
OBJECTIVES This report describes own experiences with laparoscopic management of adult men with cryptorchidism. PATIENTS AND METHODS 8 men with nonpalpable testes were referred to our department. Laparoscopy was used to assess the presence and location of the gonad and perform an orchiectomy or orchidopexy, respectively. RESULTS A uni-/bilateral atrophic testicle was palpable in 2 patients under general anesthesia and removed after inguinal exploration. In 4 individuals the testicular vessels and vas deferens were found laparoscopically entering the internal inguinal ring. Two vanishing testicles and 2 atrophic gonads were removed during subsequent inguinal exploration. In 1 patient with a solitary testis, a morphologically intact abdominal testicle was presented. In this patient, endocrine function was lost completely after stage 1 of a Fowler-Stephens orchidopexy. In 1 patient an atrophic abdominal testicle was removed laparoscopically. CONCLUSIONS These results demonstrate the suitability of laparoscopy for the treatment of cryptorchidism in the adult population. In most cases, atrophic inguinal gonads or vanishing testicles are found and should be removed. Our results suggest that in cases of intact abdominal testicles, Fowler-Stephens orchidopexy with transection of the spermatic vessels should be avoided to preserve endocrine function of the gonad.
Collapse
Affiliation(s)
- Stefan Corvin
- Department of Urology, Eberhard Karls University, Tubingen, Germany.
| | | | | | | | | |
Collapse
|
11
|
Correct answers to multiple choice questions appearing in the European Urology Update Series 2005. BJU Int 2005. [DOI: 10.1111/j.1464-410x.2005.05978.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
12
|
Affiliation(s)
- Kalpna K Patil
- Department of Paediatric Urology, Guy's & St Thomas' Hospital NHS Trust, London, UK.
| | | | | |
Collapse
|
13
|
McEachern R, Houle AM, Garel L, Van Vliet G. Lost and found testes: the importance of the hCG stimulation test and other testicular markers to confirm a surgical declaration of anorchia. HORMONE RESEARCH 2004; 62:124-8. [PMID: 15286448 DOI: 10.1159/000080018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2003] [Accepted: 06/03/2004] [Indexed: 11/19/2022]
Abstract
BACKGROUND In patients with impalpable testes,laparoscopy or open surgery is considered conclusive in establishing the absence of testicular tissue. METHODS Retrospective chart review. RESULTS Over a 22-year period, 4 out of 82 patients with a diagnosis of bilateral anorchia by laparoscopy or laparotomy had persistent testicular tissue suggested by endocrine evaluations. The clue to the presence of testicular tissue was: (1) a pubertal rise in plasma testosterone (2 patients); (2) the presence of possible Müllerian structures and of a detectable plasma anti-Müllerian hormone (1 patient), and (3) the fact that one of the gonads had not been seen at surgery (1 patient who still had a testosterone response to hCG postoperatively). Testes were localized by venography (3 patients) and laparotomy (1 patient). CONCLUSION A surgical diagnosis of bilateral anorchia needs to be confirmed by hCG stimulation, gonadotropin levels, or other markers of testicular function.
Collapse
Affiliation(s)
- Rebecca McEachern
- Endocrinology Service, Department of Pediatrics, Sainte-Justine Hospital and Research Center, Université de Montréal, Montréal, Québec, Canada
| | | | | | | |
Collapse
|