The frequency of undescended testis from birth to adulthood: a review

Staged laparoscopic orchiopexy of intra-abdominal testis: Spermatic vessels division versus traction? A multicentric comparative study

BACKGROUND

Staged laparoscopic management of intra-abdominal testes using pedicular section is recognized as gold standard technique, successful in 85 % of cases for scrotal testicular position with less than 10 % testicular atrophy. Recently, Shehata proposed a new technique without pedicular division for these testes, using spermatic vessels traction, but did not provide a comparative study of the two techniques.

OBJECTIVE

To evaluate the laparoscopic spermatic pedicular traction (Shehata technique, ST) for the treatment of intra-abdominal testis, as an alternative to gold standard pedicular section (2-stage Fowler-Stephens, FS).

STUDY DESIGN

Intra-abdominal testes of 129 patients in two tertiary pediatric urology centers were managed laparoscopically (2011-2019) either by 2-stage FS orchidopexy or ST according to the surgeon preference. Testicular position and size were statistically compared.

RESULTS

A total of 147 testes were pulled down by 80 ST and 67 FS, including 18 bilateral cases. Median (IQR) age at surgery was 24.2 (15.6-46.4) months (ST) and 18.3 (13.1-38.2) months (FS) (p = 0.094). Scrotal pulling-down of the testis was performed after a median (IQR) period of 2.3 (1.6-3.4) months (ST) and 6.1 (4.7-8.3) months (FS), respectively (p < 0.005). Although ST had collapsed in 17 cases (21.3 %), only one (1.3 %) redo procedure was required. After a median (IQR) follow-up of 22 (12-40) and 19 (8.75-37) months (p = 0.59), the testis was in the scrotum in 85 % and 81 % of ST and FS cases, respectively (p = 0.51). Testicular atrophy occurred in 10 % of ST and 13.4 % of FS (p = 0.61). Multivariate analysis using the propensity score analysis did not identify any difference between the two techniques.

DISCUSSION

Our results seem to confirm that FS and ST achieve the same results regarding final testicular position and testicular atrophy rate, with a long-term follow-up. Our study supports pediatric surgeons to favor laparoscopic spermatic pedicular traction (ST) which preserves the testicular vascularization and may ensure better spermatogenesis after puberty. More details on the size and position of the testicle at the beginning of the first laparoscopy seem however essential to assess more accurately the outcomes of each surgical technique. Our outcomes will also be re-evaluated when our patients have reached puberty, from an exocrine and endocrine points of view.

CONCLUSIONS

This study showed similar results after laparoscopic traction or section of spermatic vessels for intra-abdominal testis in a long-term follow-up, providing more evidence for the use of ST as a valuable alternative to FS.

Orchidopexy for undescended testis-rate and predictors of re-ascent

PURPOSE

This study aimed to investigate the rate of re-ascent requiring re-operation after primary orchidopexy and to investigate eventual differences between the inguinal and scrotal approach as well as other potential predictors for re-ascent.

METHODS

A retrospective cohort study of children treated for undescended testis (UDT) with orchidopexy between 2018 and 2022 was conducted. The primary outcome was re-ascent requiring re-operation, and the secondary outcome was atrophy rate. Independent variables were age, underlying conditions, side, surgical approach, operation time, bilaterality, congenital/ascended UDT, presence of scrotal hypoplasia, presence of a patent processus vaginalis, division of external oblique, and suture of the testis. Univariate and logistic regression were used to evaluate differences between groups and risk for re-ascent.

RESULTS

A total of 662 testes in 554 patients were included. Re-operation occurred in 6% (7% with inguinal approach, 3% with scrotal approach, p = 0.04). Re-operation was associated with younger age, congenital UDT, and inguinal approach, but neither of these variables remained significant in multivariate analyses. Atrophy occurred in one testis.

CONCLUSION

The rate of re-ascent was 6% and the atrophy rate was 0.15%. A larger study may find predictors for re-ascent but with very low absolute risk. The lower rate of re-ascent with the scrotal approach is probably due to selection bias.

The epidemiology of cryptorchidism and potential risk factors, including endocrine disrupting chemicals

Congenital cryptorchidism, also known as undescended testis, is the condition where one or both testes are not in place in the scrotum at birth and is one of the most common birth defects in boys. Temporal trends and geographic variation in the prevalence of cryptorchidism from 1% to 9% have been reported in prospective cohort studies. The testes develop in the abdominal cavity and descend to the scrotum in two phases, which should be completed by gestational week 35. Thus, the risk of cryptorchidism is higher in preterm boys. In many cases a spontaneous descent occurs during the first months of life during the surge of gonadotropins and testosterone. If not, the testis is usually brought down to the scrotum, typically by surgery, to increase future fertility chances and facilitate cancer surveillance. The increasing frequency of impaired semen quality and testicular cancer, with which cryptorchidism is associated, represents a concern for male reproductive health in general and a need to understand its risk factors. The risk of cryptorchidism is closely related to gestational factors (preterm birth, low birth weight and intrauterine growth restriction), and especially maternal smoking seems to be a risk factor. Evidence is accumulating that the increasing prevalence of cryptorchidism is also related to prenatal exposure to environmental chemicals, including endocrine disrupting compounds. This association has been corroborated in rodents and supported by ecological studies. Conducting human studies to assess the effect of endocrine disrupting chemicals and their interactions is, however, challenged by the widespread concomitant exposure of all humans to a wide range of chemicals, the combined effect of which and their interactions are highly complex.

Anti-Müllerian hormone, testicular descent and cryptorchidism

Anti-Müllerian hormone (AMH) is a Sertoli cell-secreted glycoprotein involved in male fetal sex differentiation: it provokes the regression of Müllerian ducts, which otherwise give rise to the Fallopian tubes, the uterus and the upper part of the vagina. In the first trimester of fetal life, AMH is expressed independently of gonadotropins, whereas from the second trimester onwards AMH testicular production is stimulated by FSH and oestrogens; at puberty, AMH expression is inhibited by androgens. AMH has also been suggested to participate in testicular descent during fetal life, but its role remains unclear. Serum AMH is a well-recognized biomarker of testicular function from birth to the first stages of puberty. Especially in boys with nonpalpable gonads, serum AMH is the most useful marker of the existence of testicular tissue. In boys with cryptorchidism, serum AMH levels reflect the mass of functional Sertoli cells: they are lower in patients with bilateral than in those with unilateral cryptorchidism. Interestingly, serum AMH increases after testis relocation to the scrotum, suggesting that the ectopic position result in testicular dysfunction, which may be at least partially reversible. In boys with cryptorchidism associated with micropenis, low AMH and FSH are indicative of central hypogonadism, and serum AMH is a good marker of effective FSH treatment. In patients with cryptorchidism in the context of disorders of sex development, low serum AMH is suggestive of gonadal dysgenesis, whereas normal or high AMH is found in patients with isolated androgen synthesis defects or with androgen insensitivity. In syndromic disorders, assessment of serum AMH has shown that Sertoli cell function is preserved in boys with Klinefelter syndrome until mid-puberty, while it is affected in patients with Noonan, Prader-Willi or Down syndromes.

Contemporary disparities in progression to orchiopexy for cryptorchidism as reported in the Pediatric Health Information System (PHIS) database

INTRODUCTION

When evaluating the timeliness of orchiopexy for cryptorchidism, health disparities are apparent among Hispanic and African American males and those with public insurance. Since the publication of these data, the COVID-19 pandemic has stressed our healthcare system and significantly affected the provision of pediatric urology care.

OBJECTIVE

We sought to assess if certain groups were disproportionately affected in progression to orchiopexy after the diagnosis of cryptorchidism during and after the pandemic in US freestanding children's hospitals.

STUDY DESIGN

Using the PHIS database, pediatric patients ≤5 years who underwent orchiopexy between January 2018 and December 2022 were retrospectively analyzed. Exclusion criteria included prematurity, retractile testes, and testicular torsion. Primary outcomes were age at orchiopexy and the proportion of individuals undergoing timely orchiopexy for cryptorchidism.

RESULTS

Over the study period 3140 patients ≤5 years old underwent orchiopexy for cryptorchidism. Non-Hispanic Blacks and Hispanics were significantly less likely to have timely orchiopexy and underwent orchiopexy 2.13 and 3.60 months later compared to whites (p < 0.01). As compared to pre-COVID-19, during the pandemic the proportion of patients who had timely surgery was higher and the median age was significantly lower (p = 0.01 and p < 0.01, respectively) in white patients only. Over the study period, patients with public insurance were less likely to have timely orchiopexy and underwent orchiopexy 2.94 months later (p < 0.01) than patients with private insurance. Compared to during the pandemic, post-pandemic a significantly lower proportion of publicly insured patients have since undergone timely orchiopexy (p = 0.04). Patients in the West were less likely to have timely orchiopexy and had a higher age at time of orchiopexy (p < 0.01) than other regions. However, in the West during the pandemic, the proportion of children who had timely surgery was higher compared to pre-and post-COVID-19 (p < 0.01).

DISCUSSION

Overall, regardless of insurance status, race, or location, a significant proportion of patients did not undergo timely orchiopexy. During the pandemic white patients had a lower median age and an increased proportion underwent timely orchiopexy, despite the number of orchiopexies remaining constant. Disparities in the post-COVID-19 era have been further exacerbated for publicly insured patients, who a significantly lower proportion of have since undergone timely orchiopexy. Specific efforts are required across the United States to increase timely orchiopexy for all boys.

CONCLUSIONS

Progression to timely orchiopexy remains low for all boys in the era surrounding COVID-19; certain groups appear to be more adversely affected.

Undescended testis: A roundtable discussion based on clinical scenarios - Part 1

Undescended testis (UDT, cryptorchidism) is the most common congenital anomaly of the genital tract. Despite its high incidence, the management of UDT varies between specialties (urology, pediatric surgery, pediatric urology, pediatric endocrinology). Therefore, as the European Association of Urology - Young Academic Urologists Pediatric Urology Working Group, we requested experts around the world to express their own personal approaches against various case scenarios of UDT in order to explore their individual reasoning. We intended to broaden the perspectives of our colleagues who deal with the treatment of this frequent genital malformation.

Advantages of single-site laparoscopic orchiopexy for palpable undescended testes in children: a prospective comparison study

PURPOSE

To evaluate the feasibility of single-site laparoscopic orchiopexy for palpable undescended testes in children.

METHODS

We prospectively studied patients with undescended testes between July 2021 and June 2022. In total, 223 patients were included in our study: 105 underwent single-site laparoscopic orchiopexy and 118 underwent conventional laparoscopic orchiopexy. During single-site laparoscopic orchiopexy, 3 ports were inserted within the umbilicus.

RESULTS

No differences were observed between the groups in terms of age and laterality. For unilateral undescended testes, the operating time was longer in the single site group than in the conventional group at the early stages (55.31 ± 12.04 min vs. 48.14 ± 14.39 min, P = 0.007), but it was similar to the conventional group at the later stages (48.82 ± 13.49 min vs. 48.14 ± 14.39 min, P = 0.78). Testicular ascent occurred in one patient from each group. There was no significant difference in the success rate between the single-site group and the conventional group (99.0% vs. 99.2%, P = 0.93). In the single-site group, no visible abdominal scarring was observed, while in the conventional group, there were two noticeable scars on the abdomen.

CONCLUSION

Single-site laparoscopic orchiopexy offers superior cosmetic results and comparable success rates compared to conventional laparoscopic orchiopexy for palpable undescended testes.

G Protein-Coupled Estrogen Receptor (GPER) and ERs Are Modulated in the Testis-Epididymal Complex in the Normal and Cryptorchid Dog

There is growing evidence by the literature that the unbalance between androgens and estrogens is a relevant condition associated with a common canine reproductive disorder known as cryptorchidism. The role of estrogens in regulating testicular cell function and reproductive events is supposedly due to the wide expression of two nuclear estrogen receptors (ERs), ER-alpha and ER-beta and a trans-membrane G protein-coupled estrogen receptor (GPER) in the testis. In this study, immunohistochemistry, Western blotting and qRT-PCR were used to assess the distribution and expression of GPER in the testis-epididymal complex in the normal and cryptorchid dog. ER-alpha and ER-beta were also evaluated to better characterize the relative abundances of all three receptors. In addition, in these tissues, the expression level of two proteins as SOD1 and Nrf2 normally associated with oxidative stress was investigated to evaluate a possible relationship with ERs. Our data revealed changes in the distribution and expression of the GPER between the normal and cryptorchid dog. In particular, dogs affected by cryptorchidism showed an upregulation of GPER at level of the examined reproductive tract. Also considering the obtained result of a modulation of SOD1 and Nrf2 expression, we could hypothesize the involvement of GPER in the cryptorchid condition. Further studies are, however, necessary to characterize the role of GPER and its specific signaling mechanisms.

The Time of Diagnosis and Surgical Treatment of Congenital Cryptorchidism: A Single Center's Observational Study in Greece

PURPOSE

Congenital cryptorchidism or undescended testes (UDT) is one of the most common congenital abnormalities in newborns. Current guidelines recommend that surgical management should be scheduled by the 12th month and no later than the 18th month of the child's life. This is the first study to evaluate the age of diagnosis and surgical treatment of children with UDT in Greece, as well as the compliance with current guidelines worldwide.

METHODS

A retrospective analysis of patients with UDT who underwent orchidopexy from 2015 to 2019 was conducted. Patient age at diagnosis and orchidopexy and the meantime between were recorded. Patients were separated into groups, based on the diagnosis age: group A, diagnosis until the 11th month; group B, diagnosis between the 12th and 18th month; and group C, diagnosis at >18th month.

RESULTS

We identified 217 children who were diagnosed with UDT and underwent orchidopexy in our department. The majority of the patients (47.4%) had right-sided UDT, while 25.3% of them had UDT on both sides. There were 89 (41%) children in group A, 20 (9.2%) in group B, and 108 (49.8%) males in group C. The median age at diagnosis was 18 months (range: 1-164 months), while for groups A, B, and C, the median age at diagnosis was five, 15, and 71.5 months, respectively. The median age at orchidopexy was 23 months (range: 6-166 months), and for each aforementioned group, it was 11, 16.5, and 74 months. The median waiting time for the orchidopexy was 84 days (range: 1-692 days), and for each group, it was 157, 42, and 56 days, respectively. The delay between diagnosis and surgery was significantly greater for group A compared to groups B and C (p A versus B = 0.01 and p A versus C< 0.0001), while there was no difference in the delay between groups B and C (p > 0.05).

CONCLUSIONS

Patient age at diagnosis and applied orchidopexy was within the recommended range for almost half of the patients. The rest of them had delayed diagnosis and surgery due to delayed referral. In delayed cases, the time from diagnosis to treatment was significantly shorter. Early surgical referral leading to prompt treatment will increase compliance with the guidelines and improve the quality and the outcomes of the provided health-care services.

Immediate Versus Delayed Surgical Management of Infant Cryptorchidism With Inguinal Hernia

INTRODUCTION

Cryptorchidism is commonly treated with orchiopexy at 6-12 months of age, often allowing time for undescended testicle(s) (UT) to descend spontaneously. However, when an inguinal hernia (IH) is also present, some surgeons perform orchiopexy and inguinal hernia repair (IHR) immediately rather than delaying surgery. We hypothesize that early surgical intervention provides no benefit for newborns with both IH and UT.

METHODS

The Nationwide Readmissions Database was used to identify newborns with diagnoses of both IH and UT from 2010 to 2014. Patients were stratified by management: IHR performed on initial admission (Repair) or not (Deferral). Demographics, outcomes, and complications were compared. Results were weighted for national estimates.

RESULTS

We analyzed 1306 newborns (64% premature) diagnosed with both IH and UT. IHR was performed at index admission in 30%. Repair was more common in premature babies (43% vs. 8% full-term, p < 0.001) and patients with congenital anomalies (33% vs. 27% without congenital anomaly, p = 0.012). There was no difference in readmission rates. Repair patients had higher rates of orchiectomy than did Deferral. No Deferral patients were readmitted for bowel resection, and <1% were readmitted for orchiectomy or hernia incarceration.

CONCLUSION

In newborns with UT and IH, immediate repair is not associated with improved outcomes. Even with incarceration on initial presentation, rates of readmission with incarceration or bowel compromise for patients who undergo Deferral of surgery are minimal. Moreover, Repair newborns have higher rates of orchiectomy. We found no benefit to early operative intervention; thus, we recommend waiting until 6-12 months of age to reassess for surgery.

LEVEL OF EVIDENCE

Level III TYPE OF STUDY: Retrospective Comparative Study.

Laparoscopic-Assisted Scrotal Approach for the Treatment of Inguinal Cryptorchidism with Patent Processus Vaginalis: Clinical Efficacy Analysis

Objective: This study aimed to compare the clinical outcomes of two surgical approaches, laparoscopic-assisted scrotal incision and conventional inguinal-scrotal incision, for treating cryptorchidism with unobliterated processus vaginalis. Methods: Clinical data from 60 pediatric patients with inguinal cryptorchidism who were admitted to our institution between January 2018 and January 2022 were retrospectively analyzed. Depending on the surgical technique used, the patients were split into two groups: the laparoscopic group (n = 30) underwent a laparoscopic-assisted scrotal incision, whereas the conventional group (n = 30) underwent a conventional inguinal-scrotal incision for testicular descent and fixation. The length of the procedure, intraoperative blood loss, and the typical hospital stay following the procedure were compared between the two groups. Also assessed was the frequency of postoperative complications including wound infection and hematoma development. Results: The laparoscopic group demonstrated a notably shortened average surgical duration compared with the traditional group, and this discrepancy held statistical significance (P = .017). Moreover, the laparoscopic approach resulted in a reduced volume of intraoperative blood loss, with a statistically significant distinction (P = .002), along with a decreased average length of hospital stay after surgery, also statistically significant (P = .009). Testicular retraction, atrophy, inguinal hernias, or hydrocele were not present in any group. Although the difference between the laparoscopic and open groups was not statistically significant (P > .05), the laparoscopic group saw a reduced frequency of scrotal hematoma. The frequency of wound infection was also decreased in the laparoscopic group compared with the open group, although there was no statistically significant difference (P > .05). Conclusion: The laparoscopic-assisted scrotal incision approach for testicular descent and fixation offers precise localization of cryptorchidism, reduced surgical trauma, shorter postoperative recovery time, and results in smaller scars with minimal tissue damage. The procedure showcases enhanced overall clinical effectiveness, fewer postoperative complications, heightened safety, and superior cosmetic outcomes.

Knowledge Level of Undescended Testis in Saudi Arabia: Why Are We Facing Delayed Presentation?

Background Undescended testis (UDT) or cryptorchidism is a common pediatric surgical presentation. The accepted time for surgical correction (orchidopexy) is when the patient is aged from six months, and should ideally be completed before one year of age. In Saudi Arabia, the median age at the time of orchidopexy is 25 months, exceeding the recommended surgery time. Objective The objective of the study was to determine the factors that cause delayed presentation of UDT among children in Saudi Arabia. Methods A cross-sectional, nationwide study targeting the general population of Saudi Arabia. The study was conducted in November 2022 using a validated questionnaire distributed through social media platforms. Results A total of 2360 participants were enrolled. Over half (54.92%) had not heard about UDT. Further, 48.5% of the participants did not know the age of UDT presentation, and 49.1% had no idea about the treatment modality. Moreover, 13.9% had known someone diagnosed with UDT, while 17.68% discovered UDT after more than a year. In addition, 1.5% had previous experience with UDT, and 22.86% were diagnosed after more than a year. There was a significantly high level of knowledge among participants who had experienced UDT. The three most common reasons for delaying the intervention for UDT patients were a lack of community awareness of UDT, parents' ignorance and neglect, and a lack of early screening programs (22.3%, 21.7%, and 19.7%, respectively). Conclusion Our data demonstrated a significant lack of awareness of UDT among the Saudi population since 1296 (54.92%) of the participants had not heard about UDT. The presence of such an awareness gap necessitates cultural education about the topic of UDT by all capable facilities, including medical schools, hospitals, and primary healthcare centers.

Are we still too late? Timing of orchidopexy

An undescended testis is the most common genitourinary disease in boys. The German guidelines, first published in 2009, proposed the timing of orchidopexy to be before 12 months of age. The aim of the study was to analyze the implementation of these guidelines 10 years after publication. The national cumulative statistics of hospital admissions, provided by the Institute for the Remuneration System in Hospitals (InEK), and the statistics concerning procedures performed in private pediatric surgical practices of the professional association of pediatric surgeons (BNKD) regarding the time of surgeries for the year 2019 were analyzed. Data from InEK included all German hospital admissions. Data from BNKD included data from 48 private pediatric surgical practices. The hospitals treated 6476 inpatients with undescended testis, and 3255 patients were operated in private practices. Regarding the age at treatment, 15% of the hospital patients and 5% of the private practice patients were younger than 1 year and fulfilled the guideline recommendations. Forty percent of the hospital patients and 29% of the private practice patients were 1 or 2 years of age. All other patients were 3 years of age or older at the time of orchidopexy.  Conclusions: The rate of orchidopexy within the first 12 months of life is remarkably low even 10 years after the publication of the guidelines. Awareness of the existing guideline must be increased for both referring pediatric and general practitioners. What is Known: • In Germany, orchidopexy is performed by pediatric surgeons and urologists either in hospital settings or in private practices. • Most international guidelines set the age for surgical treatment of undescended testis between 12 and 18 months of age. The German guidelines, published in 2009, sets the time-limit at one year of age. Until five years after publication of the German guidelines, the number of patients treated before the first year of life was low; studies show an orchidopexy ratebetween 8% and 19% during this time. What is New: • This study the first to cover all administered hospital patients in Germany and a large group of patients treated in private practices. It contains the largest group of German patients with undescended testis. • Although almost all children participate in the routine check-up at the age of seven months, which includes investigation for undescended testis, adherence to the orchidopexy guidelines is still low. Only 15% of the hospital patients and 5% of the patients in private practice were treated before their first birthdays.

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.

Cryptorchidism: The dog as a study model

Cryptorchidism (CO) or undescended testicle is an abnormality of male gonadal development that can generate long-term repercussions in men, such as infertility and germ cell neoplasia in situ (GCNIS). The origin of these alterations in humans is not completely clear, due to the absence of an animal model with similar testicular development as in humans with CO. This work intends to describe the testicular histological development of dogs with congenital CO, and determine whether the species could adequately serve as a study model for this pathology in humans. The study was carried out with 36 dogs, equally distributed in two groups: healthy control (CTRL) and CO groups. The contralateral testis to the undescended one in CO group of the animals was considered and analyzed. Each group was subdivided in three stages of development: (1) peripubertal stage (6–8 months), (2) young adult (9–48 months) and (3) senile (49–130 months). Histological development, the presence of cells with gonocyte morphology, cell proliferation, testicular lipoperoxidation and hormonal concentrations of testosterone, estradiol, FSH and LH were evaluated and described. In the cryptorchid testes, the first histological alterations appeared from the first stage of development and were maintained until the senile stage. A pronounced testicular lipoperoxidation occurred only in the second stage of development. The histological alterations due to CO were markedly evident in the young adult stage. Testosterone concentrations witnessed a decrease starting from in the second stage and kept on until the last stage. The contralateral testes of the CO animals showed alterations that positioned them between the control and CO testes. Testicular development of dogs with CO is similar to that of humans. The results of the study suggest that this species could serve as a suitable model for the study of CO in humans.

16 years follow-up evaluation of immediate vs delayed vs. combined hormonal therapy on fertility of patients with cryptorchidism: results of a longitudinal cohort study

BACKGROUND

To investigate in a longitudinal cohort study, the best treatment to preserve fertility in cryptorchid subjects. Patients treated with immediate hormonal vs. delayed vs. combined (hormone plus surgery) therapy consecutively enrolled during the period 1987-1997, were evaluated.

METHODS

Two hundred fifty-five subjects were enrolled and 192 patients completed the follow-upt. One hundred fifty-six patients and 36 out 192 had monolateral and bilateral cryptorchidism, respectively. Twenty-nine out of 192 were previously treated by surgery alone (Group A), 93/192 by hormone therapy alone (Group B), 51/192 received sequential combined hormone therapy plus surgery (Group C) whilst 19/192 refused any type of treatment (Group D). The other 63 patients were considered lost to follow-up. All the patients underwent medical consultation, scrotal ultrasound scan, sperm analysis and Inhibin B, Follicular Stimulating Hormone (FSH) and Testosterone (T) serum level determination.

RESULTS

Testicular volume was found decreased in the Group D patients whilst hormone serum levels were comparable in all groups. Statistically significant differences for sperm characteristics were found in patients treated with hormonal therapy alone or combined with surgery (Groups B and C). These two groups reported better semen quality than patients who received surgery alone or no treatment. No differences were observed between monolateral and bilateral cryptorchidism patients.

CONCLUSIONS

Early prolonged hormonal therapy is advisable in all patients with cryptorchidism independently from the surgical option of promoting testicular descent to the scrotum. Hormonal therapy provides in our study better chance to obtain adequate sperm quality in adult life.

Maternal Cigarette Smoking During Pregnancy and Genital Anomalies in Boys: A Register-Based Cohort and Sibling-Matched Design Study

Purpose

Cryptorchidism and hypospadias share several prenatal risk factors. However, in published studies, boys exposed to cigarette smoking during pregnancy have a higher risk of cryptorchidism and a lower risk of hypospadias. Using Danish register-based data, we revisited these findings with a cohort and sibling-matched design to investigate the potential effect of shared time-stable factors.

Patients and Methods

For the cohort study, we included 823,670 live-born, singleton boys born from 1991 to 2016. Crude and adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated using Cox regression models for each genital anomaly according to maternal cigarette smoking during pregnancy. For the sibling-matched design, we included 399,258 brothers and used a stratified Cox regression model creating family-adjusted results.

Results

In the cohort study, we found a higher risk of cryptorchidism (aHR = 1.18, 95% CI: 1.12, 1.24) and a lower risk of hypospadias (aHR = 0.84, 95% CI: 0.76, 0.93) when comparing boys exposed to cigarette smoking with non-exposed, and for increasing numbers of cigarettes smoked. In comparison, the sibling-matched analyses suggested a slightly weaker association for cryptorchidism and an association of similar magnitude for hypospadias, both in the same direction as in the cohort study.

Conclusion

Shared, familial confounding does not seem to explain earlier findings of higher risk of cryptorchidism and lower risk of hypospadias.

The Fate of Leydig Cells in Men with Spermatogenic Failure

The steroidogenic cells in the testicle, Leydig cells, located in the interstitial compartment, play a vital role in male reproductive tract development, maintenance of proper spermatogenesis, and overall male reproductive function. Therefore, their dysfunction can lead to all sorts of testicular pathologies. Spermatogenesis failure, manifested as azoospermia, is often associated with defective Leydig cell activity. Spermatogenic failure is the most severe form of male infertility, caused by disorders of the testicular parenchyma or testicular hormone imbalance. This review covers current progress in knowledge on Leydig cells origin, structure, and function, and focuses on recent advances in understanding how Leydig cells contribute to the impairment of spermatogenesis.

Comparative study of testicular volume in children with unilateral cryptorchidism of different ages in the tropical province of China

OBJECTIVE

To assess the testicular volume in children with unilateral cryptorchidism of different ages in Hainan Province, China.

METHODS

The study included 424 children (ranging in age from 0 month to 4 years) with unilateral cryptorchidism or normal who were treated from 2017 to 2021 at our institution. They were divided into different groups according to age. We evaluated the correlation of testicular volume between the children with cryptorchidism and the normal children among different groups.

RESULTS

There was a significant difference in testicular volume between the affected side and the healthy side. There was no difference in testicular volume between the left side and the right side of each control group. There were significant differences between the affected side of cryptorchid groups and the same side of the control groups. There were no significant differences between the healthy side of cryptorchid groups and the same side of the control groups. There were no significant differences between the affected side of left cryptorchid groups and right cryptorchid groups. There were no significant differences between the healthy side of left cryptorchid groups and right cryptorchid groups. There were significant differences in testicular volume among different age groups of the control group, while there were no differences in the cryptorchid groups.

CONCLUSIONS

The development of testicular volume in children with unilateral inguinal cryptorchidism is affected in earlier age, and there was no compensatory testicular adaptation in the healthy testis.

Histopathological Features of Vanishing Testes in 332 Boys: What Is Its Significance? A Retrospective Study From a Tertiary Hospital

The purpose of this study is to analyze the histopathological features of resected testicular remnant specimens, ascertain the incidence of the presence of either germ cells (GCs) or seminiferous tubules (SNTs), and assess whether surgical excision of the remnant is necessary. A total of 332 boys with vanishing testis underwent surgical removal of unilateral testicular remnants, with age 7-164 months (median age 25 months). Among the total 332 cases, 212 (63.8%) were younger than 36 months and 143 (66.5%) were found to have hypertrophied contralateral testes larger than 1.6 cm in longitudinal diameter under sonography. SNTs were only present in 21 (6.3%) cases and GCs were present in 7 (2.1%) cases. Compared to the review studies, the very low incidence of SNTs and GCs in which implies extremely low chances of potential malignancy. We propose that surgical removal of vanishing testis remnants in an inguinal or scrotal position may not be necessary.

The Management of Intraabdominal Testis: A Survey of the World Federation of Associations of Pediatric Surgeons (WOFAPS) Practices

BACKGROUND AND OBJECTIVE

The optimal treatment protocol of intraabdominal testis is still a matter of debate and until now there are a lot of areas of controversy as regards this challenging subtype. The aim of this report is to document current practice patterns among surgeons from different continents through an online Redcap survey supervised the World Federation of the Association of Pediatric Surgeons (WOFAPS).

METHODS

A 16-question-survey related to the management of intraabdominal testis was created and administered via RedCap. The WOFAPS headquarters sent an email to all members inviting voluntary survey participation. Data were entered using Microsoft EXCEL spreadsheet and analyzed. Descriptive statistics were performed for each survey item.

RESULTS

There were 436 WOFAPS members who participated in this study with a response rate of 29%, and the vast majority were pediatric surgeons. Only 13% tried to use hormone therapy aiming to induce testicular descent or to improve future fertility. The choices of various surgical techniques were noted. During laparoscopy, if vessels and cord structure were seen entering the ipsilateral internal inguinal ring, most respondents chose to explore the groin. On the other hand, should there was an absent or atrophic testis, the respondents were split on whether to perform a contralateral orchiopexy.

CONCLUSION

This survey describes the current practices of a sample of pediatric surgeons and urologists in the management of intraabdominal testis. The use of hormonal treatment, timing of fixation and management in case of passing through vas and vessels through DIR were undisputable. However, management of low-lying and peeing testis together with the management of contralateral testis were still debatable.

Hormonal therapy is effective and safe for cryptorchidism caused by idiopathic hypogonadotropic hypogonadism in adult males

BACKGROUND

Hormonal therapy is a reasonable treatment for cryptorchidism caused by idiopathic hypogonadotropic hypogonadism (IHH). However, the clinical evidence on whether it is effective and safe for the treatment of cryptorchidism caused by IHH is lacking.

AIM

To evaluate the effect of hormonal therapy in testicular descent, puberty development, and spermatogenesis in adult males with cryptorchidism caused by IHH.

METHODS

This retrospective study included 51 patients with cryptorchidism caused by IHH from the Andrology Clinic of University affiliated teaching hospital. Patients were divided into two groups: group A patients received hormonal therapy; group B patients received surgical treatment for cryptorchidism followed by hormonal therapy.

RESULTS

The rate of successful testicular descent following hormonal therapy (19/32 in group A) or surgical treatment (11/19 in group B) shows no statistically significant difference. There was also no statistically significant difference in penile length, Tanner stage of pubic hair, testicular volume, and success rate of spermatogenesis between the two groups. Testicular atrophy was seen in a single patient in group B.

CONCLUSIONS

Hormone therapy in adult males with cryptorchidism caused by IHH is effective and safe regarding testicular descent, puberty development, and spermatogenesis. This study provides new insight into the treatment of cryptorchidism caused by IHH and highlights that hormonal therapy could be an effective, safe, and economic treatment option for cryptorchidism in males caused by IHH.

Prevalence of congenital cryptorchidism in Estonia

BACKGROUND

Cryptorchidism is one of the most common urogenital malformations. Cryptorchidism prevalence varies greatly in different countries and populations. The aim of the current study was to determine and analyse cryptorchidism prevalence in Estonia.

MATERIALS AND METHODS

During 2012-2015, all consecutively born 5014 boys at Tartu University Hospital were examined for cryptorchidism. All the subjects with cryptorchidism were followed up for at least 6 months to assess spontaneous testicular descent.

RESULTS

Note that 2.1% cases had one or both testicles undescended at birth, 1.6% cases at expected date of birth, 1% cases at 3 months of age, and 0.8% cases at the age of 6 months had cryptorchidism. Cryptorchidism prevalence at birth was higher in preterm boys (11.9%), boys of low birth weight (16.7%) and boys small for gestational age (14%) but was lower in full-term newborn boys (1.1%). During follow-up, testes descended spontaneously in 61.6% of boys, more commonly in prematurely born boys (92%) and boys with low gestational weight (93%) as compared to full-term cryptorchid boys (29.2%) and cryptorchid boys with normal birth weight (34%). At the age of 6 months, cryptorchidism prevalence was equalized in preterm boys (0.9%) and boys with low birth weight (1%) as compared to full-term boys (0.7%) and boys with normal birth weight (0.7%). Boys SGA required surgical intervention more commonly than boys with normal birth weight. Ethnically, cryptorchidism prevalence at birth was similar among Estonians and non-Estonians.

CONCLUSION

Our data revealed that cryptorchidism prevalence, especially in full-term boys, is lower in Estonia than reported in the other Nordic-Baltic countries and worldwide.

Unnecessary ultrasounds in children with undescended testes: An interrogation of the impact of the Choosing Wisely campaigns and clinical practice guidelines

OBJECTIVES

Over the past decade, clinical practice guidelines and educational campaigns have counselled against the use of routine ultrasound (US) in the diagnosis of undescended testes (UDT). We aimed to establish whether or not there has been change in the proportion of children with UDT undergoing pre-referral US prior to referral to our centre over this period. We also sought to determine whether type of referring specialist, UDT diagnosis, and patient distance from the hospital had impacted the rate of pre-referral US.

METHODS

A select sample of hospital charts of children undergoing orchidopexy at a single tertiary paediatric urological referral centre between 2010 and 2019 were reviewed. Data regarding age at surgery, cryptorchidism diagnosis, type of referring physician, patient distance from institution, and evidence of US as part of diagnostic work-up were extracted.

RESULTS

Five hundred charts were examined. Referring provider specialty impacted the number of US ordered (P=0.01). On subset analysis, paediatricians ordered fewer US for children with palpable UDT in 2014 (P=0.03). In 2018, community urologists ordered no US (P=0.02). These findings had temporal relationships with guideline release. The proportion of children undergoing US each year remained consistently between 50% and 62%, except in 2014, when only 36% had US. Distance from hospital and UDT diagnosis were of no significance.

CONCLUSION

Despite clinical practice guidelines and Choosing Wisely campaign recommendations, significant numbers of children with UDT still undergo US. Transient changes in sub-specialty guideline adherence are observed. Strategies to improve sustained guideline awareness in referring clinicians need to be considered.

The Impact of Targeted Education of American Urological Association Cryptorchidism Guidelines in a Rural State: Improvement Still Needed

Background

The American Urological Association published guidelines in 2014 regarding management of undescended testicles (UDT). Despite these guidelines, prior studies have indicated discordance between guidelines and actual practice, especially in rural states. This study aims to identify if educating referring providers improves management of UDT.

Methods

Patients with UDT referred to our institution were divided into two groups: those referred prior to (Group 1) and after (Group 2) targeted education. A retrospective review was performed to compare the groups in terms of age at time of referral and surgery, laterality, specialty, and practice setting of referring provider, and whether or not ultrasound (US) was performed prior to referral.

Results

A total of 100 patients were identified in Group 1 and 168 in Group 2. No significant differences were noted between groups regarding age, variability of referring provider, or those receiving US prior to referral. Median age at referral was 20.7 months (range=0-194) and 33 months (range=0-205.1) in Groups 1 and 2, respectively (p=0.26). Sixty-two (37%) patients underwent surgical evaluation within 18 months of age or younger in Group 1 compared to 39 (39%) in Group 2 (p=0.73). Private practice pediatricians comprised the majority of referring providers in both cohorts. US was performed prior to referral in 41% of patients in Group 1 compared to 35.8% in Group 2 (p=0.51). The number of US ordered prior to referral significantly decreased from 10 (50%) to six (19%) following education among academic providers (p=0.02). No significant difference was found following education for private practice physicians (p=0.27).

Conclusion

Targeted education did not improve age at referral in the short-term, which may reflect suboptimal healthcare access. Additionally, more research is needed to evaluate whether more diverse targeted education provided on a regular basis to both physician and mid-level providers would have a meaningful impact.

Effects of the prenatal environment on cryptorchidism: A narrative review

Cryptorchidism, the absence of testes from the scrotum, is the most common genital disorder in boys and a risk factor for reduced fertility and testicular cancer. The mechanism responsible for cryptorchidism involves two discrete stages: a transabdominal and an inguinoscrotal phase. These phases of testicular descent are regulated by the prenatal sex hormone environment, including levels of testosterone, insulin-like factor 3, and calcitonin gene-related peptide. Environmental endocrine disruptors, which are unfavorable environmental factors, may also affect testicular descent through prenatal sex hormones. This review examined the effects of environmental factors, particularly environmental endocrine disruptors, such as phthalates, organochlorine pesticides, diethylstilbestrol, bisphenol A, dioxins/dioxin-like compounds, and perfluoroalkyl substances, and parental lifestyles on the risk of cryptorchidism. Although some studies have shown that environmental endocrine disruptors can affect testicular descent by changing the hormonal environment during the prenatal period, no significant association has been established between exposure to environmental endocrine disruptors and the incidence of cryptorchidism. Therefore, the role played by environmental endocrine disruptor exposure (if any) in the pathogenesis of cryptorchidism remains unknown. Further studies are needed to examine these issues.

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.

Exploring dysregulated miRNAs in cryptorchidism: a systematic review

Objective

To identify dysregulated miRNAs in testicular tissues from animal models and patients with cryptorchidism.

Methods

Databases were systematically searched for studies published before 10 May 2020 that had investigated miRNAs in cryptorchidism. Predicted targets of the identified miRNA biomarkers were obtained by searching TargetScan and Starbase. Gene ontology (GO) and Kyoto Encyclopaedia of Genes and Genomes (KEGG) pathway enrichment analyses were subsequently conducted.

Results

Five publications met the eligibility criteria for the review. 21 differentially expressed miRNAs were the most abundantly reported in 185 animal and human tissue samples. Three miRNAs (miR-210, miR-449a and miR-34c) were dysregulated in both animal and human testicular tissues. The top five relevant lncRNAs associated with the miRNAs were NEAT1, KCNQ1OT1, XIST, AC005154.1, and TUG1.

Conclusions

Further research is warranted to explore the potential of these dysregulated miRNAs as biomarkers or therapeutic targets for male infertility associated with cryptorchidism.

Testicular Ectopia in a Child's Anterior Abdominal Wall: A Case Report and Literature Review

Patient: Male, 1.5-year-old

Final Diagnosis: Abdominal wall testicular ectopia

Symptoms: Abdominal swelling • undescended testis

Medication: —

Clinical Procedure: Diagnostic laparoscopy and single stage laparoscopic orchidopexy

Specialty: Pediatrics and Neonatology • Surgery

Comparison of diagnostic and treatment guidelines for undescended testis

Cryptorchidism or undescended testis is the single most common genitourinary disease in male neonates. In most cases, the testes will descend spontaneously by 3 months of age. If the testes do not descend by 6 months of age, the probability of spontaneous descent thereafter is low. About 1%-2% of boys older than 6 months have undescended testes after their early postnatal descent. In some cases, a testis vanishes in the abdomen or reascends after birth which was present in the scrotum at birth. An inguinal undescended testis is sometimes mistaken for an inguinal hernia. A surgical specialist referral is recommended if descent does not occur by 6 months, undescended testis is newly diagnosed after 6 months of age, or testicular torsion is suspected. International guidelines do not recommend ultrasonography or other diagnostic imaging because they cannot add diagnostic accuracy or change treatment. Routine hormonal therapy is not recommended for undescended testis due to a lack of evidence. Orchiopexy is recommended between 6 and 18 months at the latest to protect the fertility potential and decrease the risk of malignant changes. Patients with unilateral undescended testis have an infertility rate of up to 10%. This rate is even higher in patients with bilateral undescended testes, with intra-abdominal undescended testis, or who underwent delayed orchiopexy. Patients with undescended testis have a threefold increased risk of testicular cancer later in life compared to the general population. Self-examination after puberty is recommended to facilitate early cancer detection. A timely referral to a surgical specialist and timely surgical correction are the most important factors for decreasing infertility and testicular cancer rates.

Effect of the occupational environment of parents on cryptorchidism

BACKGROUND

The early detection and treatment of cryptorchidism are necessary to preserve male fertility. This study aimed to assess the effect of parents' occupational environment on the incidence of cryptorchidism in their sons.

METHODS

The study enrolled 51 316 newborn males, whose mothers were recruited in the Japan Environment and Children's Study. We analyzed cryptorchidism incidence in male newborns according to 14 categories of occupation of their parents. We also analyzed the effect of the mother's occupational environment during gestation, including working and night-shift work, on cryptorchidism incidence. Information on occupations was obtained from self-administered questionnaires. Cryptorchidism was identified through a survey at birth or 1 month after birth using medical records.

RESULTS

Cryptorchidism was identified in 305 male infants (0.59%) at birth or 1 month after birth. Weight, height, head circumference, and chest circumference at birth were significantly lower in male infants with cryptorchidism than in those without the condition. Gestational age was also shorter in mothers whose infants developed cryptorchidism. Moreover, maternal age at delivery and smoking during gestation also had an effect on cryptorchidism incidence. However, multivariate analysis of the 14 categories of occupation of parents during gestation showed no significant effect on cryptorchidism incidence in their male infants.

CONCLUSIONS

This study revealed that the work environment of parents did not significantly affect the incidence of cryptorchidism in their sons. However, this study might have underestimated mild and transient cases of cryptorchidism. Further studies are necessary to investigate the risk factors of cryptorchidism in relation to parents' occupation.

Intra-abdominal mass with empty scrotum in adult male

Cryptorchidism is one of the most common congenital anomaly affecting new born males. Early identification and management at 6–12 months is recommended. Occasionally adult male can present for the first time with intra-abdominal mass with empty ipsilateral scrotum. These tumors may present at advanced stage and management may be challenging at times.

Testicular Surveillance Post-Orchidopexy and its Impact on Early Diagnosis of Testicular Cancer

Paediatric surgeons are expected to counsel patients about the potential risk of cancer post-orchidopexy and the need to self-examine in adulthood. The study objectives were to examine if such advice is being given and identify the stage of cancer at presentation in adult patients with history of orchidopexy. This was a 5-year observational, retrospective collaborative study between a tertiary paediatric surgical unit and its regional adult testicular cancer service, examining the nature of counselling given by paediatric surgeons to orchidopexy patients and their carers and estimating the local incidence of testicular cancer in adults with previous orchidopexy during the same period. Orchidopexy was performed in 228 patients with a mean follow-up of 11.9 months. Twenty-two patients had documented advice to self-examine from puberty onwards. The advice was not influenced whether the surgery was staged or single (p = 0.39). During the 5 years, 133 adults were diagnosed with testicular cancer, 6 (4.5%) were cases of previous cryptorchidism, seminoma (n = 5) and non-seminoma germ cell tumour (n = 1). In our study, the incidence of cryptorchidism in testicular cancer was 4.5%, with all cancer patients presenting with early disease despite documented advice to self-examine being low (9.7%).

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.

Timing of pubertal development in boys born with cryptorchidism and hypospadias: a nationwide cohort study

Pubertal development may be altered in boys with cryptorchidism and hypospadias, but existing knowledge is inconsistent. Therefore, we investigated the association between cryptorchidism and hypospadias and pubertal development in a large cohort study. Boys in the Puberty Cohort, a cohort nested within the Danish National Birth Cohort, were included in this study. Information on cryptorchidism and hypospadias was retrieved from the Danish National Patient Register. From 11 years until 18 years or full pubertal development, information on physical markers of pubertal development was provided biannually, including Tanner stages, axillary hair, acne, voice break, and first ejaculation. In multivariate regression models for interval censored data, the mean (95% confidence intervals [CIs]) differences in months in obtaining the pubertal markers between boys with and without the anomalies were estimated. Among 7698 boys, 196 (2.5%) had cryptorchidism and 60 (0.8%) had hypospadias. Boys with hypospadias experienced first ejaculation and voice break 7.7 (95% CI: 2.5-13.0) months and 4.5 (95% CI: 0.3-8.7) months later than boys without hypospadias. The age at attaining the Tanner stages for gonadal and pubic hair growth was also higher, though not statistically significant. Pubertal development seemed unaffected in boys with mild as well as severe cryptorchidism. In conclusion, hypospadias may be associated with delayed pubertal development, but pubertal development seems unaffected by cryptorchidism. The relation between hypospadias and later pubertal development may be due to the underlying shared in utero risk or genetic factors.

Timing of paediatric orchidopexy in universal healthcare systems: international administrative data cohort study

BACKGROUND

International guidelines in 2008 recommended orchidopexy for undescended testis at 6-12 months of age to reduce the risk of testicular cancer and infertility. Using administrative data from England, Finland, Ontario (Canada), Scotland and Sweden (with data from Victoria (Australia) and Iceland in supplementary analyses), the aim of this study was to investigate compliance with these guidelines and identify potential socioeconomic inequities in the timing of surgery before 1 and 3 years.

METHODS

All boys born in 2003-2011 with a diagnosis code of undescended testis and procedure codes indicating orchidopexy before their fifth birthday were identified from administrative health records. Trends in the proportion of orchidopexies performed before 1 and 3 years of age were investigated, as were socioeconomic inequities in adherence to the guidelines.

RESULTS

Across all jurisdictions, the proportion of orchidopexies occurring before the first birthday increased over the study period. By 2011, from 7·6 per cent (Sweden) to 27·9 per cent (Scotland) of boys had undergone orchidopexy by their first birthday and 71·5 per cent (Sweden) to 90·4 per cent (Scotland) by 3 years of age. There was limited evidence of socioeconomic inequities for orchidopexy before the introduction of guidelines (2008). Across all jurisdictions for boys born after 2008, there was consistent evidence of inequities in orchidopexy by the first birthday, favouring higher socioeconomic position. Absolute differences in these proportions between the highest and lowest socioeconomic groups ranged from 2·5 to 5·9 per cent across jurisdictions.

CONCLUSION

Consistent lack of adherence to the guidelines across jurisdictions questions whether the guidelines are appropriate.

Comparison Between Processus Vaginalis Sac Tightening Technique and the Conventional Technique in Orchiopexy Surgery Over 10 Years

Background

Undescended testis (UDT) is a common congenital urogenital anomaly that is treated by orchiopexy. We aimed to introduce patent processus vaginalis (PPV) sac tightening (PVST) technique and compare it to the conventional technique.

Methods

We retrospectively studied all the operated UDT patients during 10 years. In the conventional technique, it was necessary to ligate PPV sac after being peeled off from the spermatic cord. PVST was dissected longitudinally from the two sides of where the PPV sac wall was attached to the spermatic cord till the proximal part, and only a narrow thin layer sticking to the spermatic cord was left and the proximal PVV sac opening was tightened as much as possible with vicryl suture at the internal inguinal ring level. The significance level was <0.05.

Results

Of 821 orchiopexy (mean age 24.5±24.2 months), 36.3% were done by conventional and 63.7% by PVST technique. Hematoma, edema, hydrocele, and wound infection were lower in the PVST technique, but it was not significant (p>0.05). Testicular atrophy and operation time were significantly lower in the PVST than the conventional technique (p<0.001).

Conclusion

The orchiopexy PVST technique has lower complications and seems to be easier, faster and safer than the conventional technique.

Acute abdomen caused by rupture of a torted intra-abdominal testicular mass: Case report

INTRODUCTION

Cryptorchidism is defined as the absence of one or both testicles from the scrotum, which is considered one of the most common birth defects of male genitalia. Mostly the undescended testes are in the inguinal region, while the intra-abdominal location accounts for only 10 % of the cases. The potential risk of malignant transformation in an undescended testis is approximately 2.5-8 times higher than in scrotal position. Torsion of the cryptorchid testis is a very rare cause of acute abdominal pain with few cases published in literature.

CASE PRESENTATION

A 44-year-old male patient presented to the emergency room with acute abdominal pain. General examination revealed relevant tachycardia. Upon abdominal examination there was tenderness and rebound tenderness all over the abdomen, more evident in the lower abdomen. Interestingly, routine examination of the inguino-scrotal region revealed empty right hemi-scrotum despite the patient not being aware. Routine blood tests showed marked anemia Hb: 7.4 g/dl. Urgent pelvi-abdominal U/S showed moderate free intra-abdominal collection in addition to a pelvic mass. CT of the abdomen showed a well-defined heterogenous hypodense mass measuring about 8.5 × 5.5 cm in the pelvis. Urgent exploratory laparotomy was done, and a mass was found to be torted and ruptured. Excision was done and histo-pathological examination revealed testicular mixed germ cell tumor.

CONCLUSION

Undescended testis is associated with an increased risk of infertility, testicular cancer and torsion. In any male with undescended testis and intra-abdominal mass; the risk of intra-abdominal testicular tumor should be considered.

The Diagnosis and Treatment of Impalpable Testes at King Salman Armed Forces Hospital, Tabuk, Saudi Arabia

Background

Impalpable testes may be caused by atrophy, congenital dysgenesis/agenesis, or the presence of testes at unusual sites. Early intervention can improve patient outcomes. The recommended age for surgery ranges from 6 to 18 months.

Objective

To investigate the diagnosis, treatment, and outcomes of impalpable testes and sensitivity and specificity of ultrasonography to diagnose impalpable testes at King Salman Armed Forces Hospital (KSAFH), Tabuk, Saudi Arabia.

Methods

We conducted a retrospective study to review cases of impalpable testes admitted to KSAFH, Tabuk, Saudi Arabia from January 1, 2015 to May 20, 2019. Fifty patients diagnosed with impalpable testes were treated surgically in our center during the period. Patients’ data were tabulated, and statistical analysis was performed using Statistical Package for Social Sciences software (SPSS, version 22; IBM, Armonk, NY). 

Results

We included 50 patients in our study, with a total number of 66 impalpable testes. The median age at diagnosis was 7 months, while the median age at surgery was 17.5 months. The median interval between diagnosis and surgery was 8.5 months, with 44% of cases undergoing surgery after the age of 1.5 years. Two-thirds of the cases were unilateral. The most common site was intracanalicular (57.6%) followed by intra-abdominal (34.8%). The testicular size was average in 36.4%, small in 42.4%, and atrophic in 21.2% of the evaluated cases. 

Conclusions

The overall sensitivity of ultrasonography was 56.1% (it correctly detected the location of 37 out of 66 impalpable testes). The sensitivity of ultrasonography for the detection of intra-abdominal testes was 43.5%, while that of intracanalicular testes was 71.1%.

Surgical Management of Undescended Testis - Timetable and Outcome: A Debate

Around 1.4-3.8% of boys in the Western world are operated because of cryptorchidism. This means that orchidopexy remains one of the most common surgical procedures performed in boys. As a consequence, several consensus reports, guidelines, and reviews dealing with the management of cryptorchidism have been published recently. Based on our research and 30 years' experience with the management of cryptorchidism, the intention of the present publication is to advise on the surgical management and comment on the expected outcome, especially with focus on the controversies related to guidelines and reviews. Except for late referral and waiting lists, which may be practical problems, there is no reason to postpone orchidopexy for nonsyndromic congenital cryptorchid testes beyond 6 months. There is good evidence that such strategy improves the fertility potential and decreases the risk of testicular cancer. In cases with genuine gonadotropin insufficiency, early surgical correction is not enough and adjuvant LH-RH treatment should be implemented to improve the fertility potential. Cryopreservation may be an option in case of treatment failure of adjuvant LH-RH. A prerequisite for such management includes serum hormone assessment and evaluation of testicular biopsies at orchidopexy. Ascended testes contribute to 20-60% of operative cases and should be treated when diagnosed.

Congenital Hypogonadotrophic Hypogonadism: Minipuberty and the Case for Neonatal Diagnosis

Congenital hypogonadotrophic hypogonadism (CHH) is a rare but important etiology of pubertal failure and infertility, resulting from impaired gonadotrophin-releasing hormone secretion or action. Despite the availability of effective hormonal therapies, the majority of men with CHH experience unsatisfactory outcomes, including chronic psychosocial and reproductive sequelae. Early detection and timely interventions are crucial to address the gaps in medical care and improve the outlook for these patients. In this paper, we review the clinical implications of missing minipuberty in CHH and therapeutic strategies that can modify the course of disease, as well as explore a targeted approach to identifying affected male infants by integrating clinical and biochemical data in the early postnatal months.

An updated mortality risk analysis of the post-pubertal undescended testis

INTRODUCTION

The undescended testicle (UDT) presents a problem in post-pubertal (PP) men, as it carries an increased risk of developing a germ cell tumour (GCT). Management of the PP patient with an UDT must weigh the relative risk (RR) of perioperative mortality (POM) from orchiectomy against the lifetime risk of death from a GCT.

METHODS

The most recent data on GCT mortality were obtained from the National Centre for Health Statistics. Standard life tables were used to calculate the cumulative risk over a man's lifetime based on age. The increased RR of GCT in men with UDT was determined by weighing the observed and expected rates from literature review. Life table data was then multiplied by the RR to define the risk of GCT in men with UDT. Data from patients undergoing similar risk surgical procedures stratified by American Society of Anesthesiologists (ASA) class was used to determine POM.

RESULTS

Lifetime risk of dying from GCT decreases with increasing age. POM exceeded risks of death from GCT for men after age 50.2 for ASA class 1 and age 35.4 for ASA class 2. Men with an ASA class higher than 2 have a higher risk of POM compared to GCT for all ages.

CONCLUSIONS

We found different ages from previous reports at which observation is advised. We consider prophylactic orchiectomy only in men who are under 50.2 years if ASA class 1 and under 35.4 years if ASA class 2. Men with an ASA class 3 or higher should always undergo observation.

Insulin-Like Peptide 3 (INSL3) Serum Concentration During Human Male Fetal Life

Context: Insulin-like peptide 3 (INSL3), a protein hormone produced by Leydig cells, may play a crucial role in testicular descent as male INSL3 knockout mice have bilateral cryptorchidism. Previous studies have measured human fetal INSL3 levels in amniotic fluid only. Objective: To measure INSL3 serum levels and mRNA in fetal umbilical cord blood and fetal testes, respectively. Design: INSL3 concentrations were assayed on 50 μl of serum from male human fetal umbilical cord blood by a non-commercial highly sensitive and specific radioimmunoassay. For secondary confirmation, quantitative real-time PCR was used to measure INSL3 relative mRNA expression in 7 age-matched human fetal testes. Setting: UT Southwestern Medical Center, Dallas, TX and Medical University of South Carolina, Charleston, SC. Patients or other Participants: Twelve human male umbilical cord blood samples and 7 human male testes were obtained from fetuses 14-21 weeks gestation. Male sex was verified by leukocyte genomic DNA SRY PCR. Interventions: None. Main Outcome Measures: Human male fetal INSL3 cord blood serum concentrations and testicular relative mRNA expression. Results: INSL3 serum concentrations during human male gestational weeks 15-20 were 2-4 times higher than published prepubertal male levels and were 5-100 times higher than previous reports of INSL3 concentrations obtained from amniotic fluid. Testicular fetal INSL3 mRNA relative expression was low from weeks 14-16, rose significantly weeks 17 and 18, and returned to low levels at week 21. Conclusions: These findings further support the role of INSL3 in human testicular descent and could prove relevant in uncovering the pathophysiology of cryptorchidism.

Hypogonadism and Cryptorchidism

Congenital cryptorchidism (undescended testis) is one of the most common congenital urogenital malformations in boys. Prevalence of cryptorchidism at birth among boys born with normal birth weight ranges from 1.8 to 8.4%. Cryptorchidism is associated with a risk of low semen quality and an increased risk of testicular germ cell tumors. Testicular hormones, androgens and insulin-like peptide 3 (INSL3), have an essential role in the process of testicular descent from intra-abdominal position into the scrotum in fetal life. This explains the increased prevalence of cryptorchidism among boys with diseases or syndromes associated with congenitally decreased secretion or action of androgens, such as patients with congenital hypogonadism and partial androgen insensitivity syndrome. There is evidence to support that cryptorchidism is associated with decreased testicular hormone production later in life. It has been shown that cryptorchidism impairs long-term Sertoli cell function, but may also affect Leydig cells. Germ cell loss taking place in the cryptorchid testis is proportional to the duration of the condition, and therefore early orchiopexy to bring the testis into the scrotum is the standard treatment. However, the evidence for benefits of early orchiopexy for testicular endocrine function is controversial. The hormonal treatments using human chorionic gonadotropin (hCG) or gonadotropin-releasing hormone (GnRH) to induce testicular descent have low success rates, and therefore they are not recommended by the current guidelines for management of cryptorchidism. However, more research is needed to assess the effects of hormonal treatments during infancy on future male reproductive health.

Anomalies of the genitourinary tract in children with 22q11.2 deletion syndrome

The 22q11.2 deletion syndrome (22q11.2DS) involves multiple organ systems with variable phenotypic expression. Genitourinary tract abnormalities have been noted to be present in up to 30-40% of patients. At our institution, an internationally recognized, comprehensive, and multidisciplinary 22q11.2DS care center has been providing care to these children. We sought to report on the incidence of genitourinary tract anomalies in this large cohort and, therefore, retrospectively reviewed all patients who underwent a complete evaluation from 1992 to March 2017. We identified all children with any genital or urinary tract anomaly. For all children with a diagnosis of hydronephrosis, the underlying etiology was determined, when possible. Overall, 1,073 of 1,267 children with 22q11.2DS underwent renal evaluations at our institution. Hundered Sixty-Two (15.1%) children had structural abnormalities of their kidneys/urinary tracts. The majority of children with hydronephrosis (63%) had isolated upper tract dilation without any additional diagnoses. Boys were significantly more likely to be diagnosed with a genital abnormality than girls (7.7 vs. 0.5%, p < 0.001). Of the 649 boys in the entire cohort, 24 (3.7%) had cryptorchidism and 24 (3.7%) had hypospadias, which was noted to be mild in all except one boy. Overall, findings of hydronephrosis, unilateral renal agenesis, and multicystic dysplastic kidney occur at higher rates than expected in the general population. Given these findings, in addition to routine physical examination, we believe that all patients with 22q11.2DS warrant screening RBUS at time of diagnosis.

Impalpable Testis: Evaluation of Diagnostic and Treatment Procedures and Our Treatment Protocol

Introduction

The aim of this study is to present our treatment protocol for impalpable testis.

Material and Methods

In a retrospective study we analyzed clinical data including diagnostic procedures, intraoperative findings, final diagnosis, treatment modality, and outcome of patients with impalpable testis who underwent surgery from January 2010 until December 2015.

Results

Ninety-one patients were admitted under the diagnosis of impalpable testis. In 39 patients ultrasound detected testis in the inguinal canal and orchidopexy was done. In 25 patients (48.08%) laparoscopy showed the entrance of the spermatic cord into the inguinal canal. Open exploration of the inguinal canal was done, testicular remnant removed, and appropriate testicular prosthesis implanted. Twenty patients (20/52) underwent orchidopexy of the abdominal testis (46.51%), 4 of which underwent Fowler-Stevens procedure in two stages, and in 16 patients deliberation of the testis and spermatic cord was sufficient to place the testis into the scrotum.

Conclusions

Excision of the testicular nubbin is highly recommendable, as well as implantation of the testicular prosthesis at the time of orchiectomy.

Congenital genital abnormalities detected during routine circumcision at a South African institution: a retrospective record review

BACKGROUND

Due to the reduction in HIV transmission through male medical circumcisions (MMC), numerous clinics throughout South Africa offer a voluntary free service to boys from the age of ten years and above. An examination prior to the procedure may detect congenital abnormalities missed after birth.

OBJECTIVES

The aim of this study was to measure the incidence of these abnormalities, determine the demographic and clinical characteristics of this group and determine what referral systems, interventions, and follow-up is available to them.

METHODS

The study was a descriptive, observational, retrospective analysis of de-identified medical records at a routine MMC service at a Johannesburg clinic in 2015. The participants were male patients between the ages of 10 - 49.

RESULTS

Out of 1548 participants, 91.0% (n=1409) had a normal genital examination while 3.7% (n=57) had an abnormal examination and 5.1% (n=79) had no examination recorded. Thirty five congenital anomalies were detected and only 2 patients (diagnosed with hypospadias) were seen at the urology out-patient's department.

CONCLUSION

The incidence of congenital genital abnormalities of males presenting for routine circumcision is low. Despite the low incidence the effect on fertility, sexuality, ability to urinate and on psychological wellbeing is significant. Referral services to the urology department should be restructured to improve all outcomes.

Age at presentation of undescended testicles: a single-center study in Saudi Arabia

BACKGROUND

The undescended testis (UDT) is the most common genital anomaly encountered in pediatrics with an estimated incidence of 1% to 4% in full-term and 1% to 45% in preterm newborn boys. Over the years, studies on progressive histological deterioration and cancer risk has led to a change in recommendations for when orchidopexy should be done.

OBJECTIVES

Determine age at presentation of patients for UDT to a specialist in Saudi Arabia, age of operation and whether the recommended targeted time frame has been met.

DESIGN

Descriptive retrospective medical record review.

SETTINGS

University hospital setting in urban location.

SUBJECTS AND METHODS

The records of patients presenting to our center with UDT between the years 1996-2015 were reviewed for data on the age at presentation and age of operation.

MAIN OUTCOME MEASURES

Age at time of evaluation and at time of surgical intervention compared with the international standard.

SAMPLE SIZE

331 cases.

RESULTS

Out of the cases included, 195 met the inclusion criteria. The median age of presentation was 13.7 (range: 0-123.2) months. The median age at time of orchiopexy was 25 (range: 7.5-130.2) months. The median waiting time for elective surgery was 4.8 months ( less than 1 day to 49.4 months).

CONCLUSION

Despite the international recommendation of carrying out orchidopexy between the ages of 6-12 months, the targeted recommended time frame is not met in Saudi Arabia. This is mainly related to late referral age and the long waiting time for elective surgery.

LIMITATIONS

Small sample size and retrospective design.

CONFLICT OF INTEREST

None.