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Baydilli N, Dönmez Mİ, Wilcox DT, Hadziselimovic F, Hayashi Y, Oswald J, Ziylan O, Thorup J, Kapelari K, Soygür T, Favorito LA, Braga LH, 't Hoen LA, O'Kelly F, Sforza S, Lammers R, Bindi E, Paraboschi I, Haid B, Quiroz Madarriaga Y, Banuelos Marco B. Undescended testis: A roundtable discussion based on clinical scenarios - Part 1. J Pediatr Urol 2024; 20:95-101. [PMID: 37845102 DOI: 10.1016/j.jpurol.2023.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 09/14/2023] [Accepted: 09/27/2023] [Indexed: 10/18/2023]
Abstract
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.
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Affiliation(s)
- Numan Baydilli
- Department of Pediatric Urology, Erciyes University Faculty of Medicine, Kayseri, Turkey.
| | - M İrfan Dönmez
- Division of Pediatric Urology, Department of Urology, İstanbul University İstanbul Faculty of Medicine, İstanbul, Turkey.
| | - Duncan T Wilcox
- Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO, USA.
| | - Faruk Hadziselimovic
- Department of Pediatrics, Children's Day Care Center Liestal, Cryptorchidism Research Institute, Liestal, Switzerland.
| | - Yutaro Hayashi
- Department of Pediatric Urology Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.
| | - Josef Oswald
- Department of Pediatric Urology, Hospital of the Sisters of Charity, Linz, Austria.
| | - Orhan Ziylan
- Division of Pediatric Urology, Department of Urology, İstanbul University İstanbul Faculty of Medicine, İstanbul, Turkey.
| | - Jorgen Thorup
- Department of Pediatric Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.
| | - Klaus Kapelari
- Department for Children and Adolescent Medicine, Innsbruck Medical University, Tyrol, Austria.
| | - Tarkan Soygür
- Division of Pediatric Urology, Department of Urology, Ankara University School of Medicine, Ankara, Turkey.
| | - Luciano Alves Favorito
- Unidade de Pesquisa Urogenital, Universidade do Estado do Rio de Janeiro - Uerj, Rio de Janeiro, RJ, Brazil.
| | - Luis H Braga
- Department of Surgery/Urology, McMaster University, Hamilton, Ontario, Canada.
| | - Lisette A 't Hoen
- Department of Pediatric Urology, Erasmus MC University Medical Center, Rotterdam-Sophia Children's Hospital, Rotterdam, the Netherlands.
| | - Fardod O'Kelly
- Division of Paediatric Urology, Beacon Hospital, University College Dublin, Dublin, Ireland.
| | - Simone Sforza
- Paediatric Urology, Meyer Children Hospital, University of Florence, Florence, Italy.
| | - Rianne Lammers
- Department of Urology, University Medical Center Groningen, Groningen, the Netherlands.
| | - Edoardo Bindi
- Ospedale Pediatrico G Salesi, Department of Pediatric Urology, G Salesi Paediatric Hospital, Ancona, Italy.
| | - Irene Paraboschi
- Department of Pediatric Urology, Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milano, Italy.
| | - Bernhard Haid
- Department of Pediatric Urology, Hospital of the Sisters of Charity, Linz, Austria.
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Baidya A, Basu AK, Bhattacharjee R, Biswas D, Biswas K, Chakraborty PP, Chatterjee P, Chowdhury S, Dasgupta R, Ghosh A, Ghosh S, Giri D, Goswami S, Maisnam I, Maiti A, Mondal S, Mukhopadhyay P, Mukhopadhyay S, Mukhopadhyay S, Pal SK, Pandit K, Ray S, Chowdhury BR, Raychaudhuri M, Raychaudhuri P, Roy A, Sahana PK, Sanyal D, Sanyal T, Saraogi RK, Sarkar D, Sengupta N, Singh AK, Sinha A. Diagnostic approach in 46, XY DSD: an endocrine society of bengal (ESB) consensus statement. J Pediatr Endocrinol Metab 2023; 36:4-18. [PMID: 36424806 DOI: 10.1515/jpem-2022-0515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 10/31/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES 46, XY difference/disorder of sex development (DSD) is a relatively uncommon group of heterogeneous disorders with varying degree of underandrogenization of male genitalia. Such patients should be approached systematically to reach an aetiological diagnosis. However, we lack, at present, a clinical practice guideline on diagnostic approach in 46, XY DSD from this part of the globe. Moreover, debate persists regarding the timing and cut-offs of different hormonal tests, performed in these cases. The consensus committee consisting of 34 highly experienced endocrinologists with interest and experience in managing DSD discussed and drafted a consensus statement on the diagnostic approach to 46, XY DSD focussing on relevant history, clinical examination, biochemical evaluation, imaging and genetic analysis. CONTENT The consensus was guided by systematic reviews of existing literature followed by discussion. An initial draft was prepared and distributed among the members. The members provided their scientific inputs, and all the relevant suggestions were incorporated. The final draft was approved by the committee members. SUMMARY The diagnostic approach in 46, XY DSD should be multidisciplinary although coordinated by an experienced endocrinologist. We recommend formal Karyotyping, even if Y chromosome material has been detected by other methods. Meticulous history taking and thorough head-to-toe examination should initially be performed with focus on external genitalia, including location of gonads. Decision regarding hormonal and other biochemical investigations should be made according to the age and interpreted according to age-appropriate norms Although LC-MS/MS is the preferred mode of steroid hormone measurements, immunoassays, which are widely available and less expensive, are acceptable alternatives. All patients with 46, XY DSD should undergo abdominopelvic ultrasonography by a trained radiologist. MRI of the abdomen and/or laparoscopy may be used to demonstrate the Mullerian structure and/or to localize the gonads. Genetic studies, which include copy number variation (CNV) or molecular testing of a candidate gene or next generation sequencing then should be ordered in a stepwise manner depending on the clinical, biochemical, hormonal, and radiological findings. OUTLOOK The members of the committee believe that patients with 46, XY DSD need to be approached systematically. The proposed diagnostic algorithm, provided in the consensus statement, is cost effective and when supplemented with appropriate genetic studies, may help to reach an aetiological diagnosis in majority of such cases.
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Affiliation(s)
- Arjun Baidya
- Department of Endocrinology, Nil Ratan Sircar Medical College and Hospital, Kolkata, India
| | - Asish Kumar Basu
- Department of Endocrinology & Metabolism, Medical College, Kolkata, West Bengal, India
| | - Rana Bhattacharjee
- Department of Endocrinology & Metabolism, Medical College, Kolkata, West Bengal, India
| | - Dibakar Biswas
- Department of Endocrinology & Metabolism, IPGME&R/SSKM Hospital, Kolkata, India
| | | | | | | | - Subhankar Chowdhury
- Department of Endocrinology & Metabolism, IPGME&R/SSKM Hospital, Kolkata, India
| | - Ranen Dasgupta
- Department of Endocrinology, Nil Ratan Sircar Medical College and Hospital, Kolkata, India
| | - Amritava Ghosh
- Department of Endocrinology, All India Institute of Medical Sciences, Raipur, India
| | - Sujoy Ghosh
- Department of Endocrinology & Metabolism, IPGME&R/SSKM Hospital, Kolkata, India
| | | | - Soumik Goswami
- Department of Endocrinology, Nil Ratan Sircar Medical College and Hospital, Kolkata, India
| | - Indira Maisnam
- Department of Endocrinology & Metabolism, IPGME&R/SSKM Hospital, Kolkata, India
| | - Animesh Maiti
- Department of Endocrinology & Metabolism, Medical College, Kolkata, West Bengal, India
| | - Sunetra Mondal
- Department of Endocrinology & Metabolism, IPGME&R/SSKM Hospital, Kolkata, India
| | - Pradip Mukhopadhyay
- Department of Endocrinology & Metabolism, IPGME&R/SSKM Hospital, Kolkata, India
| | | | | | - Salil Kumar Pal
- Department of Medicine, Calcutta National Medical College, Kolkata, India
| | - Kaushik Pandit
- Department of Endocrinology & Metabolism, IPGME&R/SSKM Hospital, Kolkata, India
| | - Sayantan Ray
- Department of Endocrinology, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Bibek Roy Chowdhury
- Department of Endocrinology & Metabolism, IPGME&R/SSKM Hospital, Kolkata, India
| | | | - Pradip Raychaudhuri
- Department of Endocrinology & Metabolism, Medical College, Kolkata, West Bengal, India
| | - Ajitesh Roy
- Department of Endocrinology, Vivekananda Institute of Medical Sciences, Kolkata, India
| | - Pranab Kumar Sahana
- Department of Endocrinology & Metabolism, IPGME&R/SSKM Hospital, Kolkata, India
| | - Debmalya Sanyal
- Department of Endocrinology, KPC Medical College, Kolkata, India
| | - Trinanjan Sanyal
- Department of Biochemistry, Malda Medical College & Hospital, Malda, India
| | | | - Dasarathi Sarkar
- Department of Endocrinology, G.D Hospital & Diabetes Institute, Kolkata, India
| | - Nilanjan Sengupta
- Department of Endocrinology, Nil Ratan Sircar Medical College and Hospital, Kolkata, India
| | | | - Anirban Sinha
- Department of Endocrinology & Metabolism, Medical College, Kolkata, West Bengal, India
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Identification of the Rare Ala871Glu Mutation in the Androgen Receptor Gene Leading to Complete Androgen Insensitivity Syndrome in an Adolescent Girl with Primary Amenorrhea. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121900. [PMID: 36553343 PMCID: PMC9777019 DOI: 10.3390/children9121900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 11/29/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
Complete Androgen Insensitivity Syndrome (CAIS) is a rare genetic condition by mutations in the androgen receptor (AR) gene resulting in target issue resistance to androgens and a female phenotype in genetically male individuals. A 16-year-old phenotypically female individual presented to our clinic with primary amenorrhea. Her clinical evaluation showed normal female external genitalia, Tanner III breast development and sparse pubic and axillary hair (Tanner stage II). Hormonal assessment revealed increased concentrations of Luteinizing Hormone (LH), Testosterone and Antimüllerian Hormone (AMH). Image studies detected no uterus or gonads, but a blind vagina and the karyotype was 46, XY. These findings suggested the diagnosis of CAIS, and genetic testing of the AR gene revealed a rare pathogenic mutation of cytosine to adenine (c.2612C>A) replacing alanine with glutamic acid at position 871 (p.Ala871Glu) in the AR, previously described once in two adult sisters. The patient underwent gonadectomy and received hormonal replacement therapy. This study expands the AR mutation database and shows the complexity and the importance of prompt diagnosis, proper management, and follow-up for CAIS patients, underlining the need for standardized protocols.
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Fazal K, Hussain S, Khan F, Ullah I, Tahir MJ, Mehmood Q, Yousaf Z. To determine the sensitivity, specificity, and diagnostic accuracy of diffusion-weighted MRI in localization of non-palpable undescended testes taking laparoscopic findings as the gold standard: A cross-sectional study from Pakistan. Ann Med Surg (Lond) 2022; 73:103161. [PMID: 35079354 PMCID: PMC8767264 DOI: 10.1016/j.amsu.2021.103161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 12/04/2021] [Accepted: 12/05/2021] [Indexed: 11/25/2022] Open
Abstract
Background Cryptorchidism, undescended testes, is a pathological condition that is due to failure of descent of testes in the scrotum. This study was aimed to determine the diagnostic accuracy of diffusion-weighted magnetic resonance imaging (DW-MRI) in localization of undescended testes taking laparoscopic findings as the gold standard. Methods A cross-sectional study was conducted in the radiology department of a tertiary care hospital from September 27, 2018 to September 26, 2019. A total of 416 patients were included. Abdomen-pelvic and scrotal ultrasound were performed. Preoperative abdominal and pelvic DW-MRI was performed with a 1.5-T MRI system using a body coil. All study patients underwent laparoscopic exploration. Intra-abdominal atrophic testes were treated with laparoscopic orchiectomy and orchiectomy samples were taken for histopathologic examination. DW-MRI findings were correlated with laparoscopic findings. A 2 x 2 table was used to calculate the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of DW-MRI taking laparoscopy as the gold standard. Results The mean age was 17.08 ± 7.99 years and the mean BMI was 19.36 ± 4.96 kg/m2. In our study, 34.1% of cases were diagnosed as undescended testes localized by DWI-MRI and 51% of cases were diagnosed as undescended testes localized via laparoscopy. Sensitivity, specificity, PPV, NPV and accuracy were 65.1%, 98%, 97.2%, 73% and 81.3% respectively. Conclusion DW-MRI improves the detection of undescended testes. DW-MRI can be a recommended imaging tool to increase the preoperative diagnostic accuracy of MRI in localizing nonpalpable undescended testes. Undescended testis or cryptorchidism is the most common congenital genitourinary anomaly in boys. This study was aimed to determine the DW-MRI in localization of undescended testes taking laparoscopic findings as the gold standard. DW-MRI improves the detection of undescended testes. DW-MRI can be a recommended imaging tool to increase the preoperative diagnostic accuracy of MRI in localizing nonpalpable undescended testes.
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Affiliation(s)
- Kamran Fazal
- Department of Radiology, Aga Khan University Hospital, Karachi, Pakistan
| | - Shaiq Hussain
- Department of Radiology, Jinnah Postgraduate Medical Center, Karachi, Pakistan
| | - Faheemullah Khan
- Department of Radiology, Aga Khan University Hospital, Karachi, Pakistan
| | - Irfan Ullah
- Kabir Medical College, Gandhara University, Peshawar, Pakistan
| | | | | | - Zohaib Yousaf
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
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Lotti F, Bertolotto M, Maggi M. Historical trends for the standards in scrotal ultrasonography: What was, what is and what will be normal. Andrology 2021; 9:1331-1355. [PMID: 34089245 DOI: 10.1111/andr.13062] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Ultrasonography is the gold standard imaging method for scrotal investigation. Colour Doppler ultrasonography, contrast-enhanced ultrasonography and sonoelastography allow sonographers to assess size, echotexture, vascular features and stiffness of the scrotal organs and abnormalities. Scrotal ultrasonography has been used to investigate male reproductive health, scrotal pain, masses and trauma. However, ultrasonography thresholds/classifications used to distinguish normal and pathologic features of the scrotal organs have changed over time, and have not yet been fully standardized. OBJECTIVES To evaluate historical trends for the standards in scrotal ultrasonography: what was, what is and what will be normal. METHODS An extensive Medline search was performed identifying the most relevant studies in the English language from inception to date. RESULTS We provide here (i) a brief overview of the history of ultrasonography, (ii) current indications for scrotal ultrasonography and (iii) previous and current normal values, cut-offs and classifications of the main colour-Doppler ultrasonography parameters/characteristics of the scrotal organs, as derived from recent guidelines and evidence-based studies. In addition, we report recommendations and the clinical utility of contrast-enhanced ultrasonography and sonoelastography. Finally, we discuss critical issues needing further evidence and future directions to fill in the current gaps. DISCUSSION Several studies on scrotal ultrasonography are available. However, guidelines/recommendations dealing with specific ultrasonography applications have been published only in recent years. More recently, the European Academy of Andrology published evidence-based scrotal colour-Doppler ultrasonography reference ranges/normative parameters derived from a cohort of healthy, fertile men. In addition, a standardization of the methodology to evaluate qualitative and quantitative colour-Doppler ultrasonography parameters was reported. Other international societies reported indications, methodological standards, clinical utility and limitations of contrast-enhanced ultrasonography and sonoelastography. CONCLUSIONS To date, colour-Doppler ultrasonography normative values for the scrotal organs are available. However, a wide international consensus on assessment and classification of several ultrasonography parameters is still lacking. An alignment of the world societies on these issues is advocated.
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Affiliation(s)
- Francesco Lotti
- Andrology, Female Endocrinology and Gender Incongruence Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Florence, Italy
| | - Michele Bertolotto
- Department of Radiology, Cattinara Hospital, University of Trieste, Trieste, Italy
| | - Mario Maggi
- Endocrinology Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Florence, Italy
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Tsili AC, Argyropoulou MI, Dolciami M, Ercolani G, Catalano C, Manganaro L. When to ask for an MRI of the scrotum. Andrology 2021; 9:1395-1409. [PMID: 33964115 PMCID: PMC8596813 DOI: 10.1111/andr.13032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/23/2021] [Accepted: 05/01/2021] [Indexed: 12/29/2022]
Abstract
Background Multiparametric MRI (mpMRI) of the scrotum has been established as a useful second‐line diagnostic tool for the investigation of scrotal diseases. Recently, recommendations on clinical indications for scrotal MRI were issued by the Scrotal and Penile Imaging Working Group of the European Society of Urogenital Radiology. Objective To update current research on when to ask for an MRI of the scrotum. Methods PubMed database was searched for original articles and reviews published during 2010–2021. Results Eighty‐three articles fulfilled the search criteria. Scrotal MRI is mainly recommended after inconclusive US findings or inconsistent with the clinical examination and should be asked in the following cases: differentiation between intratesticular and paratesticular lesions (in rare cases of uncertain US findings), characterization of paratesticular and intratesticular lesions (when US findings are indeterminate), discrimination between germ cell and sex cord‐stromal testicular tumors, local staging of testicular malignancies (in patients planned for testis‐sparing surgery), differentiation between seminomas and non‐seminomatous tumors (when immediate chemotherapy is planned and orchiectomy is delayed), assessment of acute scrotum and scrotal trauma (rarely needed, in cases of non‐diagnostic US findings) and detection and localization of undescended testes (in cases of inconlusive US findings). Although preliminary data show promising results in the evaluation of male infertility, no established role for mpMRI still exists. Conclusion Multiparametric MRI of the scrotum, by assessing morphologic and functional data represents a valuable problem‐solving tool, helping to improve our understanding on the nature of scrotal pathology and the process of spermatogenesis. The technique may improve patient care and reduce the number of unnecessary surgical procedures.
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Affiliation(s)
- Athina C Tsili
- Department of Clinical Radiology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Maria I Argyropoulou
- Department of Clinical Radiology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Miriam Dolciami
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Roma, Italy
| | - Giada Ercolani
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Roma, Italy
| | - Carlo Catalano
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Roma, Italy
| | - Lucia Manganaro
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Roma, Italy
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Emad-Eldin S, Abdelaziz O, Shokr M. Spigelian-cryptorchidism syndrome in an adult male complaining of primary infertility: Case report. Andrologia 2020; 53:e13838. [PMID: 33099792 DOI: 10.1111/and.13838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 08/18/2020] [Accepted: 08/20/2020] [Indexed: 11/30/2022] Open
Abstract
History of cryptorchidism is present in about 10% of infertile patients seeking medical help, whereas 20% of them are azoospermic. Most of the patients with bilateral cryptorchidism have a low testicular volume and high serum FSH level. Ectopic testes are present only in 5% of the patients with cryptorchidism. The anterior abdominal wall is a rare site for ectopic testis where Spigelian hernia is usually accompanied. We present a case of bilateral ectopic anterior abdominal wall testes associated with Spigelian hernia on the left side.
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Affiliation(s)
- Sally Emad-Eldin
- Department of Diagnostic and Intervention Radiology, Cairo University Hospitals, Cairo, Egypt
| | - Omar Abdelaziz
- Department of Diagnostic and Intervention Radiology, Cairo University Hospitals, Cairo, Egypt
| | - Mohamed Shokr
- Department of Andrology, Cairo University Hospitals, Cairo, Egypt
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Carpenter CP, Johnston D, Tourville E, Sharadin C, Alzubaidi AN, Giel DW. Inappropriate imaging for management of cryptorchidism: Has the choosing Wisely® recommendation reduced occurrence? J Pediatr Urol 2020; 16:462.e1-462.e6. [PMID: 32674979 DOI: 10.1016/j.jpurol.2020.06.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/06/2020] [Accepted: 06/12/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Cryptorchidism is one of the most common referral diagnoses to pediatric urologists. It is well recognized in the urologic community that diagnostic imaging is unnecessary in the work-up of these patients, and the Choosing Wisely® recommendation (CWR) on this subject re-emphasized this in 2013. Many boys, however, still are sent for testing prior to referral. OBJECTIVE The purpose of our study was dual in nature. We pursued, first, to identify any factors that make patients more likely to be sent for imaging prior to referral, and second, to determine if rates of diagnostic imaging for cryptorchidism decreased after the release of the CWR. STUDY DESIGN We included all boys who had surgery for cryptorchidism by Urology at our institution between January 2007 and August 2018. Demographics and clinical data were collected including height, weight, race, insurance type, pre-referral imaging status, testis location at time of surgery, and distance from our medical center. Chi-squared analysis was utilized to compare imaging use before and after CWR. Influence of other clinical and socioeconomic factors on imaging utilization was also evaluated using chi-squared and two-sample t tests. Those found to be significant at the 0.2 level were analyzed in multivariate logistic regression. Significance was set at 0.05. RESULTS 1010 boys were available for analysis. Of the 256 patients (25.3%) with pre-referral studies, 7 had axial exams (CT or MRI), and the remainder underwent ultrasounds. Children living closer to the medical center were more likely to undergo imaging (p < 0.01) as were boys with testes not found in the inguinal canal at the time of surgery (p = 0.007). Race, insurance status, age at first visit, and increased body mass index were not found to be influential. Similarly, the release of CWR had no impact on the imaging usage (p = 0.61). CONCLUSION Utilization of pre-referral diagnostic imaging remains inappropriately high despite evidence demonstrating the ineffectiveness of the studies. Boys living closer to the medical center and those with non-inguinal testes are more likely to undergo these studies, but no other factors were found to have an effect. Further, the Choosing Wisely® recommendation has not improved rates of inappropriate imaging use in boys with cryptorchidism in our referral area. Our findings indicate the need for increased efforts to disseminate this evidence-based guideline more widely to primary care providers in order to promote more cost-effective and timely care of boys with undescended testes.
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Affiliation(s)
- Christina P Carpenter
- Department of Urology, Division of Pediatric Urology, Columbia University Irving Medical Center, NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA; Department of Urology, Division of Pediatric Urology, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA.
| | | | - Elizabeth Tourville
- Department of Urology, Division of Pediatric Urology, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Cynthia Sharadin
- Department of Urology, Division of Pediatric Urology, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ahmad N Alzubaidi
- Department of Urology, Division of Pediatric Urology, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Dana W Giel
- Department of Urology, Division of Pediatric Urology, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
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Perineal ectopic testis with unilateral scrotal hypoplasia. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2019. [DOI: 10.1016/j.epsc.2019.101298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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León NY, Reyes AP, Harley VR. A clinical algorithm to diagnose differences of sex development. Lancet Diabetes Endocrinol 2019; 7:560-574. [PMID: 30803928 DOI: 10.1016/s2213-8587(18)30339-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 11/27/2018] [Accepted: 11/27/2018] [Indexed: 12/15/2022]
Abstract
The diagnosis and management of children born with ambiguous genitalia is challenging for clinicians. Such differences of sex development (DSDs) are congenital conditions in which chromosomal, gonadal, or anatomical sex is atypical. The aetiology of DSDs is very heterogenous and a precise diagnosis is essential for management of genetic, endocrine, surgical, reproductive, and psychosocial issues. In this Review, we outline a step-by-step approach, compiled in a diagnostic algorithm, for the clinical assessment and molecular diagnosis of a patient with ambiguity of the external genitalia on initial presentation. We appraise established and emerging technologies and their effect on diagnosis, and discuss current controversies.
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Affiliation(s)
- Nayla Y León
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Alejandra P Reyes
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, VIC, Australia; Genetics Department, Children's Hospital of Mexico Federico Gómez, Mexico City, Mexico
| | - Vincent R Harley
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, VIC, Australia.
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Allam MFAB, Elian MMM, Rahman AMA, Allam FAFAB. The utility of chemical shift imaging and related fat suppression as standalone technique in cryptorchidism using low field MRI. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2018. [DOI: 10.1016/j.ejrnm.2018.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Accuracy of ultrasound in pediatric undescended testes. ASIAN BIOMED 2018. [DOI: 10.2478/abm-2010-0131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Abstract
Background: The undescended testis represents a common condition affecting male infants with significant clinical implications such as infertility and testicular malignancy. There is controversy as to the diagnosis when a clinical examination fails to identify a testis. Objective: Investigate the value of ultrasound in the diagnosis of undescended testis, and evaluate the correlation between the preoperative ultrasonographic data and operative findings. Material and method: Thirty-nine boys (age: 3months -12 years) with undescended testes were examined between January 2003 and December 2007. All the boys had undergone a sonogram performed for localizing the undescended testes. Only 20 boys were sent for inguinal exploration, or other surgical procedures for localizing the undescended testes. We calculated specificity, sensitivity, positive predictive value (PPV), negative predictive value (NPV), and the accuracy of ultrasonographic diagnosis in boys with undescended testes. Results: Twenty-nine undescended testes were included in this study. Ultrasonography had a sensitivity of 82%, a specificity of 0%, PPV of 96%, NPV of 0%, and accuracy of 79% in the diagnosis of the undescended testis. Conclusions: The sensitivity and specificity including NPV of uetrasound had the unsatisfactory outcomes.
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MRI of the scrotum: Recommendations of the ESUR Scrotal and Penile Imaging Working Group. Eur Radiol 2017; 28:31-43. [DOI: 10.1007/s00330-017-4944-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 06/06/2017] [Accepted: 06/12/2017] [Indexed: 01/08/2023]
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Mathur M, Mills I, Spektor M. Magnetic resonance imaging of the scrotum: pictorial review with ultrasound correlation. Abdom Radiol (NY) 2017; 42:1929-1955. [PMID: 28401283 DOI: 10.1007/s00261-017-1127-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The purpose of this review is to showcase the added value of scrotal magnetic resonance imaging (MRI) in the workup of neoplastic and non-neoplastic entities. While ultrasound (US) remains the first-line imaging modality for evaluating scrotal pathology, MRI may add valuable information, particularly when US findings are equivocal. The inherent soft tissue resolution characteristics of MRI, as well as the ability to detect subtle enhancement and provide wider field-of-view imaging, can prove useful in evaluating inconclusive US findings. The added value of MR in these instances is critical as it may have a significant impact on patient management.
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Affiliation(s)
- Mahan Mathur
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, 333 Cedar Street, Room TE-2, PO Box 208042, New Haven, CT, 06520, USA.
| | - Ian Mills
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, 333 Cedar Street, Room TE-2, PO Box 208042, New Haven, CT, 06520, USA
| | - Michael Spektor
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, 333 Cedar Street, Room TE-2, PO Box 208042, New Haven, CT, 06520, USA
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Abstract
PURPOSE While the nonpalpable testis represents a small portion of all cryptorchid testes, it remains a clinical challenge for pediatric urologists. Controversy exists surrounding the best evaluation and management of this entity. In this review we update what is known about the nonpalpable testis, including the etiology, preoperative evaluation and best surgical management as well as novel techniques and ongoing controversies. MATERIALS AND METHODS We searched PubMed® and MEDLINE® from January 2000 to January 2017 using relevant key terms. Of 367 articles 115 were considered for inclusion based on a priori design. Using a narrative review format, an update on the evaluation and management of the nonpalpable testis including novel concepts and techniques was synthesized. RESULTS The nonpalpable testis should be evaluated by physical examination only. Imaging is not indicated for routine cases. The optimal surgical approach and technique remain debatable but several novel techniques have been described. Due to the rarity of the nonpalpable testis, randomized controlled trials and other quality comparisons are difficult. Therefore, management remains controversial. CONCLUSIONS Evaluation and management of the nonpalpable testis remain difficult, and some aspects are still debated. Future research should focus on multi-institutional collaborative trials to determine the optimal operative management.
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Affiliation(s)
| | - Kate H Kraft
- Department of Urology, University of Michigan, Ann Arbor, Michigan
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Efficiency of combined diffusion weighted imaging and conventional MRI in detection of clinically nonpalpable undescended testes. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2017. [DOI: 10.1016/j.ejrnm.2016.09.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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17
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Niedzielski JK, Oszukowska E, Słowikowska-Hilczer J. Undescended testis - current trends and guidelines: a review of the literature. Arch Med Sci 2016; 12:667-77. [PMID: 27279862 PMCID: PMC4889701 DOI: 10.5114/aoms.2016.59940] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 02/26/2015] [Indexed: 11/17/2022] Open
Abstract
The best mode of undescended testis (UDT) treatment remains controversial. However, knowledge gained from randomized controlled studies and meta-analyses allowed different groups of researchers to set out guidelines on management of patients with UDT. The authors reviewed recent literature and came to the following conclusions: (1) Hormonal treatment is not recommended, considering both the immediate results (only 15-20% of retained testes descend) and the possible long-term adverse effects on spermatogenesis. (2) Surgery is the treatment of choice; orchiopexy is successful in about 95% of UDT, with a low rate of complications (about 1%). (3) Orchiopexy should be performed between 12 and 18 months of age, or at first contact if diagnosed later.
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Affiliation(s)
- Jerzy K. Niedzielski
- Department of Pediatric Surgery and Urology, Medical University of Lodz, Lodz, Poland
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18
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El-Agwany AMS. Androgen insensitivity syndrome with inguinal testes: MRI diagnosis. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2016. [DOI: 10.1016/j.ejrnm.2016.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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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.
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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
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Hamidi N, Telli O, Bagci U, Esen B, Karagoz MA, Hascicek AM, Soygur T, Burgu B. Outcomes of Laparoscopic Treatment Modalities for Unilateral Non-palpable Testes. Front Pediatr 2016; 4:13. [PMID: 26973822 PMCID: PMC4778551 DOI: 10.3389/fped.2016.00013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 02/15/2016] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To date, laparoscopy has gradually become the gold standard for treatment of non-palpable testicles (NPT) with different success and complication rates. In this study, we aimed to evaluate outcomes of laparoscopic approaches for NPT. MATERIALS AND METHODS We reviewed data of 82 consecutive patients who underwent laparoscopic treatment for unilateral NPT at two institutions by two high volume surgeons from 2004 January to 2014 December. Laparoscopic-assisted orchidopexy (LAO) and two-stage Fowler-Stephens technique (FST) was performed for 45 and 37 patients, respectively. Age (at surgery), follow-up time, laterality of testes, and postoperative complications were analyzed. Modified Clavien classification system (MCCS) was used for evaluating complications. RESULTS The median age (at surgery) and median follow-up time were 18 (range: 6-56) and 60 (range: 9-130) months, respectively. Overall success rate for two laparoscopy techniques was 87.8% during the maximal follow-up time. We observed wound infection in two, hematoma in one, testicular atrophy in five, testicular re-ascending in two patients at follow-up period. There was no statistical difference between two laparoscopic techniques for grade I (five vs. two patients, p = 0.14) and grade IIIb MCCS complications (five vs. two patients, p = 0.44). CONCLUSION Our results have shown that two laparoscopic approaches have low complication rates.
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Affiliation(s)
- Nurullah Hamidi
- Department of Urology, Ankara University School of Medicine , Ankara , Turkey
| | - Onur Telli
- Department of Pediatric Urology, Ankara University School of Medicine , Ankara , Turkey
| | - Uygar Bagci
- Department of Urology, Ankara University School of Medicine , Ankara , Turkey
| | - Baris Esen
- Department of Urology, Ankara University School of Medicine , Ankara , Turkey
| | - Mehmet Ali Karagoz
- Department of Urology, Ankara Training and Research Hospital , Ankara , Turkey
| | | | - Tarkan Soygur
- Department of Pediatric Urology, Ankara University School of Medicine , Ankara , Turkey
| | - Berk Burgu
- Department of Pediatric Urology, Ankara University School of Medicine , Ankara , Turkey
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Agladioglu K, Herek D, Herek O, Agladioglu S, Cördük N, Ozhan B. Can ultrasound elastography be used as a new technique in the differentiation of undescended testes and reactive lymph nodes in children? Clin Radiol 2015; 70:1269-75. [DOI: 10.1016/j.crad.2015.06.099] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 06/03/2015] [Accepted: 06/29/2015] [Indexed: 12/21/2022]
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Komarowska MD, Hermanowicz A, Debek W. Putting the pieces together: cryptorchidism - do we know everything? J Pediatr Endocrinol Metab 2015. [PMID: 26226123 DOI: 10.1515/jpem-2015-0098] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cryptorchidism is one of the most common birth defects in male children, and it has a potential impact on future health. It is the best-characterized risk factor for reduced fertility and testicular cancer. However, the etiology of cryptorchidism remains largely unknown. In the literature, we find different opinions and theories on this topic. Probably, the etiology is multifactorial, and hormonal, genetic and environmental factors may regulate testicular development and descent from intra-abdominal location into the bottom of the scrotum. The descent of the testis is a complex, two-stage process. A critical role in testicular descent has been attributed to androgens, insulin-like hormone 3 (insl3) and anti-Müllerian hormone. It is believed that interaction between Leydig and Sertoli cells may cause impaired spermatogenesis. Based on recent knowledge of germ cell development, it is believed that the best treatment for undescended testis is orchiopexy between 6th and 12th month of life. Long follow-up studies are needed to focus on the effect of this recommendation.
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Oliveira MDS, de Paiva-e-Silva RB, Guerra-Junior G, Maciel-Guerra AT. Parents' experiences of having a baby with ambiguous genitalia. J Pediatr Endocrinol Metab 2015; 28:833-8. [PMID: 26068900 DOI: 10.1515/jpem-2014-0457] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 01/09/2015] [Indexed: 11/15/2022]
Abstract
Health professionals must be aware of the impact on parents of the birth of children with ambiguous genitalia. This study aimed to analyze the experiences and perceptions of such parents. Parents of 30 children who were evaluated in a reference center for disorders of sex development (DSD) were interviewed. The questionnaire covered the prenatal period, the moment they were told about the disorder, initial management by health professionals, and problems they experienced. Only two cases were detected during pregnancy. The news was usually given to the mother alone by pediatricians. Most parents kept it secret and avoided exposing the baby to the prejudice of others. Parents of children who were referred without sex assignment usually held a personal belief of their child's sex. Previous assignment was based on clinical examination and/or karyotype. Spreading knowledge about DSD could increase awareness of this issue, thus reducing parents' shock and societal stigma. Training of neonatal care teams is required to avoid assignment before evaluation.
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Sharma B, Sharma S. Bilateral cryptorchidism associated with micropenis – Case report with MRI appearance. INDIAN JOURNAL OF MEDICAL SPECIALITIES 2015. [DOI: 10.1016/j.injms.2014.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Magnetic resonance imaging for detection of non palpable undescended testes: Diagnostic accuracy of diffusion-weighted MRI in comparison with laparoscopic findings. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2015. [DOI: 10.1016/j.ejrnm.2014.10.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Usefulness and role of magnetic resonance imaging in a case of complete androgen insensitivity syndrome. Radiol Case Rep 2015; 10:1119. [PMID: 27398128 PMCID: PMC4921180 DOI: 10.2484/rcr.v10i2.1119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Complete androgen insensitivity syndrome (CAIS) is an X-linked, recessive disorder caused by mutations of the androgen receptor (AR), in which genetic males (46,XY) show female external genitalia. Individuals with CAIS have mostly normal external genitalia, lack of Müllerian structures (Fallopian tubes, uterus, proximal portion of the vagina) and undescended testes (intra-abdominal, inguinal, or labial). Management and diagnosis of CAIS should be undertaken by a multidisciplinary team of experts in sexual development disorders. Gonadectomy represents a standard therapeutic choice to prevent testicular malignancy in the prepubertal period, with subsequent hormonal replacement therapy, or in late adolescence, after completion of pubertal development. Imaging examinations play a pivotal role in the diagnosis, assessment, and detection of the gonads before surgical treatments. Magnetic resonance imaging (MRI) is the gold standard to diagnose and locate the gonads, and to plan laparoscopic gonadectomy and gonadic surveillance, in particular in the increasingly large number of patients who decide to delay or ultimately not to undergo gonadectomy. We present a case of a 14-year-old female with primary amenorrhea.
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Kolon TF, Herndon CDA, Baker LA, Baskin LS, Baxter CG, Cheng EY, Diaz M, Lee PA, Seashore CJ, Tasian GE, Barthold JS. Evaluation and treatment of cryptorchidism: AUA guideline. J Urol 2014; 192:337-45. [PMID: 24857650 DOI: 10.1016/j.juro.2014.05.005] [Citation(s) in RCA: 263] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Cryptorchidism is one of the most common pediatric disorders of the male endocrine glands and the most common genital disorder identified at birth. This guideline is intended to provide physicians and non-physician providers (primary care and specialists) with a consensus of principles and treatment plans for the management of cryptorchidism (typically isolated non-syndromic). MATERIALS AND METHODS A systematic review and meta-analysis of the published literature was conducted using controlled vocabulary supplemented with key words relating to the relevant concepts of cryptorchidism. The search strategy was developed and executed by reference librarians and methodologists to create an evidence report limited to English-language, published peer-reviewed literature. This review yielded 704 articles published from 1980 through 2013 that were used to form a majority of the guideline statements. Clinical Principles and Expert Opinions were used for guideline statements lacking sufficient evidence-based data. RESULTS Guideline statements were created to inform clinicians on the proper methods of history-taking, physical exam, and evaluation of the boy with cryptorchidism, as well as the various hormonal and surgical treatment options. CONCLUSIONS Imaging for cryptorchidism is not recommended prior to referral, which should occur by 6 months of age. Orchidopexy (orchiopexy is the preferred term) is the most successful therapy to relocate the testis into the scrotum, while hormonal therapy is not recommended. Successful scrotal repositioning of the testis may reduce but does not prevent the potential long-term issues of infertility and testis cancer. Appropriate counseling and follow-up of the patient is essential.
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Affiliation(s)
- Thomas F Kolon
- American Urological Assocation Education and Research, Inc., Linthicum, Maryland
| | - C D Anthony Herndon
- American Urological Assocation Education and Research, Inc., Linthicum, Maryland
| | - Linda A Baker
- American Urological Assocation Education and Research, Inc., Linthicum, Maryland
| | - Laurence S Baskin
- American Urological Assocation Education and Research, Inc., Linthicum, Maryland
| | - Cheryl G Baxter
- American Urological Assocation Education and Research, Inc., Linthicum, Maryland
| | - Earl Y Cheng
- American Urological Assocation Education and Research, Inc., Linthicum, Maryland
| | - Mireya Diaz
- American Urological Assocation Education and Research, Inc., Linthicum, Maryland
| | - Peter A Lee
- American Urological Assocation Education and Research, Inc., Linthicum, Maryland
| | - Carl J Seashore
- American Urological Assocation Education and Research, Inc., Linthicum, Maryland
| | - Gregory E Tasian
- American Urological Assocation Education and Research, Inc., Linthicum, Maryland
| | - Julia S Barthold
- American Urological Assocation Education and Research, Inc., Linthicum, Maryland
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Role of laparoscopy and ultrasound in the management of "impalpable testis" in children. Asian J Surg 2014; 37:200-4. [PMID: 24661449 DOI: 10.1016/j.asjsur.2014.01.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 01/14/2014] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Undescended testes is one of the most common congenital abnormalities in boys. In cases of impalpable testes, ultrasound is often used to find the testis, which frequently provides false-negative results. Recently, laparoscopy has become popular in the management of impalpable testes. METHODS Retrospective study of all children with impalpable testes presenting for laparoscopy between August 2007 and July 2011 who had undergone ultrasound examinations without localizing the testes was conducted and the role of laparoscopy in diagnosing impalpable testes was evaluated. RESULTS Twenty-three patients presented with impalpable testes for laparoscopy. All patients underwent ultrasound examinations in which the testes could not be identified. Of the 23 patients, Five patients were found to have palpable testes in the superficial inguinal pouch under anesthesia and proceeded to conventional open exploration during which the testes were brought into the scrotum. Eighteen patients were found to have impalpable testes in an evaluation under anesthesia (EUA) and proceeded to laparoscopy. Twelve patients were found to have intra-abdominal testes and underwent laparoscopic-assisted orchidopexy. Three patients underwent a two-stage Fowler-Stephens procedure, and two patients with "vanishing" testes with the vas and atrophic vessels entering a closed internal ring proceeded to open exploration and orchidectomy for atrophic testes. In addition, a teenager with atrophic testes underwent laparoscopic orchidectomy. CONCLUSIONS Laparoscopy is superior to ultrasound in the management of impalpable testes when high-resolution ultrasound is not available during the diagnostic process, with respect to both the sensitivity of localizing the testis and being more time and cost effective.
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Alagaratnam S, Nathaniel C, Cuckow P, Duffy P, Mushtaq I, Cherian A, Desai D, Kiely E, Pierro A, Drake D, De Coppi P, Cross K, Curry J, Smeulders N. Testicular outcome following laparoscopic second stage Fowler-Stephens orchidopexy. J Pediatr Urol 2014; 10:186-92. [PMID: 24045121 DOI: 10.1016/j.jpurol.2013.08.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 08/01/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess outcome after laparoscopic second-stage Fowler-Stephens orchidopexy (L2(nd)FSO). PATIENTS AND METHODS Retrospective review of 94 children (aged 0.75-16 years, median 2.75 years), who underwent L2(nd)FSO for 113 intra-abdominal testes between January 2000 and May 2009: 75 unilateral, 19 bilateral (11 synchronous; 8 metachronous). Follow-up (range 3 months-10.9 years, median 2.1 years) was available for 88 children (102 testes: 71 unilateral, 31 bilateral). RESULTS Testicular atrophy occurred in 9 out of 102 (8.8%), including 8 out of 71 (11.3%) unilateral and 1 out of 31 (3.2%) bilateral intra-abdominal testes (multivariate analysis: p = 0.59). Testicular ascent ensued in 9 out of 102 (8.8%), comprising four (5.6%) unilateral and five (16.1%) bilateral testicles (multivariate analysis: p = 0.11). Of the 18 bilateral testes brought to the scrotum synchronously none atrophied and four (22.2%) ascended, compared to one (7.7%) atrophy and one (7.7%) ascent among the 13 testes brought to the scrotum on separate occasions (Fisher exact test: p = 0.42 and p = 0.37, respectively). Mobilization of the testis through the conjoint tendon tended towards less ascent (multivariate analysis p = 0.08) but similar atrophy (p = 0.56) compared to mobilization through the deep-ring/inguinal canal. Logistical regression analysis identified no other patient or surgical factors influencing outcome. CONCLUSIONS This is the largest series of L2(nd)FSO to date. A successful outcome is recorded in 85 out of 102 (83.3%) testicles. Atrophy occurred in 8.8% and ascent in 8.8%.
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Affiliation(s)
- Swethan Alagaratnam
- Department of Paediatric Urology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond Street, London, UK.
| | - Calvin Nathaniel
- Department of Paediatric Urology, University College London Hospitals NHS Foundation Trust, Euston Road, London, UK.
| | - Peter Cuckow
- Department of Paediatric Urology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond Street, London, UK; Department of Paediatric Urology, University College London Hospitals NHS Foundation Trust, Euston Road, London, UK.
| | - Patrick Duffy
- Department of Paediatric Urology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond Street, London, UK.
| | - Imran Mushtaq
- Department of Paediatric Urology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond Street, London, UK.
| | - Abraham Cherian
- Department of Paediatric Urology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond Street, London, UK; Department of Paediatric Urology, University College London Hospitals NHS Foundation Trust, Euston Road, London, UK.
| | - Divyesh Desai
- Department of Paediatric Urology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond Street, London, UK; Department of Paediatric Urology, University College London Hospitals NHS Foundation Trust, Euston Road, London, UK.
| | - Edward Kiely
- Department of Paediatric Surgery, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond Street, London, UK.
| | - Agostino Pierro
- Department of Paediatric Surgery, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond Street, London, UK.
| | - David Drake
- Department of Paediatric Surgery, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond Street, London, UK.
| | - Paolo De Coppi
- Department of Paediatric Surgery, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond Street, London, UK.
| | - Kate Cross
- Department of Paediatric Surgery, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond Street, London, UK.
| | - Joe Curry
- Department of Paediatric Surgery, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond Street, London, UK.
| | - Naima Smeulders
- Department of Paediatric Urology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond Street, London, UK; Department of Paediatric Urology, University College London Hospitals NHS Foundation Trust, Euston Road, London, UK.
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Vieira JFL, Brahme G, Pandya N, Desai A. Empty scrotum: undescended testis or ectopic? BMJ Case Rep 2013; 2013:bcr-2013-009152. [PMID: 23929605 DOI: 10.1136/bcr-2013-009152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This case of ectopic testis highlights the importance of a thorough first newborn examination followed by senior review when appropriate, and the expertise required to interpret neonatal ultrasounds. Following a provisional diagnosis of unilateral undescended testicle in a newborn, an ultrasound scan was unable to correctly identify the condition, resulting in a delay in diagnosis. The condition was later recognised incidentally, which led to a successful surgical correction. The early clinical examination and recognition of ectopic testis allows a timely surgical intervention preventing potential complications.
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Abstract
BACKGROUND AND OBJECTIVES Disorders of sex development (DSDs), formerly termed ambiguous genitalia, are a group of conditions where the external genitalia appear abnormal. It represents a true medical and social emergency that needs a multidisciplinary team approach for elucidation. The pediatric radiologist plays an important role in defining the genital anatomy that remains one of the most important factors in sex determination, in addition to chromosomal analysis. DESIGN AND SETTINGS A retrospective study, conducted between January 1995 and December 2010. MATERIALS AND METHODS Imaging studies (ultrasound, genitogram, and/or magnetic resonance imaging) were performed in patients with ambiguous genitalia, confirmed by chromosomal analysis and appropriate hormonal investigations. RESULTS The sensitivity of ultrasound is 89.5%, while its specificity reaches 100%. Retrograde genitogram is more invasive and less sensitive, as the yield of determining the presence of a uterus +/- vagina is 84.2%. However, magnetic resonance imaging (MRI) is more sensitive for gonadal tissue identification. Its specificity reaches up to 100% and can provide detailed internal structures (uterus, fallopian tubes, and gonads). CONCLUSION Ultrasound examination is still the main modality of choice for screening patients with ambiguous genitalia. It is cheap and readily available everywhere. In addition to elucidating the uterus in 89.5%, it can also give more information on the adrenal glands. However, genitography is good--84.2% in elucidating genital anatomy--but it gives no information of the gonads and it is time consuming and invasive. MRI is helpful in cases with equivocal ultrasound, reaches 100% in elucidating internal extractor, and therefore could be reserved for that.
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Affiliation(s)
- Nasir AlJurayyan
- From the Pediatrics, King Khalid University Hospital, Riyadh, Saudi Arabia
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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.
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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
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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.
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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
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Nezzo M, De Visschere P, T'Sjoen G, Weyers S, Villeirs G. Role of imaging in the diagnosis and management of complete androgen insensitivity syndrome in adults. Case Rep Radiol 2013; 2013:158484. [PMID: 23762728 PMCID: PMC3677018 DOI: 10.1155/2013/158484] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 05/01/2013] [Indexed: 01/22/2023] Open
Abstract
Complete androgen insensitivity syndrome is an X-linked recessive androgen receptor disorder characterized by a female phenotype with an XY karyotype. Individuals affected by this syndrome have normal female external genitalia but agenesis of the Müllerian duct derivatives, that is, absence of the Fallopian tubes, uterus, cervix, and the proximal part of the vagina, with presence of endoabdominal, labial, or inguinal testes. The estimated prevalence is between 1 and 5 in 100,000 genetic males. Complete androgen insensitivity syndrome can be diagnosed as a result of mismatch between the prenatal sex prediction and the phenotype at birth, can be detected by chance, or remain undetected until investigations for primary amenorrhea. Imaging can be important both to diagnose the pathology and to localize gonads prior to surgical treatment. In this paper, we present three cases of complete androgen insensitivity syndrome in adult women of 34, 22, and 38 years old.
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Affiliation(s)
- Marco Nezzo
- Department of Radiology, University of Rome Tor Vergata, 00133 Rome, Italy
| | | | - Guy T'Sjoen
- Department of Endocrinology, Ghent University Hospital, 9000 Ghent, Belgium
| | - Steven Weyers
- Department of Gynaecology, Ghent University Hospital, 9000 Ghent, Belgium
| | - Geert Villeirs
- Department of Radiology, Ghent University Hospital, 9000 Ghent, Belgium
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Moshiri M, Chapman T, Fechner PY, Dubinsky TJ, Shnorhavorian M, Osman S, Bhargava P, Katz DS. Evaluation and management of disorders of sex development: multidisciplinary approach to a complex diagnosis. Radiographics 2013; 32:1599-618. [PMID: 23065160 DOI: 10.1148/rg.326125507] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Various disorders of sex development (DSD) result in abnormal development of genitalia, which may be recognized at prenatal ultrasonography, immediately after birth, or later in life. Current methods for diagnosing DSD include a thorough physical examination, laboratory tests to determine hormone levels and identify chromosomal abnormalities, and radiologic imaging of the genitourinary tract and adjacent organs. Because of the complex nature of DSD, the participation of a multidisciplinary team is required to address the patient's medical needs as well as any psychosocial issues that the patient or the family may encounter after the diagnosis. The first step in the management of DSD is sex assignment, which is based on factors such as the genotype; the presence, location, and appearance of reproductive organs; the potential for fertility; and the cultural background and beliefs of the patient's family. The primary goal of sex assignment is to achieve the greatest possible consistency between the patient's assigned sex and his or her gender identity. Once the sex is assigned, the next step in management might be surgery, hormone therapy, or no intervention at all. Patients with ovotesticular DSD and gonadal dysgenesis may require a gonadectomy, followed by reconstructive surgery. Some patients may need hormone replacement therapy during puberty. An understanding of the immediacy of families' need for sex assignment and clinicians' need for reliable diagnostic imaging results will help radiologists participate effectively in the prenatal and postnatal assessment of patients with DSD.
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Affiliation(s)
- Mariam Moshiri
- Department of Radiology, University of Washington School of Medicine, Box 357115, 1959 NE Pacific St, Seattle, WA 98195, USA.
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Kurkcuoglu A, Otgun I, Pelin C, Zagyapan R, Agah Tekindal M. Undescended testis: its anatomical localization and aetiological factors. INTERNATIONAL JOURNAL OF UROLOGICAL NURSING 2013. [DOI: 10.1111/j.1749-771x.2012.01163.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Mansour S, Hamed S, Adel L, Kamal R, Ahmed D. Does MRI add to ultrasound in the assessment of disorders of sex development? Eur J Radiol 2012; 81:2403-10. [DOI: 10.1016/j.ejrad.2011.12.036] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2011] [Revised: 07/06/2011] [Accepted: 12/14/2011] [Indexed: 11/16/2022]
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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.
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Affiliation(s)
- Manas Ranjan Pradhan
- Department of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India
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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.
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Affiliation(s)
| | - Hillary L. Copp
- Department of Urology, University of California, San Francisco
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Tasian GE, Yiee JH, Copp HL. Imaging use and cryptorchidism: determinants of practice patterns. J Urol 2011; 185:1882-7. [PMID: 21421239 DOI: 10.1016/j.juro.2010.12.065] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Indexed: 11/20/2022]
Abstract
PURPOSE We determined the rate of diagnostic imaging use for the preoperative evaluation of boys with cryptorchidism and the factors that influence referring providers to obtain imaging. MATERIALS AND METHODS We conducted a national cross-sectional survey of pediatricians randomly sampled from the American Medical Association Physician Masterfile. The primary outcome was whether the respondent obtained imaging at the initial evaluation of boys with cryptorchidism. Participants were queried regarding practice location and type, length of time in practice, frequency of reading academic journals and the accessibility of surgical subspecialists. For those who ordered imaging, respondents were asked how frequently they ordered imaging, and were asked to select patient factors and professional beliefs that influenced their decision to obtain imaging. Factors associated with imaging use were identified using multivariate logistic regression. RESULTS Of the pediatricians who acknowledged contact by surveyors 47% completed the survey and 34% of respondents reported always or usually ordering imaging. Of those who obtained imaging 96.4% used ultrasound. Pediatricians in practice fewer than 20 years (OR 3.43, 95% CI 1.92-6.16) and those in nonacademic practices (OR 3.00, 95% CI 1.34-6.71) were more likely to order imaging. Pediatricians obtained imaging because of beliefs that imaging reliably identifies a nonpalpable testis, reassures the family and assists the surgeon with operative planning. CONCLUSIONS Ultrasound is heavily used by pediatricians for the preoperative evaluation of cryptorchidism, especially when the testis is nonpalpable. Given the poor diagnostic performance of ultrasound in this setting, we recommend developing strategies to reduce imaging use in cryptorchidism.
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Affiliation(s)
- Gregory E Tasian
- Department of Urology, University of California, San Francisco 94143-0738, USA
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Penna FJ, Nguyen HT, Passerotti CC, Sandy NS, Nelson CP, Diamond DA. The concordance of testicular anatomic location in bilateral cryptorchidism. J Pediatr Urol 2011; 7:52-6. [PMID: 20392672 DOI: 10.1016/j.jpurol.2010.02.204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2009] [Accepted: 02/12/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To determine the frequency of concordance of testicular anatomical location between both undescended testes based on surgical findings. BACKGROUND Cryptorchidism occurs in approximately 1% of boys over one year of age, and in 10-20% of these cases, the condition is bilateral. We report a series of 168 patients with a preoperative diagnosis of bilateral undescended testes who underwent surgical exploration and in whom two testes were surgically identified. METHODS The testicular location of both testes was stratified according to six anatomic regions. For each patient the anatomic site of each testis, both palpable and impalpable, and the surgical procedure required for orchidopexy were recorded. RESULTS The mean age was 59.3 months (2.5 months-21 years). In 90% of the cases the surgical technique was identical for both sides. Approximately two thirds of the patients were found to have both testes in concordant anatomical locations and in 88% the location of one testis was predictive within one anatomic "step" of the location of the contralateral gonad. CONCLUSION These findings may have significant implications for counseling families and anticipating the necessary surgical approach required when only one undescended testis has been localized preoperatively.
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Affiliation(s)
- Frank J Penna
- Department of Urology, Children's Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
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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.
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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
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Diagnostic performance of diffusion-weighted MRI in the detection of nonpalpable undescended testes: comparison with conventional MRI and surgical findings. AJR Am J Roentgenol 2010; 195:W268-73. [PMID: 20858788 DOI: 10.2214/ajr.10.4221] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of this feasibility study was to evaluate the role of diffusion-weighted MRI in the evaluation of nonpalpable undescended testes. MATERIALS AND METHODS Thirty-six boys with undescended testes underwent preoperative abdominal and pelvic MRI to identify the location of the testes. MRI included free-breathing diffusion-weighted imaging (DWI) with b values of 50, 400, and 800 s/mm(2), a T1-weighted turbo spin-echo sequence, and a T2-weighted fat-suppressed turbo spin-echo sequence. After laparoscopic examinations, two observers independently reviewed the preoperative images. The DW images alone were reviewed first, followed by the conventional MR images alone and the conventional MR and the DW images together. The laparoscopic and MRI findings were compared. Sensitivity, specificity, and accuracy in the identification of nonpalpable undescended testes were calculated for DWI, conventional MRI, and the combination of DWI and conventional MRI. RESULTS The combination of DWI and conventional MRI was the most sensitive and most accurate technique. Observer 1 found 31 undescended testes, and observer 2, 30 testes with this technique. Sensitivity was 0.91 and 0.88 for observers 1 and 2, and accuracy was 0.92 and 0.86. With DWI alone, observer 1 located 30 testes, and observer 2, 28 testes (sensitivity, 0.88 and 0.82; accuracy, 0.86 and 0.81). Using conventional MRI alone, both observers located 29 testes (sensitivity, 0.85; accuracy, 0.86 and 0.84). The accuracy of locating testes was superior with the combination of DWI and conventional MRI for both observers (accuracy, 0.92 and 0.86). An intraabdominal atrophic testis managed by laparoscopic orchiectomy was found by neither observer with DWI or with conventional MRI. CONCLUSION Use of DWI with a high b value yields information that complements conventional MRI findings, improving identification and location of nonpalpable undescended testes. We recommend the use of conventional MRI in addition to DWI to increase the preoperative sensitivity and accuracy of identifying and locating nonpalpable testes.
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Kato T, Kojima Y, Kamisawa H, Takeuchi M, Mizuno K, Sasaki S, Kohri K, Hayashi Y. Findings of fat-suppressed T2-weighted and diffusion-weighted magnetic resonance imaging in the diagnosis of non-palpable testes. BJU Int 2010; 107:290-4. [DOI: 10.1111/j.1464-410x.2010.09513.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Mirheydar H, Evason K, Coakley F, Baskin LS, DiSandro M. 46, XY female with cloacal exstrophy and masculinization at puberty. J Pediatr Urol 2009; 5:408-11. [PMID: 19592306 DOI: 10.1016/j.jpurol.2009.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Accepted: 03/20/2009] [Indexed: 10/20/2022]
Abstract
Cloacal exstrophy of the bladder is a rare complex disorder occurring 1 in 400,000 live births and associated with cryptorchidism, vesicoureteral reflux, severe phallic inadequacy, omphalocele with short-gut syndrome, exstrophied bladder separated by exstrophied ileocecal segment, and pubic symphyseal diastasis. The association of undescended and ectopic testis with cloacal exstrophy is not uncommon, but the presence of an unexpected persistent ectopic testis at the time of puberty is quite unusual. We report the case of a 17-year-old girl with a history of 46, XY cloacal exstrophy and gender reassignment presenting with an ectopic testis of unclear location. We then review controversial literature surrounding gender assignment in these patients.
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Affiliation(s)
- H Mirheydar
- Department of Urologic Surgery, University of Minnesota, Mayo Mail Code 394, Minneapolis, MN 55455, USA.
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Rose A, Sperling H, Steffens J, Lümmen G, Hauffa B, Rohrmann D, Conrad S, Hoyer P, Rübben H. [Multimodal therapy of cryptorchism]. Urologe A 2009; 45 Suppl 4:214-8. [PMID: 16927081 DOI: 10.1007/s00120-006-1185-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- A Rose
- Klinik und Poliklinik für Urologie, Universitätsklinikum, Hufelandstrasse 55, 45122 Essen.
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Mathers MJ, Sperling H, Rübben H, Roth S. The undescended testis: diagnosis, treatment and long-term consequences. DEUTSCHES ARZTEBLATT INTERNATIONAL 2009; 106:527-32. [PMID: 19738919 PMCID: PMC2737432 DOI: 10.3238/arztebl.2009.0527] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2008] [Accepted: 01/15/2009] [Indexed: 11/27/2022]
Abstract
BACKGROUND The late descent of a testicle into the scrotum may impair its development. Reduced fertility is the main risk of primary cryptorchidism even after timely treatment, as histopathological changes (Leydig cell hypoplasia) already become apparent in the first few months of life. There is evidence, however, that treatment is often delayed. Hormonal and surgical treatments complement each other and should be provided before the child's first birthday. METHODS Selective literature search in PubMed (January 2008) based on the following keywords: "cryptorchidism", "maldescensus testis", "etiology", "therapy", "semen quality", "testicular cancer". Particular attention was paid to the current S2 guidelines on cryptorchidism. RESULTS/DISCUSSION Hormone therapy is the best initial treatment in most cases, with a few exceptions. If this is unsuccessful, surgery should be performed without delay. The success of treatment depends on the initial position of the testicle. Treatment does not lessen the risk of malignancy. Parents must be informed about this risk. The undescended testicle is the most common genital malformation in boys. When diagnosed, it should be treated hormonally and/or surgically before the child's first birthday to minimize the risk of impaired fertility. Successful treatment before age 13 appears not to lessen the risk of testicular cancer, but it does facilitate early detection by enabling physical examination of the testicle.
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Affiliation(s)
- Michael J Mathers
- Urologische Gemeinschaftspraxis Remscheid, Kooperationspraxis der Klinik für Urologie und Kinderurologie, Klinikum Wuppertal, Universität Witten/Herdecke.
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Magnetic Resonance Arteriography/Venography is Not Accurate to Structure Management of the Impalpable Testis. J Urol 2008; 180:1805-8; discussion 1808-9. [DOI: 10.1016/j.juro.2008.04.075] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2007] [Indexed: 11/19/2022]
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Elwagdy S, Razmy S, Ghoneim S, Elhakim S. Diagnostic performance of three-dimensional ultrasound extended imaging at scrotal mass lesions. Int J Urol 2008; 14:1025-33. [PMID: 17956531 DOI: 10.1111/j.1442-2042.2007.01881.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES High resolution two-dimensional ultrasound (2D US) difficulty in evaluation of some scrotal mass lesions is not frequent. The aim of the present study was to prospectively evaluate the diagnostic performance of three-dimensional ultrasound extended imaging (3D XI) in characterization of those lesions. METHODS The study protocol had the approval of the University's review board all participants' informed consents were obtained. The study included 28 selected patients (12 testicular and 16 para-testicular mass lesions) examined by 2D US and 3D XI applications including computed multi-slice view (MSV) and multi-resolution enhanced images (XI MR). Results were correlated with histopathological findings. RESULTS Two-dimensional ultrasound did not adequately characterize 28 patients out of 329 (8.5%). 3D XI interrogation was an easy procedure and distinctive of the pathological findings in 27 patients out of 28 (96.4%). The performance of XI MR with respect to characterization provided additional diagnostic information over MSV. CONCLUSIONS The performance of 3D XI with respect to testicular mass characterization proved better than static 2D US. Subsequently, the results of this study suggest that the routine use of 2D US in diagnosis of scrotal mass lesions should preferably be upgraded to 3D XI methods.
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Affiliation(s)
- Salah Elwagdy
- Department of Radiology, Azhar University Hospital, 133 Shubra Street, Shubra, Cairo, Egypt.
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Firat AK, Uğraş M, Karakaş HM, Erdem G, Kurus M, Ugras M, Celik T, Kahraman B, Doğanay S. 1H magnetic resonance spectroscopy of the normal testis: preliminary findings. Magn Reson Imaging 2008; 26:215-20. [DOI: 10.1016/j.mri.2007.06.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2007] [Revised: 06/21/2007] [Accepted: 06/22/2007] [Indexed: 10/22/2022]
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