Evaluation of testicular stiffness in boys with unilateral cryptorchidism after orchiopexy by ultrasound strain elastography

PURPOSE

We assessed the stiffness of unilateral undescended testes after orchiopexy, examining its value in tracking histopathological changes and fertility potential during postoperative follow-up. Additionally, we explored the optimal timing for surgery based on testicular stiffness.

PATIENTS AND METHODS

Thirty-six boys who had been diagnosed with unilateral undescended testis and treated with orchiopexy were included in the study. Testicular stiffness was evaluated several times over respective follow-up periods by ultrasound strain elastography after orchiopexy. The strain ratios were measured as the ratios of the elasticities of the descended testis to those of the operated testes. The patients were divided into two groups based on the age at which they underwent orchiopexy:under < 2 years (Group A) and ≥ 2 years (Group B).

RESULTS

The mean strain ratios were 0.90 ± 0.32 and 0.92 ± 0.20 in Groups A and B, respectively. In Group A, the strain ratio was constant regardless of postoperative months (r = 0.01, p = 0.99); however, in Group B, it tended to increase with postoperative months (r = 0.42, p = 0.07).

CONCLUSIONS

Evaluation of testicular stiffness may be useful for the estimation of histopathological changes and fertility potential in boys with unilateral undescended testes at follow-up appointments after orchiopexy. Our data indicate that performing orchiopexy as early as possible may be recommended to avoid testicular damage.

Cryptorchidism and puberty

Cryptorchidism is the condition in which one or both testes have not descended adequately into the scrotum. The congenital form of cryptorchidism is one of the most prevalent urogenital anomalies in male newborns. In the acquired form of cryptorchidism, the testis that was previously descended normally is no longer located in the scrotum. Cryptorchidism is associated with an increased risk of infertility and testicular germ cell tumors. However, data on pubertal progression are less well-established because of the limited number of studies. Here, we aim to review the currently available data on pubertal development in boys with a history of non-syndromic cryptorchidism-both congenital and acquired cryptorchidism. The review is focused on the timing of puberty, physical changes, testicular growth, and endocrine development during puberty. The available evidence demonstrated that the timing of the onset of puberty in boys with a history of congenital cryptorchidism does not differ from that of non-cryptorchid boys. Hypothalamic-pituitary-gonadal hormone measurements showed an impaired function or fewer Sertoli cells and/or germ cells among boys with a history of cryptorchidism, particularly with a history of bilateral cryptorchidism treated with orchiopexy. Leydig cell function is generally not affected in boys with a history of cryptorchidism. Data on pubertal development among boys with acquired cryptorchidism are lacking; therefore, more research is needed to investigate pubertal progression among such boys.

Risk factors on testicular function in adolescents

PURPOSE

Adolescence represents an important window for gonadal development. The aim of this review is to carry out a critical excursus of the most recent literature on endogenous and exogenous risk factors related to testicular function, focusing the research on adolescence period.

METHODS

A comprehensive literature search within PubMed was performed to provide a summary of currently available evidence regarding the impact on adolescence of varicocele, cryptorchidism, cancer, diabetes, lifestyle factors, endocrine disruptors, obesity and sexually transmitted diseases. We focused on human studies that evaluated a possible impact of these factors on puberty timing and their effects on andrological health.

RESULTS

Evidence collected seems to suggest that andrological health in adolescence may be impaired by several factors, as varicocele, cryptorchidism, and childhood cancer. Despite an early diagnosis and treatment, many adolescents might still have symptoms and sign of a testicular dysfunction in their adult life and at the current time it is not possible to predict which of them will experience andrological problems. Lifestyle factors might have a role in these discrepancies. Most studies point out towards a correlation between obesity, insulin resistance, alcohol, smoking, use of illegal drugs and testicular function in pubertal boys. Also, endocrine disruptors and sexually transmitted diseases might contribute to impair reproductive health, but more studies in adolescents are needed.

CONCLUSION

According to currently available evidence, there is an emerging global adverse trend of high-risk and unhealthy behaviors in male adolescents. A significant proportion of young men with unsuspected and undiagnosed andrological disorders engage in behaviors that could impair testicular development and function, with an increased risk for later male infertility and/or hypogonadism during the adult life. Therefore, adolescence should be considered a key time for intervention and prevention of later andrological diseases.

Dihydrotestosterone through blockade of TGF-β/Smad signaling mediates the anti-fibrosis effect under hypoxia in canine Sertoli cells

The hypoxic microenvironment of cryptorchidism is an important factor to induce the impairment of the structure and function of Sertoli cells and thus lead to spermatogenesis loss or tumorigenesis. Dihydrotestosterone (DHT), as a potent nonaromatizable 5α-reduced androgen, has both positive and negative effect on pathological fibrosis process. However, it is still unknown whether DHT can regulate hypoxia-induced fibrosis of Sertoli cells. Herein, in this study, we evaluate the DHT level, two 5α-reductase isoforms, 5α-red1 and 5α-red2, as well as HIF-1α expression pattern in canine cryptorchidism and contralateral normal testis. Results showed that the abdominal testes presented low DHT levels and 5α-red1 and 5α-red2 expression, while significantly higher HIF-1α expression and ECM production compared with the scrotum. Moreover, we established a hypoxia-induced fibrosis model in canine Sertoli cells induced by cobalt chloride (CoCl₂), and found that DHT inhibited the fibrosis of Sertoli cells in a dose-dependent manner. Meanwhile, DHT interfered with the TGF-β signaling by reducing the expression of TGF-βRI and TGF-βRII and inhibiting the expression and phosphorylation of Smad2 and Smad3, while flutamide (androgen receptor inhibitor) inhibited these effects of DHT. Furthermore, use of LY2109761 (TGF-β receptor type I/II inhibitor) to interfere with the TGF-β/Smad pathway showed a similar effect with DHT suppression of the fibrosis in Sertoli cells. Our research data demonstrated that cryptorchidism is located in a hypoxic and DHT deficiency microenvironment. Moreover, supplementing DHT can alleviate the fibrosis process of Sertoli cells caused by hypoxia, which is associated with AR regulating the inhibition of TGF-β/Smad signaling.

Effects of vancomycin linoleic acid nanoparticles on male reproductive indices of Sprague-Dawley rats

The management of bacterial infections, especially trains of methicillin-resistant Staphylococcus aureus observe in health care settings, has markedly improved with the introduction of established drugs but using newer nano-based formulations. This study investigates the effects of vancomycin-linoleic acid nanoparticles on testicular tissue in an experimental animal model. Twenty-five adult male Sprague-Dawley rats maintained at the Animal House of the Biomedical Resources Unit were assigned to five groups namely E - solid lipid nanoparticles; F - vancomycin solid lipid nanoparticle; G - linoleic acid nanoparticle; H - vancomycin linoleic acid; and A - control. Perturbations in seminal fluid parameters showed a reduced sperm count in groups F & G which was statistically significant (p < .05) but motility and morphology were not significant when compared to controls (A). Reduced testosterone levels were found in groups E, F and H but were not statistically significant (p > .05). There was also increased luteinizing hormone (LH) and decreased in follicular stimulating hormone (FSH) levels was statistically significant (p < .05). Hypoplasia, tubular atrophy and shrinkage were observed in histologic sections of the treated groups with basement membrane thickening. Vancomycin solid lipid nanoparticle and its constituents SLN and LA disrupted testicular morphometry and the hormonal milieu sufficient to potentially induce altered reproductive function.

Fertility of Cryptorchid Testis-An Unsolved Mistery

Cryptorchidism (undescended testis) is one of the most common diagnoses in the pediatric urologist office. Even in the modern era, there still are a lot of debates regarding the optimal time for surgery related to the expected results in relation with the testicular function, including fertility. The review below intends to clarify issues regarding the impact of cryptorchidism on testicular histology and function, semen analysis, the relation between hormonal and surgical treatment, future fertility, and paternity rate.

Heat stress response of somatic cells in the testis

The testis is a temperature-sensitive organ that needs to be maintained 2-7 °C below core body temperature to ensure the production of normal sperm. Failure to maintain testicular temperature in mammals impairs spermatogenesis and leads to low sperm counts, poor sperm motility and abnormal sperm morphology in the ejaculate. This review discusses the recent knowledge on the response of testicular somatic cells to heat stress and, specifically, regarding the relevant contributions of heat, germ cell depletion and inflammatory reactions on the functions of Sertoli and Leydig cells. It also outlines mechanisms of testicular thermoregulation, as well as the thermogenic factors that impact testicular function.

The potential protective and therapeutic effects of platelet-rich plasma on ischemia/reperfusion injury following experimental torsion/detorsion of testis in the Albino rat model

AIMS

This study was designed to evaluate the protective and therapeutic efficacy of platelet-rich plasma (PRP) against testicular degeneration and germ cell apoptosis after induced spermatic cord torsion/detorsion (TD) in rats.

MATERIALS

Forty rats were allocated into 5 groups: 1) control, 2) short torsion/detorsion (STD), 3) long torsion detorsion (LTD), 4) protective (PRP/P) and 5) treatment (PRP/T). Testicular ischemia was induced by twisting the right testis 1080° clockwise for 2.5 h. PRP (10 μl) was injected intra-testicular 5 min before (PRP/P) and 3 h after (PRP/T) detorsion. At the end of the experiment, rats were euthanized at 2, 30, 2, and 30 days for groups 2-5 respectively. Nitric oxide, malondialdehyde, catalase, total antioxidant capacity, reduced glutathione, glutathione-S-transferase, interleukin1 beta, tumor necrosis factor, caspase-3, and B-cell lymphoma 2 expressions were assessed in the testes. Moreover, histological examination was performed.

KEY FINDINGS

PRP treatment significantly mitigated the torsion-detorsion induced testicular degeneration. Particularly, by improving the state of oxidative stress (NO, P = 0.0001) and antioxidant markers (TAC, GSH, GST, P = 0.0001-0.01) and decreasing the expression of IL-1β, TNF-α and cas 3 and increase the BCL2 fold changes (P = 0.0001). The protective use of PRP is superior to the therapeutic use of PRP in the restoration of the testicular histoarchitecture following TD.

SIGNIFICANCE

This study illustrates the cyto-protective role of PRP against TD induced testicular cell injury that highlight possible application of PRP as a complementary therapy in different testicular degenerative diseases which might attribute to its ability to ameliorate the oxidative stress and inhibit induced apoptosis.

Plasma level of laminin 5 and collagen IV in cryptorchidism

PURPOSE

Laminin 5 and collagen IV are the main compounds of the extracellular matrix of the germinal epithelium. The purpose of this study was to evaluate the concentration of these two markers of fibrosis in the plasma of boys with congenital unilateral cryptorchidism.

MATERIALS AND METHODS

The study group comprised 43 boys aged 1-3 years with congenital unilateral cryptorchidism. The control group included 54 healthy, age matched boys, admitted for planned hernioplasty. To assess laminin 5 and collagen IV in the plasma of boys with unilateral cryptorchidism, we used a new biosensor with Surface Plasmon Resonance Imaging technique detection.

RESULTS

The median concentration of laminin 5 and collagen IV in the serum of boys with congenital, unilateral cryptorchidism was higher than in boys with normal scrotal testis. The difference was statistically significant (p < 0.0001). We did not notice a correlation between a higher position of the testicles in the inguinal and/or their condition and levels of laminin 5 and collagen IV in the plasma.

CONCLUSION

Laminin 5 and collagen IV concentrations in the plasma were higher in patients with congenital unilateral cryptorchidism. We believe that in the future, our results could be compared with fertility level in adulthood.

Hypogonadism and Cryptorchidism

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

Evaluation of Pediatric Undescended Testes with Elastosonography

Background

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

Materials and methods

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

Results

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

Conclusion

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

Acquired cryptorchidism: More harm than thought?

INTRODUCTION

Acquired cryptorchidism (AC) has been recognized as a subgroup of undescended testes (UDT). There is growing evidence that the compromising effect equals that of congenital UDT (cUDT). This prospective study included an extensive histological examination of biopsies taken from AC patients.

PATIENTS AND METHODS

From August 2013 to December 2014, 21 boys (3-12 years of age) underwent testicular biopsy during orchiopexy for AC. Patient and family histories were taken. The amount of germ cells (GC) per tubule (T) and the amount of adult dark spermatogonia (Ad-S) per T were determined by resin semi-thin sections examination. The samples were also scanned for signs of malformation. Immunohistochemical stains were performed as markers for atypical germ cells.

RESULTS

Four (19%) boys were born prematurely, two (9.5%) were small for gestational age (SGA), and nine (43%) had a positive family history of UDT. The median of GC/T was 1.06 in boys <9 years, and 0.60 in boys ≥9 years. The median of Ad-S/T was 0.02 in boys <9 years and 0.01 in boys ≥9 years. There were no signs for malformation and no atypical cells. The immunohistochemical stains were negative in all specimens.

CONCLUSIONS

Prematurity, SGA, and a positive family history appeared to be predictors for AC. Extensive histopathological examination of AC revealed a significant reduction of germ cell count and fertility markers, comparable with that in cUDT. The alterations were more severe in boys aged ≥9 years. It is unclear as to whether or not this was possibly caused by a longer duration of inguinal position, but this finding suggests that routine checks of testicular position throughout childhood are needed, and that there is a cause for continued efforts in educating parents and primary care physicians regarding AC. Current data support the notion of surgical correction once the diagnosis is made.

Mast cells, estrogens, and cryptorchidism: A histological based review

If untreated, cryptorchidism leads to age dependent decreases in germ cell number (GCN) and testicular fibrosis. The pathophysiology of this process and its long-term effects on fertility are unclear. Mast cells are intricately involved in inflammation and fibrosis in a variety of organ systems. Their secretory products have mitogenic effects on fibroblasts and promote collagen deposition. Mast cell activation and migration are under the influence of estrogens and this interaction has been demonstrated in the testes in several animal models. Models of cryptorchidism have shown increased estrogen levels and expression of estrogen receptors in undescended testes compared to controls. Mast cell numbers have positively correlated with testicular fibrosis in human studies and decreased spermatogenesis as well. We found no human studies of mast cells in cryptorchid testes. However several animal models have investigated the effect of estrogens on mast cells and spermatogenesis in undescended testes. In this review we examine the possible links between estrogens, mast cells, and testicular fibrosis in cryptorchidism, focusing on histological studies.

What lessons can be learned from testicular histology in undescended testes?

Over the last 40-50 years studies involving thousands of testicular biopsies in boys with cryptorchidism have contributed to our knowledge of testicular histopathology and our understanding of the effects of cryptorchidism on the normal development of the germinal epithelium. Growth and maturation of germ cells and Leydig cells are crucial to allow boys to reach normal fertility potential. The following aberrations in testicular development are seen in cryptorchid testes: a decrease in total germ cell numbers, failure of fetal gonocytes (stem cells) to transform into adult dark (Ad) spermatogonia, failure for Ad spermatogonia to mature into primary spermatocytes, Leydig cell hypoplasia, and testicular fibrosis. All of these findings have been found to have a strong negative correlation with a boy’s age at the time of orchidopexy. Some of these findings have prognostic significance in regards to fertility potential especially when coupled with key clinical findings such as hormonal findings, age at orchidopexy, testicle size, laterality and location of cryptorchid testes. This review focuses on key lessons learned from testicular histology in cryptorchid testes.

Simian immunodeficiency virus infection and immune responses in the pig-tailed macaque testis

The testis is a site of immune privilege in rodents, and there is evidence that T cell responses are also suppressed in the primate testis. Local immunosuppression is a potential mechanism for HIV persistence in tissue reservoirs that few studies have examined. The response of the pig-tailed macaque testis to SIVmac239 infection was characterized to test this possibility. Testes were surgically removed during early-chronic (10 wk) and late-chronic (24-30 wk) SIV infection in 4 animals and compared with those from 7 uninfected animals. SIV infection caused only minor disruption to the seminiferous epithelium without marked evidence of inflammation or consistent changes in total intratesticular leukocyte numbers. Infection also led to an increase in the relative proportion of testicular effector memory CD8(+) T cell numbers and a corresponding reduction in central memory CD4(+) T cells. A decrease in the relative proportion of resident-type CD163(+) macrophages and DCs was also observed. SIV-specific CD8(+) T cells were detectable in the testis, 10-11 wk after infection by staining with SIV Gag-specific or Tat-specific MHC-I tetramers. However, testicular CD8(+) T cells from the infected animals had suppressed cytokine responses to mitogen activation. These results support the possibility that local immunosuppression in the testis may be restricting the ability of T cells to respond to SIV or HIV infection. Local immunosuppression in the testis may be an underexplored mechanism allowing HIV persistence.

The role of ketotifen in the prevention of testicular damage in rats with experimental unilateral undescended testes

The aims of this study conducted on rats were to determine mast cell (MC) proliferation on undescended testes (UDTs); whether there is a correlation between MC proliferation and testicular damage; and whether testicular damage can be prevented with administration of an MC blocker. Sixty-five newborn male rats were divided into three groups. During the neonatal period, unilateral UDTs were experimentally induced in Group 2 and Group 3. The rats in Group 3 were given 1 mg/kg/day ketotifen orally until the end of the study. Groups 2 (n=30) and 3 (n=15) were divided into groups of ten and five rats, respectively, each of which underwent bilateral orchiectomy in either the prepubertal, pubertal, or adult period. Group 1 (n=15) underwent a sham operation followed by bilateral orchiectomy, with five rats in each of the prepubertal, pubertal, and adult periods. Testicular MCs in the interstitial and subtubular areas, biopsy scores, interstitial connective tissue, seminiferous tubule (ST) diameters, and the basement membrane thickness of STs were evaluated. In Group 2 the ST diameters in the UDTs decreased, the number of MCs in the interstitial and subtubular areas increased, ST basement membranes thickened, and spermatogenesis decreased. The number of MCs in the interstitial and subtubular areas of the descended testes increased and spermatogenesis decreased. In Group 3, the number of MCs in the interstitial and subtubular areas decreased. In unilateral UDTs, the number of MCs in the interstitial and subtubular areas increased in both testes. Fibrosis developed in the ST basement membranes and interstitial areas, and spermatogenesis deteriorated. Testicular fibrosis may be prevented with administration of an MC blocker.

Mast cell numbers negatively correlate with fibrosis in cryptorchid testes

PURPOSE

Mast cells have been found to play a role in fibrotic processes in multiple organ systems and are increased in number in the testes of infertile men. We have reviewed the literature and to date have found no studies investigating the role of mast cells in fibrosis of undescended testis. We examined the expression of mast cells in human cryptorchid testes and compared mast cell expression with testicular fibrosis in these testes.

METHODS

Testicular biopsies from cryptorchid testis were collected over 2 years. Biopsies from 78 patients were retrospectively sectioned, stained, and reviewed for the amount of fibrosis (graded 0-3) as well as mast cell number (MCN). MCNs were quantified by tryptase staining, and the average MCN per high-powered field (HPF) was determined. Statistical analysis was performed using a one-way ANOVA with a Kruskal-Wallis test and post hoc analysis with the Dunn test when significant.

RESULTS

Larger MCNs were significantly associated with lower fibrotic indices at the time of orchidopexy. The average MCNs were 2.06, 0.86, 0.37, and 0.58 for fibrotic indices of 0, 1, 2, and 3, respectively. MCNs were significantly higher in biopsies with a fibrotic index of 0 than all other groups (p < 0.05).

CONCLUSION

Mast cell expression correlates inversely with testicular fibrosis in cryptorchid testes. Further studies correlating mast cell expression with testicular function in boys with cryptorchidism are warranted.

Benign testicular enlargement due to diffuse interstitial fibrosis associated with cryptorchid testis in 11-month-old boy

Benign testicular enlargement secondary to diffuse interstitial fibrosis is a rare clinical entity, especially in pediatric patients. To our knowledge, this is the first pediatric case reported of benign testicular enlargement due to interstitial fibrosis in a cryptorchid testis. We report a rare case of an 11-month-old boy with a cryptorchid testis found intraoperatively to have an asymmetrically enlarged testis secondary to diffuse, benign interstitial fibrosis of the testis. Additionally, we discuss previous case reports of testicular enlargement due to interstitial fibrosis, the potential etiology and the management.

Intra-abdominal testis: histological alterations and significance of biopsy

PURPOSE

Intra-abdominal testes represent only 5% of undescended testes. Review of the literature reveals that few data exist on the histological analysis of intra-abdominal testes. We studied histological alterations in intra-abdominal testes in relation to patient age at orchiopexy.

MATERIALS AND METHODS

A total of 57 boys underwent laparoscopy for impalpable undescended testes between October 2002 and June 2005. Testicular biopsies were taken from intra-abdominal testes, fixed in 3% glutaraldehyde, embedded in Epon, sectioned at 1 micron thickness and stained with toluidine blue. Histomorphometric analysis was performed by light microscopy. Effect of age at operation on histological evaluation of abdominal testes was also studied.

RESULTS

Testicular biopsies from 29 patients with intra-abdominal testes showed the histological alterations of decreased mean diameter of seminiferous tubules, germinal cell depletion (55%) and presence of microliths (6.9%).

CONCLUSIONS

As age at orchiopexy increases, deviation from the norm is more evident and absence of germ cells on biopsy becomes more pronounced, reaching a rate of 93% after age 3 years. Further studies on orchiopexy with or without biopsy in the first few months of life would likely improve our understanding and treatment of cryptorchidism.