Factors associated with delay in undescended testis referral

INTRODUCTION

Undescended testis (UDT) is one of the most common congenital disorders and is associated with infertility and testicular cancer. Multiple guidelines internationally have recommended orchiopexy by 18 months. Multiple large retrospective studies published in the last decade have found persistent delay in timing of orchiopexy.

OBJECTIVE

The aim of the study was to determine timing at which UDTs are referred at the tertiary pediatric hospital and assess factors that are associated with delay in UDT referral.

STUDY DESIGN

Based on clinical observations and previous data, a series of clinical and socio-economic variables were constructed to design a prospective database. All patients who underwent orchiopexy for UDT from March 1, 2017, to August 31, 2018, were reviewed for demographic and clinical data. Referral appointments after 18 months were considered delayed. Factors associated with delay in UDT referral were analyzed using univariate and multivariate analysis with logistic regression.

RESULTS

One hundred seventy-eight patients underwent orchiopexy for UDT. The median age was 44 months, and 64% of them had delay in referral. On univariate analysis, normal birth testicular examination, diagnosis of 'retractile testicle,' long gap without seeing pediatrician, diagnosis by a new physician, and primary language non-English were associated with delayed UDT referral. On multivariate analysis, delayed referral was associated with normal testicular examination at birth, history of 'retractile testis,' diagnosis not by the regular primary care provider, and other health or social issues that may have led to delay.

DISCUSSION

This is the first prospective study analyzing timing of referral for boys with cryptorchidism. It was found that timing of treatment of UDT with orchiopexy has not improved over the last decade. Major causes in delay in referral may be due to poor of education of families and lack of routine testicular examinations by referring providers. Secondary ascent may account a significant number of delayed orchiopexy cases.

CONCLUSION

Most patients at Doernbecher had delayed referral of cryptorchidism. Factors associated with delay were determined. To improve treatment of cryptorchidism, quality-based interventions and the importance of education and routine testicular examinations need to be focused on.

Efficacy and safety of human chorionic gonadotropin for treatment of cryptorchidism: A meta-analysis of randomised controlled trials

AIM

Although human chorionic gonadotropin (hCG) has long been employed in the management of cryptorchidism, its safety and efficacy is still controversial. Hence, in the present study, we conducted a meta-analysis of the treatment of cryptorchidism using hCG.

METHODS

We searched the Medline, Embase, CINAHL, EBSCO, The Cochrane Library, China National Knowledge Infrastructure and WanFang databases. Data were extracted by two reviewers using the designed extraction form. Data up to July 2015 were obtained using the terms 'cryptorchidism', 'chorionic gonadotropin' and 'randomised controlled trials'. All the publications were downloaded, and the respective authors were contacted for any further details and clarifications, if deemed necessary. The data analysis included randomised controlled trials that compared hCG with other hormone treatments offered to prepubescent males presenting with cryptorchidism. Testicular descent rate was used as the final positive outcome of the treatments offered. The software Review Manager (RevMan 5.3, The Cochrane Collaboration, London, UK) was used to review the management and data analysis. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled with a fixed effect model if no heterogeneity was present.

RESULTS

A total of seven trials satisfied the selection criteria. The overall quality of the studies downloaded from various databases was low. Data from these seven studies were divided into three subgroups depending on the design of the trials: Two studies compared hCG with a placebo, and three studies compared hCG with gonadotropin-releasing hormone (GnRH) in unilateral cryptorchidism, whereas two other studies compared hCG with GnRH in bilateral cryptorchidism. Analysis of these trials revealed no significant differences between the effectiveness of hCG treatment and GnRH treatment in bilateral (RR 0.05, 95% CI (-0.29-0.40), two trials, n = 104, P = 0.76) as well as unilateral cryptorchidism (RR 0.04, 95% CI (-0.12, 0.21), three trials, n = 81, P = 0.61). A meta-analysis of these studies showed that hCG treatment is not superior to placebo (RR 7.74, 95% CI (0.14-425.72), two trials, n = 31, P = 0.32).

CONCLUSION

A meta-analysis of the seven studies led us to conclude that hCG treatment is no more effective than placebo, and there were no significant differences in the effectiveness of hCG versus GnRH treatment.

INSL3 and AMH in patients with previously congenital or acquired undescended testes

BACKGROUND

In previous reports no differences in Leydig and Sertoli cell function were found between congenital undescended testis (CUDT) and acquired UDT (AUDT) on the basis of serum levels of LH, testosterone, FSH or inhibin B. This study tried to detect differences in Leydig and Sertoli cell function between CUDT and AUDT using insulin-like peptide 3 (INSL3) and anti-Müllerian hormone (AMH).

METHOD

118 men with a history of UDT (CUDT N=55 (6/55 bilateral), AUDT N=63 (15/63 bilateral)) were investigated. Differences between CUDT and AUDT, influence of age at surgery in CUDT, and effect of spontaneous descent or orchiopexy in AUDT were evaluated.

RESULTS

For INSL3, no significant differences were found. AMH levels in bilateral CUDT were significantly lower compared with bilateral AUDT (6.4 (1.7-11.4) vs 13.2 (6.1-30.1) μg/l, p=0.02). AMH levels in unilateral CUDT were significantly higher than in bilateral CUDT (12.1 (2.4-43.7) vs. 6.4 (1.7-11.4) μg/l, p=0.02).

CONCLUSION

No differences in Leydig cell function on the basis of INSL3 levels between the different UDT groups were found. Sertoli cell function evaluated by AMH, was more negatively affected in bilateral CUDT in comparison with bilateral AUDT and unilateral CUDT.

LEVEL OF EVIDENCE RATING

Level III Treatment Study.

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

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

Cryptorchidism: A practical review for all community healthcare providers

Cryptorchidism is one of the most common congenital anomalies of the male genitalia, occurring in 1% of boys by the age of one year. Even though the etiology of cryptorchidism is multifactorial, management has evolved with the clear recognition that hormonal treatment is not effective and surgery between 6-18 months of age leads to better testicular outcomes. Diagnostic laparoscopy is considered the standard approach for management of non-palpable testes, and can be combined with one or two-stage orchidopexy, with up to 80-90% success rates. This review discusses the natural history of retractile testicles, indications for hormonal treatment and orchidectomy, ultrasound's role as a diagnostic tool, risks of infertility and testicular cancer, and surgical techniques for inguinal and intra-abdominal testes.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

AIM

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

DESIGN OF STUDY

Observational study.

SETTING

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

METHOD

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

RESULTS

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

CONCLUSION

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

Natural history and long-term testicular growth of acquired undescended testis after spontaneous descent or pubertal orchidopexy

OBJECTIVE

To assess prospectively the natural history and long-term testicular growth of acquired undescended testis (UDT) after spontaneous descent or pubertal orchidopexy in case of nondescent.

PATIENTS AND METHODS

From 1996 until 2008, 391 boys with 464 acquired UDT were included in the study. In accordance with Dutch consensus on non-scrotal testes, spontaneous descent at puberty was awaited; if this did not take place, orchidopexy was performed at puberty. Acquired UDT was defined as a testis previously residing in the scrotum that can no longer be manipulated into a stable scrotal (high scrotal) or nonscrotal (inguinal, impalpable) position. After referral, testis position, testis volume and puberty stage were monitored annually until adolescence. Testis volume was assessed using an orchidometer and compared with the Dutch standard. All investigations were carried out by the same physician (W.H.). Of these boys, 84 (mean age 12.9 years, range 6.4-21.3) were also clinically assessed by a second physician (J.G.), unaware of the results of the first examination. In addition, these boys were assessed with testicular ultrasonography, carried out by both physicians.

RESULTS

Currently the mean (range) follow-up is 4.7 (0.1-12.0) years, and 253 acquired UDT have reached the scrotum. In 196 of these 253 cases (77.5%), there was spontaneous descent at puberty (mean age at descent 12.9 years, range 9.8-16.9); in the other 57 cases (22.5%), pubertal orchidopexy was required due to nondescent; five cases required orchidectomy. Of the 494 testis volume measurements after spontaneous descent, 458 (92.7%) were at ≥10th centile for age, of which 311 (63.0%) were ≥50th centile, and 107 (21.7%) ≥90th centile. After pubertal orchidopexy for nondescent, of the 85 measurements, 79 (92.9%) were at ≥10th centile, 53 (62.4%) ≥50th centile and 12 (14.1%) ≥90th centile. In unilateral cases, after spontaneous descent 174 of the 294 (59.2%) retained testes were found to be smaller than their counterpart and 90 of 294 (30.6%) were equal in size. After pubertal orchidopexy in unilateral cases, 40 of the 51 (78.4%) testes were smaller, and nine (17.6%) were equal in size. There was a strong correlation between both investigators for the measurement of testicular volume by orchidometer, and for the main investigator (W.H.) between his measurements by ultrasonography and the Prader orchidometer.

CONCLUSION

Acquired UDT has a 77.5% tendency of spontaneous descent at puberty. In nearly all cases, after spontaneous descent as well as after pubertal orchidopexy, long-term testicular growth is within the normal range.