Epididymal-testicular fusion anomalies in cryptorchidism are associated with proximal location of the undescended testis and with a widely patent processus vaginalis

Abdominal Cryptorchidism with Complete Dissociation between the Testis and Deferent Duct Mimicking Testicular Regression Syndrome

Complete separation of the deferent duct from the epididymis in cryptorchid testes residing in the abdomen is an extremely rare variant of developmental disorders of the testis and epididymis. Available sources mention only three clinical cases similar to our observations. The unique anatomic aspects of this disorder hamper the correct diagnosis of an intra-abdominal cryptorchid testis. Two boys with nonpalpable left-sided cryptorchidism underwent diagnostic laparoscopy, revealing an intra-abdominally located testis. The epididymis was completely separated from the deferent duct, and the epididymis and testis were supplied by testicular vessels. Exploration of the inguinal canal revealed blind-ending deferent ducts. The testis was brought down through the inguinal canal and fixed in the scrotum in both boys. The follow-up examination at 6 months revealed no signs of testicular atrophy or malposition of the testis in either patient. With our observations in mind, the exclusive use of a transscrotal or transinguinal approach as the initial surgical exploration in the treatment of patients with nonpalpable forms of cryptorchidism may be inappropriate. Careful laparoscopic examination of the abdominal cavity is indispensable in children with suspected testicular regression syndrome or nonpalpable forms of cryptorchidism.

Does Orexin B-Binding Receptor 2 for Orexins Regulate Testicular and Epididymal Functions in Normal and Cryptorchid Dogs?

Orexins A (OXA) and B (OXB) and the receptors 1 (OX1R) and 2 (OX2R) for orexins are hypothalamic peptides found in several mammalian organs and participated to the control of a wide assortment of physiological and pathological functions. The distribution of OXA and OX1R has been extensively studied in the male gonad of mammals. Here, we examined the expression and localization of OXB and OX2R as well as their possible involvement in the regulation of testicular and epididymal functions, in healthy and cryptorchid dogs, employing some techniques such as immunohistochemistry, Western blotting, and real-time RT-PCR. In vitro tests were also carried out for evaluating the steroidogenic effect of OXB. OXB and OX2R were expressed in spermatocytes, spermatids, and Leydig cells in normal testis. Their localization was restricted to Sertoli and Leydig cells in cryptorchid conditions. OXB was found to be localized in all tracts of both normal and cryptorchid epididymis, whereas OX2R was found only in the caput. Because the small molecular weight of the peptides OXA and OXB, the expression of their precursor prepro-orexin (PPO), OX1R, and OX2R proteins and mRNAs were investigated by means of Western blot and real-time RT-PCR analyses, respectively, in all tested groups of. In particular, the mRNA level expression of all three genes was higher in cryptorchid dogs than in normal ones. In vitro tests demonstrated that OXB—by binding OX2R—is not involved in testicular steroidogenic processes. Therefore, the findings of this study might be the basis for further functional and molecular studies addressing the possible biochemical effects of OXB and OX2R in normal and pathological conditions of the male reproductive system.

Gubernaculum and Epididymo-Testicular Descent: Review of the Literature

Cryptorchidism is a common disorder in boys that has been widely studied both experimentally and clinically. The role of the gubernaculum, a mesenchymal tissue extending from the fetal testis and epididymis to the developing scrotum, is still unclear. Even the name is debated: 'gubernaculum epididymis' or 'gubernaculum testis'. This review does not aim to provide a global overview of competing theories on testicular descent, but focuses on the role of the gubernaculum in epididymo-testicular descent. We identified four major pitfalls of gubernaculum research: the role of the gubernaculum, of insulin-like peptide 3, anti-Müllerian hormone, and androgens. The major critical issues were that the gubernaculum plays a guiding role for the epididymis, descending prior to the testis and expanding the inguinal canal; insulin-like peptide 3 is not as important for the process of descent in humans as the rate of insulin-like peptide 3 mutations is low; anti-Müllerian hormone plays no significant role in epididymo-testicular descent; androgens and gonadotropins play a crucial role in epididymo-testicular descent. The role of the epididymis in the complex process of gubernaculum, epididymis, and testis migration is underestimated and should be included in future research.

Testicular, Epididymal and Vasal Anomalies in Pediatric Patients with Cryptorchid Testes and Testes with Communicating Hydrocele

The goal of this study was to determine the prevalence of the testicular, epididymal, and vasal anomalies (TEVA) in cryptorchid and communicating hydrocele pediatric patients. Six hundred and ninety-one prepubertal boys underwent inguinal exploration for 741 undescended (UDT) or hydrocele testes. Two hundred and fifty-five TEVA were detected in 154 UDT boys, compared to 32 defects in 24 hydrocele patients (p < 0.001). The TEVA were more frequent in bilateral UDT (p = 0.009). Multiple defects were observed more frequently in the intra-abdominal testicles (p = 0.028). A correlation was found between the testicular atrophy index (TAI) and the incidence and number of TEVA in the UDT boys (p < 0.001). The smaller the testis (higher TAI), the more the defects that appeared in it and the higher the frequency of their appearance. Another correlation was established between testis position and the incidence and number of TEVA (p < 0.001). The higher the testis position, the more the defects that appeared in it and the higher the frequency of their appearance. A correlation was established between the position and the volume of the affected testis (p < 0.001). The higher the gonad position, the more severe the atrophy observed in it. The TEVA were more frequent in the UDT boys than in the hydrocele patients. We revealed that the risk of abnormal fusion between the testis, epididymis, and vas deferens is connected with the testis position (intra-abdominal testes) and bilateral non-descent.

Epididymal disjunction anomalies in undescended testis - a factor associated with spermatic obstruction

Background:

To analyze the incidence of epididymal anomalies (EAs) associated to spermatic obstruction in patients with undescended testis (UT) according to testicular position and age.

Materials and Methods:

We studied 87 patients (110 testis) with cryptorchidism and analyzed the presence of EAs correlated with the testicular position, age and patency of the processus vaginalis (PV). To analyze the relations between the testis and epididymis we considered three situations: (a) Normal pattern: the epididymis was attached to the testis at the head and tail and epididymis totally attached to the testis; (b) EAs: when the epididymis was attached to the testis only at the head (Figure-1A) and (c) EAs associated to spermatic obstruction: epididymis was attached to the testis only at the tail (Figure-1B) and when there are no visible connection between testis and epididymis (Figure-1C). We used the Wilcoxon-Mann-Whitney test and the Chi-square test for contingency analysis (p <0.05).

Results:

The mean age of the patients was 5.18 years (SD=2.867). Of 110 testes analyzed, 14 were abdominal (12.72%); 83 inguinal (75.45%) and 13 suprascrotal (11.81%). Normal relationships between testis and epididymis were observed in 54 patients (62.1%) with no significant differences in relation to the patient's age (p=0.666). Epididymal tail disjunction was observed in 23 patients (26.44%), with no significant differences in relation to age (p=0.59). EAs associated to spermatic obstruction were observed in 16 patients (18.4%), also with no significant differences in relation to age (p=0.684). We did not observe significant correlation between the testis position and the incidence of EAs (p=0.119). We did not observe significant correlations between patency of the PV (64.7%) and incidence of EAs (p=0.742).

Conclusions:

Epididymal anomalies associated with spermatic obstruction are present in almost 20% of undescended testes, without significant correlation with age, testicular position and patency of the PV. This information needs to be correlated to the infertility risk of this congenital anomaly.

A spectrum of epididymis and vas deferens anomalies among children with cryptorchidism: a retrospective multi-center study

Background

Vasoepididymal anomalies are not rare among children with cryptorchidism. They may affect fertility following orchiopexy. Herein, we describe the cases of abnormalities of the vas deferens and epididymis in children undergoing orchidopexy for cryptorchidism. Data were collected retrospectively from six centers providing care for patients with undescended testicles from September 2017 to February 2019. All patients whose congenital anomalies of the epididymis or vas deferens were discovered incidentally during operative intervention for cryptorchidism and where photographs of the anomalies were taken were included.

Results

The total incidence of congenital anomalies on the 467 testicles which had operations was 13.2%. Congenital epididymal and vas deferens anomalies were more common on the left side than the right side in patients with cryptorchidism (P = 0.038). Attachment anomalies between the epididymis and testis were the most common epididymal anomaly (36.3%), while a vanished vas deferens was the most frequent vas deferens anomaly (18%). Three patients had absent vas deferens, two had curled vas deferens, two had vas deferens separated from the epididymis, and one had a duplicated vas deferens. Three patients had an epididymal cyst, one had an enlarged appendix of the epididymis, and one had epididymal agenesis.

Conclusion

Attention must be paid during any surgery on an undescended testicle as an anomaly of the vas deferens could lead to unexpected complications. Anomalies of the vas deferens or epididymis that present in cases of cryptorchidism occur mostly on the left side.

The incidence of epididymal anomalies in the bilateral and unilateral cryptorchidism cases: A comparative study

OBJECTIVE

Our study was planned based on the hypothesis that epididymal anomalies may be more incidental and more severe in cases with bilateral undescended testicles compared to unilateral undescended cases. We also aimed to review the classifications of epididymal anomalies in the literature and to establish a simpler and clinically applicable classification in the present study.

MATERIALS AND METHODS

In this study, we retrospectively reviewed 197 pediatric patients who had been operated for undescended testis between January 2014 and January 2018. In the collective analysis of bilateral undescended testes cases, if the present anomaly were present in any testis, the anomaly was considered to be present for these cases and subjected to statistical analysis.

RESULTS

The study included a total of 241 testicles of 197 patients. The incidence of epididymal anomalies was found to be significantly higher in cases with bilateral undescended testicles compared to unilateral cases (68.2%, 43.1%, respectively; p = 0.003). It was observed that the incidence of epididymal anomaly and the severity of the anomaly statistically significantly decreased as the localization of the undescended testicle changed between the intraabdominal position and the external inguinal ring (p = 0.0001).

DISCUSSION

The effects of the undescended testicles on fertilization have been subject to evaluation in a limited number of studies and it has been reported that the rate of fertility is lower in patients with bilateral undescended testicles, whereas the fertility rate is close to that of healthy males in patients with unilateral undescended testicles. The incidence of epididymal anomalies was found to be higher in cases with bilateral undescended testicle, as shown in our study. However, based on these data, it is not possible to make a comment about whether this condition leads to infertility or not. Furthermore, accurate documentation of epididymal anomalies and standardization of the classifications of epididymal anomalies may be guiding in the prevention of complications for the surgeons in the treatment of patients who will undergo orchiopexy.

CONCLUSIONS

We concluded that the incidence of epididymal anomalies was significantly higher in cases with bilateral undescended testicles compared to unilateral cases. In our study, based on a comprehensive high-quality surgical image archive, we believe that the differentiation of epididymal anomalies according to the classification we have proposed will make it possible to create a database that is easier to use clinically in a more objective way.

Three‑Dimensional Ultrasonography in Preoperative and Postoperative Volume Assessment of the Undescended Testicle

BACKGROUND Ultrasound (US) is the preferred imaging method for cryptorchidism, but most guidelines indicate that its value is questionable. The aim of this study was to evaluate the clinical value of ultrasonic mobility and testicular atrophy index (TAI) based on three‑dimensional US (3DUS) in preoperative and postoperative assessment of the undescended testis. MATERIAL AND METHODS Data from 158 children with unilateral extraperitoneal cryptorchidism were collected and their diagnoses were surgically confirmed. They were divided into different age groups and into 2 ultrasonic mobility groups: the mobile group (MG) and the restricted group (RG). Differences in sonographic characteristics between different groups were compared. Three-dimensional ultrasound performed with virtual organ computer-aided analysis (VOCAL) was used to determined preoperative and postoperative TAI and the reliability of TAI was analyzed. RESULTS Measurement of testicular volume with the VOCAL method was significantly more reliable than that done with the two-dimensional Lambert method. In all age groups, preoperative testicular volumes were smaller than that in the contralateral scrotal testis and postoperatively, they increased steadily. Both preoperative and postoperative TAI were higher in the RG than in the MG. In the MG, postoperative TAI decreased significantly in all age groups. In the RG, in contrast, effective volume growth was only achieved in patients who had undergone surgery before they reached age 1 year. CONCLUSIONS TAI values determined with 3DUS using the VOCAL technique objectively reflect recovery of testicular volume following surgery for undescended testicle. Ultrasonic mobility evaluation is beneficial for clinical management of the condition.

Sentinel nubbin: A potential pitfall in the management of undescended testis secondary to epididymo-testicular nonunion

INTRODUCTION

Epididymal anomalies are common in boys with undescended testis. Epididymo-testicular non-union with a nubbin in the scrotum is a rare anomaly and may be confusing during management of cryptorchidism. The non-fused epididymis and vas deferens which are descended to the scrotum, may be regarded as nubbin tissue secondary to testicular atrophy and proximal testis may be overlooked.

OBJECTIVE

To evaluate a relatively rare anomaly of epididymo-testicular non-union in which vas deferens and epididymis are descended to the scrotum resembling a nubbin tissue, while a separate testis remains in a proximal peritoneal fold (hernia or processus vaginalis)which could potentially be missed during the management of patients with undescended testis.

STUDY DESIGN

The charts of the fourteen patients with epididymo-testicular non-union and a scrotal nubbin are retrospectively evaluated.

RESULTS

Median age of the patiens was 1.5 years (0.5-12), 11 were left and 3 were right. No connection could be demonstrated between the testis and vaso-epididymal unit in any of the patients. Orchidopexy was performed in 13 patients while orchidectomy in1 patient. The scrotal nubbin tissue is excised in 4 patients and histological examination revealed sections of vas deferens and epididymis. One of the patients underwent inguinal exploration and orchidectomy for assumed testicular atrophy elsewhere but histological examination revealed vas deferens and epididymis without any sign suggesting an atrophic testis. An intrabdominal testis was found incidentally in this patient and he underwent 2 additional procedures for orchidopexy.

DISCUSSION

Although epididymo-testicular anomalies are common in boys with undescended testis, nonunion is the rarest type of this anomaly. Similar cases are reported in the literature as simple fusion anomalies with indefinite clinical significance or even polyorchidism although no accessory testis could be demonstrated. However, the scrotal nubbin tissue which actually contains epididymis and vas is a potential decoy and may result in missing of the proximal testis if regarded as a sign of testicular atrophy and further evaluation is obviated. As this is retrospective study, actual incidence of the condition is yet to be determined.

CONCLUSION

A scrotal nubbin tissue may be secondary to epididymo-testicular nonunion as well as testicular atrophy. As feasibility of radiological imaging studies are limited, a laparoscopic exploration may be considered to confirm or to exclude a separate testis in patients with scrotal nubbin. Prospective studies are needed to evaluate the actual incidence of the condition and gain-loss analysis of laparoscopic exploration.

Autophagy is increased in cryptorchid testis resulting in abnormal spermatozoa

Autophagy is involved in spermatogenesis by regulating germ cell maturation. This catabolic process increases with hyperthermic conditions to prevent the accumulation of damaged organelles. Cryptorchidism is associated with impairment of germ cell maturation revealed by the presence of immature forms of sperm cells in ejaculates. The aim of the present study was to evaluate the status of autophagy in sperm cells from cryptorchid patients. Semen samples of cryptorchid patients and normozoospermic controls were analyzed by immunocytochemistry and electron microscopy. Autophagy proteins, autophagy-related protein 9 (ATG9) and microtubule-associated protein, 1A/1B-light chain 3 (LC3) were localized by immunocytochemistry on the acrosome and on the equatorial segment of sperm cells. LC3 was also detected in the midpiece of cryptorchid sperm tail. Autophagy substrate p62 protein was present in the acrosome and in the postequatorial segment of sperm in control samples, but not in the cryptorchid ones. Transmission electron microscopy revealed double-membrane-limited autophagosomes in postequatorial part of spermatozoa head and midpiece in cryptorchid samples. Partly degraded mitochondria were frequently discerned in autophagic vacuoles. In conclusion, autophagy is increased in sperm cells from patients with cryptorchid history comparatively to control. Our work provides insights into the role of autophagy in the maturation and survival of human male gametes in pathological conditions. Thus, regulating autophagy could represent a potential way to improve sperm quality in cryptorchid men.

The spectrum of testicular-epididymal fusion anomalies in children with cryptorchidism: Personal experience, systematic review and meta-analysis

BACKGROUND

Testicular-epididymal fusion anomalies (TEFA) have been documented in the literature. The pathological significance of TEFA and their relationship to testicular maldescent is unclear. We aimed to clarify the real incidence of TEFA in children with undescended testes and their impact on testicular development after surgery.

METHODS

We conducted a retrospective review (2010-2018) of all patients who underwent orchidopexy. Cases with TEFA confirmed intra-operatively were matched against controls with normal fusion for age at the time of surgery. Records from follow-up visits were assessed to compare testicular size at six-months. A systematic review and meta-analysis of the literature (1980-2019) was also performed.

RESULTS

In our retrospective review, 54 (21.4%) of 252 cryptorchid testes were found to have TEFA (Table). Intra-abdominal testes were more likely to exhibit TEFA than inguinal testes (20.4% vs. 9.6%, RR 1.8 [1.0-3.1], P = 0.03). There were no differences in testicular size at the time of surgery (P = 0.29) or the six-month followup (P = 0.18). The systematic review identified eight studies with 4871 children (5240 orchidopexies). The overall rate of TEFA was 25.8% [95% CI 15.2-38.0]. Tail nonfusion (NF) (10.7% [95% CI 5.4-17.4]) was the most common followed by head NF (7.2% [95% CI 3.2-12.5]) and complete NF (6.3% [95% CI 3.7-9.5]). Intra-abdominal testes were more likely to exhibit TEFA than inguinal testes RR 2.6 [95% CI 1.9-3.5]; P < 0.001.

CONCLUSIONS

Data from our retrospective review and the literature indicate that TEFA are present in approximately one-quarter of cryptorchid testes and are more commonly associated with intra-abdominal cryptorchidism. There appears to be no impact on testicular size at short-term followup. The clinical significance of TEFA remains unclear; long-term followup studies are necessary to better understand their impact on testicular development and function.

Epididymal polar dissociation: A rare entity

Epididymal fusional anomalies have been found to be associated with conditions of testicular maldescent with the several studies investigating this association reporting several variations in epididymal anatomy and epididymal-testicular fusion. To our knowledge, a single case of an isolated lower epididymal pole with a normal vas deferens, dubbed “Epididymal Polar Dissociation”, has been reported in the literature. In this report, we report the second case of epididymal polar dissociation discovered in a 17-year-old during surgical management of left testicular torsion.

We, the developing rete testis, efferent ducts, and Wolffian duct, all hereby agree that we need to connect

BACKGROUND

The mechanisms by which the rete testis joins the efferent ducts, which joins the Wolffian duct during development, are not known. Mouse and chick models have been helpful in identifying genes that are important for the development of each part, but genes have not been identified as to those that play a role in the joining of each part. Clinical implications of the failure of the male reproductive tract to form a fully functional conduit for spermatozoa are not trivial. Epididymal disjunction, the failure of the efferent ducts to join the testis, is one of several epididymal anomalies that have been observed in some boys who were cryptorchid at birth.

OBJECTIVE

A systematic review of studies focusing on the morphogenesis of the mesonephric duct and mesonephric tubules in different species, and identification of clinical issues should there be failure of these tissues to develop.

DESIGN

PubMed and GUDMAP databases, and review of books on kidney development were searched for studies reporting on the mechanisms of morphogenesis of the kidney and epididymis.

MAIN OUTCOMES MEASURE(S)

Gaps in our knowledge were identified, and hypotheses coupled with suggestions for future experiments were presented.

RESULTS

A total of 64 papers were identified as relevant, of which 53 were original research articles and 11 were book chapters and reviews covering morphogenesis and clinical issues. Investigators utilized multiple species including, human, mouse, chick, Xenopus, bovine, and sheep.

CONCLUSION

Fundamental understanding of the morphogenesis of the male reproductive tract is limited, especially the morphogenesis of the rete testis and efferent ducts. Therefore, it is not surprising that we do not understand how each part unites to form a whole. Only one mechanism of joining of one part of the tract to another was identified: the joining of the Wolffian duct to the cloaca via controlled apoptosis.

Long-Term Outcome of Low Scrotal Approach Orchiopexy without Ligation of the Processus Vaginalis

PURPOSE

We performed low scrotal approach orchiopexy in patients with prescrotal cryptorchidism. The processus vaginalis was not ligated if it was not widely patent. We retrospectively evaluated the long-term outcomes of low scrotal approach orchiopexy without processus vaginalis ligation.

MATERIALS AND METHODS

A total of 137 patients (227 testes) were diagnosed with prescrotal cryptorchidism between October 2009 and April 2014. All patients underwent low scrotal approach orchiopexy. Mean age at surgery was 34.9 months. The processus vaginalis was deemed to be not widely patent when a sound could not be passed into the abdominal cavity through the internal inguinal ring, and the processus vaginalis was not ligated in such cases.

RESULTS

Intraoperative findings revealed that the processus vaginalis was widely patent in 10 testes and was not widely patent in 217. A widely patent processus vaginalis was closed via scrotal approach in 5 testes, while an inguinal approach was necessary in 5. Median followup was 44 months (range 20 to 73). Postoperative complications included reascending testis in 1 case where an inguinal approach was necessary. No patient manifested testicular atrophy or inguinal hernia.

CONCLUSIONS

Low scrotal approach orchiopexy is a useful and safe procedure for treating patients with prescrotal cryptorchidism. Ligation is unnecessary when the processus vaginalis is not widely patent.

Anatomical variations in epididymal-testicular fusion in stallions and their possible clinical significance

REASONS FOR PERFORMING STUDY

Fusion anomalies of the epididymis with the testis may be clinically relevant in horses. However, anatomical variations in epididymal-testicular fusion have not been classified, and their clinical significance is unknown.

OBJECTIVES

To describe anatomical variations and clinical significance of epididymal-testicular fusion in stallions.

STUDY DESIGN

Anatomical study of testes from castrations, and description of 2 clinical cases with atypical epididymal-testicular fusion.

METHODS

A total of 104 testes were obtained from equine castrations. Eight patterns of epididymal-testicular fusion were identified. Two clinical cases with epididymal dislocation were also described.

RESULTS

Close attachment of the entire epididymis to the testis was the most common pattern of fusion (40%). Ninety-five per cent of cryptorchid testes and 34% of scrotal testes in the studied sample had elongated proper ligaments of the testes. Dislocation of the epididymal tail was observed in 2 stallions that had atypically long proper ligaments inserted on the dorsal aspect of the testes.

CONCLUSIONS

Patterns of epididymal-testicular fusion can vary in stallions. Elongated proper ligaments of the testes occur mostly in cryptorchid testes but are also found in stallions with scrotal testes. Epididymal dislocation may develop in stallions with long proper ligaments that are inserted dorsally on the testes.