The vanishing testis

Surgical exploration of 417 clinically impalpable cryptorchid testes revealed 84 (20%) instances of absent testes. Thirty-five (42%) of the 84 explorations showed complete absence of the testes along with the epididymis and vas, whereas 49 (58%) were associated with blind-ending cord structures: the vanishing testis syndrome. The presence of a vas deferens and vessels lying side by side in the inguinal canal strongly suggests that a testis existed at one time and subsequently vanished, probably as a result of antenatal vascular accident. The incidence of vanishing testes in our patients was higher than the true congenital absence of testis including vas deferns and epididymis. Offprint requests to: P. Puri at the above address     

The ascending testis

This study relates the timing and incidence of orchidopexy to possible ascent of the testis. During 1985, 341 patients underwent surgery for undescended testes at the Royal Children's Hospital, Melbourne. In 85 (25%), surgery was performed before 2 years of age. The number of children managed surgically over the age of 2 years is high (75%) despite our surgical policy to perform orchidopexy at 2 years of age. Statistical analysis shows a bimodal distribution for age at the time of surgery for undescended testis, with 16% of the orchidopexy population in the older age group. It also demonstrates that the overall orchidopexy rate of 2.6% is three times the expected incidence of undescended testes at 1 year of age. Possible explanations for these observations include: (1) the diagnosis and referral of undescended testis is being made late; (2) surgery is being performed on retractile testes; or (3) some later presenting undescended testes are acquired, the so-called ascending testes. Offprint requests to: A. A. Woodward     

The undescended testis

Testicular development is determined by the influence of the SRY gene on the Y chromosome of the fetus. This influences the germ cells to produce testosterone and Mullerian inhibiting substance which control descent of the testis. Maldescent of the testis occurs in 0.8% of boys. Current best advice is to perform orchidopexy before the age of two years, therefore a programme for examination by skilled healthcare workers should be established in the first year of life. Indications for surgery include a possible beneficial effect on fertility, malignant potential particularly if intra-abdominal, torsion or trauma and social considerations. Hormonal treatment in the first three months of life is recommended by some. Laparoscopy is the optimum method for evaluating and managing the intra-abdominal testis.     

Management of undescended testis

The term cryptorchidism indicates a testis, which has failed to descend to the scrotum and is located at any point along the normal path of descent or at an ectopic site. Hormones play a pivotal role in testicular descent except during the migration to the level of internal inguinal ring. Cryptorchidism is present in about 4.5% of newborns with a higher incidence in preterms. The incidence decreases to 1.2% by the first year. It is classified as palpable and impalpable. The most common site of an ectopic testis is superficial inguinal pouch. Retractile testis is often bilateral and most common in boys between 5 and 6 years of age. Hypospadias and inguinal hernias are the most common associated anomalies seen with undescended testis. A thorough clinical examination helps in arriving at the etiology. A short hCG stimulation test helps to exclude anorchia. Different imaging techniques are of little help in diagnosis and require the help of an experienced radiologist. Laparoscopy has an important role in the diagnosis and management of undescended testis. The common complications include torsion and atrophy of testis. Infertility is seen in about 40% of unilateral and 70% of bilateral cryptorchidism. Undescended testis is 20 to 40 times more likely to undergo malignant transformation than normal testis. Both hCG and GnRH have been used with limited success in these children. All boys with cryptorchidism should be referred to a pediatric surgeon before 2 years of age. These children should be followed up every year after surgery to identify testicular tumors.     

单侧睾丸扭转对大鼠两侧睾丸生精功能的损害

目的 研究单侧睾丸扭转对大鼠两侧睾丸精子发生的影响。方法 制作单侧睾丸扭转不同时间的大鼠模型，以乳酸脱氢酶X(LDH—X)为观测指标，分析附睾内的精子数量和活力，从而反映睾丸生成精子的能力。部分组别的动物在扭转复位前注射别嘌呤醇，观察药物对组织的保护作用。结果 单侧睾丸扭转后，患侧附睾管腔内的精子数量及活力明显降低；对侧改变出现于扭转6h以后；应用别嘌呤醇能改善扭转2h以内患侧的精子发生。结论 单侧睾丸扭转造成两侧睾丸生精功能下降，下降程度与先前扭转时间有关；早期手术复位加以别嘌呤醇的应用能对受损组织提供有限保护。     

Intra-abdominal testis with mature teratoma

Tumors in an undescended testis are rare in children. We report a mature teratoma arising in the intra-abdominal testis (IAT) of a 1-year-old boy. Preoperative laparoscopy revealed a right IAT near the inguinal ring. As the right testis exposed through the inguinal incision seemed to be a neoplastic mass, an orchidectomy was performed. Histologic examination disclosed a mature teratoma. This is a review of seven cases (including the present one) of a prepubertal tumor originating in an IAT. We speculate that the undescended testes did not cause the neoplasia, but were induced by it. Accepted: 20 January 1997     

Appendix testis and appendix epididymis

Testicular appendages represent remnants of embryonic structures. The more important are appendix testis (AT) and appendix epididymis (AE). We searched for the presence of an AT or AE in 103 consecutive inguinal hernia and 39 cryptorchidism operations performed at our department during the last 2 years and found 114 ATs (80.28%) and 52 AEs (36.31%). In 24 cases (16.9%) we found both appendages. The ages of our patients ranged from 2 months to 14 years. The diameter of the appendages was 0.3–1.7 cm. Histologically, ATs and AEs consisted of relatively vascular fibrous connective tissue. The surface epithelium was cuboidal in 77 cases, flat in 27, stratified-ciliated in 21, and cuboidal-ciliated in 19. ATs and AEs are penduculated structures and consequently subject to torsion, which is the commonest cause of testicular swelling in childhood and is accompanied by severe pain. To avoid this possibility, we suggest excision of these appendages in every operation for inguinal hernia and cryptorchidism.     

Assessment of the undescended testis

The testis descends from the urogenital ridge to the scrotum in two phases: the first, transabdominal migration, appears to be dependent on Mullerian Inhibiting Factor substance; and the second stage, inguinoscrotal descent, relies on androgens. A peritoneal extension, the processus vaginalis, elongates into the gubernaculum, which in turn migrates into the scrotum. Between weeks 26 and 28 of gestation the testis descends through the processus vaginalis in the inguinal canal to reach the scrotum by 35–40 weeks.     

Cystic dysplasia of the testis

Testicular cysts are an uncommon in the pediatric population unlike adults where they occur frequently. We describe a case of cystic dysplasia of the testis in a prepubertal boy. The known literature is reviewed and the sonographic appearance of the lesion is correlated with pathologic findings.     

Die Therapie des Maldescensus testis

Undescended testes is the most common urological disease in male infants, and if left untreated can quickly lead to irreparable lesions to the testicular tissue. In later life these are then the main reasons for infertility and an elevated risk of malignant transformation. Undescended testes can be treated conservatively with either intranasal GnRH (LHRH) or intramuscular hCG. These hormonal treatments should be used as the first-line treatment and must be started at the age of 4–6 months. Even in nonresponders such “hormonal priming” may have long-lasting positive effects on germ cell quality. Several operative techniques have been developed for each type of undescended testis, ranging from a laparoscopic approach to transscrotal fixation of the testis. As in the case of the hormonal treatments, the age of the patient when treated also has a major impact on the degree of success seen postoperatively. In association with a lower recommended age of under 1 year for the treatment of undescended testes, both hormonal treatment and surgical orchidopexy can contribute to improving fertility in men with a history of undescended testes.