Prognosis of hormonal treatment of undescended testis related to testicular position at birth

The effect of treatment of 73 boys (mean age 7 years) with undescended testes with human chorionic gonadotropin (hCG) was related to the testicular status at birth as recorded in their birth charts. In 24 boys with diagnosed congenital cryptorchidism, hCG treatment was unsuccessful in 19 cases and operation was performed. In the remaining 5 boys hCG treatment alone was sufficient. Forty-nine boys had normal scrotal testes at birth and hCG therapy was successful in 38, while the remaining 11 required surgical correction. It is concluded that knowledge of the testicular status at birth is of value in clinical practice to evaluate the prognosis of treatment with hCG.     

Cryptorchidism: a morphological study of 670 biopsies

Among a series of 512 boys with an empty scrotum, 495 (96.7%) were found to have cryptorchidism, 4 had ectopia and 13 unilateral anorchia. Cryptorchidism was bilateral in 106 boys (21.4%). The only anomaly consistently associated with cryptorchidism was a detached epididymis, present in 31 patients. A total of 670 biopsies were studied, 441 of which came from cryptorchid and 229 from scrotal testes. Spermatogonial counts, performed according to Mancini's method, showed the germ cell population to be diminished in nearly all cryptorchid testes. The seven boys who still had a well preserved germ cell population were found in a group of 51 patients operated before age three; four of the seven boys with normal counts were below age one. No difference in the mean spermatogonial counts was found between uni- und bilateral cryptorchidism and ectopia, with the exception of bilaterally intraabdominal testes whose spermatogonial cell loss was particularly severe. Mean counts remained constant during childhood, no gradual increase with age having been observed. The scrotal testes in unilateral cryptorchidism showed cell loss in 30.1% of the cases, the germ cell depletion being severe in one out of every six cases. In the remaining scrotal testes, the counts were in the low normal range with a significantly lower mean than that found in scrotal testes associated with anorchia. Control biopsies were performed several months or years after orchidopexy in 18 boys with unilateral and in 24 boys with bilateral cryptorchidism. Orchidopexy does not improve the number of germ cells in either originally cryptorchid or in scrotal testes, the only postoperative change being an increase in tubular diameter. A search for malignant tumours which could have developed in this series has remained negative. According to our data, no optimal time for orchidopexy can be proposed. The damage to germ cells, once established, seems to remain unchanged during childhood at least after age three, and does not warrant special timing for operative correction of cryptorchidism.     

Testicular histology related to fertility outcome and postpubertal hormone status in cryptorchidism

BACKGROUND: Early surgical correction of an undescended testis is performed to prevent the development of male infertility. However, in boys with cryptorchidism early successful surgery cannot prevent infertility if they lack Ad spermatogonia. In this study, sperm concentrations and postpubertal hormone levels were correlated to bilateral testicular histology. The aim was to define the risk of future infertility via a testis biopsy program for boys with cryptorchidism. METHODS: Eighty-nine boys who had an orchidopexy were subjected to bilateral testicular biopsy. Histological analysis of 178 biopsies indicated three groups of high, intermediate, and low risk of infertility according to the presence of Ad spermatogonia. After puberty, sperm concentrations were analysed and correlated with plasma gonadotropin and testosterone levels. FINDINGS: In patients with unilateral cryptorchidism 70% of scrotal testes had an impaired transformation of Ad spermatogonia, indicating that cryptorchidism is a bilateral disease. Sperm concentrations correlated to the number of Ad spermatogonia found at the time of orchidopexy (p<0.001). All males in the high risk of infertility group were oligospermic (mean: 8.9x10 (6) sperm/ejaculate) and 20% were azoospermic. These patients had 25 times less sperm compared to the group with presence of Ad spermatogonia in both testes (p<0.001). Correlations between testicular histology and postpubertal hormone levels confirmed a relative gonadotropin deficiency in the majority of males with cryptorchidism. INTERPRETATIONS: Ad spermatogonia proved to be a discriminating factor for the fertility outcome in cryptorchidism. Gonadotropin treatment following orchidopexy should be considered in cryptorchidism when no Ad spermatogonia are found in undescended gonads and scrotal testis have Ad germ cell counts <0.005 per tubule.     

Cryptorchidism: a prospective study of 7500 consecutive male births, 1984-8. John Radcliffe Hospital Cryptorchidism Study Group.

A total of 7441 boys were examined for cryptorchidism at birth and, if present, again at 3 months of age. After excluding boys with severe congenital malformations noted at birth, the cryptorchidism rates at 3 months in babies weighing less than 2000 g, 2000-2499 g, and greater than or equal to 2500 g were 7.7%, 2.5%, and 1.41% respectively. The overall rate was 1.55%. The cryptorchidism rate at birth had increased by 35.1% and at 3 months by 92.7%, over Scorer''s rates in the 1950s. Part of these increases may be attributable to differences in neonatal mortality, but the increases in babies weighing 2500 g or more of 50.2% at birth and 77.4% at 3 months are unlikely to be overestimates. At birth 1.92% of boys had bilateral cryptorchidism and 3.0% unilateral cryptorchidism. Boys with cryptorchidism at 3 months were more likely to have hypospadias, a small scrotum, and poor scrotal rugation compared with boys having normally descended testes at birth. Factors predicting descent by 3 months in babies cryptorchid at birth are birth weight, laterality and scrotal size, babies with low birth weight, bilateral cryptorchidism, and normal scrotal size being more likely to have normally descended testes by 3 months. Descent by 3 months was more likely the lower the testis along the normal pathway of descent. The orchidopexy rate at an average age of 3 years was 1.24%. This is substantially lower than in other series and lower than our estimated rate of 2.9% using Hospital In-Patient Enquiry data for England and Wales.     

隐睾患者血清抑制素B水平的变化特征及其诊断意义的研究进展

隐睾是男性最常见的泌尿生殖系统发育异常,以单侧或双侧睾丸下降至阴囊过程发生障碍为主要特征。血清促卵泡刺激素和血清抑制素B是两种常见的用以评估睾丸支持细胞/曲细精管功能是否异常的内分泌指标。很多针对隐睾症开展的研究显示,睾丸支持细胞/曲细精管功能(精子发生)均受累,但睾丸间质细胞(Leydig cell)的功能几乎没有受到影响。由此可见,隐睾患者在青春期前睾丸功能的评估重点是睾丸支持细胞的受损程度,而血清抑制素B是睾丸支持细胞的典型内分泌标志物,也是评估隐睾下降固定术后睾丸功能的一种安全、方便、间接的途径。本文将针对隐睾患者血清抑制素B水平的变化特征及其诊断意义的研究进展进行综述。     

Testicular torsion: a 15-year single-centre clinical and histological analysis

Aim: This study reviewed the demographic, epidemiological and clinical factors of boys seen at a single centre who underwent surgical exploration for testicular torsion. Methods: Retrospective single‐centre review of boys with testicular torsion between 1996 and 2011 was made. Results: Testicular torsion (right n = 43, left n = 60, bilateral n = 1) was identified in 104 boys between 0 and 18 years. Ten newborns presented with 11 intrauterine torsions. Nine torsions presented in undescended inguinal testes (one intrauterine). In 94 boys with descended testes, presentation included pain (76%), scrotal swelling (65%) and abdominal symptoms (22%). Ultrasonography was performed in 85 patients with false‐negative results in 4 (4.7%). Orchiectomy was performed during initial exploration in 41, with significantly higher rates of orchiectomies in patients with late (>6 h) versus patients with early referrals (<6 h) (56% vs. 9.1%). Histological evaluation was carried out in 68 testes, with 43 resected testes demonstrating haemorrhagic necrosis. In 25 biopsied testes, histology revealed acute parenchymal bleeding (n = 14), onset of parenchymal infarction (n = 8), orchitis (n = 1) and normal tissue (n = 2). Eighty‐two patients were followed up with pathological findings in four patients: testicular atrophies requiring orchiectomy (n = 2), testicular autolysis (n = 1) and small testicular vein thrombosis (n = 1). Conclusion: Chances of testicular salvage after torsion are higher if patients present early. The majority of patients presenting late (>6 h) require orchiectomy owing to testicular necrosis.     

Histopathology of undescended testes

This paper presents a survey of the morphological findings in cryptorchid testes, especially of children. There is no doubt that undescended testes not operated on early in life are seriously damaged. Cryptorchid testes of adults are much smaller than normal. The tubules are atrophic, the germinal epithelium is generally largely absent and the Leydig-cells are vacuolated, and loaded with lipids. Foci of hypoplastic tubules and so-called ring-like tubular structures are frequent.In children the testicular lesions of cryptorchidism are less pronounced than in adults. They are characterized by disturbances in tubular structure and particularly by a diminution of germ cells or, especially in cases of bilateral cryptorchidism, by a complete lack of such elements. These tubular lesions are manifested already in the second year of life. In addition, the interstitial tissue of undescended testes is generally more abundant and Leydig-cells seem to be more atrophic than in normal testes. Some of these lesions found in cryptorchid testes seem to be the result of a malformation rather than of testicular malposition alone.Finally, in patients with cryptorchidism the higher risk of developing a testicular germ cell tumor must be considered. In adults with cryptorchidism so-called atypical germ cells can be demonstrated even if there are no clinical signs of a malignant testicular tumor. Considering the relatively high frequency of malignant germ cell tumors in adults with cryptorchidism, testicular biopsies should be performed if a primary orchidectomy is refused. As testicular tumors may not only develop in the cryptorchid testis but in the descended partner as well, even bilateral testicular biopsies may be indicated.     

不同日龄隐睾复位大鼠睾丸组织结构观察

目的 观察不同13龄隐睾复位大鼠睾丸组织结构的变化.方法 72只21 d雄性SD大鼠随机分为单侧隐睾组、双侧隐睾组、假手术对照组各24只.建立单、双侧隐睾动物模型.2周后行隐睾大鼠睾丸下降固定术,于日龄40、60 d处死取睾丸,采用苏木素.伊红染色光镜下观察各组大鼠精曲小管生育力指数(TFI)和平均精曲小管直径(MTD);生物素-dUTP/酶标亲和素法(TUNEL法)检测睾丸生殖细胞凋亡情况.结果 隐睾侧睾丸MTD、TFI显著低于阴囊内睾丸,而隐睾生殖细胞凋亡指数(AI)明显增高于阴囊内睾丸(P＜0.05);单侧隐睾组阴囊内睾丸TFI低于相应日龄的假手术对照组,但无统计学意义(P＞0.05).40 d时单侧隐睾组隐睾侧睾丸生殖细胞AI较双侧隐睾组低(P＜0.05),日龄60 d,各组隐睾侧睾丸AI较40 d时明显降低(P＜0.05),但单侧隐睾和双侧隐睾AI比较无统计学差异(P＞0.05).结论 实验隐睾复位大鼠睾丸AI升高,同时单侧隐睾鼠对侧睾丸组织存在不同程度的损害.随着复位时间的延长,隐睾组织的病理损害有恢复的趋势.     

Pituitary-gonadal axis in male undermasculinisation.

AIMS: To study the value of assessing serum concentrations of luteinising hormone (LH), follicle stimulating hormone (FSH), testosterone, and dihydrotestosterone (DHT) in patients with male undermasculinisation not caused by androgen insensitivity. METHODS: A retrospective study of a register of cases of male undermasculinisation (20 with abnormal testes, eight with 5alpha-reductase deficiency, three with testosterone biosynthetic defects, seven with Drash syndrome, and 210 undiagnosed). RESULTS: A human chorionic gonadotropin (hCG) stimulation test was performed in 66 of 185 children with male undermasculinisation. In 41 of 66 patients the dose of hCG was either 1000 U or 1500 U on three consecutive days. The rise in testosterone was related to basal serum testosterone and was not significantly different between the two groups. Testosterone:DHT ratio in patients with 5alpha-reductase deficiency was 12.5-72.8. During early infancy, baseline concentrations of LH and FSH were often within normal reference ranges. In patients with abnormal testes, median pre-LHRH (luteinising hormone releasing hormone) concentrations of LH and FSH were 2 and 6.4 U/l, respectively, and post-LHRH concentrations were 21 and 28 U/l. An exaggerated response to LHRH stimulation was observed during mid-childhood in children where the diagnosis was not clear and in all children with abnormal testes. CONCLUSIONS: The testosterone:DHT ratio following hCG stimulation is more reliable than the basal testosterone:DHT ratio in identifying 5alpha-reductase deficiency. During infancy, the LHRH stimulation test may be more reliable in identifying cases of male undermasculinisation due to abnormal testes than basal gonadotrophin concentrations.     

Testicular growth from birth to two years of age, and the effect of orchidopexy at age nine months: a randomized, controlled study

AIM: To study whether surgical treatment at age 9 mo in boys with congenital unilaterally palpable undescended testes (cryptorchidism) is followed by improved growth of the previously retained testes compared to non-treatment. METHODS: At the age of 6 mo, 70 boys were randomized to surgical treatment at 9 mo and 79 boys to treatment at 3 y of age. The boys were then followed at 12 and 24 mo. Ultrasonography was used to determine testicular volume. RESULTS: After orchidopexy, the previously retained testes resumed growth and were significantly larger than the non-operated testes at 2 y (0.49 ml vs 0.36 ml, p<0.001). Testicular growth after orchidopexy was also demonstrated by a higher mean ratio between the previously retained and the scrotal testes of the individual boys at 2 y: 0.84 for the surgically treated group, compared to 0.63 for the untreated group (p<0.001). CONCLUSION: Surgery at 9 mo has a beneficial effect on the growth of previously undescended testes.     

Studies of cryptorchidism in experimental animal models

Undescended testes are the most common inborn anomaly in boys but our understanding of the causes is still sparse. Experimental models of cryptorchidism in various species of animals have been used by many investigators in order to gain a better understanding of the aetiology, pathophysiology and potential treatment of the disorder. This review presents what has been gained so far by studies using experimental animal models of cryptorchidism. Conclusions: Early orchidopexy in experimentally cryptorchid animals of different species prevents, at least partially, against testicular damage and infertility. This supports an early intervention strategy in the management of cryptorchidism in humans although animal data on the correct timing of such treatment cannot be directly translated into human clinical practice due to the species differences in pre and postnatal testis maturation. Treatment with pharmacological doses of hCG has poor efficacy in experimental animals and may cause adverse effects. Thus, clinically relevant doses of hCG causes acute inflammation-like changes in rodent testes and there are also indications that it may induce morphologically detectable permanent testicular damage.     

Phenotypic variation in a family with partial androgen insensitivity syndrome

A family with partial androgen insensitivity syndrome exhibited considerable variation in phenotypic expression of their androgen resistance. One subject died at 2 1/2 years of age of a Wilms' tumor. In the two living members, one had a micropenis with otherwise normal genitalia, while the other had a small phallus, perineoscrotal hypospadias, bifid scrotum, and persistence of a vaginoutricular pouch. At puberty, plasma androgens and serum gonadotropins increased to normal or elevated values. However, despite adequate endogenous plasma testosterone levels and testosterone therapy, these patients showed poor virilization and were sterile. Studies of cultured sexual skin fibroblasts showed adequate 5 alpha-reductase activity and normal receptor affinity and capacity for dihydrotestosterone. An X-linked mode of inheritance is postulated, although autosomal dominance cannot be ruled out.     

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.     

隐睾症中激素和雌雄激素受体的研究

目的　从激素和雌雄激素受体变化探讨隐睾症发病机制。方法　化学发光免疫技术检测30例隐睾症和16例斜疝(对照组)患儿血清促卵泡生成激素(FSH)、促黄体生成激素(LH)和睾丸酮(T)激素水平;免疫组化技术观察隐睾症患儿睾丸引带、阴囊肉膜、阴囊皮肤和斜疝患儿疝囊组织雄激素受体(AR)和雌激素受体(ER)表达情况。结果　①激素水平:隐睾症组血清LH和T水平与斜疝组二者之间无显著性差异(P<0.05);双侧隐睾组血清FSH水平高于斜疝组(0.01相似文献   

Growth patterns in young men treated for undescended testes in childhood

Testicular maldescent may be caused by endocrinological deficiency in some cases, and, on the other hand, cryptorchidism itself may have an injurious effect on testicular development and function. The purpose was to examine whether testicular maldescent is associated with abnormal growth in various body dimensions in otherwise healthy males treated for the malformation during childhood. A total of 76 young men, 16–30 years of age, who were treated for undescended testes at an age ranging from 10 months to 13 years, were examined by measuring various body dimensions. Previously cryptorchid men were slightly taller than age-matched controls, except for those with bilateral cryptorchidism treated preoperatively with hCG. The most prominent finding was a high bihumeral to bicristal ratio. In addition, testicular volume was positively correlated to both the bicristal and bihumeral width, as well as to the sitting and total height.     

青春期前隐睾患儿手术前后抗精子抗体检测的意义

目的检测青春期前隐睾患儿手术前后血清抗精子抗体（AsAb），探讨AsAb与睾丸位置、手术、单／双侧和伴输精管／附睾畸形等因素的关系。方法收集隐睾患儿,50例，取腹股沟斜疝患儿和腹股沟区正常儿童各50例作为对照组。分别抽取患儿术前及术后6个月血清，采用AsAb金标免疫斑点法检测其血清AsAb IgG、IgM水平。结果隐睾组术前及行睾丸下降固定术后AsAb的阳性率分别明显高于腹股沟斜疝组术前及术后和健康对照组（Pa〈0．01）。睾丸下降固定术、单／双侧隐睾、术前睾丸位置及伴输精管和（或）附睾畸形均与AsAb无显著相关（Pa〉0．05）。结论青春期前隐睾患儿血清AsAb阳性率显著升高，与手术、术前睾丸位置、单／双侧隐睾及是否伴输精管／附睾畸形无显著关系。     

An old technique for surgery of 'high' undescended testis revisited

IntroductionMost undescended testes resolve spontaneously in the first year of life. If the testis remains undescended by the second year, the most probable means of scrotal placement is orchiopexy. After the first successful operation for orchiopexy, many surgical modifications were described. This study presents our limited experience with Prentiss' maneuver in six boys with high undescended testes.Patients and methodsTwo left, two right and two bilateral testes, in six patients, were operated. Five patients were admitted with the complaint of unilaterally or bilaterally ‘empty scrotum’. The sixth patient previously had a right high undescended testis which had been placed in a high scrotal position. Following the standard steps of inguinal orchiopexy Prentiss' maneuver were performed and yielded adequate distance to place the testes mid scrotum.ResultsOn follow-up, Doppler ultrasound examination revealed normal sized testes with normal blood flow in all patients with dimensions correlated with age.ConclusionAlthough perhaps only useful in orchiopexy for high undescended testis, incision of the transversalis fascia preserves testicular blood flow by relieving tension on the testicular vessels.     

Penoscrotal hypospadias and coarctation of the aorta with mixed gonadal dysgenesis

A 45,X/46,Xidic(Y)(q11.2) mosaicism was found in a 4-year-old boy. The clinical appearance was characterized by bilateral cryptorchidism, penoscrotal hypospadias, short penis, and coarctation of the aorta. The latter is the only abnormality also seen in Turner syndrome. A biopsy of the gonads revealed normal prepubertal testicular tissue. A chromosome analysis in all boys with penoscrotal, scrotal, or perineal hypospadias and a thorough examination of the heart in children with 45,X/46,XY mosaicism are recommended. Accepted: 6 August 1999     

Inguinal approach for the management of unilateral non-palpable testis: Is diagnostic laparoscopy necessary?

ObjectiveDuring the last decade laparoscopy has increasingly been advocated as the primary investigative procedure for the management of the non-palpable testis. We reviewed the medical records in a consecutive series of boys with non-palpable testis to examine the contribution of the initial inguinal approach in the management of unilateral non-palpable testis.Materials and methodsAmong the 183 consecutive patients with cryptorchidism from 2003 to 2012, there were 21 patients with unilateral and three with bilateral non-palpable testes. All unilateral patients then underwent inguinal and scrotal exploration through an inguinal incision. For those patients with an intra-abdominal peeping testis, the gonad was placed into the scrotum after meticulous cranial mobilization of the spermatic cord.ResultsPatient age ranged from 11 months to 144 months (mean age: 23 months). Among the 21 unilateral cases, testicular absence or atrophy was confirmed in seven patients with a scrotal nubbin in six, and blind-ending vas and vessels at the external inguinal ring in one patient. Among the remaining 14 patients with sizeable testes, 12 testes were intra-abdominal peeping testes and two testicles were seen within the distal inguinal canal, which may be missed on physical examination owing to patient obesity. The intra-abdominal peeping testicle had the opened processus vaginalis entering the internal ring in which testicle was found. These were fixed into the scrotum successfully by cranial mobilization of spermatic vessel sometimes cutting the internal oblique muscle and by Prentiss and Fowler-Stephen's maneuver. Diagnostic laparoscopy was done on three patients with bilateral cases.ConclusionsGiven the result that most of nubbins are within the scrotum and testes with intra-abdominal peeping testes are fixed down safely into the scrotum, the inguinal approach may suffice for the management of unilateral non-palpable testis. Laparoscopy should be reserved for patients with bilateral non-palpable undescended testes.