Clinical and cytogenetic studies in undescended testes.

168 boys and 2.5-16.8 years with unilateral or bilateral undescended testes or anorchia were studied. Retention was severe (canalicular or intraabdominal) in 1/4 and moderate in 3/4 of the cases. In unilateral retention, the volume of the scrotal testis was usually normal throughout childhood whereas pubertal testicular growth was delayed. In unilateral anorchia, the scrotal testis showed compensatory hypertrophy. In all age groups examined, the mean volume of the undescended testes was abnormally small. Undescended testes were accompanied by abnormalities of the epididymis in 3.6% of cases, of the ductus deferens in 7.8% and of the spermatic vessels in 8.3%. In anorchia such abnormalities were found regularly. Inguinal hernia accompanied 62.8% of the undescended testes and was most frequent in severe cases. Patients aged 8.0-9.9 years with unilateral undescended testis had advanced bone age. Cytogenic investigations of 167 patients revealed one case of Klinefelter's syndrome (47, XXY). Gonadotrophin treatment was tried in 50 patients and was succesful in 12. Surgical results were satisfactory in 86.1% of the operated testes.     

ENDOCRINOLOGICAL STUDIES IN UNDESCENDED TESTES

Abstract. A cross-sectional study was carried out on 168 boys aged 2.5–16.8 years with unilateral or bilateral testicular maldescent. Urinary excretion of testosterone, Δ₄-androstenedione, LH and FSH was investigated. The results were related to chronological age, bone age and sexual maturation stage. Urinary testosterone excretion was elevated in unilateral and bilateral cases of undescended testis under 9 years of age. The pubertal increase of testosterone excretion seemed to be moderately delayed in the patients. In pubertal stage V the testosterone excretion was normal. The mean testosterone/androstenedione relationship was normal in all age groups up to 14.9 years and increased in patients above this age. After HCG stimulation, the testosterone excretion increased at all ages studied whereas the androstenedione excretion increased only in bilateral cases under 11 years of age. Urinary LH excretion was diminished in bilateral cases aged 6.0–7.9 years and elevated in unilateral cases in pubertal stage V. Urinary FSH excretion was normal below 8 years of age, moderately elevated in bilateral cases aged 8.0–11.9 years and increased in unilateral cases in pubertal stage V. Patients with bilateral anorchia in pubertal stage I, had normal basal testosterone and androstenedione excretion while the LH and FSH levels were increased. The findings in this study indicated that disturbances in the pituitary-gonadal function of cryptorchids might be operative from early childhood and throughout pubertal years.     

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.     

单侧隐睾症患者睾丸大小及位置的术前超声评估

目的运用超声检查探讨单侧隐睾症患者年龄及睾丸所在部位与睾丸体积之间的关系。方法采用彩色多普勒超声检查双侧睾丸位置,测量睾丸各径线,计算睾丸体积。按年龄和睾丸所在位置分组。采用方差分析睾丸体积、年龄及睾丸所在位置的关系。结果608例年龄6个月至13岁经超声检查及手术证实的单侧隐睾患儿中,左侧306例,右侧302例。51例隐睾位于腹腔内,557例位于腹腔外。单侧隐睾患儿未下降睾丸位于腹腔内组与位于腹腔外组患侧睾丸体积比较无明显差异（P=0．658）;6个月至13岁各年龄组患儿患侧睾丸体积均明显较对侧睾丸体积小（P〈0．001）;单侧隐睾患儿双侧睾丸体积在1-11岁之间比较,差异无统计学意义（P〉0．05）。结论隐睾症对小于1岁的婴儿睾丸体积发育已造成影响,宜在1岁以前尽早手术。1-11岁双侧睾丸体积均未见明显变化,睾丸发育处于相对静止期。     

The differences in testicular volumes in boys 8-36 months old with undescended, retractile and hydrocele testis--usefulness of scrotal screening ultrasound

Purpose

The aim of the study was quantitative and qualitative assessments of scrotal abnormalities diagnosed in boys 8 to 36 months old during ultrasound screening and estimation if these abnormalities influence testes volume.

Materials and methods

High frequency scrotal ultrasound was performed in 1448 patients aged 8–36 months as additional exam during screening ultrasound program for children including cervical and abdominal ultrasound. The mean age of examined boys was 17 months. For further analysis the children were divided in 5 age groups.

Results

The abnormalities in scrotal ultrasound were found in 20.1% of boys. Undescended, cryptorchid testes were found in 4.8% of patients, mobile testicle in 7.6% and hydrocele in 2.8%. The volume of undescended testes was statistically lower than volume of the descended testes in 3 youngest groups of boys (p = 0.003–0.011). The volume of mobile testicles did not increase with age, while in patients with hydrocele the testicular volume decreased with age.

Conclusion

Scrotal screening ultrasound performed in boys up to 3 years old may deliver information about the number and type of existing pathologies as well as their influence on the testicular volume. The volume of the pathological testes was lower than the volume of the normal ones. Improper growth of testes may potentially have important clinical implication for the function of testes in the future.     

The high scrotal (“gliding”) testis revised

BACKGROUND: At present, the high scrotal testis is considered a distinct and separate entity of undescended testis. OBJECTIVES: The aim of this study was to assess whether high scrotal testis is actually either a congenital- or acquired-undescended testis. DISCUSSION: In 527 consecutive boys (aged 0.4 to 16.5 years, mean 7.5) referred for non-scrotal testis, the number of high scrotal testis was prospectively determined. According to previous testis position, the high scrotal testis was classified into congenital- and acquired-high scrotal testis. In congenital-high scrotal testis orchidopexy was performed whereas spontaneous descent at puberty was awaited in acquired-high scrotal testis. In 210 testes, the gonad was diagnosed as high scrotal. In six testes the condition was congenital and 204 testes were diagnosed as acquired. All cases of congenital-high scrotal testis were treated surgically. In 100 acquired-high scrotal testis follow-up was performed. Of these, 75 testes descended spontaneously at puberty. CONCLUSION: We propose that the high scrotal testis should be regarded, not as a distinct and separate entity, but as a part of the spectrum of either congenital-undescended testis or acquired-undescended testis. Since spontaneous descent can occur at puberty in acquired-high scrotal testis, therapy may be different between both forms.     

Comparison of testicular volumes between patients with undescended testes and inguinal hernias

During the past 29 years from 1962 to 1990, 222 cases of undescended testes were operated upon in our department. The ratio of right to left undescended testes was 1.15:1, and 18% were bilateral. Associated diseases were found in 22% of the patients, more than half of which were inguinal hernias. The volumes of the undescended testes were compared to those on the unaffected side of patients with unilateral inguinal hernias. The undescended testes were found to be significantly smaller than those of the controls in all age groups. Furthermore, the volumes of the scrotal testes also became significantly smaller than the controls in patients older than 5 years. These results suggest poor postnatal development of undescended and scrotal testes. Correspondence to: M. Kubota     

Endocrinological studies in undescended testes.

A cross-sectional study was carried out on 168 boys aged 2.5-16.8 years with unilateral or bilateral testicular maldescent. Urinary excretion of testosterone, delta4-androstenedione, LH and FSH was investigated. The results were related to chronological age, bone age and sexual maturation stage. Urinary testosterone excretion was elevated in unilateral and bilateral cases of undescended testis under 9 years of age. The pubertal increase of testosterone excretion seemed to be moderately delayed in the patients. In pubertal stage V the testosterone excretion was normal. The mean testosterone/androstenedione relationship was normal in all age groups up to 14.9 years and increased in patients above this age. After HCG stimulation, the testosterone excretion increased at all ages studied whereas the androstenedione excretion increased only in bilateral cases under 11 years of age. Urinary LH excretion was diminished in bilateral cases aged 6.0-7.9 years and elevated in unilateral cases in pubertal stage V. Urinary FSH excretion was normal below 8 years of age, moderately elevated in bilateral cases aged 8.0-11.9 years and increased in unilateral cases in pubertal stage V. Patients with bilateral anorchia in pubertal stage I, had normal basal testosterone and androstenedione excretion while the LH and FSH levels were increased. The findings in this study indicated that disturbances in the pituitary-gonadal function of cryptorchids might be operative from early childhood and throughout pubertal years.     

Is mobile testis a true pathological condition due to a gubernaculum abnormality?

The present study was conducted to clarify whether a gubernaculum abnormality exists in mobile testis or not. Testicular fixation was performed in 57 patients with mobile testis with a mean age of 3.6 years (range; 7 months–12 years). Twenty-six patients were bilateral and 31 patients were unilateral cases. Control gubernaculum findings were obtained from 12 patients with hydrocele testis with a mean age of 3.3 years (1.6–5 years). In 12 patients with hydrocele testis, the gubernaculum was found from the lower third of the testis to the scrotal base inside the tunica vaginalis (plica gubernaculi), while outside the tunica vaginalis pars infravaginalis gubernaculi further extended into the scrotal base. On the other hand, in 57 patients with mobile testis, the gubernaculum was easily identified only inside the tunica vaginalis without any recognizable gubernaculum outside the tunica vaginalis. In 31 unilateral patients, associated anomalies of the contralateral testis were found in 13 patients (42%); 11 cases with undescended testis and two cases with ectopic testis. These results suggest that mobile testis might therefore be a true pathological condition, which were highly associated with contralateral testicular morbidities.     

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.     

Groin and scrotal swellings in children aged 5 years and below: a review of 535 cases

There is limited literature dedicated to the surgical problems of infants and childhood, especially diseases of the groin and scrotum, in the setting of sub-Saharan Africa. We do not know the morbidity and mortality rates associated with surgical conditions of the groin and scrotum in children of our sub-region. This study was carried out among children aged 5 years and below in a regional referral hospital in Kumasi, Ghana, to determine the surgical conditions of the groin and scrotum treated at elective surgery. Inguinal hernias constituted 74% of the children with groin and scrotal diseases; this was followed by hydroceles - 14.2%; then undescended testis - 10.5%; and inguinal lymphadenopathy - 0.7%. The rest were testicular abscess, seminoma and cystic lymphangioma, representing 0.2% each of groin and scrotal conditions treated in this hospital among this age group. The last three are rare conditions of the groin and scrotum as shown by our data. The recurrence rate after herniotomy was 0.7%. Orchidopexy was successfully performed in 89% of children with undescended testes; in 7.1% of cases, orchidectomy was carried out for rudimentary and small, dysplastic testes. Over 98% of the children with groin and scrotal surgical problems were treated on day-care basis. There were no recorded deaths in the series.     

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.     

Undescended testis: evaluation by magnetic resonance imaging.

We describe our experience of prospective magnetic resonance imaging (MRI) study in patients of undescended testis, with a 1.5 T equipment using body coil. There were thirty two patients, aged 1.5 to 14 years with a mean age of nine years. Surgical follow up was obtained for thirty one patients. We were able to indicate the position of 26 testes in 22 patients and absence of five testes in three patients. MRI was falsely positive and negative for five and two testes, respectively. Testicular tissue at ectopic site was identified by presence of characteristic signal intensity pattern, mediastinum testis and its location along empty spermatic canal in cases of inguinal testis either singly or in combination. MRI was able to detect atrophic changes in four testes, confirmed on surgery. The study concludes that MR imaging is useful in the localization and tissue characterization of a non palpable testis. However, it is not sensitive enough for complete exclusion of the diagnosis of an undescended testis. Thus a surgical or laproscopic exploration may be needed further in selective cases for the management of patient.     

Testicular undescent and torsion

The higher the testis resides above the scrotum, the more dysgenetic the morphology is likely to be. High testes are rarely responsive to HCG and should be treated by orchiopexy by the age of 2 to 3 years. The undescended testis does not mature normally after the age of 2 years and may produce adverse effects on the contralateral descended testis, possibly by an autoimmune mechanism. A course of HCG for boys with low-lying undescended testes, both unilateral and bilateral, may produce descent in as many as 15 per cent of patients and may make the technical aspects of orchiopexy easier in those who do not respond. Unilateral cryptorchid testes that are dysplastic or located high should generally be removed before adolescence.     

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     

High scrotal (Bianchi) single-incision orchidopexy: a “tailored” approach to the palpable undescended testis

Our aim was to evaluate the utility of the high scrotal orchidopexy (Bianchi) approach for palpable undescended testis (UDT) and to assess long-term follow-up. We reviewed the records of orchidopexies performed between 1999 and 2002. The patients were then categorized by intraoperative exam under anesthesia as to whether their testes were palpable or nonpalpable. All palpable UDT that were initially thought to be amenable to a single high scrotal approach (Bianchi) were then reviewed. These cases were then analyzed to assess the impact of patient age, initial location of the testis, and prior inguinal/scrotal surgery with respect to the necessity to convert to a standard two-incision technique, and to analyze success and complications at 6–12-week and 1-year follow-up. Two hundred and nineteen orchidopexies were performed on 204 patients over this 4-year period. There were 178 testes palpable, and the transscrotal approach was used in 85 patients (100 orchidopexies). The preoperative positions of the testes that were thought to be amenable to Bianchi technique included the following: gliding (19), secondary trapped (25), superficial inguinal pouch (42), and location within the inguinal canal (2), while the remaining 12 testes were ectopic. Six patients required conversion to a traditional inguinal approach because of insufficient cord length via the single incision to allow the testis to lie in the scrotum. All patent processes vaginalis were ligated via the scrotal incision, regardless of their size. All patients, except for one who had a testis in the superficial inguinal pouch, had palpable testes of stable size and in a dependent position at 6–12-week follow-up. Of the 62 children who returned for 1-year follow-up, all had findings identical to those at their initial 6-week visits, with no atrophy or secondary reascent. Postoperative complications included transient postoperative scrotal hematoma in a single patient. The single failure underwent a successful two-incision orchidopexy for secondary reascent and a resultant trapped testis. Children with primary palpable undescended, gliding, or trapped testes can be managed successfully through the transscrotal route in the majority of cases. With use of a tailored approach to the palpable UDT, an additional groin incision is necessary only for a minority of appropriately selected cases.     

MRI findings of bilateral juvenile granulosa cell tumor of the testis in a newborn presenting as intraabdominal masses

Juvenile granulosa cell tumor (JGCT) of the testis is a rare benign tumor that typically presents as a relatively small (<2 cm) unilateral scrotal mass in neonates or infants. Bilateral JGCT of the testes presenting as large intraabdominal masses in the neonate is very rare. Utilizing preoperative MRI findings, we report a rare case of bilateral JGCT of the testes presenting as large multiseptated abdominal masses originating from undescended intraabdominal testes in a neonate.     

Epididymal and vasal abnormalities in undescended testes and azoospermia

Epididymal and vasal abnormalities (EVA) have long been known to be associated with cryptorchidism. In order to provide data concerning the incidence of EVA in undescended testicles, we operatively examined the anatomic relationship of the epididymis, vas, and testis in 456 cryptorchid patients (390 unilateral and 66 bilateral, over-all 522 undescended testes). As a control group we examined 50 adults postmortem and 96 pediatric patients operated upon for inguinal hernia or hydrocele. We divided the operative findings into two groups: simple variants of normal, and forms of complete anatomic disconnection of the spermatic ducts.We were unable to find any anatomic disconnection in either control group. In contrast, in 99 of the 522 maldescended testes operated upon (19%) we found some form of anatomic disconnection along the proximal spermatic ducts. The incidence was 17% in unilateral cryptorchidism and 26% in bilateral cases, in 16% of whom the EVA was bilateral. According to the literature and our previous study, azoospermia is present in about 18%–20% of adults operated upon for bilateral cryptorchidism. Our present study may suggest that in bilateral cryptorchid patients who were operated upon in the pediatric age range, the azoospermia in adulthood could be partially related to some form of bilateral occlusion or interruption of the spermatic ducts. Correspondence to: G. Belloli     

Testicular descent: when to interfere?

Spontaneous descent of testes after birth can occur in up to 70% of cases, yet the factors contributing to it are still controversial. This study aims to evaluate factors contributing to spontaneous descent of palpable undescended testes. Eighty-four newborns with 126 palpable undescended testes (42 unilateral and 42 bilateral) were followed up for a period of one year to study the occurrence and time of testicular descent and its relation to gestational age, birth weight, uni- or bilaterality and levels of FSH, LH and testosterone. A total of 58 testes (46%) descended between 3 and 6 months. Spontaneous descent occurred in 10 premature patients (14 testes 63%) compared to 44 testes of full-term patients (43%). Descent occurred in 14 unilateral undescended testes (33%) compared to 44 (52%) in bilateral cases. In patients with spontaneous testicular descent there was postnatal peak of LH and testosterone at 2 to 3 months of age which returned to basal level at 6 months of age. In patients with permanent undescended testes the peak of LH and testosterone was very low and almost absent in some of them; no significant difference was found between the mean values of FSH in both groups. No spontaneous testicular descent occurred after the 4th month in the full-term group, whereas in the pre-term group spontaneous descent occurred up to 6 months of age. This study concluded that spontaneous descent of palpable undescended testes is closely related to the presence of LH and testosterone surge. Therapy of undescended testes should start at 4 months of age in a full-term baby and at 6 months of age in a pre-term baby.     

Comparative studies of fertility and histologic development of contralateral scrotal testes in two rat models of unilateral cryptorchidism

 Fertility and the development of the contralateral scrotal testis in patients with unilateral cryptorchidism (UCO) remain controversial. This study investigated these controversies in two different UCO rat models using 43 Wistar King A rats. The animals were divided into three groups: I: an endocrinologic model of UCO was obtained by injecting pregnant dams with flutamide 100 mg/kg per day on days 15–17 of gestation (n = 12); II (n = 21): a mechanical model of UCO was obtained by extra-abdominal fixation of the gubernaculum in the neonatal period, III (n = 10): non-treated rats were used as controls. At the age of 90 days, 5 rats from each group were segregated into individual cages and housed with two virgin adult females for 2 weeks. The occurrence of pregnancy and litter sizes were counted in order to study fertility. All the animals were then weighed and killed. The occurrence of testicular descent, growth of the external genitalia, and epididymal development were examined. Morphologic and histologic evaluations were performed in the cryptorchid and contralateral testes. In the endocrinologic model (group I) the 10 female rats failed to show any offspring (0%), while in the mechanical model (group II) 9 out of 10 rats had offspring (90%, P < 0.001); 10 out of 10 control rats showed offspring. All of the rats in groups I and II had UCO, and the undescended testes were located in the superficial inguinal position, while the contralateral and control testes descended into the scrotum. Hypospadias and a small epididymis were frequently noted in the flutamide-treated rats. Testicular weight, seminiferous tubular diameter, and spermatogenesis were all significantly reduced in the undescended testes (UDT) compared to the contralateral and control testes. Moreover, the development of the contralateral testis was inhibited in group I compared to groups II and III. Our observations showed that short-term exposure to flutamide in utero induced significantly reduced fertility and degenerated contralateral scrotal testes in UCO rats compared to mechanically-induced UCO rats by early adulthood. It is suggested that fertility potential and testicular development in unilateral UDT may be partially due to the factors that induce testicular maldescent, especially in cases due to intrauterine hormonal abnormalities. These cases may show inhibited fertility and testicular development even after orchiopexy. Accepted: 3 February 2000