Previous testicular position in boys referred for an undescended testis: further explanation of the late orchidopexy enigma?

OBJECTIVE: To investigate the significance of the acquired undescended testis (UDT), which is differentiated into congenital and acquired forms, by assessing the previous testicular position in affected boys. PATIENTS AND METHODS: The study comprised 261 boys who had been referred for a non-scrotal testis to the outpatient clinic during an 8-year period (1993-2000). There was a bimodal distribution of age, with peaks at 2.0 and 10.0 years. In each boy with UDT the previous testicular position was ascertained. RESULTS: On referral, 340 testes were not in the scrotum (182 uni- and 79 bilateral). Of the 340 testes, 82 (24%) in 61 boys were diagnosed as retractile, whereas the remaining 258 in 221 boys were undescended. The previous testicular position was known in 208 of 221 boys (94%), with 244 UDTs. In 65 of these 244 (26.6%) the testis had never been scrotal (congenital UDT); in 179 (73.4%) a previous intrascrotal position was recorded in early childhood (acquired UDT) at least once, in 149 (61%) at least twice and in 117 (48%) at least three times. The mean age at referral for congenital UDT was 2.1 years and for acquired UDT was 8.4 years. CONCLUSIONS: These results show that acquired UDT is frequent, and occurs at about three times the rate of congenital UDT. Because these boys are referred for treatment later in childhood, the acquired UDT probably accounts for the high rate of (late) orchidopexy.     

Long-term testicular position and growth of acquired undescended testis after prepubertal orchidopexy

PurposeThe aim of the study was to determine long-term testicular position and growth of acquired undescended testis (UDT) after prepubertal orchidopexy.MethodsPatients who had undergone prepubertal orchidopexy for acquired UDT at our hospital between 1986 and 1999 were recruited to assess long-term testicular position and volume. Testis position was assessed by physical examination. Testis volume was measured with Prader orchidometry and ultrasound and was compared with normative values reported in the literature.ResultsA total of 105 patients (aged 14.0-31.6 years) were included with 137 acquired UDT (32 bilateral, 33 left sided, and 40 right sided). All but 1 of the orchidopexied testes (99.3%) were in low scrotal position. The mean volume of the orchidopexied testes in unilateral UDT (n = 73, 10.57 ± 3.74 mL) differed significantly from the size of the testes at the contralateral side (14.11 ± 4.23 mL) (P = .000). The operated testes (10.28 ± 3.45 mL) were smaller than the mean adult testis volume reported in the literature (13.4-13.6 mL; cutoff, 13.2 mL).ConclusionTestis position after prepubertal orchidopexy for acquired UDT was nearly always low scrotal. The volume of the orchidopexied testes was smaller than both the volume of the contralateral testes and the normative values reported in the literature.     

Congenital inguinal hernia,hydrocoele and undescended testis

Congenital inguinal hernias (CIH), hydrocoeles and undescended testes (UDT) are common groin conditions in neonates, infants and children that are encountered by general practitioners, paediatricians, general surgeons and paediatric surgeons. CIH, hydrocoeles and UDT share a common embryological origin. Clinical differentiation between the three conditions can be challenging, particularly as they may exist in isolation or combination in the same patient. Accurate clinical distinction is imperative as the management and outcome is different for each condition. Surgery and outcomes for these conditions is discussed.     

Congenital inguinal hernia,hydrocoele and undescended testis

Congenital inguinal hernias (CIH), hydrocoeles and undescended testes (UDT) are common groin conditions in neonates, infants and children that are encountered by general practitioners, paediatricians, general surgeons and paediatric surgeons. CIH, hydrocoeles and UDT share a common embryological origin. Clinical differentiation between the three conditions can be challenging, particularly as they may exist in isolation or combination in the same patient. Accurate clinical distinction is imperative as the management and outcome is different for each condition. Surgery and outcomes for these conditions is discussed.     

Puberty stage and spontaneous descent of acquired undescended testis: implications for therapy?

We assessed spontaneous descent of acquired undescended testis (UDT) at puberty. 299 Boys (aged 1.2-16.5 years, mean 9.4) with 350 acquired-UDT were examined annually during a 12.6-year period (mean 3.1). An acquired-UDT was defined as a previously intrascrotal testis which can no longer be manipulated into a stable scrotal position. Each year, position of the testis and pubertal development according to Tanner's stages were assessed. Early puberty was defined as puberty stage G2 (testicular volume 4-9 mL), mid-puberty as puberty stages G3 (testicular volume 10 mL) and G4 (testicular volume 11-15 mL), and late puberty as puberty stage G5 (testicular volume >15 mL). Follow-up was completed if spontaneous descent had occurred, if mid-pubertal orchidopexy (ORP) had to be performed, if the boy was lost for follow-up, or if pre-pubertal ORP was performed in another hospital. In 139 boys with 164 acquired-UDT follow-up was meanwhile completed. Twelve boys with 14 UDT were lost for follow-up. In an additional 16 boys with 21 UDT, ORP was performed in another hospital. In 98 of the remaining 129 (76.0%) acquired-UDT spontaneous descent at puberty occurred. Mean follow-up was 2.5 years (range 0.2-8.5). In 70 of 98 testes (71.4%) descent occurred in early puberty, in 26 of 98 testes (26.5%) in mid-puberty, and in two testes in late puberty. In 31 of 129 testes (24.0%) ORP had to be performed at mid (30 cases) or late (one case) puberty. In this series, 98 of 129 acquired-UDT (76.0%) descended spontaneously at puberty, whereas in 31 of 129 (24.0%) pubertal ORP was performed. If ORP is postponed until puberty stage G3 (testicular volume of 10 mL) three of four acquired-UDT will descend spontaneously.     

Diagnosis and Management of Cryptorchidism

Among males born at full term or prematurely, 1–30% are affected by cryptorchidism. Approximately 70% of cryptorchid testes will spontaneously descend by 3 mo.The cause of cryptorchidism is multifactorial. A prerequisite for testicular descent is a normal hypothalamic-pituitary-gonadal axis. In addition, an undisturbed interaction with the anatomic structures is required, as well as the appropriate hormonal milieu and environmental conditions. Hereditary factors also play a major role.The Kaplan classification distinguishes between palpable testes (80%) and nonpalpable testes (20%). The nonpalpable group includes intra-abdominal, inguinal, and absent (vanishing) testes, whereas palpable testes can be between the internal and external inguinal ring, high scrotal, or in a superficial pouch between the oblique and the Scarpa fascia in the so-called Denis Browne pouch.Therapy for undescended testis (UDT) is usually carried out when a child is between 6 and 12 mo; individuals with high UDT especially benefit from an early orchidopexy. The lower the pretreatment position, the more chance there is of spontaneous descent as well as better results of surgical intervention.Although the management of a palpable testis is standardized, there are no guidelines for the management of boys with a nonpalpable testis. It seems that both preoperative and postoperative hormonal treatment may have a beneficial effect on fertility later in life. Because of the increased risk of testicular malignancy, lifelong follow-up is mandatory.     

Congenital abdominal wall defects and testicular maldescent--a 10-year single-center experience

PurposeThe relationship between congenital abdominal wall defects (AWDs) and undescended testes (UDTs) is poorly defined. We report a study of infants with AWD and UDT.MethodsHospital records of newborns with AWD managed during 1998 to 2008 were reviewed. Data analyzed included nature of AWD, position of the testes at birth, final position of the testes, and surgical management.ResultsA total of 218 newborns with AWD were identified; 106 (49%) were boys. Of 79 boys with gastroschisis, 26 (33%) had UDT involving 35 testes. Of 27 with exomphalos, 6 (22%) had UDT involving 11 testes. Prolapsed testes were placed in the abdomen at AWD repair, whereas others were observed for “spontaneous” descent. Of 35 UDT in gastroschisis infants, 18 descended spontaneously, and 10 required orchidopexy. Three boys underwent laparoscopy for impalpable testes, 2 underwent orchidectomy, and 1 had bilaterally absent testes. Three cases await orchidopexy. In exomphalos boys with 11 UDTs, 1 gonad descended spontaneously, and 6 had groin exploration (1 absent testis and 5 orchidopexies). Two boys await orchidopexy, and 1 boy (bilateral impalpable testes) was lost to follow-up.ConclusionAbdominal wall defects are strongly associated with UDT. In boys with gastroschisis, spontaneous descent of the testes may be anticipated in 50% of cases. In those with exomphalos, orchidopexy should be scheduled.     

The low scrotal approach to the ectopic or ascended testicle: prevalence of a patent processus vaginalis

PURPOSE: The scrotal approach to undescended testis has been described using a high scrotal incision and including hernia repair. We describe an approach that uses a low scrotal incision with an inguinal incision if a patent processus is identified. We retrospectively reviewed the likelihood of a patent processus in children selected to undergo this technique. MATERIALS AND METHODS: A total of 56 consecutive patients determined by history and physical examination to have ectopic or ascended testes underwent orchiopexy using an initial scrotal approach for a total of 71 undescended testes. Inguinal surgery had previously been done in 5 testes, which were not included in patent processus analysis. Charts were reviewed for testicular position, need for inguinal incision and demographic data. RESULTS: Of the patients 16 (19 testes) were younger than 2 years, 19 (26 testes) were 2 to 6 years old and 17 (21 testes) were older than 6 years. In 20% of the patients an inguinal incision was made for a patent processus vaginalis. The incidence of a patent processus was 26% in those younger than 2 years, 15% in those 2 to 6 years old and 19% in those older than 6 years (p = 0.17). All patients had satisfactory scrotal placement with at least 1 followup examination. CONCLUSIONS: Children with ectopic or ascended testes on physical examination findings may be treated successfully via a low scrotal approach with only 20% requiring concomitant inguinal hernia repair through a standard inguinal incision. Overall 80% of the children avoided an inguinal incision. This technique has become our standard approach to these testes.     

The blind-ending vas: the fate of the contralateral testis

From August 1980 to January 1983, 48 testes were explored for orchiopexy (28 unilateral and 20 bilateral testes). Unilateral anorchism (surgically identified blind-ending vas and vessels) was found in 7 of 48 cases (14.5 per cent). One simultaneous and 5 secondary contralateral scrotal explorations confirmed abnormal testicular fixation (bell-clapper deformity) in 5 of 6 testes (83 per cent). During documentation of unilateral anorchism, simultaneous contralateral scrotal exploration should be performed.     

Management of boys with nonpalpable undescended testes

An undescended testis (UDT) is one of the most common genital anomalies in boys. Complications of a UDT include testicular cancer, infertility, and testicular torsion. Prompt treatment can minimize the risk of these complications. Although there are standardized guidelines for boys with palpable undescended testes, there are no formal guidelines for managing boys with nonpalpable testes. In this mini-review, we look at current trends in diagnosing and treating this disorder as well as surgical procedures. Laparoscopy is both a diagnostic and therapeutic procedure, which is safe when performed by a skilled operator.     

Ptosischirurgie

Ptosis can be congenital but is more commonly an acquired condition occurring in particular as involutional forms. In addition to the aesthetic aspects ptosis mostly also leads to functional problems. Congenital ptosis in particular carries a high risk of amblyopia in childhood, therefore competent and close-knit pediatric ophthalmological treatment is important. Correction of ptosis is surgical and direct or indirect procedures are available depending on the conditions. Transcutaneous levator surgery has proven to be the universally applicable method for ptosis of all degrees of severity and can be combined with other corrective measures, such as temporal canthopexy or blepharoplasty, particularly for eyelids of elderly patients. In cases of severely impaired levator function and poor Bell phenomenon the indirect frontalis suspension method can be used. Congenital ptosis in childhood should be surgically treated at an early stage because of a substantial risk of amblyopia even if the central visual axis is still clear. The results of ptosis surgery are generally good and serious complications are rare.     

Management of an unusually high postpubertal presentation of cryptorchidism

A high proportion (43%) of postpubertal presentation of cryptorchid testes was found in 114 patients with undescended testes (UDT). Bilateral presentation of UDT was observed in 25% of patients. Orchiopexy was performed on 75% of postpubertal cases, the determinant factor for choice of operation being cosmetic and psychological. Follow-up results appear to be promising in this environment with very low incidence of testicular cancer.     

Perioperative surgical findings in congenital and acquired undescended testis

Purpose

Perioperative surgical findings in congenital and acquired undescended testis (UDT) were prospectively assessed.

Methods

We included all boys with congenital or acquired UDT who underwent orchidopexy at our hospital between January 2006 and August 2009. Perioperatively, we scored the position and volume of the testis, the insertion of the gubernaculum, the patency of the processus vaginalis, and the obtained position.

Results

We included 69 boys (aged 0.9-14.6 years) with 76 congenital UDT and 28 boys (aged 2.2-18.5 years) with 30 acquired UDT. In the congenital group, the testis was in intracanalicular position in 55 cases (72%), whereas in the acquired UDT group, this was in 11 cases (37%; P < .001). The insertion of the gubernaculum was at the bottom of the scrotum in 13 cases (17%) of the congenital UDT group and in 12 cases (40%) of the acquired UDT group (P < .05). The processus vaginalis was open in 63 cases (83%) of the congenital and in 9 cases (30%) of the acquired UDT group (P < .001).

Conclusion

Compared to congenital UDT, acquired UDT are more likely to be situated in the superficial inguinal pouch, to have a normal insertion of the gubernaculums, and to have a closed processus vaginalis.     

Hodenhochstand

Undescended testis (UDT) is the most frequent congenital malformation affecting 1% of 1-year-old mature birth boys. If untreated UDT leads to progressive histological changes with impaired spermatogenesis and an increasing risk of testicular cancer. For clinical reasons palpable testes should be differentiated from impalpable testes. Spontaneous testicular descent can be expected only before 6 months of age. Subsequently, treatment should start without delay and be finished before the child has reached the age of 1 year. Surgery is the cornerstone of treatment. Inguinal approaches are standard practice for palpable testes, whereas laparoscopy is used in non-palpable testes. Hormonal treatment is ineffective for inducing testicular descent but facilitates germ cell maturation and an improvement in fertility potential. Only early reatment of UDT reduces germ cell loss, improves fertility and reduces the risk of testicular cancer.     

Assessment of referral patterns for boys with suspected undescended testes and identification of risk factors to aid diagnosis

IntroductionUndescended testis (UDT) is a clinical diagnosis and a common reason for referral to paediatric urology outpatients. Our aim was to assess current referral patterns at our unit and to identify predictive factors that may better aid primary care physicians (PCP) in diagnosing UDT based on history and physical exam.MethodsA retrospective analysis of referrals to outpatients from 2014 to 2016 was performed to assess current referral patterns including referral source, age, reason for referral and outcome following assessment by a single consultant paediatric urologist.A prospective analysis of new referrals was performed to identify predictive factors which may aid in the diagnosis of UDT including gestational age, presence of scrotal asymmetry and previously obtained imaging.ResultsFrom 2014 to 2016, 259 boys were referred with suspected UDT. The majority of referrals were received from PCPs (62%) followed by Neonatology (29%), Paediatrics (8%) and general surgery (1%). Median age at time of assessment was 29 (5–180) months. One hundred and eight (41.7%) boys were diagnosed with UDT.There were 74 boys assessed prospectively. Median age at assessment was 24.5 (6–171) months. We identified 3 predictors of a diagnosis of UDT; history of prematurity (p = 0.001), UDT mentioned to the parents at birth (p = 0.027) and scrotal asymmetry on examination (p < 0.001). Greatest diagnostic inaccuracy was found in boys referred beyond one year of age (27.7%). In this cohort, the absence of all three risk factors was associated with a negative predictive value of 94.1%.ConclusionThe majority of boys with suspected UDT are referred beyond the age recommended for orchidopexy (6–12 months). The majority of boys referred for assessment did not have UDT. We have identified three predictive factors that may aid referring physicians when assessing boys, particularly those older than 1 year.     

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.     

Update on congenital versus acquired undescended testes: incidence, diagnosis and management

Congenital and acquired undescended testes are two distinct entities. Current management is surgery in the first 6-12 months of life for congenital undescended testes. Current management of acquired undescended testes is surgery at the time of diagnosis. Accurate diagnoses and expedient management are imperative in this condition to minimize the long-term sequelae of infertility and testicular cancer.     

Elephantiasis of the penis and scrotum. A review of 350 cases

Three hundred fifty patients with elephantiasis of the penis and scrotum were surgically treated by excision of all elephantoid skin and subcutaneous tissues. Before attempting to excise the extensive elephantoid tissues, the spermatic cord and testes with their coverings were taken out by two small lateral incisions, which made the operation easier and less time-consuming and minimized the complications. The skin of the scrotal neck was found to be the best for reconstruction of the scrotum to accommodate the two testes. The fascial penis is an ideal bed for intermediate split-thickness skin grafts. There was mechanical improvement in the physical disability, restoration of potency and sexual habits, and reduction of mental anguish.     

An unusual congenital scrotal lymphatic malformation with absent corpora cavernosa: a case report

Congenital lymphatic malformations of the genitourinary tract are rare. A 2-day-old male child who presented with congenital scrotal swelling extending into the penile shaft was investigated and successfully treated with complete excision. We report this unusual case of congenital scrotal lymphatic malformation with absent corpora cavernosa for its rarity, which is not yet discussed in the medical literature.     

Malondialdehyde and CA II autoantibody levels are elevated in children with undescended testes

Purpose

In the pathogenesis of sub-fertility/infertility and testicular cancer related to undescended testes, oxidative stress, inflammation and autoimmunity are important factors. Therefore, the present study was designed to determine serum oxidative stress markers and carbonic anhydrase (CA) II autoantibodies in boys with undescended testes (UDT), and to investigate the relationship between these parameters.

Methods

Serum CA II autoantibody titers, malondialdehyde (MDA), ischemia modified albumin (IMA), protein carbonyl content and soluble CD40 ligand (sCD40L) levels were measured in 59 boys with UDT and 30 healthy subjects.

Results

MDA levels were significantly higher in the UDT group compared with the control group (p = 0.003). There was no significant difference between serum IMA, sCD40L or protein carbonyl levels. CA II autoantibody titers in the UDT group were significantly higher compared with those of the control group (p = 0.048). A weak positive correlation was determined between anti-CA II antibody titers and MDA and IMA levels (p = 0.041, p = 0.005, respectively).

Conclusions

MDA is the most reliable and decisive biochemical marker displaying oxidative damage in undescended testes, and an autoimmune response may be triggered by oxidative stress against CA II during the UDT process.