Testis histopathology in boys with cryptorchidism correlates with future fertility potential

PURPOSE: We studied the ability of testis biopsy to predict eventual fertility potential. MATERIALS AND METHODS: A total of 25 patients with unilateral undescended testis and 11 with bilateral undescended testes who previously underwent orchiopexy at a median age of 9 years were followed until after age 18 years. Semen analysis, testicular volume, follicle-stimulating hormone, luteinizing hormone, testosterone and inhibin B were compared to previously obtained biopsies of each testis. Biopsies were graded as mild, moderate or severe histology based on published data for normal and undescended testis histology. RESULTS: Patients with unilateral undescended testis and moderate histology were more likely to have a sperm density of greater than 20 million per cc than those with severe histology (p = 0.006), although no difference in hormonal parameters was noted. Patients with bilateral undescended testes and moderate histology were more likely to have normal follicle-stimulating hormone and inhibin B than those with severe histology (p = 0.05 and 0.002, respectively), although no difference in semen analysis was observed. Overall 7 of the 9 patients with bilateral undescended testes had less than 20 million sperm per cc. CONCLUSIONS: Testis biopsy provides useful prognostic information about semen analysis in patients with unilateral undescended testis. In the 9 patients with bilateral undescended testes testis biopsy divided them into normal and abnormal groups in terms of hormonal parameters. Testis biopsy was not able to provide additional prognostic information on semen analysis in patients with bilateral undescended testes since they were uniformly poor.     

腹腔镜诊治未触及隐睾29例(34侧)

目的探讨腹腔镜技术诊断和治疗未触及隐睾的疗效。方法2002年7月～2005年3月对29例34侧未触及隐睾利用腹腔镜技术进行诊断和治疗。结果29例均得到明确诊断。21侧腹腔内隐睾中16侧行一期睾丸固定术，5侧行分期Fowler-Stephens睾丸固定；13侧为睾丸缺如。29例随访0，5～1年，睾丸无回缩或萎缩。结论腹腔镜对小儿未触及隐睾的诊断和治疗具有创伤小、恢复快、治疗效果好等优点，可作为未触及隐睾患儿的首选诊治方法，如条件许可，一期睾丸固定术也能取得满意的临床疗效。     

Natural course of acquired undescended testis in boys

BACKGROUND: Although orchidopexy is commonly performed for acquired undescended testis, therapy is still controversial. A prospective study on the natural course of acquired undescended testis in boys was initiated. METHODS: At present, the study includes 63 boys with 74 acquired undescended testes in whom treatment and follow-up has been completed. In 15 boys with 20 acquired undescended testes, orchidopexy was performed before the onset of puberty, mainly at the request of the parents. In the remaining 48 boys with 54 acquired undescended testes, the onset of puberty was awaited. Of these, four boys with four acquired undescended testes were lost to follow-up. RESULTS: In 42 of 50 boys the testis descended spontaneously at puberty with a testicular volume appropriate for age. In the remaining eight boys the testis failed to descend at puberty and orchidopexy was performed. CONCLUSION: The preliminary results of this study indicate that spontaneous descent at puberty commonly occurs in boys with acquired undescended testes, with testicular volume appropriate for age. It is suggested that surgical intervention before onset of puberty may not always be necessary in acquired undescended testis.     

Prospective evaluation of human chorionic gonadotropin in the differentiation of undescended testes from retractile testes

PURPOSE: We prospectively evaluated the efficacy of human chorionic gonadotropin (HCG) in the treatment of undescended testis and sought to determine whether HCG assists in the differentiation of undescended testis from retractile testis. MATERIALS AND METHODS: Patients with undescended testes were offered HCG. Testis position, laterality and the presence or absence of a hypoplastic scrotum were noted. The same physician (G. W. K.) recorded physical findings prospectively and stated clinical impression of descent. RESULTS: A total of 67 patients with 90 undescended or retractile testes were treated and evaluated with HCG. Of the 64 undescended testes 13 (20%) descended with HCG therapy, with none requiring subsequent surgery. Of the 26 retractile testes 15 (58%) descended with HCG (p <0.001). Based on physical examination, 100% of retractile testes descended if the testis was in the high scrotal position but only 40% descended if the testis was in the superficial pouch or inguinal area. In the undescended testes group no ectopic or nonpalpable testis descended with HCG. Evaluation of HCG with age demonstrated minimal response (15%) to HCG at less than 24 months, and a peak response between ages 2 and 6 years (75%) with response decreasing thereafter. CONCLUSIONS: HCG may have a limited role in the evaluation of undescended testis in patients younger than 2 years. HCG can serve as an adjunct in the clinical diagnosis of retractile testis in older children.     

Surgical management of undescended testis: retrospective study of potential fertility in 274 cases

To determine the fertility potential of men with an undescended testis a retrospective study was performed on 274 patients by evaluating sperm density and sperm motility, as well as histopathological findings of the seminiferous tubules. The patients, who had been treated surgically when they were 2 to 5 or 9 to 12 years old and who were examined when they were 18 to 39 years old, were divided into 4 groups: group 1 (61 patients) underwent bilateral orchiopexy, group 2 (149) underwent unilateral orchiopexy, group 3 (26) underwent unilateral orchiectomy and group 4 (38) received no surgical treatment for a unilateral undescended testis. Significant differences in the sperm density and motility were detected between group 1 (normal range 0 to 7 per cent) and group 2 or 3 (normal range 72 to 79 per cent), and between group 2 or 3 and group 4 (normal range 42 to 58 per cent). Histopathological differences were significant between group 1 or 2 (Johnsen's score count 6.06 to 6.11) and group 4 (4.72) for the affected side, and between group 2 or 3 (9.09 to 9.20) and group 4 (8.60) for the unaffected side. The results suggest that surgical treatment may not significantly ameliorate the fertility potential of patients with bilateral undescended testes. On the other hand, in patients with unilateral undescended testis an operation not later than at early puberty is advisable to maintain the spermatogenic function in the unaffected testis. It is suggested that some unknown factors relating to the highly impaired unilateral undescended testis may in some way inhibit function of the contralateral unaffected testis.     

Ectopic and undescended testes: 2 variants of a single congenital anomaly?

PURPOSE: We compared pathological findings in ectopic and undescended testis to determine whether the pathological evidence supports the hypothesis that the 2 conditions are variants of the same congenital anomaly. MATERIALS AND METHODS: We identified 24 boys with ectopic testis not in the superficial inguinal pouch of Denis Browne. Seven boys were excluded from study due to unavailable clinical records for 3, contralateral undescended testis in 2 and inadequate biopsy specimens in 2. Pathological findings of ectopic testis in the remaining 17 patients were compared with those of age matched patients with unilateral undescended testis. Total germ cell count, testicular volume, patency of the processus vaginalis and epididymal abnormalities were compared. Data were analyzed using the Wilcoxon matched pairs signed rank and Fisher's exact tests. RESULTS: No difference was noted in total germ cell count (p = 0.33), testicular volume (p = 0.1475), processus vaginalis patency (p = 0.0854) or epididymal abnormalities (p = 1.00) in the 2 groups. Of the 24 boys (8%) with ectopic testis 2 also had a contralateral undescended testis. CONCLUSIONS: Similar pathological findings in ectopic and undescended testes as well as the association of ectopic testis with a contralateral undescended testis suggest that ectopic and undescended testes are variants of the same congenital anomaly. Thus, boys with ectopic testis may have an increased incidence of subfertility and testicular malignancy. This spectrum of abnormal testicular position, and its range of pathological conditions and complications may appropriately be called the undescended testis sequence.     

Long term results of orchidopexy: transscrotal fixation versus Dartos-pouch

The aim in treating the undescended testis is to move the testis, without tension, permanently and deeply into the scrotum. Depending on the treatment, literature reveals a quote of relapses up to > 10 %. It was the aim of our investigations to judge in how far the quote of relapses after operative treatment of undescended testes can be related to the technique of operation. METHODS: Two groups with maldescensus testis treated by two different techniques of orchidopexy were compared retrospectively. 692 boys (mean age: 4.7 years; median age: 4.0 years) with 867 undescended testes underwent operative orchidopexy by the Gross technique (group 1). In comparison, the Petrivalsky/Schoemaker technique was performed on 493 boys (mean age: 5.0 years; median age: 4.0 years) with 609 undescended testes (group 2). Three months to eight years after operative treatment, the localisation and size of the testis was recorded. RESULTS: (1) In group 1 there were 39.3 % right-sided, 35.4 % left-sided and 25.3 % bilateral undescended testes. Primary operations were performed on 612 of 692 boys (88.4 %), whereas 469 patients (76.6 %) had a follow-up examination: the operation by using the Gross technique was successful in 90.6 % of the cases; there was an atrophy of the testis in 0.2 % and relapses were found in 9.2 %. (2) In group 2 there were 41.2 % right-sided, 35.3 % left-sided and 23.5 % bilateral undescended testes. Primary operations were performed on 446 of 493 boys (90.5 %), whereas 353 patients (79.1 %) had a follow-up examination: the operation using the Petrivalsky/Schoemaker technique was successful in 95.5 % of the cases; there was an atrophy of the testis in 0.3 % and relapses were found only in 4.2 %. (3) Under the same outer conditions the amount of relapses after orchidopexy was significantly (p < 0.025) smaller in group 2 (Petrivalsky/Schoemaker technique) than in group 1 (Gross technique). CONCLUSION: Our observations show that the Petrivalsky/Schoemaker technique for the operative treatment of undescended testis results in a significantly lower rate of relapses. However, the consequences of both techniques concerning fertility must be discussed after further investigations.     

The ascending testis and the testis undescended since birth share the same histopathology

PURPOSE: The etiology of the ascending testis is controversial. We propose that ascending testis, defined as a testis previously thought to be descended and later noted to be out of the scrotum, is due to mild hypogonadotropic hypogonadism affecting both testes. The diagnosis of these low types of true undescended testes is difficult to make clinically in children since they are frequently confused with retractile testes. In this study we compared testicular biopsies in a group of boys with ascending testes with those in boys who had an undescended testis since birth (primary undescended testis). MATERIALS AND METHODS: Between 1985 and 1995, 91 patients with ascending testes underwent orchiopexy and bilateral testis biopsy. The total germ cell count, processus vaginalis status, age at surgery and whether followup was done by a pediatrician or pediatric urologist were compared in patients with ascending and unilateral primary undescended testes. RESULTS: The total germ cell count was similar in the undescended and the contralateral descended testis in patients with ascending and primary undescended testes. The processus vaginalis was more likely to be closed in ascending testes (57% versus 36%, p = 0.0001). Age at surgery and the total germ cell count were similar in patients followed by pediatricians and pediatric urologists. CONCLUSIONS: The ascending testis has the same germ cell count as the primary undescended testis. Yearly followup by the primary care physician is recommended for patients with retractile testes.     

The histopathology of iatrogenic cryptorchid testis: an insight into etiology

PURPOSE: Iatrogenic undescended testis may develop after inguinal hernia repair, presumably as a result of mechanical tethering of the testis or cord in scar tissue. Because some true cryptorchid testes appear to be completely descended at birth and later ascend during childhood, some iatrogenic undescended testes may be low lying undescended testes. To determine whether iatrogenic undescended testes may be unrecognized cryptorchid testes at herniorrhaphy we examined biopsies of iatrogenic undescended testes and the corresponding contralateral descended testis. MATERIALS AND METHODS: Between 1985 and 1999 bilateral testis biopsies were obtained at orchiopexy in 37 boys 1.5 to 11.8 years old who previously underwent inguinal hernia correction. Histomorphometric analysis of germ cell counts was performed on the undescended and contralateral descended testes, and compared to the count in bilateral biopsies of 37 age and position matched patients with true unilateral cryptorchidism. RESULTS: There were no significant differences in volume or total and differential germ cell counts in the undescended and contralateral descended testes in the study groups and age matched controls with primary unilateral cryptorchidism. The mean number of germ cells per tubule in the undescended testis in patients with a greater than 5-year interval from herniorrhaphy to orchiopexy was significantly decreased compared to those with an operative interval of less than 5 years (0.27 +/- 0.33 versus 0.93 +/- 1.4, p = 0.026). CONCLUSIONS: Some patients with iatrogenic undescended testis may have an unrecognized low cryptorchid testis. Careful physical examination before and after inguinal surgery is recommended. The early repair of iatrogenic undescended testis is warranted to prevent further damage.     

Human chorionic gonadotrophin hormone for treatment of congenital undescended testis: Anatomical barriers to its success

Background/PurposeAlthough the surgical treatment was proved to be the recommended line of management for congenital undescended testis, hormonal therapy with human chorionic gonadotrophin hormone has been started long years ago and is still used in some areas with variable degrees of success. The factors responsible for treatment failure are not well explored. In this study, we aimed to highlight the anatomical abnormalities in the congenital undescended testis that might contribute to treatment failure.MethodsDuring the period from January 2014 to December 2015, 75 boys with congenital undescended testes received treatment with human chorionic gonadotrophin, in pediatric surgery department, Faculty of medicine, Ain Shams University. Their age ranged between 6 months and 4 years (mean 1.6 years, median 2 years). In 70 boys, the testes were palpable and in the remaining 5 boys, the testes were impalpable. Fifty boys had unilateral and 25 had bilateral undescended testes. Seven of the palpable testes were high scrotal in position and the remaining 83 were palpated in the inguinal canal. The patients were followed up for 6 months to determine the position of the testis after the treatment and surgical intervention was done for those who did not respond to the hormonal treatment either partially or completely.ResultsOnly 7 testes showed complete descent (7%) (2 bilateral and 3 unilateral) and they were initially high scrotal in position, 8 testes showed partial descent (8%) (2 bilateral and 4 unilateral) and they were inguinal in 6 which became high scrotal and impalpable in 2 which became peeping. The remaining 85 (85%) did not respond to the hormonal treatment. Upon surgical exploration, abnormal attachment of the gubernaculum was found in 83 testes (83%), 2 testes were peeping (2%), short testicular vessels were found in 4 testes (4%), 3 testes were vanishing (3%) and a closed internal ring was found in one testis (1%).ConclusionsTreatment of congenital undescended testis with human chorionic gonadotrophin hormone had low success rates. Anatomical abnormalities in the congenital undescended testis might contribute to this treatment failure.Type of the studyClinical research paper.Level of evidencelevel III.     

Adult patients presenting with undescended testis in awareness-poor region

Objectives  

The majority of patients with undescended testis present during childhood with minimal complications owing to straightforward treatment with excellent postoperative outcome. This paper reports the mode of presentation, challenges and outcome of management of adult patients with undescended testis.     

Fowler-Stephens手术治疗高位隐睾12例报告

目的:探讨Fowler-Stephens手术方法治疗高位隐睾的效果。方法:报告12例高位隐睾患者的临床资料。12例均患侧阴囊空虚,并在腹股沟不能扪及隐睾,其中9例通过B超及CT明确定位了高位隐睾位置,3例不能明确定位。手术先找到隐睾,在输精管汇入精索以上位置行Fowler-Stephens试验,明确手术方法可行后在该处离断精索,将隐睾下降固定于阴囊,术中注意避免对精索进行广泛游离。结果:12例患者经6个月~3年的随访,10例睾丸的大小、质地及多普勒彩超结果满意,2例发生睾丸萎缩。结论:Fowler-Stephens手术是治疗高位隐睾的有效方法。提高手术成功率关键在于:选择好手术适应证;术中避免对精索的广泛游离,不要破坏精索血管与输精管间的系膜,以保全侧枝循环对睾丸的血供。     

Inter-observer variation in assessment of undescended testis. Analysis of kappa statistics as a coefficient of reliability

In a prospective study the inter-observer variation in the diagnosis of undescended testis was analysed. Two physicians assessed independently the position and motility of the testes of 37 boys referred for undescended testis. The boys were examined in the supine and squatting positions. The observed agreement rate between the observers was 0.90 to 0.97. Using kappa (kappa) statistics, the values were adjusted for the expected chance agreement; kappa values between 0.47 and 0.81 were obtained, slightly higher values for patients in the supine position. Complete agreement on all observations was reached in 13.5% of the patients. Inter-observer variation may be a substantial source of bias in diagnosing the undescended testis and one of the reasons for the varying results in studies of hormonal treatment of this condition. It is also a fact that the number of orchiopexies in some countries exceeds the incidence of this condition.     

Cryptorchidism: the surgical implications of non-union of the epididymis and testis

A boy with a non-palpable undescended testis was found to have a 7.5 cm. separation between the detached epididymis and testis. This anomaly of non-union of the epididymis and testis emphasizes the need for careful exploration of the non-palpable undescended testis.     

腹腔型隐睾腹腔镜下二期Fowler-Stephens术的经验总结

目的探讨腹腔镜下二期Fowler-Stephens术（F-S术）治疗腹腔型隐睾的可行性。 方法回顾性分析2014年9月至2018年10月,南方医科大学附属南方医院和张家界市中医医院收治的35例（37侧）腹腔型隐睾患儿,其中29例（31侧）完成了二期F-S术,第2期手术后6个月复查彩色多普勒超声（随访28例,1例失访）,评估睾丸有无萎缩。 结果26例单侧腹腔型隐睾患儿中术侧睾丸血供正常22侧（84.62%）,睾丸直径≥1 cm,且位于阴囊内;术后出现睾丸萎缩4侧（15.38%）。2例双侧腹腔型隐睾患儿4侧（100%）术后均出现双侧睾丸萎缩。单双侧隐睾睾丸萎缩率比较,差异有统计学意义（P=0.003）。而睾丸萎缩率在不同年龄段和腹腔内睾丸距离内环口不同的距离之间,差异均无统计学意义（P>0.05）。 结论腹腔镜下二期F-S术治疗腹腔型隐睾,术后睾丸萎缩率不低,需要谨慎选择患者。对于睾丸位置位于内环口2 cm以内的腹腔型隐睾,直接行腹腔镜下一期睾丸下降固定术,减少术后睾丸萎缩的发生率。对于双侧腹腔型隐睾,可考虑分侧手术,如果一侧睾丸术后出现萎缩,那么另一侧就要考虑不离断精索血管的手术方式。     

Differential expression of androgen and estrogen receptor of appendix testis in patients with descended and undescended testes

Objectives:   The incidence of appendix testis has been shown to be 76% in descended and 24% in undescended testis in our previous intraoperative survey. To determine the possible role of the appendix testis in the process of testicular migration, we compared the androgen and estrogen receptor status of appendix testis in descended and undescended testes.
Methods:   Thirty-seven appendix testes were collected intraoperatively and the expression of androgen and estrogen receptors were examined with immunostaining and immunofluorescence labeling. Based on the diagnosis, the specimens were divided into three groups. Group H (groin hernia, n  = 11, as a group of descended testis), Group AU (acquired undescended testis, n  = 14), and Group CU (congenital undescended testis, n  = 12).
Results:   The testicular appendages were found to express both androgen and estrogen receptors in Group H and Group AU, but specimens in Group CU were only estrogen receptor positive, whereas androgen receptors were not present.
Conclusion:   The presence of the androgen receptor in the appendix testis of the descended testes and acquired undescended testes and its absence in patients with congenital undescended testis suggests that the appendix testis might play a role in the process of testicular descent.     

Undescended epididymo-testicular metastasis from prostatic carcinoma

Dear Sir, Metastasis of prostatic carcinoma to testis is un- common in the clinical situation, and the involvement of the epididymis is even rarer. Heidrich et al. [1] found only 80 cases of testicular involvement in prostate cancer in published reports. In 1993, Wiebe et al. [2] found only 14 previous cases of epididymal metastasis from prostatic carcinoma in published work. The simulta- neous involvement of testis and epididymis was reported by Suhler and Blanchard in 1980 [3]. To our knowledge, this was the first documented case of a prostatic carcinoma metastasizing to undescended testis and epididymis.     

Μesothelial cyst of the spermatic cord as a cause of acquired cryptorchidism

Mesothelial cysts of the spermatic cord (MCSC) are a rare entity. A 2-year-old cryptorchid boy with an inguinal mass was found to have a MCSC which was confused with undescended testis. The testis was readily placed into the hemiscrotum after excision of the cyst. MCSC may present as undescended testis and may be an unusual cause of acquired cryptorchidism. It should be excised and the inguinal canal should be explored for the existence of an undescended testis.     

Torsion of the spermatic cord in undescended testis: report of two cases

We report two cases of torsion of the spermatic cord in undescended testis. Case 1: A 23-year-old man was admitted to our hospital with the complaints of fever and left inguinal pain. He had cerebral palsy in his past history. Tentative diagnosis of acute epididymitis of left undescended testis was made, and antibacterial drugs were given. Response was poor, and torsion of the spermatic cord was suspected strongly. Torsion of the spermatic cord in undescended testis and severe testicular infarction were seen in surgery after 13-day conservative treatment. Orchiectomy was performed. Case 2: A 6-year-old boy was admitted to our hospital with the chief complaints of left inguinal mass and pain. He had felt abdominal pain for 3 days. Scrotal contents were impalpable and the diagnosis of torsion of the spermatic cord was made. Orchiectomy was performed due to severe testicular infarction.     

Dissociation of testis and epididymis in incomplete descent

Failure of fusion between testis and epididymis will usually be encountered during operations for undescended testis in children and for infertility in adults. In 325 groin dissections for undescended testis monorchism was diagnosed in 3.7% and nonfusion of testis and epididymis in 1.2%. Case reports of three unilateral and one bilateral conditions are presented. Intraoperative misjudgement of this condition is likely to occur if the blind ending epididymis is mistaken for an atrophic testis. Careful search for the missing testis is mandatory.