The vanishing testis

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

The ascending testis

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

The undescended testis

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

The return of the solitary testis

Purpose

To assess what is done and what is recommended concerning fixation of the solitary testis.

Material and method

We conducted an e-mail survey of current practices in 28 pediatric surgery departments in 28 university or general hospitals in France. We then reviewed what evidence could be found in the literature.

Results

All surgeons fix the contralateral solitary testis following intravaginal torsion. Sixteen out of 28 fix the contralateral solitary testis following extravaginal torsion, 13/28 in cases of monorchia, and 8/28 following orchiectomy for trauma or tumour. Five surgeons have observed one case each of torsion of a solitary testis, and three have witnessed testicular necrosis following orchiopexy.

Conclusion

There is no consensus regarding fixation of the remaining testis in the literature. Scientific evidence does not show clearly whether fixation is necessary, regardless of the clinical situation. However, if fixation is performed it should be done using the dartos pouch sutureless technique.     

AYA testis cancer: The unmet challenge

Testis cancer is considered a rare‐incidence cancer but comprises the third most common cancer diagnosed within the adolescent and young adult (AYA) years (15–39 years). Most testis cancer patients can anticipate a survival outcome in excess of 95%. However, there are subgroups of AYA patients where outcomes are considerably worse, including younger adolescents, patients with certain histological subtypes, or from certain ethnic backgrounds. For those cured with chemotherapy, the toxicity of treatment and burden of late effects is significant. Newer germ cell tumor–specific biomarkers may identify patients who do not require further treatment interventions or may detect early recurrence, potentially reducing the burden of treatment required for cure. An international collaboration for this rare tumor is creating the forum for trial design, where these biomarker research questions are embedded. Going forward, AYA testis cancer patients could benefit from having a more personalized treatment plan, tailored to risk, that minimizes the overall burden of late effects.     

The lost testis: Failure of physical examination and diagnostic laparoscopy to identify inguinal undescended testis

Children presenting with nonpalpable undescended testes are evaluated with diagnostic laparoscopy. The laparoscopic findings of blind-ending vessels and vas deferens are felt to be diagnostic for ‘vanished’ testes. We present a case of an overweight male in whom the testis was not palpable in the office or under anesthesia and in whom blind-ending vessels were identified on laparoscopy. Inguinal exploration revealed a normal appearing inguinal testis. Although not advocated as a tool in the evaluation of the child presenting with an undescended testis, inguinal ultrasound may have a role in overweight children in whom the examination may be difficult. Furthermore, we would advocate inguinal exploration in overweight children, given the limitations of laparoscopy in this overweight child.     

The effect of needle biopsy procedure on prepubertal rat testis

Testicular needle biopsies were performed in 20 prepubertal rats. Ten rats were used as a control group. Spermatohistogenesis was observed in the tubuli (mean number: 17) of each biopsy. The biopsy procedure caused tubular damage which extended to 0.2-4% of the entire testicular volume. Twenty percent of the rats had severe unilateral testicular atrophy at the site of the procedure. A significant compensatory tubular hypertrophy occurred in the contralateral testis that was observed 50 days after the procedure. Eighty percent of the rats produced the normal number of offspring, independent of the occurrence of unilateral testicular atrophy. The histology of the contralateral testis was normal in all animals; thus, no adverse effect from the biopsied testis occurred.     

The value of laparoscopy in the management of non-palpable testis

ObjectTo retrospectively review the value of laparoscopy in the management of impalpable testis.Materials and methodsIn 1993–2006, 182 laparoscopies for impalpable testis were performed for a total of 194 testicular units. Five laparoscopic findings were considered: testicular ectopia, intra-abdominal testis, and cord structures that are blind ending, completely absent (agenesis) or entering the internal inguinal ring.ResultsIn 62 cases an intra-abdominal testis was found; 18 were classified as high and managed by a laparoscopic Fowler–Stephens procedure. Cord structures entering the inguinal ring were observed in 77 patients and 45 underwent an inguinal exploration: a testis was found in 12 cases and in 33 a remnant was excised. In 35 cases, intra-abdominal blind ending vas and vessels were observed and eight showed testicular agenesis. No major surgical complications were recorded. Follow up ranged from 1 to 3 years.ConclusionsOur study confirms the value of laparoscopy in the management of non-palpable testis, providing a definitive diagnosis by the direct view of spermatic bundle and testis. Ninety-three patients were managed by laparoscopy only, and in 44 it was essential for the subsequent surgical approach. When the internal inguinal ring is patent and/or normal spermatic vessels are present an inguinal exploration is mandatory.     

Management of undescended testis

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

单侧睾丸扭转对大鼠两侧睾丸生精功能的损害

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