Torsion of undescended testis: Clinical,imaging, and surgical findings

Torsion of undescended testis located within the inguinal canal is a rare entity, represents a surgical emergency, and must be dealt with immediately. We present a case of torsion of undescended testis in a 44-year-old man, who had progressive left inguinal pain for 2 days and in whom surgical exploration showed a twisted gangrenous testis. Orchiectomy was performed and pathological examination confirmed the diagnosis of testicular torsion. The English literature since 1978 was also reviewed to illustrate the clinical characteristics and current treatments.     

The frequency of undescended testis from birth to adulthood: a review

We performed a systematic review and critique of the literature on the frequency of undescended testis (UDT) among boys from birth to adolescence. Special attention was given to whether previous testicular position was taken into account to distinguish between congenital and acquired UDT. We searched Medline, Embase, Cinahl and the Cochrane Library. Any study reporting on the frequency of UDT was included. Study population age, number of boys studied, period of examination, primary examiner, area of study, study design, ethnicity, definitions used and previous testicular position were analysed. A total of 46 studies met the inclusion criteria. Twenty-three of the 46 (50%) studies involved newborns. Definitions were described in half of the studies; however, the definitions used were heterogeneous. Previous testis position was described in 11% (5/46) of the studies. At birth, in term and/or birth weight >2.5 kg infants, the UDT rate ranged from 1.0 to 4.6%, and in premature and/or birth weight <2.5 kg infants from 1.1 to 45.3%. At the age of 1 year UDT in term and/or birth weight >2.5 kg infants was seen in 1.0-1.5%, at 6 years in 0.0-2.6%, at 11 years in 0.0-6.6% and at 15 years in 1.6-2.2% of boys. The frequency of UDT shows variable figures in the literature. The actual frequency of acquired UDT essentially remains unclear because of the shortage of studies performed at an older age, and of studies reporting on previous testicular position.     

Volume alteration of undescended testes: Before and after orchiopexy

ObjectivesWe used ultrasound to investigate the volume of undescended testes before and after orchiopexy, and compared these data with normally descended testes.Materials and MethodsWe retrospectively reviewed boys in the age range of 0–18 years who had undergone unilateral or bilateral orchiopexy due to undescended testes (International Classification of Diseases-Ninth Revision, ICD-9 752.51) in National Taiwan University Hospital, Taipei, Taiwan between January 2010 and December 2013. A total of 116 boys received preoperative testicular ultrasound evaluation, and 75 of them received regular ultrasound during a mean follow-up period of 2.5 years. The volume of the testes was calculated by applying Hansen formula [testicular volume = length (L) × width (W)² × 0.52] and compared with a cohort of 92 boys constructed for normative values of testicular volume from The Netherlands.ResultsThe mean volume of the 145 undescended testes among 118 boys was 0.238 mL. The volume of the undescended testes was significantly smaller (p < 0.001) than the mean normative value of 0.418 mL. The volume of postorchiopexy undescended testes (0.356 mL) revealed a growing trend in the mean 2.5-year follow-up with a significance increase of size (p = 0.001), but has not yet reached the normal testicular size (0.604 mL).ConclusionThe preorchiopexy volumes of undescended testes are significantly smaller than normative values. The follow-up postorchiopexy volumes of undescended testes actually increased in size, although they were still smaller than normative values. These Taiwanese testicular growth curves should become reference values in pediatric clinical practice when evaluating testicular development.Keywords: cryptorchidism, orchiopexy, testicular volume, treatment outcome, undescended testis     

Surgical findings in acquired undescended testis

Background/purpose

The aim of this study was to retrospectively review the findings at orchidopexy in acquired undescended testis (UDT).

Methods

The authors reviewed a 14-year (1986 through 1999) surgical experience in 360 boys in whom 461 orchidopexies were performed for acquired-UDT. The operative notes were reviewed to determine at operation testis position and volume, persistence of patent processus vaginalis (PV), and attachment of the gubernaculum. Also, testis position after orchidopexy was evaluated.

Results

Age at operation ranged from 2 to 19 years (mean, 8.9 years), 205 of the 461 orchidopexies (44.5%) had been performed between 9 and 12 years of age. In 327 of the 461 cases (70.9%), testis position was documented as intraoperative; in 281 of these cases (86.0%), the testis was located in the superficial inguinal pouch (SIP). A note was made regarding the presence or absence of a hernial sac in 207 of the cases: 113 (54.6%) were associated with an open PV, which usually was slightly open. In 122 of the 461 cases (26.5%), the gubernacular attachment was assessed; in 121 of these (99.2%), a normal attachment of the gubernaculum was noted. At the end of orchidopexy, in 438 of the 461 cases (95.0%), testis position was recorded. Three hundred eighty-two of these testes (87.2%) were at the bottom of the scrotum.

Conclusions

Acquired UDT usually is characterized by SIP position, closed or (small) open PV, and normal gubernaculum attachment. The results of surgery seem excellent.     

Seminoma associated with bilateral cryptorchidism in Down's syndrome: A case report

BACKGROUND: A case of testicular typical seminoma associated with bilateral undescended testes in Down's syndrome is reported. A 42-year-old institutionalized male patient developed left testicular seminoma with retroperitoneal metastasis. METHODS/RESULTS: Neither adjuvant chemotherapy nor radiotherapy were performed due to his severe mental retardation. He died as a result of the cancer 2 years after a left radical orchiectomy and an autopsy was carried out. DISCUSSION: Recently an increase in the incidence of the association of testicular tumors and Down's syndrome has been repeatedly documented. Thirty-six cases of testicular tumors associated with Down's syndrome have been reported and of these 17.1% had cryptorchidism. This is a much lower percentage considering the high risk of cryptorchidism in males with Down's syndrome. The relationship between testicular germ cell tumors associated with cryptorchidism and Down's syndrome is discussed.     

In vitro metabolism of progesterone by the human undescended testis

Testicular biopsy specimens from 28 boys with undescended testis, and from 6 men operated post-pubertally for undescended testis, were incubated in vitro with [³H]progesterone (P). Significant steroid metabolic activity was demonstrated in all biopsies. Before puberty the total conversion rate was low and only a small amount of 17α-hydroxy-progesterone (17α-OH-P) was formed. The amount of newly formed 20α-dihydro-progesterone (20α-DH-P) was relatively constant regardless of increasing maturity. After puberty the total conversion rate was higher. More 17α-OH-P was synthesized, and the ratio between formed 20α-DH-P and 17α-OH-P decreased significantly. The position of the undescended testis did not appear to influence progesterone metabolism. In no case could we demonstrate deficient steroidogenesis. In one 17-year old boy the 20α-DH-P/17α-OH-P ratio was lower in the undescended testis (0.9) than in the scrotal testis (4.0) suggesting increased steroidogenesis per mg tissue in the malpositioned testis. The indication from the present study, that even grossly displaced testes have a relatively undisturbed steroidogenic capability, suggests that the reason for impaired descent may not simply reflect disturbed androgen synthesis, but must involve other mechanisms.     

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.     

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.     

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.     

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.     

The morphology of the human undescended testis with special reference to the Sertoli cell and puberty

The morphology of the undescended testis was studied in 50 boys aged 1-15 years. A low mean number of spermatogonia was found, but there were marked differences between the boys, some having high numbers whereas others were devoid of spermatogonia. Most Sertoli cells did not undergo normal maturation during puberty, but instead seemed to proliferate at a slow rate. It is concluded that treatment of undescended testes should be performed during the prepubertal period. It is also suggested that some undescended testes have a primary defect whereas others are damaged during the onset of puberty.     

Low sperm recovery from the undescended testis with testicular sperm extraction in postpubertal cryptorchids: preliminary report

As postpubertal cryptorchid testes are generally atrophic and have high malignancy risk, orchiectomy is recommended as the treatment method. However, a few case reports advocated orchiopexy due to finding sperm afterwards. The present clinical study aimed at determining the possibility of finding spermatozoa in postpubertal cryptorchid testis with testicular sperm extraction (TESE). Initially testicular biopsy and later TESE was performed in the undescended testis of 22 unilateral postpubertal cryptorchids and in one of the testes of three bilateral postpubertal cryptorchids. Histopathological assessment of testicular biopsy specimen showed that three patients had maturation arrest and 22 had seminiferous tubular atrophy. By TESE, spermatozoa were found in only one specimen of 25 testes. Our results show that the expectancy to find spermatozoa in postpubertal cryptorchid testis is extremely low by current sperm recovery methods and orchiectomy is still the accurate method of treatment.     

A novel technique for reinforcing the neourethra in hypospadias associated with bilateral undescended testis: use of the gubernaculum

The authors present 3 cases of proximal hypospadias associated with bilateral undescended testes (UDT) in which the gubernaculum was used to reinforce the neourethra to prevent urethrocutaneous fistula. This is the first report of the gubernaculum being used to reinforce the neourethra. The technique is simple and should be applicable to any hypospadias patient with concomitant UDT, especially in severe hypospadias. Good outcome is likely because of the excellent blood supply of the gubernaculum.     

Bilateral testicular tumors in androgen insensitivity syndrome

We report on a case of complete androgen insensitivity syndrome with bilateral testicular tumors and a point mutation in the androgen receptor gene. A bilateral gonadecotmy was performed and both of the resected tumors were histologically diagnosed as pure seminoma. Direct sequencing of amplified exons E-G of the androgen receptor gene from the resected tumor identified a CGA to CAA substitution in exon E, resulting in arginine to glutamine replacement at codon 752. To our knowledge, this is the first reported case of androgen insensitivity syndrome with bilateral testicular tumors.     

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。     

Semen Quality and Hormonal Status of Patients Following Testicular Torsion

16 patients, 4 months to five years following unilateral torsion of the testis were evaluated as to semen quality and hormonal status. In patients operated within 12 hours of the onset of pain 44% had normal semen quality while in those operated following more than 12 hours only 20% had normal semen analysis. FSH, LH and testosterone levels were normal in 14 of the 16 patients. One patient had a low testosterone level and slightly elevated FSH, another patient had slightly elevated levels of both FSH and LH.     

Atlanto-axial subluxation in Down''s syndrome

A case of atlanto-axial subluxation in a patient with Down's syndrome is described. The gradual deterioration in the patient's locomotor ability caused a delay in diagnosis. Patterns of presentation of this condition are discussed.