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Franco M, Khorrami Chokami K, Albertelli M, Teti C, Cocchiara F, Gatto F, Trombetta C, Ferone D, Boschetti M. Modulatory activity of testosterone on growth pattern and IGF-1 levels in vanishing testis syndrome: a case report during 15 years of follow-up. BMC Endocr Disord 2023; 23:13. [PMID: 36631784 PMCID: PMC9835337 DOI: 10.1186/s12902-022-01258-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 12/21/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The vanishing testis syndrome (VTS), is a 46, XY disorder of sex development (46, XY DSD) and is characterized by the absence of testis in a 46, XY subject with male genitalia, gonadal dysgenesis and consequent hypergonadotropic hypogonadism. CASE PRESENTATION A young man affected by VTS has been followed up for more than 15-year in our center. The patient received different testosterone formulations, which modulated his IGF-1 levels and height velocity, depending on different stimulatory effects, mimicking pubertal spurt until achieving a final height in line with his genetic target. Exogenous testosterone, activating GH/IGF-1 system, can directly influence growth pattern. With this particular case report we demonstrate that an accurate monitoring of patients with VTS, as well as a perfect reproduction of testosterone secretion during pubertal spurt, can guarantee a normal growth and development and, consequently, a high level of quality of life in adulthood. CONCLUSION Testosterone levels act an important role during pubertal spurt in modulating the GH/IGF-1 axis, besides its well-known impact in sexual development. Very little amount of exogenous testosterone can stimulate IGF-1 secretion and provide to growth velocity the drive that characterizes the initial phases of the growth spurt.
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Affiliation(s)
- Marta Franco
- Endocrinology Unit, UOSD Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy
| | - Keyvan Khorrami Chokami
- Endocrinology Unit, Department of Internal Medicine & Medical Specialties (DiMI), IRCCS Ospedale Policlinico San Martino, University of Genoa, Viale Benedetto XV, 16132, Genoa, Italy
| | - Manuela Albertelli
- Endocrinology Unit, Department of Internal Medicine & Medical Specialties (DiMI), IRCCS Ospedale Policlinico San Martino, University of Genoa, Viale Benedetto XV, 16132, Genoa, Italy
| | - Claudia Teti
- Endocrinology, Diabetology and Metabolic Diseases Unit, ASL1, Imperia, Italy
| | | | - Federico Gatto
- Endocrinology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Carlo Trombetta
- Department of Medicine, Surgery and Health Sciences, Urological Clinic, University of Trieste, Trieste, Italy
| | - Diego Ferone
- Endocrinology Unit, Department of Internal Medicine & Medical Specialties (DiMI), IRCCS Ospedale Policlinico San Martino, University of Genoa, Viale Benedetto XV, 16132, Genoa, Italy
| | - Mara Boschetti
- Endocrinology Unit, Department of Internal Medicine & Medical Specialties (DiMI), IRCCS Ospedale Policlinico San Martino, University of Genoa, Viale Benedetto XV, 16132, Genoa, Italy.
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Boehm K, Fischer ND, Qwaider M, Haferkamp A, Schröder A. Contralateral testicular hypertrophy is associated with a higher incidence of absent testis in children with non-palpable testis. J Pediatr Urol 2022; 19:214.e1-214.e6. [PMID: 36460587 DOI: 10.1016/j.jpurol.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVE The objective of our study is to examine the impact of monorchism on contralateral testicular size in children with non-palpable testis (NPT). Enhanced contralateral testicular volume or longitudinal diameter (length) serves as a predictor of monorchism. In the present study, we assessed the ability of ultrasound measured enlarged contralateral testicular length for predicting monorchism (and hence a testicular nubbin) in children with NPT. Furthermore, we evaluated the general prevalence of viable versus non-viable testes in patients referred to our institution with unilateral undescended testis between 2005 and 2020. STUDY DESIGN We analysed the records of 54 patients who underwent diagnostic laparoscopy for NPT between 2005 and 2020 in a European tertiary care centre. Testicular lengths (longitudinal diameter) and testicular volume of the contralateral testis, as well as surgeon (surgeon 1 vs surgeon 2 vs others) and age at surgery (months) were assessed and stratified according to intraoperative findings (presence or absence of a testicular nubbin). Testicular length and volume were evaluated by ultrasound examination in office prior to surgery. Chi-square and t-test for descriptive analyses as well as uni- and multivariable logistic regression analyses were performed using R Version 3.1.0 (R Project for Statistical Computing, www.R-project.org). RESULTS A total of 15 children presented with viable testes and 39 patients with testicular nubbin. Mean age was 20.5 months in the overall cohort and 22.6 vs 19.7 months in children with viable testis vs testicular nubbin (p = 0.4). In patients with presence of a testicular nubbin, the contralateral testis was larger (median length 17 mm (16-19.2)) as compared to patients with a viable testis (median length 15 mm (14-17), p = 0.001). Similarly, contralateral testicular volume was lower in patients with a present viable testis (0.6 ccm vs 0.8 ccm; p < 0-001). This effect remained statistically significant when logistic regression analyses were adjusted for age and weight at surgery, year of surgery, surgeon, and laterality. OR (odds ratio) for presence of a testicular nubbin was 1.6 (per mm) [95% CI (confidence interval) 1.13-2.17; p = 0.007]. CONCLUSION Patients with preoperative increased length and volume of the contralateral testis in the ultrasound examination are at significantly higher risk of monorchism than their counterparts with lower testicular length. This should be emphasized during counselling of the parents prior to surgery. In our experience parents cope more easily with the diagnosis of monorchism, once this has already been discussed and explained thoroughly prior to surgery.
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Affiliation(s)
- Katharina Boehm
- Department of Urology, University Medical Center, Carl-Gustav-Carus University, Dresden.
| | - Nikita Dhruva Fischer
- Department of Urology and Pediatric Urology, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Mohammad Qwaider
- Department of Urology and Pediatric Urology, University Medical Center, Johannes Gutenberg University, Mainz, Germany; Department of Urology, Klinikum Darmstadt, Darmstadt, Germany
| | - Axel Haferkamp
- Department of Urology and Pediatric Urology, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Annette Schröder
- Department of Urology and Pediatric Urology, University Medical Center, Johannes Gutenberg University, Mainz, Germany
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Papparella A, Umano GR, Romano M, Delehaye G, Cascone S, Trotta L, Noviello C. In Which Patients and Why Is Laparoscopy Helpful for the Impalpable Testis? Minim Invasive Surg 2022; 2022:1564830. [PMID: 36249585 PMCID: PMC9553680 DOI: 10.1155/2022/1564830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/08/2022] [Indexed: 11/18/2022] Open
Abstract
Since laparoscopy has been proposed in the management of the nonpalpable testis (NPT), this technique has been widely diffused among pediatric surgeons and urologists, but its application is still debated. We conducted a retrospective review to highlight how diagnostic and surgical indications for laparoscopy are selective and should be targeted to individual patients. From 2015 to 2019, 135 patients with NPT were admitted to our surgical division. Of these, 35 were palpable on clinical examination under anesthesia and 95 underwent laparoscopy. The main laparoscopic findings considered were: intra-abdominal testis (IAT), cord structures that are blind-ending, completely absent, or entering the abdominal ring. The patients' mean age was 22 months. In 48 cases, an IAT was found, and 42 of these underwent primary orchidopexy while 6 had the Fowler-Stephens (FS) laparoscopic procedure. Of the first group one patient experienced a testicular atrophy while two a reascent of the testis. In the FS orchidopexy group, one patient had testicular atrophy. Cord structures entering the internal inguinal ring were observed in 35 children, and all were surgically open explored. In 3 cases of these, a hypotrophic testis was revealed and an open orchidopexy was executed. In the remaining the histological examination revealed viable testicular cells in four patients and fibrosis, calcifications, and hemosiderin deposits in the others. Eleven patients presented with intrabdominal blind-ending vessels and one a testicular agenesia. A careful clinical examination is important to select patients to submit to laparoscopy. Diagnostic laparoscopy, and therefore, the anatomical observation of the testis and cord structures are strictly related to develop a treatment plan. In IAT, many surgical strategies can be applied with good results. Laparoscopy offers a concrete benefit to the patient.
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Affiliation(s)
- Alfonso Papparella
- Pediatric Surgery Unit, Department of Women Children General and Specialist Surgery, Campania University “Luigi Vanvitelli”, Naples, Italy
| | - Giuseppina Rosaria Umano
- Pediatric Surgery Unit, Department of Women Children General and Specialist Surgery, Campania University “Luigi Vanvitelli”, Naples, Italy
| | - Mercedes Romano
- Pediatric Surgery Unit, Department of Women Children General and Specialist Surgery, Campania University “Luigi Vanvitelli”, Naples, Italy
| | - Giulia Delehaye
- Pediatric Surgery Unit, Department of Women Children General and Specialist Surgery, Campania University “Luigi Vanvitelli”, Naples, Italy
| | - Salvatore Cascone
- Pediatric Surgery Unit, Department of Women Children General and Specialist Surgery, Campania University “Luigi Vanvitelli”, Naples, Italy
| | - Letizia Trotta
- Pediatric Surgery Unit, Department of Women Children General and Specialist Surgery, Campania University “Luigi Vanvitelli”, Naples, Italy
| | - Carmine Noviello
- Pediatric Surgery Unit, Department of Women Children General and Specialist Surgery, Campania University “Luigi Vanvitelli”, Naples, Italy
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Gates RL, Shelton J, Diefenbach KA, Arnold M, St Peter SD, Renaud EJ, Slidell MB, Sømme S, Valusek P, Villalona GA, McAteer JP, Beres AL, Baerg J, Rentea RM, Kelley-Quon L, Kawaguchi AL, Hu YY, Miniati D, Ricca R, Baird R. Management of the undescended testis in children: An American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee Systematic Review. J Pediatr Surg 2022; 57:1293-1308. [PMID: 35151498 DOI: 10.1016/j.jpedsurg.2022.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 12/31/2021] [Accepted: 01/08/2022] [Indexed: 01/03/2023]
Abstract
PURPOSE Management of undescended testes (UDT) has evolved over the last decade. While urologic societies in the United States and Europe have established some guidelines for care, management by North American pediatric surgeons remains variable. The aim of this systematic review is to evaluate the published evidence regarding the treatment of (UDT) in children. METHODS A comprehensive search strategy and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were utilized to identify, review, and report salient articles. Five principal questions were asked regarding imaging standards, medical treatment, surgical technique, timing of operation, and outcomes. A literature search was performed from 2005 to 2020. RESULTS A total of 825 articles were identified in the initial search, and 260 were included in the final review. CONCLUSIONS Pre-operative imaging and hormonal therapy are generally not recommended except in specific circumstances. Testicular growth and potential for fertility improves when orchiopexy is performed before one year of age. For a palpable testis, a single incision approach is preferred over a two-incision orchiopexy. Laparoscopic orchiopexy is associated with a slightly lower testicular atrophy rate but a higher rate of long-term testicular retraction. One and two-stage Fowler-Stephens orchiopexy have similar rates of testicular atrophy and retraction. There is a higher relative risk of testicular cancer in UDT which may be lessened by pre-pubertal orchiopexy.
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Affiliation(s)
- Robert L Gates
- University of South Carolina School of Medicine - Greenville, Greenville, SC, United States
| | - Julia Shelton
- University of Iowa, Stead Family Children's Hospital, Iowa City, IA, United States
| | - Karen A Diefenbach
- Ohio State University, Nationwide Children's Hospital, Columbus, OH, United States
| | - Meghan Arnold
- University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, MI, United States
| | | | - Elizabeth J Renaud
- Alpert Medical School of Brown University, Hasbro Children's Hospital, Providence, RI, United States
| | - Mark B Slidell
- Comer Children's Hospital, The University of Chicago Medicine, Chicago, IL, United States
| | - Stig Sømme
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, United States
| | - Patricia Valusek
- Pediatric Surgical Associates, Children's Minnesota, Minneapolis, MN, United States
| | | | - Jarod P McAteer
- Providence Pediatric Surgery, Sacred Heart Children's Hospital, Spokane, WA, United States
| | - Alana L Beres
- University of California, Davis, Sacramento CA, United States
| | - Joanne Baerg
- Loma Linda University Children's Hospital, Loma Linda, CA, United States
| | | | - Lorraine Kelley-Quon
- Children's Hospital Los Angeles, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | - Akemi L Kawaguchi
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Yue-Yung Hu
- Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Doug Miniati
- Division of Pediatric Surgery, Kaiser Permanente Roseville Women and Children's Center, Roseville, CA, United States
| | - Robert Ricca
- University of South Carolina School of Medicine - Greenville, Greenville, SC, United States.
| | - Robert Baird
- Division of Pediatric Surgery, BC Children's Hospital, University of British Columbia, Vancouver, BC, United States
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Al Hindi S, Khalaf Z. The outcome of laparoscopic assisted orchidopexy in very young children: A single hospital experience. J Pediatr Urol 2021; 17:536.e1-536.e7. [PMID: 33827777 DOI: 10.1016/j.jpurol.2021.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 03/06/2021] [Accepted: 03/08/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Early orchidopexy has been linked to improved long term outcomes of fertility and reduced malignancy rates. However, the optimal age of intervention has been subject to change over the years. OBJECTIVE This study aims to study males aged 6 months or less who undergo laparoscopic assisted orchidopexy for intraabdominal testes to establish the safety, efficacy, and benefit in the defined age group. STUDY DESIGN We prospectively assessed 19 boys at or below 6 months of age, who had laparoscopic assisted orchidopexy for intraabdominal undescended testes at Salmaniya Medical Complex in Bahrain between January 2014 and December 2018. We examined: demographics, laterality, testicular locations, testicular volumes, operative time, complications, and durations of hospitalization and follow-up. Ultrasound-derived testicular volumes were assessed before and after orchidopexy. They were calculated using the Hansen formula (Testicular volume = 0.52 × length [L] × width [W]2 [1]. They were then compared with reference ranges from a Dutch cohort study of 769 healthy boys. Successful outcomes were correct intrascrotal position with minimal complications and normal testicular volumes. RESULTS A total of 19 males were operated at a mean age of 5.6 months and followed for a mean of 2.35 years. Of these, 7 had left-sided and 12 had right-sided cryptorchidism. Testicular locations were noted intra-operatively; 10 were above the internal ring, 5 near the iliac vessels, and 4 close to the kidney. The mean operative time was 59.58 minutes. Only 2 minor complications occurred and no cases of testicular atrophy. None of the patients required hospital-stay beyond 24 hours. The success rate was 89.46% in achieving correct scrotal position. Testicular volumes were normal before and after orchidopexy. They significantly increased after orchidopexy (P ≤ 0.05). The testicular growth rate after 24 months was slightly higher than normal. DISCUSSION In line with previous studies we were 89.46% successful in re-positioning testes [2]. In contrast to studies intervening at older ages which associated intra-abdominal testes with greater risks of complications, we found few minor complications and no testicular atrophy [3,4]. Testicular volumes in the affected testes were normal, contrary to decreased volumes found by other researchers [5]. Limitations of this study are the small number of patients and short follow-up which limits assessment of long-term outcomes. CONCLUSION Early orchiopexy is safe and effective. Laparoscopic assisted orchidopexy at an early age was beneficial and resulted in normal testicular volumes before and after surgery.
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Affiliation(s)
- Saeed Al Hindi
- Department of Pediatric Surgery, Salmaniya Medical Complex, P.O. Box 12, Manama, Bahrain.
| | - Zahra Khalaf
- Rotating Doctor, Department of Pediatric Surgery, Salmaniya Medical Complex, P.O. Box 12, Manama, Bahrain.
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Hayes M, Patel A, Seideman C. Staged Fowler Stephens, Who Requires a Third Procedure? Curr Urol Rep 2021; 22:32. [PMID: 34009488 DOI: 10.1007/s11934-021-01049-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE OF REVIEW The two-stage Fowler-Stephens orchiopexy is a well-described surgical approach for most pediatric urologists tackling the high intra-abdominal testis. Testicular ascent is a well-reported outcome of the surgery and a problem that could be fixed with a repeat procedure. The purpose of this review is to determine the rate of subsequent testicular ascent and repeat surgery after a two-stage Fowler-Stephens using best available evidence. RECENT FINDINGS/RESULT We selected 16 studies that pertained to our topic. 0-13% of testicles were deemed to be in an inappropriate position on follow-up (6-37 months). The definition of appropriate postoperative position varied between studies and rates of repeat procedures were sparsely available. Available data reports a repeat orchiopexy rate of 2.6-7.5% after two-stage Fowler-Stephens. Two-stage Fowler-Stephens orchiopexy is a highly successful surgical technique to manage high intra-abdominal testes. Rates of testicular ascent are difficult to ascertain due to varying definitions and small sample sizes. While repeat procedures are typically indicated, the actual rate of repeat orchiopexy is rarely reported and long-term outcomes following a third procedure is sparse.
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Affiliation(s)
- Mitchell Hayes
- Department of Urology, Oregon Health & Science University, Portland, OR, USA.,Department of Pediatric Urology, Doernbecher Children's Hospital, Portland, OR, USA
| | - Amir Patel
- Department of Urology, Oregon Health & Science University, Portland, OR, USA. .,Department of Pediatric Urology, Doernbecher Children's Hospital, Portland, OR, USA.
| | - Casey Seideman
- Department of Urology, Oregon Health & Science University, Portland, OR, USA.,Department of Pediatric Urology, Doernbecher Children's Hospital, Portland, OR, USA
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Papparella A, De Rosa L, Noviello C. Laparoscopic Fowler-Stephens orchidopexy for intra-abdominal cryptorchid testis: a single institution experience. LA PEDIATRIA MEDICA E CHIRURGICA 2021; 42. [PMID: 33522214 DOI: 10.4081/pmc.2020.224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 10/24/2020] [Indexed: 11/22/2022] Open
Abstract
Fowler-Stephens Laparoscopic Orchiopexy (FSLO) permits the mobilization of Intra-Abdominal Testis (IAT) to the scrotal position after spermatic vessel ligation. We reported our experience of FSLO for IAT. The charts of all boys who underwent a FSLO were retrospectively reviewed. Data were analysed for demographic data, procedure, complications and follow-up results. From January 2008 to June 2016, 160 laparoscopies for Non Palpable Testis (NPT) were performed at a mean age of 3,2 years. 61% of patients had a right NPT, while 6% were bilateral. In 64 cases, an IAT was found: 20 were managed by FSLO with a two-stage procedure in 11 patients. There were no differences in hospitalisations; one patient had a prolonged ileus. Follow-up ranged from 1 to 8 years. Of the 20 patients who underwent FSLO, testicular atrophy developed in three; the remaining testes were in the scrotal position, with normal consistency. FSLO was applied in 31% of IAT. The overall success rate of the technique was 85 %. The percentage of atrophy associated after spermatic vessels interruption appears to provide a good chance of testicular survival.
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Affiliation(s)
- Alfonso Papparella
- Pediatric Surgery, Department of Women, Children, General, and Specialist Surgery, Campania University "Luigi Vanvitelli", Napoli.
| | - Laura De Rosa
- Pediatric Surgery, Department of Women, Children, General, and Specialist Surgery, Campania University "Luigi Vanvitelli", Napoli.
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Özkan MB, Bilgic M, Bicakci U, Germiyanoglu C. Diagnostic Accuracy of Virtual Touch Quantification and Virtual Touch Imaging Quantification Sonoelastography Techniques in Pediatric Undescended Testes Patients. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2019. [DOI: 10.1177/8756479318818077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The purpose of this study was to determine the usefulness of virtual touch quantification (VTQ) and virtual touch imaging quantification (VTIQ) techniques for assessing undescended testes stiffness, by age and location. One testicle from each of 84 participants (31 of whom were healthy volunteers) was assessed by the point shear-wave elastography (p-SWE) method, using both VTQ and VTIQ techniques. The patients were grouped by location of assessment (intra-abdominal, inguinal, and scrotal) and age (group 1, healthy patients; group 2, patients age one and younger; and group 3, patients older than age one). Although the VTQ and VTIQ methods for group 2 showed similar results in the Bland-Altman plot, for group 3, the VTIQ method was more effective than the VTQ method. The use of p-SWE with VTIQ may be an appropriate technique for determining the tissue stiffness of testes located in the inguinal canal and for patients over one year of age.
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Affiliation(s)
- Mehmet Burak Özkan
- Department of Pediatric Radiology Department, Dr Sami Ulus Research and Training Hospital, Altindag, Ankara, Turkey
| | - Meltem Bilgic
- Department of Pediatric Radiology, Omu, Samsun, Turkey
| | - Unal Bicakci
- Department of Pediatric Surgery, Omu, Samsun, Turkey
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Anwar AZM, Fathelbab TK, Abdelhamid AM, Galal EM, Ali MM, Tawfiek ER. Initial laparoscopy and optimized approach for unilateral nonpalpable testis: review of 8-year single-center experience. Int Urol Nephrol 2018; 50:2139-2144. [PMID: 30311046 DOI: 10.1007/s11255-018-2006-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 10/05/2018] [Indexed: 01/16/2023]
Abstract
PURPOSE We evaluated the role of initial laparoscopy and optimized approach in cases of unilateral nonpalpable testis. METHODS Seventy-four patients with nonpalpable testes were presented. We excluded 9 patients, with palpable testes under anesthesia. Laparoscopy was offered to 65 patients. Contralateral testis hypertrophy with length ≥ 1.8 cm was confirmed in 47 patients. Ultrasound results were available for 35 patients. RESULTS Age ranged from 1 to 10 years. Of 65 nonpalpable testes, right side comprised 23 (35.4%) and the left 42 (64.6%). Laparoscopy revealed intra-abdominal testis in 18 patients (27.7%), blind-ending vessels and vas in 8 (12.3%), and vas and vessels traversing the internal ring in 39 (60%). Treatment of intra-abdominal testes included Fowler-Stephens orchiopexy in 7 patients, laparoscopic orchiopexy in 9, and laparoscopic orchiectomy in 2. In 8 patients with blind-ending vas and vessels, laparoscopy was terminated. In 39 patients with vas and vessels traversing the internal ring, scrotal exploration was performed in 36 patients with closed internal ring and inguinal exploration in 3 with open internal ring. Vanished testes were present in 43/47(91.5%) of patients with contralateral testis hypertrophy ≥ 1.8 cm. Ultrasound detected the presence of a testis in only 4/11 (36.3%) of patients, although it could not identify vanished testis. CONCLUSIONS Initial laparoscopy should be retained as one of the standard treatment for nonpalpable testis. It was the only required modality in 26 patients (40%) and optimized further treatment in 39 patients (60%) by evaluation of the condition of the internal ring.
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Affiliation(s)
| | | | | | - Ehab Mohmed Galal
- Urology Department, School of Medicine, University Hospital, 61111, Minia, Egypt
| | - Mostafa Magdi Ali
- Urology Department, School of Medicine, University Hospital, 61111, Minia, Egypt
| | - Ehab Rifat Tawfiek
- Urology Department, School of Medicine, University Hospital, 61111, Minia, Egypt
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Bipolar diathermy as another method for testicular vascular division in laparoscopic two-stage Fowler–Stephens orchidopexy. ANNALS OF PEDIATRIC SURGERY 2018. [DOI: 10.1097/01.xps.0000544637.78778.98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Nonpalpable testes: Ultrasound and contralateral testicular hypertrophy predict the surgical access, avoiding unnecessary laparoscopy. J Pediatr Urol 2018; 14:163.e1-163.e7. [PMID: 29199091 DOI: 10.1016/j.jpurol.2017.10.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 10/11/2017] [Indexed: 11/20/2022]
Abstract
INTRODUCTION In up to 20% of patients presenting with undescended testes, one or both are non-palpable. Whereas the most reliable means to exclude an abdominal testis is laparoscopy, there has been a lot of debate about the role of inguinal ultrasound (US) in detecting non-palpable inguinal testis. While we do not aim to add another paper claiming the benefits of US, we wanted to determine the excess capability of US to determine the correct surgical approach - inguinal or laparoscopy. In the light of avoiding unnecessary diagnostic laparoscopies, even the cost-effectiveness raised in many current papers might be called into question. PATIENTS AND METHODS Of a total of 684 boys who underwent surgery for undescended testes at our department between 2011 and 2014, in 58 (8.5%), one or both testes were neither palpable preoperatively nor under general anesthesia. These boys were examined by two experienced pediatric urologists clinically as well as by US. Besides the size of the contralateral testis, the presence of a testis in the inguinal channel was investigated. The additional impact of US over clinical exam and consideration of the size of the contralateral testis was assessed by means of intra-individual comparisons using Cochran-Q as well as McNemar tests. RESULTS Clinical exam without considering the size of the contralateral testis had a sensitivity of 9% (95% CI 2-24%) and a specificity of 100% (95% CI 86-100%) to accurately predict the surgical approach deemed appropriate postoperatively. The consideration of the size of the contralateral testis - taken as an isolated factor - accurately predicted the surgical approach with a sensitivity of 21% (95% CI 9-38%) and a specificity of 88% (95% CI 68-97%). Ultrasound accounted for a sensitivity of 53% (95% CI 35-70%) and a specificity of 100% (95% CI 86-100%). The addition of US increased the sensitivity to correctly predict an inguinal incision from 29% to 71% and specificity slightly increased from 88% to 92%. This difference is significant (p = 0.008) in the bilateral McNemar test (Figure). CONCLUSION Inguinal US of non-palpable testes and measurement of the contralateral testis are synergistic in predicting the surgical approach. The addition of ultrasound to a clinical exam, performed also under general anesthesia and by an experienced pediatric urologist significantly increases the prediction of the correct surgical approach. Our results translate into five boys needing an US of the NPT to prevent one laparoscopy. Whereas cost-effectiveness of US might be debatable in regard to different healthcare systems, it is proven to be an effective, non-harmful tool to avoid unnecessary diagnostic laparoscopies.
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Nataraja RM, Yeap E, Healy CJ, Nandhra IS, Murphy FL, Hutson JM, Kimber C. Presence of viable germ cells in testicular regression syndrome remnants: Is routine excision indicated? A systematic review. Pediatr Surg Int 2018; 34:353-361. [PMID: 29124402 DOI: 10.1007/s00383-017-4206-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2017] [Indexed: 10/18/2022]
Abstract
There is no consensus in the literature about the necessity for excision of testicular remnants in the context of surgery for an impalpable testis and testicular regression syndrome (TRS). The incidence of germ cells (GCs) within these nubbins varies between 0 and 16% in previously published series. There is a hypothetical potential future malignancy risk, although there has been only one previously described isolated report of intratubular germ-cell neoplasia. Our aim was to ascertain an accurate incidence of GCs and seminiferous tubules (SNTs) within excised nubbins and hence guide evidence-based practice. The systematic review protocol was designed according to the PRISMA guidelines, and subsequently published by the PROSPERO database after review (CRD42013006034). The primary outcome measure was the incidence of GCs and the secondary outcome was the incidence of SNTs. The comprehensive systematic review included articles published between 1980 and 2016 in all the relevant databases using specific search parameters and terms. Strict inclusion and exclusion criteria were ultilised to identify articles relevant to the review questions. Twenty-nine paediatric studies with a total of 1455 specimens were included in the systematic review. The mean age of the patients undergoing nubbin resection was 33 months and the TRS specimen was more commonly excised from the left (68%). The incidence of SNTs was 10.7% (156/1455) and the incidence of GCs, 5.3% (77/1455). Histological analysis excluding the presence of either SNTs or GCs was consistent with TRS, fibrosis, calcification or haemosiderin deposits. There is limited evidence on subset analysis that GCs and SNTs may persist with increasing patient age. This systematic review has identified that 1 in 20 of resected testicular remnants has viable GCs and 1 in 10 has SNTs present. There is insufficiently strong evidence for the persistence of GCs and SNTs with time or future malignant potential. Intra-abdominal TRS specimens may contain more elements and, therefore, require excision, although this is based on limited evidence. However, there is no available strong evidence to determine that a TRS specimen requires routine excision in an inguinal or scrotal position.
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Affiliation(s)
- Ramesh Mark Nataraja
- Department of Paediatric Surgery, Monash Children's Hospital, 246 Clayton Road, Melbourne, 3168, Australia. .,Department of Paediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia.
| | - Evie Yeap
- Department of Paediatric Surgery, Monash Children's Hospital, 246 Clayton Road, Melbourne, 3168, Australia
| | - Costa J Healy
- Department of Paediatric Surgery, Barts Healthcare NHS Trust, London, UK
| | - Inderpal S Nandhra
- Department of Paediatric Surgery, Barts Healthcare NHS Trust, London, UK
| | - Feilim L Murphy
- Department of Paediatric Surgery and Urology, St George's Healthcare NHS Trust, Blackshaw Rd, London, SW17 0QT, UK
| | - John M Hutson
- Department of Paediatrics, University of Melbourne, Melbourne, Australia.,F Douglas Stephens Surgical Research Laboratory, Murdoch Children's Research Institute, Melbourne, Australia
| | - Chris Kimber
- Department of Paediatric Surgery, Monash Children's Hospital, 246 Clayton Road, Melbourne, 3168, Australia.,Department of Paediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
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13
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Abstract
PURPOSE While the nonpalpable testis represents a small portion of all cryptorchid testes, it remains a clinical challenge for pediatric urologists. Controversy exists surrounding the best evaluation and management of this entity. In this review we update what is known about the nonpalpable testis, including the etiology, preoperative evaluation and best surgical management as well as novel techniques and ongoing controversies. MATERIALS AND METHODS We searched PubMed® and MEDLINE® from January 2000 to January 2017 using relevant key terms. Of 367 articles 115 were considered for inclusion based on a priori design. Using a narrative review format, an update on the evaluation and management of the nonpalpable testis including novel concepts and techniques was synthesized. RESULTS The nonpalpable testis should be evaluated by physical examination only. Imaging is not indicated for routine cases. The optimal surgical approach and technique remain debatable but several novel techniques have been described. Due to the rarity of the nonpalpable testis, randomized controlled trials and other quality comparisons are difficult. Therefore, management remains controversial. CONCLUSIONS Evaluation and management of the nonpalpable testis remain difficult, and some aspects are still debated. Future research should focus on multi-institutional collaborative trials to determine the optimal operative management.
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Affiliation(s)
| | - Kate H Kraft
- Department of Urology, University of Michigan, Ann Arbor, Michigan
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14
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Alam A, Delto JC, Blachman-Braun R, Wayne G, Mittal AG, Castellan M, Kozakowski K, Labbie A, Gosalbez R. Staged Fowler-Stephens and Single-stage Laparoscopic Orchiopexy for Intra-abdominal Testes: Is There a Difference? A Single Institution Experience. Urology 2016; 101:104-110. [PMID: 27845220 DOI: 10.1016/j.urology.2016.09.060] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 09/22/2016] [Accepted: 09/26/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare single-stage laparoscopic orchiopexy (SSLO) and staged Fowler-Stephens (SFS) procedures in the management of intra-abdominal undescended testes, and to analyze postoperative atrophy and malpositioning as end points. MATERIALS AND METHODS A retrospective chart review identified laparoscopic orchiopexy patients with intra-abdominal testes between November 2006 and November 2014. Of 167 patients who had laparoscopic orchiopexy, 73 (85 testes) were identified as having laparoscopic orchiopexy. Baseline characteristics, as well as testicular scrotal position and size at follow-up, were recorded. Regression analysis was performed to compare outcomes between patients who underwent SFS and SSLO. RESULTS Of the 85 laparoscopic orchiopexies, 35 underwent SFS and 50 had SSLO. Patient demographics were comparable in both groups. The median age at surgery was 12 months (5-151 months), and the average follow-up was 17.3 months. On follow-up, there were 0 recorded cases of SFS patients with abnormally positioned testes postoperatively, whereas there were 10 (20.0%) SSLO patients who had abnormally positioned testes (odds ratio: 0.05, 95% confidence interval: 0.01-0.44). Differences in atrophy rates were not significant. CONCLUSION These results suggest that there may be no difference between the 2 approaches in terms of postoperative atrophy. However, the SFS appears to be more successful in securing a favorable scrotal position. Atrophy does not seem to be associated with other patient factors. Prospective, randomized studies are indicated to further explore outcome differences between the 2 approaches.
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Affiliation(s)
- Alireza Alam
- Division of Pediatric Urology, Nicklaus Children's Hospital, Miami, FL.
| | - Joan C Delto
- Urology Department, Mount Sinai Medical Center, Miami Beach, FL
| | | | - George Wayne
- Urology Department, Mount Sinai Medical Center, Miami Beach, FL
| | - Angela G Mittal
- Division of Pediatric Urology, Nicklaus Children's Hospital, Miami, FL; Department of Pediatric Urology, Texas Children's Hospital and Baylor School of Medicine, Houston, TX
| | - Miguel Castellan
- Division of Pediatric Urology, Nicklaus Children's Hospital, Miami, FL
| | | | - Andrew Labbie
- Division of Pediatric Urology, Nicklaus Children's Hospital, Miami, FL
| | - Rafael Gosalbez
- Division of Pediatric Urology, Nicklaus Children's Hospital, Miami, FL
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15
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Sepúlveda X, Egaña PJL. Current management of non-palpable testes: a literature review and clinical results. Transl Pediatr 2016; 5:233-239. [PMID: 27867845 PMCID: PMC5107370 DOI: 10.21037/tp.2016.10.06] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Cryptorchidism is a common pathology that occurs in 3% in full term newborns, and it decreases to 0.8-1.2% at 1 year of age. Nearly a 20% of undescended testes are non-palpable. Various surgical treatments have been described, but its management is still controversial. A literature review was made of non-palpable testes, analysing diagnostic tools, treatment and its results. Additionally we reviewed non-palpable testes cases treated in our centre in the last 20 years. Different techniques are described for the management of non-palpable testes; with or without section of the spermatic vessels and/or in 1 or 2 stages. Nowadays, literature supports the laparoscopic management in two stages. In our experience, we have better results in two-stage Fowler-Stephens than one-stage, with lower rates of testicular atrophy. Non-palpable testes are a common pathology in paediatric urology. Analysing the literature and our experience we recommend a two-stage surgery for intra-abdominal testes, which has demonstrated good results and lower percentage of atrophic testis.
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Affiliation(s)
- Ximena Sepúlveda
- Department of Pediatric Surgery, University of Valparaíso, Dr. Gustavo Fricke Hospital, Viña del Mar, Chile
| | - Pedro-José López Egaña
- Pediatric Urology Service, Dr. Exequiel González Cortés Hospital, Santiago, Chile;; Department of Pediatrics and Pediatric Surgery, School of Medicine, University of Chile, Santiago, Chile;; Clínica Alemana, Santiago, Chile
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16
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Vikraman J, Hutson JM, Li R, Thorup J. The undescended testis: Clinical management and scientific advances. Semin Pediatr Surg 2016; 25:241-8. [PMID: 27521715 DOI: 10.1053/j.sempedsurg.2016.05.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Undescended testes (UDT), where one or both testes fail to migrate to the base of the scrotum, can be congenital (2-5% of newborn males) or acquired (1-2% of males). The testis may be found in any position along its usual line of descent. Cryptorchidism affects the developing testicular germ cells and increases the risk of infertility and malignancy. Clinical management aims to preserve spermatogenesis and prevent the increased risk of seminoma. Examination to document the testicular position will guide the need for imaging, medical management and the surgical approach to orchidopexy.
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Affiliation(s)
- Jaya Vikraman
- Douglas Stephens Surgical Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - John M Hutson
- Douglas Stephens Surgical Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia; Department of Urology, The Royal Children׳s Hospital, 50 Flemington Rd, Parkville, Victoria 3052, Australia.
| | - Ruili Li
- Douglas Stephens Surgical Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Jorgen Thorup
- Department of Paediatric Surgery and Surgical Clinic, Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
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17
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Chan KWE, Lee KH, Wong HYV, Tsui SYB, Wong YS, Pang KYK, Mou JWC, Tam YH. Use of laparoscopy as the initial surgical approach of impalpable testes: 10-year experience. World J Clin Pediatr 2015; 4:155-159. [PMID: 26566489 PMCID: PMC4637807 DOI: 10.5409/wjcp.v4.i4.155] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 07/23/2015] [Accepted: 08/14/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To review the experience in the management of impalpable testes using laparoscopy as the initial approach and the need for inguinal exploration.
METHODS: From January 2004 to June 2014, 339 patients with undescended testes underwent operation in our institute. Fifty patients (15%) had impalpable testes. All children with impalpable testes underwent initial laparoscopy. A retrospective review was conducted on this group of patients and the outcome was analyzed.
RESULTS: Forty children had unilateral impalpable testis. Ten children had bilateral impalpable testes. Thirty-one children (78%) in the unilateral group underwent subsequent inguinal exploration while 4 children (40%) in the bilateral group underwent inguinal exploration (P < 0.05). Orchidopexy was performed in 16 children (40%) in the unilateral group and 9 children (90%) in the bilateral group (P < 0.05). Regarding the 24 children with unilateral impalpable testis and underwent orchidectomy for testicular nubbin (n = 19) or atrophic testes (n = 2) or has vanishing testes (n = 3); contralateral testicular hypertrophy was noticed in 10 (41%). No intra-operative complication was encountered. Two children after staged Fowler-Stephens procedure and 1 child after inguinal orchidopexy had atrophic testes.
CONCLUSION: The use of laparoscopy in children with impalpable testes is a safe procedure and can guide the need for subsequent inguinal exploration. Children with unilateral impalpable testis were associated with an increased need for inguinal exploration after laparoscopy. Orchidopexies could be performed successfully in 90% of children with bilateral impalpable testes.
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18
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Riquelme M, Elizondo RA, Aranda A. Palpable Undescended Testes: 15 Years of Experience and Outcome in Laparoscopic Orchiopexy. J Endourol 2015; 29:978-82. [DOI: 10.1089/end.2015.0118] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mario Riquelme
- Department of Pediatric Surgery, Christus Muguerza Hospital, Monterrey, Mexico
| | | | - Arturo Aranda
- Department of Pediatric Surgery, Wright State University, Dayton, Ohio
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19
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Wayne C, Chan E, Nasr A. What is the ideal surgical approach for intra-abdominal testes? A systematic review. Pediatr Surg Int 2015; 31:327-38. [PMID: 25663531 DOI: 10.1007/s00383-015-3676-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2015] [Indexed: 01/08/2023]
Abstract
There is controversy regarding the ideal surgical management of intra-abdominal testes (IAT) to preserve fertility; we conducted a systematic review to address this problem. We performed a comprehensive electronic search of CENTRAL, MEDLINE, EMBASE, and CINAHL from 2008 to September 2014 (the date range was limited due to an abundance of literature), as well as reference lists of included studies. Two researchers screened all studies for inclusion, and quality assessed each relevant study using AMSTAR for systematic reviews (SRs), Cochrane 'Risk of bias' tool for randomized controlled trials (RCTs), and MINORS for non-randomized studies. We identified two relevant SRs and 29 non-randomized studies. Due to the heterogeneity of the data, meta-analysis was not possible. Ultrasound and magnetic resonance imaging are insufficient for identification or localization of IAT; laparoscopic or surgical exploration is necessary. Primary orchiopexy is effective for low IAT, and Fowler-Stephens orchiopexy (FSO) is effective for high IAT. There is no clear benefit of one- vs. two-stage FSO, or of open vs. laparoscopic technique. Several alternative or modified techniques also show promise. RCTs are needed to confirm the validity of these findings, and to assess long-term outcomes.
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Affiliation(s)
- Carolyn Wayne
- Department of Pediatric Surgery, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada,
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20
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Runge JJ, Mayhew PD, Case JB, Singh A, Mayhew KN, Culp WTN. Single-port laparoscopic cryptorchidectomy in dogs and cats: 25 cases (2009–2014). J Am Vet Med Assoc 2014; 245:1258-65. [DOI: 10.2460/javma.245.11.1258] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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21
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Vos A, Vries AMD, Smets A, Verbeke J, Heij H, van der Steeg A. The value of ultrasonography in boys with a non-palpable testis. J Pediatr Surg 2014; 49:1153-5. [PMID: 24952806 DOI: 10.1016/j.jpedsurg.2013.09.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 09/09/2013] [Accepted: 09/11/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND In patients with a non-palpable testis (NPT) on physical examination, the testis is assumed either to be situated intra-abdominally or to be hypoplastic or absent. Diagnostic laparoscopy in these boys is considered the preferable first step. In this study the diagnostic value of pre-operative ultrasound for NPT is assessed in comparison with laparoscopy. METHODS All boys aged under the age of 17 years who were diagnosed with an NPT by a pediatric surgeon from 2000 till 2012 were evaluated. All patients of whom clinical, ultrasonographic, and operative findings were available were included. RESULTS Ninety-six boys with 117 NPTs were included. With ultrasound 67 testes were detected in the inguinal canal, which was confirmed peroperatively for 61 testes. Of the 15 testes with an intra-abdominal position on ultrasound, 10 were found intra-abdominally during surgery. The positive predictive value of the ultrasonography is 91% for inguinally located testes and 67% for intra-abdominally located testes. CONCLUSION Ultrasonography has a high positive predictive value for inguinally located testes. When ultrasound locates a testis in an inguinal location, a primary inguinal exploration can be considered, preventing an unnecessary diagnostic laparoscopy.
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Affiliation(s)
- Alexander Vos
- Pediatric Surgical Center of Amsterdam, Emma Children's Hospital AMC and VU University Medical Center, Box 22660, 1100 DD, Amsterdam, The Netherlands.
| | - Annebeth Meij-de Vries
- Pediatric Surgical Center of Amsterdam, Emma Children's Hospital AMC and VU University Medical Center, Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Anne Smets
- Academic Medical Center, Radiology department, Amsterdam, The Netherlands
| | - Jonathan Verbeke
- VU University Medical Center, Radiology Department, Amsterdam, The Netherlands
| | - Hugo Heij
- Pediatric Surgical Center of Amsterdam, Emma Children's Hospital AMC and VU University Medical Center, Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Alida van der Steeg
- Pediatric Surgical Center of Amsterdam, Emma Children's Hospital AMC and VU University Medical Center, Box 22660, 1100 DD, Amsterdam, The Netherlands.
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22
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Cobellis G, Noviello C, Nino F, Romano M, Mariscoli F, Martino A, Parmeggiani P, Papparella A. Spermatogenesis and cryptorchidism. Front Endocrinol (Lausanne) 2014; 5:63. [PMID: 24829558 PMCID: PMC4013472 DOI: 10.3389/fendo.2014.00063] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 04/14/2014] [Indexed: 12/24/2022] Open
Abstract
Cryptorchidism represents the most common endocrine disease in boys, with infertility more frequently observed in bilateral forms. It is also known that undescended testes, if untreated, lead to an increased risk of testicular tumors, usually seminomas, arising from mutant germ cells. In normal testes, germ cell development is an active process starting in the first months of life when the neonatal gonocytes transform into adult dark (AD) spermatogonia. These cells are now thought to be the stem cells useful to support spermatogenesis. Several researches suggest that AD spermatogonia form between 3 and 9 months of age. Not all the neonatal gonocytes transform into AD spermatogonia; indeed, the residual gonocytes undergo involution by apoptosis. In the undescended testes, these transformations are inhibited leading to a deficient pool of stem cells for post pubertal spermatogenesis. Early surgical intervention in infancy may allow the normal development of stem cells for spermatogenesis. Moreover, it is very interesting to note that intra-tubular carcinoma in situ in the second and third decades have enzymatic markers similar to neonatal gonocytes suggesting that these cells fail transformation into AD spermatogonia and likely generate testicular cancer (TC) in cryptorchid men. Orchidopexy between 6 and 12 months of age is recommended to maximize the future fertility potential and decrease the TC risk in adulthood.
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Affiliation(s)
- Giovanni Cobellis
- Paediatric Surgery, Salesi Children’s Hospital, Università Politecnica delle Marche, Ancona, Italy
- *Correspondence: Giovanni Cobellis, Paediatric Surgery, Salesi Children’s Hospital, Università Politecnica delle Marche, Via Corridoni, Ancona 11, Italy e-mail:
| | - Carmine Noviello
- Paediatric Surgery, Salesi Children’s Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Fabiano Nino
- Paediatric Surgery, Salesi Children’s Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Mercedes Romano
- Paediatric Surgery, Salesi Children’s Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Francesca Mariscoli
- Paediatric Surgery, Salesi Children’s Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Ascanio Martino
- Paediatric Surgery, Salesi Children’s Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Pio Parmeggiani
- Paediatric Surgery, Department of Paediatrics, Faculty of Medicine, Second University of Naples, Naples, Italy
| | - Alfonso Papparella
- Paediatric Surgery, Department of Paediatrics, Faculty of Medicine, Second University of Naples, Naples, Italy
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23
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Castillo-Ortiz J, Muñiz-Colon L, Escudero K, Perez-Brayfield M. Laparoscopy in the surgical management of the non-palpable testis. Front Pediatr 2014; 2:28. [PMID: 24783184 PMCID: PMC3986523 DOI: 10.3389/fped.2014.00028] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 03/24/2014] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION To demonstrate that laparoscopic intervention should be considered as the initial surgical approach in the management of the non-palpable testis (NPT). METHODS From 2007 to 2011, 100 testicular units underwent same surgeon laparoscopic management for NPT. Diagnostic laparoscopy was performed in all NPT and intra-abdominal testes (IAT) were managed by laparoscopic orchiopexy if low, laparoscopic Fowler-Stephens technique if high, and laparoscopic orchiectomy if atrophic. Percutaneous access to the abdomen was performed in most cases and laparoscopic management was performed with three 5 mm ports. We compared patient's age, race, pre/post-operative exam, pre-operative work up, and IAT location upon laparoscopic intervention with surgical outcome. Fisher's exact test for two independent proportions was used for statistical analysis and reported our results. RESULTS One hundred testicular units underwent diagnostic laparoscopy for NPT. All patients were from Puerto Rican descent. 55.0% were found to be intra-abdominal and were subdivided into groups according to surgical intervention. Mean post-operative follow-up was 24 months. Patients 24 months of age or younger undergoing diagnostic laparoscopy for NPT had a statistically significant probability of resulting in successful laparoscopic orchiopexy as opposed to laparoscopic orchiectomy due to an atrophied IAT (n = 55 testicular units, p < 0.05). No laparoscopic related complications were reported. CONCLUSION Our findings support the use of an initial laparoscopic approach in the NPT as the majority of these patients will have IAT, avoiding unnecessary inguinal and scrotal explorations. We also recommend that patients with IAT should undergo laparoscopic orchiopexy prior to 2 years of age to increase probability of successful management. Further studies focusing in patients with NPT are needed in the future to confirm our findings.
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Affiliation(s)
| | - Luis Muñiz-Colon
- Division of Urology, University of Puerto Rico , San Juan, PR , USA
| | - Karina Escudero
- Division of Urology, Inter-American Hospital for Advanced Medicine , Caguas, PR , USA
| | - Marcos Perez-Brayfield
- Division of Urology, University of Puerto Rico , San Juan, PR , USA ; Division of Urology, Inter-American Hospital for Advanced Medicine , Caguas, PR , USA
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24
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Shehata SM, Shehata SMK, A Baky Fahmy M. The intra-abdominal testis: lessons from the past, and ideas for the future. Pediatr Surg Int 2013; 29:1039-45. [PMID: 23995239 DOI: 10.1007/s00383-013-3406-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The intra-abdominal testis (IAT) has been always an enigma for both diagnosis and treatment. Imaging techniques are known for low sensitivity for localizing the IAT. It has been universally accepted that the gold standard for localizing the IAT is diagnostic laparoscopy. Orchiopexy techniques for IAT are complicated and attended with a higher rate of failure and complication than those for the palpable testis. For the low-lying abdominal testis, a one-stage procedure without interruption of the vessels has a high success rate. The Prentiss maneuver bridges the borders of normal pathway to gain a straighter course to the scrotum. The interruption of the main vascular supply of the testis, depending on collateral circulation, has been used for many years but with questionable effects on the microscopic delicate structure of the testis. Microvascular autotransplantation was intended to avoid this effect, but it is technically demanding and requires special expertise. The principle of traction has been used in the past but was abandoned due to high rate of atrophy. Recently, traction has been revisited with a new approach with very encouraging results. The key to success in any technique for orchiopexy is the complete absence of tension.
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Affiliation(s)
- Sameh M Shehata
- Pediatric Surgery, Alexandria University, Alexandria, Egypt,
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25
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Alzahem A. Laparoscopy-assisted orchiopexy versus laparoscopic two-stage fowler stephens orchiopexy for nonpalpable testes: Comparative study. Urol Ann 2013; 5:110-4. [PMID: 23798870 PMCID: PMC3685740 DOI: 10.4103/0974-7796.110010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Accepted: 02/22/2013] [Indexed: 12/21/2022] Open
Abstract
Background/Purpose: To assess the outcome of the primary laparoscopy-assisted orchiopexy (LAO) and the laparoscopic two-stage Fowler Stephens orchiopexy (FSO) for managing patients with nonpalpable testis in terms of safety, feasibility and efficacy. Materials and Methods: This study included 94 patients (110 nonpalpable testes) who underwent laparoscopy at King Khalid University Hospital, Riyadh between July 1998 and June 2012. Patients were evaluated postoperatively to check the location and size of testes and to exclude any other complications. Results: Mean age at presentation was 24+/−19 months (9-96 months). Orchiectomy was done for 5 atrophic testes. 36 open orchiopexy was done for 29 canalicular testes and 7 peeping testes. 35 LAO were done for 1 canalicular testis, 5 peeping testes, 16 low intraabdominal testes and 13 high intraabdominal testes. 34 FSO were done for 23 high intraabdominal testes, 9 low intraabdominal testes and 2 peeping testes. Median follow up was 12 months (1-84 months) and 6 patients were lost to follow up. The overall success rates for LAO and FSO were 88% and 63%, respectively. Overall testicular atrophy rates were 3% and 30% for LAO and FSO, respectively (OR 0.08 [95% CI, 0.01-0.69], P = 0.006). For high intraabdominal testes, the atrophy rates were 3% and 20% for LAO and FSO, respectively (OR 0.14 [95% CI, 0.02-1.21, P = 0.049).Testicular displacement rates were 9% and 7% for LAO and FSO, respectively (OR 1.5, 95% CI, 0.24-9.59, P = 0.514). Conclusions: Laparoscopy provides a safe and accurate modality for diagnosing and managing patients with nonpalpable testes. LAO appears to be feasible and effective in management of high intraabdominal testes. Further well-conducted comparative studies are needed.
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Affiliation(s)
- Abdulrahman Alzahem
- Division of Pediatric Surgery, Faculty of Medicine and King Khalid University Hospital, King Saud University, Riyadh 11472, Kingdom of Saudi Arabia
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26
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Multi-incisional transumbilical laparoscopic surgery for nonpalpable undescended testes: a report of 126 cases. J Pediatr Surg 2012; 47:2298-301. [PMID: 23217893 DOI: 10.1016/j.jpedsurg.2012.09.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2012] [Accepted: 09/01/2012] [Indexed: 12/31/2022]
Abstract
PURPOSE The aim of this study was to evaluate the feasibility of multi-incisional transumbilical laparoscopic surgery for the management of nonpalpable undescended testes. MATERIAL AND METHODS A series of 126 patients with 162 nonpalpable undescended testes underwent transumbilical laparoscopic surgery. Their mean age was 1.8 years (range, 1.1-6.5 years). Of the 126 cases, 73 were left-sided, 17 were right-sided, and 36 had bilateral cryptorchidism. Primary orchidopexy and the Fowler-Stephens procedure were used to mobilize the testes. RESULTS All the operations were successfully performed without intraoperative complications. No additional ports or any conversions to an open procedure were required. Of the 162 nonpalpable undescended testes, 21 were absent or atrophied. One-hundred thirteen testes underwent primary orchidopexy, and 28 cases underwent a Fowler-Stephens orchidopexy. Patients were followed-up for 6-15 months. Only one case of testicular retraction was observed, and all others maintained a good size and the correct position. The scars were hidden within the umbilicus. CONCLUSION Transumbilical laparoscopic surgery is safe and feasible for nonpalpable undescended testes, and leaves no obvious abdominal or inguinal scar.
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Crossed-fused testicular ectopia: a case for the use of laparoscopy to evaluate nonpalpable testicles. J Pediatr 2012; 160:879. [PMID: 22226575 DOI: 10.1016/j.jpeds.2011.11.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2011] [Accepted: 11/23/2011] [Indexed: 01/09/2023]
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Ekenze SO, Nwankwo EP, Okere PCN. The Utility of Ultrasonography in the Management of Undescended Testis in a Developing Country. World J Surg 2012; 37:1121-4. [DOI: 10.1007/s00268-012-1532-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Laparoscopic management of impalpable testes: comparison of different techniques. Pediatr Surg Int 2011; 27:1327-30. [PMID: 21882045 DOI: 10.1007/s00383-011-2970-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/17/2011] [Indexed: 01/25/2023]
Abstract
PURPOSE Laparoscopy is an important modality for management of impalpable testes. We present long-term outcomes of intra-abdominal testes managed by either single stage orchidopexy or two-stage Fowler Stephen's orchidopexy (FSO) over 12 years. METHODS Data were prospectively collected and retrospectively analyzed on patients who underwent laparoscopy for impalpable testes between 1998 and 2010. Demographic data, intra-operative findings, management, histology and follow-up findings were collected and analyzed. Fisher's Exact test was used for statistical analysis. RESULTS Laparoscopy was performed for 168 impalpable testes (78 left, 58 right and 16 bilateral). Patients were between 8 months and 15 years of age (median 1 year 10 months). Ninety-three testes were found to have cord structures entering the inguinal ring (canalicular), 65 were intra-abdominal and 10 had blind ending vas and/or vessel. Fifty-seven (34%) testes were atrophic and underwent orchidectomy; 100 (60%) testes underwent orchidopexy: either two-stage FSO (48) or single stage orchidopexy (52) and 10 (7%) had findings consistent with 'vanishing testes'. Histopathologically, the excised remnants (34%) showed no viable testicular tissue. The follow-up was a median of 8 months (3 months to 6 years). Four patients were lost to follow-up (two each after FSO and single stage orchidopexy) while, two FSO are awaiting follow-up. At follow-up, 36/44 testes (FSO) and 13/13 testes (single stage orchidopexy) are in the scrotum and of good size. Eight testes had atrophied after two-staged FSO. CONCLUSION Canalicular testes are often difficult to palpate (55%). Laparoscopy allows direct visualization and definitive management. There is no statistically significant difference between the results following single stage orchidopexy or two-stage FSO for impalpable testes.
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Neissner C, Ebert AK, Rösch WH. [Analysis of laparoscopic orchidopexy in intra-abdominal testis]. Urologe A 2011; 50:573-8. [PMID: 21503664 DOI: 10.1007/s00120-011-2528-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Laparoscopy is an established diagnostic procedure but is less frequently used as a therapeutic method for impalpable testes. To compare the results of the classic two-stage orchidopexy described by Fowler-Stephens with a testicular vessel-sparing single-stage approach in the management of intra-abdominal testes we retrospectively analyzed our data.From January 2005 to September 2010, 105 patients (mean age 32 months) underwent laparoscopy for impalpable testes. In cases of intra-abdominal testes, laparoscopic orchidopexy was performed either in a two-stage procedure including initial ligation of the testicular vessels or as a direct single-stage procedure without ligation of the vessels. The results of both approaches were evaluated postoperatively clinically and by ultrasonography. Among the 122 impalpable testes 63 were located intra-abdominally; single-stage orchidopexy was performed in 29 testes whereas a two-stage approach was conducted in 14 testes. Fourteen gonads had to be removed due to atrophy and in six cases no testis was found at all. In the other 59 cases inguinal exploration followed resulting in 22 orchidopexies, 34 removals and 3 blind-ending vessels. During a mean follow-up of 17 months none of the 29 testes treated by single-stage orchidopexy atrophied or reascended. By contrast, two cases of atrophy, one reascent and one subumbilical wound infection occurred after the two-stage procedure. Considering our excellent experiences with single-stage management, we conclude that the single-stage approach is a reliable, safe and efficacious treatment modality of intra-abdominal testes. However, the two-stage procedure including testicular vessel ligation should be restricted to high abdominal testes with very short vessels.
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Affiliation(s)
- C Neissner
- Klinik für Kinderurologie in Kooperation mit dem Lehrstuhl für Urologie der Universität Regensburg, Klinik St. Hedwig, Steinmetzstraße 1-3, 93049 Regensburg, Deutschland.
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