Is the vanished testis always a scrotal event?

The optimum cut-off value of contralateral testis size in the prediction of monorchidism in children with nonpalpable testis: A systematic review

BACKGROUND

Contralateral Testis Hypertrophy (CTH) is a clinical marker that could be used to guide the choice of the main surgical strategy. In patients with a Non-palpable Testis (NPT), the degree of CTH as measured by testicular length or volume has been shown to be able to predict whether the undescended testis will survive.

OBJECTIVE

The purpose of this study was to establish the proper cut-off for identifying non-viable testes based on the current literature.

DESIGN

We systematically searched several medical databases as well as Google Scholar search engines for references and citations. All the studies that reported CTH as a result of NPT in prepubertal boys were included. Data from the included articles was gathered by two independent reviewers. The checklist developed by the Joanna Briggs Institute (JBI) was used to evaluate the methodological quality of the studies that were included. Due to the incredibly high degree of heterogeneity among the studies, no meta-analysis was done.

RESULTS

The current systematic review included 17 studies that assessed the cut-off point to detect non-viable testis. The size and length of the testes were taken into consideration based on our findings. We found that different studies reported various ideal cut-off values for predicting non-viable testes, which can be brought on by various measuring techniques, evaluation ages, and patient groupings. The difference in testis volume was greater than the difference in its length, which can be attributable to the fact that some studies used an orchidometer to measure the testis's length directly or indirectly.

CONCLUSION

According to the results of our study, it seems that defining a cut point for diagnosis of CTH based on the size of the testis, cannot demonstrate the absence of a non-palpable testis.

The undescended testis in children and adolescents. Part 1: pathophysiology, classification, and fertility- and cancer-related controversies

Undescended testis (UDT) is defined as failure of a testis to descend into the scrotum. It is one of the most common reasons for consultation in pediatric surgery and urology with an incidence of 3% in live-born male infants. Decades ago, classical studies established that the failure of a testis to descend alters the development of its germ cells increasing the risk of infertility and testicular cancer in adulthood. More recent publications have rebutted some of the myths and raised controversies regarding the management of these patients, which, far from being limited to surgical treatment, should include pathophysiological and prognostic aspects for a comprehensive approach to the condition. Therefore, here we present an updated review divided into two parts: the first assessing the pathophysiological aspects and risks of these patients focused on fertility and cancer, and the second addressing the different treatment options for UDT.

The undescended testis in children and adolescents part 2: evaluation and therapeutic approach

Undescended testis (UDT) is defined as failure of a testis to descend into the scrotum and it is a common reason for consultation in pediatric urology. As extensively discussed in "The undescended testis in children and adolescents: part 1", the failure of a testis to descend alters testicular germ-cells development, increasing the risk of infertility and testicular cancer in adulthood. Here, we present the second part of our review and analysis of this topic with the aim to propose an updated and well-informed approach to UDT together with a treatment flow chart that may be useful to guide pediatric surgeons and urologists in the care of these patients. The main goal of the management of patients with UDT is to diminish the risk of infertility and tumor development and is based on the clinical findings at the time of diagnosis.

Abnormal histology in testis from prepubertal boys with monorchidism

BACKGROUND

Little is known about the histology of contralateral descended testes in boys with unilaterally absent testis. We investigated whether absence of one testis is associated with abnormal tissue architecture of the solitary contralaterally descended testis.

DESIGN SETTING AND PATIENTS

For this retrospective study, we examined the results of biopsies of the contralateral descended testis in 43 boys with monorchidism. Data from 26 control testes from boys of matching ages were selected from results published in 1977 and 2009. During surgery, any nubbins were removed. In each case, the scrotal testis was biopsied, and the testis fixed by subdartos pouch or suture.

RESULTS

Of the 43 affected boys, 23 had normal testicular histology in the contralateral descended testis, whereas 20 (46%) had abnormal histology. Eight of the abnormal biopsies matched the criteria for high infertility risk. Samples from three boys in this latter group revealed a Sertoli-cell-only phenotype. Immunohistochemical assays were positive for steroidogenic acute regulatory (STAR) protein in Leydig cells and spermatogonia. STAR expression was stronger in the monorchid group with normal testicular histology.

CONCLUSIONS

Almost half of the patients with unilateral absent testis were at risk for subfertility or infertility. Our results emphasize the need for testicular biopsy of the solitary testis in boys with monorchidism to appropriately assess infertility risk.

Initial laparoscopy and optimized approach for unilateral nonpalpable testis: review of 8-year single-center experience

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.

Surgical exploration for impalpable testis: Which should be first, inguinal exploration or laparoscopic abdominal exploration?

PURPOSE

To discuss an optimal surgical approach for impalpable testis in children, our own treatment results and those reported in the literature were reviewed.

MATERIALS AND METHODS

Seventy-two impalpable testes were diagnosed in 68 patients: unilateral in 64 patients and bilateral in 4 patients. All patients underwent surgical exploration at the ages of 6 to 140months (median, 15months). The inguinal canal was initially explored, and abdominal exploration was performed with laparoscopy when an extra-abdominal testis was not identified. In addition, articles regarding surgical exploration for impalpable testis, published over the last 20years, were retrieved and the results were examined.

RESULTS

Testes were detected by inguinal exploration in 28 of 72 (39%) impalpable testes: intracanalicular in 22 testes and at the internal inguinal ring (peeping or low abdominal testis) in 6 testes. All these testes were treated by conventional inguinal orchidopexy. Laparoscopic exploration was performed in 44 (61%) impalpable testes, and 4 (5.6%) high abdominal testes were detected and treated by two-stage Fowler-Stephens orchidopexy. Vanishing or absent testis was the final diagnosis in the remaining 40 testes (55.6%). The literature review showed that the ratios of intra- and extra-abdominal testes were lower in the articles that reported the results of inguinal or scrotal exploration than in those of laparoscopic exploration, although the difference was not significant.

CONCLUSIONS

Considering the relatively low incidence of high abdominal testis, we recommend to start with inguinal exploration for impalpable testis. When an extra-abdominal testis is not detected, transinguinal laparoscopic exploration should be indicated.

LEVEL OF EVIDENCE

Treatment study, Level IV.

Presence of viable germ cells in testicular regression syndrome remnants: Is routine excision indicated? A systematic review

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.

Blind ending vessels on diagnostic laparoscopy for nonpalpable testis: Is a nubbin present?

INTRODUCTION

The traditional management paradigm for nonpalpable testis (NPT) has been that inguinal or scrotal exploration for a nubbin may be omitted when blind ending vessels are observed during diagnostic laparoscopy. Our aim was to examine whether blind ending vessels excluded the presence of a nubbin in a series of boys who underwent exploration in this setting.

MATERIALS AND METHODS

Using a surgical database and chart review, pre-pubertal boys (≤12 years) with the diagnosis of undescended or atrophic testis who underwent a diagnostic laparoscopy for unilateral NPT between 2000 and 2015 were retrospectively identified. Physical exam, procedural and pathologic findings were confirmed by chart review.

RESULTS

595 boys underwent diagnostic laparoscopy for NPT by 11 surgeons. Of these, 318 had an intra-abdominal testis and 18 underwent diagnostic laparoscopy alone. Of the remaining 259, 32 had an open internal ring and inguinal or scrotal exploration was performed. The remaining 227 with a closed ring comprised the cohort for our analysis, of whom 188 had vessels entering the ring, 36 had blind ending vessels, and in three the vessel status was unavailable. In the 188 boys with vessels entering the ring, 164 (87%) had a nubbin excised during inguinal or scrotal exploration, of which 93% were grossly identified as an atrophic testis. Pathology confirmed the presence of hemosiderin in 44% and calcifications in 54%. In the 36 boys with blind ending vessels, 26 (72%) had a nubbin excised during inguinal or scrotal exploration, of which 96% were grossly identified as an atrophic testis. Pathology confirmed hemosiderin in 54% and calcifications in 58%. All seven cases with both blind ending vas and vessels had an atrophic testis grossly identified. Of all 207 excised remnants in this series, nubbins with viable testicular elements (seminiferous tubules in 11, germ cells in two) were only excised during cases that reported a non-atretic vas or any vessels entering the internal ring.

CONCLUSION

In this large multi-institutional series, blind ending vessels were associated with a nubbin noted during inguinal or scrotal exploration in the majority of cases. Based on this series if the surgeon's goal is to remove all nubbins, exploration is necessary regardless of vessel appearance. However, viable testicular elements were rarely identified and only when either a non-atretic vas or any vessels were observed to enter the ring.

Reliance of preoperative scrotal examination versus final operative findings in the evaluation of non-palpable testes

OBJECTIVE

The current study evaluates whether the preoperative scrotal examination in children with non-palpable testes is sufficient in all cases or if laparoscopy is necessary to confirm the examination findings. Are the findings different amongst physicians depending on their level of experience?

MATERIALS AND METHODS

This retrospective study was done between October 2009 and May 2013. Children with non-palpable testes underwent an examination under anesthesia prior to surgery to feel for a testis or nubbin, followed by a diagnostic laparoscopy to validate the scrotal examination. The test was considered correct if the laparoscopic findings supported the scrotal examination. It was considered incorrect if laparoscopy revealed a different finding.

RESULTS

A total of 74 testes were evaluated. All patients underwent examination under anesthesia by the surgeon and senior resident. The findings were recorded separately. Despite careful examination by experienced surgeons under anesthesia, the scrotal examination was incorrect in 14 patients. Four viable testes would have been missed if laparoscopy had not been performed.

CONCLUSION

Laparoscopy should be considered in case of palpable scrotal nubbins to ensure no testis is left within the abdominal cavity.

Is there an optimal contralateral testicular cut-off size that predicts monorchism in boys with nonpalpable testicles?

OBJECTIVE

To identify a contralateral testicular cut-off size that would predict monorchism (intra-abdominal vanishing testis or inguinal/scrotal nubbin) in boys with unilateral nonpalpable testis (NPT).

MATERIALS AND METHODS

Boys with cryptorchidism, treated by a single surgeon at a tertiary care center from 2009 to 2013, were grouped based on intra-operative findings: boys with a solitary gonad (monorchism group, M) and two control groups: intra-abdominal testis (IAT) and palpable undescended testis (pUDT). Immediately before the procedures, the contralateral descended testes were measured using callipers. Boys with NPT underwent diagnostic laparoscopy. Sensitivity, specificity, positive and negative predictive values, likelihood ratios and receiver operating characteristic (ROC) curves were calculated.

RESULTS

Out of the 324 boys with cryptorchidism, 58 were found to have pUDT and 85 had NPT. Of these 85 boys with NPT, 50 had an IAT and 35 had monorchism. Mean ages at surgery for groups M, IAT and pUDT were similar (28.0, 31.3 and 30.4 months, respectively; P = 0.4). Mean length of the contralateral descended testes in groups M, IAT and pUDT was 24.3, 16.5 and 18.8 mm, respectively. Contralateral testicular cut-off lengths of 18, 19 and 20 mm had positive likelihood ratios (LR+) of 6.5, 7.4 and 10.1, respectively. The area under the ROC curve was 95% (95% CI: 91-100%).

CONCLUSION

A contralateral testicular cut-off length of 19-20 mm had the best accuracy in predicting monorchism in boys aged 11-30 months with unilateral NPT.

Inguinal approach for the management of unilateral non-palpable testis: is diagnostic laparoscopy necessary?

OBJECTIVE

During the last decade laparoscopy has increasingly been advocated as the primary investigative procedure for the management of the non-palpable testis. We reviewed the medical records in a consecutive series of boys with non-palpable testis to examine the contribution of the initial inguinal approach in the management of unilateral non-palpable testis.

MATERIALS AND METHODS

Among the 183 consecutive patients with cryptorchidism from 2003 to 2012, there were 21 patients with unilateral and three with bilateral non-palpable testes. All unilateral patients then underwent inguinal and scrotal exploration through an inguinal incision. For those patients with an intra-abdominal peeping testis, the gonad was placed into the scrotum after meticulous cranial mobilization of the spermatic cord.

RESULTS

Patient age ranged from 11 months to 144 months (mean age: 23 months). Among the 21 unilateral cases, testicular absence or atrophy was confirmed in seven patients with a scrotal nubbin in six, and blind-ending vas and vessels at the external inguinal ring in one patient. Among the remaining 14 patients with sizeable testes, 12 testes were intra-abdominal peeping testes and two testicles were seen within the distal inguinal canal, which may be missed on physical examination owing to patient obesity. The intra-abdominal peeping testicle had the opened processus vaginalis entering the internal ring in which testicle was found. These were fixed into the scrotum successfully by cranial mobilization of spermatic vessel sometimes cutting the internal oblique muscle and by Prentiss and Fowler-Stephen's maneuver. Diagnostic laparoscopy was done on three patients with bilateral cases.

CONCLUSIONS

Given the result that most of nubbins are within the scrotum and testes with intra-abdominal peeping testes are fixed down safely into the scrotum, the inguinal approach may suffice for the management of unilateral non-palpable testis. Laparoscopy should be reserved for patients with bilateral non-palpable undescended testes.

The prevalence of bell clapper anomaly in the solitary testis in cases of prior perinatal torsion

PURPOSE

Bell clapper anomaly is associated with an increased risk of intravaginal testicular torsion. However, perinatal torsion is thought to be secondary to an extravaginal process. We quantified the contralateral prevalence of bell clapper anomaly in children found to have atrophic testicular nubbins secondary to presumed torsion during gestation to better define the subsequent risk of metachronous testicular torsion.

MATERIALS AND METHODS

Inspection results for the presence of contralateral bell clapper anomaly was recorded by a single surgeon in 50 consecutive cases in which exploration for nonpalpable testes revealed a testicular nubbin. For comparison data were collected in 27 consecutive cases of acute testicular torsion. Anatomy of the normal contralateral testis was compared between the 2 groups.

RESULTS

Average age at surgery in the perinatal torsion group was 15 months vs 12.7 years in the acute torsion group. One case of partial contralateral bell clapper anomaly was discovered in the perinatal torsion group but no complete anomaly was found. In contrast, in older boys with acute testicular torsion complete bell clapper anomaly was found in 21 of the 27 contralateral testes (78%).

CONCLUSIONS

In older boys with acute testicular torsion contralateral bell clapper anomaly is highly prevalent, supporting the standard practice of contralateral testicular fixation in this clinical situation. However, the prevalence of contralateral bell clapper anomaly is exceedingly small in cases of monorchism after perinatal torsion, substantiating an insufficient risk of subsequent torsion to justify routine fixation of the solitary testis.

The value of finding a closed internal ring on laparoscopy in unilateral nonpalpable testis

PURPOSE

There is an ongoing debate about whether initial laparoscopy is as efficient as initial extra-abdominal exploration for unilateral nonpalpable testis. The aim of this study was to clarify whether the finding of a closed internal ring on laparoscopy accurately predicts extra-abdominal findings in unilateral nonpalpable testis.

METHODS

Both laparoscopy and subsequent extra-abdominal exploration were prospectively performed in consecutive patients with unilateral nonpalpable testis. Laparoscopic findings were reviewed with respect to the status of the vas deferens, spermatic vessels, and the appearance of the internal ring. Except for patients with an abdominal testis, all patients underwent subsequent open exploration regardless of the laparoscopic findings. Open explorations were primarily performed by scrotal incision. During open exploration, any testicular remnants were removed and evaluated histologically.

RESULTS

A total of 100 patients with unilateral nonpalpable testis were evaluated, of whom 15 had an abdominal testis. Of the 85 patients without an abdominal testis, an open internal ring was recognized in only 8. Of the remaining 77 with a closed internal ring, subsequent open exploration revealed testicular nubbins in all patients (100%), regardless of the laparoscopic findings of the vessels and vas. Nine nubbins were associated with intra-abdominal vanishing vessels above the closed internal ring. All nubbins were confirmed by histological findings, and the incidence of viable germ cell elements was 7.4%.

CONCLUSIONS

When laparoscopy demonstrates no abdominal testis in patients with unilateral nonpalpable testis, the finding of a closed internal ring on laparoscopy is always associated with the presence of an extra-abdominal nubbin, regardless of the status of the vessels and the vas at the internal ring. Subsequent extra-abdominal exploration can be obviated in this circumstance if nubbin excisions are skipped. Initial diagnostic laparoscopy for unilateral nonpalpable testis provides not only the intra-abdominal findings, but also exact prediction of the extra-abdominal findings in patients with a closed internal ring.

Imaging studies for non-palpable testis: Are they at all required?

Undescended testis is one of the common surgical disorders in childhood and twenty percent of the undescended testes are nonpalpable. Surgical management is required in almost all cases for the repositioning or removal of the undescended testes and early intervention is preferred for optimal outcome. Use of imaging studies for accurate preoperative localisation of the nonpalpable testis is a wide prevalent practice. However, available evidences have questioned the need of such studies.

Neonatal testicular torsion: a systematic literature review

Neonatal testicular torsion (NTT) is rare and reported salvage rates vary widely both in their cited frequency and plausibility. The timing and necessity of surgery is controversial with different centers arguing for the conservative management of all cases while others argue for prompt exploration for all. Confusion also reigns over the need to fix the contralateral testis. In order to clarify the issue the authors reviewed the literature and found 18 case series of NTT, containing 268 operated cases suitable for analysis. This paper reviews the literature on NTT specifically regarding salvage rates and timing/necessity of surgery. Its primary aim is to produce an overall salvage rate in the operated group. Overall salvage rate was 8.96%, 24 testes. When operation is specified as an emergency, salvage may be as high as 21.7%. While salvage of a testis torted at birth is rare, it is reported. Early asynchronous torsion is also rare but reported. Worryingly, bilateral torsion can present with unilateral signs.Given these findings, we would suggest early surgery with fixation of the contralateral side.

The testicular regression syndrome--do remnants require routine excision?

AIM

Excision of testicular remnants is debatable in the scenario where hypoplastic vas and vessels can be seen entering a closed internal ring during laparoscopy for impalpable testes. We aimed to establish how frequently excised remnants have identifiable testicular tissue and, hence, malignant potential.

METHODS

This study is a retrospective review of all excised testicular remnants in children with impalpable testis. Specimens that were excised for indications other than testicular regression syndrome were excluded. Pathology reports of excised specimens were reviewed, and the presence of multiple histologic features was noted. Histologic confirmation of testicular/paratesticular tissue required the presence of 1 or more of the following: seminiferous tubules, germ cells, Sertoli cells, Leydig cells, vas deferens, or epididymal structures. Malignancy potential was defined by the presence of germ cells or seminiferous tubules. All patients with seminiferous tubules were further examined by a single histopathologist.

RESULTS

A total of 208 testicular remnants from 206 children were excised over the 11-year period (1999-2009). Histologic evidence confirmed excision of testicular/paratesticular tissue in 180 cases (87%). Seminiferous tubules were noted in 27 (15%), and germ cells were present in 19 (11%) cases.

CONCLUSION

Viable germ cells were found in 11% of examined remnants, which, in our opinion, justifies their removal.

New insights into perinatal testicular torsion

Perinatal testicular torsion is a relatively rare event that remains unrecognized in many patients or is suspected and treated accordingly only after an avoidable loss of time. The authors report their own experience with several patients, some of them quite atypical but instructive. Missed bilateral torsion is an issue, as are partial torsion, possible antenatal signs, and late presentation. These data are discussed together with the existing literature and may help shed new light on the natural course of testicular torsion and its treatment. The most important conclusion is that a much higher index of suspicion based on clinical findings is needed for timely detection of perinatal torsion. It is the authors' opinion that immediate surgery is mandatory not only in suspected bilateral torsions but also in cases of possible unilateral torsions. There is no place for a more fatalistic "wait-and-see" approach. Whenever possible, even necrotic testes should not be removed during surgery because some endocrine function may be retained.

Extravaginal testicular torsion: a clinical entity with unspecified surgical anatomy

PURPOSE

To review and evaluate the anatomical definitions of perinatal extravaginal torsion (EVT) of the testis.

MATERIALS AND METHODS

An extensive review of the literature was made to reveal the prevalent anatomical background predisposing to EVT. Gross appearance of twisted testes obtained during surgery for 14 cases of EVT was used to test the validity of the above theories.

RESULTS

The most commonly accepted suggestions describe an EVT within dartos muscle that includes all layers of spermatic cord or an EVT outside parietal layer of tunica vaginalis within internal spermatic fascia. However, both of them were found inadequately documented, while a large volume of controversial data has been accumulated, that raises doubts regarding the validity of such definitions. The gross appearance of twisted testes failed to confirm both an EVT including all layers of the spermatic cord and also an EVT outside tunica vaginalis as possible mechanisms of torsion.

CONCLUSION

The anatomical basis of EVT remains unclear and further investigation is required.

Cryptorchidism and testicular cancer: separating fact from fiction

PURPOSE

We dissected prevailing assumptions about cryptorchidism and reviewed data that support and reject these assumptions.

MATERIALS AND METHODS

Five questions about cryptorchidism and the risk of testicular cancer were identified because of their implications in parent counseling and clinical management. Standard search techniques through MEDLINE were used to identify all relevant English language studies of the questions being examined. Each of the 5 questions was then examined in light of the existing data.

RESULTS

The RR of testicular cancer in a cryptorchidism case is 2.75 to 8. A RR of between 2 and 3 has been noted in patients who undergo orchiopexy by ages 10 to 12 years. Patients who undergo orchiopexy after age 12 years or no orchiopexy are 2 to 6 times as likely to have testicular cancer as those who undergo prepubertal orchiopexy. A contralateral, normally descended testis in a patient with cryptorchidism carries no increased risk of testis cancer. Persistently cryptorchid (inguinal and abdominal) testes are at higher risk for seminoma (74%), while corrected cryptorchid or scrotal testicles that undergo malignant transformation are most likely to become nonseminomatous (63%, p <0.0001), presumably because of a decreased risk of seminoma.

CONCLUSIONS

Orchiectomy may be considered in healthy patients with cryptorchidism who are between ages 12 and 50 years. Observation should be recommended in postpubertal males at significant anesthetic risk and all males older than 50 years. While 5% to 15% of scrotal testicular remnants contain germinal tissue, only 1 case of carcinoma in situ has been reported, suggesting that the risk of malignancy in these remnants is extremely low.

Scrotal Exploration for Unilateral Nonpalpable Testis

PURPOSE

We previously reported initial scrotal exploration for unilateral nonpalpable testis, followed by laparoscopy when a viable testis was not found. Although we concluded that scrotal exploration could often make laparoscopy unnecessary, the knowledge that patients with presumed nubbins would undergo laparoscopy meant that the surgeon did not have to decide whether findings were definitive. In a second series of consecutive patients laparoscopy was used only when it appeared indicated.

MATERIALS AND METHODS

Boys with unilateral nonpalpable testis underwent initial scrotal exploration. Laparoscopy was only performed when neither a nubbin nor a testis was found, when there was a patent processus vaginalis and/or when gross findings suggesting a nubbin were thought inconclusive.

RESULTS

There were 43 patients, including 30 (70%) with monorchism and 13 (30%) with an extra-abdominal (7) or intra-abdominal (6) testis. Of 30 patients found to have monorchism laparoscopy was performed only in 7 (23%), including 2 with scrotal nubbins with a patent processus vaginalis, 1 with a questionable nubbin, 1 with a definitive nubbin but preoperative magnetic resonance imaging suggesting a testis and 3 with an empty scrotum (intra-abdominal vanished testis in 1 and inguinal nubbins in 2). The finding of monorchism was strongly predicted by a contralateral descended testicular length of 1.8 cm or greater.

CONCLUSIONS

Scrotal exploration is potentially definitive for the diagnosis and management of extra-abdominal testes and nubbins in patients with unilateral nonpalpable testis. Laparoscopy is only definitive when an intra-abdominal testis is found, which occurs in a minority of cases.

Histological evaluation of the testicular nubbins in patients with nonpalpable testis: assessment of etiology and surgical approach

There is a controversy in the literature whether testicular nubbins carry malignancy risk and excision of the nubbin is necessary in patients with nonpalpable testis. It is also controversial whether vanishing testis has the same etiopathogenesis and risk with true undescended testis. The aim of this study is to investigate the histological findings of testicular nubbins in patients with nonpalpable testis and to question etiology and surgical indications for vanishing testis. We reviewed the histopathological results of 44 testicular nubbins in 40 patients (mean age: 4.1 years, range 1-13 years) with nonpalpable testis between 1992 and 2004, retrospectively. Exploration revealed 5 intraabdominal and 39 inguinal testicular nubbins. Of 44 specimens only 5 (11.3%) from inquinal testicular nubbins were found to have seminiferous tubules. Two of the five had seminiferous tubule structures with viable germ cells showing maturation correlating with age. The other two with scarce seminiferous tubules were seen on only a single area and one had Sertoli cells only. None of the excised tissue had malignant degeneration. The vas deferens was identified in 23 (52.2%), vessels in 26 (59%), calcification in 14 (31.8%) and hemosiderin in 12 (27.2%) of excised tissue. Presence of calcification in one-third of the nubbins supports vascular accident thesis in the etiopathogenesis of vanishing testis. The possibility for the presence of seminiferous tubules and viable germ cells in the testicular nubbin is low. These facts decrease theoritical risk of malingnancy. Therefore, an inguinal exploration for testicular nubbin in patients with vas deferens and vessels entering into the inquinal canal diagnosed at laparoscopy can be postponed untill testicular prosthesis implantation and the nubbin can be removed at this operation.

Histopathological features of testicular regression syndrome: relation to patient age and implications for management

Testicular regression syndrome (TRS) represents a congenital condition in which no normal testicular tissue can be identified following exploration for a clinically impalpable testis. A spectrum of pathological findings may be present but there is little literature systematically examining these features. We searched a pediatric histopathology database to identify cases of TRS, and the histopathological findings were reviewed and pooled with those of all previously published smaller series. A total of 117 cases were identified during the period (1989-2004), median age 2 (range birth-12) years. In 52 (44%) a nodule was identified macroscopically, median maximum diameter 0.5 (range 0.1-2.0) cm. Microscopic hemosiderin-laden macrophages were present in 85 (73%), dystrophic calcification in 52 (44%), residual testicular tubules in 12 (10%), vas deferens in 71 (61%), and epididymal tissue in 39 (33%). The prevalence of hemosiderin laden macrophages and dystrophic calcification were significantly greater in cases < or =3 years (84% versus 64% and 55% versus 32%, respectively). But there was no significant difference in the frequency of other findings between the younger and older age groups; in particular, the presence of residual testicular tubules was similar (7% versus 13%, respectively). Furthermore, there was no significant correlation between identification of a macroscopically distinct nodule and presence of residual tubular structures, tubules being identified in 6 of the 65 cases in which no clearly identifiable nodule was seen macroscopically. The presence of hemosiderin-laden macrophages and foci of dystrophic calcification showed a positive association. TRS is associated with specific histopathological features, the findings being consistent with changes secondary to intrauterine testicular torsion. Residual testicular tubules are found in 10% of cases regardless of the presence or absence of a macroscopically identifiable nodule.

INITIAL SCROTAL INCISION FOR UNILATERAL NONPALPABLE TESTIS

PURPOSE

We investigated use of initial scrotal incision for the management of unilateral nonpalpable testis.

MATERIALS AND METHODS

Scrotal incision followed by laparoscopy was performed in a consecutive series of 40 boys with unilateral impalpable testis.

RESULTS

Initial scrotal incision revealed 22 scrotal nubbins and 4 extra-abdominal testes among the 40 patients. Of 13 patients with intra-abdominal testis 6 had a looping vas that was dissected to the internal ring via the scrotal incision, and the incision was used for orchiopexy in 12. Laparoscopy detected 1 case of intra-abdominal vanished testis but falsely diagnosed 6 additional cases based upon blind-ending vas and vessels despite a known scrotal nubbin. It also detected 13 intra-abdominal testes but was inconclusive in 14 cases in which vas and vessels exited the internal ring, not including the 4 patients with extra abdominal testes who did not undergo laparoscopy.

CONCLUSIONS

Scrotal incision may be sufficient to diagnose testicular loss when a nubbin is encountered, and can detect an extra abdominal testis not palpated with the patient under anesthesia. The incision is used for orchiopexy in those patients with a testis that can be brought to the scrotum in a single stage. Laparoscopy potentially can be reserved for cases in which no nubbin is found and in all cases when a patent processus vaginalis is encountered.

Is an empty left hemiscrotum and hypertrophied right descended testis predictive of perinatal torsion?

PURPOSE

We determine whether the finding of a nonpalpable left testis and hypertrophied(2 cc or greater) right testis is predictive of an atrophic (perinatal torsion) left testis.

MATERIALS AND METHODS

Prospectively, all boys with a nonpalpable left testis and hypertrophied right testis seen between May 2000 and May 2002 were included in the study. Testicular measurement was performed preoperatively with an orchidometer. In 19 of 22 boys size was also confirmed intraoperatively. Surgical exploration was done initially through a scrotal incision. Diagnostic laparoscopy was performed in boys in whom intrascrotal tissue that was consistent with a "nubbin" was not found. All tissue removed was submitted for histological evaluation.

RESULTS

In 19 of 22 boys tissue was found in the left hemiscrotum that was clinically consistent with a scrotal nubbin, and histological confirmation was absolute in 18. In 1 patient a hollow oval mass attached to a cord extending to the external inguinal ring was found without the other classic histological features of torsion. In 3 cases scrotal exploration was negative and diagnostic laparoscopy was performed. Of this group the pathognomonic findings of a closed internal ring with hypoplastic vas and vessels were noted in 2 cases, and normal vas and vessels were seen to exit an open internal inguinal ring in 1. Inguinal exploration demonstrated an enlarged intracanalicular testis measuring 3 cc in volume, comparable in size to the descended right testicle.

CONCLUSIONS

The combination of a nonpalpable left testis and an enlarged right testis is highly predictive of perinatal testicular torsion. When both criteria were met 20 of 22 (91%) consecutive patients had histological or laparoscopically confirmed perinatal torsion and 1 had only clinical features. This finding supports the concept of scrotal exploration as the initial procedure in the child who has an empty left hemiscrotum and hypertrophied descended right testis. Laparoscopy should be reserved for boys in whom a distinct remnant is not found on scrotal exploration.

Adult nonpalpable testis: is laparoscopy always required?

Laparoscopy is widely used in the diagnosis and treatment of nonpalpable testes. Some nonpalpable testes are vanishing testes. In such cases, unnecessary laparoscopic interventions can be avoided by a careful selection of cases. Between 1996 and 2001, laparoscopic intervention was applied to 107 patients with nonpalpable testes. Of the cases, 23 were bilateral and 84 were unilateral. Patients were between 19 and 27 years of age (average age, 23 years). Diagnostic ultrasonography was performed in 44 of the 84 patients with nonpalpable testes. Dimensions of the scrotal testis were determined by the Prader orchiometer method. The dimensions of the opposite scrotal testis (of the scrotal nubbin) and the abdominal testis were compared with the dimensions of 20 normal, healthy individuals' scrotal testis (control group). Results were evaluated by the Mann-Whitney U test. During laparoscopy, 24 (28.5%) of the patients were found to have a vanishing testis. The vas deferens and the testicular blood vessels ended bluntly at the anterior edge of the interior inguinal ring in one patient, inside the inguinal canal in five patients, and in the scrotum in 18 patients. Among the 84 patients with nonpalpable testes, no testis was found in any of the 18 patients with palpable scrotal nubbins. The opposite scrotal testes were hypertrophic in 17 (70.8%) of 24 patients who had vanishing testis (P < .05), and they were hypertrophic in 22 (36%) of the 60 patients (P > .05) who had laparoscopically identified intraabdominal testes. We conclude that clinical and radiologic diagnosis is sufficient for adult patients with nonpalpable testicles and palpable scrotal nubbins and hypertrophic contralateral scrotal testes. Laparoscopic intervention should be applied to patients who do not have palpable scrotal nubbins.