Epidemiology, classification and management of undescended testes: does medication have value in its treatment?

Knowledge and Awareness of Screening for Children With Cryptorchidism in the Al-Qunfudhah Governorate, Saudi Arabia

Background Undescended testis is a common pediatric surgical presentation condition with potential long-term consequences if left untreated. It is characterized by the failure of one or both testes to descend into the scrotum. This study aims to measure and enhance awareness and knowledge about undescended testis through comprehensive medical research and provide evidence-based recommendations. Objective The objective of this study was to evaluate participants' knowledge regarding undescended testes and assess the level of interest and awareness among individuals and parents about the importance of early examination and treatment. Methods It is a cross-sectional, nationwide study targeting the population of Al-Qunfudhah. The study was conducted in December 2023 using a validated questionnaire distributed through social media platforms. Results The study analyzed data from 459 participants to assess their knowledge and attitudes regarding undescended testis. Participants' knowledge was evaluated. In general, the mean ± SD score of knowledge was 3.61 ± 2.33. Higher education level, occupation, and having children were associated with greater knowledge. Attitudes were measured. The mean attitudes score was 2.37 ± 1.58. Higher education level, occupation, and marital status influenced attitudes. Conclusion This study provides valuable insights into the knowledge and attitudes of individuals regarding undescended testis. Participants displayed moderate levels of knowledge and positive attitudes, with educational attainment and occupation playing significant roles. These findings highlight the importance of targeted educational interventions to improve awareness and promote positive attitudes toward undescended testis.

Laparoscopic totally extraperitoneal exploration of intra-abdominal testis, orchidectomy and inguinal hernia repair in an adult patient

The presence of undescended testis predisposes to the development of an inguinal hernia due to the persistent processus vaginalis. This coexistence is not very rare in the paediatric population. Here, we report an adult man who presented with inguinal hernia and an intra-abdominal testis and successfully underwent an extended totally extraperitoneal (e-TEP) approach for extraperitoneal exploration of the testis in the left iliac fossa, and orchidectomy along with inguinal hernia repair. Review of the literature revealed only two case reports in which TEP has been used in the treatment of undescended testis in adults, and in both cases, the testes were intracanalicular. This case, as per our extensive bibliographical research, is the first reported case of an intra-abdominal testis, with descent arrested at the iliac fossa, explored using e-TEP along with inguinal hernia repair. Such minimally invasive procedures may be offered to the patients without the risks of intraperitoneal entry.

Testicular ectopia: A case report

This paper mainly describes three cases of children with ectopic testis, of which two patients with transverse testicular ectopia (TTE) and one with perineal ectopic testis (PET). All patients who underwent orchidopexy at the same pediatric surgical unit in the Affiliated Hospital of Jining Medical University (Jining, China) between June 2010 and February 2021 were retrospectively evaluated (age range, 14-34 months). A total of two patients (67%) was admitted with asymptomatic unilateral inguinal masses and the contralateral testis missing; the first patient was diagnosed with TTE intraoperatively, whereas the other patient was diagnosed with TTE through physical examination and ultrasound preoperatively. The third patient (33%) was admitted with the right testis missing and a left perineal mass, which was confirmed using PET by physical and ultrasound examination before the operation. The first two patients underwent transseptal orchidopexy, whereas the third patient underwent simple orchidopexy. Postoperative complications were not observed (follow-up, 10-24 months). The low incidence and poor understanding of ectopic testis compels us to report our findings and further discuss this particular disease of testicular ectopia, including its pathogenesis, diagnostic and treatment options.

Comparison of conventional Doppler imaging techniques and superb microvascular imaging in determination of vascularization in undescended testes

Aim

Our aim was to gain an idea about testicular injury by comparing the reduced volume, which is one of the indirect indicators of testicular damage in undescended testes, and by evaluating the reduced microvascular blood flow by superb microvascular imaging, and also to determine whether superb microvascular imaging modes could detect microvascular blood flow in more detail in the decreased volume of undescended testes.

Material and methods

We compared testicular blood flow in undescended testes via conventional Doppler imaging, color superb microvascular imaging, and monochrome superb microvascular imaging techniques with contralateral normally located testis and normal control group. Each sample of testicular tissue was evaluated using a qualitative method. Spot color encoding and linear flow color encoding counts determined in testicular parenchyma were counted separately and expressed as numerical data. The localization of the examined testes in the grayscale was noted (proximal inguinal canal, medial inguinal canal, distal inguinal canal, and scrotal). The volume of undescended testes was calculated automatically via a formula for volume.

Results

Monochrome superb microvascular imaging is significantly superior in visualizing the vascularity of undescended testes compared with color Doppler, power Doppler and color superb microvascular imaging (p = 0.001). Also, undescended testes have a significantly lower blood flow compared with contralateral normal testes (p = 0.001). The volume of undescended testes was significantly lower than the contralateral normal testes.

Conclusions

The volume, structure and blood flow are indirect signs of testicular damage in undescended testes. Monochrome superb microvascular imaging can detect vascularity in undescended testes better than the conventional Doppler imaging technique and color superb microvascular imaging. Based on our findings, we can report that monochrome superb microvascular imaging can be used to evaluate testicular injury and vascularity of undescended testes.

Update on canine anorchia: A review

Abnormalities of the external genitals are an important issue in dog breeding because of the unfavourable qualities and characteristics of breeds, resulting in consistent economic losses. Despite their significance, little scientific attention has been given to these problems. Although there are several reviews on cryptorchidism in dogs, none have described anorchia. Testicular agenesis is a rare reproductive disorder with a congenital origin. Moreover, no author has described the diagnostic procedure for making a definitive diagnosis of anorchia in dogs. It is important to have a well-structured diagnostic scheme to help practical veterinarians make a confirmatory diagnosis. This review article aims to provide an update on canine anorchia diagnosis based on the poor research studies published in recent years. We have also contributed to the pathogenesis of this disorder using human medicine studies. Finally, the review includes therapeutic hypotheses that can be expanded in future studies.

Racial and ethnic disparities in the timing of orchiopexy for cryptorchidism

INTRODUCTION

Many children do not undergo surgery for cryptorchidism in a timely fashion, increasing risk of infertility and malignancy. Racial and ethnic disparities in surgery timing has been suggested in other specialties, but has not been well-explored in Pediatric Urology.

OBJECTIVES

Our aim was to investigate the association of race and ethnicity with age at orchiopexy.

MATERIALS AND METHODS

We performed a retrospective cohort study of individuals <18 years of age as captured in the NSQIPP PUF from 2012 to 2016. Those with cancer were excluded. The primary outcome of interest was age at time of surgery. Secondary outcome was the proportion of individuals undergoing surgery by recommended age. Generalized linear models and logistic regression models were created for the outcomes of interest.

RESULTS

The median age at orchiopexy was 17.4 months (10.7, 43.0) and overall, 51% of subjects underwent orchiopexy by 18 months of age. Non-Hispanic white individuals were most likely to have undergone orchiopexy by 18 months of age, at 56%, compared with only 44% of non-Hispanic black individuals (p < 0.001). When adjusting for co-morbidities and developmental delay, Hispanic patients underwent orchiopexy 5 months later than white patients, on average, and black patients had a delay of 7 months compared to white patients.

DISCUSSION

These data suggest that orchiopexy is happening at younger ages compared to prior large-scale studies. However, minority patients are on average older at time of orchiopexy, potentially increasing future risk of infertility or malignancy. While an estimated average delay of 5-7 months may not seem high, studies suggest there is an appreciable change in risk with a 6-month delay. Patient, provider, and system-level factors likely all contribute, and these need to be further elucidated.

CONCLUSIONS

Many racial and ethnic minorities with cryptorchidism have later orchiopexies, and are more likely to have surgery outside the recommended timeframe. Further investigation is warranted to determine the factors contributing to these disparities.

Micro-testicular sperm extraction outcomes for non-obstructive azoospermia in a single large clinic in Victoria

AIMS

To evaluate the results of microdissection testicular sperm extraction (micro-TESE) and intracytoplasmic sperm injection (ICSI) for treatment of non-obstructive azoospermia (NOA).

MATERIALS AND METHODS

We retrospectively analysed data of 88 consecutive patients with clinical NOA who were treated with micro-TESE by a single surgeon, between August 2014 and September 2020, in Melbourne, Victoria. Upon a successful sperm retrieval, sperm was either used fresh for ICSI, frozen for future use or both. The outcome measures were sperm retrieval rate (SRR), and in vitro fertilisation (IVF)/ICSI results. Furthermore, SRR was calculated for the predominant causes and histopathological patterns.

RESULTS

The overall SRR was 61.2%. It was significantly higher in patients with a history of cryptorchidism and other childhood diseases (100%) than in the other NOA groups (P < 0.05). Patients with Klinefelter syndrome had a 75% SRR. Among the different types of testicular histology, the highest SRR were noted in patients with complete hyalinisation (100%) and hypospermatogenesis (92.9%), and low with Sertoli cell-only syndrome (46.3%). The SRR has significantly increased from 33.3% in 2015-2016 to 73.6% in 2019-2020 (P = 0.009). Of the 52 patients with SSR, 47 underwent IVF/ICSI. Fertilisation rate was 42.4%. Twenty-nine couples achieved at least one good-quality embryo and had embryo transfer. Nineteen achieved pregnancy (40.4%), and in three patients a miscarriage resulted.

CONCLUSIONS

This is the first report from Australia showing that micro-TESE is an effective treatment for NOA with high SRR. The increasing success rates over several years indicate the importance of surgical skill and laboratory staff experience.

Testicular torsion in unilateral undescended testis: A case report and literature review

Early diagnosis of undescended testis (UDT) in patients under 2 years old plays a vital role in therapy success. However, in developing countries, UDT is often diagnosed in over 2 years. This case report described unilateral UDT in a patient aged 19 years accompanied by testicular torsion, which was found intraoperatively and not vital. Thus, the operator decided to do an orchiectomy. The operation was successful, and the patient was discharged the day after the surgery.

Testicular arteries anatomy applied to fowler-sthephens surgery in high undescended testis - a narrative review

Objectives:

In this review we will describe the testicular vessels anatomy and the implications of these vessels in surgical treatment of high undescended testis.

Material and Methods:

We performed a narrative review of the literature about the role of the testicular arteries anatomy in the treatment of high undescended testis. We also studied two human testes to illustrate the testicular vascularization.

Results:

Each testis is irrigated by three arteries: testicular artery (internal spermatic artery), a branch of the right aorta; deferential artery (vasal artery), a branch of the inferior vesicle artery that originates from the anterior trunk of internal iliac artery and cremasteric artery (external spermatic artery), a branch of the inferior epigastric artery. There are important communications among the three arteries with visible anastomotic channels between the testicular and deferential arteries.

Conclusions:

Laparoscopic transection of the testicular vessels by dividing the spermatic vessels (Fowler-Stephens surgery) is safe in patients with high abdominal testis due to the great collateral vascular supply between testicular, vasal and cremasteric arteries; also, two-stage Fowler-Stephens orchiopexy appears to carry a higher rate of success than the single stage approach.

Endocrine Dysfunction in Children with Zika-Related Microcephaly Who Were Born during the 2015 Epidemic in the State of Pernambuco, Brazil

Congenital viral infections and the occurrence of septo-optic dysplasia, which is a combination of optic nerve hypoplasia, abnormal formation of structures along the midline of the brain, and pituitary hypofunction, support the biological plausibility of endocrine dysfunction in Zika-related microcephaly. In this case series we ascertained the presence and describe endocrine dysfunction in 30 children with severe Zika-related microcephaly from the MERG Pediatric Cohort, referred for endocrinological evaluation between February and August 2019. Of the 30 children, 97% had severe microcephaly. The average age at the endocrinological consultation was 41 months and 53% were female. The most frequently observed endocrine dysfunctions comprised short stature, hypothyroidism, obesity and variants early puberty. These dysfunctions occurred alone 57% or in combination 43%. We found optic nerve hypoplasia (6/21) and corpus callosum hypoplasia (20/21). Seizure crises were reported in 86% of the children. The most common-and clinically important-endocrine dysfunctions were pubertal dysfunctions, thyroid disease, growth impairment, and obesity. These dysfunctions require careful monitoring and signal the need for endocrinological evaluation in children with Zika-related microcephaly, in order to make early diagnoses and implement appropriate treatment when necessary.

Male infertility and genitourinary birth defects: there is more than meets the eye

Male factor infertility is a significant problem present in up to 50% of infertile couples. The relationship between male infertility and systemic disease is of significant interest, and emerging evidence suggests a relationship between male infertility and male genitourinary (GU) birth defects (cryptorchidism, hypospadias, ambiguous genitalia, and congenital anomalies of the kidney and urinary tract). Many of these birth defects are treated in isolation by busy urologists without acknowledgment that these may be related to more global syndromic conditions. Conversely, geneticists and nonurologists who treat variable systemic phenotypes may overlook GU defects, which are indeed related conditions. Many of these defects are attributed to copy number variants dosage-sensitive genes due to chromosome microdeletions or microduplications. These variants are responsible for disease phenotypes seen in the general population. The copy number variants described in this review are syndromic in some cases and responsible for both GU birth defects as well as other systemic phenotypes. This review highlights the emerging evidence between these birth defects, male infertility, and other systemic conditions.

Cryptorchidism in Children with Zika-Related Microcephaly

The genitourinary tract was recently identified as a potential site of complications related to the congenital Zika syndrome (CZS). We provide the first report of a series of cryptorchidism cases in 3-year-old children with Zika-related microcephaly who underwent consultations between October 2018 and April 2019 as part of the follow-up of the children cohort of the Microcephaly Epidemic Research Group, Pernambuco, Brazil. Of the 22 males examined, eight (36.4%) presented with cryptorchidism. Among 14 undescended testis cases, 11 (78.6%) could be palpated in the inguinal region. Seven of the eight children had severe microcephaly. Conventional risk factors for cryptorchidism were relatively infrequent in these children. We hypothesize that cryptorchidism is an additional manifestation of CZS present in children with severe microcephaly. As in our cases, for most of the children, the testes were located in the inguinal region, and the possible mechanisms for cryptorchidism were gubernaculum disturbance or cremasteric abnormality.

Predictors of surgical sperm retrieval in non-obstructive azoospermia: summary of current literature

Intracytoplasmic sperm injection (ICSI), combined with surgical sperm retrieval (SR) techniques, is the sole option for patients with non-obstructive azoospermia to achieve fertility; however, with suboptimal results. Given the variability in clinical presentation, the potential role of factors that can predict the likelihood of successful testicular SR needs to be clarified. This article summarizes the current evidence concerning the variables predicting SR success in non-obstructive azoospermic patients with spermatogenic failure. For this, we used 60 articles, including 46 original papers and six meta-analyses. Clinical and laboratory factors, as well as adjuvant therapies and surgical retrieval methods, were the factors most commonly investigated. We found that Klinefelter syndrome, Y chromosome microdeletions in regions AZFa/b, and Sertoli cell-only histopathology were associated with reduced SR success. By contrast, testis volume > 12.5 ml, history of cryptorchidism, use of micro-TESE as the sperm retrieval method, and adjuvant therapy were associated with improved SR success. None of the predictors, alone or combined, provide definitive information about the chances of harvesting sperm in men with non-obstructive azoospermia, except for Y chromosome microdeletions in regions AZFa/b. In the latter, SR success is virtually nil. We conclude that SR outcomes in men with non-obstructive azoospermia are difficult to predict based on the existing variables. Although several predictors can be used for patient counseling, their clinical value is limited to either ensure SR success or discourage reproductive urologists from recommending SR to men with non-obstructive azoospermia seeking fertility. A notable exception includes the deletions involving the regions AZFa and/or AZFb of the Y chromosome; the affected patients should be counseled against undergoing SR.

Ontogeny of Hypothalamus-Pituitary Gonadal Axis and Minipuberty: An Ongoing Debate?

The fetal hypothalamus-pituitary gonadal (HPG) axis begins to function during mid-gestation but its activity decreases during late pregnancy due to the suppressive effects of placental estrogens. Placental hormones drop immediately after birth, FSH and LH surge at around 1 week and peak between 1 and 3 months of life. The HPG axis is activated in both sexes, but a sexual dimorphism is evident with higher LH values in boys, while FSH prevails in girls. Both gonadotrophins decline in boys by around 6 months of age. In girls, LH declines at the same time as in boys, while FSH persists elevated up to 3 or 4 years of age. As a result of gonadotropin activation, testicular testosterone increases in males and ovarian estradiol rises in females. These events clinically translate into testicular and penile growth in boys, enlargement of uterus and breasts in girls. The functional impact of HPG axis activity in infancy on later reproductive function is uncertain. According to the perinatal programming theory, this period may represent an essential programming process. In boys, long-term testicular hormonal function and spermatogenesis seem to be, at least in part, regulated by minipuberty. On the contrary, the role of minipuberty in girls is still uncertain. Recently, androgen exposure during minipuberty has been correlated with later sex-typed behavior. Premature and/or SGA infants show significant differences in postnatal HPG axis activity in comparison to full-term infants and the consequences of these differences on later health and disease require further research. The sex-dimorphic HPG activation during mid-gestation is probably responsible for the body composition differences observed ad birth between boys and girls, with boys showing greater total body mass and lean mass, and a lower proportion of fat mass. Testosterone exposure during minipuberty further contributes to these differences and seems to be responsible for the significantly higher growth velocity observed in male infants. Lastly, minipuberty is a valuable "window of opportunity" for differential diagnosis of disorders of sex development and it represents the only time window before puberty when congenital hypogonadism can be diagnosed by the simple analysis of basal gonadotropin and gonadal hormone levels.

Age at Surgery and Outcomes of Undescended Testes at King Salman Armed Forces Hospital, Tabuk, Saudi Arabia

Objective

The aim of this study was to investigate the age at diagnosis and surgery of undescended testes and patients’ outcomes.

Methods

This is a retrospective study that reviewed the files of patients who underwent orchidopexy at the King Salman Armed Forces Hospital (KSAFH), Tabuk, Saudi Arabia (SA), between January 1, 2015, and March 30, 2019. All children from birth until 13 years old who were admitted within the specified time frame and underwent orchidopexy were included in this study. The gathered data were analyzed through the Statistical Package for Social Sciences software (SPSS, version 23; SPSS Inc., Chicago, IL, USA).

Results

 A total of 175 patients were included in this study. The rate of orchidopexy at our institution was 12.2%. The median ages at diagnosis and surgery were 12 and 24 months, respectively. The median duration between diagnosis and surgery was eight months. The most common site of undescended testis was inguinal (80.6%). Bilateral undescended testes were recorded in 24.6% of cases, and 25.7% of cases were impalpable. The size of the undescended testis was average in half the cases, small in 44.6% and atrophic in 6.4% of cases. Postoperative complications were reported in 4.0% of cases. Cox regression analysis revealed that the age at diagnosis was a significant risk factor affecting the time of surgery.

Conclusion

The findings of this study revealed that most cases of undescended testes in Tabuk were operated beyond the age recommended by international guidelines. The age at diagnosis seems to significantly affect the time of surgery.

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

BACKGROUND/PURPOSE

Although the surgical treatment was proved to be the recommended line of management for congenital undescended testis, hormonal therapy with human chorionic gonadotrophin hormone has been started long years ago and is still used in some areas with variable degrees of success. The factors responsible for treatment failure are not well explored. In this study, we aimed to highlight the anatomical abnormalities in the congenital undescended testis that might contribute to treatment failure.

METHODS

During the period from January 2014 to December 2015, 75 boys with congenital undescended testes received treatment with human chorionic gonadotrophin, in pediatric surgery department, Faculty of medicine, Ain Shams University. Their age ranged between 6 months and 4 years (mean 1.6 years, median 2 years). In 70 boys, the testes were palpable and in the remaining 5 boys, the testes were impalpable. Fifty boys had unilateral and 25 had bilateral undescended testes. Seven of the palpable testes were high scrotal in position and the remaining 83 were palpated in the inguinal canal. The patients were followed up for 6 months to determine the position of the testis after the treatment and surgical intervention was done for those who did not respond to the hormonal treatment either partially or completely.

RESULTS

Only 7 testes showed complete descent (7%) (2 bilateral and 3 unilateral) and they were initially high scrotal in position, 8 testes showed partial descent (8%) (2 bilateral and 4 unilateral) and they were inguinal in 6 which became high scrotal and impalpable in 2 which became peeping. The remaining 85 (85%) did not respond to the hormonal treatment. Upon surgical exploration, abnormal attachment of the gubernaculum was found in 83 testes (83%), 2 testes were peeping (2%), short testicular vessels were found in 4 testes (4%), 3 testes were vanishing (3%) and a closed internal ring was found in one testis (1%).

CONCLUSIONS

Treatment of congenital undescended testis with human chorionic gonadotrophin hormone had low success rates. Anatomical abnormalities in the congenital undescended testis might contribute to this treatment failure.

TYPE OF THE STUDY

Clinical research paper.

LEVEL OF EVIDENCE

level III.

Bilateral orchidopexies: synchronous or metachronous? Survey of BAPS and BAPU members and single-centre comparison

BACKGROUND/AIM

Approximately 20% of undescended testes (UDT) are bilateral. It is unclear whether bilateral orchidopexy (BO) should be undertaken synchronously (SBO) or metachronously (MBO). Our aim was to investigate current UK practice and the complications of SBO vs MBO.

MATERIALS & METHODS

Following approval of BAPS and BAPU ethics committee, a survey was circulated to UK consultant pediatric surgeons and urologists regarding practice. A departmental retrospective review was additionally carried out for patients undergoing BO between 2005 and 2017.

RESULTS

Forty-three consultant surgeons from 20 centres completed the survey. Overall, SBO was preferred by 70% for bilateral palpable UDT versus 30% for bilateral impalpable UDT. When one side was palpable and the other impalpable, 70% preferred SBO. Pediatric urologists were significantly more likely to undertake SBO than pediatric general surgeons. One hundred eighty-eight patients (376 testicular units) were identified who had undergone BO with a median follow up of 9 months. 144/188 (76.6%) underwent SBO, while 44 had MBO. There was no statistical difference in the complication rate between the two groups (7.6% in SBO vs 9.1% in MBO; p = 0.66).

CONCLUSIONS

The majority of the responding UK consultants, in particular pediatric urologists, favor SBO. This potentially offers a reduction in cost, more rapid completion of treatment, and is not associated with additional complications by comparison to MBO. We recommend SBO to be standard practice for bilateral UDT whenever possible.

LEVEL OF EVIDENCE

Level III, Retrospective Comparative Study.

Utilization of scrotal orchidopexy for palpable undescended testes among surgeons

Introduction:

Scrotal orchidopexy for palpable undescended testicle (UDT) has received attention in the last decade due to its lower morbidity. This study was conducted to determine the frequency and factors related to the use of the scrotal approach in the surgical treatment of palpable UDT among surgeons.

Methods:

An observational cross-sectional study was carried out using an online survey, which was sent to different pediatric urologists, pediatric surgeons, and urologists groups. The survey consisted of questions on demographics as well as surgeons opinions and experience toward scrotal orchidopexy.

Results:

Of 163 respondents, 57 (35.0%) were pediatric surgeons, 98 (60.1%) were pediatric urologists, and 8 (4.9%) were urologists. There were 86 respondents (52.8%) who used the scrotal orchidopexy approach for UDT at any time in their practice. Pediatric urologists tended to use the scrotal orchidopexy approach for UDT more significantly than others (P < 0.001). There were significantly more scrotal orchidopexies for UDT performed by the pediatric urologists throughout their practice and per year compared to others, respectively (P < 0.001). Fifty-two respondents (31.9%) claimed that scrotal orchidopexy is not a good option for their patients, while seven respondents (4.3%) claimed that the procedure was hard to perform.

Discussion:

Based on the results of this study, we believe that there is a discrepancy in the reported advantages and success rate of scrotal orchidopexy in the published literature and the utilization of such an approach among surgeons managing palpable UDT in children.

Conclusion:

Scrotal orchidopexy is an underutilized approach in the management of palpable UDT in children. Only 52.8% of our respondents used it for UDT. One of the main reasons why scrotal orchidopexy is underutilized is due to the surgeons’ perception that scrotal orchidopexy is not the procedure of choice for their patients and their unfamiliarity with the procedure.

Role of Ozone Therapy in Preventing Testicular Damage in an Experimental Cryptorchid Rat Model

Background

Cryptorchidism is the most common developmental abnormality of the male reproductive system. If left untreated, it results with infertility and testicular cancer. According to current evidence, surgery is the mainstay of treatment, and hormonal therapy approaches are still under investigation. For the protection of testicular functions, antioxidants have emerged as novel options. This study aimed to evaluate the protective properties of ozone, a strong antioxidant, on testicular tissue.

Material/Methods

Thirty-five male Wistar-albino rats, 1-month-old, were used for the study. Groups were formed as follows: 1) control, 2) sham surgery (cryptorchidism), 3) cryptorchidism plus ozone, 4) cryptorchidism plus human chorionic gonadotropin (hCG), and 5) ozone plus hCG. Surgical procedures were performed on all rats except the control group. All rats except the control group were used to create an experimental cryptorchidism model, and left testes of animals were surgically placed into the abdomen. After 1 month of surgery, groups 3, 4, and 5 were given corresponding treatments intraperitoneally for 4 weeks. At the end of the study period, testicular atrophy index (TAI) and testicular sperm motility (TSM) were assessed and biochemical, histopathological, and immunohistochemical tests were performed.

Results

TAI and TSM were higher in the ozone, hCG, and ozone plus hCG groups than in the sham surgery group (p=0.001). TSM in the ozone group was significantly higher than in the hCG and ozone plus hCG groups. In biochemical analyses, the parameters of oxidative stress (GPx1, MDA, CAT, GSH, SOD) indicated increased oxidative activity in cryptorchidism, which was resolved by applying ozone and hCG (p=0.001). In addition, apoptotic markers, Caspase 3 and bcl-2 were significantly decreased by applying ozone and hCG (p=0.001).

Conclusions

Results of this study suggest that ozone therapy, either as a single agent or in combination with hCG, is a promising approach for protection of testicular functions.

Age at presentation of undescended testicles: a single-center study in Saudi Arabia

BACKGROUND

The undescended testis (UDT) is the most common genital anomaly encountered in pediatrics with an estimated incidence of 1% to 4% in full-term and 1% to 45% in preterm newborn boys. Over the years, studies on progressive histological deterioration and cancer risk has led to a change in recommendations for when orchidopexy should be done.

OBJECTIVES

Determine age at presentation of patients for UDT to a specialist in Saudi Arabia, age of operation and whether the recommended targeted time frame has been met.

DESIGN

Descriptive retrospective medical record review.

SETTINGS

University hospital setting in urban location.

SUBJECTS AND METHODS

The records of patients presenting to our center with UDT between the years 1996-2015 were reviewed for data on the age at presentation and age of operation.

MAIN OUTCOME MEASURES

Age at time of evaluation and at time of surgical intervention compared with the international standard.

SAMPLE SIZE

331 cases.

RESULTS

Out of the cases included, 195 met the inclusion criteria. The median age of presentation was 13.7 (range: 0-123.2) months. The median age at time of orchiopexy was 25 (range: 7.5-130.2) months. The median waiting time for elective surgery was 4.8 months ( less than 1 day to 49.4 months).

CONCLUSION

Despite the international recommendation of carrying out orchidopexy between the ages of 6-12 months, the targeted recommended time frame is not met in Saudi Arabia. This is mainly related to late referral age and the long waiting time for elective surgery.

LIMITATIONS

Small sample size and retrospective design.

CONFLICT OF INTEREST

None.

Extended clinical features associated with novel Glis3 mutation: a case report

BACKGROUND

Mutations in the GLI-similar 3 (GLIS3) gene encoding the transcription factor GLIS3 are a rare cause of neonatal diabetes and congenital hypothyroidism with 12 reported patients to date. Additional features, previously described, include congenital glaucoma, hepatic fibrosis, polycystic kidneys, developmental delay, facial dysmorphism, osteopenia, sensorineural deafness, choanal atresia, craniosynostosis and pancreatic exocrine insufficiency.

CASE PRESENTATION

We report a new case for consanguineous parents with homozygous novel mutation in GLIS3 gene who presented with neonatal diabetes mellitus, severe resistant congenital hypothyroidism, cholestatic liver disease, bilateral congenital glaucoma and facial dysmorphism. There were associated abnormalities in the external genitalia in form of bifid scrotum, bilateral undescended testicles, microphallus and scrotal hypospadias which might be a coincidental finding.

CONCLUSIONS

We suggest that infants with neonatal diabetes associated with dysmorphism should be screened for GLIS3 gene mutations.

Inguinoscrotal pathology

Infants, children, and adolescents with inguinoscrotal pathology comprise a significant proportion of emergency department and outpatient visits. Visits to the emergency department primarily comprise individuals presenting with scrotal pain due to testicular torsion or torsion of the testicular appendages. At such time, immediate urological consultation is sought. Outpatient visits comprise those individuals with undescended testes, hydroceles, and varicoceles. Rare, but important problems, such as pediatric testicular tumours, may also present in the office setting. Many of these outpatient visits are to primary care physicians, who should have an appreciation of the timing and need for referral. The purpose of this review is to familiarize the general urologist and primary care physician with these varied pathologies and give insight into their assessment and management. Some of these same conditions are seen in adult patients, but there are some significant differences in their management in the pediatric group. In addition, the utility of imaging studies, such as ultrasound, are discussed within each pathological entity. It is hoped that this overview will assist our general urology and primary care colleagues in patient management for diverse inguinoscrotal pathologies.

US of the Inguinal Canal: Comprehensive Review of Pathologic Processes with CT and MR Imaging Correlation

Ultrasonography (US) has a fundamental role in the initial examination of patients who present with symptoms indicating abnormalities of the inguinal canal (IC), an area known for its complex anatomy. A thorough understanding of the embryologic and imaging characteristics of the contents of the IC is essential for any general radiologist. Moreover, an awareness of the various pathologic conditions that can affect IC structures is crucial to preventing misdiagnoses and ensuring optimal patient care. Early detection of IC abnormalities can reduce the risk of morbidity and mortality and facilitate proper treatment. Abnormalities may be related to increased intra-abdominal pressure, which can result in development of direct inguinal hernias and varicoceles, or to congenital anomalies of the processus vaginalis, which can result in development of indirect hernias and hydroceles. US is also helpful in assessing postoperative complications of hernia repair, such as hematoma, seroma, abscess, and hernia recurrence. In addition, it is often the modality initially used to detect neoplasms arising from or invading the IC. US is an important tool in the examination of patients suspected of having undescended testes or posttraumatic testicular retraction and is essential for the examination of patients suspected of having torsion or infectious inflammatory conditions of the spermatic cord. Online supplemental material is available for this article. ^©RSNA, 2016.

Case Report of a Well-Differentiated Papillary Mesothelioma of the Tunica Vaginalis in an Undescended Testis With Review of Literature

Well-differentiated papillary mesothelioma (WDPM) affecting the tunica vaginalis testis is a rare tumor, and very little is known about the clinicopathological spectrum of this variant as a distinct entity. Most patients with WDPM suffer from scrotal pain or swelling, but hydrocele seems to be the most common presenting symptom. These lesions are usually not aggressive and are accompanied by an indolent clinical behavior. In this article, we report the first case known of WDPM in an undescended testis, and in addition, we review the literature for similar cases.

Maternal gestational smoking, diabetes, alcohol drinking, pre-pregnancy obesity and the risk of cryptorchidism: a systematic review and meta-analysis of observational studies

Background

Maternal gestational smoking, diabetes, alcohol drinking, and pre-pregnancy obesity are thought to increase the risk of cryptorchidism in newborn males, but the evidence is inconsistent.

Method

We conducted a systematic review and meta-analysis of studies on the association between maternal gestational smoking, diabetes, alcohol drinking, and pre-pregnancy obesity and the risk of cryptorchidism. Articles were retrieved by searching PubMed and ScienceDirect, and the meta-analysis was conducted using Stata/SE 12.0 software. Sensitivity analysis was used to evaluate the influence of confounding variables.

Results

We selected 32 articles, including 12 case—control, five nested case—control, and 15 cohort studies. The meta-analysis showed that maternal smoking (OR = 1.17, 95% CI: 1.11–1.23) or diabetes (OR = 1.21, 95%CI: 1.00–1.46) during pregnancy were associated with increased risk of cryptorchidism. Overall, the association between maternal alcohol drinking (OR = 0.97, 95% CI: 0.87–1.07), pre-pregnancy body mass index (OR = 1.02, 95% CI: 0.95–1.09) and risk of cryptorchidism were not statistically significant. Additional analysis showed reduced risk (OR = 0.89, 95% CI: 0.82–0.96) of cryptorchidism with moderate alcohol drinking during pregnancy. No dose—response relationship was observed for increments in body mass index in the risk of cryptorchidism. Sensitivity analysis revealed an unstable result for the association between maternal diabetes, alcohol drinking and cryptorchidism. Moderate heterogeneity was detected in studies of the effect of maternal alcohol drinking and diabetes. No publication bias was detected.

Conclusion

Maternal gestational smoking, but not maternal pre-pregnancy overweight or obesity, was associated with increased cryptorchidism risk in the offspring. Moderate alcohol drinking may reduce the risk of cryptorchidism while gestational diabetes may be a risk factor, but further studies are needed to verify this.

Surgical approach to the palpable undescended testis

An undescended testis may be associated with abnormal testicular development and function. A number of testes that are undescended at birth have been observed to descend spontaneously. The goal of orchidopexy remains to place those testes in the scrotum that would not have descended spontaneously. How long should the surgeon wait for spontaneous descent? By what age should the testis be positioned in the scrotum to avert further damage? Does earlier intervention result in a better functioning testis? Do different surgical techniques differ in their success in retaining the testis in the scrotum when dealing with the palpable undescended testis? This article reviews the current information on the timing and types of surgical intervention of the palpable undescended testes and their outcomes.