A novel homozygous splice site variant in ARL2BP causes a syndromic autosomal recessive rod-cone dystrophy with situs inversus, asthenozoospermia, unilateral renal agenesis and microcysts

BACKGROUND

This report presents a clinical case of syndromic rod-cone dystrophy due to a splice site variant in the ARL2BP gene causing situs inversus, asthenozoospermia, unilateral renal agenesis and microcysts. The presence of renal agenesis and cryptorchidism expands the clinical manifestations due to ARL2BP variants. The detailed, long-term follow-up contributes valuable insights into disease progression, aiding clinical diagnosis and patient management.

CASE PRESENTATION

The male patient complained of photophobia as the first symptom when he was 20 years old followed by nyctalopia, loss of central visual acuity and peripheral visual field ten years later. Genetic analysis identified a likely pathogenic homozygous variant (c.294-1G > C) involving the splicing acceptor site of intron 4. Reported symptoms together with full-field stimulus threshold testing, electroretinogram and advanced multimodal imaging allowed us to recognize the typical characteristics of a mixed retinal dystrophy. Despite the end-stage retinal disease, this patient still retained a useful residual vision at 63 years and had a slow disease progression during the last 5 years of evaluation.

DISCUSSION AND CONCLUSIONS

Our findings underscore the variable clinical presentation of ARL2BP variants, emphasizing the importance of a nuanced approach in diagnosing and managing patients. The presence of renal cysts warrants consideration of a differential diagnosis, particularly with Senior-Loken (SLS), Bardet-Biedl (BBS) and Joubert syndromes (JS) but also with Short Rib Thoracic Dysplasia 9, highlighting the need for careful phenotypic evaluation in these cases.

Testicular expression of heat SHOCK proteins 60, 70, and 90 in cryptorchid horses

Heat shock proteins are the most evolutionarily conserved protein families induced by stressors including hyperthermia. In the context of pathologies of the male reproductive tract, cryptorchidism is the most common genital defect that compromises the reproductive potential of the male because it induces an increase in intratesticular temperature. In equine species, cryptorchidism affects almost 9 % of newborns and few studies have been carried out on the molecular aspects of the retained testis. In this study, the expression pattern of HSP60, 70, and 90 in abdominal and inguinal testes, in their contralateral descended normally testes, and in testes of normal horses were investigated by Western blot and immunohistochemistry. The histomorphological investigation of retained and scrotal testes was also investigated. The seminiferous epithelium of the retained testes showed a vacuolized appearance and displayed a completely blocked spermatogenesis for lacking meiotic and spermiogenetic cells. On the contrary, the contralateral scrotal testes did not show morphological damage and the seminiferous epithelium displayed all phases of the spermatogenetic cycle as in the normal testes. The morphology of Leydig cells was not affected by the cryptorchid state. Western blot and immunohistochemistry evidenced that equine testis (both scrotal and retained) expresses the three investigated HSPs. More in detail, the Western blot evidenced that HSP70 is the more expressed chaperone and that together with HSP90 it is highly expressed in the retained gonad (P < 0.05). The immunohistochemistry revealed the presence of the three HSPs in the spermatogonia of normal and cryptorchid testes. Spermatogonia of retained testes showed the lowest expression of HSP60 and the highest expression of HSP90. Spermatocytes, spermatids of scrotal testes, and the Sertoli cells of retained and scrotal testes did not display HSP60 whereas expressed HSP70 and HSP90. These two proteins were also localized in the nucleus of the premeiotic cells. The Leydig cells displayed the three HSPs with the higher immunostaining of HSP70 and 90 in the cryptorchid testes. The results indicate that the heat stress condition occurring in the cryptorchid testis influences the expression of HSPs.

Achieving an optimal pregnancy outcome through the combined utilization of micro-TESE and ICSI in cryptorchidism associated with a non-canonical splicing variant in RXFP2

PURPOSE

To identify the genetic cause of a cryptorchidism patient carrying a non-canonical splicing variant highlighted by SPCards platform in RXFP2 and to provide a comprehensive overview of RXFP2 variants with cryptorchidism correlation.

METHODS

We identified a homozygous non-canonical splicing variant by whole-exome sequencing and Sanger sequencing in a case with cryptorchidism and non-obstructive azoospermia (NOA). As the pathogenicity of this non-canonical splicing variant remained unclear, we initially utilized the SPCards platform to predict its pathogenicity. Subsequently, we employed a minigene splicing assay to further evaluate the influence of the identified splicing variant. Microdissection testicular sperm extraction (micro-TESE) combined with intracytoplasmic sperm injection (ICSI) was performed. PubMed and Human Genome Variant Database (HGMD) were queried to search for RXFP2 variants.

RESULTS

We identified a homozygous non-canonical splicing variant (NM_130806: c.1376-12A > G) in RXFP2, and confirmed this variant caused aberrant splicing of exons 15 and 16 of the RXFP2 gene: 11 bases were added in front of exon 16, leading to an abnormal transcript initiation and a frameshift. Fortunately, the patient successfully obtained his biological offspring through micro-TESE combined with ICSI. Four cryptorchidism-associated variants in RXFP2 from 90 patients with cryptorchidism were identified through a literature search in PubMed and HGMD, with different inheritance patterns.

CONCLUSION

This is the first cryptorchidism case carrying a novel causative non-canonical splicing RXFP2 variant. The combined approach of micro-TESE and ICSI contributed to an optimal pregnancy outcome. Our literature review demonstrated that RXFP2 variants caused cryptorchidism in a recessive inheritance pattern, rather than a dominant pattern.

Abnormalities of the Scrotum and Testes

Abnormalities of the bovine scrotum and testes are an important cause of infertility. Proper evaluation of the male reproductive system is a critical first step in screening for such abnormalities. Excessive periscrotal fat, cutaneous scrotal defects, and unilateral scrotal swelling are common deformities that warrant further investigation. Early diagnosis and surgical intervention are often needed to restore reproductive soundness. This article reviews these conditions and provides therapeutic modalities.

A closer look to the timing of orchidopexy in undescended testes and adherence to the AWMF-guideline

BACKGROUND

To lower the risk of testicular malignancies and subfertility, international guidelines recommend orchidopexy for undescended testis (UDT) before the age of 12-18 months. Previous studies reported low rates of 5-15% of timely surgery. Most of these studies are based on DRG and OPS code-based data from healthcare system institutions that do not distinguish between congenital and acquired UDT.

METHODS

In a retrospective study data of all boys who underwent orchidopexy in a university hospital and two outpatient surgical departments from 2009 to 2022 were analyzed. The data differentiates congenital from acquired UDT.

RESULTS

Out of 2694 patients, 1843 (68.4%) had congenital and 851 (31.6%) had acquired UDT. In 24.9% of congenital cases surgery was performed before the age of 12 months. The median age at surgery for congenital UDT was 16 months (range 7-202). Over the years there was an increased rate of boys operated on before the age of 2 (40% in 2009, 60% in 2022). The median age fluctuated over the years between 21 and 11 months without a trend to younger ages.. The covid pandemic did not lead to an increase of the median age at surgery. The median time between referral and surgery was 46 days (range 1-1836). Reasons for surgery after 12 months of age were a delayed referral to pediatric surgeries (51.2%), followed by relevant comorbidities (28.2%).

CONCLUSION

Compared to recent literature, out data show that a closer look at details enables a more realistic approach. Still, there is no trend towards the recommended age for surgical treatment observable, but the rate of timely operated boys with congenital UDT is significantly higher than stated in literature.

Contemporary disparities in progression to orchiopexy for cryptorchidism as reported in the Pediatric Health Information System (PHIS) database

INTRODUCTION

When evaluating the timeliness of orchiopexy for cryptorchidism, health disparities are apparent among Hispanic and African American males and those with public insurance. Since the publication of these data, the COVID-19 pandemic has stressed our healthcare system and significantly affected the provision of pediatric urology care.

OBJECTIVE

We sought to assess if certain groups were disproportionately affected in progression to orchiopexy after the diagnosis of cryptorchidism during and after the pandemic in US freestanding children's hospitals.

STUDY DESIGN

Using the PHIS database, pediatric patients ≤5 years who underwent orchiopexy between January 2018 and December 2022 were retrospectively analyzed. Exclusion criteria included prematurity, retractile testes, and testicular torsion. Primary outcomes were age at orchiopexy and the proportion of individuals undergoing timely orchiopexy for cryptorchidism.

RESULTS

Over the study period 3140 patients ≤5 years old underwent orchiopexy for cryptorchidism. Non-Hispanic Blacks and Hispanics were significantly less likely to have timely orchiopexy and underwent orchiopexy 2.13 and 3.60 months later compared to whites (p < 0.01). As compared to pre-COVID-19, during the pandemic the proportion of patients who had timely surgery was higher and the median age was significantly lower (p = 0.01 and p < 0.01, respectively) in white patients only. Over the study period, patients with public insurance were less likely to have timely orchiopexy and underwent orchiopexy 2.94 months later (p < 0.01) than patients with private insurance. Compared to during the pandemic, post-pandemic a significantly lower proportion of publicly insured patients have since undergone timely orchiopexy (p = 0.04). Patients in the West were less likely to have timely orchiopexy and had a higher age at time of orchiopexy (p < 0.01) than other regions. However, in the West during the pandemic, the proportion of children who had timely surgery was higher compared to pre-and post-COVID-19 (p < 0.01).

DISCUSSION

Overall, regardless of insurance status, race, or location, a significant proportion of patients did not undergo timely orchiopexy. During the pandemic white patients had a lower median age and an increased proportion underwent timely orchiopexy, despite the number of orchiopexies remaining constant. Disparities in the post-COVID-19 era have been further exacerbated for publicly insured patients, who a significantly lower proportion of have since undergone timely orchiopexy. Specific efforts are required across the United States to increase timely orchiopexy for all boys.

CONCLUSIONS

Progression to timely orchiopexy remains low for all boys in the era surrounding COVID-19; certain groups appear to be more adversely affected.

Heresy - Is there a role for ultrasound in management of the non-palpable testicle?

INTRODUCTION

AUA Guidelines do not support the routine use of ultrasound (US) in evaluation of boys with an undescended testicle (UDT) prior to urology referral. Multiple studies have demonstrated that real time US is inferior to a physical examination by a pediatric urologist in detecting an UDT. However, improved US technology, which now permits detection of the non-palpable testis located just proximal to the internal ring, may aid in guiding the surgical approach to the non-palpable testis. We evaluated US findings of boys deemed to have a non-palpable UDT and compared them to surgical findings.

OBJECTIVE

To assess the role of pre-operative ultrasonography in guiding surgical management in boys deemed to have a non-palpable testis by a pediatric urologist.

STUDY DESIGN

US of boys with a non-palpable UDT, as reported by a pediatric urologist on physical exam, during a 3-year period, were reviewed. All US were performed jointly by a technician and pediatric radiologist. Patient demographics, laterality, and intra-operative findings were assessed.

RESULTS

Thirty-one boys with a non-palpable testicle on physical exam underwent scrotal/inguinal/pelvis US at a median age of 7.5 months (IQR 2.5-12.3 months). Two patients had bilateral non-palpable testicles, 21 had a non-palpable left sided testicle and 8 had a non-palpable right sided testicle. Of the 33 non-palpable testes, 5 (15.2%) were identified in the inguinal canal. Sixteen (48.5%) were visualized in the lower pelvis just proximal to the internal ring and graded as intra-abdominal. Four (12.1%) nubbins or very atrophic testes were identified in the inguinal region or scrotum and 5 (15.2%) testes were not identified on US. Three (9.1%) testes were observed to be mobile between the lower pelvis just proximal to the internal ring and the inguinal canal. Of the 8 patients with testes that were identified in the inguinal canal, or mobile between the lower pelvis and inguinal canal, 7 avoided a diagnostic laparoscopy and underwent an inguinal orchiopexy. Of the 16 testicles located in the lower pelvis proximal to the internal ring, only 2 underwent laparoscopy/laparoscopic orchiopexy.

DISCUSSION

In cases of a non-palpable testicle following a physical examination by a urologist, an ultrasound can impact the operative plan, and allow for patients to avoid laparoscopy. In our cohort, 87.5% of non-palpable testes avoided laparoscopic surgery after ultrasound identification of a viable testis.

CONCLUSIONS

US in the evaluation of cryptorchidism can guide surgical management in select cases in which a testis is non-palpable following careful examination by a urologist.

Undescended testis: A roundtable discussion based on clinical scenarios - Part 1

Undescended testis (UDT, cryptorchidism) is the most common congenital anomaly of the genital tract. Despite its high incidence, the management of UDT varies between specialties (urology, pediatric surgery, pediatric urology, pediatric endocrinology). Therefore, as the European Association of Urology - Young Academic Urologists Pediatric Urology Working Group, we requested experts around the world to express their own personal approaches against various case scenarios of UDT in order to explore their individual reasoning. We intended to broaden the perspectives of our colleagues who deal with the treatment of this frequent genital malformation.

Staged laparoscopic orchiopexy of intra-abdominal testis: Spermatic vessels division versus traction? A multicentric comparative study

BACKGROUND

Staged laparoscopic management of intra-abdominal testes using pedicular section is recognized as gold standard technique, successful in 85 % of cases for scrotal testicular position with less than 10 % testicular atrophy. Recently, Shehata proposed a new technique without pedicular division for these testes, using spermatic vessels traction, but did not provide a comparative study of the two techniques.

OBJECTIVE

To evaluate the laparoscopic spermatic pedicular traction (Shehata technique, ST) for the treatment of intra-abdominal testis, as an alternative to gold standard pedicular section (2-stage Fowler-Stephens, FS).

STUDY DESIGN

Intra-abdominal testes of 129 patients in two tertiary pediatric urology centers were managed laparoscopically (2011-2019) either by 2-stage FS orchidopexy or ST according to the surgeon preference. Testicular position and size were statistically compared.

RESULTS

A total of 147 testes were pulled down by 80 ST and 67 FS, including 18 bilateral cases. Median (IQR) age at surgery was 24.2 (15.6-46.4) months (ST) and 18.3 (13.1-38.2) months (FS) (p = 0.094). Scrotal pulling-down of the testis was performed after a median (IQR) period of 2.3 (1.6-3.4) months (ST) and 6.1 (4.7-8.3) months (FS), respectively (p < 0.005). Although ST had collapsed in 17 cases (21.3 %), only one (1.3 %) redo procedure was required. After a median (IQR) follow-up of 22 (12-40) and 19 (8.75-37) months (p = 0.59), the testis was in the scrotum in 85 % and 81 % of ST and FS cases, respectively (p = 0.51). Testicular atrophy occurred in 10 % of ST and 13.4 % of FS (p = 0.61). Multivariate analysis using the propensity score analysis did not identify any difference between the two techniques.

DISCUSSION

Our results seem to confirm that FS and ST achieve the same results regarding final testicular position and testicular atrophy rate, with a long-term follow-up. Our study supports pediatric surgeons to favor laparoscopic spermatic pedicular traction (ST) which preserves the testicular vascularization and may ensure better spermatogenesis after puberty. More details on the size and position of the testicle at the beginning of the first laparoscopy seem however essential to assess more accurately the outcomes of each surgical technique. Our outcomes will also be re-evaluated when our patients have reached puberty, from an exocrine and endocrine points of view.

CONCLUSIONS

This study showed similar results after laparoscopic traction or section of spermatic vessels for intra-abdominal testis in a long-term follow-up, providing more evidence for the use of ST as a valuable alternative to FS.

Immediate Versus Delayed Surgical Management of Infant Cryptorchidism With Inguinal Hernia

INTRODUCTION

Cryptorchidism is commonly treated with orchiopexy at 6-12 months of age, often allowing time for undescended testicle(s) (UT) to descend spontaneously. However, when an inguinal hernia (IH) is also present, some surgeons perform orchiopexy and inguinal hernia repair (IHR) immediately rather than delaying surgery. We hypothesize that early surgical intervention provides no benefit for newborns with both IH and UT.

METHODS

The Nationwide Readmissions Database was used to identify newborns with diagnoses of both IH and UT from 2010 to 2014. Patients were stratified by management: IHR performed on initial admission (Repair) or not (Deferral). Demographics, outcomes, and complications were compared. Results were weighted for national estimates.

RESULTS

We analyzed 1306 newborns (64% premature) diagnosed with both IH and UT. IHR was performed at index admission in 30%. Repair was more common in premature babies (43% vs. 8% full-term, p < 0.001) and patients with congenital anomalies (33% vs. 27% without congenital anomaly, p = 0.012). There was no difference in readmission rates. Repair patients had higher rates of orchiectomy than did Deferral. No Deferral patients were readmitted for bowel resection, and <1% were readmitted for orchiectomy or hernia incarceration.

CONCLUSION

In newborns with UT and IH, immediate repair is not associated with improved outcomes. Even with incarceration on initial presentation, rates of readmission with incarceration or bowel compromise for patients who undergo Deferral of surgery are minimal. Moreover, Repair newborns have higher rates of orchiectomy. We found no benefit to early operative intervention; thus, we recommend waiting until 6-12 months of age to reassess for surgery.

LEVEL OF EVIDENCE

Level III TYPE OF STUDY: Retrospective Comparative Study.

Advocating hormonal treatment to prevent adult in-fertility in patients diagnosed with congenital un-descended testes

In 2007 the Nordic group came to the following unanimous conclusions: In general, hormonal treatment is not recommended, considering the poor immediate results and the possible long-term adverse effects on spermatogenesis. Thus, surgery is to be preferred. However, defective mini puberty inducing insufficient gonadotropin secretion is one of the most common causes of nonobstructive azoospermia in men suffering from congenital isolated unilateral or bilateral cryptorchidism. The extent of alteration in the unilateral undescended testis correlate with the contralateral descended testis, indicating that unilateral cryptorchidism is a bilateral disease. Idiopathic central hypogonadism explains the phenomenon of defective mini puberty in otherwise healthy cryptorchid boys. We therefore recommend hormonal treatment for cryptorchid boys with defective mini puberty. Gonadotropin releasing hormone agonist (GnRHa) treatment following surgery to correct cryptorchidism restores mini puberty via endocrinological and transcriptional effects and prevents adult infertility in most cases. Several genes are important for central hypogonadotropic hypogonadism in mammals, including many that are transcribed in both the brain and testis. At the molecular level, there is no convincing evidence that heat shock is responsible for the observed pathological testicular changes. Thus, impaired transformation of gonocytes is not the result of temperature stress but rather a hormonal imbalance. Cryptorchidism should therefore be considered a serious andrological problem that cannot be successfully treated by early orchidopexy alone.

The Inhibin-B Level at Orchidopexy and Follow-up of 280 Boys With Non-syndromic Unilateral Cryptorchid Testes

PURPOSE

An impaired germ cell number per tubular cross-section (G/T) at orchidopexy indicates a high risk of infertility. A recent study in boys with bilateral cryptorchidism showed a very high predictive value for a low serum inhibin-B level, indicating bilateral impaired G/T. Several other studies have shown a fairly strong correlation between inhibin-B and G/T. We aimed to evaluate if inhibin-B levels at orchidopexy improved at follow-up in boys with unilateral cryptorchidism.

METHODS

We included 280 boys with unilateral non-syndromic cryptorchidism at the median age of 1 year (4 months-9 years) who underwent orchidopexy. They were evaluated for serum FSH, LH and inhibin-B levels at surgery and at follow-up (median 16 months later), including multiple of the median (MoM) estimations of inhibin-B due to the age dependency of normal levels.

RESULTS

The inhibin-B MoM score improved significantly at follow-up. At orchidopexy, 59 (21%) boys had inhibin-B levels below the normal 2.5-percentile indicating impaired G/T bilaterally. At follow-up, 36% of the boys still had low inhibin-B. At orchidopexy, 221 (79%) boys had inhibin-B levels above normal 2.5-percentile and only 5% had low inhibin-B levels at follow-up. The risk of low inhibin-B levels at follow-up was significantly different between the two groups (p < 0.0001). At follow-up, totally, 32 (11%) boys had low inhibin-B levels, hereof only 3 patients with increased FSH.

CONCLUSIONS

Orchidopexy benefits the fertility potential. About 10% of boys with unilateral non-syndromic cryptorchidism may have a bilateral testicular disease reducing their fertility potential. Insufficient gonadotropin stimulation may possibly be the cause.

The continuous type of splenogonadal fusion: A rare case report and literature review

INTRODUCTION

We report a rare case of the continuous type of splenogonadal fusion (SGF) in a young adolescent with preserved testis.

CASE PRESENTATION

A 19-year-old male patient with a history of left inguinal hernia repair 10 years ago presented with a palpable mass on the left side. Computed tomography revealed a 58x37mm mass with a tissue density of 47HU, demonstrating vigorous enhancement following contrast administration and displaying well-defined margins with the left testicle. It was noted to be growing vertically in the left inguinal canal and to be continuous with the lower pole of the native spleen. The patient underwent laparoscopic surgery to remove the splenic tail in the abdomen and to separate the scrotal spleen from the left testicle through the left inguinal tract. The histopathological examination confirmed the presence of splenic tissue.

DISCUSSION

SGF is often diagnosed incidentally during exploration or surgery for scrotal swelling or mass, cryptorchidism, or inguinal hernia in young patients. It is important to be aware of this condition to avoid unnecessary radical orchiectomy.

CONCLUSION

Diagnosing the SGF preoperatively can be challenging. However, a combination of imaging modalities and negative tests for alpha-fetoprotein (AFP), lactate dehydrogenase (LDH), and beta-human chorionic gonadotropin (b-HCG) can aid in making an initial diagnosis. The use of laparoscopic surgery can further improve the diagnostic process, allowing clinicians to accurately diagnose SGF and make well-informed treatment decisions.

Early Surgery Versus Watchful Waiting Strategy for Infantile Abdominoscrotal Hydrocele

BACKGROUND

Infantile abdominoscrotal hydrocele is generally managed with early surgery. However, whether these patients actually benefit from an initial watchful waiting strategy is yet to be determined.

METHODS

This single-center, comparative observational analysis included 36 consecutive patients (9 bilateral cases) diagnosed between January 1998 and December 2019. Initial 16 patients (21 lesions) underwent surgical repair shortly after diagnosis (Group A) at a mean (SD) age of 8 (4) months. Remaining 20 patients (24 lesions) underwent initial nonoperative management (Group B). Overall follow-up was 82.74 (63.84) months.

RESULTS

Six lesions of Group B spontaneously regressed at a mean age of 23.8 (7.8) months. Remaining 18 hydroceles underwent surgical management at a mean age of 18.7 (12.6) months. Early postoperative morbidity was high (43%) in both groups (Clavien-Dindo grade I-II). During follow-up, there were 1 recurrent hydrocele and 1 testicular atrophy, both events occurring in Group A patients. Group B patients required a higher need for concomitant ipsilateral orchidopexy (61% versus 14%; p = 0.001), and developed a higher rate of ipsilateral inguinal hernia (39% versus 5%; p = 0.01), occurring within 8.3 (3.53) months of surgery. On multivariable analysis, nonoperative management was associated with unplanned second surgery (odds ratio 5.5, 95% CI 1.25-24.17, p = 0.02), regardless of the type of hydrocelectomy performed.

CONCLUSIONS

Nonoperative management provides effective spontaneous resolution in about 25% of infantile abdominoscrotal hydrocele. Clinicians must balance the potential benefits of such strategy against the impact of pressure induced detrimental effects on the success of future surgery when dealing with longstanding lesions.

LEVEL OF EVIDENCE

III.

Abdominal testicular vessel distribution in human fetuses - basis for fowler-Stephens surgery

PURPOSE

To analyze the histology and distribution of abdominal testicular vessels in human fetuses Patients and Methods: We studied 19 fetuses (34 testes) ranging in age from 12 to 19 weeks post-conception. The fetuses were evaluated regarding crown-rump length (CRL), total length (TL) and body weight immediately before dissection. Each testis was dissected and embedded in paraffin, from which 5 μm thick sections were obtained and stained with Masson's trichrome and Anti-CD31 antibody to quantify the vessels. The stereological analysis was carried out with the Image Pro and Image J programs, using a grid to determine volumetric densities (Vv). Means were statistically compared using the unpaired T-test (p<0.05).

RESULTS

The fetuses presented mean weight of 222.5g, mean CRL of 15.3 cm and mean TL of 23.2 cm. All testes were in the abdominal position. The mean percentage of vessels (Vv) in the upper portion of the testis was 7.6% (4.6 to 15%) and in the lower portion the mean was 5.11% (2.3 to 9.8%), with a significant difference (p=0.0001). In the analysis between the upper portion of the right and left testes (p=0.99) and in the analysis of the lower portion of the right and left testes (p=0.83), we did not observe significant differences.

CONCLUSION

The upper portion of the abdominal testis in human fetuses had a higher concentration of vessels than the lower portion. These results suggest that manipulation of the lower end of the testis during Fowler-Stephens surgery should be avoided in order to preserve the collateral circulation.

Female splenogonadal fusion: A PLEA for conservative management

Splenogonadal fusion in female patients is seldom reported. We describe a 6-month-old girl who represents the youngest living female with splenogonadal fusion reported to date. The lesion was diagnosed as an incidental finding during screening abdominal ultrasonography performed for a vulvar infantile hemangioma. A tail-like structure with splenic echotexture connecting a normally located spleen and the left ovary was detected and better characterized by MRI. We also reviewed the pertinent literature on managing this usually asymptomatic condition, especially in female patients. Greater professionals' awareness of this benign anomaly is paramount to avoid the unnecessary removal of an otherwise normal gonad.

Unilateral renal agenesis and ipsilateral absence of the vas deferens in a cryptorchid infant with Klippel-Feil syndrome

We report an exceedingly rare case of Klippel-Feil syndrome (KFS), compounded by ipsilateral absence of the vas deferens, renal agenesis, and diaphragmatic hernia. Unilateral absence of the vas deferens was found incidentally during orchidopexy. To the best of our knowledge, no case of unilateral absence of the kidney and vas deferens has been reported in children with KFS.

Low placental weight may be involved in the etiology of congenital cryptorchidism in neonatal boys

INTRODUCTION

Several factors have been reported to be associated with the etiology of cryptorchidism; however, clear evidence regarding the risk factors for cryptorchidism is elusive. In the present study, we evaluated the clinical characteristics of cryptorchidism using the common neonatal intensive-care unit (NICU) database of the National Hospital Organization and explored one of possible factors associated with the development of cryptorchidism.

METHODS

A total of 7882 male neonates were included in this study. We separated them into two groups: those without cryptorchidism (n = 7852) and those with cryptorchidism (n = 30) at the time of discharge from the NICU. Cryptorchidism was defined as a condition in which the testis was located out of the scrotum on the route of descent at the time of NICU discharge. The associations between cryptorchidism and the maternal, placental, and neonatal information were analyzed. Analyses were performed statistically to compare nominal variables between the groups using Fisher's direct establishment calculation method and logistic regression analyses.

RESULTS

Univariate analyses showed the placental weight <10% tile (odds ratio 3.31, 95% confidence interval [CI] 1.18-8.64), birth height <-2 standard deviations (SD) (odds ratio 3.65, 95% CI 0.92-10.6), birth weight <-2SD (odds ratio 4.06, 95% CI 1.55-9.51), and small for gestational age (odds ratio 3.82, 95% CI 1.46-8.97) were significantly associated with the development of cryptorchidism. Multivariate analyses showed that placental weight <10th percentile (odds ratio 2.86, 95% CI 1.11-7.44) was significantly associated with the development of cryptorchidism.

DISCUSSION

Although, this study population was limited to infants admitted to the ICU, the data indicated a possible association between low placental weight and the development of cryptorchidism in neonatal boys.

Epigenetics, cryptorchidism, and infertility

BACKGROUND

Cryptorchid boys with defective mini-puberty and impaired differentiation of Ad spermatogonia (high infertility risk) have altered expression of several genes encoding histone methyltransferases compared to patients with intact differentiation of gonocytes into Ad spermatogonia (low infertility risk).

RESULTS

High infertility risk cryptorchid boys display hypogonadotropic hypogonadism, which, together with the diminished expression of histone deacetylases and increased expression of HDAC8 decrotonylase, indicates altered histone marks and, thus, a perturbed histone code. Curative GnRHa treatment induces normalization of histone methyltransferase, chromatin remodeling, and histone deacetylase gene expression. As a result, histone changes induce differentiation of Ad spermatogonia from their precursors and, thus, fertility. In this short report, we describe key functions of histone lysine methyltransferases, chromatin remodeling proteins, and long-noncoding RNAs, and discuss their potential roles in processes leading to infertility.

CONCLUSION

Our findings suggest that epigenetic mechanisms are critical to better understanding the root causes underlying male infertility related to cryptorchidism and its possible transgenerational transmission.

Anti-Müllerian hormone levels in serum and testes of male dogs: relations with neuter status and bilateral abdominal cryptorchidism

Anti-Müllerian hormone (AMH) analysis has contributed to new information in the reproductive endocrinology of domestic animals, due to clinically available diagnostic tools. An accurate and rapid diagnostic method to distinguish between neutered and bilateral abdominal cryptorchid dogs is needed in veterinary practice. Therefore, this study uses an enzyme-linked immunosorbent assay to evaluate the clinical relevance of AMH analysis in peripheral blood as a diagnostic tool for dogs with suspected bilateral abdominal cryptorchidism. The possible alteration of the AMH localization in testicular tissue caused by this pathologic condition was also investigated using immunohistochemistry. Male dogs were divided into three groups of healthy intact (n = 14), healthy castrated (n = 14), and bilateral abdominal cryptorchid (n = 14) dogs. The results demonstrated a higher level of serum AMH in the cryptorchid group compared to the intact group (P < 0.01), while serum AMH levels of all castrated dogs were below the limit of detection (<0.05 ng/mL). Moreover, the percentage of positive AMH immunostaining of the intact group was less than that of the cryptorchid group (P < 0.01). A significantly positive correlation was found between serum AMH concentration and localization in testicular tissues (r = 0.93, P < 0.01). Our findings suggest that AMH levels in the peripheral blood could be used as an alternative and rapid screening method for detecting dogs with abdominal cryptorchidism.

Assessment of testicular volume in neonates in the tropical province of China

BACKGROUND

Testicular volume in neonates is a potential indicator of testicular development during the fetal period, particularly the masculinization programming window. Reliable measurements of testicular volume provide an opportunity for early detection of testicular abnormalities. This study aimed to assess the testicular volume in neonates and evaluate its relationship with gestational week and birth weight in Hainan Province, China.

METHODS

Data on 458 neonates who underwent ultrasonography examinations at our institution from 2018 to 2022 were collected. The neonates were categorized by gestational week, birth weight, and presence of cryptorchidism. We evaluated the testicular volume among different groups and its relationship to gestational week and birth weight.

RESULTS

There was no significant difference between the right and left testicular volume in neonates without cryptorchidism. However, a significant difference was observed between normal birth weight and low birth weight neonates in terms of testicular volume. Similarly, there was a significant difference between premature and full-term neonates in testicular volume. Bilateral testicular volume showed positive and significant correlations with gestational week and birth weight. Additionally, a significant difference was noted in testicular volume between the affected side in neonates with cryptorchidism and the same side in normal birth weight full-term neonates.

CONCLUSIONS

We established the normal range of testicular volume for neonates in Hainan Province and demonstrated that testicular volume is positively correlated with both birth weight and gestational week. Cryptorchidism also affects testicular volume during the neonatal period, likely due to reduced androgenic exposure in utero, particularly during the masculinization programming window. The findings of this study have significant implications for assessing testis development during fetal development.

MicroRNA as epigenetic regulators of canine cryptorchidism

Cryptorchidism, the failed descent of one or both testes into the scrotum, is a common developmental disorder in male dogs. Cryptorchidism may affect canine fertility, reducing the quality of the semen, and may promote spermatic cord torsion and onset of neoplasia. MicroRNAs (miRNAs) are epigenetic regulators of gene expression and their dysregulation is associated with disorders of spermatogenesis and testis neoplasia. The present study aimed at investigating the expression of miRNAs in formalin-fixed, paraffin-embedded (FFPE) canine retained testes and testes affected by seminoma, and at integrating miRNAs to their target genes. Forty testicular FFPE specimens from 30 dogs were included - 10 scrotal and 10 contralateral retained from 10 unilateral cryptorchid dogs; 10 tumoral testes affected by seminoma from non-cryptorchid dogs; 10 scrotal normal testes from non-cryptorchid dogs included as the control. The expression level of three miRNAs, namely miR-302c-3p, miR-302a-3p, and miR-371-3p, associated with testicular disorders, were quantified using RT-qPCR. The comparative analysis demonstrated that the level of miR-302a-3p and miR-371a-3p were quantifiable exclusively in control testes. The expression level of miR-302c-3p was higher in the control than in the other groups; its expression decreased in retained testes compared to scrotal testes and testes with seminoma. Gene Ontology analysis pointed out that these miRNAs may be involved in the modulation of estrogen and thyroid hormone signaling pathways. In conclusion, this study demonstrated that miRNAs are dysregulated in canine cryptorchid and seminoma-affected testes compared to control tissues, confirming the pivotal role of miRNAs in cryptorchidism.

Stereological study of testes following experimentally-induced unilateral cryptorchidism in rats

OBJECTIVE

Cryptorchidism is one of the main causes of infertility and can result in testicular cancer. This study aimed to present quantitative data on the damage caused by cryptorchidism using stereological analysis.

METHODS

Thirty newborn rats were randomly divided into control and experimental groups. The experimental group underwent surgery to induce unilateral cryptorchidism in the left testis, whereas the control group underwent a sham surgical procedure 18 days after birth. The testes were removed at designated time points (40, 63, and 90 days after birth) for stereological evaluation and sperm analysis. Total testicular volume, interstitial tissue volume, seminiferous tubule volume and length, and seminiferous epithelium volume and surface area were measured. Other parameters, such as sperm count, sperm morphology, and sperm tail length, were also examined.

RESULTS

Statistically significant differences (p<0.05) were observed between the experimental and the control groups at different ages regarding the volumes of various parameters, including the surface area of the germinal layer, the length of the seminiferous tubules, sperm count, and sperm morphology. However, no significant differences were observed in the epithelial volume and the sperm tail length of the groups.

CONCLUSION

Given the substantial effect of cryptorchidism on different testicular parameters, as well as the irreversible damage it causes in the testes, it is important to take this abnormality seriously to prevent these consequences.

Streptococcus canis prostatitis and endocarditis with thromboembolism in a dog with sertoli cell tumour in a cryptic testis and prostatic squamous metaplasia

We describe an unusual case of prostatitis caused by Streptococcus canis evolving to endocarditis and splenic, renal, and cerebral thromboembolism in a dog, associated with a Sertoli cell tumour in a cryptic testis and diffuse prostatic squamous metaplasia. A nine-year-old, intact male, mixed-breed dog was presented to a veterinary teaching hospital with abdominal pain and prostration. Physical examination and abdominal ultrasonography revealed an atrophic right testicle located in the subcutaneous tissue. The left testicle was in the abdominal cavity with increased dimensions and irregular contours. Complete blood count analysis showed marked neutrophilic leukocytosis and thrombocytopenia. After clinical worsening, euthanasia was performed, and the dog was submitted to post-mortem examination. The main gross findings included testicular malposition with one cryptic and one ectopic testis, enlarged prostate with purulent content, distension of the urinary bladder with cloudy urine, vegetative valvular endocarditis in the mitral valve, and spleen and renal infarcts. Histological examination showed a Sertoli cell tumour in the abdominal testis, diffuse prostatic squamous metaplasia with marked keratinization associated with bacterial prostatitis, fibrinonecrotic cystitis, bacterial endocarditis with marked myxomatous degeneration in the mitral valve, and splenic, renal, and cerebral thromboembolism. Microbiological analysis identified Streptococcus canis in the prostate and mitral valve. Sertoli cell tumour of cryptic testis increases oestrogen production and leads to squamous metaplasia of the prostate, which should be considered as predisposing factors for ascending S. canis infection from the urogenital tract to the prostate. Then, haematogenous spread of S. canis from the prostate to mitral valve cause endocarditis and subsequent thromboembolism and infarcts, all decisive to poor prognosis in this case.

Bibliometric analysis of scientific publications on cryptorchidism: Research hotspots and trends between 2000 and 2022

Background

Cryptorchidism is defined as failure of unilateral or bilateral testicular descent, which increases the risk of infertility and testicular carcinoma. Although there is much research on cryptorchidism, few studies have used the bibliometric analysis method. The purpose of this study was to conduct a comprehensive analysis of cryptorchidism from muti-dimensional perspectives to summarize the research hotspots and trends in cryptorchidism research.

Methods

Relevant studies on cryptorchidism were retrieved from the Web of Science Core Collection (WoSCC) database from 2000 to 2022. A comprehensive bibliometric analysis of cryptorchidism was performed by using the CiteSpace, Tableau Public, and VOSviewer software, including the annual distributions of publications, countries, authors, institutions, journals, references, and keywords.

Results

From January 1st, 2000 to May 17th, 2022, a total of 5023 papers concerning cryptorchidism were identified for analysis. The USA contributed the most publications (n = 1193) in this field, and the annual number of publications rose rapidly in China. The University of Melbourne published the largest number of papers (n = 131). "Hutson, John M." was the most core author ranked by publications (n = 51), and "Skakkebaek, Niels E." enjoyed the largest number of citations (4441). The JOURNAL OF UROLOGY published the largest number of papers (n = 225), while the average citations per publication of the 75 papers in HUMAN REPRODUCTION reached 62.38. Additionally, burstness analysis of references and keywords showed that cryptorchidism research was mainly focused on the exploration of the optimal mode of treatment for cryptorchidism, including hypogonadism such as Kallmann syndrome and Klinefelter syndrome.

Conclusion

Cryptorchidism has attracted continuous attention from the scientific community concerned. International collaboration in the field has witnessed significant growth in recent years and remains essential to further enhance collaborative efforts between scholars from different countries. In addition, the exploration of the optimal treatment modality for cryptorchidism, especially in the prevention of adult infertility, remains a major focus of future research. High-quality follow-up studies are also needed in the future. The pathogenesis (especially at the genetic level) and treatment of hypogonadism such as Kallmann syndrome and Klinefelter syndrome have attracted increasing attention recently, which may usher in some breakthroughs in coming years.

Stepwise mini-incision microdissection testicular sperm extraction in NOA patients with a history of cryptorchidism: a case-control study

BACKGROUND

Although the orchiopexy is recommended for cryptorchidism to preserve male fertility, non-obstructive azoospermia (NOA) may occur in adulthood. Fortunately, a great many of azoospermic men may obtain sperm by microdissection testicular sperm extraction (mTESE). Due to the potential injuries caused by testicular diagnostic biopsy and vascular damage at the time of orchidopexy, minimal invasiveness is particularly important during mTESE, aims to reduce the surgical damage and avoids secondary testicular failure. This comparative study aims to investigate the efficacy of stepwise mini-incision mTESE technique by comparison with standard mTESE in the treatment of NOA patients with a history of cryptorchidism.

RESULTS

A total of 73 mTESE procedures were divided into two groups: Group 1 included 37 cases performed by stepwise mini-incision mTESE, while Group 2 included 36 cases with standard mTESE. The overall sperm retrieval rate (SRR) in the two groups was 68.5% (50/73), with no significant difference in SRR between Group 1 (78.4%, 29/37) and Group 2 (58.3%, 21/36) (P = 0.1). In addition, 46.0% of the patients (17/37) obtained sperm in the first mini-incision step in Group 1, which was also equal to an overall SRR in Group 2 (58.3%, 21/36) (P = 0.3). The operation time in Group 1 (72.6 ± 33.9 min) was significantly shorter than that in Group 2 (90.4 ± 36.4 min) (P = 0.04). Patients with an orchidopexy age no more than 10 years old had a higher SRR (79.5%, 31/39) than others (55.9%, 19/34) (P = 0.03). There were no postoperative complications including wound infection, scrotal hematoma, persistent pain, and testicular atrophy during a follow-up period of at least 6 months.

CONCLUSIONS

In conclusion, our study suggests that the stepwise mini-incision mTESE could be a promising approach for sperm retrieval in NOA men with a history of cryptorchidism. While the technique may potentially reduce operation time and surgical invasiveness, further research is needed to validate these findings on a larger scale. The results also suggest that age at orchidopexy may affect SRR and have important implications for the management of cryptorchidism.

Diagnosis, Classification, and Contemporary Management of Undescended Testicles

This article provides a comprehensive review regarding undescended testicles and other related conditions. We have included background information summarizing variable clinical presentations, epidemiology, and the implications of undescended testis (UDT) on fertility and malignancy risk. This article has an emphasis on the approach to diagnosis and surgical management for the UDT. The purpose of this review is to provide readers with useful clinical tools for assessing and treating patients with cryptorchidism.

Laparoscopic assisted trans-scrotal orchiopexy versus traditional orchiopexy for inguinal cryptorchidism: a retrospective study based on 154 patients

BACKGROUND

The purpose of this study was to investigate the clinical effect of laparoscopic assisted trans-scrotal orchiopexy versus traditional orchiopexy for inguinal cryptorchidism.

METHODS

A retrospective analysis of cryptorchidism patients who were admitted to our hospital from July 2018 to July 2021. The patients were divided into the laparoscopic assisted trans-scrotal surgery group (n = 76) and the traditional surgery group (n = 78) according to the surgical method.

RESULTS

All patients were successfully operated. There was no significant difference in operation time between the laparoscopic assisted trans-scrotal group and the traditional group (P>0.05). Although there was no significant difference in the postoperative hospital stay between the two groups, the time of postoperative hospital stay of the laparoscopic assisted trans-scrotal surgery group was lower than that in the traditional surgery group (P = 0.062). Additionally, there was no significant difference in discharge rate on the first day after surgery between the two groups, but the discharge rate on the first day after surgery was more than 90% in both groups. In terms of postoperative complications, there were no cases of testicular retraction, testicular atrophy, inguinal hernia, or hydrocele that occurred in both groups. There was no significant difference in the incidence of scrotal hematoma between the two groups(P>0.05). Although there was no significant difference in the incidence of poor wound healing between the two groups(P>0.05), the incidence in the laparoscopic assisted trans-scrotal surgery group was lower than that in the traditional surgery group (2.6% vs. 6.4%).

CONCLUSION

Laparoscopic assisted trans-scrotal surgery is as safe and effective method as traditional surgery for patients with inguinal cryptorchidism, and could also provide a good appearance.

Intratesticular arteriovenous malformation: A rare benign testicular lesion in an adolescent male

We present the clinical course and imaging findings of an intratesticular arteriovenous malformation found in an adolescent patient. The patient presented for evaluation of a possible testicular mass. Evaluation included grayscale and Doppler ultrasound that demonstrated a vascular mass. Serum tumor markers were unremarkable. Magnetic resonance imaging was used to make the diagnosis of intratesticular arteriovenous malformation. Intratesticular arteriovenous malformations are exceedingly rare, with only four other cases noted on literature review. This case presents unique findings including testicular microlithiasis and a history of cryptorchidism. The case was managed conservatively with ultrasound surveillance at six months.

Seminoma arising in splenogonadal fusion: a case report and literature review

BACKGROUND

Splenogonadal fusion (SGF) is a rare congenital malformation in which the spleen is abnormally connected to the gonads or to the mesonephric derivatives. There is no obvious causality between SGF and testicular neoplasm. However, cryptorchidism, which is a well-known risk factor of testicular germ cell tumors, are the most frequent malformations associated with SGF. To our knowledge, there are only four reported cases of SGF associated with testicular neoplasm so far. Herein, we reported a patient of this condition, and briefly reviewed the related literature.

CASE PRESENTATION

A 48-year-old man was diagnosed with bilateral cryptorchidism 30 years prior, and only underwent a right orchiopexy for the left testicle could not be explored during the operation. At that time, doctors failed to realize the possibility of SGF due to the lack of sufficient knowledge of this condition. This time, the patient was treated for a left abdomen mass that was diagnosed as stage III metastatic seminoma. Then, a right orchiectomy, robot-assisted laparoscopic left retroperitoneal tumor resection, and left retroperitoneal lymph node dissection was performed after four cycles of BEP (bleomycin + etoposide + cisplatin) systemic chemotherapy in our center. The final diagnosis of SGF was made by postoperative pathology. The patient was re-examined in our center at 3 months and 6 months after the operation, and no obvious abnormalities were found.

CONCLUSIONS

Surgeons should always bear in mind the possibility of association between bilateral cryptorchidism and splenogonadal fusion to avoid malignant transformation caused by delayed treatment.

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.

Compared outcomes of high-level cryptorchidism managed by Fowler-Stephens orchiopexy versus the Shehata technique: A systematic review and meta-analysis

BACKGROUND

The surgical approach for high-level intra-abdominal testis (IAT) is variable. While most pediatric urologists prefer staged Fowler-Stephens orchiopexy (FSO), Shehata publicized a novel approach-known as staged laparoscopic traction orchiopexy (SLTO) or the Shehata technique-to better manage IATs.

OBJECTIVE

This study compares the overall success rates, atrophy rates, retraction rates, and operation times of the two procedures to assist surgeons with developing procedure strategies.

METHODS

Databases were searched for relevant literature involving these two approaches, and studies meeting the eligibility criteria were involved; RevMan 5.4 was used to conduct this meta-analysis. The relative risk (RR), weighted mean difference, 95% confidence interval (CI), p-value, publication bias, and heterogeneity were calculated.

RESULTS

The Shehata technique demonstrated better performance than staged FSO regarding the overall success and atrophy rate, while the retraction rate and operation time had no statistical difference.

CONCLUSIONS

This study revealed that the Shehata technique may be an alternative to staged FSO for managing high-level IATs. Additional high-quality studies regarding the Shehata technique, as well as a long-term follow-up, are required for further and more credible analysis.

Are we still too late? Timing of orchidopexy

An undescended testis is the most common genitourinary disease in boys. The German guidelines, first published in 2009, proposed the timing of orchidopexy to be before 12 months of age. The aim of the study was to analyze the implementation of these guidelines 10 years after publication. The national cumulative statistics of hospital admissions, provided by the Institute for the Remuneration System in Hospitals (InEK), and the statistics concerning procedures performed in private pediatric surgical practices of the professional association of pediatric surgeons (BNKD) regarding the time of surgeries for the year 2019 were analyzed. Data from InEK included all German hospital admissions. Data from BNKD included data from 48 private pediatric surgical practices. The hospitals treated 6476 inpatients with undescended testis, and 3255 patients were operated in private practices. Regarding the age at treatment, 15% of the hospital patients and 5% of the private practice patients were younger than 1 year and fulfilled the guideline recommendations. Forty percent of the hospital patients and 29% of the private practice patients were 1 or 2 years of age. All other patients were 3 years of age or older at the time of orchidopexy.  Conclusions: The rate of orchidopexy within the first 12 months of life is remarkably low even 10 years after the publication of the guidelines. Awareness of the existing guideline must be increased for both referring pediatric and general practitioners. What is Known: • In Germany, orchidopexy is performed by pediatric surgeons and urologists either in hospital settings or in private practices. • Most international guidelines set the age for surgical treatment of undescended testis between 12 and 18 months of age. The German guidelines, published in 2009, sets the time-limit at one year of age. Until five years after publication of the German guidelines, the number of patients treated before the first year of life was low; studies show an orchidopexy ratebetween 8% and 19% during this time. What is New: • This study the first to cover all administered hospital patients in Germany and a large group of patients treated in private practices. It contains the largest group of German patients with undescended testis. • Although almost all children participate in the routine check-up at the age of seven months, which includes investigation for undescended testis, adherence to the orchidopexy guidelines is still low. Only 15% of the hospital patients and 5% of the patients in private practice were treated before their first birthdays.

Whole-Exome Sequencing Indicated New Candidate Genes Associated with Unilateral Cryptorchidism in Pigs

INTRODUCTION

Cryptorchidism is a hereditary anomaly characterized by the incomplete descent of one or both testicles to the scrotum. One of the challenges of this anomaly is that the retained testicle maintains its endocrine function. As a consequence, cryptorchid animals produce hormone-tainted meat in comparison to castrated animals and are likely to be more aggressive. Cryptorchidism can lead to reduced animal welfare outcomes and cause economic losses. Identifying genetic markers for cryptorchidism is an essential step toward mitigating these negative outcomes and may facilitate genome manipulation to reduce the occurrence of cryptorchidism. Attempts to identify such markers have used genome-wide association studies. Using whole-exome sequencing, we aimed to identify single nucleotide polymorphisms (SNPs) in the coding regions of cryptorchid pigs and to characterize functional pathways concerning these SNPs.

METHODS

DNA was extracted and sequenced from 5 healthy and 5 cryptorchid animals from the Landrace breed, using the Illumina HiSeq 2500 platform. Data were pre-processed using the SeqyClean tool and further mapped against the swine reference genome (Sus scrofa 11.1) using BWA software. GATK was used to identify polymorphisms (SNPs and InDels), which were annotated using the VEP tool. Network prediction and gene ontology enrichment analysis were conducted using the Cytoscape platform, and STRING software was used for visualization.

RESULTS

A total of 63 SNPs were identified across the genes PIGB, CCPG1, COMMD9, LDLRAD3, TRIM44, MYLPF, SEPTIN, ZNF48, TIA1, FAIM2, KRT18, FBP1, FBP2, CTSL, DAPK1, DHX8, GPR179, DEPDC1B, ENSSSCG00000049573, ENSSSCG00000016384, ENSSSCG00000022657, ENSSSCG00000038825, and ENSSSCG00000001229. Using pathway enrichment analyses and network prospection, we have identified the following significant adjusted p value threshold of 0.001 involved with the biological function pathways of estrogen signaling, cytoskeleton organization, and the pentose phosphate pathway.

CONCLUSION

Our data suggest the involvement of new SNPs and genes in developing cryptorchidism in pigs. However, further studies are needed to validate our results in a larger cohort population. Variations in the GPR179 gene, with implications at the protein level, may be associated with the appearance of this anomaly in the swine. Finally, we are showing that the estrogen signaling pathway may be involved in the pathophysiological mechanisms of this congenital anomaly as previously reported in GWAS.

Low-dose every-second-day LHRH treatment following bilateral orchidopexy in children with bilateral cryptorchidism may improve their fertility outcome

INTRODUCTION/BACKGROUND

Currently the standard treatment for bilateral cryptorchidism is bilateral surgical orchidopexy. Whether a hormonal treatment should be routinely administered postoperatively to increase fertility is debatable. Low-dose postoperative luteinizing hormone releasing hormone (LHRH) can increase spermatogonial numbers, but the effect of native LHRH (Kryptocur®) on adult fertility is unclear.

OBJECTIVE

To determine if low-dose every-second-day postoperative LHRH administration in children with bilateral cryptorchidism improves fertility in adulthood and if Nistal testicular histological grading could guide the decision to administer LHRH.

STUDY DESIGN METHODS

All patients, actually at least 16yr of age, that underwent a bilateral orchidolysis and orchidopexy for bilateral cryptorchidism (surgery between 1997 and 2018) were contacted and offered a clinical exam, hormone levels, sperm analysis, and a scrotal ultrasound. At the original surgery, testicular biopsy was performed (if 60% of the tubuli contain >1 spermatogonia, this is normal = Nistal-1, if 30-60% filled = Nistal-2, if <30% = Nistal-3 and if Sertoli only = Nistal-4) and if in at least one testis impaired. A low dose native LHRH treatment was offered to the patients, as this treatment is known to increase the number of spermatogonia in a short term. Kryptocur® (LHRH, Gonadorelin, Hoechst®) was prescribed and dosed at 200 μg (one spray in one nostril) every other day for 6-8 months.

RESULTS AND LIMITATIONS

Forty-two men were eligible for this study. 20/42 accepted the invitation for a clinical and hormonal evaluation. 16/20 men accepted the invitation for an additional sperm analysis. Fourteen of 20 men received low-dose LHRH postoperatively in a nonrandomized manner. Three men had Nistal grade 1, eight grade 2, seven grade 3, and two had grade 4. Inhibin B levels were higher in men with Nistal 1 and 2 compared with Nistal 3 and 4 P ≤ 0.037). Severe oligospermia/azoospermia (<1 × 10⁶/ejaculate) was observed in 33% of the treated group vs 67% of the untreated group (P ≤ 0.036.) DISCUSSION AND CONCLUSIONS: Low-dose every-second-day postoperative LHRH treatment improves fertility outcome in bilateral cryptorchidism. Histological analysis of prepubertal testes according to Nistal grading cannot be used as a predictive diagnostic test for LHRH treatment.

Geospatial analysis of hypospadias and cryptorchidism prevalence rates based on postal code in a Canadian province with stable population

INTRODUCTION

Hypospadias and cryptorchidism are hormone-mediated malformations that occur during male development. Prevalence rates of hypospadias and cryptorchidism are thought to be increasing worldwide. In-utero exposure to endocrine-disrupting chemicals (EDCs) may have a role in the occurrence of these malformations. Our group has reported significant clustering of hypospadias and cryptorchidism at the county level in areas of intense agricultural activity in the Canadian province of Nova Scotia (NS). Finer scale spatial analysis has shown clustering near urban centres.

OBJECTIVES

The objectives of the study were: 1) to perform a granular geospatial analysis of hypospadias and cryptorchidism prevalence, at the postal code level, of all babies born in NS over a 26-year period; and 2) to determine whether there is spatial correlation between these conditions and industries linked to toxic output.

STUDY DESIGN

Cases of hypospadias and cryptorchidism were identified based on ICD-10 codes from the Nova Scotia Atlee Perinatal Database with records of all live births in NS between 1988 and 2013. Data were geocoded and mapped based on the three first digits of the maternal postal code (Forward Sortation Area [FSA]). Regional prevalence of congenital anomalies was calculated for each of the 77 FSAs. To identify statistically significant high and low prevalence clusters for each anomaly, Local Morans I was used on the spatial data. Geospatial point data was created for industries linked to toxic output and correlation between clusters of malformations and proximity to these industries was assessed.

RESULTS

During the study period, there were 1045 cases of hypospadias and 993 cases of cryptorchidism. Both hypospadias and cryptorchidism demonstrated statistically significant areas of high prevalence clusters. There was no significant spatial correlation between the local clustering of the congenital malformations and proximity to toxic industries.

DISCUSSION AND CONCLUSION

Our study shows heterogeneity in the distribution of hypospadias and cryptorchidism, which is consistent with previously published works. In this follow-up, granular geospatial analysis of hypospadias and cryptorchidism prevalence in an area with stable population, we did not confirm the previous findings of high clustering in areas of intense agricultural activity. Furthermore, our analysis did not find high clustering of the congenital malformations in areas near toxic industries to support a clear environmental role in their development. Some of the limitations include underdiagnosis of hypospadias and cryptorchidism (as they both present with a clinical spectrum and are non-life threatening), and limited data currently available on the route of exposure to EDC industries in Nova Scotia.

A Surgical and Clinical Approach to Persistent Müllerian Duct Syndrome: Laparoscopic, Histological, and Molecular Findings

BACKGROUND

Persistent müllerian duct syndrome (PMDS) is characterized by the persistence of müllerian duct derivatives in otherwise normally virilized 46,XY males. Biallelic mutations of the anti-müllerian hormone (AMH) and AMH receptor type 2 (AMHR2) genes lead to PMDS type 1 and 2, respectively.

AIM

The aims of the study were to report the clinical, hormonal, and genetic findings in a patient with PMDS and discuss surgical strategies to achieve successful orchidopexy.

RESULTS

A 4-year-old boy was evaluated after the incidental finding of müllerian derivates during laparoscopy for nonpalpable gonads. Karyotype was 46,XY and laboratory tests revealed normal serum gonadotropin and androgen levels but undetectable serum AMH levels. PMDS was suspected. Molecular analysis revealed a novel variant c.902_929del in exon 5 and a previously reported mutation (c.367C>T) in exon 1 of the AMH gene. Successful orchidopexy was performed in two sequential surgeries in which the müllerian duct structure was preserved and divided to protect the vascular supply to the gonads. Histological evaluation of the testicular biopsy showed mild signs of dysgenesis. Doppler ultrasound showed blood flow in both testes positioned in the scrotum 1.5 years after surgery.

CONCLUSION

PMDS is a rare entity that requires a high index of suspicion (from surgeons) when evaluating a patient with bilateral cryptorchidism. Surgical treatment is challenging and long-term follow-up is essential. Histological evaluation of the testis deserves further investigation.

A giant intra-abdominal right testicular seminoma in a bilateral undescended testicle: a case report

Cryptorchidism is the most common congenital malformation of the male genitourinary tract. An undescended testicle has a 10% chance of developing cancer, with an intra-abdominal testicle having the highest risk. We present a 24-year-old man with a history of bilateral cryptorchidism, complaining of lower abdominal mass for two months. An abdominal computed tomography scan showed an intra-abdominal mass lesion measuring 13 x 9 cm and displacing the bladder caudally. Exploratory laparotomy revealed a right intra-abdominal testicular tumor. A right orchiectomy and left orchidopexy was performed. Histopathological examination revealed a testicular seminoma. The patient was discharged without complications and was referred to the oncology department for chemotherapy and further management. Our findings support the early treatment and close monitoring of cases of cryptorchidism due to the risk of malignancy as well as the necessity of routine scrotal examinations in all males presenting with an abdominal mass.

Persistent Müllerian duct syndrome: A surgical surprise and management during laparoscopic transabdominal pre-peritoneal repair

Persistent Müllerian duct syndrome is an intersex disorder which occurs due to the failure of regression of Müllerian structures in genotypical and phenotypical males. It is a rare disorder of male internal pseudohermaphroditism with normal secondary sexual characters and XY karyotype. We report a male patient with the diagnosis of bilateral inguinoscrotal hernia with cryptorchidism scheduled for laparoscopic bilateral transabdominal pre-peritoneal (TAPP) mesh repair with bilateral orchidopexy. Intra-operatively, there was a rudimentary uterus with tubes on both sides. Bilateral testicular biopsy was taken to confirm the presence of testicular tissue and to exclude malignancy and ovarian tissue. Hernia surgery was deferred in the first stage. After 2 weeks, he underwent laparoscopic bilateral orchidopexy with TAPP mesh repair. At 6-year follow-up, there is no recurrence of hernia or features of malignancy in the retained testis.

Birth prevalence of genital anomalies among males conceived by intracytoplasmic sperm injection cycles: A cross-sectional study

Background

Several studies have been conducted worldwide to evaluate the prevalence and relative risks of congenital anomalies associated with assisted reproductive technology cycles; however, there is limited data in Iran.

Objective

To investigate male genital anomalies among live births from assisted reproductive technology.

Materials and Methods

This cross-sectional study was conducted on children born after intracytoplasmic sperm injection (ICSI) at Royan Institute, Tehran, Iran from April 2013-December 2015. The prevalence of male genitalia disorders that included hypospadias, epispadias, cryptorchidism, micropenis, and vanishing testis were reported. The relationship between the cause of infertility and type of embryo transfer (fresh or frozen), gestational age at birth (term or preterm), and birth weight with these male genitalia anomalies were evaluated.

Results

In total, 4409 pregnant women were followed after their ICSI cycles to evaluate genitalia anomalies in their children. Out of 5608 live births, 2614 (46.61%) newborns were male, of which 14 cases (0.54%) had genital anomalies. The prevalence of various anomalies were cryptorchidism (0.34%), hypospadias (0.038%), micropenis (0.038%), vanishing testis (0.038%), and epispadias (0.077%). No relationship was found between the cause of infertility, type of embryo transfer (fresh or frozen), gestational age at birth (term or preterm), and male genital malformation (p = 0.33, p = 0.66, and p = 0.62, respectively).

Conclusion

The prevalence of each male genital anomaly after the ICSI cycle was rare and less than 0.5%; however, no significant infertility-related factor was observed with these anomalies.

Germ cell neoplasms of the testis: Update for 2022

Germ cell neoplasia in situ (GCNIS) is the precursor of both seminomatous and non-seminomatous germ cell tumors. It consists of distended tubules that may have either intratubular seminoma or intratubular embryonal carcinoma cells. Many invasive non-seminomatous tumors contain a mixture of tumor types, which are reviewed here. Morphology, aided by a panel of immunostains, can determine the presence and percent of embryonal carcinoma, yolk sac tumor, choriocarcinoma, or teratoma in such tumors. Use of immunostains, required for diagnosis in perhaps 25% of testicular neoplasms, is reviewed. Changes of classification in the AJCC (8^th edition) in 2016 are discussed, including the partitioning of two tumor types: the central role of chromosome 12p amplification allows both teratoma and yolk sac tumor to be divided into prepubertal types (lacking amplification) and post-pubertal types. Occasionally, sex cord-stromal tumors, hematolymphoid tumors, or epididymal adenomatoid tumors enter the differential diagnosis of germ cell neoplasms.

Azoospermic Men with a History of Cryptorchidism Treated by Orchiopexy Have Favorable Outcomes after Testicular Sperm Extraction: A Systematic Review and Meta-Analysis

PURPOSE

This systematic review and meta-analysis investigated the sperm retrieval rate (SRR) and pregnancy rate after testicular sperm extraction in men with azoospermia and those with a history of cryptorchidism treated by orchiopexy.

MATERIALS AND METHODS

The SRR and clinical pregnancy rate were investigated. We performed a sub-analysis that included factors such as bilaterality, age, and idiopathic non-obstructive azoospermia (iNOA). The analysis comprised 13 studies from January 1995 to July 2021. The data sources were PubMed/MEDLINE, Embase, and the Cochrane Library included "cryptorchidism", "orchidopexy", "azoospermia", and "testicular sperm extraction".

RESULTS

The overall mean SRR was 63.3% (95% confidence interval [CI], 57.6%-68.6%; I²=62.4%), and the overall mean clinical pregnancy rate was 30.1% (95% CI, 22.6%-38.8%; I²=69.9%). The meta-analysis comparing the SRR, there was no significant difference between patients with a history of bilateral and unilateral orchiopexy (relative risk [RR]=1.02; 95% CI, 0.89-1.16; p=0.79). Orchiopexy performed under the age of 10 years showed significantly increased SRR compared to the age of over 10 years (RR=1.25; 95% CI, 1.06-1.47; p=0.008). Azoospermic men with a history of cryptorchidism treated by orchiopexy had significantly higher SRR than iNOA (RR=1.90; 95% CI, 1.40-2.58; p<0.0001).

CONCLUSIONS

Men with azoospermia and a history of cryptorchidism treated by orchiopexy had significantly higher SRR than those with iNOA after testicular sperm extraction. Furthermore, patients who underwent orchiopexy before the age of ten years had significantly higher SRR than patients operated at an older than the age of ten years.

Identification of endocrine-disrupting chemicals targeting the genes and pathways of genital anomalies in males

Hypospadias and cryptorchidism are the most common congenital malformations in male neonates, both of which are also the important clinical manifestations of testicular dysgenesis syndrome and share a same origin. Many studies have suggested that prenatal exposure to endocrine-disrupting chemicals (EDCs) is associated with hypospadias and cryptorchidism development. However, the consistent mechanisms remain unclear. To identify the key EDCs, genes and biological networks related to the development of hypospadias and cryptorchidism respectively and commonly, we conduct the present study and found a new method for predicting the correlation between the interactive genes of hypospadias/cryptorchidism and chemicals. Transcriptome profiles were obtained from the Comparative Toxicogenomics Database (CTD). Gene ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways enrichment analyses and protein-protein interaction (PPI) network were applied for integrative analyses. The rat model and molecular docking were applied to furtherly verifying the findings of the integrative analyses. Besides the highly related genes, most enriched pathways and chemicals for hypospadias and cryptorchidism respectively, we found hypospadias and cryptorchidism share many same highly associated EDCs (e.g., dibutyl phthalate) and genes (e.g., androgen receptor and estrogen receptor 1) through comparing highly related chemicals or genes of hypospadias and cryptorchidism respectively. GO and KEGG analysis showed that these same interactive genes were mainly enriched in steroidogenesis, response to steroid hormone and nuclear receptor activity. PPI network analysis identified 15 biological hub genes. Furtherly, hypospadias and cryptorchidism were induced by prenatal dibutyl phthalate exposure. Decreased serum testosterone level, downregulation of nuclear androgen-dependent and upregulation of cytoplasmic estrogen-dependent pathways may lead to hypospadias and cryptorchidism. This study proposed a new method for predicting the correlation between the interactive genes of hypospadias/cryptorchidism and chemicals and found that hypospadias and cryptorchidism share many same highly associated EDCs and genes.

Loss of WNT4 in the gubernaculum causes unilateral cryptorchidism and fertility defects

Undescended testis (UDT) affects 6% of male births. Despite surgical correction, some men with unilateral UDT may experience infertility with the contralateral descended testis (CDT) showing no A-dark spermatogonia. To improve our understanding of the etiology of infertility in UDT, we generated a novel murine model of left unilateral UDT. Gubernaculum-specific Wnt4 knockout (KO) mice (Wnt4-cKO) were generated using retinoic acid receptor β2-cre mice and were found to have a smaller left-unilateral UDT. Wnt4-cKO mice with abdominal UDT had an increase in serum follicle-stimulating hormone and luteinizing hormone and an absence of germ cells in the undescended testicle. Wnt4-cKO mice with inguinal UDT had normal hormonal profiles, and 50% of these mice had no sperm in the left epididymis. Wnt4-cKO mice had fertility defects and produced 52% fewer litters and 78% fewer pups than control mice. Wnt4-cKO testes demonstrated increased expression of estrogen receptor α and SOX9, upregulation of female gonadal genes, and a decrease in male gonadal genes in both CDT and UDT. Several WNT4 variants were identified in boys with UDT. The presence of UDT and fertility defects in Wnt4-cKO mice highlights the crucial role of WNT4 in testicular development.

The positive predictive value of using fsh and Inhibin-B serum levels to diagnose gonadotropin insufficiency in bilateral cryptorchid boys is high

AIM OF STUDY

Despite early surgery, many boys with bilateral cryptorchidism at surgery have a reduced number of germ cells per tubular cross-section (G/T) in testicular biopsies and/or low inhibin-B with no elevated follicle-stimulating hormone (FSH) as expected based on a normal gonadotropin feed-back mechanism. Such boys have a high risk of later infertility because of insufficient gonadotropin stimulation and may benefit from adjuvant hormonal treatment. Testicular biopsies are not always wanted or accepted. The study aim was to investigate the value of a low inhibin-B and normal FSH to identify patients that might benefit from adjuvant hormonal treatment avoiding the need for testicular biopsy.

METHODS

A series of boys with cryptorchidism were evaluated with serum levels of inhibin-B and FSH in relation to G/T in testicular biopsies, which were compared to previously published age-matched normal control values.

RESULTS

A total of 365 boys who underwent bilateral orchidopexy between 0.4 and 7.8 (median: 2) years of age were included. Twenty-seven (7%) patients had increased FSH and low G/T, whereas 11 of these also had low inhibin-B indicating hypergonadotropic hypogonadism. Moreover, 85 (23%) patients between 0.75 and 7.5 (median: 2) years of age had both low G/T (median: 0.3) and low inhibin-B (median: 56 pg/ml) but normal FSH (median: 0.6 U/l) indicating a gonadotropin insufficiency. Three patients with normal FSH and low inhibin B had normal G/T.

DISCUSSION

Our study shows that if surgeons prefer to avoid testicular biopsies and only wish to rely on hormonal parameters (low inhibin-B and normal FSH) in order to diagnose a gonadotropin insufficiency as the cause of hypogonadism, they will identify only about 30% of such cases and overlook about 70% of patients sharing the same endocrinopathy. In addition, if surgeons treat patients for gonadotropin insufficiency only based on low inhibin-B and normal FSH they will solely treat patients with gonadotropin insufficiency and would not overtreat patients.

CONCLUSION

Adjuvant hormonal treatment was indicated by a gonadotropin insufficiency discerned in 23% of boys with bilateral cryptorchidism. Without histology, the clinicians are left with more difficult clinical judgments to identify patients for adjuvant hormonal treatment. The positive predictive value of low inhibin-B and normal FSH corroborated by low G/T was 0.97 (85/85 + 3), but the sensitivity was low (0.30).