Evaluating testicular function changes in unilateral cryptorchid chinese infants underwent orchidopexy in the first year of life

OBJECTIVE

Management of cryptorchidism is typically recommended within the first 18 months of life to maximize fertility potential. However, there is a paucity of longitudinal postoperative data for Chinese infants. We aim to evaluate the Testicular function change when the procedure is done within the first year of life.

METHOD

We prospectively enrolled 51 children diagnosed with unilateral inguinal cryptorchidism into the surgical group between January 2021 and January 2022. Orchidopexy was carried out through a single transverse scrotal incision. Assessments of anti-Mullerian hormone (AMH), inhibin B (InhB), testosterone (T) levels, testicular volume and testicular atrophy index (TAI) were conducted at baseline, 6 months, and 1 year following surgery. Concurrently, clinical data from 42 healthy age-matched controls were collected during their routine physical examinations.

RESULTS

At 6- and 12-months post-surgery, testicular volume increased significantly to 0.98 ± 0.12 mL and 1.01 ± 0.12ml. AMH levels also rose from 76.40 ± 15.77 ng/mL to 81.52 ± 15.32 ng/mL and 87.50 ± 15.36 ng/mL. However, these parameters are significantly lower than age-matched healthy controls (both P < 0.001). InhB levels significantly increased after surgery and even surpassed those of healthy controls after 6 months (both P < 0.001). The TAI was 16.7% and 8.6% at 6- and 12-months following surgery.

CONCLUSION

Although orchiopexy can improve testicular growth and function, the restoration of testicular function to the level of healthy peers might take longer. To expedite the recovery of testicular function and bring it in line with that of peers, we recommend addressing cryptorchidism at the earliest opportunity.

A nomogram for predicting risk factors of testicular salvage after testicular torsion in children

OBJECTIVES

This study aimed to establish a nomogram for predicting the probability of testicular salvage after testicular torsion in children.

METHODS

We retrospectively collected data of children with testicular torsion who were treated at Shenzhen Children's Hospital between September 2005 and August 2022. Of the training cohort, 113 patients who underwent orchiectomy and five with testicular atrophy after orchiopexy were included in the failed testicular salvage group. Additionally, 37 patients who underwent orchiopexy without postoperative testicular atrophy were included in the successful testicular salvage group. The predictive factors affecting testicular salvage were determined using univariate and multivariate logistic regression analyses; a nomogram was constructed. The nomogram was verified using data from the validation group.

RESULTS

Using multivariate logistic regression analysis, the independent risk factors of testicular salvage after testicular torsion were symptom duration (p = 0.034), intratesticular blood flow (p = 0.003), spermatic cord torsion degree (p = 0.037), and monocyte count (odds ratio: 0.012, p = 0.036). A nomogram was established based on these four risk factors. In the training cohort, the area under the receiver operating characteristic curve was 0.969. The area under the receiver operating characteristic curve of the verification cohort was 0.965, indicating good discrimination ability of the nomogram. Increased symptom duration without intratesticular blood flow increased the monocyte count and spermatic cord torsion degree and decreased the success rate of testicular salvage.

CONCLUSION

This prediction model could obtain the corresponding probability of testicular salvage according to the clinical characteristics of different patients with testicular torsion, providing reference for clinicians and parents.

Evaluation of testicular stiffness in boys with unilateral cryptorchidism after orchiopexy by ultrasound strain elastography

PURPOSE

We assessed the stiffness of unilateral undescended testes after orchiopexy, examining its value in tracking histopathological changes and fertility potential during postoperative follow-up. Additionally, we explored the optimal timing for surgery based on testicular stiffness.

PATIENTS AND METHODS

Thirty-six boys who had been diagnosed with unilateral undescended testis and treated with orchiopexy were included in the study. Testicular stiffness was evaluated several times over respective follow-up periods by ultrasound strain elastography after orchiopexy. The strain ratios were measured as the ratios of the elasticities of the descended testis to those of the operated testes. The patients were divided into two groups based on the age at which they underwent orchiopexy:under < 2 years (Group A) and ≥ 2 years (Group B).

RESULTS

The mean strain ratios were 0.90 ± 0.32 and 0.92 ± 0.20 in Groups A and B, respectively. In Group A, the strain ratio was constant regardless of postoperative months (r = 0.01, p = 0.99); however, in Group B, it tended to increase with postoperative months (r = 0.42, p = 0.07).

CONCLUSIONS

Evaluation of testicular stiffness may be useful for the estimation of histopathological changes and fertility potential in boys with unilateral undescended testes at follow-up appointments after orchiopexy. Our data indicate that performing orchiopexy as early as possible may be recommended to avoid testicular damage.

Successful Treatment of Transverse Testicular Ectopia by Laparoscopically Assisted Orchiopexy

Transverse testicular ectopia (TTE) is a rare congenital malformation where both testes descend through the same inguinal canal and are located in the same hemiscrotum. It is usually treated with transseptal orchiopexy. In this article, we report the case of a 1-year-old boy diagnosed with TTE who was successfully treated with laparoscopically assisted orchiopexy by going through the anatomical conventional route. A four-month-old boy was referred to our department with bilateral empty scrotum. On the physical examination, the left testis was palpable in the left groin region and the right testis was impalpable. A follow up ultrasonography was performed after 4 months, and an oval-shaped testis-like structure was detected in left internal inguinal ring near the left testis. Right side TTE was suspected in the initial diagnosis. Laparoscopic surgery was performed at age one. The left testis was observed in the inguinal canal, and the right testis was ectopically located in the left opening inguinal canal above the left testis. Two spermatic cord and testes were separated respectively, and the right testis was pulled into abdominal space laparoscopically and brought down to the right hemiscrotum via the right inguinoscrotal canal. Bilateral orchiopexy was performed via the normal anatomical route. The postoperative course was uneventful, and testes were in the scrotum bilaterally one year after orchiopexy.

Comparison of scrotal and inguinal orchiopexy for palpable undescended testis: a meta-analysis of randomized controlled trials

INTRODUCTION

Scrotal and inguinal orchiopexy are two commonly used surgical approaches for palpable undescended testis (UDT), each with distinct advantages. However, the optimal approach remains a matter of debate, warranting a comprehensive meta-analysis of randomized controlled trials (RCTs) to guide clinical decision-making.

MATERIALS AND METHODS

A comprehensive literature search was conducted, adhering to PRISMA guidelines, to select RCTs comparing scrotal and inguinal orchiopexy for palpable UDT. Eight RCTs were selected for meta-analysis. Outcome measures included operative time, hospitalization duration, total complications, wound infection or dehiscence, testicular atrophy or hypotrophy, and testicular re-ascent rate. The evaluation of the study's quality was conducted by utilizing the revised Cochrane risk-of-bias tool.

RESULTS

Scrotal orchiopexy showed significantly shorter operative time compared to the inguinal approach (WMD: - 15.06 min; 95% CI: - 21.04 to - 9.08). However, there was no significant difference in hospitalization duration (WMD: - 0.72 days; 95% CI: - 1.89-0.45), total complications (OR: 1.08; 95% CI: 0.70-1.66), wound infection or dehiscence (OR: 0.73; 95% CI: 0.27-1.99), testicular atrophy or hypotrophy (OR: 1.03; 95% CI: 0.38-2.78), and testicular re-ascent (OR: 1.43; 95% CI: 0.67-3.06) between the two approaches. A small proportion of cases (7.3%) required conversion from scrotal to inguinal orchiopexy due to specific anatomical challenges.

CONCLUSION

Both scrotal and inguinal orchiopexy are safe and effective for palpable UDT, with comparable outcomes in terms of hospitalization and complications. Scrotal orchiopexy offers the advantage of shorter operative time. Clinicians can use this evidence to make informed decisions on the surgical approach for palpable UDT.

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.

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.

A Surprise During "Routine" Orchidopexy: An Extrarenal Wilms Tumor Case Report

We present the case of a 12-month-old male diagnosed with an extrarenal Wilms tumor found incidentally at the time of inguinal orchiopexy. He was staged and treated according to Children's Oncology Group (COG) protocol, with no evidence for disease at the end of treatment. We review the patient's presentation and treatment course, followed by a review of current literature on extrarenal Wilms tumor and considerations for management.

Inguinal Polyorchidism Found Incidentally During Orchiopexy in 9-Year-Old Male: A Case Report and Review of Orchiopexy of Nonscrotal Supernumerary Testes

Polyorchidism, the presence of more than two testes, usually presents as a painless scrotal mass or is diagnosed incidentally during the management of another condition.1 It is a rare congenital abnormality with approximately 200 reported cases in the literature. Most cases are found on the left side within the scrotum. We report a case of right-sided polyorchidism in a 9-year-old patient found incidentally during inguinal orchiopexy. As there is debate on the management of polyorchidism, a careful approach is required as the surgeon must decide between either scrotal fixation or the removal of the supernumerary testis. This case report will discuss the anatomical and clinical considerations when making this decision.

Microdissection testicular sperm extraction outcomes in azoospermic patients with bilateral orchidopexy

BACKGROUND

Cryptorchidism is considered to be one of the most common causes of non-obstructive azoospermia. There are several surgical techniques to retrieve sperm in these patients. Microdissection testicular sperm extraction (m-TESE) is a recent sperm retrieval technique which is considered to be a safe, non-blind, and feasible method.

OBJECTIVES

This study aimed to investigate sperm retrieval rate (SRR) by the mTESE method in patients who have undergone orchidopexy due to bilateral cryptorchidism.

MATERIALS AND METHODS

In this retrospective study, 56 ex-cryptorchid patients, who underwent mTESE due to post orchidopexy azoospermia, were included. Patients with hypogonadotropic hypogonadism, Klinefelter syndrome, azoospermia factors (AZF) microdeletion, or chromosomal translocation were excluded from the study. Data were obtained from medical files.

RESULTS

SRR in this study was 46%. Patients were divided into two groups of negative (n = 30) and positive (n = 26) based on the sperm extraction outcomes. There was no statistically significant difference between two groups regarding the mean age at mTESE, mean age at orchidopexy, testicular size, and serum testosterone concentration. However, testicular location, histological patterns, FSH, and LH level showed to have statistically significant relation with sperm retrieval results. But, according to our logistic regression, none of the included variable in the model including FSH, LH, histopathology, and testis location have a significant effect on the presence of the sperm.

DISCUSSION

In the present study, SRR was significantly higher in patients with scrotal testis and low level of FSH and LH.

CONCLUSIONS

Performing mTESE could be recommended in ex-cryptorchid patients with post orchidopexy NOA. Preoperative testicular biopsy seems to be unnecessary while clinical criteria can perfectly define NOA.

Association between lower limb spasticity and cryptorchidism in males with cerebral palsy

AIM

To explore the association between presence and severity of lower limb spasticity (LLS) and risk of orchidopexy for cryptorchidism among people with cerebral palsy (CP) and to further define the cremasteric muscle spasticity theory.

METHOD

We queried the Pediatric Health Information System database for male patients with CP, stratified patients into those with/without LLS, and compared groups for orchidopexy occurrence. Comparative statistics were performed using χ2 and Mann-Whitney U tests for categorical and continuous variables respectively. The association between orchidopexy and spasticity type was investigated using logistic regression.

RESULTS

In total, 44 561 males with CP were identified. Of these, 1.6% underwent orchidopexy (median age: 7 years 8 months [interquartile range: 4 years 6 months-11 years 4 months]). LLS presence was significantly associated with higher orchidopexy rate compared to spasticity absence (odds ratio [OR] = 1.33 [1.10-1.59], p = 0.003). Among 7134 patients with LLS, intervention was significantly associated with higher orchidopexy rate (injection procedures: OR = 2.47 [2.27-6.39], p = 0.034; surgical procedure: OR = 2.60 [1.22-6.76], p = 0.026). LLS groin proximity was significantly associated with higher orchidopexy rate (OR = 2.52 [1.42-4.96], p = 0.003).

INTERPRETATION

A strong association exists between LLS presence and severity and orchidopexy risk among people with CP. These findings support a cremasteric spasticity hypothesis as an important factor of cryptorchidism in CP. Providers should continue to examine for cryptorchidism in males with CP as they age.

WHAT THIS PAPER ADDS

Lower limb spasticity (LLS) is associated with higher orchidopexy rate in cerebral palsy. Orchidopexy rate was higher in more severe LLS. Orchidopexy rate was higher in more proximal LLS.

Cut-off time for surgery and prediction of orchiectomy in spermatic cord torsion: a retrospective multicentric study over 15 years

PURPOSE

Cut-off time to avoid orchiectomy relies on small series of patients. The objective was to determine the cut-off time to avoid orchiectomy in torsion of the spermatic cord in a large cohort.

METHODS

We performed a retrospective multicenter study (TORSAFUF cohort) of patients with suspected spermatic cord torsion between 2005 and 2019. All patients aged > 12 years who were suspected of having a torsion of the spermatic cord in 14 University Hospitals in France were included (n = 2986). Patients for whom data on pain duration were not available (n = 923) or for whom the final diagnosis was not torsion of the spermatic cord (n = 807) were excluded. The primary outcome was orchiectomy. The secondary outcomes were testicular survival time and the prediction of orchiectomy with the duration of pain.

RESULTS

1266 patients were included with an orchiectomy rate of 12% (150 patients). The mean age was 21.5 years old in the salvage group and 23.7 years old in the orchiectomy group (p = 0.01), respectively. The median time from the onset of pain to surgery was 5.5 (IQR = 5) hours in the salvage group and 51.1 (IQR = 70) hours in the orchiectomy group (p < 0.0001). The risk of orchiectomy increased after a time cut-off of 6 h 30. A delay of 15 h 30 in pain duration was found to predict orchiectomy (sensitivity: 0.81; specificity: 0.87).

CONCLUSIONS

Pain duration can predict the probability of salvaging the testicles and performing orchiectomy. Rapid intervention should be recommended, regardless of the time elapsed from the onset of pain.

Low-Grade Injury following Testicular Torsion: A Multicenter Study Confirming a Disturbing Possibility

INTRODUCTION

There is an ongoing debate whether to perform orchiectomy or orchidopexy following testicular torsion (TT) in cases where the testis seems non-viable. The main problem is lack of objective criteria defining testicular viability. The aim of this study was to investigate the grade of injury in orchiectomy specimens obtained from cases of TT and its association with clinical findings.

METHODS

This multicenter retrospective study involved double-blinded reassessment of the patient files and the pathological specimens using Mikuz classification to analyze the relation between clinical and pathological findings.

RESULTS

A total of 289 patient charts from 14 centers were reviewed and 228 were included in this study. Twenty (8.8%) patients had grade 1 injury which refers to reversible injury. The clinical findings of these 20 patients were compared to 208 patients with higher grades of injury. As expected, there was statistically significant difference regarding duration of symptoms (p < 0.001); however, range was wide in both groups (as long as 96 h for grade 1 and as short as 7 h for higher grades). There was no statistically significant difference in any other variable including age (median 14 for both, p = 0.531), symptoms (pain: 19/20 vs. 189/202, p = 0.801; swelling: 13/19 vs. 168/197, p = 0.094), absence of blood flow in Doppler US (15/19 vs. 164/197, p = 0.635), or degree of torsion (median 720° for both, p = 0.172).

CONCLUSION

Our study revealed necessity for better criteria to define viability of testis following TT. Histopathological injury appeared to be reversible even in some patients with more severe perioperative findings, late admission, or high degree of twisting. Our findings support the tendency for testicular fixation instead of orchiectomy as none of the clinical or perioperative findings could be attributed to high-grade injury.

The effect of scrotal versus inguinal orchiopexy on the testicular function of children with clinically palpable, inguinal undescended testis: a randomized controlled trial

To compare the impact of the scrotal vs inguinal orchidopexy approach on the testicular function of infants with cryptorchidism, a randomized controlled trial was conducted involving boys who were 6-12 months old at surgery and were diagnosed with clinically palpable, inguinal undescended testis. Between June 2021 and December 2021, these boys at Fujian Maternity and Child Health Hospital (Fuzhou, China) and Fujian Children's Hospital (Fuzhou, China) were enrolled. Block randomization with a 1:1 allocation ratio was employed. The primary outcome was testicular function assessed by testicular volume, serum testosterone, anti-Müllerian hormone (AMH), and inhibin B (InhB) levels. Secondary outcomes included operative time, amount of intraoperative bleeding, and postoperative complications. Among 577 screened patients, 100 (17.3%) were considered eligible and enrolled in the study. Of the 100 children who completed the 1-year follow-up, 50 underwent scrotal orchidopexy and 50 underwent inguinal orchidopexy. The testicular volume, serum testosterone, AMH, and InhB levels in both groups increased markedly after surgery (all P < 0.05), but there were no apparent differences between groups at 6 months and 12 months after operation (all P > 0.05). No differences between the scrotal and inguinal groups were noted regarding the operative time ( P = 0.987) and amount of intraoperative bleeding ( P = 0.746). The overall complication rate (2.0%) of the scrotal group was slightly lower than that of the inguinal group (8.0%), although this difference was not statistically significant ( P > 0.05). Both scrotal and inguinal orchiopexy exerted protective effects on testicular function in children with cryptorchidism, with similar operative status and postoperative complications. Scrotal orchiopexy is an effective alternative to inguinal orchiopexy in children with cryptorchidism.

Reference value of testicular temperature measured by finite element analysis after first staged inguinal orchidopexy in children with abdominal testis and short spermatic cord

PURPOSE

This study aims to build a 3D reconstruction computed simulation model and to establish a regression equation for detecting the testis's temperature by its location after first staged open orchidopexy in children with abdominal undescended testis (UDT) and short spermatic cords.

METHODS

In this cross-sectional study, we enrolled 31 children with abdominal UDT and short spermatic cords who underwent first staged orchiopexy between 2017 and 2020. Using ultrasonography to obtain the testis's location distance from the skin surface (X1), external iliac vessel (X2), and internal inguinal ring (X3), we input the data into a 3D reconstruction computed simulation along with COMSOL to calculate the testicular temperature. We also used multivariate regression to establish the testicular temperature regression equation from the gathered data.

RESULT

The mean age of the participants was 4.47 ± 1.21 years. The mean size of the operated testis was 0.39 ± 0.13 cc. The mean distance of the testis from X1, X2, and X3 was 3.27 ± 1.25 mm, 21.06 ± 6.42 mm, and 27.19 ± 10.09 mm, respectively. The testicular temperature regression equation derived from testis location was calculated by the formula: 34.57 + 0.0236 X12 - 0.0105 X2 - 0.0018 X3. The concordance for testis temperature calculated via the computational method and regression equation was 83%.

CONCLUSIONS

The current study provided a reference value for the testicular temperature of children with abdominal UDT and short spermatic cords after the first stage of orchiopexy. A testicular temperature regression equation can be established based on the testis location, which will provide relevant information for the testicular development assessment, disease diagnosis, and follow-up, and possibly determination of the time of the second stage of orchiopexy.

Factors affecting testicular volume after orchiopexy for undescended testes

PURPOSE

Children with undescended testes (UDTs) undergoing orchiopexy at a later age reportedly experience more negative effects on post-orchiopexy testicular volume (TV). This study aimed to investigate the effect of orchiopexy according to the age at operation.

METHODS

We included 93 patients (127 testes) who underwent orchiopexy between 2008 and 2020. According to their age at orchiopexy, they were divided into Group 1 (< 24 months; n = 36, median follow-up: 17 [14-39] months) and Group 2 (≥ 24 months; n = 57, median follow-up: 16 [13-34] months). TV was measured with ultrasonography preoperatively and postoperatively. In unilateral UDTs, the testicular volume rates (TVR) were calculated as diseased-side TV/intact-side TV × 100%. A TVR < 50% indicated preoperative testicular atrophy (pre-op TA), whereas volume loss ≥ 50% from baseline indicated postoperative testicular atrophy (post-op TA).

RESULTS

Only seven patients experienced pre-op TA. The TV of these 14 atrophic testes improved after orchiopexy (TVR: 100% (7/7) in Group 1 and 85% (6/7) in Group 2). Furthermore, the median TVR significantly improved after orchiectomy, from 27 to 58% (p < 0.01) and from 32 to 61% in Groups 1 and 2 (p < 0.05), respectively. Post-op TA was found in four testes (8%) in Group 1 and three testes (4%) in Group 2. Multivariate analysis showed that only preoperative testicular location predicted post-op TA.

CONCLUSION

Post-orchiopexy TA may occur regardless of the patient's age at orchiopexy, and orchiopexy is recommended irrespective of age at diagnosis.

Traumatic testicular dislocation in the abdomen: diagnosis and management

Testicular dislocation in the abdomen after scrotal trauma is a rare and sometimes unrecognised event.Early detection and timely management reduce possible complications which include the risk of fertility loss, endocrine dysfunction, and future malignancy.We present the case of a man who suffered a traumatic dislocation of the right testis in the abdomen after a motorcycle crash. The large scrotal haematoma did not permit adequate physical examination. Furthermore, during the clinical management of the polytrauma, the main focus was on active arterial bleeding, multiple pelvic fractures and clinical investigation of the integrity of the lower urinary tract. Therefore, the diagnosis and surgical management of the testicular dislocation were delayed.The patient underwent abdominal-inguinal surgical exploration, haematoma evacuation, identification of the right testis and right orchidopexy.After 6 months, the right testis of the patient is of regular volume, consistency and physiologic echogenicity on ultrasound evaluation.Hormonal evaluation and semen analysis were normal after 3 months.

Assessment of Prior Well Child Checks in Children With Concerns for Testicular Position: Opportunities for Early Referral From an Integrated Health System

OBJECTIVE

To assess, through an integrated primary and specialty care pediatric health system, the association of well-child checks prior to referral with final urological diagnosis with the aim to identify opportunities for earlier referral of care.

METHODS

We performed a retrospective review of children referred from primary care to urology for undescended testis (UDT) within our integrated primary-specialty care health system in 2019, comparing children who had undescended testicles to those with either normal or retractile testicles based on the final urology examination. Demographics, including age, comorbidities, and the status of prior well-child check (WCC) within primary care, were reviewed. Outcomes of age at referral and surgical intervention for UDT were compared across referral categories.

RESULTS

Stratifying by final diagnosis of 88 children included in the analysis, children with UDT were referred much later (85months, interquartile ranges 31-113) than children without UDT on final diagnosis (33months, interquartile ranges 15-74, P = .002). Furthermore, children with UDTs had a greater proportion with prior abnormal WCCs (N = 21/41, 51%) than those without UDT (N = 8/47, 17%) (P < .001).

CONCLUSION

Children with prior abnormal WCCs were more likely to have a final diagnosis of UDT, with prior abnormalities being documented approximately 12months prior to referral, indicating opportunities for improved referral patterns to urology.

A Case of Conservative Management of Intra-abdominal Polyorchidism in a Child

Polyorchidism is defined as the presence of 2 or more testes on the same side. A 7-year-old boy (46 XY) with multiple congenital abnormalities and nonpalpable bilateral gonads is presented. He underwent diagnostic laparoscopic surgery at 8 months old which revealed duplicated right testes and contralateral presence of persistent left Mullerian duct structures. A successful Fowler-Stephens orchidopexy in 2 stages was performed on both testicles. Postoperative ultrasonography showed orthotopic right testes of 0.15 and 0.28 cc. We propose testicular preservation in these patients to prevent early anorchia.

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.

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

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

Clinical Presentation, Diagnostic Approach, Laparoscopic Evaluation and Treatment of Impalpable Testis

OBJECTIVE

To find out the clinical presentation, utility of ultrasound for diagnosis, laparoscopic findings and treatment for clinically impalpable testis.

STUDY DESIGN

Cross-sectional study.

PLACE AND DURATION OF STUDY

Department of Paediatric Surgery, National Institute of Child Health, Jinnah Sindh Medical University Karachi, from September 2019 to April 2020.

METHODOLOGY

Patients with clinically impalpable testis were included. Ultrasound of inguinal region was done to locate testis. Presence of testis and its position was confirmed at laparoscopy and surgical procedure done according to the findings. Data was stratified according to the age and Chi-square test and Student t-test were applied to find out statistical significance among different variables in children below and above five years of age. A p <0.05 was taken as significant.

RESULTS

Ninety-one patients with 113 testes were included. The median age of the children was 48 months. Sixty-nine (75.8%) patients had unilateral undescended testis and 22 (24.2%) bilateral undescended testes. Fifty-three (58.2%) patients were less than five years of age. On ultrasound, testis was found near deep ring in 23 (25.3%) patients. At laparoscopy, 74 (81.3%) testes were found within the abdominal cavity. In 7 (7.7%) patients, only nubbin of tissue was identified and removed. The first stage of Fowler Stephen procedure was done in the majority of the patients. There was statistically no significant difference following stratification in relation to laterality and position of undescended testis (p = 0.556 and p = 0.846, respectively). However, mean size of the testis was found statistically significant (p = 0.032).

CONCLUSIONS

Most of the patients were above five years of age. Ultrasound helped in identifying low-lying intra-abdominal testis in more than 80% of patients. Laparoscopy was helpful in further defining the position of the testis and selection of surgical procedure.

KEY WORDS

Undescended testis, Cryptorchidism, Laparoscopy, Orchiopexy.

Are Parents Informed Well Enough About Their Child's Long-term Risks Related to Undescended Testis?

Worldwide, recommendations for timely surgical repair of undescended testis (UDT) are not well translated into clinical practice, potentially due to suboptimal patient/parent education. We evaluated the frequency and content of information provided to affected parents of 310 consecutive cases of UDT undergoing orchidopexy. Parents were enquired regarding details of education provided by the attending clinician. 18% of parents were not provided with detailed information regarding any long-term consequences of untreated UDT. In the 79% who were educated, information about impaired fertility was frequent, while malignant degeneration, hypogonadism and testicular atrophy were poorly communicated. 49% of all parents searched for further information on the internet or through a second medical opinion. The frequency and level of detail of information regarding long-term complications provided to parents of children with UDT is suboptimal and needs to be improved.

Testicular descent: A review of a complex, multistaged process to identify potential hidden causes of UDT

BACKGROUND/PURPOSE

What causes normal descent of the testis in a fetus, and what goes wrong with this complex process to cause undescended testes (UDT), or cryptorchidism? Over the last 2 decades, most authors searching for the cause(s) of UDT have looked at the 2 main hormones involved, insulin-like hormone 3 (Insl3) and testosterone (T)/ dihydrotestosterone (DHT), and their known upstream (hypothalamic-pituitary axis) and intracellular 'downstream' pathways. Despite these detailed searches, the genetic causes of UDT remain elusive, which suggest the aetiology is multifactorial, and/or we are looking in the wrong place.

METHODS

In this review we highlight the intricate morphological steps involved in testicular descent, which we propose may contain the currently 'idiopathic' causes of UDT. By integrating decades of research, we have underlined many areas that have been overlooked in the search for causes of UDT.

RESULTS

It is quite likely that the common causes of UDT are still hidden in these areas, and we suggest examining these processes is worthwhile in the hope of finding the common genetic anomalies that lead to cryptorchidism. Given the fact that a fibrous barrier preventing descent is often described at orchidopexy, examination of the extracellular matrix enzymes needed to allow gubernacular migration may be a fruitful place to start.

CONCLUSION

This review of the complex anatomical steps and hormonal regulation of testicular descent highlights many areas of morphology and signalling pathways that have been overlooked in the search for causes of UDT.

Testicular volume in adult patients undergoing cryptorchidism surgery in childhood, and impact on paternity

OBJECTIVE

To determine the impact of orchiopexy on testicular volume. To determine whether age at surgery impacts testicular volume. To determine whether paternity is associated with testicular volume.

METHODS

Patients born between 1961 and 1985 who had undergone cryptorchidism surgery at the Pediatric Surgery Department of Miguel Servet University Hospital were included. Testis location and macroscopic appearance data were collected. Control testicular ultrasonographies and paternity surveys were carried out. Initially, the study was descriptive, and subsequently, inferential.

RESULTS

Ultrasonography was performed in 216 testicular units a mean of 14.9 years following surgery, whereas the paternity survey was conducted among 157 respondents a mean of 41.9 years following surgery. There were significant differences (p = 0.0038) in testicular volume distribution according to epididymal dissociation. There was a linear correlation between older age at surgery and lower testicular volume, but without statistical significance. Significant differences (p < 0.0001) in testicular volume according to groups - operated and non-operated -, as well as between unilateral and bilateral cases, were found. No differences in paternity rates according to testicular volume were noted.

CONCLUSION

Operated testes have lower volumes than normally descended testes. Older age at surgery may contribute to lower final volumes. Testes with full epididymal-testicular dissociation have lower total volumes. No relation between testicular volume and paternity rates was found. Further long-term studies are required.

Laparoscopic staged management of high intrabdominal testis: A prospective randomized study

OBJECTIVE

To prospectively compare outcomes and complications of both staged laparoscopic techniques used in management of high intrabdominal testis (IAT).

MATERIALS AND METHODS

Forty five patients were included in the study in whom unilateral high IAT were identified and were subjected to two-stage laparoscopic orchiopexy. Patients were prospectively randomized into two groups according to laparoscopic technique in use; either two stage Fowler-Stephens laparoscopic orchiopexy (FSLO) or staged laparoscopic traction orchiopexy (SLTO). Intraoperative evaluation for the distance of the testis from the internal ring, state of the internal ring (closed or open), operative time (min), intraoperative and early postoperative complications were recorded after first stage. Surgical outcomes of both techniques included operative time, intraoperative complications, success rate, final scrotal site position, testicular size and vascularity, and these were recorded within 48h of the second stage procedure and at 6 month follow-up.

RESULTS

Staged FSLO was performed on 25 testes. Four cases were lost during follow up. Out of these 21 cases, one child had an atrophic testis before the second stage based on previously recorded operative size. SLTO was done on 20 testes. We had 2 cases of fixation suture slippage rendering a total of 18 patients who underwent second stage operation. No patients converted from laparoscopic to open surgery. At 6 month follow-up visits, 27 testes were found on examination to have a low scrotal position, (14 in the FSLO group and 13 in the SLTO group), 9 testes in high scrotal position (5 in the FSLO group and 4 in the SLTO group). Testicular ascent occurred in one patient in each group. Testicular atrophy was identified in 3 cases among the FS group, while no case of testicular atrophy occurred in the traction group of patients (p = 0.048).

CONCLUSIONS

Both staged laparoscopic techniques had comparable success rates as regard final scrotal position for high undescended IAT in children, and were associated with no intra or post operative complications. SLTO had a better outcome as it was not associated with any testicular atrophy compared to FSLO at 6 months follow up.

Acquired cryptorchidism: an unexpected consequence of inguinoscrotal lymphatic malformation treated with Eppikajutsuto

Lymphatic malformation (LM) that causes inguinoscrotal swelling is extremely rare. Surgery, sclerotherapy and pharmacotherapy have been reported as possible treatment options for LM. Recently, Eppikajutsuto (TJ-28), a traditional Japanese herbal medicine has emerged as therapeutic option for LM. We report the case of a 2-year-old boy who presented with a left inguinoscrotal swelling, which was diagnosed as retroperitoneal LM extending into the left scrotum. The surgical approach was less favourable, given the risk of damaging the testicular vasculature or the spermatic cord. Therefore, the patient received medical treatment with TJ-28. As a result, a volume reduction of 83% was obtained, as well as the unexpected consequence of the left testicle retracting into the inguinal area. Laparoscopic exploration was performed and a small bulge on the internal inguinal ring was detected. The patient's acquired cryptorchidism was subsequently treated by orchidopexy.

Rare case of traumatic bilateral testicular dislocation

Bilateral traumatic testicular dislocation is an uncommon condition and usually occurs after a direct impact on the scrotum. Herein, we report this as a rare case of a 21-year-old man presenting with bilateral traumatic dislocation of testes into the inguinal canal following a motorcycle accident. Imaging studies ruled out any other associated injuries. The patient underwent bilateral orchidopexy without any further complications.

Comparison of the perspectives of the pediatric surgeons and pediatric urologists in management of cryptorchidism in Saudi Arabia

Objectives:

To evaluate the variability in perspectives between pediatric surgeons and pediatric urologists in managing cryptorchidism.

Methods:

We conducted this survey among pediatric surgeons and pediatric urologists managing cryptorchidism in Saudi Arabia in October 2020. We distributed a questionnaire to 187 consultants using the Google forms platform. We collected data related to the consultant’s experience, preoperative management, management of nonpalpable testes, management of palpable undescended testes, management of the cryptorchidism in special situations.

Results:

The response rate was 77% for pediatric surgeons (n=77) and 46% for pediatric urologists (n=40). The number of cases managed by each specialty per year differed significantly (p=0.02); however, there was no significant difference in their experience (p=0.37). The preferred age for orchidopexy was 6-12 months for both specialties. Pediatric surgeons tend to prescribe preoperative ultrasound more frequently for nonpalpable testes (p=0.05). Laparoscopy was the preferred surgical approach by both specialties. Management of intra-abdominal testes not reaching the contralateral internal ring differed between groups (p<0.001), and it was related to the number of procedures performed annually (p=0.03). Both groups responded differently to the management of unsatisfactory testicular position after orchidopexy (p<0.001). Pediatric surgeons managed it with either observation or re-operative inguinal orchidopexy; however, most pediatric urologists preferred re-operative inguinal orchidopexy. This response was affected by the number of procedures performed annually (p=0.04).

Conclusion:

In Saudi Arabia, practicing pediatric surgeons and pediatric urologists have different perspectives in the management of cryptorchidism. The results of this survey demonstrated the need to establish national guidelines to manage patients with cryptorchidism.

Effect of adjunctive hormonal therapy on testicular descent and spermatogenic function among children with cryptorchidism: a systematic review and meta-analysis

OBJECTIVES

To systematically evaluate the effect of adjunctive hormonal therapy on testicular descent and spermatogenic function among children with cryptorchidism.

METHODS

A comprehensive literature search of electronic databases up to February 21, 2019 was performed. Continuous data of fertility indices were evaluated using weighted mean difference (WMD) with 95% confidence interval (CI), while nominal data of fertility indices and the complete descent rates were analyzed by risk ratio (RR) with 95% CI. A fixed effect or random effect model was used.

RESULTS

A total of 27 previous studies were included for the current analysis. Hormonal therapy increased complete testicular descent rate, reaching statistical significance (RR = 3.74; 95% CI, 2.78-5.04; P < 0.001). The success rate was 22.43%. A similar result was found in subgroup analysis of hormonal category and effect on unilateral or bilateral cryptorchidism. Studies reporting primary outcome as continuous data showed that cryptorchid males have significantly increased germ cell numbers per tubule (WMD = 0.10; 95% CI, 0.01-0.20, P = 0.032) after hormonal therapy. The nominal data of pooled studies showed no significant difference (RR = 1.62; 95% CI, 0.65-4.00, P = 0.298). In addition, a significant result was noted in the luteinizing hormone-releasing hormone (LHRH) therapy group but not in those undergoing human chorionic gonadotropin (hCG) treatment.

CONCLUSIONS

Our findings have demonstrated that hormonal therapy can effectively increase the success rate of complete testicular descent, while some boys may benefit as regards improvement of the fertility index.

The incidence of epididymal anomalies in the bilateral and unilateral cryptorchidism cases: A comparative study

OBJECTIVE

Our study was planned based on the hypothesis that epididymal anomalies may be more incidental and more severe in cases with bilateral undescended testicles compared to unilateral undescended cases. We also aimed to review the classifications of epididymal anomalies in the literature and to establish a simpler and clinically applicable classification in the present study.

MATERIALS AND METHODS

In this study, we retrospectively reviewed 197 pediatric patients who had been operated for undescended testis between January 2014 and January 2018. In the collective analysis of bilateral undescended testes cases, if the present anomaly were present in any testis, the anomaly was considered to be present for these cases and subjected to statistical analysis.

RESULTS

The study included a total of 241 testicles of 197 patients. The incidence of epididymal anomalies was found to be significantly higher in cases with bilateral undescended testicles compared to unilateral cases (68.2%, 43.1%, respectively; p = 0.003). It was observed that the incidence of epididymal anomaly and the severity of the anomaly statistically significantly decreased as the localization of the undescended testicle changed between the intraabdominal position and the external inguinal ring (p = 0.0001).

DISCUSSION

The effects of the undescended testicles on fertilization have been subject to evaluation in a limited number of studies and it has been reported that the rate of fertility is lower in patients with bilateral undescended testicles, whereas the fertility rate is close to that of healthy males in patients with unilateral undescended testicles. The incidence of epididymal anomalies was found to be higher in cases with bilateral undescended testicle, as shown in our study. However, based on these data, it is not possible to make a comment about whether this condition leads to infertility or not. Furthermore, accurate documentation of epididymal anomalies and standardization of the classifications of epididymal anomalies may be guiding in the prevention of complications for the surgeons in the treatment of patients who will undergo orchiopexy.

CONCLUSIONS

We concluded that the incidence of epididymal anomalies was significantly higher in cases with bilateral undescended testicles compared to unilateral cases. In our study, based on a comprehensive high-quality surgical image archive, we believe that the differentiation of epididymal anomalies according to the classification we have proposed will make it possible to create a database that is easier to use clinically in a more objective way.

Effect of Pediatric Testicular Torsion on Testicular Function in the Short Term

PURPOSE

To evaluate short-term testicular outcome after torsion in children.

METHODS

Fifty-four children and adolescents were evaluated after 6 months of the operation for testicular torsion. Testicular volume was measured and circulating Inhibin B, FSH, LH and testosterone levels were checked.

RESULTS

Delay from the onset of symptoms to surgery was shorter in the orchidopexy group (n = 47), than in the orchiectomy group (n = 7, p = 0.001). In the orchidopexy group, the median volume of the affected testis was 83% (IQR 43-104) of the contralateral testis (p = 0.002). The plasma hormone levels in orchidopexy and orchiectomy groups were: 148 ng/l (IQR 108-208) vs. 129 ng/l (IQR, 123-138, p = 0.269) for Inhibin B; 4.5 IU/L (IQR2.6-6.9) vs. 11.7 IU/L (IQR 4.3-12.8, p = 0.037) for FSH; 2.9 IU/L (IQR 1.3-3.7) vs. 4.8 (IQR 3.0-5.6, p = 0.066) for LH; and 13.6 nM (IQR 6.5-18.0) vs. 14.5 nM (IQR 6.7-15.9, p = 0.834) for testosterone. The association between FSH, LH as well as testosterone levels was most clear with the volume of the contralateral testis (Rho = 0.574, p < 0.001, Rho = 0.621, p = 0.001 and Rho 0.718, p < 0.001 respectively).

CONCLUSIONS

Testicular function is mainly dependent on the volume of contralateral testicle after testicular torsion. However, testis preserving surgery tends to maintain better function than orchiectomy.

TYPE OF STUDY

Retrospective review.

LEVEL OF EVIDENCE

III.

[Laparoscopic orchiopexy for inguinal palpable cryptorchidism]

OBJECTIVE

To investigate the feasibility and advantages of laparoscopic orchiopexy in the treatment of inguinal palpable cryptorchidism.

METHODS

This study included 773 cases of inguinal palpable cryptorchidism with 869 undescended testes, 218 on the left, 459 on the right and 96 bilaterally. The patients were aged 6 months to 8 years, averaging 20 months. The surgical procedures involved cutting open the posterior peritoneal wall with the ultrasonic scalpel, dissecting the spermatic cord close to the inferior pole of the kidney, separating the posterior peritoneum from the vas deferens, severing the testicular gubernaculum, pulling the testis back into the abdominal cavity and, with the vas deferens protected, bringing the testis down into the scrotum and getting it fixed.

RESULTS

All the operations were successfully performed, with an average operation time of 34.8 ± 5.4 minutes and no conversion to open surgery. Ipsilateral patent processus vaginalis was found in 692 (89.5%) of the 773 cases, and contralateral concealed hernia in 233 (34.4%) of the 677 cases of unilateral cryptorchidism, which were all treated by high ligation of the hernial sac. There was no subcutaneous emphysema intraoperatively or vomiting, abdominal distension, wound bleeding and obvious pain postoperatively. The patients were followed up for 6 to 18 months, during which, regular Doppler ultrasonography revealed that the testes were located in the scrotum with no testicular retraction and atrophy, inguinal hernia or hydrocele.

CONCLUSIONS

Laparoscopic orchiopexy is safe and effective for the treatment of inguinal palpable cryptorchidism, and meanwhile can be used for the detection and management of contralateral concealed hernia and the prevention of metachronous inguinal hernia.

Testicular torsion in a newborn: a case report

Discovery of an apparent scrotal mass is a non common entity in neonates. Testicular torsion is rare in newborn infants and is an urologic emergency that requires emergency surgical management. We present a rare case of testicular torsion in a neonate.

Children with Cryptorchidism Complicated by Testicular Torsion: A Case Series

OBJECTIVE

To investigate the clinical features, diagnosis, treatment and prognosis of children with cryptorchidism complicated by testicular torsion.

METHODS

The clinical data of 6 children with cryptorchidism complicated by testicular torsion admitted to our hospital from December 2000 to December 2016 were analyzed retrospectively.

RESULTS

All 6 children were diagnosed with cryptorchidism by surgery, their age was from 12 days up to 11 years, and the average time between onset of symptoms and diagnosis was 20.5 h. Torsion testis was located in the groin area and the rate of left to right was about 2:1. Twist was 600° on average. All children were admitted because of the inconsolable cry, abdominal pain, and the swelling of the groin. Three patients underwent orchidectomy, while the other 3 patients underwent detorsion and cryptorchidopexy. Color Doppler ultrasound examination showed normal testes at 6 months after operation. Only 1 case was diagnosed with cryptorchidism after birth.

CONCLUSIONS

Cryptorchidism is an emergency in pediatric urology and often leads to a low testicular salvage rate, especially in infants, due to lack of knowledge, delayed diagnosis, and late treatment. Neonatal genital examination is important for the early diagnosis and management of cryptorchidism.

Transverse testicular ectopia associated with persistent Müllerian duct syndrome treated by transseptal orchiopexy: A case report

RATIONALE

Persistent Müllerian duct syndrome (PMDS) is rare form of male pseudohermaphroditism characterized by the presence of uterus and fallopian tubes with normal external genitalia and secondary sexual characteristics. Transverse testicular ectopia (TTE) is also a rare form of testicular ectopia that may be associated with PMDS.

PATIENT CONCERNS

We present a 2-year-old boy who presented with bilateral non-palpable testes with left inguinal mass.

DIAGNOSIS

TTE with PMDS.

INTERVENTIONS

On exploration, both testes were present in the left inguinal region. Uterus and fallopian tubes were located between the testes. A hysterectomy was perfomed with resection of the underdeveloped fallopian tubes. Bilateral orchiopexy was performed by placing both gonads into subdartos pouches in each scrotum with transseptal approach.

OUTCOMES

Both testes were palpable in both the scrotum at 1-year postoperative follow-up and we are planning a regular follow-up.

LESSONS

In case of TTE with PMDS, optimal surgical approach with orchiopexy and excision of Müllerian duct should be needed. A long-term postoperative follow-up is necessary for assessment of malignant transformation and infertility.

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

PURPOSE

We evaluated the role of initial laparoscopy and optimized approach in cases of unilateral nonpalpable testis.

METHODS

Seventy-four patients with nonpalpable testes were presented. We excluded 9 patients, with palpable testes under anesthesia. Laparoscopy was offered to 65 patients. Contralateral testis hypertrophy with length ≥ 1.8 cm was confirmed in 47 patients. Ultrasound results were available for 35 patients.

RESULTS

Age ranged from 1 to 10 years. Of 65 nonpalpable testes, right side comprised 23 (35.4%) and the left 42 (64.6%). Laparoscopy revealed intra-abdominal testis in 18 patients (27.7%), blind-ending vessels and vas in 8 (12.3%), and vas and vessels traversing the internal ring in 39 (60%). Treatment of intra-abdominal testes included Fowler-Stephens orchiopexy in 7 patients, laparoscopic orchiopexy in 9, and laparoscopic orchiectomy in 2. In 8 patients with blind-ending vas and vessels, laparoscopy was terminated. In 39 patients with vas and vessels traversing the internal ring, scrotal exploration was performed in 36 patients with closed internal ring and inguinal exploration in 3 with open internal ring. Vanished testes were present in 43/47(91.5%) of patients with contralateral testis hypertrophy ≥ 1.8 cm. Ultrasound detected the presence of a testis in only 4/11 (36.3%) of patients, although it could not identify vanished testis.

CONCLUSIONS

Initial laparoscopy should be retained as one of the standard treatment for nonpalpable testis. It was the only required modality in 26 patients (40%) and optimized further treatment in 39 patients (60%) by evaluation of the condition of the internal ring.

[Cerebellar infarct following orchidopexy under spinal anesthesia]

The report describes a case of peri-operative stroke that presented as diplopia and gait difficulty on 2nd post-operative day after routine orchidopexy under spinal anesthesia in an otherwise healthy young boy. Magnetic resonance imaging of the brain revealed acute infarct in bilateral cerebellar hemispheres, left half of medulla and left thalamus. A diagnosis of acute stroke (infarct) was made and patient was started on oral aspirin 75mg.day^-1, following which his vision started improving after 2 weeks. Possible mechanisms of development of stroke in the peri-operative period are discussed, but, even after extensive investigations, the etiology of infarct may be difficult to determine. Acute infarct after elective non-cardiac, non-neurological surgery is rare; it may not be possible to identify the etiology in all cases. Clinicians must have a high index of suspicion to diagnose such unexpected complications even after routine surgical procedures in order to decrease the morbidity and long term sequelae.

Advances in paediatric urology

Paediatric urological surgery is often required for managing congenital and acquired disorders of the genitourinary system. In this Series paper, we highlight advances in the surgical management of six paediatric urological disorders. The management of vesicoureteral reflux is evolving, with advocacy ranging from a less interventional assessment and antimicrobial prophylaxis to surgery including endoscopic injection of a bulking agent and minimally invasive ureteric reimplantation. Evidence supports early orchidopexy to improve fertility and reduce malignancy in boys with undescended testes. A variety of surgical techniques have been developed for hypospadias, with excellent outcomes for distal but not proximal hypospadias. Pelvi-ureteric junction obstruction is mostly detected prenatally; indications for surgery have been refined with evidence, and minimally invasive pyeloplasty is now standard. The outlook for patients with neurogenic bladder has been transformed by a combination of clean intermittent catheterisation, algorithms of diagnostic investigations, and innovative medical and surgical therapies. Posterior urethral valves are associated with considerable mortality; fetal diagnosis allows stratification of candidates for intervention, but ongoing bladder dysfunction in patients after valve ablation remains a cause of long-term morbidity.

[Orchidopexy increases the levels of serum anti-Müllerian hormone and inhibin B in cryptorchidism patients]

OBJECTIVE

To investigate the levels of serum anti-Müllerian hormone (AMH) and inhibin B (INHB) in patients with unilateral cryptorchidism before and after orchidopexy.

METHODS

This study included 58 cases of unilateral cryptorchidism treated by orchidopexy and 32 healthy controls. Before and at 6 months after surgery, we measured the length and circumference of the penis, the volume of the undescended testis, and levels of serum AMH and INHB.

RESULTS

There were statistically significant differences between the unilateral cryptorchidism and healthy control groups in the levels of serum AMH (［102.80 ± 17.35 vs 108.76 ± 13.64］ ng/ml, P<0.05) and INHB (［70.24 ± 5.73］ vs ［ 77.72 ± 5.94］ pg/ml, P<0.05) at the baseline, but not at 6 months after orchidopexy (AMH: ［109.76 ± 17.25］ vs ［108.03 ± 14.13］ ng/ml, P>0.05; INHB: ［75.76 ± 5.94］ vs ［77.63 ± 5.99］ pg/ml, P>0.05). No remarkable differences were observed between the unilateral cryptorchidism and healthy control groups in the preoperative penile length (［2.05 ± 0.23］ vs ［2.11 ± 0.22］ cm, P>0.05), penile circumference (［3.91 ± 0.23］ vs ［3.99 ± 0.20］ cm, P>0.05) and volume of the undescended testis (［0.45 ± 0.02］ vs ［0.46 ± 0.02］ ml, P>0.05), or in the postoperative penile length (［2.09 ± 0.23］ vs ［2.16 ± 0.22］ cm, P>0.05), penile circumference (［4.00 ± 0.25］ vs ［3.98 ± 0.19］ cm, P>0.05) and volume of the undescended testis (［0.45 ± 0.02］ vs ［0.45 ± 0.02］ ml, P>0.05). Compared with the baseline, the cryptorchidism patients showed markedly increased levels of serum AMH (［102.80 ± 17.35］ vs ［109.76 ± 17.25］ ng/ml, P<0.05) and INHB (［70.24 ± 5.73］ vs ［75.76 ± 5.94］ pg/ml, P<0.05) after orchidopexy.

CONCLUSIONS

Orchidopexy can elevate the levels of serum AMH and INHB and protect the testicular function of cryptorchidism patients.

Testicular Ischemia Caused by Incarcerated Inguinal Hernia in Infants: Incidence, Conservative treatment procedure, and Follow-up

PURPOSE

Testicular ischemia and necrosis, especially in the infant age, may result from incarcerated inguinal hernia. Duration of ischemia is a significant factor for the affected testicle. We aimed to present a case series on the conservative management in the testicular ischemia caused by incarcerated inguinal hernia.

MATERIALS AND METHODS

Inguinal hernia repairs performed in between March 2009 and December 2014 were investigated retrospectively. Patients' characteristics, hernia side, incarceration, testicular ischemia and complications were recorded. Color Doppler ultrasonography was performed in the incarcerated inguinal hernia patients preoperatively and was repeated on 3 and 7 days and then at 1, 3 and 6 months postoperatively. The testicle sizes, volumes, and arterial flow patterns of them were recorded at the same time.

RESULTS

Total 785 inguinal hernias were treated in 738 male patients, ranging from 18 days to 16 years. From all male patients, 44 (5.9%) had the IIH. There were 16 (36.3%) irreducible hernias in 44 incarcerated hernia patients. Of these 16, testicular ischemia was determined in 9 (56.2%) infants with the irreducible incarcerated hernia. Orchidopexyprocedure was performed in these patients. Testicular atrophy was occurred in two patients (22.2%). In the others, testicular volumes and perfusions were normal during follow-up (mean 8.3 &plusmn; 2.2 months).

CONCLUSION

Testicular ischemia resulting from incarcerated inguinal hernia may be treated conservatively without orchiectomy for the ischemic testicle and testicular ischemia may be followed with color Doppler ultrasound for atleast 6 months. The inguinal hernia repair in infants should be subject to urgent surgery rather than elective surgery. So, the testicular ischemia in infants with the inguinal hernia will be an avoidable complication.

Age at referral for undescended testes: has anything changed in a decade?

AIM

Undescended testis (UDT) affects 1-6% of males and is one of the most common disorders in paediatric surgery.Updated consensus guidelines now recommend surgical management of UDT by 18 months. We compare the age at referral and subsequent timing of orchiopexy with data published from 1996-1998 at our institution, prior to the advent of updated guidelines.

METHODS

A retrospective review of all patients undergoing an orchiopexy for UDT from 2014 to 2016 was conducted. The age at time of first referral, first outpatient review and age at date of surgery were recorded. Calculations were made for time between referral and clinic visit (T-1) and between clinic visit and surgery (T-2). Data are reported as median (range).

RESULTS

In the 2014-2016 group (n=216), the median age at time of referral was 5.3 (range 0-182) months. Following referral, children were seen in the clinic at a median interval 1.84 (T-1: range 0.16-17) months. The median interval between the clinic visit and operation was 2.95 (T-2: range 0-30.7) months. The median age at time of surgery was 12.6 (range 4.6-191.3) months. Compared to the data from 1996-1998 (n=325), there was a drop in the median ages both at time of referral (23 months vs 5.3) and at time of operation (38.8 months vs 12.6). In this cohort, 66% (n=143) of boys had surgery before eighteen months of age. The median times between referral and clinic visit (T-1: 1.7 months vs 1.84) and between clinic and operation (T-2: 3.3 months vs 2.95) were essentially unchanged.

CONCLUSION

Our second snapshot in time (2014-2016) shows improvements in median age at referral (under six months) and age at time of operation (at 12.6 months) when compared to the older snapshot (1996-1998). These timings are more in keeping with recommendations for orchiopexy.

Intermittent Testicular Torsion in Adults: An Overlooked Clinical Condition

OBJECTIVES

The aim of this study was to describe the management protocol for intermittent testicular torsion (ITT) in adults and report the outcome of this clinical condition, which is commonly overlooked in adults.

SUBJECTS AND METHODS

Sixty-three patients were included in the study. The inclusion criterion was the presence of sudden intermittent testicular pain over a duration of 3 months. All the patients underwent clinical examination, urine analysis, culture, and scrotal ultrasound with Doppler. The testicle was in an abnormal or in transverse lie and/or could easily be twisted. Scrotal support and analgesia were given for 1 month, then patients were offered orchidopexy or conservative treatment. Nineteen patients chose orchidopexy while 44 chose conservative treatment. Follow-up ranged from 3 months to 2 years. The improvement was assessed using a visual analog pain score. The outcome of the treatment was compared between the surgical and conservative groups using a χ2 test.

RESULTS

The median age of the patients was 28 years (range: 17-50). Of the 19 patients who underwent orchidopexy, the pain resolved or visual analog pain scores improved (median 1/10) in 18 (94.7%) cases. On the other hand, 21 of the 44 (47.7%) cases that chose the conservative approach claimed their pain resolved or improved (visual analog pain scores: median 3/10) with a median of 13 months of follow-up.

CONCLUSION

In this study, scrotal orchidopexy proved to be superior to conservative measures in cases of ITT in adults.

[Long-term evolution of detorsion of the testes after acute scrotum]

OBJECTIVES

To assess the long-term evolution of the testicles preserved after testicular torsion (TT).

MATERIAL AND METHODS

We realized a prospective study by ultrasound of patients diagnosed TT that underwent orchidopexy. We reviewed 85 patients treated for acute scrotum (2004-2014), finding 49TT. We excluded from the study 15 perinatal torsions, 14 orchiectomies and 5 patients who refused to participate. We analyzed 15 patients, comparing testicular volumes between affected and contralateral testes, and the difference in volume between the two testes of the 15 cases with 14 control patients (Mann-Whitney U test).

RESULTS

15 patients underwent surgery at a mean age of 10,7 years, with an average time of 6 hours evolution [0,7-24]. The control ultrasound was performed at a mean age of 14,7 years, after a mean time of 47 months after the episode, finding a medium volume of the affected and contralateral testicle of 9,3 cc and 12,6 cc, respectively (p = 0,683). The median of the difference between the volumes was 0'8 cc [0,1-12,80]. In the control group, ultrasounds were performed at a mean age of 16 years, with an average volume of 6,64 cc on right testicle and 6,26 cc on the left, and median volume difference of 0,34 cc [0,05-4,59]; with no statistically significant difference (p = 0,270) between testicular volume differences of cases and controls.

CONCLUSION

Testicular orchidopexy in patients with TT with less than 6 hours of evolution does not affect the long-term testicular growth, compared with the contralateral testis growth and testes of the normal population.

[Impact of unilateral cryptorchidism on the levels of serum anti-müllerian hormone and inhibin B]

OBJECTIVE

To investigate the influence of unilateral cryptorchidism on the levels of serum anti-müllerian hormone (AMH) and inhibin B in children.

METHODS

We enrolled 65 patients with unilateral cryptorchidism and 45 healthy children in this study. We measured the length and circumference of the penis, the testis volume in the cryptorchidism side, and the levels of serum AMH and inhibin B at the age of 6 and 12 months, respectively.

RESULTS

Compared with the healthy controls, the patients with unilateral cryptorchidism showed significant decreases at 12 months in serum AMH (［108.06±12.40］ vs ［103.26±17.57］ ng/ml, P<0.05) and inhibin B (［77.43±5.66］ vs ［70.21±5.69］ pg/ml, P<0.05). No statistically significant differences were found in the length and circumference of the penis and the testis volume in the cryptorchidism side at 6 and 12 months (P>0.05), or in the levels of serum AMH and inhibin B at 6 months (P>0.05).

CONCLUSIONS

Unilateral cryptorchidism affects the gonadal function of the patient, and orchiopexy should be timely performed in order to reduce its impact.