INSL3 and LGR8 expressions in perididymis and gubernaculum of patients with unilateral cryptorchidism

To study the effect of diethylstilbestrol (DES) at different doses on transabdominal testicular descent in rats and the expression of INSL3 in the testis and HOXA10 in the gubernaculum. Fifty E13.5 (embryonic day 13.5) pregnant female SD rats were randomly divided into five groups that received a subcutaneous injection of DMSO, 2.5, 5.0, 10.0 and 20.0 mg/kg DES (group A, B, C, D and E), respectively. Male offspring were killed at E19.5, and then fetal mortality, the degree of transabdominal testicular ascent (DTA) was determined by a stereomicroscope. The mRNA expressions of INSL3 in the testis and HOXA10 in the gubernaculum were determined by RT-PCR. The expression of INSL3 protein was determined by Western blotting. Male fetal mortality in group A, B, C, D, and E were 3.57%, 6.90%, 12.00%, 19.23% and 36.36%, respectively, which showed a dose-effect relationship between DES and the male fatal mortality (r=0.999, P<0.01). DTA in group B, C, D and E were (23.7+/-1.7) U, (38.8+/-1.9) U, (49.3+/-1.8) U and (58.6+/-2.1) U that were significantly larger than that in group A [(8.5+/-1.3) U] (q=46.12, 88.53, 120.44 and 141.37, respectively, P<0.01). There was also a dose-effect relationship between DES and DTA. In group B, C, D, and E, the expression of INSL3 mRNA were 0.9570+/-0.1490, 0.6760+/-0.1380, 0.0170+/-0.0040 and 0.0013+/-0.0003, respectively; the expressions of INSL3 protein were 0.8360+/-0.1520, 0.5310+/-0.1070, 0.0140+/-0.0020 and 0.0011+/-0.0003, respectively, which were significantly larger than the expression of INSL3 mRNA (1.801+/-0.126) and INSL3 protein (1.612+/-0.134) in group A (qmRNA=40.4840, 52.4402, 83.1585 and 82.0582, respectively, and qprotein=38.6151, 52.2747, 77.2756 and 76.1983, respectively, P<0.01). The expression of HOXA10 mRNA in group A, B, C, D, and E were 0.945+/-0.125, 0.940+/-0.119, 0.656+/-0.115, 0.544+/-0.118 and 0.463+/-0.114, respectively. Compared with the expression of HOXA10 mRNA in group A, the expression of group B was not significantly different (q=0.2213, P>0.05), those in other groups were down-regulated significantly (q=12.4304, 17.2477 and 20.2789, respectively, P<0.01). DES inhibited transabdominal testicular descent dose-dependently via down-regulating the expression of INSL3. HOXA10 may play no role in low-dosage DES induced intra-abdominal cryptorchidism, but down-regulated HOXA10 mRNA was involved in high-dosage DES induced ones.

Objective To evaluate the advantages and surgical experience of laparoscopic internal loop ligation in treatment of recurrent indirect indirect inguinal hernia in children. Methods From January 2013 to January 2018, a total of 34 children with recurrent indirect inguinal hernia admitted to the Guangzhou Women and Children′s Medical Center were selected as research subjects. Clinical cases data were analyzed retrospectively. According to the surgical treatment adopted this time, they were divided into laparoscopic group (n=19, by laparoscopic internal loop ligation) and open surgery group (n=15, by high ligation of hernia sac). Independent-samples t test and chi-square test were used to compare the general clinical data, intraoperative and postoperative situation between two groups of children. This study was in line with World Medical Association Declaration of Helsinki revised in 2013. All guardians of the children signed informed consents for surgery before surgery. Results ①There were 3 patients developed scrotal hematoma, and 1 patient developed iatrogenic cryptorchidism after operation in open surgery group. None of the other complications such as wound infection, testicular atrophy, scrotal hydrocele and recurrence occurred in two groups. ②There were no significant differences between two groups in the proportion of male children, age and the proportion of laparoscopic surgery for the first time (P>0.05). The duration operation, intraoperative blood loss volume, duration of hospital stay and postoperative complication rate in laparoscopic group were (30.0±10.7) min, (1.0±0.3) mL, (1.2±0.4) d, and 0, respectively, which were shorter or less than those of (44.7±24.5) min, (2.3±1.3) mL, (3.3±1.0) d and 26.7% in open surgery group; while the hospitalization costs of (7 547±820) yuan in laparoscopic group was higher than that of (5 488±1 218) yuan in open surgery group, and these differences were statistically significant (t=-2.347, P=0.044; t=-3.859, P=0.002; t=-8.171, P<0.001; P=0.029; t=5.580, P<0.001). Conclusions Laparoscopic internal loop ligation for the treatment of recurrent inguinal hernia in children has the advantages of safe and effective, good intraoperative condition and less postoperative complications, but the hospitalization cost was higher. Key words: Laparoscopes; Hernia, inguinal; Recurrence; Ligation; Child

Objective To access the long term fertility after orchidopexy in children with unilateral or bilateral cryptorchidism through analysis of fertility rate and semen evaluation. Methods Between October 1981 and November 1997, totally 342 cases of cryptorchidism underwent orchidopexy procedure in our centre, and the follow up study was conducted. The procreation status among married patients and semen analysis for unmarried patients were targeted to investigate their fertilities. The clinical information was collected through mail, telephone and subsequent visit. Results Complete clinical information could be collected in 49 (14.3％) of all populations, in which unilateral cryptorchidism was found in 33 cases and bilateral ones in 16 cases. Among married patients the fertility rate was 92.9％ in unilateral cases, while 37.5 ％ in bilateral ones. For those patients whose wives gave birth, the mean time of planned pregnancy was 3 months in unilateral cases, and 6.3 months in bilateral ones. While for infertility patients, semen from 4 cases was already normal after drug treatment, in which 3 patients' wives already gave birth. Among unmarried populations, normal rate of semen in unilateral cryptorchidism was 84.2％ and 25％ in bilateral ones. The abdominal cryptorchid could be found in 66.7 percent of in bilateral cryptorchidism with abnormal semen. Conclusions Long term fertility in children with unilateral cryptorchidism is similar with the normal ones, while fertility rate and normal semen in bilateral ones are significantly lower than unilateral ones after surgery. Compared with the unilateral ones, the planned pregnancy time for bilateral ones are long. Part of infertility has fertility potential after drug treatment. The semen in bilateral abdominal cryptorchid is more likely to be abnormal. Key words: Cryptorchidism; Orchidopexy; Semen analysis; Fertility rate

Objective To explore the influence of oblique inguinal hernia on testicle volume and serum inhibin B (Inh B) in children under 2 years old. Methods 127 patients with left oblique inguinal hernia were set as hernia group, 132 patients with cryptorchidism was set to cryptorchidism group, and 185 normal children with similar age with children in above groups were control group. The children in each group were divided into two subgroups (6-12 months subgroup and 13-24 months subgroup) according to differential age. The testicle volume and Inh B level were tested in various subgroups. Results ①Comparison of serum Inh B level:in 6-12 months subgroup InhB level in control group, hernia group and cryptorchidism group was respectively 196.90 ± 22.78 pg/ml, 114.69 ±102.87 pg/ml and 70.50 ± 54.09 pg/ml. Compared with control, both hernia and cryptorchidism group had lower level (P＜0.01). The level in cryptorchidism group were much lower than hernia group; in 13-24 months subgroup Inh B level of control, hernia group and cryptorchidism group was respectively 175.99 ± 22.83 pg/ml, 72.00 ± 48.02 pg/ml and 66.01 ± 38.92 pg/ml. Compared with control, both hernia and cryptorchidism group had lower level (P＜0.01 ). No difference between hernia and cryptorchidism group was seen (P =0.37). ② The course of disease in 13-24 months subgroup in hernia group was 9.2 ± 5.2months, which longer than that in 6-12 months subgroup 5.1 ± 2.6months(P＜0.01 ). ③6-12 month subgroup:The correlation between Inh B level and course of disease in hernia group was not significant, but in 13-24 months subgroup(r =-0.272, P =0.019). It showed longer course of disease and lower Inh B level. ④6-12 months subgroup:The left testicular volume in hernia group(0.48 ± 0.18 cm3 ) was larger than the right side (0.38 ± 0.17 cm3 ) (P =0.019) and control group(0.39 ± 0.16 cm3 ) (P =0.038), but the right testicular volume in hernia group was smaller than the right side in control group (. 45 ± 0.20 cm3 ) (P =0.105). In 13-24months subgroup:no difference could be noted among left and right as well as normal testicular volume. Conclusions Oblique inguinal hernia can contribute to testicular enlarge in earlier stage and reduce the serum Inh B level, furthermore, present negative correlation with course of disease. There fore, the patients with oblique inguinal hernia should undergo surgery in relatively earlier time. Key words: Hernia, inguinal; Inhibin B; Testis

Objective To improve the understanding of the implications of testicular microlithiasis(TM) in paediatric patients by summarizing the clinical characteristics of TM. Methods One hundred and eighteen boys diagnosed as TM based on ultrasound between March 2006 and December 2014 at Shengjing Hospital Affiliated to China Medical University were retrospectively reviewed.Demographic data, imaging data, indications for ultrasound, associated inguinoscrotal pathologies and follow-up data were collected. Results There were 118 cases of patients aged from 0.25 to 14.00 years(averaging 7.98 years). The indication for ultrasound included health check(22 cases), testicular discomfort(28 cases), small testes(6 cases), scrotal mass(10 cases), with history of cryptorchidism(36 cases), with history of hydrocele(15 cases). Concomitant diseases included congenital anomaly of testis in 44 cases[cryptorchidism(34 cases), testicular absence(4 cases), testicular hypoplasia(6 cases)], hydrocele of tunica vaginalis or hernia(15 cases), testicular epididymitis(12 cases), varicocele(6 cases), epididymal cyst(5 cases), testicular teratomas(2 cases), adrenal cortical hyperplasia(1 case), testicular torsion(1 case), and none associated disease(32 cases). Bilateral TM was in 87 cases(the typical TM in 38 cases, limited TM in 49 cases), while unilateral TM was in 31 cases(the typical TM in 8 cases, limited TM in 23 cases). Fifty-three cases were followed up for 1 month to 36 months(averaging 12.5 months), and the condition was stable, no testicular malignancy was observed during follow-up. Conclusions The TM in children is not a rare disease.The etiology of TM is not clear and there are no special clinical symptoms.TM is often associated with testicular abnormality in pediatric patients and the correlation between children′s TM and adult testicular tumor can not be determined yet.The distribution and involving degree of TM is stable in the short term with infrequent testiculoma, but an appropriate follow-up scheme is required, especially during and after puberty. Key words: Child; Testis; Microlithiasis; Sonography

Objective To explore the value of laparoscopy in the diagnosis and treatment of recurrent inguinal hernia in children. Methods The clinical data of 67 cases receiving laparoscopic treatment for recurrent inguinal hernia in children at the Department of General Surgery, Wuhan Children′s Hospital, Tongji Medical College, Huazhong University of Science & Technology were retrospectively analyzed, including the type of hernia recurrence, operation time, intraoperative and postoperative complications, such as short-term hydrocele formation and testicular atrophy and so on. Results In 67 cases, there were 65 males and 2 females.Open repair surgery and laparoscopic surgery were respectively performed in 48 cases and 19 cases for the first operation and the hernia defects were found after operation.Contralateral patent vaginal process deformities were found in 11 sides in the reoperation.Among 67 cases of recurrent inguinal hernia, incomplete ligation of hernia sac was found in 21 cases, low level ligation of hernia sac in 17 cases, no ligation of hernia sac in 14 cases, omissive direct inguinal hernia in 4 cases, loose ligation of hernia sac in 4 cases, overlarge inner ring in 4 cases, weak abdominal muscles in 2 cases, and increased abdominal pressure (long-term constipation, asthma) in 1 case.All the patients were treated by laparoscopic hernia repair and no serious complications occurred during the operation.The average time of unilateral operation was (15.0±2.2) minutes (13-25 minutes), and bilateral operation was (27.0±4.3) minutes (18-41 minutes). All patients were discharged on the second day.Two patients showed short-term postoperative hydrocele and were cured with conservative treatment.During the follow-up time of (23±2) months (9-39 months), no recurrence or testicular atrophy was found. Conclusions Laparoscopy can confirm the type of recurrent inguinal hernia and contribute to reduce postoperative recurrence.Laparoscopic management of recurrent inguinal hernia in children is safe and feasible, which is expected to replace open hernia repair. Key words: Laparoscopy; Recurrent inguinal hernia; Technical improvement; Child

Objective To investigate the effect of single-arch laparoscopic combined with self-made spring clip line with arc wire feeding needle and thread needle in the treatment of traffic hydrocele. Methods From May 2013 to February 2017, 130 cases of traffic hydrocele were collected, aged between 1 and 8 years, with an average age of 2.3 years. Among them, 25 cases of lateral scabbard (hernia) were combined, and all cases were selected for laparoscopic single-hole method combined with wire needle and pin for the scabbard high ligation, and the therapeutic effect was observed. Results All the 130 cases were successful, with one side operation time (5.0±1.5) min and bilateral operation time (12.0±1.8) min. There was no obvious bleeding in the operation, no blood vessels in the abdominal wall, no vasectomy and vasectomy, no cases of transshipment. There was no obvious pain in the children with 6 h after surgery. No postoperative complications such as scrotal hematoma, iatrogenic cryptorchidism, reactivity of line junction, prodding hernia, and testicular atrophy occured. Postoperative 1-2 d, all patients was discharged and no recurrence was observed for 3-24 months. Conclusions By umbilical single-arch laparoscopic combined with self-made spring clip line with arc wire feeding needle and thread needle in the treatment of traffic hydrocele, the clinical curative effect is significant, and the apparatus is simple and easy to operate, and the trauma is small, the recovery was quick, and no scar, and it can discover and deal with unclosed (hernia) of the scabbard.The method is worthy of clinical popularization and application. Key words: Testicular Hydrocele; Laparoscopy

We measured the testis volume of patients with unilateral cryptorchidism preoperatively and compared with a unilateral hydrocele testis to assess testicular development in these patients. The present study included 129 children (ranging in age from 10 months to 5 years) with unilateral cryptorchidism who were treated from 2000 to 2006 at our institution. We evaluated the correlation between testicular volume and the location of testes or the age of these children. We also examined the testicular volume of 50 children with unilateral hydrocele testis (range, 8 months to 5 years). There was no difference in testicular volume among each position of the undescended testis. The volumes of both undescended testes and hydrocele testes did not change until 5 years of age. There was a significant difference in testicular volume between undescended and hydrocele testes. The average testicular volume of cryptorchidism is significantly smaller than that of hydrocele testes both under and over 2 years old. From the viewpoint of undescended testicular volume, cryptorchid children should be operated on as early as possible.

Objective To explore the necessary of closure of the internal ring for cryptorchidism complicated with ipsilateral indirect inguinal hernia. Methods Clinical data of 50 children with cryptorchidism complicated with ipsilateral indirect henia from June 2009 to May 2016 were analyzed in this study. All the cases underwent laparoscopic orchiopexy. All testes after complete mobilization were pulled down into the scrotum through the inguinal canal. No suture was applied to close the internal ring. The operative duration, profile of testicular descending and complication were assessed. Results Patent processus vaginalis was found in all 50 cases. There were 39 cases with inguinal canal cryptorchidism, 11 cases with intra-abdominal cryptorchidism. The mean operative time was 72 minutes. Primary orchidopexy was performed in all cases. The median follow up of all cases was 3 years (9 months to 6.5 years). There were 3 cases of testicular retraction to the top of the scrotum. No case was found recurrence of a hernia in ultrasound examination. Conclusion Laparoscopic orchidopexy is a safe and effective approach for children with cryptorchidism complicated with ispilateral indirect hernia. The closure of internal ring may not be necessary. Key words: Laparoscopy; Cryptorchidism; Indirect inguinal hernia; Internal ring

Objective To describe single-port laparoscopic internal ring closure combined with the ipsilateral medial umbilical fold flap (MUFF) cover using a two-hooked core needle. Methods Fifty-nine children with huge inguinal hernias were encountered MUFF reinforcement after laparoscopic percutaneous extraperitoneal closure (LPEC). Under single-port laparoscopic vision, an inner two-hooked needle with a non-absorbable suture was inserted at abdominal transverse striation closed to hernia ring and was readily kept in an identical subcutaneous path. The hernia ring was ligated using the hydrodissection technique. Afterwards, the needle with another non-absorbable suture was inserted at identical subcutaneous path and the suture was left after penetrating the ipsilateral medial umbilical fold, then the needle was re-introduced into abdomen through lateral extraperitoneal space and the suture at bottom of medial umbilical fold was grabbed and extracorporeal ligated. The closed orifice area was additionally reinforced due to MUFF cover. Results In Fifty-nine children, A total of 65 huge inguinal hernias (including three previous recurrences and one complex hernia) were successfully completed LPEC with additional MUFF reinforcement. In which, 16 cases were found contralateral patent processus vaginalis needed to have LPEC. Mean operating time for unilateral and bilateral repairs were (11.2 ± 2.2)min and (15.8 ± 2.7)min respectively. There were no recurrence, iatrogenic cryptorchidism or testicular atrophy postoperative except for one hydrocele formation and two suture granulomas. Conclusions Single-port LPEC with MUFF reinforcement using a two-hooked core needle is safe and feasible, as a handy technique with invisible scar has proved to be a safe and effective approach and is therefore a worthy option in treatment of pediatric huge inguinal hernia. Key words: Huge inguinal hernia; Single-port laparoscopy; Two-hooked core needle; Internal ring closure; Medial umbilical fold

Objective To observe the clinical effect of hydrocele of testis treated by single port laparoscopic percutaneous extraperitoneal processus cerclage. Methods Selected 60 male children with hydrocele of tunica vaginalis from January 2014 to March 2015 as the objects, and they were randomly divided into two groups, with 30 cases in each group. Observation group: the 30 patients were treated by open operative high ligation of sheath of transverse cutting. Treatment group: the 30 patients were treated by single port laparoscopic percutaneous extraperitoneal processus cerclage. Compared the operation situation, mainly included the time of operation, length of incision and amount of bleeding of the unilateral and bilateral. Observed the contralateral occult inguinal indirect hernia, no open processus vaginalis, hydrops reflux by itself, extruding reflux and the situation of tapping of them. Compared the hospitalization condition of the two groups, which mainly included hospital stays, operation fee of anesthesia and total cost of treatment. At the sametime, the incidence of complications between the two groups were observed. Results There was no significant difference in the aperation time between the two groups (P>0.05). The operation time of the treatment group was less than the bilateral operation observation group, and the length of incision of the treatment group was shorter than that of the lonhtrol group, the amount of bleeding was less than that of the control group, there were significant differences (P 0.05). The operation fee of anesthesia and total cost of the treatment group was higher than control group, there were significant difference (P 0.05), and they had rehabilitation after expectant treatment. Conclusions It has very high application value of hydrocele of testis treated by single port laparoscopic percutaneous extraperitoneal processus cerclage, and with the advantage such as less trauma, lower bleeding and faster prognosis after operation, so it is worthy of promotion. Key words: Hydrocele of tunica vaginalis; Laparoscope; Single port laparoscopic percutaneous extraperitoneal processus cerclage; Clinical effect

From July 1994 to July 1996, 29 men with scrotal diseases and one normal volunteer, all aged 11 to 79 years, underwent MRI examination and previous ultrasonographic (7.5 MHz) study. A GE Signa 1.5-T system and surface coil were used to obtain T1-and T2-weighted images. Gadolinium diethylenetriamine pentaacetic acid (GD-DTPA) was applied for image enhance-ment. Among the patients, 6 were with inflammation, 5 with undescending testes, 5 with ischemic testicles, 3 with intratesticular tumors, 1 with an extratesticular tumor, 3 with traumatic scrotums, 3 with varicoceles, and 1 each with hydrocele, hernia and vascular disease. Ultrasonic localiza-tion made 90% accuracy rate in diagnosis of scrotal diseases; however, MRI and dynamic en-hanced MR imaging provided 100% sensitivity, specificity and accuracy. MRI studies made it unnecessary to undergo diagnostic scrotal exploration in two cases (1 vascular disease, 1 acute epididymo-orchitis) and orchiectomy in three cases (2 epidermoid cysts and 1 simple cyst with hemorrhage). It also determined one case of extra-testicular tumor. The method clearly defined proper surgical plans for 5 cases of undescended testes. All pathologic scrota showed the great-est contrast in T2-weighted images. The studay demonstrated that dynamic enhanced MR imaging is powerful in case of ischemic testis and intratesticular lesions. (J Urol R.O.C., 9:111-116, 1998)

Spigelian hernia (SH) is a rare ventral interstitial hernia occurring through a defect in the transversus abdominis aponeurosis (Spigelian fascia). Spigelian fascia is found between the lateral border of the rectus abdominis muscle and the semilunar line, which extends from the costal cartilage to the pubic tubercle. In other words, Spigelian line is where the transversus abdominis muscle ends in an aponeurosis characterized by a congenital or acquired defect in the Spigelian aponeurosis. Pediatric cases of SH are either congenital or acquired due to trauma, previous surgery or increased intra-abdominal pressure. SH in combination with ipsilateral cryptorchidism may constitute a new syndrome, as such cases are extremely rare in the literature is new syndrome is characterized by the following congenital, ipsilateral disturbances: SH, absence of inguinal canal and gubernaculum and the homolateral testis found within the Spigelian hernia sac (a hernia sac containing undescended testis). The aim of this study is to emphasize some typical findings of this specific entity, and, hence, the necessity for a thorough investigation of the origin of the SH.

The aim of this study was to describe the development of Ad spermatogonia in both unilateral and bilateral cryptorchid infants compared to a control population of comparable age and to note particularly the fate of Ad spermatogonia during the normal surge of testosterone and gonadotropin. The incidence and development of Ad (dark) adult type of spermatogonia were assessed in 270 testicular biopsies from 159 cryptorchid infants at 1-12 months of age. These results were compared to the control population of the same age. The number of Ad spermatogonia increased markedly after five months of life in the control population. The scrotal testes of unilateral cryptorchid infants also had an increase in the number of Ad spermatogonia but it was distinctly lower than that of the control population. In contrast, this surge was completely absent in the cryptorchid testes. The number of Ad spermatogonia in unilateral cryptorchid testes correlated in a nonlinear fashion with those in the contralateral scrotal testes. The total number of germ cells in the cryptorchid testes in the first six months of life is normal, after which time it declines rapidly. The impaired transformation of germ cells into Ad spermatogonia in both unilateral and bilateral cryptorchid infant testes during mini-puberty underscores the importance of hypogonadotropic-hypogonadism in the pathogenesis of this disease.

Objective To assess the safety and effectiveness of simultaneous laparoscopic herniorrhaphy by totally extraperitoneal prosthesis (TEP)and simultaneous laparoscopic herniorrhaphy and varicocelectomy by high ligation with the route of TEP. Methods Clinical data of 16 patients who suffered from varicocele combined with indirect inguinal hernia, underwent the simultaneous laparoscopic herniorrhaphy by TEP and varicocelectomy by high ligation with the route of TEP from November 2013 to November 2016 were retrospectively analyzed. Varicocele was detected by color Doppler ultrasounography with the mean diameter of (3.12±0.53)mm.The intraoperative and postoperative clinical parametes including bleeding volume, recovery time of intestinal peristalsis, use of postoperative analgesia, complication, hospital stay and postoperative recovery time were recorded and analyzed. All patients were followed up for a range of 3~24 months. Results The operation was successful in all cases.The operation time was (39.8±7.6) min, the intraoperative blood loss was (6.5±3.2) mL, and recovery time of intestinal peristalsis was (7.8±0.9)h.There was no need for postoperative analgesia. The postoperative hospital stay was (3.6±0.8) d, and it took (4.9±0.8) d for the patients to go back to their normal activities. The normal diameter (1.71±0.32)mm of spermatic veins and and good testicular blood supply were detected by the ultrasounography befor discharge. No operative complications were observed. Varieocele was disappeared in all patients at 3 months postoperatively.All patients were followed up for 3 to 24 months without testicular atrophy and hydrocele. Recurrence of either varicocele or indirect inguinal hernia was not found during follow-up. Conclusions Simultaneous laparoscopic herniorrhaphy by TEP and varicocelectomy by high ligation with the route of TEP are safe and effective for patients with varicocele combined with indirect inguinal hernia with the advantage of less trauma, faster postoperative recovery, and less complication. Key words: Varicocele; Laparoscopes; Hernia, Inguinal