Spontaneous Descent Research Articles

Natural course of undescended testes after inguinoscrotal surgery

PurposeThe purpose of the study is to study the natural course of undescended testes after inguinoscrotal surgery. MethodsFrom 2003–2010, 24 boys were observed with 26 undescended testes after inguinoscrotal surgery; 12 had previously undergone inguinal hernia repair and 12 orchidopexy. Spontaneous descent was awaited and (re-)orchidopexy would only be performed in case of non-descent at puberty. The boys were assessed annually for testis position and for testis volume as measured by ultrasound. ResultsAt the end of the study period, 19 testes had reached scrotal position; of these, 13 (68%) had descended spontaneously and 6 (32%) had been (re-)orchidopexied. No difference was found in the rate of spontaneous descent after previous orchidopexy or inguinal hernia repair (P=0.419). ConclusionSpontaneous descent of undescended testes after inguinoscrotal surgery occurs regularly. In this study, it was observed in two out of every three cases.

Fertility potential in a cohort of 65 men with previously acquired undescended testes

PurposeTo evaluate testicular function in men with previously acquired undescended testes (AUDT) in whom spontaneous descent was awaited until puberty followed by orchiopexy in case of nondescent. MethodsAndrological evaluation including paternity, scrotal ultrasound, reproductive hormones, and semen analysis was performed in three groups: men with AUDT, healthy controls, and men with previously congenital undescended testes (CUDT). ResultsIn comparison with controls, men with AUDT more often had significantly abnormal testicular consistency, smaller testes, lower sperm concentration, and less motile sperm. Except for more often a normal testicular consistency in men with AUDT, no differences were found between men with AUDT and men with CUDT. Also, no differences were found between men with AUDT which had spontaneously descended and men who underwent orchiopexy. ConclusionsFertility potential in men with AUDT is compromised in comparison with healthy controls, but comparable with men with CUDT. This suggests that congenital and acquired UDT share the same etiology. No significant difference was found between men who had spontaneous descent and men needing orchiopexy. However, fertility potential is unknown for men after immediate surgery at diagnosis, and this should be a subject for future studies.

Growth of Spontaneously Descended and Surgically Treated Testes During Early Childhood

To investigate whether in congenital unilateral cryptorchidism the growth of a spontaneously descended testis is normal, compared with the contralateral scrotal testis or similar to the growth of testes that failed to descend spontaneously and later underwent orchidopexy. Ninety-one boys with congenital unilateral cryptorchidism with later spontaneous descent of the initially retained testis were followed from birth (0-3 weeks) up to 5 years of age and compared with boys randomized to surgery at either 9 months (n = 78) or 3 years (n = 85) of age. Testicular volume was determined with ultrasonography. Eighty-two percent of spontaneous descent occurred before 2 months of age. Twenty-two percent of these descended testes were later again found in a retained position. The spontaneously descended testis was smaller than its scrotal counterpart at all ages (P < .001). We also showed a significant difference in the testicular volume between the early and late treated boys from age 2 years and onward. At 2, 4, and 5 years of age, the volumes of the spontaneously descended testes were significantly larger than those of boys operated on at 3 years but similar to those operated on at 9 months. We have shown that in boys with congenital unilateral cryptorchidism with later spontaneous descent, the originally retained testes show impaired growth compared with its scrotal counterpart from birth and onwards. Also, they are prone to later ascent to a retained position. Furthermore, the longer testes remain untreated the more they exhibit impaired growth.

Perineal Ectopic Testis with Unilateral Scrotal Hypoplasia

The ectopic testis is frequently misdiagnosed as cryptorchidism or anorchism. We present a case of three month old male infant diagnosed as right ectopic perineal testis and right hemiscrotal hypoplasia. Ectopic testes are thought to be greater at risk of trauma, testicular torsion, subfertility and malignancy. Although definitive evidence in support of these fears in case of perineal ectopia is lacking due to its rarity and lack of long follow-up. Surgical correction of undescended testes is generally done at about 6 months of age to allow for spontaneous descent. On the other hand there is no need to delay surgery in ectopic testis because possible descent as seen in undescended testis will not occur. Yet the timing of surgery can be individualized for perineal ectopia without any unnecessary delay.

Boys with Undescended Testes: Endocrine, Volumetric and Morphometric Studies on Testicular Function before and after Orchidopexy at Nine Months or Three Years of Age

A randomized controlled study was conducted comparing the outcome of surgery for congenital cryptorchidism at 9 months or 3 yr of age. The aim of the study was to investigate whether surgery at 9 months is more beneficial than at 3 yr and to identify early endocrine markers of importance for testicular development. A total of 213 biopsies were taken at orchidopexy, and the number of germ and Sertoli cells per 100 seminiferous cord cross-sections and the surface area of seminiferous tubules and interstitial tissue were analyzed. Inhibin B, FSH, LH, and testosterone were determined. Testicular volume was assessed by ultrasonography and by a ruler. The number of germ and Sertoli cells and testicular volume at 9 months were significantly larger than at 3 yr. The intraabdominal testes showed the largest germ cell depletion at 3 yr. At both ages, testicular volume correlated to the number of germ and Sertoli cells. None of the hormones measured during the first 6 months of life (LH, FSH, testosterone, and inhibin B) could predict the number of germ or Sertoli cells at either 9 or 36 months of age, nor could hormone levels predict whether spontaneous descent would occur or not. Morphometric and volumetric data show that orchidopexy at 9 months is more beneficial for testicular development than an operation at 3 yr of age. Testicular volume was furthermore shown to reflect germ cell numbers in early childhood, whereas endocrine parameters could not predict cellular structure of the testis or its spontaneous descent.

Pattern of presentation and management of patients with undescended testis at Kilimanjaro Christian Medical Center, Tanzania

To assess the pattern or presentation, management and advice given to the parents or guardians of patients with undescended testes (UDT) at Kilimanjaro Christian Medical Center, Tanzania. From July 2010 to May 2011, 30 patients with UDT were prospectively evaluated regarding age at surgery, place of birth, information given to parents or guardians, side and site affected, results of ultrasonography, findings on surgical exploration, follow-up and surgical outcome. The median age at surgery was 6 years (range 1–36 years), 4 patients (13.3%) had orchidopexy before 2 years of age, 6 (20%) before 5 years and 4 (13.3%) after 18 years of age. The UDT was on the right side in 56.7%, on the left side in 26.7%, bilateral in 16.7%, in the inguinal region in 70% and in the abdomen in 30%. An associated malformation was found in 53.5% of patients: a hernia sac in 13 (43.3%), hypospadias in 2 (6.7%) and a hydrocele in 1 (3.3%). The UDT was detected by the parents in 13 cases (43.3%), by the patient himself in 9 (30%) and by health care staff in 8 cases (26.7%). Only 10 parents (33.3%) received advice from health care staff: 6 were advised for surgery and 4 were advised to await spontaneous descent. Preoperative ultrasonography was false negative in 56% of cases. Orchidopexy was performed in 28 (93.3%) patients (the testis was secured in the scrotum in 23 and in the high inguino-scrotal position in 5), and 2 (6.7%) underwent orchidectomy. At 3-month follow-up the testes were situated in the scrotum (not retracted) in 25 patients (3 were lost to follow-up). The late presentation detected in this study is alarming, because the majority of patients were diagnosed and treated after 2 years of age. The role of ultrasound in diagnosis of UDT is limited. Health care workers should perform neonatal examination to detect UDT and inform parents that early correction of UDT will decrease the risk of infertility and facilitate future examination to detect the development of testicular malignancy.

Congenital abdominal wall defects and testicular maldescent—a 10-year single-center experience

PurposeThe relationship between congenital abdominal wall defects (AWDs) and undescended testes (UDTs) is poorly defined. We report a study of infants with AWD and UDT. MethodsHospital records of newborns with AWD managed during 1998 to 2008 were reviewed. Data analyzed included nature of AWD, position of the testes at birth, final position of the testes, and surgical management. ResultsA total of 218 newborns with AWD were identified; 106 (49%) were boys. Of 79 boys with gastroschisis, 26 (33%) had UDT involving 35 testes. Of 27 with exomphalos, 6 (22%) had UDT involving 11 testes. Prolapsed testes were placed in the abdomen at AWD repair, whereas others were observed for “spontaneous” descent. Of 35 UDT in gastroschisis infants, 18 descended spontaneously, and 10 required orchidopexy. Three boys underwent laparoscopy for impalpable testes, 2 underwent orchidectomy, and 1 had bilaterally absent testes. Three cases await orchidopexy. In exomphalos boys with 11 UDTs, 1 gonad descended spontaneously, and 6 had groin exploration (1 absent testis and 5 orchidopexies). Two boys await orchidopexy, and 1 boy (bilateral impalpable testes) was lost to follow-up. ConclusionAbdominal wall defects are strongly associated with UDT. In boys with gastroschisis, spontaneous descent of the testes may be anticipated in 50% of cases. In those with exomphalos, orchidopexy should be scheduled.

Diagnosis and Management of Cryptorchidism

Among males born at full term or prematurely, 1–30% are affected by cryptorchidism. Approximately 70% of cryptorchid testes will spontaneously descend by 3 mo.The cause of cryptorchidism is multifactorial. A prerequisite for testicular descent is a normal hypothalamic-pituitary-gonadal axis. In addition, an undisturbed interaction with the anatomic structures is required, as well as the appropriate hormonal milieu and environmental conditions. Hereditary factors also play a major role.The Kaplan classification distinguishes between palpable testes (80%) and nonpalpable testes (20%). The nonpalpable group includes intra-abdominal, inguinal, and absent (vanishing) testes, whereas palpable testes can be between the internal and external inguinal ring, high scrotal, or in a superficial pouch between the oblique and the Scarpa fascia in the so-called Denis Browne pouch.Therapy for undescended testis (UDT) is usually carried out when a child is between 6 and 12 mo; individuals with high UDT especially benefit from an early orchidopexy. The lower the pretreatment position, the more chance there is of spontaneous descent as well as better results of surgical intervention.Although the management of a palpable testis is standardized, there are no guidelines for the management of boys with a nonpalpable testis. It seems that both preoperative and postoperative hormonal treatment may have a beneficial effect on fertility later in life. Because of the increased risk of testicular malignancy, lifelong follow-up is mandatory.

53 Fertility in men with acquired undescended testis, where spontaneous testicular descent was awaited until puberty: Spontaneous descend versus orchiopexy

53 Fertility in men with acquired undescended testis, where spontaneous testicular descent was awaited until puberty: Spontaneous descend versus orchiopexy

Parental Perception of Optimal Surgical Age for Correction of Cryptorchidism: A Multicenter Surveillance Study

To perform a multicenter survey to determine how many parents understood the optimal time for surgical correction of cryptorchidism in children. We enrolled 377 parents of patients who had recently undergone surgical correction of cryptorchidism. These parents were divided into 3 groups according to their indicated preference of the optimal patient age for surgical correction: group 1 (<1 year old, 39 parents, 10.3%), group 2 (1-2 years old, 169 parents, 44.8%), and group 3 (>3 years, 169 parents, 44.8%). The mean age of the children who underwent orchiopexy was 4.9 ± 5.2 years. The interval from diagnosis to surgical correction of cryptorchidism was 17.1 ± 29.8, 15.4 ± 14.4, and 29.0 ± 24.4 months in groups 1, 2, and 3, respectively (P < .001). The mean age of the parents was significantly associated with the perception of the optimal time for surgical correction of cryptorchidism (P = .021 and P = .002). The number of highly educated parents was lowest in group 3 (P < .001). The number of parents with >2 children was 69.2% in group 1, 71.0% in group 2, and 84.0% in group 3 (P = .009). In group 3, the parents often delayed surgery because of the patient being too young (49.1%) and the parents' expectations of spontaneous descent (48.5%). Parents younger in age, with higher education levels and with fewer children, preferred early orchiopexy. Active intervention by a physician and public education for parents might be necessary to encourage earlier treatment of cryptorchidism.

Surgical Findings in Acquired Undescended Testis: an Explanation for Pubertal Descent or Non-descent?

Surgical findings were studied to find an explanation for the phenomenon that some acquired undescended testes (UDT) descend spontaneously whereas others need orchiopexy. In patients with acquired UDT spontaneous descent was awaited until at least Tanner stage P2G2. Orchiopexy was performed when a stable scrotal position had not been achieved by the end of follow-up. Orchiopexy was needed in 57 of 132 cases (43%). In cases requiring orchiopexy, the difference in testis volume compared to the contralateral healthy testis was significantly larger than for spontaneously descended testes. 41 (72%) undescended testes were found in the superficial inguinal pouch; 16 (28%) at the external annulus. 26 of the 41 testes in the superficial inguinal pouch position (63%) could be manipulated preoperatively into a non-stable scrotal position; 15 could only reach the scrotal entrance prior to surgery. None of the 16 testes located at the external annulus could reach a scrotal position. Inguinal exploration in most cases revealed a fibrous string or a partially open processus vaginalis. The mobility of acquired UDT located within the external annulus is limited. It is mainly the fibrous string and the partially open processus vaginalis that prevent normal elongation of the spermatic cord with growth. These testes are unlikely to descend spontaneously. Acquired UDT lying in the superficial inguinal pouch can often be pushed down well below the scrotal entrance. We speculate that under normal hormonal stimulation at puberty, some of these growing testes may overcome the strength of the fibrous string in the spermatic cord and descend again spontaneously.

Acquired undescended testis: putting the pieces together

Acquired undescended testis is now a well-recognized disorder. It is seen in 1.5% of pre-pubertal boys and accounts for the 1-2% orchidopexy rate in older boys. Its pathogenesis remains largely unclear, but it may be caused by a fibrous remnant of the processus vaginalis. There is much controversy over its management, and the proper management awaits a randomized-controlled trial. Until now, follow-up data are available only for cases of spontaneous descent or pubertal orchidopexy. It is speculated that acquired undescended testis is in fact congenital and because of a short funiculus at birth, allowing a low-scrotal position early in life. However, as the boy grows, the testis might evolve into an undescended state. When testosterone surges at puberty, spontaneous descent occurs in three of every four cases.

Hodenhochstand und Infertilität unter besonderer Berücksichtigung der interdisziplinären Leitlinie

Cryptorchidism is the most common genital disorder in boys. Early-born boys are affected in up to one third of the cases, while about 2-5% of full-term newborns suffer from at least one undescended testicle. As a result of short-term endogenous testosterone secretion after birth the prevalence decreases to 1-2% after 3 months. According to most studies, watchful waiting after 6 months is not justified because after this time spontaneous testicular descent only very rarely occurs. Even though the effects of testicular development and fertility in undescended testis have been extensively examined, the only fact that remains certain is that approximately 90% of untreated men with bilateral cryptorchidism develop azoospermia. The remaining scenarios of cryptorchidism (unilateral, ectopic, inguinal, treated or not treated) exhibit unpredictable fertility and likelihood of fatherhood.

Natural history and long‐term testicular growth of acquired undescended testis after spontaneous descent or pubertal orchidopexy

To assess prospectively the natural history and long-term testicular growth of acquired undescended testis (UDT) after spontaneous descent or pubertal orchidopexy in case of nondescent. From 1996 until 2008, 391 boys with 464 acquired UDT were included in the study. In accordance with Dutch consensus on non-scrotal testes, spontaneous descent at puberty was awaited; if this did not take place, orchidopexy was performed at puberty. Acquired UDT was defined as a testis previously residing in the scrotum that can no longer be manipulated into a stable scrotal (high scrotal) or nonscrotal (inguinal, impalpable) position. After referral, testis position, testis volume and puberty stage were monitored annually until adolescence. Testis volume was assessed using an orchidometer and compared with the Dutch standard. All investigations were carried out by the same physician (W.H.). Of these boys, 84 (mean age 12.9 years, range 6.4-21.3) were also clinically assessed by a second physician (J.G.), unaware of the results of the first examination. In addition, these boys were assessed with testicular ultrasonography, carried out by both physicians. Currently the mean (range) follow-up is 4.7 (0.1-12.0) years, and 253 acquired UDT have reached the scrotum. In 196 of these 253 cases (77.5%), there was spontaneous descent at puberty (mean age at descent 12.9 years, range 9.8-16.9); in the other 57 cases (22.5%), pubertal orchidopexy was required due to nondescent; five cases required orchidectomy. Of the 494 testis volume measurements after spontaneous descent, 458 (92.7%) were at ≥10th centile for age, of which 311 (63.0%) were ≥50th centile, and 107 (21.7%) ≥90th centile. After pubertal orchidopexy for nondescent, of the 85 measurements, 79 (92.9%) were at ≥10th centile, 53 (62.4%) ≥50th centile and 12 (14.1%) ≥90th centile. In unilateral cases, after spontaneous descent 174 of the 294 (59.2%) retained testes were found to be smaller than their counterpart and 90 of 294 (30.6%) were equal in size. After pubertal orchidopexy in unilateral cases, 40 of the 51 (78.4%) testes were smaller, and nine (17.6%) were equal in size. There was a strong correlation between both investigators for the measurement of testicular volume by orchidometer, and for the main investigator (W.H.) between his measurements by ultrasonography and the Prader orchidometer. Acquired UDT has a 77.5% tendency of spontaneous descent at puberty. In nearly all cases, after spontaneous descent as well as after pubertal orchidopexy, long-term testicular growth is within the normal range.

Hodenhochstand

Undescended testis (UDT) is the most frequent congenital malformation affecting 1% of 1-year-old mature birth boys. If untreated UDT leads to progressive histological changes with impaired spermatogenesis and an increasing risk of testicular cancer. For clinical reasons palpable testes should be differentiated from impalpable testes. Spontaneous testicular descent can be expected only before 6 months of age. Subsequently, treatment should start without delay and be finished before the child has reached the age of 1 year. Surgery is the cornerstone of treatment. Inguinal approaches are standard practice for palpable testes, whereas laparoscopy is used in non-palpable testes. Hormonal treatment is ineffective for inducing testicular descent but facilitates germ cell maturation and an improvement in fertility potential. Only early treatment of UDT reduces germ cell loss, improves fertility and reduces the risk of testicular cancer.

Acquired cryptorchidism is frequent in infancy and childhood

Accurate prevalence data for acquired cryptorchidism are currently sparse and systematic prospective studies have not yet been reported. Our aim was to determine the prevalence of testicular ascent in childhood. In a prospective longitudinal population-based child cohort from Copenhagen, Denmark (1997-2007), testicular position was examined according to a standardised protocol in a total of 1072 boys, at birth (n = 1051), at 3 months (n = 983), 18 months (n = 888), 36 months (n = 790) and again once between 4 1/2 and 10 years of age (n = 509). Ascensus testis was defined as ascent of the testis into a cryptorchid position after normal scrotal position at birth. A congenital cryptorchid testis with spontaneous postnatal descent followed by recurrence of cryptorchidism was named recurrent cryptorchidism. Ascensus testis occurred in 0.2%, 0.6% and 0.6% of boys at 3, 18 and 36 months of age respectively. When including recurrent cryptorchidism the prevalence was 0.2%, 1.2% and 0.8% respectively. Ascensus testis accounts for 58% of all cases of cryptorchidism (congenital and acquired) at 18 months, 71% at 36 months and thereafter 69%. Ascensus testis accounts for more than half of cryptorchid testes seen in childhood and occurs in both previously scrotal and cryptorchid testes. We therefore recommend that all boys should have testis position checked regularly during childhood, at least up to 3 years of age.

Mutations in INSL3 and RXFP2 Genes in Cryptorchid Boys

Mutations in the INSL3 and RXFP2 genes have been associated with human cryptorchidism but with contrasting data. We analyzed the frequency of mutations in these genes in 600 newborns with cryptorchidism (396 unilateral and 204 bilateral) and 300 noncryptorchid subjects. We found five RXFP2 mutations in five bilateral cryptorchid boys, one INSL3 mutation in a unilateral cryptorchid boy, and one INSL3 mutation in a boy with unilateral cryptorchidism at birth and spontaneous descent during the first month of life. Overall, the frequency of INSL3 and RXFP2 mutations was therefore 7/600 at birth (1.2%) and 7/303 (2.3%) in persistent cryptorchid boys, with a higher prevalence of bilateral forms (5/120, 4.2%). No mutations were found in controls. This study confirmed the association between INSL3 and RXFP2 gene mutations and human cryptorchidism.

Genetic Alterations Associated With Cryptorchidism

Cryptorchidism is the most frequent congenital birth defect in male children and represents an important risk factor for infertility and testicular cancer. Major regulators of testicular descent are the hormones insulin-like factor 3 (INSL3) and testosterone, and disruption of these pathways might cause cryptorchidism. To determine the frequency of genetic alterations in cryptorchidism. Case-control study in 2 departments of pediatric surgery in Italy between January 2003 and March 2005. Six hundred male infants with cryptorchidism. Boys were followed up for 2 to 3 years (through January 2008) and orchidopexy was performed in those who were persistently cryptorchid. We analyzed 300 noncryptorchid male children aged 1 to 4 years as controls. Karyotype anomalies and INSL3, INSL3 receptor, and androgen receptor gene mutations. The frequency of genetic alterations in boys with cryptorchidism was low (17/600 [2.8%; 95% confidence interval {CI}, 1.7%-4.5%]) and was significantly higher in participants with persistent cryptorchidism (16/303 [5.3%; 95% CI, 3.0%-8.4%]; P = .001) and those with bilateral cryptorchidism (10/120 [8.3%; 95% CI, 4.1%-14.8%]; P = .001) than in controls (1/300 [0.3%; 95% CI, 0.1%-0.8%]). Boys with persistent cryptorchidism had a 17-fold greater odds of having a genetic alteration (odds ratio, 16.7; 95% CI, 2.2-126.5). The most common genetic findings in those with cryptorchidism were 8 cases of Klinefelter syndrome and 5 cases of mutations in the INSL3 receptor gene. Genetic alterations were not found in boys with low birth weight or low gestational age, who had frequent spontaneous descent of the testes. In a small percentage of the study population, there was a statistically significant association between bilateral and persistent cryptorchidism and genetic alterations, including Klinefelter syndrome and INSL3 receptor gene mutations.

Undescended testes in children: the paediatric urologist's point of view

Undescended testes (UDT) are found in 1% boys at the age of 1-year old, 3% of full-term male infants and 33% in premature babies at birth. Spontaneous descent is possible until 6 months of age. The two main phases of descent of the testis during gestation are described, as well as the possible aetiologies, the consequences of an abnormal migration, and the main locations of UDTs. Clinical examination is essential and should be done in optimal conditions. Laparoscopic exploration is the only valuable complementary investigation in the case of non-palpable UDT.

Inguinal Canal Dilatation: A Novel Technique for the Repair of Failed Testicular Descent despite Hormonal Treatment

Treatment of the undescended testicle (UT) after it failed to descend on hormonal therapy is surgical. Spermatic cord elongation may impair testicular function, particularly in cases in which cord integuments or veins have to be divided to provide an extra cord length. A factor that might impede testicular descent is presence of a narrowed or obliterated inguinal canal. We investigated the hypothesis that dilatation of a narrowed or obliterated inguinal canal might assist spontaneous testicular descent. Twenty-six boys (age 3.6 +/- 0.8 years) with unilateral UT and failed hormonal treatment, whose UT was located at deep inguinal ring, were included in the study. Through an inguinal incision, the inguinal canal was dilated, spermatic cord adhesions divided, hernial sac, if present, excised, and skin closed. Testicular descent into the scrotum occurred in 22 patients within 4.2 +/- 1.3 months. The remaining four patients were reoperated on by Fowler-Stephens orchiopexy after 14 months. A technique is presented for the treatment of the UT after failure to respond to hormonal treatment. It consisted of clearing the testicular pathway of any adhesions and dilating the narrowed inguinal canal. The technique is simple, easy, and does not interfere with the testicle or spermatic cord.