Proximal Hypospadias and Acquired Cryptorchidism: Incidence, Morphology and Potential Clinical Implications.

PURPOSE: We identified the incidence of acquired cryptorchidism among patients with proximal and mid shaft hypospadias, predictors of acquired cryptorchidism, and the prevalence of testis-epididymis nonfusion with ascended testes. We hypothesized that proximal hypospadias would be associated with higher incidence of acquired cryptorchidism than mid shaft hypospadias, and that ascended testes would exhibit increased prevalence of testis-epididymis nonfusion similar to anatomical findings in an undescended testis. MATERIALS AND METHODS: A retrospective cohort study of patients who underwent primary proximal and mid shaft hypospadias repair from 2010 to 2016 was conducted. Clinical and operative notes were reviewed. Patients with congenitally undescended testes or differences of sex development were excluded. RESULTS: A total of 175 patients were identified. Those with proximal hypospadias (14/104, 13%) were more likely than those with mid shaft hypospadias (1/71, 1%) to develop acquired cryptorchidism (p=0.04). Among proximal hypospadias patients, increased risk of acquired cryptorchidism was associated with pre-term birth (p <0.01) and penoscrotal transposition (p=0.01) but not with testis position on initial examination (p >0.99). In the 14 proximal hypospadias patients with acquired cryptorchidism, 21 ascended testes underwent orchiopexy. Operative notes adequately described testis-epididymis anatomy for 8/21 ascended testes. Testis-epididymis nonfusion was described in 6/8 ascended testes. CONCLUSIONS: Risk of acquired cryptorchidism is increased among patients with proximal hypospadias. Operative notes revealed a high rate of epididymal nonfusion with ascended testes, suggesting these testes morphologically resemble undescended testes. Close followup of testis position is needed in these patients, and the threshold to perform orchiopexy may need to be lower in select patients.

Undescended Testis Does Not Affect the Outcome of Microdissection Testicular Sperm Extraction.

OBJECTIVE: To determine the sperm retrieval rates (SRRs) and predictive factors of patients with a history of undescended testis after testicular sperm extraction (TESE). METHODS: A total of 311 patients were diagnosed with nonobstructive azoospermia (NOA) and underwent TESE were included in this study. These patients were divided into 2 groups: an undescended group consisting of 62 patients who had a history of undescended testes and an idiopathic group consisting of 249 patients. Of the 62 patients with a history of undescended testes, 26 had a history of bilateral orchidopexy, 15 had a history of unilateral orchidopexy, and 21 had no history of surgery. RESULTS: The testicular spermatozoa were found in 134 (53.8%) and 31 (50%) patients in the idiopathic NOA and undescended testes groups, respectively. Similar to patients with idiopathic NOA, the overall SRRs were strongly associated with histopathology for patients with a history of undescended testes. These SRRs were 34.2%, 33.3%, 71.4%, 100%, and 100% for Sertoli Cell Only, late maturation arrest, early maturation arrest, hypospermatogenesis, and normal spermatogenesis, respectively (P <.001). In the undescended group, the SRRs of patients who underwent orchidopexy were not different than patients without a history of orchidopexy. However, patients who underwent unilateral orchidopexy had a higher SRR than those who underwent bilateral orchidopexy (P = .031). CONCLUSION: TESE is a successful treatment modality for men with NOA associated with or without a history of undescended testis. The testicular histopathology and unilateral undescended testis were identified as independent predictors of SRRs for men with a history of undescended testis.

Epidemiology, Diagnosis and Therapeutic Approaches of Cryptorchidism at the Panzi General Hospital, DR Congo: A 5-year Retrospective Study.

BACKGROUND: Cryptorchidism is a common congenital malformation characterized by unilateral or bilateral undescended testis in the scrotum. It is a common disease in pediatric urology although the prevalence is yet to be determined in the East DR Congo. The aim of this study was to describe the prevalence, clinical and therapeutic features of cryptorchidism at the Panzi General Hospital. METHODS: Medical records of patients who underwent pediatric surgery between January 2011 and December 2016 were reviewed. The prevalence of cryptorchidism, associated malformations, sociodemographic features of patients and therapeutic protocols were examined. Collected data were analyzed using SPSS software. RESULTS: A total of 5066 children were received during the study period in the service, of which 76 suffered from cryptorchidism giving a prevalence of 1.50% and an annual incidence of 12.70. Unilateral cases were found in 53(69.74%) patients among which 66.04% and 33.96% had unilateral right and left cryptorchidism respectively. Cryptorchidism was associated with other malformations in 71.1% of patients. The age of patients ranged from 0 to 15 years and 78.9% were older than two years. Surgery was the only therapeutic approach and fixation of cryptorchid testis in dartos through inguinal incision was the preferred therapeutic used method. CONCLUSION: This study indicates that cryptorchidism is a relatively common and neglected disease in the Est-DR Congo, due to late consultation. Therefore, the local population and pediatricians should be sensitized on scrotal palpation techniques in order to shorten the consultation delay and prevent testis damages.

Changing Trends in the Referral and Timing of Treatment for Congenital Cryptorchidism: A Single-Center Experience from Bosnia and Herzegovina.

BACKGROUND: Cryptorchidism is the most common male urogenital tract disorder identified at birth. Treatment delays of cryptorchidism may be associated with significant complications such as subfertility and testicular cancer. The currently recommended age for performing orchidopexy is between 6 and 12 months of age and no later than 18 months. The aim of this study was to investigate the trends in the pattern of referral and age of boys at the time of operative treatment of congenital cryptorchidism at the largest tertiary care center in Bosnia and Herzegovina. METHODS: The study included all boys who underwent orchidopexy for congenital cryptorchidism during two equivalents periods: 2008-2010 and 2015-2017. We assessed the referral age of patients, the age of patients at the time of orchidopexy, laterality of cryptorchidism, position of cryptorchidic testes palpated before surgery, the intraoperative position of cryptorchidic testis, a clinical position of the testis at follow up, and risk factors for late orchidopexy. RESULTS: In total, 324 patients with 386 testes underwent orchidopexy for congenital cryptorchidism during the study periods. Of these patients, 62 received a bilateral orchidopexy (19.1%). Total referral age of patients with congenital cryptorchidism was 23 months (range, 4-74.5 months). Total median age at surgery was 24 months (range, 6-74 months). One hundred and eleven patients (28.8%) underwent surgery at less than the age of 12 months, 136 (35.2%) at less than the age of 18 months, and 250 (64.8%) patients underwent surgery after the age of 18 months. The analysis of the observed two periods (2008-2010 and 2015-2017) showed a statistically significant decrease in the mean referral age and the mean age at surgery over the last 5 years (2015-2017) (p = 0.007 and p = 0.003, respectively). CONCLUSIONS: Current guidelines for timely operative treatment for congenital cryptorchidism have not been fully implemented in Bosnia and Herzegovina but a gradual improvement is evident. The main factor contributing to delays in orchidopexy was delayed or neglected referral by referring physicians. Optimizing the time of orchidopexy will require an improved coordination at all levels of pediatric health care to diminish the long-term consequences of cryptorchidism. TYPE OF STUDY: Retrospective. LEVEL OF EVIDENCE: III.

A comparison of clinical outcomes of acute testicular torsion between prepubertal and postpubertal males.

SHORT INTRODUCTION/BACKGROUND: Surgical intervention for acute testicular torsion can require either orchiopexy or orchiectomy. The decision of which surgery to perform is dependant on the amount of time that the testicle experienced ischemia and the viability of the testicle after reperfusion. OBJECTIVE: It is hypothesized that (1) there is a difference in orchiectomy and orchiopexy rates between prepubertal and postpubertal males with acute testicular torsion and (2) presenting symptoms may vary between the two age groups as prepubertal males may present with atypical symptoms, which could result in delayed presentation and diagnosis. STUDY DESIGN: A retrospective chart review was conducted on pediatric patients who were diagnosed with acute testicular torsion between June 2010 and August 2017. Demographic and clinical characteristics were extracted: age, ethnicity, referral pattern, primary insurance status, symptoms at presentation, prior history of ipsilateral testicular pain or intermittent torsion, recent trauma to genitalia, duration of symptoms (hours), gradual vs. acute onset of symptoms, time/weekday/season at presentation, and time interval from arrival at the study institution to surgical intervention (minutes). Patients were categorized into two groups: prepubertal group (age 1-12 years) and postpubertal group (age 13-18 years). Statistical analyses were performed using R, version 3.3.1. RESULTS: Ninety-one patients were included in the study. The overall orchiectomy rate was 30.8%. More prepubertal males underwent orchiectomy than postpubertal males (42.4% vs. 24.1%, respectively). Prepubertal males were more likely to present with abdominal pain than postpubertal males (27.3% vs. 10.3%, respectively). Those who underwent orchiectomy were more likely to present with longer duration of symptoms, testicular swelling, and abdominal pain than those who underwent orchiopexy. The risk of orchiectomy decreased by 14% per 1-year increase in age (odds ratio [OR]: 0.86, 95% confidence interval [CI]: 0.94-1.00, p = .009). A steady decline in the proportion of patients undergoing orchiectomy was seen from 1 to 12 years of age. DISCUSSION: This study found that prepubertal males are at higher risk for orchiectomy than postpubertal males. The risk of orchiectomy decreases by 14-16% per 1-year increase in age. Prepubertal males are more likely to present with atypical symptoms and delayed presentation and diagnosis, leading to delayed surgical intervention. It is important for providers to perform a genital examination in prepubertal males who present with abdominal pain to rule out acute testicular torsion. Patients presenting with longer duration of symptoms, testicular swelling, and abdominal pain are at higher risk for orchiectomy. No correlation was found between orchiectomy rate and ethnicity, referral status, primary insurance status, and time/weekday/season at presentation. CONCLUSION: Among patients presenting to a tertiary pediatric hospital with acute testicular torsion, prepubertal males (younger than 12 years) are at higher risk for orchiectomy than postpubertal males. Prepubertal males are more likely to present with atypical symptoms which results in delayed presentation and diagnosis, leading to delayed in surgical intervention.

Can haematologic parameters be used to predict testicular viability in testicular torsion?

The purpose of this study was to evaluate the predictive value of haematologic parameters for testicular survival in torsion. Children with testicular torsion (TT) treated in Beijing Children's Hospital from January 2006 to December 2018 were enrolled in this study. Patient data collected in this study included age, symptom duration, preoperative preparation time, cryptorchidism testicular torsion or not, spermatic cord torsion degree, orchiectomy/orchiopexy, testicular volume 3 months after operation by ultrasound in orchiopexy patients and haematologic parameters. The orchiopexy group comprised of 54 patients with a mean age of 135.6 ± 43.73 months, and the orchiectomy group included 58 patients with a mean age of 119.36 ± 60.82 months. The multivariate analysis showed that symptom duration (Odds Ratio = 1.11, p < 0.001), spermatic cord torsion degree (Odds Ratio = 1.006, p = 0.002) and mean platelet volume (MPV; Odds Ratio = 3.697, p = 0.044) were significant predictors of orchiectomy. The cut-off value for MPV during window time for orchiectomy was 10.55 fl (10-9  L) and provided a sensitivity of 47.8% and a specificity of 92.6%. This study found that symptom duration, spermatic cord torsion degree and MPV could be indicators of testicular viability in testicular torsion. MPV can provide valuable information before operation which can guide doctors and family members of the patients to select the appropriate treatment.

Point-of-care influences orchiectomy rates in pediatric patients with testicular torsion.

OBJECTIVES: The objective of this study was to determine whether point-of-care (community hospitals vs. tertiary centers) or treatment-delaying variables (transfer, emergency room [ER] throughput, and distance traveled) affect orchiectomy rates in minors with testicular torsion (TT) using a national database. STUDY DESIGN: This was a retrospective cohort study using prospectively collected data by the Canadian Institute of Health Information (CIHI) between 2010 and 2015. All Canadian male patients in the CIHI database aged <18 years with TT based on International Classification of Diseases (ICD) codes were included, except for those residing in Quebec. Variables collected were age, type of treating institution (community small/medium, community large, or tertiary/academic), transfer for definitive treatment, road distance traveled, and ER throughput. The outcome was testicular loss based on intervention codes for orchiectomy/orchidopexy. Univariable and multivariable analyses were performed using logistic regression. RESULTS: A total of 1713 minors with TT were included. Overall orchiectomy rate was 28%. Most patients (52%) were treated at tertiary hospitals. Small/medium community hospitals depicted the lowest odds of orchiectomy on univariable and multivariable analyses (odds ratio [OR] = 0.54, confidence interval [CI]: 0.37-0.79, p < 0.001); academic hospitals were also associated with a lower odds of orchiectomy than large community ones. Transfer and distance traveled were not associated with the outcome. Age >12 and ER throughput less than 1 h were significantly associated with lower orchiectomy rates. In a subgroup analysis of patients aged <12 years (n = 278), transfer was the only factor associated with increased risk of orchiectomy (OR = 2.41 , CI: 1.09-5.33; p = 0.03). DISCUSSION: This study showed that small and medium community hospitals had the lowest orchiectomy rates in minors with TT in Canada (Figure). However, on multivariable analysis, they performed similarly to tertiary/academic hospitals, with both being superior to large community hospitals. Transfer and distance traveled did not affect orchiectomy rates. Emergency room throughput had a statistically significant association with orchiectomy rates in every analysis and based on the study data would constitute the best target for policies aimed at reducing orchiectomy rates for TT in minors. The main limitation of this study is the inability to evaluate long-term testicular viability of patients not undergoing orchiectomy (i.e., true testicular salvage). CONCLUSIONS: Type of hospital treating facility (point-of-care) affects orchiectomy rates in minors with TT. Small/medium community hospitals depict the lowest orchiectomy rates in Canada. Transfer to another facility for definitive care and distance traveled did not affect orchiectomy rates, except in a subgroup analysis of prepubertal boys. Longer ER throughput and prepubertal age were consistently associated with loss of the testicle.

Clinical and socioeconomic factors associated with delayed orchidopexy in cryptorchid boys in China: a retrospective study of 2423 cases.

We investigated the associations of clinical and socioeconomic factors with delayed orchidopexy for cryptorchidism in China. A retrospective study was conducted on cryptorchid boys who underwent orchidopexy at Children's Hospital at Chongqing Medical University in China from January 2012 to December 2017. Of 2423 patients, 410 (16.9%) received timely repair by 18 months of age, beyond which surgery was considered delayed. Univariate analysis suggested that the laterality of cryptorchidism (P = 0.001), comorbidities including inguinal hernia/scrotal hydrocele (P < 0.001) or urinary tract disease (P = 0.016), and whether patients lived in a poverty county (P < 0.001) could influence whether orchidopexy was timely or delayed. Logistic regression analysis suggested that the following factors were associated with delayed repair: unilateral rather than bilateral cryptorchidism (odds ratio [OR] = 1.752, P < 0.001), absence of inguinal hernia or hydrocele (OR = 2.027, P = 0.019), absence of urinary tract disease (OR = 3.712, P < 0.001), and living in a poverty county (OR = 2.005, P < 0.001). The duration of postoperative hospital stay and hospital costs increased with the patient's age at the time of surgery.

Congenital diaphragmatic hernia is associated with nonscrotal testes.

BACKGROUND: Congenital diaphragmatic hernia (CDH) is a rare birth defect with a high mortality and morbidity. Nonscrotal testes (NST) are the most reported genital anomaly in boys. Both defects have known associated anomalies, but little is known about the association between CDH and NST. This study evaluates this association and the location of the NST in a large cohort of male CDH survivors. Moreover, we analyzed possible associative factors for NST in CDH patients. METHODS: A cohort of CDH patients, born between January 2000 and March 2014 and treated in a high volume expertise center, was evaluated retrospectively. Boys with a minimum follow-up of 18months were included. The patients were evaluated for testes location, performed orchidopexy, and possible associative factors such as birth weight, gestational age, other congenital anomalies and CDH characteristics (surgical treatment, approach and ECMO). RESULTS: Seventy-five CDH patients were included. Twenty-seven (36%) were diagnosed with NST, of which 22 (29%) received orchidopexy. In 54 patients (72%) there were reports on testes location at birth and location was known for all patients at the age of 18months, although side of NST was unknown in four. The location of the NST was mostly ipsilateral to the CDH (n=20, 87%), of which eight (35%) had a bilateral NST with a unilateral CDH. There were no significant differences in birth weight, gestational age, and CDH specific characteristics in patients with or without NST. CONCLUSION: This study shows a strong association between CDH and NST, with a prevalence of 36%. However, no specific characteristics of the CDH were related to the NST. The testes of all male CDH patients should be thoroughly evaluated in the first year of their life, to ensure a proper and timely treatment. LEVEL OF EVIDENCE: Level IV; case series.

Evaluation and Management of the Undescended Testis in Puerto Rico: A Single Surgeon's 10 Years of Experience.

OBJECTIVE: Cryptorchidism is an abnormality of the male genitourinary tract in which one or both testes fail to descend into the scrotum. The American Urological Association (AUA) clinical guidelines for the evaluation and treatment of cryptorchidism were recently published. We reviewed our experience with the evaluation and management of our patients and examined our findings with respect to the AUA and European Association of Urology (EAU) guidelines. METHODS: Data were obtained from pediatric patients who underwent a surgical intervention for an undescended testis from 2007 through 2017 at HIMA Hospital and the University Pediatric Hospital (both in Puerto Rico); all the surgeries were performed by the same surgeon. A total of 754 patients were identified; 142 patients were excluded due to lack of follow-up data (N = 612). The data obtained included age, testes locations, radiologic and surgical findings, and postoperative results. RESULTS: At their initial evaluations, a large proportion of the patients (46.4%) came accompanied with radiographic imaging. These findings were consistent with those of the physical examination in 58.5% of the patients and with the surgical findings in 63.1% (sensitivity 77.9%, specificity 45.8%). Our data showed that the median referral age was 24 months, which suggests that there was a significant delay in diagnosis. At the time of surgery, the average age of the patients who required an orchiectomy was 3.93 years, while those who underwent an orchiopexy had an average age of 3.28 years. CONCLUSION: Our data reveal that, despite its lack of usefulness, radiologic imaging continues to be included in the diagnostic workups of children newly identified with cryptorchidism in Puerto Rico. In addition, and contrary to the guidelines, there tends to be a significant delay in treatment with surgical intervention. It is important to continue to educate our referring physicians on the AUA and EUA guidelines in order to create awareness and encourage the proper diagnostic and treatment approach for cryptorchidism.

A Canadian national survey: understanding the differences in management of cryptorchidism among pediatric surgeons and pediatric urologists.

BACKGROUND: This investigation aims to assess the variability in practice patterns regarding management of children with cryptorchidism (UDT) among pediatric urologists (U) and pediatric surgeons (S) practicing in Canada. METHODS: All active members of Pediatric Urologists of Canada (PUC) and Canadian Association of Pediatric Surgery (CAPS) were invited to participate in an online multiple-choice type questionnaire with clinical scenarios in management of UDT. Responses were compared between U and S using Fisher's exact test. RESULTS: The response rates were 74% and 79% among CAPS members (54/73) and PUC members (27/34) respectively. CAPS members were more likely to order diagnostic ultrasounds prior to surgery (44.4% vs 18.5%, p = 0.027). For palpable testis, most (80%) CAPS members favored the classic inguinal approach, while most PUC members did not demonstrate a clear preference, and were flexible with their approach depending on the position of the palpated testes (55%; p < 0.001). There was no statistically significant difference in preferred approach to unilateral or bilateral nonpalpable testis. However, for both palpable and nonpalpable bilateral UDT, more CAPS members preferred metachronous correction, compared to PUC members who opted to approach them synchronously (p = 0.008, 0.002, respectively). CONCLUSION: Preferences with regard to use of diagnostic tools such as US, surgical approach for palpable testes and bilateral UDTs were not consistent between the two surgical specialties who perform orchidopexy across Canada. Both groups were compliant with guideline recommendations, with the exception of utilizing preoperative ultrasounds, which is uniformly not recommended by the most recent guidelines. LEVEL OF EVIDENCE: This is a level II evidence study.

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

BACKGROUND/AIM: Approximately 20% of undescended testes (UDT) are bilateral. It is unclear whether bilateral orchidopexy (BO) should be undertaken synchronously (SBO) or metachronously (MBO). Our aim was to investigate current UK practice and the complications of SBO vs MBO. MATERIALS & METHODS: Following approval of BAPS and BAPU ethics committee, a survey was circulated to UK consultant pediatric surgeons and urologists regarding practice. A departmental retrospective review was additionally carried out for patients undergoing BO between 2005 and 2017. RESULTS: Forty-three consultant surgeons from 20 centres completed the survey. Overall, SBO was preferred by 70% for bilateral palpable UDT versus 30% for bilateral impalpable UDT. When one side was palpable and the other impalpable, 70% preferred SBO. Pediatric urologists were significantly more likely to undertake SBO than pediatric general surgeons. One hundred eighty-eight patients (376 testicular units) were identified who had undergone BO with a median follow up of 9 months. 144/188 (76.6%) underwent SBO, while 44 had MBO. There was no statistical difference in the complication rate between the two groups (7.6% in SBO vs 9.1% in MBO; p = 0.66). CONCLUSIONS: The majority of the responding UK consultants, in particular pediatric urologists, favor SBO. This potentially offers a reduction in cost, more rapid completion of treatment, and is not associated with additional complications by comparison to MBO. We recommend SBO to be standard practice for bilateral UDT whenever possible. LEVEL OF EVIDENCE: Level III, Retrospective Comparative Study.

Secular trends in the incidence and timing of surgical intervention for congenital undescended testis and surgically treated hypospadias in Ontario, Canada between 1997 and 2007.

INTRODUCTION: Recent studies have suggested contradictory trends in the incidence of undescended testis (UDT) and hypospadias (HYP), partly because of methodological issues and ascertainment bias. The recently described association of "testicular dysgenesis syndrome" links concomitant UDT and HYP, with decreasing sperm counts and testicular cancer. Current guidelines suggest that orchidopexy for UDT should be performed by 18 months of age. OBJECTIVE: We conducted a retrospective population-based cohort study to estimate the incidence of UDT, HYP, and concomitant UDT and HYP in Ontario, based on a surgical procedure performed in the 5 years after birth. We hypothesized that the incidence of UDT and HYP are stable in the province of Ontario, Canada, over an 11-year time period. STUDY DESIGN: Linked administrative databases held at the Institute of Clinical Evaluative Sciences (ICES) in the province of Ontario, were used to identify all live male newborns between 1997 and 2007. Incidence rates of UDT, HYP and concomitant UDT and HYP were calculated by identifying a surgical procedure for these anomalies, within 5 years of birth. Incidence trends were analyzed using the Cochrane Armitage test for trend. Age at surgery for surgical intervention for an orchidopexy or HYP repair was determined. RESULTS: The incidence of UDT, defined by an orchidopexy within 5 years of birth, has remained stable in Ontario, Canada (8.2/1000 male live births, p-value for trend 0.9, 95% CI 8.0-8.4). The incidence of hypospadias has similarly remained stable (3.8/1000 male live births, p-value for trend 0.8, 95% CI 3.7-3.9). The incidence of concomitant UDT and HYP repair showed a significant increase over the 11-year period (0.2/1000 male live births, p-value for trend 0.03, 95% CI 0.2-0.3). The median age at orchidopexy (23 months, IQR 16-34 months) was beyond guideline recommendations, with earlier orchidopexy in recent years. The median age at hypospadias repair was 17 months (IQR 12-26 months). DISCUSSION: The variable rates of incidence for UDT and HYP can be explained by variations in study methodology and differing data sources utilized. The current study uses a surgical procedure to minimize information bias to correctly identify index cases of UDT and HYP. CONCLUSIONS: The incidence of undescended testis and hypospadias, over 5 years after birth, has remained stable in the province of Ontario between 1997 and 2007 (Summary Table). Concomitant UDT and HYP incidence showed a significant increase over this time period. Most boys in Ontario, Canada, undergo orchidopexy beyond 18 months of age.

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

BACKGROUND: The undescended testis (UDT) is the most common genital anomaly encountered in pediatrics with an estimated incidence of 1% to 4% in full-term and 1% to 45% in preterm newborn boys. Over the years, studies on progressive histological deterioration and cancer risk has led to a change in recommendations for when orchidopexy should be done. OBJECTIVES: Determine age at presentation of patients for UDT to a specialist in Saudi Arabia, age of operation and whether the recommended targeted time frame has been met. DESIGN: Descriptive retrospective medical record review. SETTINGS: University hospital setting in urban location. SUBJECTS AND METHODS: The records of patients presenting to our center with UDT between the years 1996-2015 were reviewed for data on the age at presentation and age of operation. MAIN OUTCOME MEASURES: Age at time of evaluation and at time of surgical intervention compared with the international standard. SAMPLE SIZE: 331 cases. RESULTS: Out of the cases included, 195 met the inclusion criteria. The median age of presentation was 13.7 (range: 0-123.2) months. The median age at time of orchiopexy was 25 (range: 7.5-130.2) months. The median waiting time for elective surgery was 4.8 months ( less than 1 day to 49.4 months). CONCLUSION: Despite the international recommendation of carrying out orchidopexy between the ages of 6-12 months, the targeted recommended time frame is not met in Saudi Arabia. This is mainly related to late referral age and the long waiting time for elective surgery. LIMITATIONS: Small sample size and retrospective design. CONFLICT OF INTEREST: None.

Shortcomings in the management of undescended testis: guideline intention vs reality and the underlying causes - insights from the biggest German cohort.

OBJECTIVES: To assess the implementation of the current guideline and identify potential underlying causes for late surgery in children with undescended testis (UDT) in Germany. UDT is the most common surgical issue in paediatric urology and to avoid malignant degeneration and subfertility current guidelines recommend orchidopexy during the first year of life; however, this seems not to be implemented in practice. PATIENTS AND METHODS: In all, 5 547 patients with cryptorchidism at 16 hospitals nationwide were studied regarding age at orchidopexy between 2003 and 2016. Multivariate analysis was performed to identify factors influencing timing of surgery. Additionally, a survey on knowledge of UDT management was conducted amongst physicians treating boys and final-year medical students. RESULTS: Between 2003 and 2008 only 4% of boys with UDT underwent surgery before the age of 1 year. After the guideline update from 2009, this figure was 5% from 2010 to 2012, and 8% from 2013 to 2016. The presence of a specialised department for paediatric surgery, as well as a high UDT case-to-year ratio positively influenced the timing of orchidopexy. The survey revealed discipline-specific differences in the levels of knowledge about UDT management. One-third of respondents did not know the guideline recommendations and 61% felt insufficiently informed. International comparisons revealed significant differences in the age at surgery of boys with UDT, with Germany and Great Britain ranging in the middle of the field. CONCLUSIONS: Currently, only a small proportion of boys with UDT are operated upon during their first year of life. The level of knowledge in attending physicians remains in need of improvement. This should be actively addressed, i.e. by campaigns and educational programmes. Further studies are needed to investigate the underlying causes of late orchidopexy in UDT.

Telehealth in paediatric surgery: Accuracy of clinical decisions made by videoconference.

AIM: Telehealth is a useful method of providing specialist consultation to a geographically diverse population. Canadian studies of telehealth for paediatric surgery demonstrate good accuracy, but have low numbers of cryptorchid patients in their cohorts. Our aim was to confirm Canadian studies for our cohort and to assess accuracy regarding cryptorchidism. METHODS: We conducted a cohort study of patients seen via paediatric surgical telehealth over a 12-month period, to determine accuracy of telediagnosis with respect to face-to-face diagnosis and plan. RESULTS: A total of 183 children had 224 videoconferences, resulting in 74 surgical bookings. There was high diagnostic concordance, except for undescended testes. One discharged patient, and two patients booked for review, have subsequently required an orchidopexy (false negatives). Of 15 patients booked for surgery, three did not require an operation (false positives). Other patients had their procedures upgraded (from open to laparoscopic) or downgraded (from laparoscopic to open) due to inaccuracies in far-end assessment. CONCLUSION: Telehealth for paediatric surgery is accurate for most conditions seen, but for cryptorchidism there are significant concerns.

Health Disparities in the Appropriate Management of Cryptorchidism.

OBJECTIVE: To assess regional practices in management of cryptorchidism with regard to timely fixation by the current recommended age of 18 months. STUDY DESIGN: A retrospective study was performed. Charts of all patients who underwent surgical correction for cryptorchidism by a pediatric general surgeon or urologist within a tertiary pediatric hospital in an urban setting were systematically reviewed. RESULTS: We identified 1209 patients with cryptorchidism. The median age of surgical correction was 3.7 years (IQR: 1.4, 7.7); only 27% of patients had surgical correction before 18 months of age. Forty-six percent of our patients were white, 40% were African American, and 8% were Hispanic. African American and Hispanic patients were less likely to undergo timely repair (P?=?.01), as were those with public or no insurance (P?

The management of boys under 3 months of age with an inguinal hernia and ipsilateral palpable undescended testis.

AIMS: The optimal management for boys under 3 months of age with an indirect inguinal hernia (IIH) and ipsilateral palpable undescended testis (IPUDT) is unknown. We aimed to: 1) determine the current practice for managing these boys across the UK, and 2) compare outcomes of different treatment strategies. METHODOLOGY: We undertook two studies. Firstly, we completed a National Survey of all surgeons on the British Association of Paediatric Surgeons email list in 2014. Subsequently, we undertook a multi-centre, retrospective, 10-year (2005-2015) review across 4 pediatric surgery centers of boys under 3months of age with concomitant IIH and IPUDT. Primary outcome was testicular atrophy. Secondary outcomes included need for subsequent orchidopexy, testicular ascent and hernia recurrence. Data are presented as median (range). Chi-squared test and multivariate binomial logistic regression analysis were used for analysis; p<0.05 was considered significant. RESULTS: Survey: Consultant practice varies widely across the UK, with a tendency towards performing concurrent orchidopexy at the time of herniotomy under 3 months of age. Concurrent orchidopexy is favored less in cases where the hernia is symptomatic. Case Series Review: Forty-one boys with 43 concomitant IIH and IPUDT were identified, and all included. 32 (74%) hernias were reducible, 11 (26%) were symptomatic requiring urgent or emergency repair. Post-conceptual age at surgery was 45weeks (36-65). Primary operations included: 29 (67%) open hernia repair and standard orchidopexy, 8 (19%) open hernia repair with future orchidopexy if required, 4 (9%) laparoscopic hernia repair with future orchidopexy if required, 2 (5%) open hernia repair and suturing of the testis to the inverted scrotum without scrotal incision. Variation in atrophy rate between different surgical approaches did not reach statistical significance (p=0.42). Overall atrophy rate was 18%. If hernia repair alone was undertaken (8 open and 4 laparoscopic), the testis did not descend in 8 patients, requiring subsequent orchidopexy (67%); if orchidopexy was undertaken at the time of hernia repair, 1 in 29 required a repeat orchidopexy (3%) (p=0.0001). No hernia recurred. CONCLUSION: This study suggests that orchidopexy at the time of inguinal herniotomy does not increase the risk of testicular atrophy in boys under 3months of age.

Missed Torsion of the Spermatic Cord: A Common yet Underreported Event.

OBJECTIVE: To describe the incidence of missed diagnosis and delayed presentation in children with testicular torsion, and to identify associated risk factors. MATERIALS AND METHODS: The medical records of all children over 1 month of age diagnosed with testicular torsion between 2008 and 2014 were reviewed. Data pertaining to patient characteristics and treatment outcome were collected. Orchiectomy was categorized as caused by either delayed presentation or missed diagnosis. Logistic regression analyses were used to evaluate the association between patient characteristics and treatment outcome. RESULTS: The study cohort included 100 children, 40 of whom underwent orchiectomy. Twenty-eight patients arrived with delayed presentation, and 12 were incorrectly diagnosed. On univariable logistic regression analyses, young age, long duration of pain, and prior community clinic examination were significantly associated with orchiectomy. Similarly, these variables were associated with delayed presentation and missed diagnosis when compared with the orchiopexy group. On multivariable analysis, young age and long duration of pain remained significant predictors of orchiectomy. Doppler ultrasound was performed in 70 patients; 7 of 70 ultrasounds were incorrectly diagnosed. Young age was associated with missed sonographic diagnosis, whereas ultrasound performer (senior radiologist vs resident) and time of the day were not. CONCLUSION: Missed diagnosis may account for up to 12% of orchiectomy cases. Younger age and prior community clinic examination increase the risk of incorrect diagnosis. Doppler ultrasound should be used with discretion and its results interpreted cautiously.

Comments to Recent Guidelines on Undescended Testis.

During the past couple of decades, our understanding of the treatment of undescended testis (UDT) has hugely expanded and it is still dynamically changing: new diagnostic tools are available, and experimental procedures are becoming a real-life treatment options. Our community needs to continuously update our guidelines. It is also our responsibility to build up, not a uniform, but a patient-oriented guideline which can provide information for both primary care providers and pediatric surgeons. Here, in Europe, we endeavor to change the different national guidelines to one common European pediatric surgical guideline in the treatment of UDT.