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.

Long-term testicular growth and position after orchidopexy for congenital undescended testis.

AIM: We aimed to investigate long-term testicular growth and the position of congenital undescended testes (UDT) after orchidopexy (ORP), taking into account that nowadays UDT has to be divided into congenital and acquired forms. METHODS: This study included 181 patients with 199 congenital UDT (91 right-sided, 72 left-sided, 18 bilateral), in whom ORP had been carried out (1986-2006). Long-term testicular position and growth were assessed by clinical examination and ultrasound (US). RESULTS: In 44.5% (65/146), testicular volume of the unilaterally operated congenital UDT was >50th percentile for age. In 55.5% (81/146), the volume was < or =50th percentile, and 13.0% (19/146) of these were < or =10th percentile. In 7 of 34 (20.6%) bilaterally operated congenital UDT, testicular volume was < or =10th percentile. The difference in size between the operated congenital UDT and the contralateral non-operated testes measured by both Prader orchidometer (p = 0.00) and US (p = 0.00) was statistically significant. There was a strong correlation between the orchidometer and US. On examination, 87.9% (175/199) of the operated testes were located in the lower scrotum. CONCLUSION: The findings of this study suggest that ORP for congenital UDT is safe, and even when performed later than current recommendations did not result in severe growth retardation.

The frequency of undescended testis from birth to adulthood: a review.

We performed a systematic review and critique of the literature on the frequency of undescended testis (UDT) among boys from birth to adolescence. Special attention was given to whether previous testicular position was taken into account to distinguish between congenital and acquired UDT. We searched Medline, Embase, Cinahl and the Cochrane Library. Any study reporting on the frequency of UDT was included. Study population age, number of boys studied, period of examination, primary examiner, area of study, study design, ethnicity, definitions used and previous testicular position were analysed. A total of 46 studies met the inclusion criteria. Twenty-three of the 46 (50%) studies involved newborns. Definitions were described in half of the studies; however, the definitions used were heterogeneous. Previous testis position was described in 11% (5/46) of the studies. At birth, in term and/or birth weight >2.5 kg infants, the UDT rate ranged from 1.0 to 4.6%, and in premature and/or birth weight <2.5 kg infants from 1.1 to 45.3%. At the age of 1 year UDT in term and/or birth weight >2.5 kg infants was seen in 1.0-1.5%, at 6 years in 0.0-2.6%, at 11 years in 0.0-6.6% and at 15 years in 1.6-2.2% of boys. The frequency of UDT shows variable figures in the literature. The actual frequency of acquired UDT essentially remains unclear because of the shortage of studies performed at an older age, and of studies reporting on previous testicular position.

[Undescended testis: current views and advice for treatment]. / De niet-scrotale testis: huidige inzichten en advies voor behandeling.

--Undescended testis (UDT) is one of the most common urogenital abnormalities in boys. --UDT is defined as a testis which cannot be brought into a stable scrotal position. --At present, congenital and acquired forms of UDT are recognised. Congenital UDT is defined as a UDT which has never descended from birth. Acquired UDT is defined as a UDT which has been fully descended in the past. --Congenital UDT should be treated surgically between 6 to 12 months of age. --The treatment of acquired UDT is still disputed. As yet, awaiting spontaneous descent at early puberty seems to be the most rational treatment. --In the Netherlands, the high number of late orchidopexies is due to surgery for acquired UDT. To reduce this high number, the guidelines of the first development conference on 'non-scrotal testis' dating back to 1986 should be revised on several points.

[Back pain? Don't forget the abdomen]. / Pijn in de rug? Vergeet de buik niet.

Three patients, men aged 62, 57 and 44 years, had suffered for 6-24 months from low back pain, which after an acute moment had worsened with pain radiating to one leg. In all 3 patients, a neurological cause was considered first, but investigations revealed that they had a large abdominal aortic aneurysm (AAA) resulting in emergency surgery. The oldest man died from late complications; the younger men made a good recovery. An AAA should be considered in patients with low back pain and risk factors such as male gender, older age, cigarette smoking, hypertension and previous manifestations of vascular disease. Making the diagnosis as early as possible can be lifesaving.

[Previous testicular position in boys who underwent orchidopexy due to undescended testis at the Alkmaar Medical Center, the Netherlands, during the period 1986-1999]. / De vroegere testisligging van jongens bij wie orchidopexie was verricht wegens niet-ingedaalde testis in het Medisch Centrum Alkmaar (1986-1999).

OBJECTIVE: To determine the previous testicular position in boys, in whom orchidopexy was performed for undescended testis. DESIGN: Retrospective, descriptive. METHOD: All boys, aged 0-18 years, who underwent orchidopexy in the Alkmaar Medical Centre, the Netherlands, during the period 1986-1999, were studied. The following information was obtained from the hospital medical records: indication for operation, date of the operation, laterality (unilateral or bilateral), the surgical findings and whether previous testicular position played a role in the decision to perform orchidopexy. For each boy who underwent orchidopexy for undescended testis, previous testicular positions up until the date of the operation were obtained from the appropriate youth health care institutions. RESULTS: Hospital records were available for 851 boys who had undergone orchidopexy. The operation for undescended testis was performed in 717 boys and previous testicular positions were obtained for 565 boys. On a per testicle basis, 707 operations were carried out (142 bilaterally, 205 left-sided, 218 right-sided). From these 707 testes, a previous intrascrotal position was found at least once in 572 (80.9%), at least twice in 493 (69.7%) and at least three times in 419 (59.3%); 135 (19.1%) testes had never been intrascrotal. The majority of previously undescended testes were operated on at 3 years of age; most operations on previously descended testes were performed at 10.5 years of age. For 344 (48.7%) out of 707 testes, previous testis localisation was known in the hospital's medical records, for 96 (13.6%) testes registration was unclear and in 267 (37.8%) testes it was not reported. In 8 (1.4%) boys, testis registration after the birth was used on referral to document previous testicular position. CONCLUSION: In total 80.9% of all orchidopexy operations were performed on testes that had previously been diagnosed as having descended normally. These probably included retractile testes as well as acquired forms. In 51.3% of the cases, previous testicular position was not known in the hospital's medical records at the time of operation.

Uptake of (18)F-fluoro-2-deoxyglucose in the Healthy Testes of Young Men as Assessed by Positron Emission Tomography/Computed Tomography; Including the Inter- and Intra-observer Variation.

Knowledge of the physiological testicular accumulation of (18)F-fluoro-2-deoxyglucose (FDG) is essential in order to discriminate between normal and pathological findings. In this study, the (18)F-FDG-uptake in healthy testes of young men was assessed using positron emission tomography/computed tomography (PET/CT)-scans. A total of 40 testes of 20 men with a mean age of 26.5 ± 3.9 years were evaluated. (18)F-FDG-uptake was expressed as the standardized uptake value (SUV). Testicular volume was measured on CT and PET. All scans were assessed by three researchers, one of whom assessed every scan twice. Laterality indices and inter- and intra-observer variation were evaluated. Correlation between the SUVmax and SUVpeak, between SUVmean and SUVpeak and between age and SUVpeak were assessed. Testes showed an average SUVmax of 3.42 ± 0.61, SUVpeak of 3.06 ± 0.54 and SUVmean of 2.44 ± 0.44. The average testicular volume on CT was 23.0 ± 6.4 ml, whereas on PET it was 18.0 ± 5.1 ml. Laterality indices were calculated of 0.077 ± 0.065 (SUVmax), 0.074 ± 0.066 (SUVpeak), 0.072 ± 0.063 (SUVmean), 0.245 ± 0.259 (CT), and 0.200 ± 0.188 (PET), respectively. Inter- and intra-observer reliability were found to be perfect for the SUVs (intraclass correlation coefficient [ICC] 0.992-1.0), but poor for testicular volumes (ICC 0.854-0.902). Testicular (18)F-FDG uptake in young men can be measured accurately on PET/CT and shows high symmetry. Consequently, (18)F-FDG PET/CT has the potential to become a useful instrument in the evaluation of the functioning of the individual testis.

Reduction in the number of orchidopexies for cryptorchidism after recognition of acquired undescended testis and implementation of expectative policy.

BACKGROUND: Since the mid-1990s, acquired undescended testis has gradually been recognised as a separate entity for which the efficacy of prepubertal surgery has not been univocally been demonstrated. Therefore, in our hospital, orchidopexy was no longer routinely performed for acquired undescended testis. AIM: To investigate the effect of expectative policy in our hospital on the number of orchidopexies. METHODS: Two 5-year periods were compared. Period A (1991-1995), in which undescended testis was treated surgically, and period B (2000-2004), in which prepubertal orchidopexy in our hospital was no longer performed for acquired undescended testis. In addition, a comparison was made between the percentage reduction in hospital and national figures. RESULTS: In period B, the number of orchidopexies in our hospital was reduced by 61.8% (from 387 to 148), mainly in the age group >6 years. Nationally, during the same period, the number of orchidopexies decreased only by 2.4% (from 18 024 to 17 591). CONCLUSION: The results of this study confirm that recognition of acquired undescended testis is crucial for reducing the high number of (late) orchidopexies.

Puberty stage and spontaneous descent of acquired undescended testis: implications for therapy?

We assessed spontaneous descent of acquired undescended testis (UDT) at puberty. 299 Boys (aged 1.2-16.5 years, mean 9.4) with 350 acquired-UDT were examined annually during a 12.6-year period (mean 3.1). An acquired-UDT was defined as a previously intrascrotal testis which can no longer be manipulated into a stable scrotal position. Each year, position of the testis and pubertal development according to Tanner's stages were assessed. Early puberty was defined as puberty stage G2 (testicular volume 4-9 mL), mid-puberty as puberty stages G3 (testicular volume 10 mL) and G4 (testicular volume 11-15 mL), and late puberty as puberty stage G5 (testicular volume >15 mL). Follow-up was completed if spontaneous descent had occurred, if mid-pubertal orchidopexy (ORP) had to be performed, if the boy was lost for follow-up, or if pre-pubertal ORP was performed in another hospital. In 139 boys with 164 acquired-UDT follow-up was meanwhile completed. Twelve boys with 14 UDT were lost for follow-up. In an additional 16 boys with 21 UDT, ORP was performed in another hospital. In 98 of the remaining 129 (76.0%) acquired-UDT spontaneous descent at puberty occurred. Mean follow-up was 2.5 years (range 0.2-8.5). In 70 of 98 testes (71.4%) descent occurred in early puberty, in 26 of 98 testes (26.5%) in mid-puberty, and in two testes in late puberty. In 31 of 129 testes (24.0%) ORP had to be performed at mid (30 cases) or late (one case) puberty. In this series, 98 of 129 acquired-UDT (76.0%) descended spontaneously at puberty, whereas in 31 of 129 (24.0%) pubertal ORP was performed. If ORP is postponed until puberty stage G3 (testicular volume of 10 mL) three of four acquired-UDT will descend spontaneously.

Successful treatment of acquired undescended testes with human chorionic gonadotropin.

Human chorionic gonadotrophin therapy may have its place in the management of acquired undescended testes and surgery should be reserved for those who fail to respond to therapy. Further studies are necessary to evaluate these preliminary results.

The rubber dam as a means to isolate contaminated peritoneal defects after colonic resection.

After colonic resections, peritoneal defects exposed to colonic flora and blood may become the seat of localized peritonitis and cause small-bowel adhesions and obstruction. In the past five years, we have seen 14 patients where one or both of these complications was anticipated for one of the following reasons: presence of an abscess cavity, local infection or accidental tear of the colon. In these patients a rubber sheet was stitched to the edges of the peritoneal defect with absorbable sutures and brought out through the abdominal wall. In all patients the rubber dam functioned as a passive drain and as a barrier between the peritoneal defect and the small bowel. Three weeks later the rubber dam was removed by traction. None of these patients developed small-bowel obstruction and no adverse effects from the rubber sheet were seen. The working mechanism of the rubber dam was investigated in female Wistar rats. After removing the peritoneum between the left kidney and pelvis, the defect was covered with a rubber dam. A capsule with a standard solution of Escherichia coli, Bacteroides fragilis, and autoclaved feces was used to initiate peritonitis under the rubber dam. The rubber proved to act as an efficient drain and barrier. No abscesses or small-bowel adhesions were seen. In the control group, 75 per cent of the animals died from generalized peritonitis or developed an abscess.

A new clinical classification for undescended testis.

A new classification for undescended testis (UDT), suitable for a clinical setting, is proposed. UDT is categorized into congenital and acquired forms. Congenital forms include intra-abdominal, intra-canalicular, supra-scrotal and ectopic testes. Acquired forms can be divided into primary and secondary types. Primary forms are described as either ascending testes, i.e. those which cannot be manipulated into the scrotum, or high scrotal testes, i.e. those which can still be brought through the scrotal entrance into a high scrotal (unstable) position. Secondary forms are the result of ipsilateral groin surgery and are termed "trapped testes". Congenital forms of UDT should be treated surgically at an early age, preferably at 1 year. Therapy for primary acquired forms remains controversial. Therapeutic modalities include orchidopexy, hormonal treatment (preferably with human chorionic gonadotrophin) or waiting for spontaneous descent during the peripubertal period ("laissez faire policy"). Secondary acquired forms are probably best treated surgically.

Natural course of acquired undescended testis in boys.

BACKGROUND: Although orchidopexy is commonly performed for acquired undescended testis, therapy is still controversial. A prospective study on the natural course of acquired undescended testis in boys was initiated. METHODS: At present, the study includes 63 boys with 74 acquired undescended testes in whom treatment and follow-up has been completed. In 15 boys with 20 acquired undescended testes, orchidopexy was performed before the onset of puberty, mainly at the request of the parents. In the remaining 48 boys with 54 acquired undescended testes, the onset of puberty was awaited. Of these, four boys with four acquired undescended testes were lost to follow-up. RESULTS: In 42 of 50 boys the testis descended spontaneously at puberty with a testicular volume appropriate for age. In the remaining eight boys the testis failed to descend at puberty and orchidopexy was performed. CONCLUSION: The preliminary results of this study indicate that spontaneous descent at puberty commonly occurs in boys with acquired undescended testes, with testicular volume appropriate for age. It is suggested that surgical intervention before onset of puberty may not always be necessary in acquired undescended testis.

Surgical findings in acquired undescended testis.

BACKGROUND/PURPOSE: The aim of this study was to retrospectively review the findings at orchidopexy in acquired undescended testis (UDT). METHODS: The authors reviewed a 14-year (1986 through 1999) surgical experience in 360 boys in whom 461 orchidopexies were performed for acquired-UDT. The operative notes were reviewed to determine at operation testis position and volume, persistence of patent processus vaginalis (PV), and attachment of the gubernaculum. Also, testis position after orchidopexy was evaluated. RESULTS: Age at operation ranged from 2 to 19 years (mean, 8.9 years), 205 of the 461 orchidopexies (44.5%) had been performed between 9 and 12 years of age. In 327 of the 461 cases (70.9%), testis position was documented as intraoperative; in 281 of these cases (86.0%), the testis was located in the superficial inguinal pouch (SIP). A note was made regarding the presence or absence of a hernial sac in 207 of the cases: 113 (54.6%) were associated with an open PV, which usually was slightly open. In 122 of the 461 cases (26.5%), the gubernacular attachment was assessed; in 121 of these (99.2%), a normal attachment of the gubernaculum was noted. At the end of orchidopexy, in 438 of the 461 cases (95.0%), testis position was recorded. Three hundred eighty-two of these testes (87.2%) were at the bottom of the scrotum. CONCLUSIONS: Acquired UDT usually is characterized by SIP position, closed or (small) open PV, and normal gubernaculum attachment. The results of surgery seem excellent.

Previous testicular position in boys referred for an undescended testis: further explanation of the late orchidopexy enigma?

OBJECTIVE: To investigate the significance of the acquired undescended testis (UDT), which is differentiated into congenital and acquired forms, by assessing the previous testicular position in affected boys. PATIENTS AND METHODS: The study comprised 261 boys who had been referred for a non-scrotal testis to the outpatient clinic during an 8-year period (1993-2000). There was a bimodal distribution of age, with peaks at 2.0 and 10.0 years. In each boy with UDT the previous testicular position was ascertained. RESULTS: On referral, 340 testes were not in the scrotum (182 uni- and 79 bilateral). Of the 340 testes, 82 (24%) in 61 boys were diagnosed as retractile, whereas the remaining 258 in 221 boys were undescended. The previous testicular position was known in 208 of 221 boys (94%), with 244 UDTs. In 65 of these 244 (26.6%) the testis had never been scrotal (congenital UDT); in 179 (73.4%) a previous intrascrotal position was recorded in early childhood (acquired UDT) at least once, in 149 (61%) at least twice and in 117 (48%) at least three times. The mean age at referral for congenital UDT was 2.1 years and for acquired UDT was 8.4 years. CONCLUSIONS: These results show that acquired UDT is frequent, and occurs at about three times the rate of congenital UDT. Because these boys are referred for treatment later in childhood, the acquired UDT probably accounts for the high rate of (late) orchidopexy.