Retrospective histological evaluation of orchiectomy specimens following testicular torsion reveals a 10% incidence of reversible injury. Is it time for a change of strategy?

BACKGROUND: According to standard medical practice, immediate orchiectomy is advised in the case of a non-viable testis following testicular torsion. Because of the lack of objective criteria in the evaluation of testicular viability, the fate of the testis solely depends on the discretion and experience of the surgeon. OBJECTIVE: In this study, we retrospectively reassess the management of patients with testicular torsion in our center, and we ask the question, from a retrospective point of view, of whether the decision to perform orchiectomy has always been correct. MATERIALS AND METHODS: We retrospectively reviewed all cases of patients with testicular torsion who underwent surgery in our center between 2001 and 2021. All orchiectomy specimens were reevaluated and graded by an experienced pathologist using the Mikuz grading system. RESULTS: Immediate orchiectomy was performed in 48 of the 136 patients (35%). Five (10.4%) of the 48 orchiectomy specimens were categorized as "grade 1," and 17 (35.4%) were categorized as "grade 2." The time between the onset of symptoms and surgical exploration exceeded 12 h in three of the five patients with a "grade 1" testicular injury, and in one case, it even exceeded 24 h. DISCUSSION: "Grade 1" testicular injury is potentially reversible, whereas the fate of a testis with a "grade 2" testicular injury remains unknown. Whether and to what extent partial testicular tissue salvage in a "grade 2" injury is still possible remain unclear. CONCLUSIONS: Our results indicate that at least 10% of the testicles removed in our center could, from a retrospective point of view, have been salvaged. Our study further demonstrated that the duration of symptoms is not an absolute indicator of testicular damage and that the decision of whether orchiectomy should be performed, based simply on the subjective macroscopic image of the affected testis, is not always correct.

Three­Dimensional Ultrasonography in Preoperative and Postoperative Volume Assessment of the Undescended Testicle.

BACKGROUND Ultrasound (US) is the preferred imaging method for cryptorchidism, but most guidelines indicate that its value is questionable. The aim of this study was to evaluate the clinical value of ultrasonic mobility and testicular atrophy index (TAI) based on three­dimensional US (3DUS) in preoperative and postoperative assessment of the undescended testis. MATERIAL AND METHODS Data from 158 children with unilateral extraperitoneal cryptorchidism were collected and their diagnoses were surgically confirmed. They were divided into different age groups and into 2 ultrasonic mobility groups: the mobile group (MG) and the restricted group (RG). Differences in sonographic characteristics between different groups were compared. Three-dimensional ultrasound performed with virtual organ computer-aided analysis (VOCAL) was used to determined preoperative and postoperative TAI and the reliability of TAI was analyzed. RESULTS Measurement of testicular volume with the VOCAL method was significantly more reliable than that done with the two-dimensional Lambert method. In all age groups, preoperative testicular volumes were smaller than that in the contralateral scrotal testis and postoperatively, they increased steadily. Both preoperative and postoperative TAI were higher in the RG than in the MG. In the MG, postoperative TAI decreased significantly in all age groups. In the RG, in contrast, effective volume growth was only achieved in patients who had undergone surgery before they reached age 1 year. CONCLUSIONS TAI values determined with 3DUS using the VOCAL technique objectively reflect recovery of testicular volume following surgery for undescended testicle. Ultrasonic mobility evaluation is beneficial for clinical management of the condition.

Fine-Needle Aspiration Cytology of the Testes for the Classification of Azoospermia and Its Value in the Assessment of Male Infertility.

BACKGROUND: Infertility is an ever-increasing problem in today's world. It can be due to male or female causes. Azoospermia seen in 5-10% of infertile men is due to obstructive or non-obstructive causes. Traditionally, testicular biopsy is the gold standard for evaluation. Fine-needle aspiration (FNA), however, is minimally invasive, provides qualitative and quantitative information about spermatogenesis, and can aid in assisted reproductive techniques making it a novel technique for the evaluation of male infertility. OBJECTIVE: We aimed to classify different causes of azoospermia into different patterns based upon FNA, and assess the utility of cell indices in classifying cases into different patterns. METHOD: We conducted a prospective and a retrospective study of 42 azoospermic males, confirmed on semen analysis, over a period of 5 years. Patients were subjected to FNA of the testes. Smears were prepared, air-dried, wet-fixed, and then stained with May-Grünwald Giemsa and Papanicolaou stains, respectively. Cells were identified using predetermined morphologic criteria, and various indices were calculated followed by statistical analysis of the observations. RESULTS: The mean age of 40 patients who satisfied the adequacy criteria was 32.75 years (range 22-48 years). Thirty-four patients had primary infertility and 6 had secondary infertility. Of these, 12 had normal spermatogenesis, 8 had hypo-spermatogenesis, 3 had early and 7 had late maturation arrest, 6 had Sertoli cell-only syndrome (SCOS), and there were different results in each testicle in 4 cases. The Sperm Index (SI) was significantly higher in all cases of normal spermatogenesis than in any of the hypo-spermatogenesis cases (p = 0.009). The Sertoli Index (SEI) in cases of hypo-spermatogenesis and maturation arrest was significantly higher than in cases of normal spermatogenesis (p < 0.001). The Sperm-Sertoli Index (SSI) also showed significant differences between cases of hypo-spermatogenesis and normal spermatogenesis (p < 0.001). These indices were useful in categorising patients with azoospermia. CONCLUSION: FNA helps to easily and accurately identify all types of testicular cells without biopsy. SI, SEI, and SSI are powerful cell indices for assessing the extent of spermatogenesis and classifying various causes of azoospermia. Bilateral sampling and multiple aspirations give a better mapping of spermatogenesis within the testes. Testicular FNA can thus play a very important role in the evaluation of male infertility.

Contemporary Assessment of Long-Term Survival Rates in Patients With Stage I Nonseminoma Germ-Cell Tumor of the Testis: Population-Based Comparison Between Surveillance and Active Treatment After Initial Orchiectomy.

BACKGROUND: Historical data demonstrated similar survival outcomes in patients with stage I nonseminoma germ-cell tumor of the testis (NSGCTT) subjected to either surveillance or active treatment (AT) after orchiectomy. However, data with long-term follow-up are unavailable. We tested contemporary treatment rates and their effect on cancer-specific mortality (CSM) and other-cause mortality (OCM) relative to surveillance, as well as after stratification between chemotherapy (CHT) versus retroperitoneal lymph node dissection (RPLND). PATIENTS AND METHODS: We identified patients with stage I NSGCTT with initial orchiectomy within the Surveillance, Epidemiology, and End Results (SEER) database (1988-2015). Subsequent surveillance versus CHT versus RPLND use rates were reported. Cumulative incidence plots and multivariable competing-risks regression (CRR) models were used after propensity score (PS) matching. These tests first compared surveillance versus AT (CHT vs. RPLND) and subsequently CHT versus RPLND. RESULTS: Of 5034 patients with stage I NSGCTT, 61.2%, 24.9%, and 13.9%, respectively, underwent surveillance, CHT, and RPLND. Between 1988 and 2015, surveillance (estimated annual percentage change [EAPC]: +1.1%, P < .001) and CHT (EAPC: +2.3%, P < .001) rates increased. RPLND rates decreased (EAPC: -5.7%; P < .001). After PS matching, CRR models failed to identify AT as an independent predictor of lower mortality relative to surveillance. However, after PS matching, CRR models identified RPLND as an independent predictor of lower CSM (hazard ratio, 0.26; P = .002) relative to CHT. No difference in OCM rates was recorded (hazard ratio, 1.25; P = .2). CONCLUSION: Surveillance and CHT use rates increased while RPLND decreased in the last two decades. Virtually the same outcomes were recorded between surveillance and AT. However, within AT, RPLND was associated with lower CSM than CHT.

Intraoperative assessment of tubules in predicting microdissection testicular sperm extraction outcome in men with Sertoli cell-only syndrome.

OBJECTIVE: This study aimed to assess the value of measuring the tubule diameter during microdissection testicular sperm extraction (micro-TESE) in predicting outcomes in patients with Sertoli cell-only syndrome (SCOS). METHODS: Fifty-six consecutive patients with SCOS were included. Patients were classified into two groups on the basis of the diameter of seminiferous tubules measured against 5/0 surgical suture (≥100 µm or <100 µm). RESULTS: The sperm retrieval rate (SRR) in men with a tubule diameter ≥100 µm was significantly lower than that in those with <100 µm (3.1% vs. 25.0%). The SRR from the contralateral testis in men with a tubule diameter ≥100 µm was lower than that in those with <100 µm (0% vs. 14.3%). Men with a tubule diameter ≥100 µm had a significantly larger testis and lower follicle-stimulating hormone levels than did men with <100 µm (8.1 ± 2.4 vs. 5.3±1.8 mL, 19.9 ± 9.7 vs. 25.9 ± 7.1 mIU/mL, respectively). CONCLUSIONS: The diameter of tubules is a useful predictor for a successful SRR in men with SCOS. Intraoperative assessment of homogeneous large tubules allows some men to perform a limited (superficial) contralateral micro-TESE after no spermatozoa are initially identified.

Assessment of the use of contrast enhanced ultrasound in guiding microdissection testicular sperm extraction in nonobstructive azoospermia.

BACKGROUND: The aim of this study is to assess the value of contrast-enhanced ultrasound (CEUS) as a new non-invasive approach to locate the testicular area in which spermatogenesis is most likely to be found in non-obstructive azoospermic testes and to evaluate the accuracy of CEUS as a predictor of successful sperm retrieval. METHODS: CEUS was performed in 120 nonobstructive azoospermia (NOA) patients. Microdissection testicular sperm extraction (M-TESE) was performed on the best and poorest perfusion areas selected by CEUS and on conventional areas. RESULTS: In the 187 testicles that underwent M-TESE, the sperm retrieval rates (SRRs) in the best perfusion area and poorest perfusion area over the maximal longitudinal section and conventional area were 63.1, 34.7 and 47.1%. According to receiver operating characteristic (ROC) analysis, the arrival times (AT) ≤27 s, time-to-peak intensity (TTP) ≤45 s, and peak intensity (PI) ≥11 dB were the best predictors of positive sperm retrieval. The location of the best perfusion area was able to guide M-TESE to improve the success rates. CONCLUSIONS: Testicle CEUS is suggested to be performed in all patients with NOA. If AT≤27 s, TTP ≤ 45 s or PI≥11 dB are found in the best perfusion area, M-TESE is strongly recommended.

Xenotransplantation assessment: morphometric study of human spermatogonial stem cells in recipient mouse testes.

The purpose of this study was (i) To establish in vitro propagation of human spermatogonial stem cells (hSSCs) from small testicular biopsies to obtain a high number of cells; (ii) to evaluate the presence of functional hSSCs in culture system by RT-PCR using DAZL, α6-Integrin, ß1-Integrin genes; and (iii) to evaluate the effects of cell concentration on successful xenotransplantation of hSSCs in mice testis. Donor hSSCs were obtained from men with maturation arrest of spermatogenesis duration 1 year ago. These cells were propagated in DMEM containing 1 ng ml(-1) bFGF (basic fibroblast grow factor) and 1500 U ml LIF (leucaemia inhibitory factor) for 5 weeks. Different concentrations of hSSCs transplanted into seminiferous tubules of busulfan-treated immunodeficient mice and analysed up to 8 weeks after transplantation. The results showed that expression of DAZL and α6-Integrin mRNA was increased as well as the colony formation of SSCs in vtro culture during 5 weeks. Proliferation occurred about 4 weeks after transplantation, but meiotic differentiation was not observed in recipient testis after 8 weeks. The difference in donor cells concentration had effect on homing spermatogenesis in recipient testis. Homologous transplantation of proliferated SSCs to seminiferous tubules of that patient individually may allow successful differentiation of transplanted cells.

[Faulty implants: the court of appeal has ruled surgeon's responsibility]. / Prothèse défectueuse : la responsabilité du chirurgien écartée par la Cour de cassation.

It is in this atmosphere fuelled by the recent scandal of the PIP implants that the final court of appeal has given a judgment on July 12, 2012 which reorients the debate. While patients seeked a shared responsibility between the provider of the implants and the surgeon, in this case of faulty testicular implants, the final court of appeal just ruled out the responsibility of the surgeon. But this jurisprudence can only be applied to private law, i.e. for private healthcare whereas lawsuits filed against public hospitals depend on a different legal liability system.

Varicocele repair for nonobstructive azoospermia.

PURPOSE OF REVIEW: To evaluate the role of varicocelectomy in the management of patients with varicoceles and nonobstructive azoospermia and to review predictors of successful outcomes. RECENT FINDINGS: Several small, retrospective, noncontrolled studies have documented return of sperm to the ejaculate in up to 56% of men with nonobstructive azoospermia (NOA) following varicocele repair. Additionally, a recent meta-analysis has reported a 6% spontaneous pregnancy rate in amongst NOA patients who underwent varicocele repair, regardless of surgical technique. Although these observations are promising, evidence for whether or not varicocele repair significantly improves spermatogenesis within an impaired testicle is conflicting. No clear predictors of success following varicocele repair have been identified, but a certain level of spermatogenesis on testicular biopsy appears to be necessary for a desirable outcome after varicocele repair. SUMMARY: The role of varicocelectomy for the treatment on NOA is controversial. Prospective, controlled studies are needed in order to define the true benefit of varicocele repair in men with NOA, in terms of improvement in semen parameters, testicular sperm retrieval rates, and pregnancy outcomes.

Frozen section assessment in testicular and paratesticular lesions suspicious for malignancy: its role in preventing unnecessary orchiectomy.

To investigate the role of frozen section assessment in sparing unnecessary orchiectomy for suspected lesions, we retrospectively reviewed intraoperative testicular and paratesticular frozen section assessments performed at our institution between the years 1993 and 2010. Frozen section assessments were performed on 45 testicular lesions (age, 5-60 [mean, 32.2] years; lesion size, 0.5-9.7 [mean, 2.1] cm) and 20 paratesticular lesions (age, 26-76 [mean, 43.5] years; lesion size, 0.4-11.0 [mean, 2.8] cm) before the decision to complete radical orchiectomy. Benign/malignant frozen section assessment diagnoses were reported in 26/19 testicular cases and 17/3 paratesticular cases, respectively. Of the 26 benign testicular frozen section assessments, 5 cases resulted in orchiectomy, where permanent diagnoses included epidermoid cyst, large cell calcifying Sertoli cell tumor, fibrous pseudotumor, abscesses, and sarcoidosis, caused by a concern for potential malignancy or questionable viability of the testicles. Of the 19 malignant testicular frozen section assessments, orchiectomy was performed in 16 cases with germ cell tumor, but not in the remaining 3 cases with lymphoma. Of the 17 benign paratesticular frozen section assessments, 2 cases, both fibrous pseudotumors, resulted in orchiectomy. There were statistically significant differences in the size of the testicular (P < .001) or paratesticular (P < .001) lesions between benign and malignant frozen section assessments. Thus, in 36 (83.7%) of 43 cases with benign frozen section assessments, in addition to all 3 cases of lymphoma, orchiectomy was successfully avoided. These results suggest that frozen section assessment is useful for permitting testicular preservation, especially in men with small, nonpalpable, incidentally found masses as well as other benign lesions where a clinical diagnosis of malignancy is in doubt.

Race and insurance status are risk factors for orchiectomy due to testicular trauma.

PURPOSE: Race and insurance status independently predict outcome disparities after trauma. Black patients, Hispanic patients, uninsured patients and patients who live farther from trauma centers have a worse outcome after trauma than others. To our knowledge it is unknown whether these factors have a role in the testicular salvage rate after testicular trauma. We used NTDB (National Trauma Data Bank®) to investigate whether socioeconomic status, race and rural location predict testicular salvage. MATERIALS AND METHODS: Patients who sustained testicular trauma were identified in NTDB, version 9.1. Procedure codes for orchiectomy vs testicular repair were used to determine the risk of testicular salvage. Rural location was determined by matching the injury with the urban influence code. Univariate analysis of the influence of patient age, injury severity, race, insurance status and rural location was performed. Multivariate longitudinal analysis was done to identify orchiectomy predictors. RESULTS: Of 635,013 trauma cases 980 (0.2%) involved testicular injury. Of these patients 108 (11.0%) underwent orchiectomy and 58 (5.9%) underwent testicular repair. Self-paying patients had a statistically higher rate of orchiectomy than those with private insurance (79.2% vs 48.0%, p = 0.006). Black patients had a statistically higher rate of orchiectomy than white patients (75.8% vs 53.7%, p = 0.009). No difference in the orchiectomy rate was seen between Hispanic and nonHispanic patients (68.0% vs 65.8%, p = 0.84). In terms of rurality the incidence location was similar for orchiectomy and testicular repair, including urban 46.3% and 39.7%, rural 6.5% and 3.5%, suburban 2.8% and 1.7%, and wilderness 0.9% and 3.5%, respectively (p = 0.55). No statistically significant differences were found in age (31 vs 29 years, p = 0.42), injury severity score (5.8 vs 5.8, p = 0.99), hospital stay (8.4 vs 6.7 days, p = 0.41), intensive care unit stay (14.4 vs 9.6 days, p = 0.41) or ventilator days (18.2 vs 10.2, p = 0.24) for orchiectomy and testicular repair cases. CONCLUSIONS: Although age, injury severity score, hospital stay, intensive care unit stay and days of ventilator support are similar for patients who underwent orchiectomy vs testicular repair, the orchiectomy rate was higher for uninsured and black patients. Further studies are needed to elucidate the reasons for this disparity. Standardized protocols to manage testicular injury may decrease these disparities.

The vanishing testis: a histomorphologic and clinical assessment.

Of patients with cryptorchidism, 5% have no palpable gonad. Physical examination or scrotal exploration demonstrates tissue nubbins or small nodules that constitute the vanishing testis syndrome. At the University of Chicago Hospitals (Chicago, IL; 2004-2008), 30 surgical pathology specimens from 29 patients with this clinical diagnosis underwent scrotal exploration. Histologic and immunohistochemical comparison was done with 7 fetal testes, 8 surgically removed nonneoplastic testes, and 2 cryptorchid testes. Routine histologic studies showed no seminiferous tubules in 18 cases (60%), fibrosis in all (100%), calcifications in 16 (53%), and hemosiderin deposits in 9 (30%). In 12 cases with seminiferous tubules (40%), there were Sertoli cells only. Scrotal exploration in such cases is clinically driven and results in the removal of any tissue present. Although published studies suggest the risk for future tumor development is low, possibly absent, the definitive removal of a testicle is established by an awareness of the histologic spectrum exhibited by testicular remnants.

An ultrasonically actuated silicon-microprobe-based testicular tubule assay.

Microdissection testicular sperm extraction (TESE) is an invasive surgical procedure in which sparsely located healthy larger diameter tubules carrying viable spermatazoa are identified by visual examination of the seminiferous tubules of the infertile testis under a microscope, and biopsies of regions of interest are performed. In this paper, we report on microfabricated silicon microprobes integrated with an ultrasonic horn actuator and strain gauges for microdissection probe-TESE (MP-TESE) surgery. The microprobes, with axial-force-sensitive polysilicon strain gauges, have high force sensitivity (-0.4 V/N). The probes were used to detect the boundaries between seminiferous tubules, thus enabling identification of individual tubule diameters. Insertion experiments were performed on rat testis tissue, and by monitoring the tubule puncture in the recorded force, we were able to estimate the average diameter approximately 41.2 +/- 1.6 microm of the sperm-carrying tubules in samples. We have also demonstrated the ability to sense the existence of larger tubules embedded in a mess of thinner tubules, using an analytically calculated expression for the distribution of sizes measured by the microprobe. This information is important in MP-TESE to distinguish tubules with and without fertile sperm, potentially eliminating the large incision currently required for optical spermatazoa localization.

Isolation of human embryonic stem cell-derived teratomas for the assessment of pluripotency.

This unit describes protocols on how to assess the developmental potency of human embryonic stem cells (hESCs) by performing xenografting into immunodeficient mice to induce teratoma formation. hESCs can be injected under the testis capsule, or alternatively into the kidney or subcutaneously. Teratomas that develop from grafted hESCs are surgically removed, fixed in formaldehyde, and paraffin embedded. The tissues in the teratoma are analyzed histologically to determine whether the hESCs are pluripotent and form tissues derived from of all three embryonic germ layers (ectoderm, mesoderm, and endoderm). Teratomas can also be fixed in Bouin's or cryosectioned for analysis, and they can be analyzed by immunohistochemistry for tissue markers. Methods for these procedures are included in this unit.

Histological evaluation of the testicular nubbins in patients with nonpalpable testis: assessment of etiology and surgical approach.

There is a controversy in the literature whether testicular nubbins carry malignancy risk and excision of the nubbin is necessary in patients with nonpalpable testis. It is also controversial whether vanishing testis has the same etiopathogenesis and risk with true undescended testis. The aim of this study is to investigate the histological findings of testicular nubbins in patients with nonpalpable testis and to question etiology and surgical indications for vanishing testis. We reviewed the histopathological results of 44 testicular nubbins in 40 patients (mean age: 4.1 years, range 1-13 years) with nonpalpable testis between 1992 and 2004, retrospectively. Exploration revealed 5 intraabdominal and 39 inguinal testicular nubbins. Of 44 specimens only 5 (11.3%) from inquinal testicular nubbins were found to have seminiferous tubules. Two of the five had seminiferous tubule structures with viable germ cells showing maturation correlating with age. The other two with scarce seminiferous tubules were seen on only a single area and one had Sertoli cells only. None of the excised tissue had malignant degeneration. The vas deferens was identified in 23 (52.2%), vessels in 26 (59%), calcification in 14 (31.8%) and hemosiderin in 12 (27.2%) of excised tissue. Presence of calcification in one-third of the nubbins supports vascular accident thesis in the etiopathogenesis of vanishing testis. The possibility for the presence of seminiferous tubules and viable germ cells in the testicular nubbin is low. These facts decrease theoritical risk of malingnancy. Therefore, an inguinal exploration for testicular nubbin in patients with vas deferens and vessels entering into the inquinal canal diagnosed at laparoscopy can be postponed untill testicular prosthesis implantation and the nubbin can be removed at this operation.

Vascular anatomy of normal and undescended testes: surgical assessment of anastomotic channels between testicular and deferential arteries.

OBJECTIVES: To demonstrate the vascular anatomy of the normal and undescended testes, emphasizing the surgical importance of the anastomotic channels between the testicular and deferential arteries in the undescended testis. METHODS: This study was performed on four normal testes obtained from adult cadavers and the undescended testes taken from men undergoing unilateral orchiectomy. To show the arteries and their connections, we used the injection-corrosion casting technique. RESULTS: The normal and undescended testes measured 36.3 +/- 9.2 mm x 21.2 +/- 4.3 mm x 14.3 +/- 5.4 mm and 19 x 16 x 9 mm, respectively. The testis and epididymis had an unusual shape in the undescended testes. The undescended testes were round, with a semilunar epididymis that was over the testis. All the testes, including the undescended testes, had testicular, deferential, and cremasteric arteries. The testicular, deferential, and cremasteric arterial diameter was 1.7 +/- 0.4, 1.1 +/- 0.3, and 0.5 +/- 0.3 mm in the normal testes and 1.5, 0.7, and 0.6 mm in the undescended testes, respectively. Communication among the three arteries was illustrated consistently by retrograde filling of the two noninjected arteries. Clearly visible anastomotic channels were present between the testicular and deferential arteries in the normal and undescended testes. CONCLUSIONS: We suggest that the original Fowler and Stephans concept (high ligation of the testicular artery) is valid to preserve vascularity to the testis when vascular transection orchiopexy is performed, although the number of our specimens was not enough to prove this definitively.

Qualitative and quantitative histomorphologic assessment of fathead minnow Pimephales promelas gonads as an endpoint for evaluating endocrine-active compounds: a pilot methodology study.

Although histopathology is routinely employed as a tool for the detection and assessment of xenobiotic-mediated effects in mammals, it is less frequently applied to fish. In part, this is due to a lack of method standardization regarding study design, tissue preservation, tissue sectioning, histopathological evaluation, reporting, and statistical analysis. The objectives of the present study were: (1) to test and refine a method for the microsurgical excision of fathead minnow (FHM) Pimephales promelas gonads for the purpose of histopathologic examination; (2) to determine the optimal combination of fixation and embedding procedures for the histopathologic and morphometric analysis of FHM gonads following exposure to a known estrogenic compound, 17beta-estradiol (E2); and (3) to provide a method for the categorization and quantification of cell types in FHM gonads by manually counting cells in digitized images using image analysis software. The light microscopic evaluation of individual gametogenic cells was greatly facilitated by specimen preparation techniques that included the excision of gonads via microdissection and by optimized fixation and embedding procedures.

Cost analysis of laparoscopic versus open orchiopexy in the management of unilateral nonpalpable testicles.

PURPOSE: Laparoscopic exploration for the nonpalpable testicle (NPT) has been criticized for increased costs compared with primary inguinal/scrotal exploration, mostly due to high equipment costs and the need for open inguinal/scrotal exploration in many cases. We assessed costs associated with diagnostic laparoscopy vs inguinal/scrotal exploration followed by selective open or laparoscopic treatment for unilateral NPT to identify the most important factors that influence cost. MATERIALS AND METHODS: A comprehensive literature review determined the probabilities of intra-abdominal or inguinal nubbins, blind-ending vas/vessels and intra-abdominal or inguinal gonads in patients with unilateral NPT. The costs of anesthesia, equipment and operating room use were obtained from our institution or derived from the literature. A model was created using computer software to compare the costs of initial scrotal/inguinal approach or initial laparoscopic exploration in a theoretical population of boys with unilateral NPT. We established a set of assumptions and generated a series of 1-way sensitivity analyses to detect cost influencing parameters. RESULTS: Based on the probabilities of intraoperative anatomical gonadal findings, use of reusable laparoscopic equipment and encompassing the ultimate surgical procedure needed initial laparoscopic evaluation was less costly than initial scrotal/inguinal exploration by 69 US dollars on a population basis. One-way sensitivity analyses showed that initial laparoscopic exploration was less costly if the operative time of laparoscopic exploration did not exceed 19 minutes and the cost of disposable laparoscopic equipment was less than 147 US dollars. CONCLUSIONS: On a population basis initial laparoscopic evaluation of the clinically nonpalpable testicle has a cost saving advantage (69 US dollars) over initial inguinal-scrotal exploration when reusable laparoscopic equipment is primarily used, disposable equipment costs are kept low (147 US dollars or less) and operating room time for diagnostic laparoscopy are at national standards (19 minutes or less). These findings hold true for a wide range of probabilities and duration of inguinal exploration time. Given that all of these caveats are easily achievable, cost should not be used as a factor to bias against initial laparoscopic exploration.

Laparoscopy-assisted transinguinal extracorporeal gonadectomy in six patients with androgen insensitivity syndrome.

OBJECTIVE: To describe a new surgical technique to treat prophylactic gonadectomy in patients with androgen insensitivity syndrome. DESIGN: Prospective study. University hospital. PATIENT(S): Six patients with androgen insensitivity syndrome.Laparoscopy-assisted transinguinal or suprapubic extracorporeal gonadectomy. MAIN OUTCOME MEASURE(S): Accessibility, operation time, and cost-effectiveness. INTERVENTION(S): Laparoscopy-assisted transinguinal extracorporeal gonadectomy under general anesthesia was performed successfully, with no complications, in all patients as a one-day procedure. The operation times were 12 to 22 minutes (average, 16 minutes). Histopathologic examination revealed testicles in all cases. The cost of each operation was approximately dollar 500 to dollar 1000. CONCLUSION(S): Laparoscopy-assisted transinguinal or suprapubic and extracorporeal gonadectomy has several advantages over laparotomy and operative laparoscopy, including short operating time, safety, simplicity, and cost-effectiveness.

The usefulness of testicular atrophy index in the assessment of undescended testicle--preliminary report.

PURPOSE: Cryptorchidism affects 2-8% of male newborns. There is a controversy regarding timing of surgery as well as indications for orchiopexy in boys with retractile testicle. The aim of this study was to evaluate the clinical usefulness of testicular atrophy index (TAI) as a criterion of qualifying patients with undescended testes for surgery as well as of monitoring the results of treatment. MATERIAL AND METHODS: In 1999-2000, 105 cryptorchid boys, aged 1 to 15 years (mean 4.8) underwent unilateral orchiopexy. Dimensions and volume of testes were measured by means of scrotal US and TAI was calculated before and 1 year after surgery. RESULTS: Pre- and postoperative scrotal US measurements were analyzed in 35 boys divided into five age dependent groups. The preoperative TAI values ranged from 27.1% to 52.8%. The biggest loss in volume of affected testis was found in boys aged 4 to 10 years (35.4% to 52.8%). The TAI values measured one year after orchiopexy were lower than preoperative ones. Significant difference in TAI values, ranging from 18.16% to 36.43% were observed in boys between 2 and 10 years (p < 0.001). In the youngest (0-2 yrs) and the oldest boys (> 10 yrs) the difference was not statistically significant. CONCLUSIONS: The testicular atrophy index (TAI) proved to be a valuable and objective tool for qualifying patients with undescended testes for surgery as well as for monitoring the results of treatment. Its value of 20% and more should be considered an indication for surgery in boys with retractile testes.