Excretory Urography in Asymptomatic Boys with Cryptorchidism

Vol. 109, May

THE JOURNAL OF UROLOGY

Copyright © 1973 by The Williams & Wilkins Co.

Printed in U.S.A.

EXCRETORY UROGRAPHY IN ASYMPTOMATIC BOYS WITH CRYPTORCHIDISM ROBERT E. DONOHUE,* WILLIAM L. F. UTLEY AND THOMAS M. MALING

From the Departments of Urology and Radiology, Christchurch Hospital, Christchurch, New Zealand

In 1910 Anders reported that 94 per cent of 135 children with anomalous genitalia had anomalies of the upper urinary tract. 1 In 1951 Campbell reported a 33 per cent incidence of urogenital abnormalities in an autopsy series of 292 boys with cryptorchidism. 2 Other studies have revealed a 2 to 20 per cent incidence of unsuspected urogenital abnormalities in cryptorchid cases. Several authors recommend the routine use of excretory urography (IVP) for all boys with cryptorchidism. 3 • 4 Our study, which involves a large number of patients, was undertaken in order to determine whether all patients undergoing orchiopexy for cryptorchid or ectopic testes should be studied routinely by IVP.

is defined as one resulting in significant loss of renal substance or requiring surgical correction for conservation of the renal substance. A minor abnormality is defined as one not having any present or potential clinical significance. The 2 cases with a major abnormality will be reported. The cases of minor abnormalities include 4 duplications of the urinary tracts (3 complete and 1 incomplete), 1 fetal lobulation, 1 ectopic kidney, 1 horseshoe kidney with no evidence of obstruction, 1 ureteropelvic junction obstruction (grade I, asymptomatic, with minimal loss of functioning tissue) and 4 patients with non-obstructive dilatation in 6 lumbar or sacral ureters considered to indicate past or persisting vesicoureteral reflux (fig. 1).

MATERIAL AND METHOD

There were 135 boys who underwent orchiopexy for unilateral or bilateral ectopic or cryptorchid testes at the Christchurch Hospital between July 1, 1969 and December 31, 1971. Letters were sent to the parents, requesting that arrangements be made for IVPs. Our report concerns the first 100 studies performed. The cryptorchid or ectopic testis was on the right side in 34 cases, on the left in 30 and bilateral in 36. The testis was located in the superficial inguinal pouch in 122 cases, at the external ring in 2, along the inguinal canal in 6 and above the internal ring in 6. There were no femoral, penile or perineal testes. Four testes, 2 high in thP inguinal canal and 2 above the internal ring, were removed at the original operation. The remainder were brought down successfully into the scrotum. Associated hernial sacs that necessitated ligation were noted in 51 testes in 43 patients. One sac had omentum within it and one had sigmoid colon.

CASE REPORTS

Case 1. T. M., a 10-year-old boy who had undergone left orchiopexy, had bilateral nonobstructive dilatation of both ureters down to the ureterovesical junction, accompanied by severe bilateral loss of renal substance (fig. 2). A micturition cystourethrogram revealed gross bilateral vesicoureteral reflux. There was no history of urinary tract difficulty. Physical examination was unremarkable. After cystoscopy the child underwent bilateral ureteral reimplantations and has done well postoperatively. Case 2. G. C. M., a 12-year-old boy with bilateral cryptorchidism, had complete duplication of the right collecting system with gross loss of renal substance in the lower segment and along the upper calix on the left side (fig. 3). A micturition cystourethrogram revealed gross reflux to the lower segment on the right side. Cystoscopy showed 2 ureteral orifices on the right side-the medial one was slit-like and normal and the lateral one was gapping. Right lower pole heminephrectomy and ureterectomy were successfully performed.

RESULTS

There were 2 major and 12 minor abnormalities in our series of 100 patients. A major abnormality Accepted for publication September 22, 1972. * Current address: University of Colorado Medical School, 4200 East Ninth Avenue, Denver, Colorado 80220. 1 Anders, J. M.: Congenital single kidney with report of a case. The practical significance of the condition with statistics. Amer. J. Med. Sci., 139: 313, 1910. 2 Campbell, M.: Clinical Pediatric Urology. Philadelphia: W. B. Saunders Co., 1951. 'Felton, L. M.: Should intravenous pyelography be a routine procedure for children with cryptorchism or hypospadias? J. Urol., 81: 335, 1959. 4 Farrington, G. H. and Kerr, I. H.: Abnormalities of the upper urinary tract in cryptorchidism. Brit. J. Urol., 41: 77, 1969.

DISCUSSION

Campbell reviewed 10,712 autopsies and found 292 cases of cryptorchidism. There were other urogenital anomalies in 92 of these 292 cases (33 per cent) and non-urogenital anomalies, in an additional 17 5 cases .2 Felton reviewed 169 autopsies of boys between the ages of 2 and 14 years and noted that 15 abnormal urinary tracts were recognized clinically 912

EXCRETORY UROGRAPHY IN ASYMPTOMATIC BOYS WITH CRYPTORCHIDISM

913

FIG. 1. A, IVP reveals abnormal dilatation of right ureter. B, post-micturition film shows complete emptying of ureter; non-obstructive dilatation secondary to past or persisting vesicoureteral reflux.

and that 3 of 152 presumed normal urinary tracts (2 per cent) were abnormal. 3 He also reviewed 142 boys with hypospadias, 53 of whom underwent IVP. Eight of these 53 patients had cryptorchidism and 2 had urinary abnormalities (25 per cent), whereas 4 of the remaining 45 patients with hypospadias alone had abnormalities (9 per cent). He concluded that IVP should be used when investigating the upper tracts of all patients with cryptorchidism and hypospadias. In a series of 289 cryptorchid cases reviewed by Felton, there were 61 asymptomatic boys who underwent IVP and 6 who had definite indications for the study. 3 In the asymptomatic boys, 8 major and 4 minor abnormalities were noted (20 per cent). The major abnormalities were 2 ureteropelvic junction obstructions, 2 hypoplastic kidneys, 2 non-rotated kidneys, 1 horseshoe kidney and 1 ectopic ureter. Two patients underwent an operation. The minor abnormalities included 1 duplicated collecting system, 1 hydronephrosis secondary to ureteropelvic junction and a non-rotated I

operation. All 6 patients with definite indications for IVP had abnormalities and 4 underwent an operation. In 1969 Farrington and Kerr reported on a series of 45 patients seen during an 18-month period who had undergone orchiopexy for ectopic or cryptorchid testes. All of these patients were studied by IVP and 39 were normal. 4 Six (13 per cent) had unsuspected abnormalities: 3 duplications (1 bilateral and 2 unilateral), one sheep kidney, all minor calices drain into pelvis and there are no major calices and 2 grade I hydronephrosis unilaterally. None of these patients underwent an operation for correction. Farrington and Kerr also recommend the routine use of IVP in evaluating patients with cryptorchidism. There were 2 major abnormalities noted in our series of 100 cases. Both were of clinical significance and necessitated an operation. Three renal units were damaged significantly, 2 to a minor degree. Six patients (6 per cent) had evidence of past or persisting vesicoureteral reflux involving 10 renal units with 3 kidneys showing major renal Four had rwn-obstructivs dila6 upper tracts but

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Fm. 2. A, IVP shows non-obsti:uctive dilatation of both ureters and severe bilateral loss ofrenal substance. B, IVP shows bilateral renal damage. C, micturition cystourethrogram shows gross bilateral vesicoureteral reflux.

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FIG. 3. A and B, IVPs show complete duplication of both collecting systems, gross loss of renal substance of right lower segment and left upper segment along upper calix. C, micturition cystourethrogram reveals gross reflux to lower right segment.

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DONOHUE, UTLEY AND MALING

had no evidence of impaired renal growth, caliceal dilatation or loss of renal substance on the affected side. SUMMARY

One hundred asymptomatic boys were studied by IVP after having undergone orchiopexy for cryptorchid or ectopic testes. Clinically unsuspected major abnormalities of the upper tract

that necessitated an operation were found in 2 per cent of the 100 cases. The fact that these patients were all asymptomatic at the time of orchiopexy and that at least one .was saved from the sequence of reflux nephropathy, interstitial nephritis, hypertension and renal failure, indicates the value of an IVP in these cryptorchid patients. We encourage the routine use of IVP in all patients undergoing orchiopexy.