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TESTICULAR HISTOPATHOLOGY IN PRUNE BELLY SYNDROME: CAN WE PREDICT FUTURE FERTILITY?
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THE JOURNAL OF UROLOGY®
323 SURGICAL APPROACH TO THE INCOMPLETELY DESCENDED TESTIS AFTER LAPAROSCOPIC ORCHIDOPEXY. Paul Zelkovic*, Lori Dyer, Edward Reda, Israel Franco, Tarrytown, NY Introduction and Objective: Laparoscopic orchidopexy has become a well accepted modality for the treatment of intraabdominal testis. As with all surgery, occasionally we will have an imperfect result and in other cases we have chosen not to do a vessel transection and left the testis outside of the scrotum. A review of the literature reveals no prior description of a reoperative technique to further descend the testis that has not been fully brought down after laparoscopic orchidopexy. Methods: We reviewed our records of all patients that underwent redo orchidopexy over the last 12 years after an initial laparosopic orchidopexy. We found 11 patients (12 testis) that underwent surgery to further the descend the testis. 10/11 patients received HCG preoperatively. All the testis were initially approached via an inguinal incision near the neoring. Careful mobilization of the testis and the cord is all that is necessary but at times there has been a need to extend the dissection intraabdominally to get additional length. Once adequate length is obtained the testis is placed back in the dartos pouch as with a regular orchidopexy. Results: We found that all 12 testis were adequately descended using the described dissection. In 10 patients that received HCG the dissection was facilitated and adequate length was achieved without any additional intraabdominal dissection. The one patient that did not receive preop HCG stimulation required extensive intraabdominal dissection but this patient had also undergone one prior attempt to bring the testes down that had been unsuccessful. In no instance was atrophy of the testis noted post operatively. Conclusions: It appears simple dissection of the testis that is incompletely descended after laparoscopic orchidopexy is highly successful especially if HCG stimulation is used preoperatively. Access to the abdominal cavity is simple and dissection along the cord can easily be done if additional length is needed. Source of Funding: None
324 REOPERATIVE ORCHIDOPEXY: A SCROTAL APPROACH Anne G Dudley*, Danielle D Sweeney, Ruthie R Su, Steven G Docimo, Pittsburgh, PA INTRODUCTION AND OBJECTIVE: Iatrogenic cryptorchidism after groin surgery is a condition that requires skillful technique to preserve testicular function. Traditionally the approach is inguinal with en block mobilization of the spermatic cord and external oblique fascia and extensive dissection of the proximal spermatic vessels. We report one surgeon’s series of reoperative orchidopexies approached through a single scrotal incision. METHODS: From November 2001 to February 2007, 24 patients presented with iatrogenic cryptorchidism in 27 testicles secondary to a history of previous groin surgery. Of this group 24 of the 27 testicles (21 patients) were approached through a single scrotal incision (89%). All patients underwent an exam under anesthesia to ensure that the scrotum could be manipulated over or near the relatively fixed testicle. If this was not possible a traditional inguinal incision was made (11%). Charts were retrospectively reviewed for technique and operative outcomes. RESULTS: For the scrotal cohort, mean patient age was 6.4 years (1.3 - 16.2 years), and follow-up was available on 20 patients, for a mean of 12 months (0.2-70 months). Previous groin surgeries performed included 18 (75%) inguinal hernia repairs, 7 (29.2%) inguinal orchidopexys, 1 (4.2%) scrotal orchidopexy and 1 (4.2%) laparoscopic orchidopexy. Two (8.4%) patients had records that did not specify type of previous groin surgery. A patent processus vaginalis was found in 3 (12.5%) patients and hernia repair was undertaken through the scrotal approach. There were no intraoperative complications. Postoperative complications included 1 (4.2 %) patient with unacceptable testicular position who subsequently underwent successful repeat scrotal
Vol. 181, No. 4, Supplement, Sunday, April 26, 2009
orchidopexy, and 1 (4.2%) patient with a fungal skin rash. At last recorded follow-up, all testes were in a satisfactory scrotal position. There were no cases of postoperative hydrocele, hernia or testicular atrophy. CONCLUSIONS: In our experience the majority of reoperative orchidopexies can be approached through a single scrotal incision. Retrograde serial dissection of the adhesions to the distal cord usually reveals adequate vessel length, thus avoiding an extensive inguinal and/ or retroperitoneal dissection. Source of Funding: None
325 BELT AND SUSPENDERS: DIVISION OF THE CREMASTER DURING ORCHIOPEXY IS SAFE AND EFFECTIVE Raymond M Bernal*, Philadelphia, PA; Mark R. Zaontz, Voorhees, NJ INTRODUCTION AND OBJECTIVE: It has been shown that orchiopexy utilizing suture fixation is associated with parenchymal damage involving microabscesses, decreased spermatogenesis, microvascular changes, and tissue hypoxia. In humans, failed suture fixation has been reported. Despite this, a recent survey reported that this technique remains widely prevalent, suggesting tantamount concern for recurrence. The use of tunica vaginalis eversion, subdartos pocket placement, and cordopexy have been described as means by which testicular suture fixation can be avoided. We describe a technique that blunts the Cremaster reflex, eliminating a mechanism that can incite torsion. METHODS: Depending on the testicular exam, we utilize a transverse inguinal and/or high transverse scrotal incision. The underlying tissues are opened with cautery and the testicle is mobilized and delivered into the wound. The gubernaculum is divided, and the spermatic cord is skeletonized to the external ring, addressing any hernias. Using careful cauterization, the cremaster fibers are circumferentially divided, approximately 1cm superior to the testicle, and stripped proximally. The tunica vaginalis is opened widely and everted on itself, above the testicle. A subdartos pocket is created, and absorbable sutures are used to affix the lateral aspects of the everted tunica to the dartos, keeping the testicle in a dependent position. The scrotum is then closed in an interrupted horizontal mattress fashion. RESULTS: A retrospective review identified 73 patients during a one year period for which 5 year follow-up was possible. 88 testicles were operated upon (40 right, 48 left). Median age was 76 mo. with a range of 3-199 mo. Median follow-up was 3 mo., with a range of 0-56 mo. Followup was not available for 2 patients. No patients experienced subsequent torsion, recurrence of retractile testis, or testicular ascent. Pain was not experienced more than controls. There were no major complications. There were no cases of new-onset testicular atrophy during follow-up. CONCLUSIONS: We present a modified orchiopexy technique that is safe, effective, and blunts the cremaster reflex. The testicles remained in their dependent positions during follow-up. Our technique may provide an alternative to those still utilizing suture fixation techniques. Source of Funding: None
326 TESTICULAR HISTOPATHOLOGY IN PRUNE BELLY SYNDROME: CAN WE PREDICT FUTURE FERTILITY? Sarah M Lambert*, Scott R Caesar, Howard M Snyder, III, Pasquale Casale, Stephen A Zderic, Michael C Carr, Douglas A Canning, Thomas F Kolon, Philadelphia, PA INTRODUCTION AND OBJECTIVE: Prune belly syndrome (PBS) describes a triad of deficient abdominal wall musculature, urinary tract anomalies, and cryptorchidism. Boys have intra-abdominal testes and most require orchidopexy. Limited data exist about the testicular function and histopathology in these patients. Studies of men with PBS demonstrate a risk of infertility and use testicular location to stratify boys at risk. This study reviews the clinical characteristics of a prospective
THE JOURNAL OF UROLOGY®
Vol. 181, No. 4, Supplement, Sunday, April 26, 2009
cohort of boys with PBS and evaluates the histopathological data obtained by testis biopsy at orchidopexy to provide further information regarding potential fertility. METHODS: We examine boys with PBS undergoing orchidopexy and testicular biopsy. This evaluation includes preoperative testis location, surgical technique, and testis biopsy data from a single institution over a 20 year period from 1988 to 2008. RESULTS: During this period, 16 boys presented to our institution with PBS or prune belly variant and underwent orchidopexy. In 15 of the 16 boys we performed testis biopsies at surgical intervention. Patient age at the time of orchidopexy ranged from 2 to 48 months (median 13 months). Thirteen of fifteen boys had bilateral undescended testes and 2 boys had a unilateral cryptorchid testis. Of the 28 undescended testes, 26 were intra-abdominal and 2 were at the level of the external ring. Ten Fowler-Stevens orchidopexies were performed. Twenty-nine of thirty testes were examined by testis biopsy. Leydig cells were present in 28/29 testis biopsies. The germ cells per tubule (GC/T) ranged from 0 to 11.8 GC/T (median 1.32 GC/T). Nineteen of twenty-nine biopsies revealed greater that 0.6 GC/T on biopsy. Adult dark spermatogonia were present in 48% of testis biopsies (14/29). There were no primary spermatocytes visualized. Fetal gonocytes were still present in 48% of testis biopsies (14/29). CONCLUSIONS: The presence of fetal gonocytes and absence of adult dark spermatogonia in this study document the known risk for abnormal germ cell maturation present in boys with PBS. Conversely, approximately 50% of the PBS boys with adult dark spermatogonia present and absent fetal gonocytes show evidence of normal germ cell maturation and have the potential for normal semen analyses and possible fertility. Determining the results of testicular biopsy in these boys allows the physician to selectively monitor and counsel the patients at risk for infertility. Source of Funding: None
327 CRYPTORCHIDISM AND MALE FERTILITY POTENTIAL: CLINICAL PREDICTORS OF ADVERSE HISTOLOGICAL FEATURES Gregory E Tasian*, San Francisco, CA; Adam Hittelman, New Haven, CT; Grace E Kim, Michael J. DiSandro, Laurence S Baskin, San Francisco, CA INTRODUCTION AND OBJECTIVE: This study aimed to determine the relationship between clinical variables and specific testicular histopathologic changes that have been associated with decreased fertility potential in children with cryptorchidism. METHODS: Testis biopsies of children (n = 290) who underwent orchiopexy and concurrent testicular biopsy between 1991 and 2001 were analyzed for germ and Leydig cell loss and testicular fibrosis. Multipredictor logistic regression was used to determine if age at orchiopexy, pre-operative testis palpability, unilateral vs. bilateral disease, side of undescended testis, and/or associated congenital anomalies were predictive of specific pathologic outcomes. RESULTS: Age at orchiopexy and non-palpable testes were associated with germ cell depletion. After adjusting for other variables, each month of testes undescent was associated with development of moderate/severe germ cell depletion (OR 1.02 for each month of age; p < 0.005). After adjusting for age, children with palpable testes had much lower odds of germ cell depletion than those with non-palpable testes (OR 0.46; p < 0.005). After adjusting for other variables, each month of testes undescent was associated with development of Leydig cell absence (OR 1.01 for each month of age; p < .02). This corresponds to a significant 2% risk per month of severe germ cell loss and 1% risk per month of Leydig cell depletion for each month a testis remains undescended and a 50% greater odds of germ cell depletion in non-palpable cryptorchid testes relative to palpable cryptorchid testes. CONCLUSIONS: Progressive pathologic changes occur postnatally in the testes of children with cryptorchidism. Non-palpable testes and testes that remain undescended for an increased duration are
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associated with histologic changes that likely contribute to decreased fertility in adulthood. Early orchiopexy, especially of non-palpable testes, may improve the number of germ and Leydig cells in the adult testis and, hopefully, decrease the risk of future infertility.
Source of Funding: None
328 TESTICULAR HISTOPATHOLOGY IN COMPLETE ANDROGEN INSENSITIVITY SYNDROME: ARE THEY “NORMAL” UNDESCENDED TESTES? Nikhil Bhargava, Aileen Schast, Sarah M Lambert, Douglas A. Canning, Thomas F Kolon*, Philadelphia, PA INTRODUCTION AND OBJECTIVE: Complete Androgen Insensitivity Syndrome (CAIS) is caused by a mutation of the androgen receptor gene. In this study, the histology of CAIS orchiectomy biopsies were compared to the histology of bilateral undescended testis (UDT) biopsies and of historical control biopsies to determine whether CAIS patients’ testes are “normal” UDTs. METHODS: Seven patients with CAIS underwent orchiectomies. Testes were examined by histomorphometric analysis. Age(at orchiopexy)- and position-matched non-syndromic UDTs were selected from a database of cryptorchid patients. Historical control, normal testis histology was used as reported by Paniagua and Nistal (1984), but did not include Leydig cell histology. Total germ cells per tubule (GC/T), Ad spermatogonia per tubule (Ad/T), and Leydig cells per Tubule (LC/T) were reported. Counts were compared using a paired t-test. RESULTS: The CAIS patients had a median age of 10 months. One 16 year old patient resulted in the high mean age of 40 months. The CAIS group had a significantly reduced number of germ cells, mean= 0.5 +/- 0.9 GC/T. Almost complete absence of Ads was noted, mean= 0.01 +/- 0.02 Ad/T. Leydig cell hyperplasia was noted, mean= 4.0 +/- 4.8 LC/T. Only one patient had a normal germ cell count (R= 2.2 GC/T; L = 3.16 GC/T) and any Ads present (3 present each in the right and left), with some persistent fetal gonocytes. This patient also had an increased Leydig cell count (R=6.7 LC/T; L=7.4 LC/T). The bilateral UDT patients had means of 1.5 +/- 1.7 GC/T, 0.07 +/- 0.2 Ad/T and 3.4 +/- 7.2 LC/T. One patient exhibited an increased GC count (RGC/T= 4.22; LGC/T = 6.14) and a normal Ad count (R Ad/T=0.26; L Ad/T=0.58). The eldest patient in the group (age ~16 yrs) exhibited hyperplasia of Leydig cells with adultand juvenile-type LC above normal levels (mean LC/T=19.6). These patients may account for the high standard deviation. The GC counts of the CAIS patients were significantly less than those of the bilateral UDT patients (p=0.01). While Ads were essentially absent in CAIS biopsies, bilateral UDTs had some present, although severely reduced counts. The LC counts of the CAIS patients were higher than those of the bilateral UDT patients, but not to a level of statistical significance (p=0.42). CONCLUSIONS: Compared to controls and UDT patients, CAIS testes have poorer total germ cell counts and less germ cell maturation. The UDTs of CAIS patients are not “normal” UDTs and if left in situ may not exhibit viable germ cells. Source of Funding: Abramson Chair in Pediatric Urology
THE JOURNAL OF UROLOGY®
323 SURGICAL APPROACH TO THE INCOMPLETELY DESCENDED TESTIS AFTER LAPAROSCOPIC ORCHIDOPEXY. Paul Zelkovic*, Lori Dyer, Edward Reda, Israel Franco, Tarrytown, NY Introduction and Objective: Laparoscopic orchidopexy has become a well accepted modality for the treatment of intraabdominal testis. As with all surgery, occasionally we will have an imperfect result and in other cases we have chosen not to do a vessel transection and left the testis outside of the scrotum. A review of the literature reveals no prior description of a reoperative technique to further descend the testis that has not been fully brought down after laparoscopic orchidopexy. Methods: We reviewed our records of all patients that underwent redo orchidopexy over the last 12 years after an initial laparosopic orchidopexy. We found 11 patients (12 testis) that underwent surgery to further the descend the testis. 10/11 patients received HCG preoperatively. All the testis were initially approached via an inguinal incision near the neoring. Careful mobilization of the testis and the cord is all that is necessary but at times there has been a need to extend the dissection intraabdominally to get additional length. Once adequate length is obtained the testis is placed back in the dartos pouch as with a regular orchidopexy. Results: We found that all 12 testis were adequately descended using the described dissection. In 10 patients that received HCG the dissection was facilitated and adequate length was achieved without any additional intraabdominal dissection. The one patient that did not receive preop HCG stimulation required extensive intraabdominal dissection but this patient had also undergone one prior attempt to bring the testes down that had been unsuccessful. In no instance was atrophy of the testis noted post operatively. Conclusions: It appears simple dissection of the testis that is incompletely descended after laparoscopic orchidopexy is highly successful especially if HCG stimulation is used preoperatively. Access to the abdominal cavity is simple and dissection along the cord can easily be done if additional length is needed. Source of Funding: None
324 REOPERATIVE ORCHIDOPEXY: A SCROTAL APPROACH Anne G Dudley*, Danielle D Sweeney, Ruthie R Su, Steven G Docimo, Pittsburgh, PA INTRODUCTION AND OBJECTIVE: Iatrogenic cryptorchidism after groin surgery is a condition that requires skillful technique to preserve testicular function. Traditionally the approach is inguinal with en block mobilization of the spermatic cord and external oblique fascia and extensive dissection of the proximal spermatic vessels. We report one surgeon’s series of reoperative orchidopexies approached through a single scrotal incision. METHODS: From November 2001 to February 2007, 24 patients presented with iatrogenic cryptorchidism in 27 testicles secondary to a history of previous groin surgery. Of this group 24 of the 27 testicles (21 patients) were approached through a single scrotal incision (89%). All patients underwent an exam under anesthesia to ensure that the scrotum could be manipulated over or near the relatively fixed testicle. If this was not possible a traditional inguinal incision was made (11%). Charts were retrospectively reviewed for technique and operative outcomes. RESULTS: For the scrotal cohort, mean patient age was 6.4 years (1.3 - 16.2 years), and follow-up was available on 20 patients, for a mean of 12 months (0.2-70 months). Previous groin surgeries performed included 18 (75%) inguinal hernia repairs, 7 (29.2%) inguinal orchidopexys, 1 (4.2%) scrotal orchidopexy and 1 (4.2%) laparoscopic orchidopexy. Two (8.4%) patients had records that did not specify type of previous groin surgery. A patent processus vaginalis was found in 3 (12.5%) patients and hernia repair was undertaken through the scrotal approach. There were no intraoperative complications. Postoperative complications included 1 (4.2 %) patient with unacceptable testicular position who subsequently underwent successful repeat scrotal
Vol. 181, No. 4, Supplement, Sunday, April 26, 2009
orchidopexy, and 1 (4.2%) patient with a fungal skin rash. At last recorded follow-up, all testes were in a satisfactory scrotal position. There were no cases of postoperative hydrocele, hernia or testicular atrophy. CONCLUSIONS: In our experience the majority of reoperative orchidopexies can be approached through a single scrotal incision. Retrograde serial dissection of the adhesions to the distal cord usually reveals adequate vessel length, thus avoiding an extensive inguinal and/ or retroperitoneal dissection. Source of Funding: None
325 BELT AND SUSPENDERS: DIVISION OF THE CREMASTER DURING ORCHIOPEXY IS SAFE AND EFFECTIVE Raymond M Bernal*, Philadelphia, PA; Mark R. Zaontz, Voorhees, NJ INTRODUCTION AND OBJECTIVE: It has been shown that orchiopexy utilizing suture fixation is associated with parenchymal damage involving microabscesses, decreased spermatogenesis, microvascular changes, and tissue hypoxia. In humans, failed suture fixation has been reported. Despite this, a recent survey reported that this technique remains widely prevalent, suggesting tantamount concern for recurrence. The use of tunica vaginalis eversion, subdartos pocket placement, and cordopexy have been described as means by which testicular suture fixation can be avoided. We describe a technique that blunts the Cremaster reflex, eliminating a mechanism that can incite torsion. METHODS: Depending on the testicular exam, we utilize a transverse inguinal and/or high transverse scrotal incision. The underlying tissues are opened with cautery and the testicle is mobilized and delivered into the wound. The gubernaculum is divided, and the spermatic cord is skeletonized to the external ring, addressing any hernias. Using careful cauterization, the cremaster fibers are circumferentially divided, approximately 1cm superior to the testicle, and stripped proximally. The tunica vaginalis is opened widely and everted on itself, above the testicle. A subdartos pocket is created, and absorbable sutures are used to affix the lateral aspects of the everted tunica to the dartos, keeping the testicle in a dependent position. The scrotum is then closed in an interrupted horizontal mattress fashion. RESULTS: A retrospective review identified 73 patients during a one year period for which 5 year follow-up was possible. 88 testicles were operated upon (40 right, 48 left). Median age was 76 mo. with a range of 3-199 mo. Median follow-up was 3 mo., with a range of 0-56 mo. Followup was not available for 2 patients. No patients experienced subsequent torsion, recurrence of retractile testis, or testicular ascent. Pain was not experienced more than controls. There were no major complications. There were no cases of new-onset testicular atrophy during follow-up. CONCLUSIONS: We present a modified orchiopexy technique that is safe, effective, and blunts the cremaster reflex. The testicles remained in their dependent positions during follow-up. Our technique may provide an alternative to those still utilizing suture fixation techniques. Source of Funding: None
326 TESTICULAR HISTOPATHOLOGY IN PRUNE BELLY SYNDROME: CAN WE PREDICT FUTURE FERTILITY? Sarah M Lambert*, Scott R Caesar, Howard M Snyder, III, Pasquale Casale, Stephen A Zderic, Michael C Carr, Douglas A Canning, Thomas F Kolon, Philadelphia, PA INTRODUCTION AND OBJECTIVE: Prune belly syndrome (PBS) describes a triad of deficient abdominal wall musculature, urinary tract anomalies, and cryptorchidism. Boys have intra-abdominal testes and most require orchidopexy. Limited data exist about the testicular function and histopathology in these patients. Studies of men with PBS demonstrate a risk of infertility and use testicular location to stratify boys at risk. This study reviews the clinical characteristics of a prospective
THE JOURNAL OF UROLOGY®
Vol. 181, No. 4, Supplement, Sunday, April 26, 2009
cohort of boys with PBS and evaluates the histopathological data obtained by testis biopsy at orchidopexy to provide further information regarding potential fertility. METHODS: We examine boys with PBS undergoing orchidopexy and testicular biopsy. This evaluation includes preoperative testis location, surgical technique, and testis biopsy data from a single institution over a 20 year period from 1988 to 2008. RESULTS: During this period, 16 boys presented to our institution with PBS or prune belly variant and underwent orchidopexy. In 15 of the 16 boys we performed testis biopsies at surgical intervention. Patient age at the time of orchidopexy ranged from 2 to 48 months (median 13 months). Thirteen of fifteen boys had bilateral undescended testes and 2 boys had a unilateral cryptorchid testis. Of the 28 undescended testes, 26 were intra-abdominal and 2 were at the level of the external ring. Ten Fowler-Stevens orchidopexies were performed. Twenty-nine of thirty testes were examined by testis biopsy. Leydig cells were present in 28/29 testis biopsies. The germ cells per tubule (GC/T) ranged from 0 to 11.8 GC/T (median 1.32 GC/T). Nineteen of twenty-nine biopsies revealed greater that 0.6 GC/T on biopsy. Adult dark spermatogonia were present in 48% of testis biopsies (14/29). There were no primary spermatocytes visualized. Fetal gonocytes were still present in 48% of testis biopsies (14/29). CONCLUSIONS: The presence of fetal gonocytes and absence of adult dark spermatogonia in this study document the known risk for abnormal germ cell maturation present in boys with PBS. Conversely, approximately 50% of the PBS boys with adult dark spermatogonia present and absent fetal gonocytes show evidence of normal germ cell maturation and have the potential for normal semen analyses and possible fertility. Determining the results of testicular biopsy in these boys allows the physician to selectively monitor and counsel the patients at risk for infertility. Source of Funding: None
327 CRYPTORCHIDISM AND MALE FERTILITY POTENTIAL: CLINICAL PREDICTORS OF ADVERSE HISTOLOGICAL FEATURES Gregory E Tasian*, San Francisco, CA; Adam Hittelman, New Haven, CT; Grace E Kim, Michael J. DiSandro, Laurence S Baskin, San Francisco, CA INTRODUCTION AND OBJECTIVE: This study aimed to determine the relationship between clinical variables and specific testicular histopathologic changes that have been associated with decreased fertility potential in children with cryptorchidism. METHODS: Testis biopsies of children (n = 290) who underwent orchiopexy and concurrent testicular biopsy between 1991 and 2001 were analyzed for germ and Leydig cell loss and testicular fibrosis. Multipredictor logistic regression was used to determine if age at orchiopexy, pre-operative testis palpability, unilateral vs. bilateral disease, side of undescended testis, and/or associated congenital anomalies were predictive of specific pathologic outcomes. RESULTS: Age at orchiopexy and non-palpable testes were associated with germ cell depletion. After adjusting for other variables, each month of testes undescent was associated with development of moderate/severe germ cell depletion (OR 1.02 for each month of age; p < 0.005). After adjusting for age, children with palpable testes had much lower odds of germ cell depletion than those with non-palpable testes (OR 0.46; p < 0.005). After adjusting for other variables, each month of testes undescent was associated with development of Leydig cell absence (OR 1.01 for each month of age; p < .02). This corresponds to a significant 2% risk per month of severe germ cell loss and 1% risk per month of Leydig cell depletion for each month a testis remains undescended and a 50% greater odds of germ cell depletion in non-palpable cryptorchid testes relative to palpable cryptorchid testes. CONCLUSIONS: Progressive pathologic changes occur postnatally in the testes of children with cryptorchidism. Non-palpable testes and testes that remain undescended for an increased duration are
119
associated with histologic changes that likely contribute to decreased fertility in adulthood. Early orchiopexy, especially of non-palpable testes, may improve the number of germ and Leydig cells in the adult testis and, hopefully, decrease the risk of future infertility.
Source of Funding: None
328 TESTICULAR HISTOPATHOLOGY IN COMPLETE ANDROGEN INSENSITIVITY SYNDROME: ARE THEY “NORMAL” UNDESCENDED TESTES? Nikhil Bhargava, Aileen Schast, Sarah M Lambert, Douglas A. Canning, Thomas F Kolon*, Philadelphia, PA INTRODUCTION AND OBJECTIVE: Complete Androgen Insensitivity Syndrome (CAIS) is caused by a mutation of the androgen receptor gene. In this study, the histology of CAIS orchiectomy biopsies were compared to the histology of bilateral undescended testis (UDT) biopsies and of historical control biopsies to determine whether CAIS patients’ testes are “normal” UDTs. METHODS: Seven patients with CAIS underwent orchiectomies. Testes were examined by histomorphometric analysis. Age(at orchiopexy)- and position-matched non-syndromic UDTs were selected from a database of cryptorchid patients. Historical control, normal testis histology was used as reported by Paniagua and Nistal (1984), but did not include Leydig cell histology. Total germ cells per tubule (GC/T), Ad spermatogonia per tubule (Ad/T), and Leydig cells per Tubule (LC/T) were reported. Counts were compared using a paired t-test. RESULTS: The CAIS patients had a median age of 10 months. One 16 year old patient resulted in the high mean age of 40 months. The CAIS group had a significantly reduced number of germ cells, mean= 0.5 +/- 0.9 GC/T. Almost complete absence of Ads was noted, mean= 0.01 +/- 0.02 Ad/T. Leydig cell hyperplasia was noted, mean= 4.0 +/- 4.8 LC/T. Only one patient had a normal germ cell count (R= 2.2 GC/T; L = 3.16 GC/T) and any Ads present (3 present each in the right and left), with some persistent fetal gonocytes. This patient also had an increased Leydig cell count (R=6.7 LC/T; L=7.4 LC/T). The bilateral UDT patients had means of 1.5 +/- 1.7 GC/T, 0.07 +/- 0.2 Ad/T and 3.4 +/- 7.2 LC/T. One patient exhibited an increased GC count (RGC/T= 4.22; LGC/T = 6.14) and a normal Ad count (R Ad/T=0.26; L Ad/T=0.58). The eldest patient in the group (age ~16 yrs) exhibited hyperplasia of Leydig cells with adultand juvenile-type LC above normal levels (mean LC/T=19.6). These patients may account for the high standard deviation. The GC counts of the CAIS patients were significantly less than those of the bilateral UDT patients (p=0.01). While Ads were essentially absent in CAIS biopsies, bilateral UDTs had some present, although severely reduced counts. The LC counts of the CAIS patients were higher than those of the bilateral UDT patients, but not to a level of statistical significance (p=0.42). CONCLUSIONS: Compared to controls and UDT patients, CAIS testes have poorer total germ cell counts and less germ cell maturation. The UDTs of CAIS patients are not “normal” UDTs and if left in situ may not exhibit viable germ cells. Source of Funding: Abramson Chair in Pediatric Urology