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Unilateral Abdominal Cryptorchidism
0022-5347/79/1221-0071$02. 00/0 Vol. 122, July
THE JOURNAL OF UROLOGY
Copyright © 1979 by The Williams & Wilkins Co.
Printed in U.S.A.
UNILATERAL ABDOMINAL CRYPTORCHIDISM FRANK HINMAN, JR.* From the Division of Urology, University of California School of Medicine, San Francisco, California
ABSTRACT
The unilateral non-palpable undescended testis is considered separately from other forms of cryptorchidism. It is less likely to be fertile, it is more prone to malignancy and it is more difficult to place. Removal rather than orchiopexy often is in the best interests of the child. The management of the unilateral abdominal (non-palpable) testis, which is just 1 entity of the cryptorchidism complex (fig. 1), is discussed. Recent reviews have not provided answers easily applied to individual clinical problems confronting the practicing urologist, especially the specific one of nonpalpable testis in which case the prowess of the surgeon is challenged by natural impediments. 1, 2 By concentrating on unilateral cryptorchidism, the separate problems of bilateral non-descent are avoided and by focusing on the non-palpable (abdominal) testis, no overlap with ectopy and retractility occurs (see table). 3 The unilateral non-palpable testis is an entity which can be defined, which raises its own surgical problems and around which the goals of therapy are highly controversial. In its most mature form its boundary is clearcut since it is determined by non-palpability on direct physical examination. In its most undeveloped form the unilateral nonpalpable testis shades imperceptibly into anorchism. To manage the unilateral non-palpable testis the 3 therapeutic goals must be weighed, which are fertility, avoidance of malignancy and cosmetic-psychologic satisfaction (fig. 2).
searchers today can discover these abnormalities at a younger age. 18 They further suggest that abnormalities are predetermined and that as a result testes cannot tolerate the stress of maturation. Hadziselimovic and associates found changes in patients as young as 2 years old with damage to the seminiferous tubules. 19 Developmental arrest in early infancy at the stage of type A spermatogonia was noted by Mancini and associates. 20 Similarly, Farrington found that the low mean germinal cell count (48 per cent lower than the normal testis) was not influenced by progressive age, which suggested a congenital defect rather than progressive deterioration. 21 Another study noted defective deoxyribonucleic acid synthesis in the spermatogonia in patients as young as 3½ years old. 22 Not only is the germinal epithelium affected but the adnexae may be abnormal as well. Dickinson reported such anomalies as absent epididymis and failure of urogenital union. 23 Abnormalities in the descended testis are not infrequent, which further suggests a fundamental deficit. Shida stated that all cases have a congenital defect in the contralateral testis. 24 Scorer and Farrington, 25 and Hecker and Heinz11 found that it lagged behind the normal stages of maturation. Scott noted 4 instances of arrest and 1 of Sertoli cell only among 8 cases biopsied. 26 However, Farrington found the contralateral testis to be dysgenetic in only 4 per cent of the cases. 21 The increased incidence of malignancy in the contralateral testis compared to normal testes further suggests more general testicular abnormality in patients with unilateral cryptorchidism. 27 The descended testis might also be affected by the cryptorchid testis28 but probably not, as seen from data on unilateral absent testes, which are accompanied by contralateral changes similar to those seen with cryptorchidism. Woodhead and associates found decreased spermatogenesis in 36 per cent of 34 untreated adults, 13 of whom had blind-ending vasa, and concluded that the defect was not caused by the presence or absence of the cryptorchid testis. 20 In fact, contralateral hypertrophy usually occurs. 30 • 31 A conclusion is that abnormalities of testicular development are common and inhibit normal spermatogenesis. Endocrine abnormalities. Developmental enzymatic abnormalities produce a number of recognized congenital syndromes, which are not pertinent to this discussion, but more subtle defects may be detected in boys with uncomplicated unilateral cryptorchidism. 32 Testosterone levels may be elevated4 or normal5· 7, 33 and may be less responsive to human chorionic gonadotropic stimulation. 34 Levels of follicle-stimulating hormone and luteinizing hormone are elevated initially and remain so after orchiopexy. 5· 6· 33 However, other authors have observed a mixture of responses. 35- 37 Werder and associates5 found a partial deficiency to luteinizing hormone releasing factor after orchiopexy, although Lipshultz and associates 33 found the response on luteinizing hormone levels normal but detected a 2-fold increase in follicle-stimulating hormone, suggesting Sertoli cell damage. Job and associates found no difference in basal
FERTILITY
The principal reason for preserving the abdominal testis by orchiopexy is to enhance fertility, since interstitial cell function for testosterone production is at least adequateH and operative treatment does not alter it. 7 However, either inherent deficiencies in the testis or an abnormal endocrine environment may limit this goal regardless of the time of treatment. Inherent testicular deficiencies. The adverse effect of heat on the retained testis is well established and it is generally accepted that if an operation is to be done to preserve fertility it should be done before the patient is 5 or 6 years old. Temperature effects are not the only consideration. The surgical decision must also be based on an appreciation of the proportion of cryptorchid testes affected by developmental abnormalities. These abnormalities have direct relation to impaired fertility and increased risk of malignancy. However, the data are not easily analyzed, since the results are influenced by the source of the material and variations would be expected, depending on the composition of the series. For example, a series containing more ectopic testes would differ from one with predominantly high testes. Even patients with retractile testes have less than normal fertility. Puri and Nixon found that 26 per cent of such patients were infertile. 8 They questioned whether this was owing to intrinsic factors and not merely the effect of increased temperature. Earlier studies showed that abnormalities could be detected after the patients were approximately 5 years old. D-17 ReAccepted for publication August 18, 1978. Read at annual meeting of Society for Pediatric Urology, Washington, D. C., May 20, 1978. * Requests for reprints: M-553, University of California, San Francisco, California 94143. 71
72
HINMAN
Fm. 1. Interrelationships in cryptorchidism Treatment for unilateral cryptorchidism Testis Non-palpable Palpable Symptomatic
<5 Yrs. Orchiectomy Orchiopexy Orchiopexy
5 Yrs. to Puberty Orchiectomy Orchiopexy Orchiopexy
>Puberty None, orchiectomy None, orchiectomy Orchiectomy
resistance to the action of gonadotropins. 37 Animal experiments also indicate abnormal hormonal relationships in cryptorchidism. Morehead and Morgan noted castrate cells in the pituitary in postpuberal cryptorchid rats, associated with increased pituitary weight. 40 Others noted after high fixation of the rat testis an early increase of folliclestimulating hormone level, a later lesser increase of luteinizing hormone level but a marked increase in both after castration, which indicates adequate feedback although the tubules are atrophic. 41 In rams experimental cryptorchidism produces hormonal alterations similar to those observed in humans. 42 To summarize, the endocrine environment is abnormal in many cases of unilateral cryptorchidism and these abnormalities may be either cause or effect. Effects of treatment on fertility. Data available on fertility do not distinguish palpable from non-palpable testes (although they do eliminate retractile testes). The knowledge that abdominal testes are, as a group, less well developed than palpable testes makes the results of their therapy poorer than that of the combined groups. When the semen quality of treated cases is compared to that of untreated cases from data collected from 10 series, totaling 353 patients (fig. 3), normal semen is recorded more often when no intervention has taken place. 42---51 The differences are more favorable toward the treated cases among the groups with lower counts. These results can be compared with the recent study of Lipshultz who found 62 per cent of 20 patients fertile after unilateral orchiopexy. 52 Although not as good as the 79 per cent fertility reported by Gross and Jewett53 and 76 per cent by Atkinson54 these figures are better than those obtained if only cases of abdominal testes had been followed, since the high proportion of inguinal testes would be expected to increase the over-all average. More extensive dissection is required for abdominal testes, resulting in a greater possibility for interference with the vasculature or necessitating a staged procedure. Such manipulations tend to decrease the potential for fertility in distinction to the simpler procedures used for palpable testes. In conclusion, it has not been shown that orchiopexy increases fertility nor that unilateral cryptorchidism is necessarily a unilateral disease. MALIGNANCY
Certain factors must be considered regarding malignancy: it is increased in cryptorchidism, its incidence in abdominal testes is greater than in palpable testes, it is probably related to dysgenesis rather than to temperature, its dangers must be SPERMATOGENESIS IN UNILATERAL CRYPTORCHIDISM WITH and WITHOUT ORCHIOPEXY 30
-
orchiopexy
£iim nonoperative
20
Fm. 2. Weighing therapeutic goals for non-palpable testes luteinizing hormone and follicle-stimulating hormone, and noted the same exaggerated response of follicle-stimulating hormone to luteinizing hormone releasing factor but a diminished response to luteinizing hormone. 38 They suggested a delay in gonadotropin secretion in the cryptorchid testis. Atkinson and associates found that elevation of follicle-stimulating hormone and luteinizing hormone in postpuberal boys who had had a previous orchiopexy gave a poor prognosis for fertility, since only 15 of 40 such patients were fertile. 37 Bramble and associates made similar observations. 39 Atkinson and associates suggested that this w~~ .evidence of primary
PERCENT CASES
10
o
NONE
SLIGHT MODERATE SEVERE AZOOSPERMIA IMPAIRMENT OF SEMEN QUALITY
Fm. 3. Comparison of semen analyses in treated and untreated cases of unilateral cryptorchidism.
73
UNILATERAL ABDOMINAL CRYPTORCHIDISM
weighed against operative risk, it is probably not reduced by orchiopexy and it is more difficult to cure after orchiopexy .. The risk of malignancy is 35 times greater for persons with cryptorchidism than for the general population. This relationship has been recognized since 1868 when Szymanowski advocated prophylactic excision of all non-scrotal testes. 55 Since review articles are available the statistics need not be repeated. 5&-6 1 Intra-abdominal testes have an even higher risk of malignancy. Although not more than 15 per cent of undescended testes are intra-abdominal they contain half of the tumors (fig. 4). 58, 62 • Testicular dysgenesis rather than exposure to mcreased temperature appears to be the major factor leading to neoplasia. 63 The testis is subjected to the same elevated temperature, whether it is within the abdominal cavity or lying in the groin. Thus, in abdominal testes heat cannot be responsible for higher neoplastic incidence. That early orchiopexy reduces the likelihood of malignancy has been asserted but to date no convincing evidence has been presented. 64 The impression that carcinoma is less likely if the testis is brought down early is based on series that include few early operations. 65 More importantly, the mean age of patients at the time a tumor is diagnosed is 30 years. 66 Thus, if the time of orchiopexy has an influence on malignancy >24 years must separate the orchiopexy from the followup report to provide relevant information (fig. 5). . . Furthermore inasmuch as 24 per cent of the malignancies occur in the con'tralateral testis, 64 the benefits of early fixation are even less certain. The risk of operation must be weighed against the risk of malignancy. 67 Martin and Menck have drawn a graph from facts reported in the literature showing that the risk of eventual death from carcinoma in a prepubertal boy with an abdominal testis is almost 6 per cent, much higher than the 0.2 per cent chance of a fatal outcome from orchiectomy. 56 The risk from an orchiopexy is comparable to that of removal but to that risk must be added the possibility of fatal carcinoma, a chance that is not lessened by scrotal placement of the testis. There are no data on the chance of loss of the other testis by injury or other disease but it is probably quite small. The potential for loss from malignant involvement has been discussed. Since abdominal testes range down to clusters of Leydig cells in connective tissue attached to a simple pampiniform plexus, venography may become valuable in identifying tr~e anorchia by the absence of the plexus68 and, therefore, avmd an unnecessary operation. In the postpuberal man the risk of
PROBABLE LAG PERIOD BETWEEN
100
£. MALIGNANCY
--TOTAL C A S E S - - - - - - - - - - - - -
CASES OF
80
6""
OACHIOPEXY
BY AGE
,._
~
ORCHIOPEXY
60
I.)
~ Cl: 40 MALIGNANCY 'N CASES OF RCHIOPEXY BY AGE 6
20
0 1955
60
70
80 YEARS
90
2000
2005
Fm. 5. Effect of postulated delay in development of malignancy after early orchiopexy.
operation for removal of an undescended testis must be weighed against the chance for malignant development. Although the assumptions of Martin and Menck56 weight the side for removal it is probably reasonable to operate when the patient has symptoms or shows concern, rather _than . to advocate routine orchiectomy. Finally, the lymphatic dramage of the testis is altered by opera~ion, 6n making cure_ more difficult than when the spread is only to the primary nodes. 70-72 The conclusion can be reached that the risk of malignancy is great in an abdominal testis, whether ~p or down, and probably warrants its removal when there is a contralateral testis. COSMETIC AND PSYCHOLOGIC ASPECTS
A silicone prosthesis usually will give a better cosmetic appearance than a small abdominal testis brought down to the upper or mid scrotum. However, this advantage . must be balanced against concerns of the parents about partial loss of testicular substance or later loss of the other testis. 73 The prosthesis usually must be replaced at puberty, which may done rather simply with the patient under local anesthesi~. The benefit from the superior cosmetic effect of the prosthesis probably overcomes parental concerns, which places the ~e.cision for or against orchiectomy on the chances for fertility versus malignancy.
?e
CONCLUSIONS
I NCI DENCE OF MALIGNANCY IN ABDOMINAL TESTES CAMPBELL 1942
CRYPTORCH IDISM 2,119 cases
MALIGNANCY 68 cases
PALPABLE
ABDOMINAL (14.3%)
ABDOMINAL (485%)
Fm. 4. Proportion of abdominal testes among cryptorchid patients and cryptorchid tumors. Data from Campbell. 62
In comparison to the palpable undescended_ testis the ~bdominal testis adds little to fertility, is more liable to malignancy and is marginally cosmetic after orc?-~opexy. In palp~ble testes orchiopexy somewhat improves fertility. The abd~n_im~l testis is basically abnormal so that enhancement of fertility is much less likely. Malignancy is not only significa~tly _m~re common in abdominal testes but eventual mortality is mcreased by scrotal fixation. Cosmetic appearance after placement of a small testis is less satisfactory than from a prosthesis. Thus, the unilateral abdominal testis in childhood should not be treated routinely by orchiopexy but should be removed. The parents should be advised preoperatively that the t~stis might be abnormal and require removal, _and P!eparat10~s should be made for insertion of a prosthesis. This plan will best promote the welfare of the child. REFERENCES
1. Martin, D. C.: The undescended testis: evolving concepts in
management. J.C. E. Urology, 16: 17, 1977.
74
HINMAN
2. Shapiro, S. R.: Infertility and the undescended testis. Urology Times, January 1978. 3. Scorer, C. G.: The anatomy of testicular descent-normal and incomplete. Brit. J. Surg., 49: 357, 1962. 4. Waaler, P. E.: Endocrinological studies in undescended testes. Acta Paediatr. Scand., 65: 559, 1976. 5. Werder, E. A., Illig, R., Torresani, T., Zachmann, M., Baumann, P., Ott, F. and Prader, A.: Gonadal function in young adults after surgical treatment of cryptorchidism. Brit. Med. J., 4: 1357, 1976. 6. Matsuda, S.: A study on cryptorchidism. Report 1. Changes in plasma level of FSH, LH and testosterone in cryptorchidism with loading of luteinizing hormone-releasing hormone. Japan J. Urol., 66: 462, 1975. 7. Engberg, H.: Investigations on the endocrine function of the testicle in cryptorchidism. Proc. Roy. Soc. Med., 42: 652, 1949. 8. Puri, P. and Nixon, H. H.: Bilateral retractile testes-subsequent effects on fertility. J. Ped. Surg., 12: 563, 1977. 9. Leeson, C.R.: An electron microscopic study of cryptorchid and scrotal human testes with special reference to pubertal maturation. Invest. Urol., 3: 498, 1966. 10. Robinson, J. N. and Engle, E. T.: Some observations on the cryptorchid testes. J. Urol., 71: 726, 1954. 11. Hecker, W. C. and Heinz, H. A.: Cryptorchidism and fertility. J. Ped. Surg., 2: 513, 1967. 12. Sohval, A. R.: Histopathology of cryptorchidism. A study based upon the comparative histology of retained and scrotal testes from birth to maturity. Amer. J. Med., 16: 346, 1954. 13. Rea, C. E.: Functional capacity of the undescended testis. Arch. Surg., 38: 1054, 1939. 14. Hinman, F., Jr.: Implications of testicular cytology in the treatment ofcryptorchidism. Amer. J. Surg., 90: 381, 1955. 15. Numanoglu, I., Koktiirk, I. and Mutaf, 0.: Light and electron microscopic examinations of undescended testicles. J. Ped. Surg., 4: 614, 1969. 16. Kiesewetter, W. B., Shull, W.R. and Fetterman, G. H.: Histologic changes in the testis following anatomically successful orchidopexy. J. Ped. Surg., 4: 59, 1969. 17. Czerniak, P. and Itelson, J.: Spermatogenic activity test (S.A. T.) for evaluation offertility in cryptorchidism. Fertil. Steril., 18: 135, 1967. 18. Mengel, W., Heinz, H. A., Sippe, W. G. and Hecker, W. Ch.: Studies on cryptorchidism: a comparison of histological findings in the germinative epithelium before and after the second year oflife. J. Ped. Surg., 9: 445, 1974. 19. Hadziselimovic, F., Herzog, B. and Seguchi, H.: Surgical correction of cryptorchidism at 2 years: electron microscopic and morphometric investigations. J. Ped. Surg., 10: 19, 1975. 20. Mancini, R. E., Rosemberg, E., Cullen, M., Lavieri, J.C., Vilar, 0., Bergada, C. and Andrada, J. A.: Cryptorchid and scrotal human testes. I. Cytological, cytochemical and quantitative studies. J. Clin. Endocr. Metab., 25: 927, 1965. 21. Farrington, G. H.: Histologic observations in cryptorchidism: the congenital germinal cell deficiency of the undescended testis. J. Ped. Surg., 4: 606, 1969. 22. Markewitz, M., Lattimer, J. K. and Veenema, R. J.: A comparative study of germ cell kinetics in the testes of children with unilateral cryptorchidism: a preliminary report. Fertil. Steril., 21: 806, 1970. 23. Dickinson, S. J.: Structural abnormalities in the undescended testis. J. Ped. Surg., 8: 523, 1973. 24. Shida, K.: Functional Disorders in Urology. Tokyo: Kanahara Shuppan, p. 210, 1964. 25. Scorer, C. G. and Farrington, G. H.: Histological studies of the undescended testis. In: Congenital Deformities of the Testis and Epididymis. London: Butterworth & Co., chapt. 5, p. 58, 1971. 26. Scott, L. S.: Unilateral cryptorchidism; subsequent effects on fertility. J. Reprod. Fertil., 2: 54, 1961. 27. Johnson, D. E., Woodhead, D. M., Pohl, D. R. and Robison, J. R.: Cryptorchidism and testicular tumorigenesis. Surgery, 63: 919, 1968. 28. Shirai, M., Matsushita, S., Kagayama, M., lchijo, S. and Takeuchi, M.: Histological changes of the scrotal testis in unilateral cryptorchidism. Tohoku J. Exp. Med., 90: 363, 1966. 29. Woodhead, D. M., Pohl, D. R. and Johnson, D. E.: Fertility of patients with solitary testes. J. Urol., 109: 66, 1973. 30. Laron, Z. and Zilka, E.: Compensatory hypertrophy of testicle in
31. 32.
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39. 40. 41. 42. 43. 44.
45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57.
unilateral cryptorchidism. J. Clin. Endocr. Metab., 29: 1409, 1969. Clegg, E. J.: Studies on artificial cryptorchidism: compensatory changes in the scrotal testes of unilaterally cryptorchid rats. J. Endocr., 33: 259, 1965. Rajfer, J. and Walsh, P. C.: Testicular descent. In: Morphogenesis and Malformation of the Genital System. Birth Defects: Original Article Series. Edited by R. J. Blandau and D. Bergsma. New York: Alan R. Liss, Inc., vol. XIII, No. 2, 1977. Lipshultz, L. I., Caminos-Torres, R., Greenspan, C. S. and Snyder, P. J.: Testicular function after orchiopexy for unilaterally undescended testis. New Engl. J. Med., 295: 15, 1976. Walsh, P. C., Curry, N., Mills, R. C. and Siiteri, P. K.: Plasma androgen response to hCG stimulation in prepubertal boys with hypospadias and cryptorchidism. J. Clin. Endocr. Metab., 42: 52, 1976. Lee, P. A., Hoffman, W. H., White, J. J., Engel, R. M. E. and Blizzard, R. M.: Serum gonadotropins in cryptorchidism. An indicator of functional testes. Amer. J. Dis. Child., 127: 530, 1974. Epstein, M. T., Atkinson, P. M. and Rippon, A. E.: Proceedings: plasma gonadotrophins and androgens in surgically treated cryptorchid patients. J. Endocr., 65: llP, 1975. Atkinson, P. M., Epstein, M. T. and Rippon, A. E.: Plasma gonadotropins and androgens in surgically treated cryptorchid patients. J. Ped. Surg., 10: 27, 1975. Job, J.-C., Garnier, P. E. Chaussain, J.-L., Toublanc, J. E. and Canlorbe, P.: Effect of synthetic luteinizing hormone-releasing hormone on the release of gonadotropins in hypophysogonadal disorders of children and adolescents. IV. Undescended testes. J. Ped., 84: 371, 1974. Bramble, F. J., Houghton, L. E., O'Shea, A. and Jacobs, H. S.: Proceedings: endocrine evaluation of treated cryptorchidism: results of a 10-year follow-up. J. Endocr., 64: 56P, 1975. Morehead, J. R. and Morgan, C. F.: Cryptorchidism. Its pre- and postpubertal effects on the hypophysis of the rat. Fertil. Steril., 18: 530, 1967. Altwein, J. E. and Gittes, R. F.: Effect of cryptorchidism and castration on FSH and LH levels in the adult rat. Invest. Urol., 10: 167, 1972. Schanbacher, B. D. and Ford, J. J.: Gonadotropin secretion in cryptorchid and castrate rams and the acute effects of exogenous steroid treatment. Endocrinology, 100: 387, 1977. Albescu, J. Z., Bergada, C. and Cullen, M.: Male fertility in patients treated for cryptorchidism before puberty. Fertil. Steril., 22: 829, 1971. Bramble, F. J., Houghton, A. L., Eccles, S., O'Shea, A. and Jacobs, H. S.: Reproductive and endocrine function after surgical treatment of bilateral cryptorchidism. Lancet, 2: 311, 1974. Hansen, T. S.: Fertility in operatively treated and untreated cryptorchidism. Proc. Roy. Soc. Med., 42: 645, 1949. Hohenfeller, R. and Eisenhut, L.: Evaluation of fertility in cryptorchidism. Int. J. Fertil., 9: 575, 1964. Knauth, H. and Potempa, J.: Hohenretention und Fertilitat. Urol. Int., 15: 77, 1963. Mack, W. S.: Infertility and the undescended testicle. Acta Endocr., suppl., 51: 647, 1960. Madersbacher, H.: Fertility in unilateral cryptorchidism. Urologe, 11: 210, 1973. Scott, L. S.: Fertility in cryptorchidism. Proc. Roy. Soc. Med., 55: 1047, 1962. Richter, W., Proschold, M., Butenandt, 0. and Knorr, D.: Fertility after treatment with HCG for undescended testes. Klin. Wochenschr., 54: 467, 1976. Lipshultz, L. I.: Cryptorchidism in the subfertile male. Fertil. Steril., 27: 609, 1976. Gross, R. E. and Jewett, T. C., Jr.: Surgical experiences from 1222 operations for undescended testis. J.A.M.A., 160: 634, 1956. Atkinson, P. M.: A follow-up study of surgically treated cryptorchid patients. J. Ped. Surg., 10: 115, 1975. Szymanowski, J.: quoted by Johnson, D. E., Woodhead, D. M., Pohl, D.R. and Robison, J. R.: Cryptorchidism and testicular tumorigenesis. Surgery, 63: 919, 1968. Martin, D. C. and Menck, H. R.: Undescended testis: management after puberty. J. Urol., 114: 77, 1975. Rea, C. E.: Malignancy of the testis, with special reference to
UNILATERAL ABDOMINAL CRYPTORCHIDISM
58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70.
undescended testis. Report of 76 cases (17 cases previously reported). Amer. J. Cancer, 15: 2646, 1931. Linke, C. A. and Kiefer, J. H.: Occurrence of testis tumor in undescended testis. J. Urol., 82: 347, 1959. Dinner, M. and Spitz, L.: The relationship of testicular tumours to maldescent. S. Afr. Med. J., 48: 45, 1974. Hinman, F.: Tumors of the testis. Five year cures following radical operation. Surg., Gynec. & Obst., 56: 450, 1933. Hinman, F. and Benteen, F. H.: The relationship of cryptorchidism to tumor of the testis. J. Urol., 35: 378, 1936. Campbell, H. E.: Incidence of malignant growth of the undescended testicle: a critical and statistical study. Arch. Surg., 44: 353, 1942. Sohval, A. R.: Testicular dysgenesis in relation to neoplasm of the testicle. J. Urol., 75: 285, 1956. Gehring, G. G., Rodriguez, F. R. and Woodhead, D. M.: Malignant degeneration of cryptorchid testes following orchiopexy. J. Urol., 112: 354, 1974. De Cenzo, J. M. and Leadbetter, G. W.: Early orchiopexy and testis tumors. Urology, 5: 365, 1975. Dow, J. A. and Mostofi, F. K.: Testicular tumors following orchiopexy. South. Med. J., 60: 193, 1967. Spence, H. M., Culp, 0. S., Glenn, J. F., Hinman, F., Jr. and Marshall, V. F.: Panel discussion: anomalies of external genitalia in infancy and childhood. J. Urol., 93: 1, 1965. Weiss, R. M., Glickman, M. G. and Lytton, B.: Venographic localization of the non-palpable undescended testis in children. J. Urol., 117: 513, 1977. Hinman, F., Jr.: Quoted by Charney, C. W. and Wolgin, W.: Cryptorchidism. New York: Paul H. Hoeber, Inc., 1957. Witus, W. S., Sloss, J. H. and Valk, W. L.: Inguinal node metastases from testicular tumors developing after orchiopexy. J. Urol., 81: 669, 1959.
75
71. Herr, H. W., Silber, I. and Martin, D. C.: Management of
inguinal lymph nodes in patients with testicular tumors following orchiopexy, inguinal or scrotal operations. J. Urol., 110: 223, 1973. 72. Bowles, W. T.: Inguinal nodes metastases from testicular tumor developing aftervaricocelectomy. J. Urol., 88: 266, 1962. 73. Smith, A. M. and Lattimer, J. K.: Psychosexual impact of undescended testes and implantation of prostheses. Human Sexuality, 9: 62, 1975. EDITORIAL COMMENT The author makes a strong argument for the removal of unilateral abdominally located undescended testes. I would prefer to individualize treatment since not all high undescended testes are structurally abnormal. Early orchiopexy of these testes in other patients may ultimately be shown to confer some protection against subsequent malignancy. Early orchiopexy may further improve subsequent fertility. The use of microvascular anastomosis has yet to find its place in the surgical treatment of the undescended testis but I believe that one day it may have a small role in the management of such patients. Donald C. Martin Department of Surgery University of California Irvine, California REPLY BY AUTHOR Individualization is important. Strong arguments are necessary to counteract the current practice of not individualizing cases. Striving to bring these testes down regardless of their characteristics often is counterproductive.
THE JOURNAL OF UROLOGY
Copyright © 1979 by The Williams & Wilkins Co.
Printed in U.S.A.
UNILATERAL ABDOMINAL CRYPTORCHIDISM FRANK HINMAN, JR.* From the Division of Urology, University of California School of Medicine, San Francisco, California
ABSTRACT
The unilateral non-palpable undescended testis is considered separately from other forms of cryptorchidism. It is less likely to be fertile, it is more prone to malignancy and it is more difficult to place. Removal rather than orchiopexy often is in the best interests of the child. The management of the unilateral abdominal (non-palpable) testis, which is just 1 entity of the cryptorchidism complex (fig. 1), is discussed. Recent reviews have not provided answers easily applied to individual clinical problems confronting the practicing urologist, especially the specific one of nonpalpable testis in which case the prowess of the surgeon is challenged by natural impediments. 1, 2 By concentrating on unilateral cryptorchidism, the separate problems of bilateral non-descent are avoided and by focusing on the non-palpable (abdominal) testis, no overlap with ectopy and retractility occurs (see table). 3 The unilateral non-palpable testis is an entity which can be defined, which raises its own surgical problems and around which the goals of therapy are highly controversial. In its most mature form its boundary is clearcut since it is determined by non-palpability on direct physical examination. In its most undeveloped form the unilateral nonpalpable testis shades imperceptibly into anorchism. To manage the unilateral non-palpable testis the 3 therapeutic goals must be weighed, which are fertility, avoidance of malignancy and cosmetic-psychologic satisfaction (fig. 2).
searchers today can discover these abnormalities at a younger age. 18 They further suggest that abnormalities are predetermined and that as a result testes cannot tolerate the stress of maturation. Hadziselimovic and associates found changes in patients as young as 2 years old with damage to the seminiferous tubules. 19 Developmental arrest in early infancy at the stage of type A spermatogonia was noted by Mancini and associates. 20 Similarly, Farrington found that the low mean germinal cell count (48 per cent lower than the normal testis) was not influenced by progressive age, which suggested a congenital defect rather than progressive deterioration. 21 Another study noted defective deoxyribonucleic acid synthesis in the spermatogonia in patients as young as 3½ years old. 22 Not only is the germinal epithelium affected but the adnexae may be abnormal as well. Dickinson reported such anomalies as absent epididymis and failure of urogenital union. 23 Abnormalities in the descended testis are not infrequent, which further suggests a fundamental deficit. Shida stated that all cases have a congenital defect in the contralateral testis. 24 Scorer and Farrington, 25 and Hecker and Heinz11 found that it lagged behind the normal stages of maturation. Scott noted 4 instances of arrest and 1 of Sertoli cell only among 8 cases biopsied. 26 However, Farrington found the contralateral testis to be dysgenetic in only 4 per cent of the cases. 21 The increased incidence of malignancy in the contralateral testis compared to normal testes further suggests more general testicular abnormality in patients with unilateral cryptorchidism. 27 The descended testis might also be affected by the cryptorchid testis28 but probably not, as seen from data on unilateral absent testes, which are accompanied by contralateral changes similar to those seen with cryptorchidism. Woodhead and associates found decreased spermatogenesis in 36 per cent of 34 untreated adults, 13 of whom had blind-ending vasa, and concluded that the defect was not caused by the presence or absence of the cryptorchid testis. 20 In fact, contralateral hypertrophy usually occurs. 30 • 31 A conclusion is that abnormalities of testicular development are common and inhibit normal spermatogenesis. Endocrine abnormalities. Developmental enzymatic abnormalities produce a number of recognized congenital syndromes, which are not pertinent to this discussion, but more subtle defects may be detected in boys with uncomplicated unilateral cryptorchidism. 32 Testosterone levels may be elevated4 or normal5· 7, 33 and may be less responsive to human chorionic gonadotropic stimulation. 34 Levels of follicle-stimulating hormone and luteinizing hormone are elevated initially and remain so after orchiopexy. 5· 6· 33 However, other authors have observed a mixture of responses. 35- 37 Werder and associates5 found a partial deficiency to luteinizing hormone releasing factor after orchiopexy, although Lipshultz and associates 33 found the response on luteinizing hormone levels normal but detected a 2-fold increase in follicle-stimulating hormone, suggesting Sertoli cell damage. Job and associates found no difference in basal
FERTILITY
The principal reason for preserving the abdominal testis by orchiopexy is to enhance fertility, since interstitial cell function for testosterone production is at least adequateH and operative treatment does not alter it. 7 However, either inherent deficiencies in the testis or an abnormal endocrine environment may limit this goal regardless of the time of treatment. Inherent testicular deficiencies. The adverse effect of heat on the retained testis is well established and it is generally accepted that if an operation is to be done to preserve fertility it should be done before the patient is 5 or 6 years old. Temperature effects are not the only consideration. The surgical decision must also be based on an appreciation of the proportion of cryptorchid testes affected by developmental abnormalities. These abnormalities have direct relation to impaired fertility and increased risk of malignancy. However, the data are not easily analyzed, since the results are influenced by the source of the material and variations would be expected, depending on the composition of the series. For example, a series containing more ectopic testes would differ from one with predominantly high testes. Even patients with retractile testes have less than normal fertility. Puri and Nixon found that 26 per cent of such patients were infertile. 8 They questioned whether this was owing to intrinsic factors and not merely the effect of increased temperature. Earlier studies showed that abnormalities could be detected after the patients were approximately 5 years old. D-17 ReAccepted for publication August 18, 1978. Read at annual meeting of Society for Pediatric Urology, Washington, D. C., May 20, 1978. * Requests for reprints: M-553, University of California, San Francisco, California 94143. 71
72
HINMAN
Fm. 1. Interrelationships in cryptorchidism Treatment for unilateral cryptorchidism Testis Non-palpable Palpable Symptomatic
<5 Yrs. Orchiectomy Orchiopexy Orchiopexy
5 Yrs. to Puberty Orchiectomy Orchiopexy Orchiopexy
>Puberty None, orchiectomy None, orchiectomy Orchiectomy
resistance to the action of gonadotropins. 37 Animal experiments also indicate abnormal hormonal relationships in cryptorchidism. Morehead and Morgan noted castrate cells in the pituitary in postpuberal cryptorchid rats, associated with increased pituitary weight. 40 Others noted after high fixation of the rat testis an early increase of folliclestimulating hormone level, a later lesser increase of luteinizing hormone level but a marked increase in both after castration, which indicates adequate feedback although the tubules are atrophic. 41 In rams experimental cryptorchidism produces hormonal alterations similar to those observed in humans. 42 To summarize, the endocrine environment is abnormal in many cases of unilateral cryptorchidism and these abnormalities may be either cause or effect. Effects of treatment on fertility. Data available on fertility do not distinguish palpable from non-palpable testes (although they do eliminate retractile testes). The knowledge that abdominal testes are, as a group, less well developed than palpable testes makes the results of their therapy poorer than that of the combined groups. When the semen quality of treated cases is compared to that of untreated cases from data collected from 10 series, totaling 353 patients (fig. 3), normal semen is recorded more often when no intervention has taken place. 42---51 The differences are more favorable toward the treated cases among the groups with lower counts. These results can be compared with the recent study of Lipshultz who found 62 per cent of 20 patients fertile after unilateral orchiopexy. 52 Although not as good as the 79 per cent fertility reported by Gross and Jewett53 and 76 per cent by Atkinson54 these figures are better than those obtained if only cases of abdominal testes had been followed, since the high proportion of inguinal testes would be expected to increase the over-all average. More extensive dissection is required for abdominal testes, resulting in a greater possibility for interference with the vasculature or necessitating a staged procedure. Such manipulations tend to decrease the potential for fertility in distinction to the simpler procedures used for palpable testes. In conclusion, it has not been shown that orchiopexy increases fertility nor that unilateral cryptorchidism is necessarily a unilateral disease. MALIGNANCY
Certain factors must be considered regarding malignancy: it is increased in cryptorchidism, its incidence in abdominal testes is greater than in palpable testes, it is probably related to dysgenesis rather than to temperature, its dangers must be SPERMATOGENESIS IN UNILATERAL CRYPTORCHIDISM WITH and WITHOUT ORCHIOPEXY 30
-
orchiopexy
£iim nonoperative
20
Fm. 2. Weighing therapeutic goals for non-palpable testes luteinizing hormone and follicle-stimulating hormone, and noted the same exaggerated response of follicle-stimulating hormone to luteinizing hormone releasing factor but a diminished response to luteinizing hormone. 38 They suggested a delay in gonadotropin secretion in the cryptorchid testis. Atkinson and associates found that elevation of follicle-stimulating hormone and luteinizing hormone in postpuberal boys who had had a previous orchiopexy gave a poor prognosis for fertility, since only 15 of 40 such patients were fertile. 37 Bramble and associates made similar observations. 39 Atkinson and associates suggested that this w~~ .evidence of primary
PERCENT CASES
10
o
NONE
SLIGHT MODERATE SEVERE AZOOSPERMIA IMPAIRMENT OF SEMEN QUALITY
Fm. 3. Comparison of semen analyses in treated and untreated cases of unilateral cryptorchidism.
73
UNILATERAL ABDOMINAL CRYPTORCHIDISM
weighed against operative risk, it is probably not reduced by orchiopexy and it is more difficult to cure after orchiopexy .. The risk of malignancy is 35 times greater for persons with cryptorchidism than for the general population. This relationship has been recognized since 1868 when Szymanowski advocated prophylactic excision of all non-scrotal testes. 55 Since review articles are available the statistics need not be repeated. 5&-6 1 Intra-abdominal testes have an even higher risk of malignancy. Although not more than 15 per cent of undescended testes are intra-abdominal they contain half of the tumors (fig. 4). 58, 62 • Testicular dysgenesis rather than exposure to mcreased temperature appears to be the major factor leading to neoplasia. 63 The testis is subjected to the same elevated temperature, whether it is within the abdominal cavity or lying in the groin. Thus, in abdominal testes heat cannot be responsible for higher neoplastic incidence. That early orchiopexy reduces the likelihood of malignancy has been asserted but to date no convincing evidence has been presented. 64 The impression that carcinoma is less likely if the testis is brought down early is based on series that include few early operations. 65 More importantly, the mean age of patients at the time a tumor is diagnosed is 30 years. 66 Thus, if the time of orchiopexy has an influence on malignancy >24 years must separate the orchiopexy from the followup report to provide relevant information (fig. 5). . . Furthermore inasmuch as 24 per cent of the malignancies occur in the con'tralateral testis, 64 the benefits of early fixation are even less certain. The risk of operation must be weighed against the risk of malignancy. 67 Martin and Menck have drawn a graph from facts reported in the literature showing that the risk of eventual death from carcinoma in a prepubertal boy with an abdominal testis is almost 6 per cent, much higher than the 0.2 per cent chance of a fatal outcome from orchiectomy. 56 The risk from an orchiopexy is comparable to that of removal but to that risk must be added the possibility of fatal carcinoma, a chance that is not lessened by scrotal placement of the testis. There are no data on the chance of loss of the other testis by injury or other disease but it is probably quite small. The potential for loss from malignant involvement has been discussed. Since abdominal testes range down to clusters of Leydig cells in connective tissue attached to a simple pampiniform plexus, venography may become valuable in identifying tr~e anorchia by the absence of the plexus68 and, therefore, avmd an unnecessary operation. In the postpuberal man the risk of
PROBABLE LAG PERIOD BETWEEN
100
£. MALIGNANCY
--TOTAL C A S E S - - - - - - - - - - - - -
CASES OF
80
6""
OACHIOPEXY
BY AGE
,._
~
ORCHIOPEXY
60
I.)
~ Cl: 40 MALIGNANCY 'N CASES OF RCHIOPEXY BY AGE 6
20
0 1955
60
70
80 YEARS
90
2000
2005
Fm. 5. Effect of postulated delay in development of malignancy after early orchiopexy.
operation for removal of an undescended testis must be weighed against the chance for malignant development. Although the assumptions of Martin and Menck56 weight the side for removal it is probably reasonable to operate when the patient has symptoms or shows concern, rather _than . to advocate routine orchiectomy. Finally, the lymphatic dramage of the testis is altered by opera~ion, 6n making cure_ more difficult than when the spread is only to the primary nodes. 70-72 The conclusion can be reached that the risk of malignancy is great in an abdominal testis, whether ~p or down, and probably warrants its removal when there is a contralateral testis. COSMETIC AND PSYCHOLOGIC ASPECTS
A silicone prosthesis usually will give a better cosmetic appearance than a small abdominal testis brought down to the upper or mid scrotum. However, this advantage . must be balanced against concerns of the parents about partial loss of testicular substance or later loss of the other testis. 73 The prosthesis usually must be replaced at puberty, which may done rather simply with the patient under local anesthesi~. The benefit from the superior cosmetic effect of the prosthesis probably overcomes parental concerns, which places the ~e.cision for or against orchiectomy on the chances for fertility versus malignancy.
?e
CONCLUSIONS
I NCI DENCE OF MALIGNANCY IN ABDOMINAL TESTES CAMPBELL 1942
CRYPTORCH IDISM 2,119 cases
MALIGNANCY 68 cases
PALPABLE
ABDOMINAL (14.3%)
ABDOMINAL (485%)
Fm. 4. Proportion of abdominal testes among cryptorchid patients and cryptorchid tumors. Data from Campbell. 62
In comparison to the palpable undescended_ testis the ~bdominal testis adds little to fertility, is more liable to malignancy and is marginally cosmetic after orc?-~opexy. In palp~ble testes orchiopexy somewhat improves fertility. The abd~n_im~l testis is basically abnormal so that enhancement of fertility is much less likely. Malignancy is not only significa~tly _m~re common in abdominal testes but eventual mortality is mcreased by scrotal fixation. Cosmetic appearance after placement of a small testis is less satisfactory than from a prosthesis. Thus, the unilateral abdominal testis in childhood should not be treated routinely by orchiopexy but should be removed. The parents should be advised preoperatively that the t~stis might be abnormal and require removal, _and P!eparat10~s should be made for insertion of a prosthesis. This plan will best promote the welfare of the child. REFERENCES
1. Martin, D. C.: The undescended testis: evolving concepts in
management. J.C. E. Urology, 16: 17, 1977.
74
HINMAN
2. Shapiro, S. R.: Infertility and the undescended testis. Urology Times, January 1978. 3. Scorer, C. G.: The anatomy of testicular descent-normal and incomplete. Brit. J. Surg., 49: 357, 1962. 4. Waaler, P. E.: Endocrinological studies in undescended testes. Acta Paediatr. Scand., 65: 559, 1976. 5. Werder, E. A., Illig, R., Torresani, T., Zachmann, M., Baumann, P., Ott, F. and Prader, A.: Gonadal function in young adults after surgical treatment of cryptorchidism. Brit. Med. J., 4: 1357, 1976. 6. Matsuda, S.: A study on cryptorchidism. Report 1. Changes in plasma level of FSH, LH and testosterone in cryptorchidism with loading of luteinizing hormone-releasing hormone. Japan J. Urol., 66: 462, 1975. 7. Engberg, H.: Investigations on the endocrine function of the testicle in cryptorchidism. Proc. Roy. Soc. Med., 42: 652, 1949. 8. Puri, P. and Nixon, H. H.: Bilateral retractile testes-subsequent effects on fertility. J. Ped. Surg., 12: 563, 1977. 9. Leeson, C.R.: An electron microscopic study of cryptorchid and scrotal human testes with special reference to pubertal maturation. Invest. Urol., 3: 498, 1966. 10. Robinson, J. N. and Engle, E. T.: Some observations on the cryptorchid testes. J. Urol., 71: 726, 1954. 11. Hecker, W. C. and Heinz, H. A.: Cryptorchidism and fertility. J. Ped. Surg., 2: 513, 1967. 12. Sohval, A. R.: Histopathology of cryptorchidism. A study based upon the comparative histology of retained and scrotal testes from birth to maturity. Amer. J. Med., 16: 346, 1954. 13. Rea, C. E.: Functional capacity of the undescended testis. Arch. Surg., 38: 1054, 1939. 14. Hinman, F., Jr.: Implications of testicular cytology in the treatment ofcryptorchidism. Amer. J. Surg., 90: 381, 1955. 15. Numanoglu, I., Koktiirk, I. and Mutaf, 0.: Light and electron microscopic examinations of undescended testicles. J. Ped. Surg., 4: 614, 1969. 16. Kiesewetter, W. B., Shull, W.R. and Fetterman, G. H.: Histologic changes in the testis following anatomically successful orchidopexy. J. Ped. Surg., 4: 59, 1969. 17. Czerniak, P. and Itelson, J.: Spermatogenic activity test (S.A. T.) for evaluation offertility in cryptorchidism. Fertil. Steril., 18: 135, 1967. 18. Mengel, W., Heinz, H. A., Sippe, W. G. and Hecker, W. Ch.: Studies on cryptorchidism: a comparison of histological findings in the germinative epithelium before and after the second year oflife. J. Ped. Surg., 9: 445, 1974. 19. Hadziselimovic, F., Herzog, B. and Seguchi, H.: Surgical correction of cryptorchidism at 2 years: electron microscopic and morphometric investigations. J. Ped. Surg., 10: 19, 1975. 20. Mancini, R. E., Rosemberg, E., Cullen, M., Lavieri, J.C., Vilar, 0., Bergada, C. and Andrada, J. A.: Cryptorchid and scrotal human testes. I. Cytological, cytochemical and quantitative studies. J. Clin. Endocr. Metab., 25: 927, 1965. 21. Farrington, G. H.: Histologic observations in cryptorchidism: the congenital germinal cell deficiency of the undescended testis. J. Ped. Surg., 4: 606, 1969. 22. Markewitz, M., Lattimer, J. K. and Veenema, R. J.: A comparative study of germ cell kinetics in the testes of children with unilateral cryptorchidism: a preliminary report. Fertil. Steril., 21: 806, 1970. 23. Dickinson, S. J.: Structural abnormalities in the undescended testis. J. Ped. Surg., 8: 523, 1973. 24. Shida, K.: Functional Disorders in Urology. Tokyo: Kanahara Shuppan, p. 210, 1964. 25. Scorer, C. G. and Farrington, G. H.: Histological studies of the undescended testis. In: Congenital Deformities of the Testis and Epididymis. London: Butterworth & Co., chapt. 5, p. 58, 1971. 26. Scott, L. S.: Unilateral cryptorchidism; subsequent effects on fertility. J. Reprod. Fertil., 2: 54, 1961. 27. Johnson, D. E., Woodhead, D. M., Pohl, D. R. and Robison, J. R.: Cryptorchidism and testicular tumorigenesis. Surgery, 63: 919, 1968. 28. Shirai, M., Matsushita, S., Kagayama, M., lchijo, S. and Takeuchi, M.: Histological changes of the scrotal testis in unilateral cryptorchidism. Tohoku J. Exp. Med., 90: 363, 1966. 29. Woodhead, D. M., Pohl, D. R. and Johnson, D. E.: Fertility of patients with solitary testes. J. Urol., 109: 66, 1973. 30. Laron, Z. and Zilka, E.: Compensatory hypertrophy of testicle in
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unilateral cryptorchidism. J. Clin. Endocr. Metab., 29: 1409, 1969. Clegg, E. J.: Studies on artificial cryptorchidism: compensatory changes in the scrotal testes of unilaterally cryptorchid rats. J. Endocr., 33: 259, 1965. Rajfer, J. and Walsh, P. C.: Testicular descent. In: Morphogenesis and Malformation of the Genital System. Birth Defects: Original Article Series. Edited by R. J. Blandau and D. Bergsma. New York: Alan R. Liss, Inc., vol. XIII, No. 2, 1977. Lipshultz, L. I., Caminos-Torres, R., Greenspan, C. S. and Snyder, P. J.: Testicular function after orchiopexy for unilaterally undescended testis. New Engl. J. Med., 295: 15, 1976. Walsh, P. C., Curry, N., Mills, R. C. and Siiteri, P. K.: Plasma androgen response to hCG stimulation in prepubertal boys with hypospadias and cryptorchidism. J. Clin. Endocr. Metab., 42: 52, 1976. Lee, P. A., Hoffman, W. H., White, J. J., Engel, R. M. E. and Blizzard, R. M.: Serum gonadotropins in cryptorchidism. An indicator of functional testes. Amer. J. Dis. Child., 127: 530, 1974. Epstein, M. T., Atkinson, P. M. and Rippon, A. E.: Proceedings: plasma gonadotrophins and androgens in surgically treated cryptorchid patients. J. Endocr., 65: llP, 1975. Atkinson, P. M., Epstein, M. T. and Rippon, A. E.: Plasma gonadotropins and androgens in surgically treated cryptorchid patients. J. Ped. Surg., 10: 27, 1975. Job, J.-C., Garnier, P. E. Chaussain, J.-L., Toublanc, J. E. and Canlorbe, P.: Effect of synthetic luteinizing hormone-releasing hormone on the release of gonadotropins in hypophysogonadal disorders of children and adolescents. IV. Undescended testes. J. Ped., 84: 371, 1974. Bramble, F. J., Houghton, L. E., O'Shea, A. and Jacobs, H. S.: Proceedings: endocrine evaluation of treated cryptorchidism: results of a 10-year follow-up. J. Endocr., 64: 56P, 1975. Morehead, J. R. and Morgan, C. F.: Cryptorchidism. Its pre- and postpubertal effects on the hypophysis of the rat. Fertil. Steril., 18: 530, 1967. Altwein, J. E. and Gittes, R. F.: Effect of cryptorchidism and castration on FSH and LH levels in the adult rat. Invest. Urol., 10: 167, 1972. Schanbacher, B. D. and Ford, J. J.: Gonadotropin secretion in cryptorchid and castrate rams and the acute effects of exogenous steroid treatment. Endocrinology, 100: 387, 1977. Albescu, J. Z., Bergada, C. and Cullen, M.: Male fertility in patients treated for cryptorchidism before puberty. Fertil. Steril., 22: 829, 1971. Bramble, F. J., Houghton, A. L., Eccles, S., O'Shea, A. and Jacobs, H. S.: Reproductive and endocrine function after surgical treatment of bilateral cryptorchidism. Lancet, 2: 311, 1974. Hansen, T. S.: Fertility in operatively treated and untreated cryptorchidism. Proc. Roy. Soc. Med., 42: 645, 1949. Hohenfeller, R. and Eisenhut, L.: Evaluation of fertility in cryptorchidism. Int. J. Fertil., 9: 575, 1964. Knauth, H. and Potempa, J.: Hohenretention und Fertilitat. Urol. Int., 15: 77, 1963. Mack, W. S.: Infertility and the undescended testicle. Acta Endocr., suppl., 51: 647, 1960. Madersbacher, H.: Fertility in unilateral cryptorchidism. Urologe, 11: 210, 1973. Scott, L. S.: Fertility in cryptorchidism. Proc. Roy. Soc. Med., 55: 1047, 1962. Richter, W., Proschold, M., Butenandt, 0. and Knorr, D.: Fertility after treatment with HCG for undescended testes. Klin. Wochenschr., 54: 467, 1976. Lipshultz, L. I.: Cryptorchidism in the subfertile male. Fertil. Steril., 27: 609, 1976. Gross, R. E. and Jewett, T. C., Jr.: Surgical experiences from 1222 operations for undescended testis. J.A.M.A., 160: 634, 1956. Atkinson, P. M.: A follow-up study of surgically treated cryptorchid patients. J. Ped. Surg., 10: 115, 1975. Szymanowski, J.: quoted by Johnson, D. E., Woodhead, D. M., Pohl, D.R. and Robison, J. R.: Cryptorchidism and testicular tumorigenesis. Surgery, 63: 919, 1968. Martin, D. C. and Menck, H. R.: Undescended testis: management after puberty. J. Urol., 114: 77, 1975. Rea, C. E.: Malignancy of the testis, with special reference to
UNILATERAL ABDOMINAL CRYPTORCHIDISM
58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70.
undescended testis. Report of 76 cases (17 cases previously reported). Amer. J. Cancer, 15: 2646, 1931. Linke, C. A. and Kiefer, J. H.: Occurrence of testis tumor in undescended testis. J. Urol., 82: 347, 1959. Dinner, M. and Spitz, L.: The relationship of testicular tumours to maldescent. S. Afr. Med. J., 48: 45, 1974. Hinman, F.: Tumors of the testis. Five year cures following radical operation. Surg., Gynec. & Obst., 56: 450, 1933. Hinman, F. and Benteen, F. H.: The relationship of cryptorchidism to tumor of the testis. J. Urol., 35: 378, 1936. Campbell, H. E.: Incidence of malignant growth of the undescended testicle: a critical and statistical study. Arch. Surg., 44: 353, 1942. Sohval, A. R.: Testicular dysgenesis in relation to neoplasm of the testicle. J. Urol., 75: 285, 1956. Gehring, G. G., Rodriguez, F. R. and Woodhead, D. M.: Malignant degeneration of cryptorchid testes following orchiopexy. J. Urol., 112: 354, 1974. De Cenzo, J. M. and Leadbetter, G. W.: Early orchiopexy and testis tumors. Urology, 5: 365, 1975. Dow, J. A. and Mostofi, F. K.: Testicular tumors following orchiopexy. South. Med. J., 60: 193, 1967. Spence, H. M., Culp, 0. S., Glenn, J. F., Hinman, F., Jr. and Marshall, V. F.: Panel discussion: anomalies of external genitalia in infancy and childhood. J. Urol., 93: 1, 1965. Weiss, R. M., Glickman, M. G. and Lytton, B.: Venographic localization of the non-palpable undescended testis in children. J. Urol., 117: 513, 1977. Hinman, F., Jr.: Quoted by Charney, C. W. and Wolgin, W.: Cryptorchidism. New York: Paul H. Hoeber, Inc., 1957. Witus, W. S., Sloss, J. H. and Valk, W. L.: Inguinal node metastases from testicular tumors developing after orchiopexy. J. Urol., 81: 669, 1959.
75
71. Herr, H. W., Silber, I. and Martin, D. C.: Management of
inguinal lymph nodes in patients with testicular tumors following orchiopexy, inguinal or scrotal operations. J. Urol., 110: 223, 1973. 72. Bowles, W. T.: Inguinal nodes metastases from testicular tumor developing aftervaricocelectomy. J. Urol., 88: 266, 1962. 73. Smith, A. M. and Lattimer, J. K.: Psychosexual impact of undescended testes and implantation of prostheses. Human Sexuality, 9: 62, 1975. EDITORIAL COMMENT The author makes a strong argument for the removal of unilateral abdominally located undescended testes. I would prefer to individualize treatment since not all high undescended testes are structurally abnormal. Early orchiopexy of these testes in other patients may ultimately be shown to confer some protection against subsequent malignancy. Early orchiopexy may further improve subsequent fertility. The use of microvascular anastomosis has yet to find its place in the surgical treatment of the undescended testis but I believe that one day it may have a small role in the management of such patients. Donald C. Martin Department of Surgery University of California Irvine, California REPLY BY AUTHOR Individualization is important. Strong arguments are necessary to counteract the current practice of not individualizing cases. Striving to bring these testes down regardless of their characteristics often is counterproductive.