Undescended Testes: Do We Need to Fix Them Earlier?

Transcription

1 Annals of Pediatric Surgery, Vol 1, No 1, October 2005: PP Original Article Undescended Testes: Do We Need to Fix Them Earlier? Ashraf H. M. Ibrahim *, Talal A. Al-Malki **, Ahmed M. Ghali ***, and Adel O. Musalam **** * Department of Surgery, Armed Forces Hospital-Southern Region, Khamis Mushayt, Saudi Arabia; ** Department of Surgery, King Khalid University, Abha, Saudi Arabia; *** Urology & Nephrology Center, Mansoura University, Egypt; ****Department of Pathology, Azhar University, Cairo, Egypt Background/Purpose: Patients with undescended testes (UDT) may present with acute testicular torsion or incarcerated hernia requiring immediate surgical intervention. The exact incidence of these two complications among cases of UDT is not known. The aim of this study was to investigate the frequency of such conditions in our series of undescended testes, and to evaluate whether early intervention in undescended testes could eliminate such problems. Patients and Methods: All the data of patients with undescended testes admitted for surgery in Aseer Central Hospital, Abha Saudi Arabia, over a 6-year period were reviewed. In two hundred and ninety patients, 18 presented acutely with torsion of the undescended testicle in the inguinal canal (n=11) or incarcerated inguinal hernias (n=7). The data of these 18 patients were looked up for patient characteristics. Methods of diagnosis, preoperative preparation, operative findings, operative interventions, histopathological results and outcome were all analyzed. Result: Ten out of 18 patients (55.5%) were less than six months. Nine out of eleven patients with testicular torsion required orchiectomy. The other two underwent orchiopexy, which ended up with atrophy. All patients with incarcerated hernia had simultaneous hernia repair and orchiopexy; of which, three atrophied. Conclusion: Acute testicular torsion and hernia incarceration in cases of cryptorchidism may be more prevalent than initially thought. Orchiopexy, as early as 3 months of age, may reduce the incidence of such problems. Therefore, earlier intervention in undescended testes (between 3-6 months) is recommended. Index Words: Cryptorchidism, undescended testes, testicular torsion, incarcerated hernia A INTRODUCTION cute testicular torsion and hernia incarceration in cases of cryptorchidism have been little studied in the literature. Testicular torsion associated with cryptorchidism is rarely reported. It is claimed to involve patients suffering from spastic neuromuscular disease, 1,2 although few cases without neuromuscular Correspondence to: Ashraf H. M. Ibrahim. Armed Forces Hospital, Southern Region, King Faisal Military City P. O. Box: 5062, Khamis Mushait Kingdom of Saudi Arabia ash_ib51@yahoo.com

2 Ibrahim et al disease have been reported. 3 5 A patent processus vaginalis is present in more than 90% of cases with undescended testes (UDT). 6 A symptomatic inguinal hernia makes the cryptorchid gonad more vulnerable to vascular compromise and atrophy especially if incarceration of the hernia occurs. 7 Even if the testis is deemed viable during surgery and orchiopexy is undertaken, the possibility of testicular atrophy is still substantial. 8 As the exact incidence of these two complications (Testicular Torsion and incarcerated hernia) among cases of UDT is not known, the aim of this study was to answer this question and to know whether early intervention in UDT could eliminate such problems. PATIENTS AND METHODS All the data of patients with UDT admitted for surgery in Aseer Central Hospital, Abha, Saudi Arabia, over a 6-year period (from May 1998 to May 2004), were reviewed (Aseer Central Hospital is the regional tertiary referral hospital for Aseer region and is affiliated with the College of Medicine and Medical Sciences, King Khalid University). In two hundred and ninety patients, 18 presented acutely. Eleven patients presented with torsion of the undescended testicle in the inguinal canal and seven with incarcerated inguinal hernias. The data of these 18 patients were studied for patients characteristics including age at presentation; previous history of UDT, time elapsed between onset of acute symptoms and surgery. Methods of diagnosis, preoperative preparation, operative findings, operative interventions, histopathological results and outcome were all analyzed. patients had color Doppler ultrasonography or isotopic scanning for diagnosis. All patients received preoperative antibiotics. None received any trial for manual reduction or reversal of torsion. All patients were explored through an inguinal incision. Nine out of eleven patients with testicular torsion required orchiectomy. The other two underwent orchiopexy, which ended up with atrophy. One patient had simultaneous contralateral orchiopexy. All the seven patients with incarcerated hernia had simultaneous hernia repair and orchiopexy; of which, three atrophied. One patient with strangulated hernia required resection of a gangrenous bowel segment. The operative findings and the outcome are shown in table 1. It was observed that 14/18 testes (77.8%) were finally lost. Histopathological examinations of the excised testes confirmed the diagnosis of testicular torsion. Fig 1A. 3-month old boy with tender mass in the left inguinal region (arrow). Note empty left hemiscrotum. RESULTS Out of 290 patients, eleven patients (3.8%) had emergency surgery due to acute torsion of the UDT in the inguinal canal and seven (2.4%) due to hernial incarceration (Fig 1a, 1b, 2a, and 2b). There was a time delay at presentation that ranged between 10 hours to 36 hours. None of the patients had associated neuromuscular disease. All patients presented to the hospital for the first time, although nine of them gave history of UDT. The type of pathology and age at presentation are given in (Table 1). It was observed that ten patients (55.5%) were below 6 months of age while 8 (44.5%) were 6 months of age. None of the Fig 1B. Intra-operative finding, showing extra vaginal torsion involving the spermatic cord. 22 Annals of Pediatric Surgery

3 Ibrahim et al. Fig 2A. 2-month old boy with tender mass in the right inguinal region (arrow) with empty right hemiscrotum. Fig 2B. Intra-operative finding. Mass proved to be incarcerated inguinal hernia with viable right UDT and bowel. Table 1: Intraoperative findings and outcomes. Testicular torsion(n =11) Incarcerated hernia (n = 7) Laterality: Right UDT 2 4 Left UDT 9 2 Bilateral UDT 0 1 Age at presentation: Less than 3 months months months months-1 year years 1 0 Operative findings: Gangrene 9 0 Viable/doubtful 2 7 The final outcome: Orchiectomy 9 0 Subsequent Atrophy 2 3 DISCUSSION Berkowitz et al showed that the incidence of cryptorchidism in 6935 newborn boys declined from 3.7% at birth to 1% by 3 months and remained constant at one year of age. 9 Accordingly, most of the UDT will spontaneously descend by three months of age. However, boys with a small or poorly developed scrotum and those with hypospadius are more likely to be cryptorchid at three months of age. 10 In the past, it was claimed that the incidence of torsion of a cryptorchid testis was as high as 20%. 11 At that time, orchiopexy was usually done above the age of 3 years. Recently, the incidence came down to 2.5% as mentioned in later reports. 12 Generally speaking, the frequency of testicular torsion is considered to be bimodal with one peak in the perinatal period and another at puberty. 13 Neonatal or perinatal torsion accounts for approximately 12% of all cases of testicular torsion. 14 Duckett claimed that the incidence of prenatal torsion is probably much higher than is quoted and results in the vanishing testis. 15 The cause of neonatal torsion is believed to be, in part, secondary to the hypermobility and elasticity of the testicular tissue, which will only be fixed in the scrotum during the first several days of life. 16 Therefore, most cases of postnatal torsion occur within the first 10 days of life. 17 Torsion of the UDT represents a different entity, since the bimodal rule is not applicable and hypermobility is the only possible cause of torsion in this group of patients. This danger will persist as long as the testis is not fixed. The diagnosis is usually straightforward. When a neonate, infant, or a young child with a history of UDT presents with symptoms and signs of acute abdomen, with a tender mass in the inguinal region and an empty ipsilateral hemiscrotum, diagnosis of testicular torsion is common sense. In equivocal cases, color Doppler sonography was claimed to be the best imaging modality as it can judge the anatomy as well as the blood flow to the testis. 18 However, falsenegative and false-positive results have been reported and it is operator dependant. 19,20 The nuclear scan imaging is more limited than color Doppler ultrasonograghy because it allows only assessment of the testicular blood flow. 21 False impression of an adequate blood flow may result from hyperemia of the scrotal wall, especially in children with small scrotal sacs and testes that are not dependent which Vol 1, No 1, October

4 Ibrahim et al are both difficult to image with the radionuclide imaging techniques. 22 In cases of acute scrotal testicular torsion, both nuclear scan and Doppler ultrasonography may be technically inadequate in the neonate due to the small testicular size. 23 The authors (and our institute protocol) believe that these radiological investigations are even more difficult in UDT with torsion due to the small size of the gonad, which lie independently in the inguinal canal. This location may make it more difficult to scan than when lying in a scrotal position. Hence, these investigations were considered unnecessary and were not performed in the present group of patients. Preoperatively, our patients were diagnosed clinically by the presence of a tender mass in the inguinal canal with empty ipsilateral hemiscrotum. The differentiation between these two conditions was not done preoperatively as it is usually difficult and unnecessary. Manual reduction or reversal of torsion has no role in such cases and were not contemplated in our patients. Contralateral orchiopexy was not practiced in the present group of patients except in one patient and none of the patients had torsion of the contra lateral side after a mean period of follow up of 4.5 years. However, it is advised to fix the contralateral testis to protect the sole remaining testis from possible torsion in the future. 17, 24 The outcome in undescended testes presenting acutely with torsion is dismal. 5 The patients of this study presented with a time delay that ranged between hours with a salvage rate of 0 %. The outcome in UDT with hernial incarceration looks better (57.1% salvage rate). However, the possibility of testicular atrophy and bowel gangrene exist (as clearly illustrated in our study) and it may be a disabling and life threatening condition. It is reported that the incidence of testicular infarction with hernial incarceration in normally descended testes varies between 2.2% and 14%. 25,26 In the literature and in our study, the incidence of testicular infarction or subsequent atrophy in UDT with hernial incarceration seems to be higher than that. Most authors recommend orchiopexy after six months and before 18 months of age. 27 It was striking to see the incidence of these complications to be as high as 6.2% of the presenting cases and that 55% of them were younger than the recommended age of repair. It has been reported that orchiopexy can be performed safely and effectively as young as two months of age 28, and as we found in the main cohort of data, seven patients were operated upon at the age of 2-3 months due to concomitant huge hernial sacs. The operation was safe and they were followed up until a mean age of 3.5 years with excellent outcomes. Earlier intervention (after 3 months and before 6 months) could help avoiding such disabling and life threatening complications in many patients. This may not totally eliminate the likelihood of such complications which can occur even before 3 months of age. This trend has been supported by other researcher as well. 29 However, this should only be performed in specialized pediatric surgical centers, as only in such centers can the risk be minimized. 30 Therefore, early diagnosis and referral of UDT are recommended, which can be achieved through full cooperation and understanding between family doctors, parents and surgeons. CONCLUSION Acute testicular torsion and hernia incarceration in cases of cryptorchidism may be more prevalent than initially thought. Orchiopexy, as early as 3 months of age, may reduce the incidence of these complications. Therefore, earlier intervention in undescended testes (between 3-6 months) is recommended. REFERENCES 1. Phillips NB, Holmes TW: Torsion infarction in ectopic cryptorchidism: a rare entity occurring most commonly with spastic neuromuscular disease. Surgery 71: , Schultz KE, Walker J: Testicular torsion in an undescended testis. Ann Emerg Med 13: , Tozawa K, Washida H, Honma H, et al: Torsion of the undescended testis: report of two cases. Hinyokika Kiyo 39: , Rabii R, Rais H, Hafiani M, et al: Torsion of an undescended testis: Apropose of a case. Ann Urol 32: 49-51, Candocia FJ and Sack Soloman K: An infant with testicular torsion in the inguinal canal. Pediatr Radiol 33: , Elder JS: Epididymal anomalies associated with hydrocel/hernia and cryptorchidism: implications regarding testicular descent. J Urol 148: , Romero-Perez P, Amat-Cecilia M, Santos-Serrano L, et al: Necrosis of undescended testis caused by incarcerated 24 Annals of Pediatric Surgery

5 Ibrahim et al. inguinoscrotal hernia in a newborn. Actas Urol Esp 19: , Williamson RCN: Torsion of the testis and allied conditions. Br. J. Surg. 63: 465, Berkowitz GS, Lapinski RH, Dolgin SE, et al: Prevalence and natural history of cryptorchidism. Pediatrics 92: 44-49, John Radcliffe Hospital Cryptorchidism Study Group: Cryptorchidism: a prospective study of 7500 consecutive male births, Arch Dis Child 67: , Scorer CG, Farrington G H: Congenital deformities of the testis and epididymis. New York, Appleton-Century- Crofts, MIay SM and Sayi EN: Undescended testes in pediatric patients at Muhimbili Medical Centre, Dar es Salam. East Afr Med J 71: , Melekos MD, Ashbach HW, Markoy SA: Etiology of acute scrotum in 100 boys with regard to age distribution. J Urol 139: 1023, Bourguigonon JP, Burge HG, et al: Radioimmunoassay of serum luteinzing hormone releasing hormone (LH-RH) after intranasal administration and evaluation of the pituitary gonadotropin response. Clin Endocrinol (Oxf) 3: 337, Duckett J: Routine contra lateral exploration and fixation is justified. Dial Pediatr Urol 14: 7-8, Campbell MF: The male genital tract and the female urethra. In Campbell MF, Harrison JH (eds), Urology, ed 3. WB Saunders, Philadelphia, 1970, p Das S, Singer A: Controversies of perinatal torsion of the spermatic cord: A review survey and recommendations. J Urol 143: 231, Burks DD, Markes BJ, Burkhard TK, et al: Suspected testicular torsion and ischemia: evaluation with color Doppler sonography. Radiology 175: 815, Nasrallah PF, Manzone D, King LR: Falsely negative Doppler examinations in testicular torsion. J Urol 118: 194, Baker LA, Sigman D, Mathews SI, et al: An analysis of clinical outcomes in using color Doppler testicular ultrasound for testicular torsion. Pediatrics 105: , Kogan SJ, Lutzker LG, Perez LA, et al: The values of the negative radionuclide scrotal scan in the management of the acutely inflamed scrotum in children. J Urol 122: , Leavy OM, Gittleman MC, Strashun AM: Diagnosis of acute testicular torsion using radionuclide scanning. J Urol 129: , Atala A, Relik AB: The contra lateral testis: Hazards of management. Dialogues in Pediatric Urology 14: 5, Mishriki SF, Winkle DC and Frank JD: Fixation of a single testis: always, Sometimes or Never. Br J Urol 69: , Rowe MI, Clatworthy HW: Incarcerated and strangulated hernia in children. Arch Surg 101: , Slowman JG, Mylius RE: Testicular infarction in infancy: Its association with irreducible inguinal hernia. Med J Aust 1: , Plamer JM: The undescended testis. Endocrinol Clin North Am 20: 231, Kogan SJ, Tennenbaum S, Gill B, et al: Efficacy of orchiopexy by patient age 1 year for cryptorchidism. The journal of Urol 144: , Schneck FX and Bellinger MF: Abnormalities of the testes and scrotum and their surgical management. in (ediators) Campell's pediatric Urology. 2002, p Wilson-Storen D, Mc Genity K, Dickson JAS: Orchiopexy: The younger the better? J R Coll Surg (Edinb) 35: 362, 1990 Vol 1, No 1, October