Role of Human Chorionic Gonadotropin (HCG) Hormone in Undescended Testis a Prospective Study in 100 Children

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1 Role of Human Chorionic Gonadotropin (HCG) Hormone in Undescended Testis a Prospective Study in 100 Children BA CHEECHAK 1 MY WANI 2 A HUSSAIN 3 G HASSAN 4 This is a prospective study of 100 children (122 testes) of Cryptorchidism in whom the role of HCG in causing descent of Cryptorchid testis, making impalpable testis to become palpable and making orchidopexy easier and thus improving surgical outcome, has been evaluated. Among the 70 children (86 testes) treated with HCG, 32 were bilateral, 54 were unilateral; 38 testes were impalpable and 48 testes were palpable. The dose of HCG was 5000 IU in the age group of 1-6 years and 10,000IU in the age group of 7-12 years given in weekly divided intramuscular injections. Patients were evaluated clinically for, descent, palpability and any complication. Among those patients who did not respond to HCG therapy, 30 patients were operated upon and the surgical outcome was compared with 30 patients who were operated without receiving HCG. In our study, descent occurred more in bilateral (50%) testis, as compared to unilateral (32%) UDT. The overall success rate was 38.3%. HCG was more effective in the age group 4-6 years (63% in B/L & 33% in U/L) than in 7-9 years (50% B/L & 35% U/L). We found that 47.3% impalpable UDT became palpable after HCG treatment. The best response was seen in palpable testis located prescrotally (72.7%) and in low canalicular testes (50%). Only 15.78% impalpable testis descended after HCG. At 4 months follow up, the success rate dropped to 30.2% as there was relapse in 7 testes. We found a statistically significant difference (P< 0.001) between surgical outcome in patients operated after receiving HCG and those operated without receiving HCG. Key words : Cryptorchidism, HCG, Undescended testis.. Dept of Surgery, Gandhi Medical College 4 Consultant Srinagar, Jammu & Kashmir Dr Bashir Ahmad Cheechak 1 Post Graduate Scholar Room No 16, Doctors Hostel 2 Asst Professor SMHS Hospital Srinagar Professor dr_bashir786@hotmail.com

2 ROLE OF HCG HORMONE IN UNDESCENDED TESTIS 21 Cryptorchidism represents the most common disorder of sexual differentiation and is the most prevalent disorder of childhood with an incidence rate of 0.8% above one year. 1 Since Hunters (1841), various mechanisms for descent have been proposed but endocrine factors somehow play the major role in promoting testicular descent. Testosterone and Dihydrotestosterone under the influence of hypothalamic-pituitary axis play important role in testicular descent. 2 Based on this observation exogenous hormones (HCG, GnRH) have been used for promoting testicular descent. HCG causes descent in 15-40% cases. 3 Genitofemoral Nerve after exposure to androgens releases CGRP (Calcitonin Gene Related Peptide) which modulates gubernacular function and promotes testicular descent. 4 Wide variation in hormonal response of cryptorchidism is due to inclusion of retractile testis. Hormonal response may differ according to age and laterality. 3,5 Hormone therapy also makes impalpable testis to become palpable and orchiopexy easier thus improving surgical outcome. 6,7 Methodology This study has been conducted in 100 (122 testis) children aged 1-12 years, suffering from UDT who attended the Pediatric Surgery Division, at the SMHS Hospital, Srinagar during the period 2001 to Retractile testes were excluded from the study. USG and CT scan was done for localization of impalpable testis. Among the 70 children (86 testes) treated with HCG, 32 were bilateral, 54 unilateral. Thirty eight testes were impalpable and 48 testes were palpable. The dose of HCG was 5000 IU in the age group of 1-6 years and 10,000 IU in the age group of 7-12 years given in weekly divided intramuscular injections. 8 Patients were evaluated clinically for descent, palpability and any complication at the end of treatment. Among those patients who did not respond to HCG therapy, 30 patients were operated upon and the surgical outcome was compared with 30 patients who were operated without receiving HCG. Chi-square test was applied for comparing 2 groups. Patients in whom testis descended, were followed for 4 months to exclude temporarily positive results. Table I : Response of UDT to HCG in relation to age and laterally The figures represent the number of testes and not number of patients, n = 70 patients (86 testes as 16 patients had bilateral UDT)

3 22 J INDIAN ASSOC PEDIATR SURG VOL 9 (JAN-MAR 2004) Table II : Response in relation to site of UDT Observations While undertaking the present study, regarding the response of UDT to HCG it is evident from table I that, bilateral UDT showed a higher response. Out of 32 bilateral UDT 16 (50%) had complete descent of testis and out of 54 unilateral UDT 17 (31.38%) had complete descent. Overall 33 UDT (38.3%) had descent at the end of HCG therapy. Concerning the age the best results were obtained in children above 4 years in both U/L as well as B/L UDT. Success rate in 1-3 years was 28% in B/L, 18% in U/L, in 4-6 years it was 63% in B/L and 33% in U/L, in 7-9 years it was 50% in B/L and 35% in U/L while in age group of years age it was 25% B/L and 33% U/L (table I). As far as palpability after HCG is concerned, we found that 18 (47.3%) impalpable testis became palpable after HCG. The response of HCG with location of testis is evident from table II that out of 38 impalpable testes only 6 descended (15.7%) comprising of 1 high abdominal, 2 at deep ring, 3 high canalicular testes. Out of 48 *The 6.9% & 16.6% relapse is out of successful outcome of orchiopexy. ψthe no of patients in each group equals 30 (=60 in total) #Applying chi (X2) square test X2=2.96, DF = 1 thus p = <0.001 (highly significant). It is inferred that with HCG the outcome is significant.

4 ROLE OF HCG HORMONE IN UNDESCENDED TESTIS 23 palpable testes, 27 (56.3%) descended comprising of 10 low canalicular (50%), 16 prescrotal (72.7%) and 1 ectopic. Comparing the surgical outcome between patients operated after receiving HCG to those operated without receiving HCG, we found a statistically significant difference between 2 groups (P< 0.001) as shown in table III. After 4 months of follow up 7 testes (4 B/ L & 3 U/L) had relapse (21%) out of total 33 testes which had descended after HCG treatment. Our success rate dropped to 30.5% at the end of 4 months. Discussion Cryptorchidism is a common disorder of children. Correction of UDT is necessary because it predisposes to complications like torsion, trauma, infertility, malignancy and inflammation. Hormone therapy has been used with good results. Our results of HCG therapy in Cryptorchidism are similar to those reported in many other studies. An important factor is laterality of UDT. Our data shows better results in B/L (50%) as compared to (32%) in unilateral UDT. We found that HCG was more effective in 4-9 years and caused descent in 4-6 years 63% in B/L and 33% in U/L and in 7-9 years 50% in B/L and 35% in U/L. These findings more or less coincide with those of Bierich 5 (1982), Garagori 3 (1982) and Ingersleve 9 (1991). We observed that 47% impalpable testes became palpable. Timothy 7 (2001) in his study found that 80% of impalpable testes became palpable after HCG. Another important factor is location of testis before treatment. Our study revealed that only 15.4% impalpable testis had complete descent. Best results were shown when the testes were palpable and prescrotal (72.7%) and low canalicular (50%). Similar results were observed by Roberto Lala 10 (1997) and Orkiszewskvi 11 (1989). The overall success rate at end of treatment was 38.5% (33 testis) which dropped to 30.5% at the end of 4 months follow up, as there was relapse in 7 testes (21%). Same results were seen by Hadziselimovic 12 (1982) and Bertolini 13 (2001). HCG also made the testis to increase in size and became palpable. We found that Orchiopexy became easier and more successful, thus it significantly improved surgical outcome in patients operated after preoperative HCG treatment. Timothy, 7 Polascik 14 and Urban (1986) also reported similar results. Conclusion HCG is an effective treatment modality for Cryptorchidism particularly for palpable canalicular and prescrotal testis. It shows better results in the age group above 4 years both in U/L as well as B/L UDT High response is shown in B/L UDT. HCG is helpful in causing increase in the size of testis and makes them palpable. Orchiopexy became easier and more successful after preoperative HCG treatment. Surgical outcome improves in patients who receive HCG before operation. Thus we recommend that HCG should be given to all patients with undescended testis.

5 24 J INDIAN ASSOC PEDIATR SURG VOL 9 (JAN-MAR 2004) References 1 "Rajfer J Congenital anomalies of the testes andscrotum. In : Walsh PC, Retik AB, Vaugan ED, Wein AJ, (eds). Compbell's urology. 7th edn, Phildelphia : WB Saunders company 1988; P Rajfer J, Walsh PC. Hormone Regulation of Testicular Descent. Experimental and clinical observation. J Urol 1977; 118: Garagorri JM, Job JC, Canlorbe P, et al. Results ot early treatment of Cryptorchidism with HCG. J Paediatr 1982; 101: Larkins SL, Williams MPL, Hutson JM. Localization of CGRP within the spinal nucleus of the genitofemoral nerve. Pediatr Surg Int 1991; 6: Bierich JR. Undescended testis : Treatment with Gonadotropin. Eur J Pediat 1982; 139: Urban MD. Peter AL, Lanes R. et al. HCG stimulation in children with Cryptorchidism. Clinical Paediatr 1987; 26(10): Timothy P, Sedbeny S, Richardson B. Is HCG useful for identifying & treating nonpalpable testis J Urol 2001; 165: Giuseppe S, Ghirri P Gabrielli S, et al. Hormone Therapy of Cryptorchidism with a combination of HCG & FSH. Am J Dis Child 1989; 143: Ingerslev HJ, Rassmussen TB. Hormonal therapy of UDT Ugesker Leager 1991; 161: Lala R, Matrarazzo P, Chiaboto P et al. Early hormonal & surgical treatment of Cryptorchidism, J Urol 1997; 157: Orkiszewski M, Zielink W, Wieckowski J. Treatment of UDT With HCG. Endokrynol Pol 1989; 40(l): Hadziselimovic F. "Pathogenesis and treatment of UDT. Euro-Paediatr 1982; 139 (4): Bertelloni S, Baroncelli GI, Ghirri P, et al. Hormonal treatment for unilateral inguinal testis: comparison of four different treatments. Horm Res 2001; 55(5): Polascik TJ, Kirk M. Chan-Tack, et al. Reappraisal of the role of HCG in the diagnosis & treatment of the non-palpable testis : A 10-year experience. J Urol. 1996; 156:

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