Controversy in cryptorchidism: the value of laparoscopy and fertility outcomes

Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA
Current Surgery 06/2001; 58(3):279-282. DOI: 10.1016/S0149-7944(00)00420-7
Source: PubMed
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    ABSTRACT: The management of the impalpable undescended testis is controversial. The study examines emerging trends in the management of this problem. Two groups of boys were treated consecutively and recorded prospectively from 1974 to 1984 and from 1990 to 1998 inclusive. A consistent policy of using the preperitoneal approach for impalpable testis was adopted during both time intervals but during the second study period examination under anaesthesia and diagnostic laparoscopy were introduced to ascertain testicular presence and location. Some 919 boys were treated for cryptorchidism during the study period. Ninety boys in the first group (23 per cent) underwent preperitoneal explorations for impalpable testes. Anorchia was present in 18 and orchidectomy was performed in two boys. Thirty boys in the later group (5 per cent) were diagnosed as having impalpable testes. Fifteen boys underwent successful preperitoneal orchidopexy, anorchia was present in 11 and four underwent orchidectomy, carried out for high intra-abdominal testes. Examination under anaesthesia and subsequent laparoscopic assessment for all impalpable testes has reduced the need for preperitoneal exploration for the impalpable undescended testis. In this large series, division of the testicular vessels in order to secure scrotal placement of the testis was required in one instance only.
    British Journal of Surgery 11/1999; 86(10):1280-3. DOI:10.1046/j.1365-2168.1999.01293.x · 5.54 Impact Factor
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    ABSTRACT: The management of the nonpalpable testis permits an individualized operative approach. We analyze the results of surgical management of a large series of patients with a nonpalpable testis. Between January 1986 and June 1994 we treated 1,866 boys with undescended testes. There were 447 testes (24%) that were not palpable at presentation. Intra-operative data on these patients were collected for age at presentation, bilateral testes position, testicular size, associated inguinal anomalies (vas, epididymis and processus vaginalis) and surgical approach. For intra-abdominal testes postoperative results of 2 surgical techniques, the Fowler-Stephens procedure and Koop orchiopexy (retroperitoneal mobilization of spermatic vessels and vas) were compared in 76 patients with at least 18 months of followup. Average patient age at presentation was 34 months with 63% presenting before age 48 months. Of the impalpable testes 58% were on the left side, 35% were on the right side and 7% were bilateral. At operation 181 testes (41%) were atrophic or absent, 91 (20%) were intra-abdominal with 14 (3.1%) bilateral, 136 (30%) were in the inguinal canal and 39 (9%) were in other locations, including 22 at the pubic tubercle, 2 in the upper scrotum, 13 in the superficial inguinal pouch and 2 in the perineum. Of the intra-abdominal group associated extratesticular malformations were identified in 36 cases (39%). Attachment of the vas deferens to the testis was abnormal in 23 of 64 cases (36%), including 10 that were completely detached and 13 with head or tail attachment only. Of the 91 evaluable cases in the intra-abdominal group 38 (42%) had been treated with the Fowler-Stephens repair (5 in 2 stages), 33 (36%) with inguinal orchiopexy and intraperitoneal dissection without dividing the spermatic vessels, 5 with 2-stage procedures and vessel preservation and 14 (15%) with orchiectomy. One testis was left in situ. The inguinal approach with intraperitoneal extension was successful in defining the testis location or blind-ending vas and vessels in 100% of the cases. A single operation to perform orchiopexy was successful in 92% of the cases. Overall, results were considered excellent or acceptable in 32 of 33 cases (97%) after Koop orchiopexy and 28 of 38 (74%) after the Fowler-Stephens orchiopexy. Nonpalpable testes accounted for 24% of the patients presenting with undescended testes. At surgical exploration 39% of impalpable testes were distal to the external inguinal ring, 41% were atrophic or absent and 20% were intra-abdominal. All cases were treated through a standard inguinal incision. These data provide evidence that the inguinal approach to orchiopexy with transperitoneal mobilization of the vas and vessels without transection is highly successful for the intra-abdominal cryptorchid testis and, to date, is the preferred technique for the management of the intra-abdominal undescended testis.
    The Journal of Urology 04/1998; 159(4):1340-3. DOI:10.1016/S0022-5347(01)63613-9 · 4.47 Impact Factor
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    ABSTRACT: The spermatogenic cell-specific isoform of glyceraldehyde 3-phosphate dehydrogenase (GAPD-S) may regulate glycolysis and energy production required for sperm motility. Although the steady-state level of Gapd-s mRNA is maximal at step 9 of mouse spermatogenesis, GAPD-S protein was not detected by immunohistochemistry until steps 12-13. This result suggests that Gapd-s is translationally regulated. Western blot analysis of isolated germ cells confirmed that GAPD-S is not detected in pachytene spermatocytes or round spermatids. A major immunoreactive protein migrating with a molecular weight (M(r)) of 69,200 was observed in condensing spermatids and cauda sperm. Additional minor proteins that migrated at M(r) 55,200, 32,500, and 27,500 were detected in sperm. The molecular weight of GAPD-S is higher than the predicted molecular weight of 47,445, apparently due to a proline-rich 105-amino acid domain at the N-terminus. Recombinant GAPD-S protein lacking the proline-rich region migrated at M(r) 38,250, comparably to somatic GAPD, which also lacks the proline-rich domain. Indirect immunofluorescence demonstrated that GAPD-S is restricted to the principal piece in the sperm flagellum. Western blot analysis indicated that GAPD-S is tightly associated with the fibrous sheath of the flagellum, consistent with a potential role in regulating sperm motility.
    Biology of Reproduction 03/1998; 58(3):834-41. · 3.32 Impact Factor