Original Article

Annals of Pediatric Surgery, Vol 1, No 1, October 2005: PP 21-25

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

INTRODUCTION

A 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 E-mail: ash_ib51@yahoo.com

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.

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

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.

Fig 1B. Intra-operative finding, showing extra vaginal torsion involving the spermatic cord.

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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 0 3 3-6 months 7 0 6-10 months 3 0 10 months-1 year 0 4 4 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, false-negative 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

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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 10-36 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 age28, 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.

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