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Objective: Aim of this study is to investigate the prevalence of andrologic diseases in young men (age 18 years) recruited for conscription in a north-western Italian region., Material and Method: A random sample of 1993 young men was evaluated at the Army Medical Visit Center of the Military District of Genoa. The visits were performed by the same doctor. An examination of external genitalia and secondary sex characters was made and the medical history of each conscript was recorded. Investigation procedures were standardized according to the guidelines of the WHO for the diagnosis and management of the infertile male., Results: Andrologic disorders were found in 547 subjects (27.5%) and first diagnosed in 412 (20.7%). Specific acquired or congenital disorders are discussed. Some patients with most significant diseases were referred to the Urologic Department for second level diagnostic exams., Conclusion: This study underlines the role of the army medical visit as a tool for andrologic screening in young males. The military health service may be a relevant institution for postpuberal control and it could be useful to prevent future sexual and fertility problems in adult males.

Inhibin B immunocytochemistry of both the alpha- and beta-subunits was studied in testicular biopsies from 18 prepubertal and postpubertal patients, with unilateral or bilateral cryptorchism. The present investigation was carried out to seek any prognostic significance for the expected fertility of such subjects in adulthood. All samples were also evaluated by histological and morphometric assessments, according a 1-6 grading sy-stem. In this way, the individual testicular changes were scored by quantitating tubular and germ cell hypoplasia, Sertoli cell hyperplasia, and peritubular fibrosis, where present. The results showed that in bilateral maldescended testes an unexpected expression often occurred of inhibin B beta-subunit in Sertoli cells, while inhibin B alpha-subunit there did not, denoting an early developmental arrest of the testis. It co-related with the high grade testicular damages, as a poor predictor of spermatogenesis. Unlike, unilateral retained testes mainly expressed inhibin B alpha-subunit, irrespective of tubular changes. In the latter instance, different pathogenetic factors of imbalanced testicular regulation can be perspected, other than the Inhibin-Activin system.

We investigated the possible role of Y chromosome microdeletions in regions previously shown to be important for male germ cell development in unilateral ex-cryptorchid subjects manifesting important bilateral testiculopathy, in order to clarify whether cryptorchidism could be the expression of an intrinsic congenital testicular abnormality. Microdeletion analysis of the Y chromosome long arm was performed by polymerase chain reaction and confirmed by Southern blot in 40 selected unilateral ex-cryptorchid patients with azoospermia or severe oligozoospermia sustained by severe bilateral testiculopathy (Sertoli cell-only syndrome and severe hypospermatogenesis, respectively), 20 unilateral ex-cryptorchid men with moderate oligozoospermia and normal function of the descended testis, 110 patients affected by severe idiopathic primary testiculopathies, 20 patients affected by moderate idiopathic testiculopathy and, as controls, 50 patients affected by known causes of testiculopathy and 50 fertile controls. Eleven out of the 40 (27.5%) unilateral ex-cryptorchid patients affected by bilateral testiculopathy and 28 out of 110 (25.4%) patients affected by severe idiopathic primary testiculopathy showed microdeletions in the Y chromosome long arm, while all other subjects were normal. Male relatives of patients with deletions were also normal. Microdeletions were distributed in different regions of the Y chromosome long arm, including known regions involved in spermatogenesis (DAZ and RBM genes, AZFa, b and c regions) and other still poorly defined loci. No difference in localization of deletions was evident between ex-cryptorchid and idiopathic patients. Microdeletions in the Y chromosome may be responsible for bilateral severe testicular damage: the clinical consequence, other than idiopathic azoospermia and severe oligozoospermia, may also be unilateral cryptorchidism, probably due to altered testicular responses to mechanisms regulating testicular descent.

Vas deferens anomalies have been observed with high incidence in cystic fibrosis patients, whereas the overall incidence in the general population is estimated less than 0.05%. Vas deferens anomalies are sometimes associated with renal abnormalities and they are due to a damage occurring within the first weeks of gestational age. In other cases they can be the expression of a mild form of cystic fibrosis. The authors report on 7 patients with 10 anomalies of vas deferens: 2 patients with cystic fibrosis; 3 patients with urinary tract anomalies; 2 patients with no evidence of cystic fibrosis and without urinary tract anomalies. It is suggested that every patient presenting with vas deferens anomalies and no evidence of cystic fibrosis should be further evaluated with renal ultrasound; moreover all patients without evidence of both cystic fibrosis and renal anomalies should have genetic investigations.

Since ten years laparoscopic techniques have been employed as alternatives of many established open procedures in gynecologic, abdominal and finally urologic surgery. Laparoscopic techniques show significant advantages compared to open surgery, such as less hospitalization, reduced need of analgesic drugs, quick return to daily activities and far a better cosmetic results. Laparoscopic surgery has been advocated for urologic, uro-gynecologic and andrologic diseases. Since 1983 one-day surgery was proposed for only a few gynecologic and abdominal procedures and only recently for laparoscopic renal biopsy and abdominal testis evaluation. In these preliminary experiences the conditions for a correct management of laparoscopic one-day surgery have been clearly pointed out: 1. correct surgical indication; 2. through knowledge of surgical technique; 3. duration of the procedure less than 90 minutes; 4. correct anesthesia. Technique of anesthesia must be adapted to the surgical procedure required, its duration and the physical features of the patient. General anesthesia is usually preferred for either longer and more complex procedures or when a higher abdominal insufflation pressure is needed. Spinal or local anesthesia are preferred for simpler procedures or when only one trocar is required. At date only few urologic procedures seem to be suitable to one-day laparoscopic surgery. 1) Varicocele: although laparoscopic varicocelectomy in one-day surgery has never been reported previously, it can be performed in a short time, only 3 trocars are needed and insufflation pressure can be maintained within 15 mm Hg. 2) Renal biopsy and marsupialization of renal cysts. These are usually managed percutaneously but in some particular indications procedures under direct vision should be preferable. Both are short-lasting and only superficial general anesthesia is required; as surgical access is retroperitoneal only two trocars are sufficient; at date only renal biopsies have previously been reported. 3) Diagnostic procedures on abdominal testis. The procedure is brief only superficial general anesthesia is needed and only one trocar is required. Conclusions. One-day laparoscopic surgery will require in the future a more and more strict cooperation between urologists and anesthetists in order to tailor the correct anesthesiological and laparoscopic technique to the procedure required and the features of the patient.

The authors report a rare case of persistent mullerian duct syndrome (PMDS) with transverse testicular ectopia and inguinal hernia in a 2-year-old child with family history for this syndrome. At operation the observation of a very long and thin gubernaculum and extreme mobility of both testes and uterus, which are located in the same hernial sac, allowed the Authors to propose a hypothesis to explain the role of MIF (Mullerian Inhibiting Factor) in testicular descent. Patients with PMDS present a normal outgrowth and migration phases of the gubernaculum but lack of the gubernacular regression phase. These data suggest an important function of the MIF in this phase of testicular descent.

This unusual pathology has not been described in the medical literature of the last ten years. A 39-year-old patient, affected by unilateral cryptorchidism, on the right side, and congenital inguinal hernia, reached the operating theatre suffering from occlusive intestinal syndrome, due to a clogged hernial sac. This clog was caused by a retracting testicle which in turn stopped the ileal ansa from slipping back in to the peritoneum. Through this case we can underline the excursus of such pathology, which isn't very frequent in the adult but can, nevertheless create a fairly serious pathology, often leading to neoplan.

Management of the nonpalpable testis is controversial and can be difficult as shown by the multiple modalities for evaluation and proposed treatment. In our opinion, laparoscopy is the ideal first step in the management of patients with a nonpalpable testis, having a great reliability in locating or confirming absence of an occult testis. Accurate preoperative assessment and localization will assist in selecting the appropriate surgical approach either laparoscopic, laparoscopic-assisted, or open procedure. Laparoscopy was performed on 74 patients with 86 nonpalpable testis. The technique has been demonstrated to be extremely safe and lead to diagnosis in 100% of cases. Surgical management of nonpalpable testis was directly performed by laparoscopy identifying intra-abdominal vanishing testis and locating an intra-abdominal or inguinal testis. The two-stage Fowler-Stephens orchiopexy was performed in 41 patients. The first stage consisted of laparoscopic clip ligation of the spermatic vessels. Of these, 32 underwent the second stage by vas-based orchiopexy; all testes, but one, showed a normal size and consistency. To conclude, we advocate the use of laparoscopy in all boys with nonpalpable testis.

Management of the nonpalpable testis is controversial and can be difficult as shown by the multiple modalities for evaluation and proposed treatment. In our opinion, laparoscopy is the ideal first step in the management of patients with a nonpalpable testis, having a great reliability in locating or confirming absence of an occult testis. Accurate preoperative assessment and localization will assist in selecting the appropriate surgical approach either laparoscopic, laparoscopic-assisted, or open procedure. Laparoscopy was performed on 74 patients with 86 nonpalpable testis. The technique has been demonstrated to be extremely safe and lead to diagnosis in 100% of cases. Surgical management of nonpalpable testis was directly performed by laparoscopy identifying intra-abdominal vanishing testis and locating an intra-abdominal or inguinal testis. The two-stage Fowler-Stephens orchiopexy was performed in 41 patients. The first stage consisted of laparoscopic clip ligation of the spermatic vessels. Of these, 32 underwent the second stage by vas-based orchiopexy; all testes, but-one, showed a normal size and consistency. To conclude, we advocate the use of laparoscopy in all boys with nonpalpable testis.

Management of the nonpalpable testis often represent a significant diagnostic and therapeutic challenge for the pediatric surgeon. A variety of imaging studies may locate nonpalpable testis and include ultrasound, CT, MRI, gonadal vasography, and herniography, but none is completely reliable in locating a gonad or proving its absence. Laparoscopy has the advantage of great reliability in locating testes or proving their absence and can be coupled with surgical management; the laparoscopic findings determine the subsequent operative steps. Accurate knowledge of testis location facilitates development of an appropriate surgical strategy either laparoscopic or laparoscopic-assisted or open procedure. The Authors report their preliminary experience with laparoscopy in 30 patients (age range 2-5 years) with 34 nonpalpable testes: 18 testes were intraabdominal, 7 canalicular, 9 atrophic or absent. Out of the 18 intraabdominal testes 2 patients underwent orchiectomy (very small testes), 1 patient testis detorsion and 15 internal spermatic vessels clipping and cutting (first step of staging Fowler-Stephens orchidopexy). At the moment 8 patients, after a 8-10 months interval, underwent second staged vas-based orchidopexy with good results as judged by size and throphism of the relocated testes. An inguinal exploration has been made in 7 patients: 4 orchiectomy (hypo-atrophic testis), 3 standard orchidopexy. In 9 patients the testis were absent. In order to have a good-sized adolescent scrotal pouch, insertion of an infant-size testicular prosthesis is recommended for children with a vanishing or absent testis, if the parents agree.

Cryptorchidism is a frequent abnormality which affects approximately 1% of children at age 1 year. Many nonscrotal testes are retractile and require no therapy. The pathogenesis remains controversial and involves possible mechanical, dysgenetic or hormonal factors. The latter are consistent with a partial defect in the hypothalamo-pituitary-gonadal axis, which may cause progressive histologic alterations in the testes after the first 6 months of life. Ultrasound is the simplest diagnostic technique (after clinical examination) to identify the testes in the inguinal region, while Magnetic Resonance Imaging can be performed to visualize abdominal testes. Therapy is still a matter of controversy. Hormonal treatments with HCG, LHRH or both should be used as first-intention treatment and their efficacy ranges from 0% to 60% in the various studies. LHRH nasal spray seems less effective if used alone. An early surgical treatment is recommended if the gonad is in the abdomen or close to the internal inguinal ring. The risk of cancer is increased in subjects with a history of cryptorchidism and even includes the contralateral descended testes. Early orchidopexy is not associated with a certain decrease of the risk. Cancer can be prevented by searching for in situ carcinoma with a biopsy performed after puberty. Fertility is impaired mainly in men with a history of bilateral cryptorchidism. There is weak evidence that early orchidopexy may improve fertility rates.

Diagnosis in cryptorchidism should be as early as possible for therapeutical purposes and for the achievement of most positive results. Early but also exact diagnosis allows a selective therapy concerning type of procedure and age of performance. Aims of early diagnosis and selected treatment are: prevention of infertility and eventual decrease of androgenic endocrinal function in the adult; prevention of torsion in retractile testis; prevention of trauma in perineal ectopic situation; prevention of cancer especially in cryptorchidism of the adult; prevention of psychogenic defects of the empty scrotum. Those goals can be obtained by different approaches: pharmacological (hormonal stimulation), surgical (orchidopexy) or by their association. If hormonal administration is not suitable or without results surgical approach will be adopted. Which is now the most suitable age for surgery? Testicular damages begin at the second year of life. Therefore operation should be acted in advance. However, up to date international acknowledgement is in favour of surgical management around the fourth year for the advantages of a more mature anatomical situation without reducing quality of results. Purpose of early diagnosis and selective therapy in cryptorchidism is to avoid irreversibility of severe histological alteration able to compromise gonadal, especially germinal, function. It is never to forget that the high level of infertility in cryptorchidism can be depending not only on evident alteration in number, motility and morphology of spermatozoa but also on morphofunctional defects escaping from the routine seminal examination. All that is in tight connection with the intrinsic dysmorphism in cryptorchism where the abnormal position of the testis is only a partial aspect.(ABSTRACT TRUNCATED AT 250 WORDS)

The paper reports the authors' personal experience regarding the use of magnetic resonance imaging in the diagnosis of cryptorchidism. The result of the study of 13 patients with non-palpable gonads, who all underwent surgical confirmation (with positive outcome in 66% of cases), encourage the use of this non-invasive method with a high anatomic resolution, which can be used to diagnose both the site, dimensions and possible structural alterations of the gonad.

A case of an adult with torsion and infarction of a pelvic testis, not previously diagnosed, although the patient was monorchid, is reported. The preoperative diagnosis was "acute abdomen" with pelvic mass. A brief discussion and a review of the recent literature are presented.

To evaluate the efficacy of early treatment of cryptorchidism, we studied 154 children, 133 with unilateral and 21 bilateral cryptorchidism, between the ages of 6 months and 6 years. Only fullterm newborns without other pathological signs were selected for treatment which was undertaken only after the sixth month of life, when the time of late spontaneous testicular descent has been passed. By clinical evaluation, cryptorchid testes were classified as not palpable, inguinal and prescrotal. Patients were treated by LHRH nasal spray 200 mcg in each nostril 3 times a day (total 1.2 mg/day) for 4 weeks. In the case of failure, HCG (500 I.U. im. 3 times a week for 3 weeks) was further administered. We considered as therapeutic success testicular descent into the lower half of the scrotum. By LHRH treatment 36 testes (20.5%) reached the scrotum, when HCG was added in unsuccessful cases 47 other gonads (26.8%) descended. Total descent rate by LHRH + HCG was 47.3% (table 1). Uni- and bilateral forms of cryptorchidism responded to therapy without any significant difference (table 2). Abdominal testes failed to descend into the scrotum, 28.7% of inguinal testes and 81.3% prescrotal testes descended. Scrotal descent was dependent only by position of cryptorchid testes and not by age of patients (table 3). Higher descent rates obtained at older ages were due to higher incidence of milder forms of cryptorchidism (table 3). Side effects of combined therapy were light. In our experience, medical treatment by LHRH + HCG started after the first 6 months of life causes testicular descent in about one half of testes; it can place into the scrotum gonads with better fertility prognosis.

The authors, after a nosologic review of cryptorchidism, illustrate their positive diagnostic experience with ultrasound. Limits as well as clinical advantages, in relation to the diagnosis and follow-up, are also described.

We have stimulated seventeen children (4-12 years old) with bilateral non palpable testes with LH-RH and HCG. The differential diagnosis between anorchia (5 patients) and bilateral cryptorchidism (12 patients) was possible with evaluation of FSH and Testosterone plasma levels before and after hormonic stimulation.

The testicular function has been evaluated by a single dose hCG-test in normal and cryptorchid prepubertal boys using three different protocols. No remarkable difference has been observed using different posologic protocols. Testicular function in boys affected by cryptorchidism was similar to the testicular function in normal controls. However cryptorchid boys older than 6 years of age showed a significant reduction in testicular response to hCG-test in comparison to cryptorchid boys younger than 6 years of age.