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Aim:  Congenital monorchism is considered a condition in which an initially normal testis has existed but subsequently atrophied and disappeared due to a third trimester catastrophe (presumably torsion). Since inhibin B concentrations appear related to Sertoli and germ cells number, we evaluated pre- and postoperative inhibin B of boys with congenital monorchism to determine whether the well-known hypertrophy of the contralateral testis was reflected in inhibin B concentrations., Materials and Methods:  Twenty-seven boys consecutively diagnosed with congenital monorchism (median age 12 months) underwent follow-up with reproductive hormones 1 year postoperatively (median age 25 months). The results were compared with inhibin B of 225 boys with congenital nonsyndromic unilateral cryptorchidism, by converting values to multiple of the median (MoM) for age in normal boys., Results:  Ten boys (37%) had blind-ending vessels and ductus deferens (vanished testis) and the remaining (63%) had testicular remnants. At the time of diagnostic procedure, monorchid boys did not have significantly lower inhibin B (median 114, range 20-208) than unilateral cryptorchid boys (136, 47-393) ( p  = 0.27). During follow-up, MoM values of inhibin B increased in monorchid boys (median 0.59 to 0.98) and in unilateral cryptorchid boys (0.69 to 0.89) (both p  < 0.0001). Compared with the concentration at surgery, an additional 44% monorchid boys had inhibin B MoM values higher than 1.0, whereas only additional 23% of unilateral cryptorchid boys exhibited such values ( p  = 0.04)., Conclusion:  Generally, inhibin B MoM values were normalized during follow-up in boys with congenital monorchism, reflecting compensatory hypertrophy within the first 2.5 years of life. The compensatory capacity to increase was better in monorchism than in unilateral cryptorchidism., Competing Interests: None declared., (Thieme. All rights reserved.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background: Maldescensus testis constitutes the most common diagnosis in the daily routine of a paediatric surgeon and is proved to be one of the most established risk factors for future infertility and malignancy., Material and Methods: We examined therapy strategies of paediatricians in the catchment area of the University Clinic of Würzburg in the light of the late time of orchidopexy. This study consists of a short survey sent to 100 local paediatricians. After return, the given answers were put in comparison to the 504 cases of retentio testis treated in our clinic from 2005 to 2010., Results: Theoretical knowledge regarding guidelines for the treatment of retentio testis is abundant among paediatricians in and around Würzburg. Nevertheless, the initial therapy is of a hesitant character and often leads to an unnecessary delay in operation. The average age of boys receiving orchidopexy at our clinic between 2005 and 2010 amounted to 3.3 years., Conclusion: Regarding guidelines the average age of cryptorchid boys receiving orchidopexy at the University Clinic of Würzburg was way too high between 2005 and 2010. To some extent this fact can be attributed to the hesitant manner of therapy shown by local paediatricians. An improvement in the time of operation is definitely possible and necessary in order to optimise the outcome., (Georg Thieme Verlag KG Stuttgart · New York.)

Cryptorchidism, or undescended testis (UDT), occurs in 1-3% of male term infant births. At least two-thirds of UDTs will descend spontaneously, typically during the first 6 months of life. UDTs are associated with loss of spermatogenic potential and testicular malignancy in the long term. Orchiopexy performed prior to puberty may significantly reduce the malignant potential by up to 4-fold. Neoadjuvant hormonal therapy starting at 6 months of life has been shown to potentially improve the testicle's fertility index and should be part of the therapeutic concept. However, the use of hormonal treatment and HCG beyond the first year of life is to be challenged given a potentially negative impact on testicular function. Laparoscopic exploration and therapy is the method of choice for non-palpable testes. Ideally, surgical repair of the UDT should be completed by the age of 1 year., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: The aim of this study was to determine retrospectively, the prevalence of acquired undescended testis (UDT) in boys who underwent late orchidopexies, that is, performed after the age of 2 years., Methods: We included all patients who were 2 years or older when they underwent orchidopexy (ORP) for UDT at the Juliana Children's Hospital during 1996 to 2009. Previous testis position from birth until the date of ORP was obtained from youth health care records., Results: We identified 660 boys who underwent ORP after the age of 2 years for undescended testis. For 421 of these 660 boys, the previous testicular position could be retrieved from the health records. In 143 of these 421 boys (34%), the operated testis had never been scrotal (congenital UDT), whereas in the other 278 boys (66%), a previous scrotal position had been documented twice or more (acquired UDT)., Conclusion: Our results show that two-thirds of the boys that underwent ORP after the age of 2 had previously normal descended testes. This finding may offer an additional explanation for the discrepancy between the incidence of congenital UDT and the high rate of ORP in mid and late childhood., (Georg Thieme Verlag KG Stuttgart · New York.)

Aim: Surgical findings were studied to find an explanation for the phenomenon that some acquired undescended testes (UDT) descend spontaneously whereas others need orchiopexy., Methods: In patients with acquired UDT spontaneous descent was awaited until at least Tanner stage P2G2. Orchiopexy was performed when a stable scrotal position had not been achieved by the end of follow-up., Results: Orchiopexy was needed in 57 of 132 cases (43%). In cases requiring orchiopexy, the difference in testis volume compared to the contralateral healthy testis was significantly larger than for spontaneously descended testes. 41 (72%) undescended testes were found in the superficial inguinal pouch; 16 (28%) at the external annulus. 26 of the 41 testes in the superficial inguinal pouch position (63%) could be manipulated preoperatively into a non-stable scrotal position; 15 could only reach the scrotal entrance prior to surgery. None of the 16 testes located at the external annulus could reach a scrotal position. Inguinal exploration in most cases revealed a fibrous string or a partially open processus vaginalis., Conclusion: The mobility of acquired UDT located within the external annulus is limited. It is mainly the fibrous string and the partially open processus vaginalis that prevent normal elongation of the spermatic cord with growth. These testes are unlikely to descend spontaneously. Acquired UDT lying in the superficial inguinal pouch can often be pushed down well below the scrotal entrance. We speculate that under normal hormonal stimulation at puberty, some of these growing testes may overcome the strength of the fibrous string in the spermatic cord and descend again spontaneously., (© Georg Thieme Verlag KG Stuttgart · New York.)

A case of complete separation between an abdominal testis and the epididymis discovered during diagnostic laparoscopy for impalpable testis is presented. A 13-year-old boy with impalpable testis underwent diagnostic laparoscopy for impalpable testis. The vas on the left side was seen entering a closed internal ring while a small testis was found completely separated and medial to the internal ring.

Inguinal hernia, undescended testicle and hydrocele are typical and frequent diseases in infants and children. The paediatric inguinal hernia is a congenital defect and the hernial sac usually passes the inguinal canal. In order to diagnose the inguinal hernia in infants the physician is frequently dependent on the accurate observation of the parents. Although laparoscopic herniotomia is increasingly being discussed, it cannot be recommended yet as a standard operation because of a recurrence rate of 4%. Undescended testicle is classified into several subtypes with specific diagnostics and therapies. The role of hormonal therapy is currently controversial again, but the literature seems to point to a positive role for fertility in adulthood. The appropriate therapy should be performed by the end of the first year of life. A hydrocele is no acute reason for operative therapy; normally one can wait until the 2nd-4th year of life for spontaneous regression except for very large forms.

Proper knowledge of the embryologic development of the male genitalia is paramount for correct and successful treatment. The fatal outcome of the following pedriatric case is unfortunate due to a disregard of the basic principles in urology.

Aim: The aim of this study was to investigate the feasibility and benefits of diagnosis and interventional laparoscopy in those paediatric patients with nonpalpable testes (NPT)., Patients and Methods: Between 1992 and 1999, 75 patients with NPT (mean age 3 years, range 6 months to 14 years) were treated. 86 testes were evaluated., Results: According to the laparoscopic findings 4 groups of testes were identified: Vanishing testis (n = 32), low abdominal testis (< 2 cm to the internal ring) (n = 26), high abdominal testis (> 2 cm to the internal ring) (n = 24) and intersex patients (n = 4). Of the first group, 19 testes (one bilateral) had blind-ending spermatic cord and vessels and if an atrophic testicular tissue was identified, it was removed laparoscopically. For those with spermatic cord and vessels beyond the internal ring (13 testes), atrophic testes were removed through a high scrotal incision. 19 testes of the second group had a laparoscopy-assisted orchidopexy. In the same group a laparoscopic orchidopexy was performed on 7 testes. 24 testes in the 3rd group had a Fowler-Stephens (FS) stage 1 and 18 testes had a laparotomy performed for FS stage 2 procedure (laparotomy and orchidopexy) after 6 months. At laparotomy there was no evidence of testicular atrophy in all but one testis, which was removed and the FS stage 2 procedure was completed in 17 testes. The follow-up period was between 6 months and 4 years, and two more testicular atrophies were noted after FS stage 2. The results were satisfactory in 15 out of 18 testes (83%). In the intersex group, the patient with testicular feminization underwent laparoscopic orchiectomy. The other patient with bilateral nonpalpable testis was identified as having an uterus and two intraabdominally located gonads on laparoscopy and gonadal biopsies were obtained for diagnosis. Histology demonstrated bilateral ovotestes, confirming the diagnosis of a true hermaphrodite., Conclusion: We are of the opinion that laparoscopy decreases the number of laparotomies in NPT, allows a single-stage procedure in low abdominal testis, and facilitates clip ligation of the testicular artery in high abdominal testis. Laparoscopy also provides diagnostic and therapeutic options for vanishing testis and intersex patients.

Spontaneous descent of testes after birth can occur in up to 70% of cases, yet the factors contributing to it are still controversial. This study aims to evaluate factors contributing to spontaneous descent of palpable undescended testes. Eighty-four newborns with 126 palpable undescended testes (42 unilateral and 42 bilateral) were followed up for a period of one year to study the occurrence and time of testicular descent and its relation to gestational age, birth weight, uni- or bilaterality and levels of FSH, LH and testosterone. A total of 58 testes (46%) descended between 3 and 6 months. Spontaneous descent occurred in 10 premature patients (14 testes 63%) compared to 44 testes of full-term patients (43%). Descent occurred in 14 unilateral undescended testes (33%) compared to 44 (52%) in bilateral cases. In patients with spontaneous testicular descent there was postnatal peak of LH and testosterone at 2 to 3 months of age which returned to basal level at 6 months of age. In patients with permanent undescended testes the peak of LH and testosterone was very low and almost absent in some of them; no significant difference was found between the mean values of FSH in both groups. No spontaneous testicular descent occurred after the 4th month in the full-term group, whereas in the pre-term group spontaneous descent occurred up to 6 months of age. This study concluded that spontaneous descent of palpable undescended testes is closely related to the presence of LH and testosterone surge. Therapy of undescended testes should start at 4 months of age in a full-term baby and at 6 months of age in a pre-term baby.

In a prospective study, the accuracy of magnetic resonance imaging (MRI) and laparoscopy in the diagnosis of nonpalpable testes was evaluated. Advantages and disadvantages of the two procedures were compared. 29 boys with unilateral nonpalpable testis underwent MRI. When MRI failed to demonstrate a testis, laparoscopy with a 1.9 mm mini-laparoscope was performed. All cases were verified by operative exploration of the inguinal region. MRI demonstrated 10 inguinal and 7 abdominal testes. MRI revealed no testis in 12 boys. The false positive rate was 32%, correct negative findings were confirmed in four patients. When laparoscopy was performed, preservable testis could be demonstrated in 8 of 12 patients (1 abdominal, 7 inguinal) which otherwise were not visible on MRI. The correct positive rate was 100%. We encountered no complications with laparoscopy. In summary, laparoscopic evaluation is recommended as the preferable method in pediatric cases of nonpalpable testes.

A case of bilateral nonpalpable testes is described. Ultrasonography showed no testis. Laparoscopy revealed no intraabdominal testis, vas or vessels. Human chorionic gonadotrophine test suggested the presence of testicular tissue. Computed tomography showed a testis present in each inguinal canal. Inguinal exploration confirmed the finding. This case stresses the importance of careful interpretation of the laparoscopic findings together with other diagnostic methods in localizing testicular tissue in patients with nonpalpable testes.

Magnetic resonance imaging was performed in 22 male patients for localisation of 27 nonpalpable undescended testes. The operative verification, carried out in 19 testes (15 patients) served as basis for checking on the accuracy of MRI results and for their comparison with those of sonography and laparoscopy. The impalpable testis was localised via MRI in 13 cases and its lack was correctly established in three cases. There were three false MRI diagnoses. The suspicion of two intraabdominal localised testes were not confirmed at surgery and one intracanalicular testes were not seen by MRI. The low signal intensity of the undescended testes on T2-weighted images is indicative for fibrotic changes and may be of value for more accurate planning of the operative volume. MRI offers a new promising opportunity for localisation and morphologic estimation of the undescended testis and should be performed before the invasive investigation methods.

The aim of this study was to establish whether a more precise classification of the different types of testicular maldescent could be made by using the measurement of pubic tubercle-centre of testicle distance. The pubic tubercle-centre of testicle distance was determined in 77 healthy children. The results were obtained in children aged 1 month to 15 years. The results were compared to the distances obtained in 47 children with testicular maldescent. The distance between pubic tubercle and centre of testicle represents an objective parameter in the examination of testicular maldescent. It is used to determine the testicular position precisely, and by comparing it to our graphs of normal values, it is possible to find pathological results. Our graphs of normal values for pubic tubercle-centre of testicle distance for different age groups, weight groups and body length groups in children can also be used to record the effect of hormonal or surgical therapy. Surprisingly there exists no obvious growth of the pubic tubercle-centre of testicle distance within the first seven years of life. By comparing the measurement of the pubic tubercle-centre of testicle distance of a child with testicular maldescent to our graphs of normal values, it is easy to find an objective parameter for the initiation of therapy, or for the decision to wait and see. By comparing a series of measurements of one case to our graphs of normal values, it is possible to set ideal intervals for consultations.

Two boys with high undescended testes were submitted to laparoscopic laser transsection of the internal spermatic vessels. Subsequently strong collaterals developed. Definitive scrotal transfer was performed six weeks later through an inguinal incision. Two and a half years later, the testes had recovered very well. Their volume had increased markedly, and further development was normal.