Late presentation of cryptorchidism: the etiology of testicular re-ascent

PURPOSE: We reviewed the records of 21 boys who had 23 previously documented descended testes that reascended and who underwent orchiopexy during a 2-year period. MATERIALS AND METHODS: We retrospectively reviewed a 2-year experience in 103 boys (115 undescended testes) who underwent orchiopexy in 1988 and 1989. RESULTS: In our 2-year experience 21 of the 103 boys with undescended testes had multiple recorded confirmations of testicular descent in the past. Of the boys 40% had previously been examined in the office or with general anesthesia by a pediatric urologist or pediatric surgeon for another reason, and 40% had a nurse or physician parent. Surgery was performed at ages 5 to 14 years, an average of 2 years after the initial presentation with reascent. Human chorionic gonadotropin was unsuccessful in causing testicular descent. There was no correlation with a patent processus vaginalis and no association with adhesions. The testis was located in the superficial inguinal pouch in the majority of patients, and the gubernacular attachment was in an abnormal location in all and ectopic in half of the cases. CONCLUSIONS: Our observations confirm that the etiology of this condition is a missed diagnosis at a younger age. The testis is undescended but almost completely descended. With somatic growth the distance between the terminal portion of the gubernaculum of the apparently descended testis and the scrotum increases, making the diagnosis more obvious. The potential for this condition makes it mandatory that intrascrotal testicular location be confirmed by periodic physical examination through puberty.     

High scrotal orchidopexy for palpable maldescended testes

OBJECTIVE: To confirm that most spermatic cords of palpable maldescended testes are long enough to place the testes in the scrotum and therefore that a satisfactory scrotal testicular position can be achieved by a single high scrotal incision with less dissection of the inguinal region. PATIENTS AND METHOD: Between January 1991 and June 1995, 106 high scrotal orchidopexies (HSOs) for clinically palpable maldescended testes were carried out in 96 patients (mean age 41 months, range 14 months to 11 years). Ten patients had bilateral undescended testes. Regardless of the initial testicular position or the age of the patients, all orchidopexies were commenced with a high scrotal incision. Ninety-two testes (87%) were placed satisfactorily in the scrotum and the remaining 14 testes (13%) required a second inguinal incision. RESULTS: During the follow-up (mean 16 months, range 8 months to 3 years), 85 testes (80%) showed good anatomical and cosmetic results. Five testes required a repeat conventional orchidopexy 6 months after the HSO. Three testes were excised because they showed atrophic changes; 11 of the 14 testes which required two incisions initially have shown good results. CONCLUSION: High scrotal orchidopexy is a satisfactory approach to any palpable maldescended testis, having the advantage of using a single incision and requiring less dissection and anatomical disruption of the inguinal region, with excellent cosmesis.     

Scrotal perforation by a ventriculoperitoneal shunt

A case is reported of an adult male in whom the distal ventriculoperitoneal shunt tip migrated through the right inguinal canal into the scrotum. It perforated the scrotal skin, leading to an infection of the still draining shunt. Migration of ventriculoperitoneal shunts into the scrotum occurs occasionally in children but until now has not been reported in an adult with perforation of the scrotum.     

Current concepts in the pathophysiology of testicular undescent

At present, we believe that descent of the testes within the human is a complex event mediated by both hormonal and mechanical factors. We hypothesize that descent of the testes occurs as a result of the secretion of an androgen-independent factor from a normal testis (descendin). This paracrine factor is responsible for the rapid proliferation (outgrowth) of the ipsilateral gubernaculum. The development of the gubernaculum results in creating a dilated inguinal canal, the width of which matches the testicular width. Descent of the testes through the inguinal canal is an interplay between abdominal pressure, a patent processus vaginalis, and androgen-induced gubernacular regression. We hypothesize that androgens (under control of an intact hypothalamic pituitary axis) alter the viscoelastic properties of the gubernaculum, reducing the turgidity of the gubernaculum and allowing intra-abdominal pressure to push the testis into the scrotum. Cryptorchidism can therefore result when any one or more of the involved factors malfunction.     

Congenital undescended testes in neonatal pigs and the effect of exogenous calcitonin gene-related peptide

PURPOSE: We investigated the neonatal piglet as a possible animal model for cryptorchidism and to determine whether calcitonin gene-related peptide (CGRP), which has been proposed to regulate inguinoscrotal testicular descent, could induce testicular descent in piglets with congenital cryptorchidism. MATERIALS AND METHODS: We examined 38 cryptorchid piglets to document the anatomy in 8 and to investigate the role of CGRP in 30. The 2-week-old piglets were allocated randomly to receive a mini-osmotic pump containing CGRP at various concentrations or phosphate buffered saline. The pump was inserted surgically into the ipsilateral scrotum, with the contents blinded to the surgeon. The positions of the testes, pump and anatomical landmarks were measured and photographed. The pigs were sacrificed and dissected 2 weeks later, and the positions were remeasured and photographed. The testes were examined histologically. RESULTS: The 3 variants of cryptorchidism observed were intra-abdominal in 20 cases, inguinal in 9 and lateral inguinal ectopic in 9. CGRP had no effect on intra-abdominal or ectopic testes. In contrast, for inguinal testes exogenous CGRP caused a slight but significant 10 +/- 7.9 mm. descent towards the pump in 5 cases compared to -2.9 +/- 5.8 mm. in 4 controls. CONCLUSIONS: Exogenous CGRP stimulated migration of inguinal testes that had been arrested in the line of descent while ectopic testes did not respond. These results support a role for CGRP in testicular descent and suggest that a slow release depot preparation might be useful as a possible treatment in some forms of cryptorchidism.     

Hernia repair during endoscopic extraperitoneal lymph node dissection

Cryptorchidism is frequently associated with gastroschisis, yet little is published on its management in such circumstances. In a review of 10 consecutive boys with gastroschisis since 1980, 4 had undescended testes. Gestational age and birth weight did not differ from the 6 boys with normally descended testes. The first two patients had associated arthrogryposis multiplex congenita. The first underwent bilateral orchidopexy at 9 years of age for inguinal testes. In the second patient, the left testis was intraabdominal at the level of the sigmoid colon at birth; at 3 months of age, when a left inguinal hernia repair was required, left groin exploration revealed the testis at the internal ring and orchidopexy was performed successfully. In the third patient the left spermatic vessels were divided at the time of gastroschisis repair and the testis anchored in the prebubic area. The second-stage orchidopexy was performed at 16 months. In the last patient the intraabdominal testis could be placed in a scrotal pouch without mobilisation or division of the vessels. From our experience and a review of the literature we conclude that: 1) undescended testes are frequently associated with gastroschisis; 2) mechanical factors rather than prematurity are likely responsible for this association; 3) if the testis easily reaches the scrotum, orchidopexy can be done safely at the time of gastroschisis repair; 4) if the testis does not reach easily and appears to have a gubernaculum, it may be preferable to leave it in place since spontaneous descent can occur.     

Cloning and genetic analysis of the gene encoding a new protein kinase in Saccharomyces cerevisiae

The growth of the body was studied in 30 human fetuses ranged from 10 to 22 weeks of gestation. The fetuses were fixed by immersion in 4 percent formaldehyde and the following dimensions were studied: a) lengths: arm, forearm, hand, thigh, leg, foot and crown-rump (sitting height), b) perimeters: head, thorax and abdomen. A covariance matrix was calculated from natural logarithms of all measurements. The relative growth of these measurement was computed by multivariate allometry using a principal components analysis (PCA). All characters were positively correlated with the first principal component which accounted for 94.65 per cent of the total variance. Considering the different measurements in the sequence of the increasing growth rates no one was considered to increase in isometric relationship. PCA showed that the following measurements grew with negative allometry: head perimeter, C-R length, thoracic perimeter, length of the forearm and abdominal perimeter. On the other hand, the following lengths grew with positive allometry: hand, foot, thigh, arm and leg. In conclusion, during the first two trimesters of prenatal life the growth of the body is allometrical. Limbs increase with greater growth rates than the perimeters of the body cavities.     

Early intrauterine development: II. The rate of growth in Black and Central American populations between 10 and 20 weeks' gestation

The application of the growth-rate standards, extablished for Caucasian embryos and fetuses in a previous report, to Black and Central American racial groups has been investigated. Comparison between menstrual age and crown-to-rump length indicated differences in the 10 to 15 weeks' gestation range. However, growth rates for the same groups were practically identical between the 15th and 20th weeks of pregnancy. This finding suggests that the actual rate of growth is closely similar in the respective ethnic groups and that apparent discrepancies reflect erroneous, or purposefully false, menstrual histories rather than dissimilar growth patterns. Largely identical rates of development were suggested by the crown-rump length to foot length to body weight interrelations among the various racial groups. A moderate, but rather predictable, deviation from the earlier established standards was noted in the crown-rump length versus foot length ratios of Black American fetuses, providing the only exception to what appears to be a practically identical rate of growth for the investigated ethnic groups in the first half of gestation. The evaluation of the results was extended to involve the effect of educational and social factors on currently available data of embryonic and fetal growth. It is suggested that heretofore unconsidered factors may affect the validity of widely quoted standards of intrauterine growth.     

The Green Bay cesarean section study. IV. The physician factor as a determinant of cesarean birth rates for the large fetus

OBJECTIVES: Our purpose was to determine those factors affecting the route of delivery decisions and the effect of delivery route on maternal and newborn outcomes with the macrosomic fetus. Do higher cesarean rates result in improved newborn outcomes? STUDY DESIGN: A 10-year (1985 to 1994) retrospective data set was used to analyze patients with newborns weighing > or = 4536 and 4000 to 4535 gm at two Green Bay hospitals. Patients with newborns weighing 2500 to 3999 gm were similarly analyzed for comparison purposes. Individual and obstetrician group cesarean rates and newborn and maternal outcomes were identified. RESULTS: Cesarean birth rates for the fetus weighing > 4000 gm were low and varied from 12.8% in the low obstetrician cesarean rate group to 24.0% in the high group. Higher obstetrician group cesarean rates did not result in improved newborn outcomes. Newborn morbidity and mortality were very low but significantly higher for cesarean birth newborns. Maternal complications were fairly low with cesarean birth and rare after vaginal delivery. CONCLUSION: Patients with a suspected macrosomic fetus should be given the same opportunity to achieve a vaginal delivery as patients with smaller fetuses.     

Impact of diagnostic laparoscopy in the management of the unilateral impalpable testis

OBJECTIVE: To evaluate the impact of laparoscopy on the management of children with a unilateral impalpable testis. PATIENTS AND METHODS: The study population consisted of 27 children who underwent a primary inguinal exploration for a unilateral impalpable testis. RESULTS: Twelve of 27 (44%) children had inguinal or 'peeping' testes and 10 of 27 (37%) had blind-ending vasa and vessels in the inguinal canal; four of these 10 had atrophic tubular tissue in the excised remant. Four of 27 (15%) had blind-ending vasa and vessels proximal to the internal ring. Only one child had a testis proximal to the internal ring. Only the four children (15%) with blind-ending vasa and vessels proximal to the internal ring would have benefited from a laparoscopy by avoiding an inguinal exploration. CONCLUSIONS: Because of the time, expense and limited usefulness of laparoscopy in altering the management of children with a unilateral unpalpable testis, we reserve laparoscopy for cases where inguinal exploration has failed.     

Fetal development of the white line (Zona alba) of the equine hoof

The fetal development of the white line (Zona alba) in the equine hoof is described. Its specific structure of lamellar and interlamellar horn, which in turn is composed of cap and terminal horn, is formed in the second half of the hoof's fetal development. In equine fetuses with a crown-rump length of less than 550 mm, the hoof capsule lacks a 'characteristic' white line since no borders between stratum medium, stratum internum and sole horn are discernible. In the hoof of an equine fetus with a crown-rump length of 550 mm, a narrow white line has taken shape. Its shallow lamellae are arranged like arcades. Between the horn lamellae lie the polyhedral cells of the interlamellar horn. Up until birth, the height of the horn lamellae and, therefore, the width of the white line increases significantly. In the white line of the hoof of newborn foals, the terminal horn contains horn tubules with a characteristic architecture.     

Ascent of the testis in children

Among 460 children who had an orchiopexy (ORP), we identified 72 children who had attended our institution 1-12 years earlier and in whom the testicular position had been specified. Of the 72 boys 19 were had ascended testes (26%). The age at ORP of the children with ascent of the testes was 7.0 years (1.8-14.0 years). Light and electron microscopy of 13 testicular biopsies taken at ORP, showed alterations of germ cells and Sertoli cells, similar but less pronounced than alterations seen in congenital undescended testes. Conclusion. A normally positioned testis may ascend into the inguinal region or upper scrotum and remain there fixed. This secondary cryptorchidism does not usually respond to human chorionic gonadotropin treatment and must be corrected by orchiopexy.     

A microscopic analysis of cut-bevel versus pencil-point spinal needles

OBJECTIVE: Our purpose was to establish new nomograms for the birth weight of twins on the basis of accurate methods to validate gestational age. STUDY DESIGN: The medical records of 1632 consecutive twin gestations delivered between 1984 and 1996 were reviewed. Only pregnancies induced by ovulation induction techniques or that were measured ultrasonographically for crown-rump length during the first trimester were included. Excluded were those whose fetuses (one or both) were stillborn, or if the mother smoked, had a significant chronic illness, or was prescribed any regular medications. The study comprised 520 twin pregnancies at 28 to 41 gestational weeks at delivery. RESULTS: The median and 10th and 90th percentile birth weight curves were calculated for the studied twins and plotted against previously reported singleton nomograms. Fetuses of twin pregnancies were found to be growth restricted in comparison with previously reported singletons throughout the third trimester. This trend became more evident after the thirty-fourth to thirty-sixth weeks. CONCLUSIONS: We recommend these novel birth weight nomograms for clinical use in the management of twin pregnancies.     

Structural studies of a human pi class glutathione S-transferase. Photoaffinity labeling of the active site and target size analysis

The present study analysed gubernaculum development in mice that had been induced, through transgenesis, to express human anti-Müllerian hormone (h-AMH) throughout prenatal life. Growth and differentiation of the gubernacular primordia were assessed through the analysis of serial, transverse or sagittal, histological sections of the lower abdomen. Transgenic males and females expressed biologically active amounts of h-AMH as measured by sensitive and specific ELISA and evidenced through the regression, in females, of Müllerian ducts after day 13 of prenatal life. Gubernacular primordia became distinguishable at the same age in control and transgenic male and female fetuses on day 12 after coitus. In both groups gubernacular cords (inguinal folds of the genital mesenteries) increased in length more in females than in males while gubernacular cones showed larger growth in males. h-AMH thus appeared not to affect the sexually dimorphic pattern of growth and development of these structures. Growth and differentiation of the gubernacular primordia was further examined in 18-day-old control and h-AMH transgenic fetuses that had been exposed to testosterone propionate injected into their mothers on days 12 and 14 of pregnancy. Testosterone treatment affected, to a minor extent, the growth of the female gubernacular cords: these were reduced in length (but had a larger surface area) compared with controls. The gubernacular cones were slightly increased in length but male-like differentiation of the tissues of the cones into a muscular and mesenchymal component was not noticed to any extent. The observations thus add experimental support to the contention that AMH, even in combination with testosterone, is not effective in establishing the male pattern of gubernacular primordia development.     

Neuronal nitric oxide synthase in the canine prostate: aging, sex steroid, and pathology correlations

OBJECTIVE: To clarify some anatomical controversies of the fascial structures and lymph node development of the inguinal region through an embryological study in relation to the surgical techniques of groin lymphadenectomy. METHODS: Sections of the femoral triangle belonging to four fetuses whose crown-rump (CR) length ranged from 70 to 310 mm, corresponding to a developmental age of 11 and 35 weeks, were studied. RESULTS: The femoral fascia is formed of one layer and is not divided into superficial and deep layers. The cribriform fascia has a morphogenetic origin different from that of the femoral fascia and it is defined by the thickening of the connective tissue filling the fossa ovalis and therefore would be more correctly named lamina cribrosa. The deep inguinal lymph nodes originate directly from the superficial lymphatic tissue located in the fossa ovalis. This last observation supports the fact that no lymph nodes are present beneath the femoral fascia distal to the lower margin of the fossa ovalis. CONCLUSIONS: The results of this study, from a surgical point of view, support the technique of total or radical inguinal-femoral lymphadenectomy with preservation of the femoral fascia and, from an anatomical point of view, resolve some of the contradictory statements reported in the anatomical literature regarding morphogenesis and terminology of the structures of the Scarpa's triangle. In addition, the present study provides useful anatomic and terminological landmarks to those surgical oncologists (gynecologist, urologist, dermatologist, etc.) dealing with malignant diseases requiring groin dissection practices. In addition, it could represent a useful background for a future more precise surgical terminology which represents a vital issue for institutional studies with multiple surgeons as well as for large multi-institutional studies.     

Regionalized sensorimotor plasticity after hemispherectomy fMRI evaluation

The purpose of the present study was to evaluate hand size and maturity in fetuses with trisomy 21 (Down syndrome). Twenty-five fetuses, crown-rump length (CRL) 55-222 mm, foot length (FL) 8-42 mm, were included in the study. After whole-body radiography (Hewlett Packard Faxitron), special radiographs of the hand and foot were taken. Hand length was measured as the length of the third finger from the distal tip of the distal phalanx to the proximal tip of the metacarpal bone, the digital-metacarpal length (DML). The lengths of the proximal phalangeal bone (PPL) and the metacarpal bone (MCL) of the third finger were also measured. The DML, PPL, and MCL values of each fetus were related to CRL and FL. The individual hand bones were evaluated with regard to time of appearance on radiographs, sequence in comparison with the normal sequence of appearance, and morphology. The hand length is normal during the first half of the fetal period, whereas the length of individual bones in the third finger is reduced. The normal sequence of ossification, with the middle phalanx of the fifth finger last to ossify, also occurred in Down syndrome; however, this bone appeared later in Down syndrome. In four of the fetuses it did not appear.     

Vibroacoustic Stimulation of the Fetus Using a Conventional Mechanical Alarm Clock

> Objective: For more than 20 years, vibroacoustic stimulation testing (VAST) using an artificial larynx has been used worldwide when fetal heart rate monitoring produced patterns with absent or very low variability. In addition to the artificial larynx many other appliances have been used to stimulate a seemingly dormant fetus, but these have rarely been evaluated properly. In this study we tried to evaluate the use of standard mechanical wind-up alarm clocks for VAST. Methods: VAST with an alarm clock was performed successfully in 80 women with normal pregnancies from 36 weeks to term. It was tested by placing the alarm clock on the maternal abdomen just above the fetal head or on the controlateral side of the maternal abdomen to see whether position made any difference and whether coupling with ultrasound gel applied between the alarm clock and the maternal abdomen would affect the degree of fetal reaction to VAST as expressed in heart rate acceleration. Similarly, the effect of the alarm clock VAST on subjective and objective fetal movement patterns as registered by kineto-cardiotocotraphy (K-CTG) in addition to heart rate patterns was investigated. Results: All fetuses showed heart rate acceleration, an increase in heart variability, and increase in movement patterns in the 6 min after the application of alarm clock VAST. No statistically significant difference was found which would favor a particular placement of the alarm clock on the maternal abdomen or the use of ultrasound coupling gel. When K-CTG was performed, patient-perceived fetal movements as expressed with an event marker showed agreement with the machine-registered movements only when patients could see the tracing during registration and no accordance when the K-CTG was turned toward the wall during registation. Conclusion: In keeping with the ALARA principle a conventional wind-up alarm clock appears to be an inexpensive and effective alternative to the electrolarynx.     

Abnormal myelination in a patient with ring chromosome 18

BACKGROUND: Most adult anatomical texts state that the deep inguinal ring is situated midway between the anterior superior iliac spine and the pubic tubercle. The aim of this study was to determine if this was true in prepubescent children. METHODS: A total of 107 inguinal ligaments and canals were measured during inguinal operations in 80 children (68 boys, age range 1-118 months). RESULTS: The length of the inguinal ligament increased from a median of 4.3 cm (range 3.6-6.8) at less than 1 year of age to 7.5 cm (range 6.7-10.1) at over 4 years of age. The internal ring was situated medial to the midpoint of the inguinal ligament throughout childhood. The ratio of internal ring to public tubercle over inguinal ligament length was 42% (range 27-58) at less than 2 years; and 34% (range 25-46) at over 4 years. The inguinal canal remained short (median 1 cm (range 0.7-1.1) at less than 2 years, and median 1.1 cm (range 0.7-2.3) at over 4 years) suggesting that growth of the inguinal region in this age group occurs outside the canal. CONCLUSIONS: These results have implications for the siting of incisions, and question the necessity of opening the inguinal canal in children.     

Estimation of the developmental age of the ovine fetus and lamb

Fifty-six fetuses and 33 lambs were obtained from a flock of ewes at set gestational intervals between 50 to 180 days after conception. The fetuses and lambs were killed, disected and the sizes and weights of a wide range of skeletal and soft tissues were measured. Five morphological parameters emerged as most suitable for the determination of normal foetal developmental age. By plotting the mean value and ninety-five per cent tolerance limits, the rates of growth and the variability of each parameter were studied. Crown-anus length is useful for determining fetal developmental age from 50 to 100 days gestation; brain weight, long bone length and the number of appendicular ossification centres can be used to determine fetal development age from 50 days gestation until term.     

Coagulase typing of Staphylococcus aureus in the geriatric wards after introduction of preventive measures of hospital infection

The study comprised 323 cryptorchidic boys, between 6 months and 14 years of age (mean age 5.68 years) with 440 maldescended testes. Testicular position was graded as inguinal low or prescrotal (I), inguinal middle (II), inguinal high (III), and abdominal testes (IV). Boys before 4 years of age received human chorionic gonadotropin (hCG) as intramuscular injections (I.M.), 500 IU twice a week for 5 weeks; and boys 4 or more years of age received hCG (IM), 1000 IU twice a week for 5 weeks. The objectives of this study were to evaluate the response of maldescended testes to treatment with hCG, and to investigate possible associations between the patients' ages and position of the testes with the response to hCG. Out of the 440 maldescended testes, 329 were in an inguinal location (75%) and 111 were abdominally located (25%). The overall response to hCG was 40%, and the inguinal testes response was 49%, with the highest success rates (72%) for the prescrotal testes. A positive correlation was found (p < .0001) between the rate of success and the testicular position. There was no association between the hCG response and the age at which treatment was initiated.