STERILITY--FERTILITY
TESTICULAR DEVELOPMENT FOLLOWING UNILATERAL ORCHIOPEXY MEASURED BY A NEW ORCHIOMETER TAKUYA UENO, M.D. JISABURO SAKATOKU, M.D.
HIROSHI TAKIHARA, M.D. YOSHIKAZU BABA, M.D. KAZUHIKO ISHIZU, M.D.
From the Department of Urology, Yamaguchi University School of Medicine, Ube, Yamaguehi, Japan
ABSTRACT--Of 170 patients having undergone orchiopexy for unilateral cryptorchid testes, 90 responded to our inquiry. Testicular size was measured in 55 patients using an accurate and practical orchiometer (punched-out orchiometer) developed in our department. In boys under ten years of age (prepubertal), testicular development was minimal, and the operated on and contralateral testes were not significantly different. With the onset of puberty, both testes enlarged, and no significant differences were observed. However, by age fourteen the side operated on was significantly (19 < 0.05) less well developed than the contralateral testis. No difference was detected clinically between the operated on and contralateral testes when the contralateral testis was less than 10 mL in volume. When the contralateral testis was greater than 15 mL, however, a significant difference was detected both statistically (p < O.05) and clinically. The findings suggest lima: ited prospects for the development of testes that are operated on at puberty.
Cryptorehism occurs in 1 percent of male patients and is one of the most common abnormalities in children. 1 The primary purpose of its surgical correction is to preserve fertility. ~ However, semen analysis results and paternity records of such patients are difficult to obtain in later years, and testieular development following orehiopexy remains to be fully investigated. We performed a long-term follow-up study of testieular development after orehiopexy using a new orehiometer. 3 Material and Methods A study was proposed of 170 patients with unilateral cryptorehid testes who underwent orehiopexy in the Department of Urology at Yamaguchi University School of Medicine between 1968 and 1983. All patients were notified by mail, and 90 agreed to participate in the study. Luteinizing hormone, follicle-stimulating hormone, and testosterone levels were 370
measured in duplicate by radioimmunoassay. Testicular size was measured using a punchedout orchiometer (Orchio Scale*), invented i n our department. This has proved to be an ae'i curate and practical clinical tool. 3 Patients were excluded from the study if they met any o f the following criteria: (1) orchiopexy after t h e age of seven; (2) diagnosis of hypogonadotropic hypogonadism, hypergonadotropic hypogona& ism, ehromosomal abnormalities, or PraderWilli syndrome; (3) a vanishing testis after orehiopexy. A total of 55 boys were included in: the study. Eleven boys were seen twice in f o l : low-up. Ages ranged from five to twenty-one years (mean age, 11.0 years), and age at chiopexy ranged from one to six years (mean age, 3.8 years). Orchiopexy was performed ac-: cording to the methods of Whinsberry-White or De Netto. *Medox Enterprise Inc., Honmaehi 6-18-5, Shibuya, Tokyo, Japan 151.
UROLOGY
/
OCTOBER 1990 / VOLUME XXXVI, NUMBEB 4
E
25
"13
LE
20
/ "6r~ N
t5
~0 /'
E
L)
"-= 5 tn
N
i--
~10
I0
15
20
Testicular size of thecontralateral
U3
~-5
25 (mL)
testis
Relationship between operated on and contralateral testicular size (mean +_ SE). **p < 0.01, *p < 0.05.
FIGURE 9,.
0
1-6
7
10 Age
1/* 15-16
1?-
~icur{E 1. Operated on (open circles) and contra!lateral (closed circles) testicular size as function of ~ige (mean +_ SE). **p < 0.01, *p < 0.05. :e expressed as the m e a n _+ stand[ were analyzed for statistical siglg Student's t test. Results
!evelopment of operated on ~eral testes (Fig. 1) ; than ten years old, the m e a n tesae was less than 3 m L for both m d contralateral sides. At the age an testicular volumes were about 4 age twelve m e a n volumes were 6 ~e difference between the operated alateral testes was less than 1 m L significant before twelve years of ~d on testes averaged 9.8 m L in olds, while contralateral testes avnL. This difference was not statiscant, however. n years of age, testicular volumes :antly (p < 0.01) different for (10.4 mL) and eontralateral (14.8 le differences in fifteen- to sixteen.3 m L vs 17.8 mL) and seventeen2 m L vs 22.0 mL) remained statisLeant, with p values of 0.05 and Lvely. Thus, beginning at age four-
3 C T O B E R 1990
/
teen the operated on side developed poorly c o m p a r e d with the eontralateral testis, and the difference between them became statistically significant.
Size relationship between operated on and contralateral testes (Fig. 2) The data collected on operated on and contralateral testes were c o m p a r e d over a range of contralateral testieular volumes. Given a contralateral testicular volume of 1-2 m L , operated on testes were comparable in size to contralateral testes (mean testicular volume of 1.7 m L vs 1.9 mL). For contralateral testes 3 to 4m L size (mean 3.3 mL), operated on testes were significantly smaller (2.8 mL), with a p value of less than 0.05. Differences in operated on (4.0 mL) and contralateral (5.4 mL) types of testes remained significant at the p < 0.05 level over a range of 5-6 m L . Over eontralateral volume ranges of 8-10 m L and 12-14 m L , however, no differences were demonstrated between sides. In contrast, significantly smaller volumes were noted in operated on testes over the 16-19 m L range (12.3 m L vs 17.5 m L ; p < 0.001) and the 22-26 m L range (15.8 m L vs 25.0 mL; p < 0.01). Thus, no difference between the operated on testis and the contralateral testis was detected clinically w h e n the contralateral testis was less than 10 m L . However, w h e n the eontralateral testes were 15 m L or larger, significant differences were detected both statistically and clinically.
VOLUME XXXVI, NUMBER 4
371
Comment While testieular volume has always been important in the infertility evaluation of the adult male, accurate testieular measurement is also important in the pediatric examination. The two most eommon techniques for estimating testieular volume are (1) comparative palpation using ellipsoid models of known volume, and (2) direct measurement of testieular length, width, and depth by caliper. The comparative palpation technique is imprecise, and the direct measurement technique can be difficult and time-consuming, especially in ehildren. We have previously deseribed an orehiometer that uses aspects of both the comparative palpation and direct measurement techniques. The orehiometer consists of a series of punched-out elliptical plates corresponding to certain testieular volumes. The complete orehiometer set ineludes 15 punched-out plates, each corresponding to a different testieular volume (1-6, 8, 10, 12, 14, 16, 19, 22, 26, and 30 mL). The appropriate plate is simply fitted over the mid-portion of the testis. This orchiometer is simple to use, painless, rapid, and requires minimal genital manipulation. It is more accurate than previous techniques and is reproducible, a We have previously documented that testieular size directly correlates with testieular function, and thus provides a rapid assessment of andrologieal status. 4 From the newborn years to puberty (13 or 14 years old), there is very little increase in testieular size, and a volume of 5 mL or less is considered juvenileP However, after the age of thirteen or fourteen, there is a rapid increase in testieular size, and the adult form is achieved by seventeen or eighteen years of age. 3 Adult testieular volume was found to be 17.59 _+ 1.91 mL in normal Japanese males. 3 If the mean _+ 2 S.D. is taken to define the normal range, normal adult testicular volume would vary from 13.8 to 21.4 mL. 3 Several studies have shown a high incidence of infertility in men operated on during childhood for unilateral as well as bilateral eryptorehism. 5-7 These authors believe that the operated on testis in the unilateral eryptorehid
372
patient contributes little to spermatogenesis. Further support for this view is obtained from two studies in which men, having u n d e r g o n e unilateral orehiopexy as children, had a vasectomy performed initially only on the side of the ~ normally descended testisJ 's Out of a total of 1 6 patients, 11 were azoospermie, 4 severely o l i g o , spermie, and 1 slightly oligospermie based on: ~semen production by the operated on (eryp, I torehid) testis alone. These findings prompted(~ us to investigate testicular development follow, '~! ing unilateral orehiopexy in early childhood. I n subjects older than fourteen, the mean testieu' ;! lar volume was significantly smaller for oper, ated on testes and was below the normal a d u k range determined in our department. 3 These findings suggest that only limited development of the operated on testis occurs at puberty. One of the causes of such poor development of th~ operated on testes may be testieular damage~: during the eryptorchid period. Definitive con-: elusions await the long-term follow-up of fertfli ity and testieular function in this group, cur, rently under investigation in our department, Nevertheless, these preliminary findings raise questions regarding the current role for the surgical eorreetion of eryptorehism in preserving fertility. Kogushl 144:,~i~ Ube, Yamaguehi 755 Japafi (DR TAKIHARA)~:{ References 1. Scorer CG: The descent of the testis, Arch Dis Child 39: 60i
(1964). 2. Robinson JN, and Engle ET: Some observations on the eryp~ torehid testis, J Urol 71:726 (1954). :~ . . et al" . • Significance . of testmular size measur; e~ -N 3. Takihara H, ~!i,~ mi22t Fer~lCl~t~rOil~c. I. A new orehiometer and its elinieal appllea~ • , ' "1 39:836 (1983). IK:;~ 4. Takihara H Cosentino MJ, Sakatoku J and Coekett AT ~ Significance of testieular size measurement in' andrology: II. Cor~!'~i~ relation of testicular size with testieular function l Urol 137: 41fi~
(1987).
~
~'!~
5. Werder EA, et al" Gonadal function in young adults aft6~ surgical treatment of eryptorehidism, Br Med J 9.: 1357 (1976):i~~ 6. Alpert PF, and Klein RS: 8permatogenesis in the nnilatera ~ eryptorehid testis after orehiopexy, J Urol 129:301 (1983). i~i~ 7. Lipshultz LI, Gaminos-Torres R, Greenspan C8, and Snyderi~ P: Testicular function after orehiopexy for unilaterally undes~ eended testis, N Engl J Med 295:15 (1976). ~ 8. Eldrup JE, and Steven K: Influence of orehiopexy for eryP~ torehidism on subsequent fertility, Br J 8urg 67 269 (1980). ;:~'i~
~R 4;~
UROLOGY / OCTOBER 1990 / VOLUME XXXVI, NUMB 144~
TESTICULAR DEVELOPMENT FOLLOWING UNILATERAL ORCHIOPEXY MEASURED BY A NEW ORCHIOMETER TAKUYA UENO, M.D. JISABURO SAKATOKU, M.D.
HIROSHI TAKIHARA, M.D. YOSHIKAZU BABA, M.D. KAZUHIKO ISHIZU, M.D.
From the Department of Urology, Yamaguchi University School of Medicine, Ube, Yamaguehi, Japan
ABSTRACT--Of 170 patients having undergone orchiopexy for unilateral cryptorchid testes, 90 responded to our inquiry. Testicular size was measured in 55 patients using an accurate and practical orchiometer (punched-out orchiometer) developed in our department. In boys under ten years of age (prepubertal), testicular development was minimal, and the operated on and contralateral testes were not significantly different. With the onset of puberty, both testes enlarged, and no significant differences were observed. However, by age fourteen the side operated on was significantly (19 < 0.05) less well developed than the contralateral testis. No difference was detected clinically between the operated on and contralateral testes when the contralateral testis was less than 10 mL in volume. When the contralateral testis was greater than 15 mL, however, a significant difference was detected both statistically (p < O.05) and clinically. The findings suggest lima: ited prospects for the development of testes that are operated on at puberty.
Cryptorehism occurs in 1 percent of male patients and is one of the most common abnormalities in children. 1 The primary purpose of its surgical correction is to preserve fertility. ~ However, semen analysis results and paternity records of such patients are difficult to obtain in later years, and testieular development following orehiopexy remains to be fully investigated. We performed a long-term follow-up study of testieular development after orehiopexy using a new orehiometer. 3 Material and Methods A study was proposed of 170 patients with unilateral cryptorehid testes who underwent orehiopexy in the Department of Urology at Yamaguchi University School of Medicine between 1968 and 1983. All patients were notified by mail, and 90 agreed to participate in the study. Luteinizing hormone, follicle-stimulating hormone, and testosterone levels were 370
measured in duplicate by radioimmunoassay. Testicular size was measured using a punchedout orchiometer (Orchio Scale*), invented i n our department. This has proved to be an ae'i curate and practical clinical tool. 3 Patients were excluded from the study if they met any o f the following criteria: (1) orchiopexy after t h e age of seven; (2) diagnosis of hypogonadotropic hypogonadism, hypergonadotropic hypogona& ism, ehromosomal abnormalities, or PraderWilli syndrome; (3) a vanishing testis after orehiopexy. A total of 55 boys were included in: the study. Eleven boys were seen twice in f o l : low-up. Ages ranged from five to twenty-one years (mean age, 11.0 years), and age at chiopexy ranged from one to six years (mean age, 3.8 years). Orchiopexy was performed ac-: cording to the methods of Whinsberry-White or De Netto. *Medox Enterprise Inc., Honmaehi 6-18-5, Shibuya, Tokyo, Japan 151.
UROLOGY
/
OCTOBER 1990 / VOLUME XXXVI, NUMBEB 4
E
25
"13
LE
20
/ "6r~ N
t5
~0 /'
E
L)
"-= 5 tn
N
i--
~10
I0
15
20
Testicular size of thecontralateral
U3
~-5
25 (mL)
testis
Relationship between operated on and contralateral testicular size (mean +_ SE). **p < 0.01, *p < 0.05.
FIGURE 9,.
0
1-6
7
10 Age
1/* 15-16
1?-
~icur{E 1. Operated on (open circles) and contra!lateral (closed circles) testicular size as function of ~ige (mean +_ SE). **p < 0.01, *p < 0.05. :e expressed as the m e a n _+ stand[ were analyzed for statistical siglg Student's t test. Results
!evelopment of operated on ~eral testes (Fig. 1) ; than ten years old, the m e a n tesae was less than 3 m L for both m d contralateral sides. At the age an testicular volumes were about 4 age twelve m e a n volumes were 6 ~e difference between the operated alateral testes was less than 1 m L significant before twelve years of ~d on testes averaged 9.8 m L in olds, while contralateral testes avnL. This difference was not statiscant, however. n years of age, testicular volumes :antly (p < 0.01) different for (10.4 mL) and eontralateral (14.8 le differences in fifteen- to sixteen.3 m L vs 17.8 mL) and seventeen2 m L vs 22.0 mL) remained statisLeant, with p values of 0.05 and Lvely. Thus, beginning at age four-
3 C T O B E R 1990
/
teen the operated on side developed poorly c o m p a r e d with the eontralateral testis, and the difference between them became statistically significant.
Size relationship between operated on and contralateral testes (Fig. 2) The data collected on operated on and contralateral testes were c o m p a r e d over a range of contralateral testieular volumes. Given a contralateral testicular volume of 1-2 m L , operated on testes were comparable in size to contralateral testes (mean testicular volume of 1.7 m L vs 1.9 mL). For contralateral testes 3 to 4m L size (mean 3.3 mL), operated on testes were significantly smaller (2.8 mL), with a p value of less than 0.05. Differences in operated on (4.0 mL) and contralateral (5.4 mL) types of testes remained significant at the p < 0.05 level over a range of 5-6 m L . Over eontralateral volume ranges of 8-10 m L and 12-14 m L , however, no differences were demonstrated between sides. In contrast, significantly smaller volumes were noted in operated on testes over the 16-19 m L range (12.3 m L vs 17.5 m L ; p < 0.001) and the 22-26 m L range (15.8 m L vs 25.0 mL; p < 0.01). Thus, no difference between the operated on testis and the contralateral testis was detected clinically w h e n the contralateral testis was less than 10 m L . However, w h e n the eontralateral testes were 15 m L or larger, significant differences were detected both statistically and clinically.
VOLUME XXXVI, NUMBER 4
371
Comment While testieular volume has always been important in the infertility evaluation of the adult male, accurate testieular measurement is also important in the pediatric examination. The two most eommon techniques for estimating testieular volume are (1) comparative palpation using ellipsoid models of known volume, and (2) direct measurement of testieular length, width, and depth by caliper. The comparative palpation technique is imprecise, and the direct measurement technique can be difficult and time-consuming, especially in ehildren. We have previously deseribed an orehiometer that uses aspects of both the comparative palpation and direct measurement techniques. The orehiometer consists of a series of punched-out elliptical plates corresponding to certain testieular volumes. The complete orehiometer set ineludes 15 punched-out plates, each corresponding to a different testieular volume (1-6, 8, 10, 12, 14, 16, 19, 22, 26, and 30 mL). The appropriate plate is simply fitted over the mid-portion of the testis. This orchiometer is simple to use, painless, rapid, and requires minimal genital manipulation. It is more accurate than previous techniques and is reproducible, a We have previously documented that testieular size directly correlates with testieular function, and thus provides a rapid assessment of andrologieal status. 4 From the newborn years to puberty (13 or 14 years old), there is very little increase in testieular size, and a volume of 5 mL or less is considered juvenileP However, after the age of thirteen or fourteen, there is a rapid increase in testieular size, and the adult form is achieved by seventeen or eighteen years of age. 3 Adult testieular volume was found to be 17.59 _+ 1.91 mL in normal Japanese males. 3 If the mean _+ 2 S.D. is taken to define the normal range, normal adult testicular volume would vary from 13.8 to 21.4 mL. 3 Several studies have shown a high incidence of infertility in men operated on during childhood for unilateral as well as bilateral eryptorehism. 5-7 These authors believe that the operated on testis in the unilateral eryptorehid
372
patient contributes little to spermatogenesis. Further support for this view is obtained from two studies in which men, having u n d e r g o n e unilateral orehiopexy as children, had a vasectomy performed initially only on the side of the ~ normally descended testisJ 's Out of a total of 1 6 patients, 11 were azoospermie, 4 severely o l i g o , spermie, and 1 slightly oligospermie based on: ~semen production by the operated on (eryp, I torehid) testis alone. These findings prompted(~ us to investigate testicular development follow, '~! ing unilateral orehiopexy in early childhood. I n subjects older than fourteen, the mean testieu' ;! lar volume was significantly smaller for oper, ated on testes and was below the normal a d u k range determined in our department. 3 These findings suggest that only limited development of the operated on testis occurs at puberty. One of the causes of such poor development of th~ operated on testes may be testieular damage~: during the eryptorchid period. Definitive con-: elusions await the long-term follow-up of fertfli ity and testieular function in this group, cur, rently under investigation in our department, Nevertheless, these preliminary findings raise questions regarding the current role for the surgical eorreetion of eryptorehism in preserving fertility. Kogushl 144:,~i~ Ube, Yamaguehi 755 Japafi (DR TAKIHARA)~:{ References 1. Scorer CG: The descent of the testis, Arch Dis Child 39: 60i
(1964). 2. Robinson JN, and Engle ET: Some observations on the eryp~ torehid testis, J Urol 71:726 (1954). :~ . . et al" . • Significance . of testmular size measur; e~ -N 3. Takihara H, ~!i,~ mi22t Fer~lCl~t~rOil~c. I. A new orehiometer and its elinieal appllea~ • , ' "1 39:836 (1983). IK:;~ 4. Takihara H Cosentino MJ, Sakatoku J and Coekett AT ~ Significance of testieular size measurement in' andrology: II. Cor~!'~i~ relation of testicular size with testieular function l Urol 137: 41fi~
(1987).
~
~'!~
5. Werder EA, et al" Gonadal function in young adults aft6~ surgical treatment of eryptorehidism, Br Med J 9.: 1357 (1976):i~~ 6. Alpert PF, and Klein RS: 8permatogenesis in the nnilatera ~ eryptorehid testis after orehiopexy, J Urol 129:301 (1983). i~i~ 7. Lipshultz LI, Gaminos-Torres R, Greenspan C8, and Snyderi~ P: Testicular function after orehiopexy for unilaterally undes~ eended testis, N Engl J Med 295:15 (1976). ~ 8. Eldrup JE, and Steven K: Influence of orehiopexy for eryP~ torehidism on subsequent fertility, Br J 8urg 67 269 (1980). ;:~'i~
~R 4;~
UROLOGY / OCTOBER 1990 / VOLUME XXXVI, NUMB 144~
