Download PDF
Aktuelle Urol 2013; 44(06): 445-451
DOI: 10.1055/s-0033-1358664
Übersicht
© Georg Thieme Verlag KG Stuttgart · New York

Diagnostik und Therapie des Maldeszensus testis – ein Update unter Berücksichtigung der Leitlinien

Diagnosis and Management of the Undescended Testis – An Update in the Light of the Current Guidelines
P. Rubenwolf
1   Abteilung Kinderurologie, Urologische Klinik und Poliklinik, Universitätsmedizin Mainz
,
R. Stein
1   Abteilung Kinderurologie, Urologische Klinik und Poliklinik, Universitätsmedizin Mainz
› Author Affiliations
Further Information

Publication History

Publication Date:
20 November 2013 (online)

Also available at
    Permissions and Reprints

Zusammenfassung

Hodenhochstände gehören mit einer Prävalenz von mindestens 1% zu den häufigsten Anomalien des äußeren Genitales. Ein Spontandeszensus des Hodens ist innerhalb der ersten 6 Monate möglich, sodass im ersten Lebenshalbjahr Verlaufskontrollen indiziert sind. Unbehandelt birgt ein Hodenhochstand das Risiko eines verminderten Fertilitätspotenzials sowie einer erhöhten malignen Entartung (RR 2,5–8). Eine vor der Pubertät durchgeführte Orchidopexie hat das Potenzial, das erhöhte Malignitätsrisiko des MDT auf den Faktor 2–3 zu reduzieren. Eine neoadjuvante Hormontherapie mit GnRH-Analoga ab dem 6. Lebensmonat kann den Fertilitätsindex des betroffenen Hodens verbessern und sollte insofern ein integraler Bestandteil des Therapiekonzeptes sein. Der Einsatz von HCG sowie eine Hormontherapie nach dem 1. Lebensjahr sollte jedoch aufgrund möglicher Hodenparenchymschäden kritisch hinterfragt werden. Bei nicht-tastbaren und sonografisch nicht-darstellbaren Gonaden ist die laparoskopische Exploration und Therapie Mittel der Wahl. Die operative Lagekorrektur sollte idealerweise mit dem 1. Geburtstag abgeschlossen sein.

Abstract

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.

Schlüsselwörter

Maldeszensus testis - Krytorchismus - Diagnostik - Therapie - Chirurgie - Hormontherapie

Key words

undescended testis (UDT) - cryptorchidism - diagnosis - management - surgery - hormonal therapy

Editorial Comment zur Übersicht

 

  • Literatur

  • 1 Acerini CL, Miles HL, Dunger DB et al. The descriptive epidemiology of congenital and acquired cryptorchidism in a UK infant cohort. Arch Dis Child 2009; 94: 868
    CrossrefPubMedGoogle Scholar
  • 2 Docimo SG. The results of surgical therapy for cryptorchidism: a literature review and analysis. J Urol 1995; 154: 1148
    CrossrefPubMedGoogle Scholar
  • 3 Wenzler DL, Bloom DA, Park JM. What is the rate of spontaneous testicular descent in infants with cryptorchidism?. J Urol 2004; 171: 849
    CrossrefPubMedGoogle Scholar
  • 4 Virtanen HE, Toppari J. Epidemiology and pathogenesis of cryptorchidism. Hum Reprod Update 2008; 14: 49
    CrossrefPubMedGoogle Scholar
  • 5 Hadziselimovic F, Huff D, Duckett J et al. Long-term effect of luteinizing hormone-releasing hormone analogue (buserelin) on cryptorchid testes. J Urol 1987; 138: 1043
    PubMedGoogle Scholar
  • 6 Huff DS, Hadziselimovic F, Duckett JW et al. Germ cell counts in semithin sections of biopsies of 115 unilaterally cryptorchid testes. The experience from the Children’s Hospital of Philadelphia. Eur J Pediatr 1987; 146 (Suppl 2): S25
    CrossrefPubMedGoogle Scholar
  • 7 Huff DS, Hadziselimovic F, Snyder 3rd HM et al. Histologic maldevelopment of unilaterally cryptorchid testes and their descended partners. Eur J Pediatr 1993; 152 (Suppl 2): S11
    PubMedGoogle Scholar
  • 8 Hadziselimovic F, Zivkovic D, Bica DT et al. The importance of mini-puberty for fertility in cryptorchidism. J Urol 2005; 174: 1536
    CrossrefPubMedGoogle Scholar
  • 9 Miller KD, Coughlin MT, Lee PA. Fertility after unilateral cryptorchidism. Paternity, time to conception, pretreatment testicular location and size, hormone and sperm parameters. Horm Res 2001; 55: 249
    CrossrefPubMedGoogle Scholar
  • 10 Lee PA, Coughlin MT. Fertility after bilateral cryptorchidism. Evaluation by paternity, hormone, and semen data. Horm Res 2001; 55: 28
    CrossrefPubMedGoogle Scholar
  • 11 Abratt RP, Reddi VB, Sarembock LA. Testicular cancer and cryptorchidism. Br J Urol 1992; 70: 656
    CrossrefPubMedGoogle Scholar
  • 12 Farrer JH, Walker AH, Rajfer J. Management of the postpubertal cryptorchid testis: a statistical review. J Urol 1985; 134: 1071
    PubMedGoogle Scholar
  • 13 Wood HM, Elder JS. Cryptorchidism and testicular cancer: separating fact from fiction. J Urol 2009; 181: 452
    PubMedGoogle Scholar
  • 14 Kaplan GW. Nomenclature of cryptorchidism. Eur J Pediatr 1993; 152 (Suppl 2): S17
    CrossrefPubMedGoogle Scholar
  • 15 Hutson JM, Hasthorpe S, Heyns CF. Anatomical and functional aspects of testicular descent and cryptorchidism. Endocr Rev 1997; 18: 259
    CrossrefPubMedGoogle Scholar
  • 16 Ramareddy RS, Alladi A, Siddappa OS. Ectopic testis in children: experience with seven cases. J Pediatr Surg 48: 538
    PubMedGoogle Scholar
  • 17 Stec A, Thomas J, DeMarco R et al. Incidence of testicular ascent in boys with retractile testes. J Urol 2007; 178: 1722
    CrossrefPubMedGoogle Scholar
  • 18 Villumsen A, Zachau-Christiansen B. Spontaneous alterations in position of the testes. Arch Dis Child 1966; 41: 198
    CrossrefPubMedGoogle Scholar
  • 19 Kaplan G. Iatrogenic cryptorchidism resulting from hernia repair. Surg Gynecol Obstet 1976; 142: 671
    PubMedGoogle Scholar
  • 20 Kaplan GW. Iatrogenic cryptorchidism resulting from hernia repair. Surg Gynecol Obstet 1976; 142: 671
    PubMedGoogle Scholar
  • 21 Hadziselimovic F, Herzog B. The importance of both an early orchidopexy and germ cell maturation for fertility. Lancet 2001; 358: 1156
    CrossrefPubMedGoogle Scholar
  • 22 Elder JS. Epididymal anomalies associated with hydrocele/hernia and cryptorchidism: implications regarding testicular descent. J Urol 1992; 148: 624
    PubMedGoogle Scholar
  • 23 Kanemoto K, Hayashi Y, Kojima Y et al. Accuracy of ultrasonography and magnetic resonance imaging in the diagnosis of non-palpable testis. Int J Urol 2005; 12: 668
    CrossrefPubMedGoogle Scholar
  • 24 Huff DS, Snyder 3rd HM, Hadziselimovic F et al. An absent testis is associated with contralateral testicular hypertrophy. J Urol 1992; 148: 627
    PubMedGoogle Scholar
  • 25 McEachern R, Houle AM, Garel L et al. Lost and found testes: the importance of the hCG stimulation test and other testicular markers to confirm a surgical declaration of anorchia. Horm Res 2004; 62: 124
    PubMedGoogle Scholar
  • 26 Rey R. How to evaluate gonadal function in the cryptorchid boy. Lessons from new testicular markers. J Pediatr Endocrinol Metab 2003; 16: 357
    PubMedGoogle Scholar
  • 27 Kubini K, Zachmann M, Albers N et al. Basal inhibin B and the testosterone response to human chorionic gonadotropin correlate in prepubertal boys. J Clin Endocrinol Metab 2000; 85: 134
    CrossrefPubMedGoogle Scholar
  • 28 Merguerian PA, Mevorach RA, Shortliffe LD et al. Laparoscopy for the evaluation and management of the nonpalpable testicle. Urology 1998; 51: 3
    PubMedGoogle Scholar
  • 29 Cisek LJ, Peters CA, Atala A et al. Current findings in diagnostic laparoscopic evaluation of the nonpalpable testis. J Urol 1998; 160: 1145
    CrossrefPubMedGoogle Scholar
  • 30 Hadziselimovic F. The controversy regarding the need for hormonal treatment in boys with unilateral cryptorchidism goes on: a review of the literature by B. Ludwikowski and R. Gonzalez. Eur J Pediatr 171: 1281 author reply 1283
    PubMedGoogle Scholar
  • 31 Ludwikowski B, Gonzalez R. The controversy regarding the need for hormonal treatment in boys with unilateral cryptorchidism goes on: a review of the literature. Eur J Pediatr 172: 5
    PubMedGoogle Scholar
  • 32 Hadziselimovic F, Emmons RL, Howard S. A Rotterdam controversy: the aetiology of the cryptorchid hypothalamo-pituitary-testicular axis. Int J Androl 2009; 32: 89 author reply 90
    CrossrefPubMedGoogle Scholar
  • 33 Storm D, Redden T, Aguiar M et al. Histologic evaluation of the testicular remnant associated with the vanishing testes syndrome: is surgical management necessary?. Urology 2007; 70: 1204
    CrossrefPubMedGoogle Scholar
  • 34 Penson D, Krishnaswami S, Jules A et al. Effectiveness of hormonal and surgical therapies for cryptorchidism: a systematic review. Pediatrics 131: e1897
    PubMedGoogle Scholar
  • 35 Pirgon O, Atabek M, Oran B et al. Treatment with human chorionic gonadotropin induces left ventricular mass in cryptorchid boys. J Pediatr Endocrinol Metab 2009; 22: 449
    PubMedGoogle Scholar
  • 36 Pyorala S, Huttunen NP, Uhari M. A review and meta-analysis of hormonal treatment of cryptorchidism. J Clin Endocrinol Metab 1995; 80: 2795
    CrossrefPubMedGoogle Scholar
  • 37 Schwentner C, Oswald J, Kreczy A et al. Neoadjuvant gonadotropin-releasing hormone therapy before surgery may improve the fertility index in undescended testes: a prospective randomized trial. J Urol 2005; 173: 974
    CrossrefPubMedGoogle Scholar
  • 38 Jallouli M, Rebai T, Abid N et al. Neoadjuvant gonadotropin-releasing hormone therapy before surgery and effect on fertility index in unilateral undescended testes: a prospective randomized trial. Urology 2009; 73: 1251
    CrossrefPubMedGoogle Scholar
  • 39 Cortes D, Thorup J, Visfeldt J. Hormonal treatment may harm the germ cells in 1 to 3-year-old boys with cryptorchidism. J Urol 2000; 163: 1290
    CrossrefPubMedGoogle Scholar
  • 40 Dunkel L, Taskinen S, Hovatta O et al. Germ cell apoptosis after treatment of cryptorchidism with human chorionic gonadotropin is associated with impaired reproductive function in the adult. J Clin Invest 1997; 100: 2341
    CrossrefPubMedGoogle Scholar
  • 41 Novaes HF, Carneiro Neto JA, Macedo Jr A et al. Single scrotal incision orchiopexy – a systematic review. Int Braz J Urol 39: 305
    PubMedGoogle Scholar
  • 42 Prentiss RJ, Weickgenant CJ, Moses JJ et al. Surgical repair of undescended testicle. Calif Med 1962; 96: 401
    PubMedGoogle Scholar
  • 43 Sfoungaris D, Mouravas V, Petropoulos A et al. Prentiss orchiopexy applied in younger age group. J Pediatr Urol 8: 488
    PubMedGoogle Scholar
  • 44 Fowler R, Stephens FD. The role of testicular vascular anatomy in the salvage of high undescended testes. Aust N Z J Surg 1959; 29: 92
    CrossrefPubMedGoogle Scholar
  • 45 Cortesi N, Ferrari P, Zambarda E et al. Diagnosis of bilateral abdominal cryptorchidism by laparoscopy. Endoscopy 1976; 8: 33
    Article in Thieme ConnectPubMedGoogle Scholar
  • 46 Persky L, Albert DJ. Staged orchiopexy. Surg Gynecol Obstet 1971; 132: 43
    PubMedGoogle Scholar
  • 47 Korner I, Rubben H. Undescended testis: aspects of treatment. Urologe A 49: 1199
    PubMedGoogle Scholar
  • 48 Baker LA, Docimo SG, Surer I et al. A multi-institutional analysis of laparoscopic orchidopexy. BJU Int 2001; 87: 484
    CrossrefPubMedGoogle Scholar
  • 49 Harper L, Gatibelza M, Michel J et al. The return of the solitary testis. J Pediatr Urol 2011; 7: 534
    CrossrefPubMedGoogle Scholar
  • 50 Bukowski TP, Wacksman J, Billmire DA et al. Testicular autotransplantation: a 17-year review of an effective approach to the management of the intra-abdominal testis. J Urol 1995; 154: 558
    CrossrefPubMedGoogle Scholar
  • 51 Tackett L, Wacksman J, Billmire D et al. The high intraabdominal testis: technique and long term success of laparoscopic testicular autotransplantation. J Endourol 2002; 16: 359
    CrossrefPubMedGoogle Scholar
  • 52 Kelly B, Higuera S, Cisek L et al. Combined laparoscopic and microsurgical technique for testicular autotransplantation: Is this still an evolving technique. J Reconstr Microsurg 2010; 26: 555
    Article in Thieme ConnectPubMedGoogle Scholar
  • 53 Ludwikowski B, González R. The controversy regarding the need for hormonal treatment in boys with unilateral cryptorchism goes on: a review of the literature. Eur J Pediatr 2013; 172: 5
    CrossrefPubMedGoogle Scholar