The Thesis approved by Council of scientist in Vietnam Military Medical University. At
References theThesis in: 1. Vietnam National Library 2. Library of Vietnam Military Medical University
LIST OF PUBLICATIONS This Thesis is based on the following papers: 1.
Nguyễn Mạnh Thắng (2018), “Comments on characteristics of testicle volume, hormones, spermiogram in adult male with cryptorchidism”, Vietnam Medicine, Vol 471, No 2.
Nguyễn Mạnh Thắng, Trần Quán Anh, Nguyễn Quang (2018), “Testosterone and gonadotropins in adult male with cryptorchidism: Compare pre and post orchidopexy”, Journal of military pharmaco-medicine, page196-198.
1 INTRODUCTION Cryptorchidism is a popular sequela in reproduction – urology system in male baby. The proportion of cryptorchidism accounted for 24% in full-term full-term infant and 20-30% in preterm infant. Cryptorchidism is a long-term risk factor that cause many complications such as infertility, testicle cancer, change of hormone… Some studies showed that cryptorchidism cause alters of testicle’s structure and function, and it is believed as a cause of infertility. Nowaday, some scientists concerned that relationship between decreasing competence of sperm and unilateral cryptorchidism and alter of the other normal testicle in scrotum. Cryptorchidism related closedly to testicle cancer and suffer from cancer higher than from 4 to 40 times in normal testicle in scrotum in many studies. Guideline of many Association of Urology also showed that early operation help to prevent complications, the latest age of operation was 18 months old. However, in fact there were many patients that were operated late. In Vietnam, the proportion of puberty surgery was 3040%. So that there were many male adult with cryptorchidism. Besides, removing cryptorchidism in adult is popular in Vietnam. It maybe affect to psycholory, hormone, decrease competemce of reproduction. So there is a question that orchiopexy in male adult bring to effectiveness? Our study assess outcome of orchiopexy in male adult. Objectives of our study were: 1. Studying few characteristics of morphology, function, histopathology in adult male with cryptorchidism. 2. Assessing results of orchiopexy in male adult with cryptorchidism. CHAPTER 1: BACKGROUND 1.1. The embryology of the testis 1.1.1. The non-gender stage The gender has not been differentiated from third and sixth of pregnancy. 1.1.2. The development of testis From the seventh week is the seminiferous tubules and interstitial cells development.
2 1.1.3. The testicular movement during pregnancy The movement happens during eighth to fifteenth week (including the testis formation and movement). The inguinal stage lasts from twenty-fifth to thirty-fifth week (inguinal and scrotum) 1.1.4. The contribution factor of testicular movement Up to now, it was fulfilled knowledge of mechanism, however it is concerned about anatomical and hormonal causes. 1.2. Causes of cryptorchidism Theoretically, the testicular mal-movement is caused by the failure of each stage in testicular movement. 1.2.1. Age and weight: Infants weighted under the real age (<2500 g), early delivery < 37 weeks are considered more possibility of having cryptorchidism. 1.2.2. Hormonal factor: The disturbance of hypothalamus-pituitary gland-gonadal gland leads to mal-production of testosterone, reduction sensitivity of Androgen receptors. Estrogen could affect the movement of testes. 1.2.3. Mechanical factor: Malformation of scrotum-testis ligament, epididymis disorder, lower intra-abdominal pressure. 1.2.4. The disorders related to cryptorchidism Hypospadias, feminized testes … 1.3. The anatomy of testis and the related components - The cryptorchidism testis is smaller and more round-shaped than the normal one. The cryptorchidism testis has the semilunar-shaped epididymis. - The testicular vessels normally had connection between the testicular and ductus deferens artery, and testicular parenchymal. In the cryptorchidism, the artery is smaller. The testicular artery branches into two, one for testicular, other for epididymis without connection. 1.4. LH, FSH, Testosterone and the effect to congenital physiology According to Ramaswamy S. and Weinbauer G.F.: LH/testosterone and FSH are the necessary hormones to maintain the normal semen production. Babu S.R.et al. the gonadal hormones (LH, FSH) and testosterone are the basic factors of semen production.
3 Meeker J.D. et al. showed the role of FSH, LH is negative with density, shape and mobility. 1.5. The sperm test in cryptorchidism patients The deficiencies appear in both unilateral and bilateral cryptorchidism groups 1.5.1. Bilateral cryptorchidism - According to Goel P. et al.: If untreated properly, the proportion of infertility maybe reach to 90%, and If testis of cryptorchidism are operated in the childhood, the proportion of infertility will be 32 - 46% according to surgery age. - Radmayr C.: For untreated bilateral undescended testes revealed that 100% are oligospermic and 75% azoospermic . Among those successfully treated for bilateral undescended testes, 75% still remain oligospermic and 42% azoospermic - Park J.K. showed that proportion of azoospermic was 90% if untreated properly. 1.5.2. Unilateral cryptorchidism - According to Goel P. et al.: If untreated properly, azoospermic 13%, and 10% in cryptorchidism with operation in infant. - Sakellaris G. (2012): 50-70% patients with one testicle of cryptorchidism were untreated asthenozoospermia or azoospermic, Proportion of azoospermic in the patients was 13%, it did not relate to treatment. 1.6. Histopathology of cryptorchidism 1.6.1. Mechanism In male baby, the cryptorchidism patients has the number of gonocytes and spermatogonia lower than the others. It leads to decrease number of primary spermatocyte, caused non-fertilization later on.. The high temperature of cryptorchidism is strongly believed relating to mal-production of spermatocyte. Others cells which not participate in sperm production, might be affected, leading to change of shape and function. The Leydig cells seem stable in these condition. 1.6.2. The change of histopathology according to age The change of testis histopathology was positive relationship to age. From the second year, 38% of one or two testis cryptorchidism has not gonocytes. The histology change fits in the age, the older, the more fibrosis.
4 1.6.3. The malignancy of spermatogenesis cells The high temperature leads to abnormal development spermatogenesis cells, reaction of oxydation and temperature shock made to injury cells. 1.7. The complication of cryptorchidism 1.7.1. Infertility 126.96.36.199. Infertility caused by bilateral cryptorchidism + Untreated bilateral cryptorchidism: it is believed as a cause of infertility + Treated bilateral cryptorchidism before adulthood: according to Chung E, it was higher prevalence of infertility than unilateral cryptorchidism. + Treated bilateral cryptorchidism after adulthood: it was showed the mobility improvement in many researches. 188.8.131.52. Infertility caused by unilateral cryptorchidism Recently, some authors concern on the relation between infertility and reduce spermatogenesis in unilateral cryptorchidism after adolescence. 184.108.40.206. Infertility and time of operation The infertility could be prevented if the operation is performed before 18 months of age 1.7.2. Testis cancer 220.127.116.11. The characteristics of testis cancer The prevalence of testis cancer is 1% among male. In cryptorchidism, the risk could increase 5-10 times. In Green R, the prevalence could increase 35 times. The higher risk in case of abdominal testis, and lower risk with inguinal testis. 18.104.22.168. Testis cancer caused by cryptorchidism and time of operation The cancer risk is variety according to age. Recently, some studies shows the benefit of operation before adolescence. In term of prevention, some authors supposed to discectomy the abdominal testis. 1.7.3. Torsion testis The torsion in cryptorchidism is not common, however it happens more than normal one. 1.7.4. Inguinal herniation Cryptorchidism frequently accompanies with hydrocele, therefore inguinal herniation is a certain consequence
5 1.7.5. Psychological problem It happens from adolescence to adulthood. 1.8. Therapy of cryptorchidism 1.8.1. Hormonal therapy Luteinizing hormone releasing hormone (LHRH) and human chorionic gonadotropin (HCG) are available through so many years, however it could be discussed more about the outcome 1.8.2. Orchidopexy (open surgery) According to Urology Association, early intervention is necessary, especially from sixth to eighteenth month. 22.214.171.124. Firor technique It is archived by many stages. 126.96.36.199. Prentiss technique Isolation of testicular vessels from the peritonea could help to increase the length up to 12 cm, following Prentiss. 188.8.131.52. Jones technique Isolation of testicular vessels is performed by the peritoneal approach. 184.108.40.206. Bianchi and Squire technique Approaching from the scrotum, the midline in case of bilateral, and horizontal incision at the lowest point with unilateral is performed. 220.127.116.11. Kỹ thuật Walther-Ombredane In case of inguinal testis: Isolation each components of inguinal cord, tighten the hydrocele at the proximal 18.104.22.168. Fowler – Stephens - The research of Fowler and Stephen (FS): the blood supply for testis is ductus deferens artery, scrotum muscle, gubernaculum, therefore testicular artery could be dissected to pull down the testis. FS technique 1 stage: Clamp the testicular artery, assessment the supplies after some minutes, then dissection. FS technique 2 stages: Clamp but no dissection. After 3-6 months for correlation circulation, then dissection. 22.214.171.124. Itself testis graft Artery-Vein testis were cut nearly in root and connected to Arteryvein espigastria later-inferior. Bukowski T.P. showed that patient with two testes of cryptorchidism was high position, they have to at least one testis was vessel graft.
6 1.8.3. Techniques of orchidopexy by laparoscope Techniques were popularly applied to non-palpble testis cryptorchidism. 126.96.36.199. Orchidopexy by standard laparoscope techniques Techniques were used to abdomial testis cryptorchidism with longstem vessel to take testis down scrotum. 188.8.131.52. Laparoscope to ochidopexy by Fowler Stephens Laparoscope to ochidopexy with one or two stages by FS was applied similar to open-surgery for scretching testis vessels, taking testis down scortum. 184.108.40.206. Laparoscope to ochidopexy by robot Robot is used at laparoscope to ochidopexy is a new operation that is being continue in the present and future for its effectiveness. CHAPTER 2: SUBJECTS AND METHODS 2.1 The objects 112 adult-patients with cryptorchidism was operated (orchidopexy) in Center of Andrology and Department of Urology. Viet Duc Hospital in Hanoi from 2013 to 2014. 2.1.1. The selection criteria - Male adult on biology had ejaculation - These patients was operated (orchidopexy) to treat cryptorchidism - These patients was examined investigation for hormone and/ or semen test 2.1.2. Elimination criteria - These patients was operated to take down testis but unsuccess - These patients dropped out - These patients with two testes cryptorchidism only accepted one testis operation, or was operated another hospital but no information for the operation. - These patients with cryptorchidism was treated orchiectomy. - These patients with cryptorchidism had disorder of sex 2.2. Methodology It was cross-sectional, prospective study 2.2.1. Location of the study It was in Center of Andrology and Department of Urology. Viet Duc Hospital in Hanoi
7 2.2.2. Design of the study 220.127.116.11. Studying on characteristics of morphology, function, hispathology of cryptorchidism in male adult - Age of patient: divided age groups as following: <20 years old, 2029 years old, 30-39 years old and ≥40 years old. - Chief complaint - Medical history of sexual intercourse, marriage, parturition: to assess competence of reprodution in patient with cryptorchidism. - Asscessing development of constitution, discovering morbility specially the diseases were cause of cryptorchidism. - Examination: + The density of testis: soft, solid, , stiff + Location of testis: palpable or impalpable + Volume of cryptorchidism: being touching and defining volume of the other normal testis in scrotum (if it was unilateral cryptorchidism) by Prader orchidometer - Imaging diagnose: + Ultrasound: to assess location, volume of testis with cryptorchidism and the other normal testis in scrotum (if it was unilateral cryptorchidism) Volume of testis on ultrasound was calculated by Lambert formula: L x W x H x0,71 (L: Length, W: Width, H: Height). + CT Scanner: was applied for difficult diagnose or abnormal testis, groin, abdomen. - Investigation of male hormones: LH, FSH, testosterone test to study the change and reply of testis to hypophysis. Comparing LH, FSH, testosterone between bilateral cryptorchidism and unilateral cryptorchidism - Semen test: according to WHO-1999 - Antibody of sperm before operation: to appoint to cases with testis biopsy, noting characteristics of antibody of sperm in patients with cryptorchidism. - To assess location, size and density of testis in surgery. Comparing before and after the operation each patient. - Noting characteristics of epididymis - Assessing characteristics of testis vessels: tight vessel, non-tight vessel or vessel so short that take down it in scrotum.
8 - Another characteristics: general morbidity, combined injury in testis such as groin hernia, cyst of epididymis, cyst of spermatic cord. - Biopsy of testis to histopathology test: was carried out in operation by technical biopsy of Dohle G.R. Slitting a small line in testis about 0.5cm to take a piece with 3x3x3 mm diameter. - Assessing process of reproduction based on Dohle GR classification a - No seminiferous tubules (fibrosis of seed-sperm tube) b - No germ-cell in seminiferous (Sertoli cell only syndrome) c - Uncompleted spermatogenesis (maturation arrest) d - Full-stage of spermatogenesis including sperm, but hypospermatogenesis. e - Normal spermatogenesis. 18.104.22.168. Assessing results of orchiopexy - Time of following up the patients - Assessing clinical characteristics and investigations after one-year operation: + Location, volume, density of testis. Comparing the characteristics before and after operation. + Noting changes of hormone, sperm test. Comparing the characteristics before and after to define restoring of testis. - Re-test of antibody sperm Outcome of orchidopexy Verygood results: - Testis was entirely in scrotum, volume of testis after operation was similar to or bigger than its before operation. - Improving clearly to density of testis: azoospermic before operation but cryptospermia after operation. Cryptospermia before operation but oligozoospermia after operation. Oligozoospermia before operation, normozoospermia after operation. Good results: - Testis was entirely in scrotum, volume of testis after operation was similar to or bigger than its before operation. - Improving unclearly to density of testis or only improve of sperm movement - Improving clearly to hormones (increasing testosteron, decreasing LH and FSH)
9 Average results: - Testis was entirely in scrotum, volume of testis after operation was similar to or bigger than its before operation. - No improving to hormones. - No improving to spermiogram. Bad results: - Testis was led to high position or in scrotum but atrophy testis. - No improving or decline of hormones and spermiogram. 2.2.3. Operating techinique In the study openned-surgery technique with the peritoneal approach is performed. First stage: exposing testis and spermatic cord Secone stage: Liberating testicular vessels. Isolation of testicular superior vessels. Interior vessels of testis was isolated. Isolation of seed-fibrosiser. Merging these vessels to one vessel in scrotum Third stage: Fixed testis in scrotum by tehnique of Dartos’s bag 2.2.4. Statistical analysis - Registering information of patient, code of patient data in studying record - Data were entered using SPSS 22.0 - Algorithms: frequency, proportion, mean, mean-variance analysis. - The comparision is statistical significance whether p <0.05 2.2.5. Study ethic - The study was approved by ethic Council in Vietnam Military Medical University. - The study was accepted by board of managers, ethic Council Department of collecting and planning, Training center and Department of Urology in Viet Duc Hospital. - The study also ensured secret and voluntary to patient. CHAPTER 3: RESULTS 3.1. General characteristics There were 76 unilateral cryptorchidism patients and 36 bilateral cryptorchidism patients. Number of testicles in the thesis were 148 ones, in which 2 atropic testicles. Number of testicles were taken down 146 ones.
10 Graph 3.1: Distribution of aging group in patients with cryptorchidisms: Minimum age was 15 years old. Maximum age was 43 years old. Mean age was 25.69±5.7 years old. Graph 3.2: Chief complaint: No testis in scrotum was the best popular reason (63.4%), infertility reason accounted for 23.2%. Table 3.1: History of marriage and having baby: the proprotion of single and no information for having baby was 65.1%, the proprotion of over one-year-marriaged patient with no baby was 24.1%. Table 3.2: History of sexuality: The proportion of patient with normal sexuality was the hihgest (59.8%). The proprotion of erectile dysfunction was 14.3%. Graph 3.3. Unilateral or two bilateral cryptorchidism were respectively 67.9% and 32.1% Graph 3.4: Unilateral or bilateral cryptorchidism and chief complaint for infertility Unilateral cryptorchidism, chief complaint for infertility 11/76 BN (14.5%) Bilateral cryptorchidism, the proportion of being admitted hospital for infertility accounted for 15/36 patients (41.7%) Graph 3.5: Unilateral or bilateral cryptorchidism and erectile dysfunction - The proprotion of erectile dysfunction in bilateral accounted for 12/36 patients (33.3%). - The proprotion of erectile dysfunction in unilateral cryptorchidism accounted for 4/76 patients (5.3%) Table 3.3. Normal physical development in unilateral cryptorchidism were 73/76 patients (96.1%), in bilateral cryptorchidism were 24/36 patients (66.7%). Table 3.4: Morbidity in groin-scrotum: No disease accounted for 95/112 patients (84.8%), number of groin-hernia were 12/112 patients (10.7%) and cyst of epididymis were 5/112 patients (4.5%) 3.2. Characteristics of cryptorchidism morphology and function Graph 3.6: Palpable or impalpable undescended testes: 93/148 impalpable testes (62.8%), 55/148 palpable testes (37.2%). Table 3.5: Location of undescended testes by ultrasound Patients with testis in deep-groin hole were 37/148 testes (25%), Patients with testis in abdomen were 35/148 testes (23.6%), scrotum root were 4.1%, shallow-groin hole were 8.1%. No exploring of undescended testes accounted for 5/148 testes (3.4%)
11 Table 3.6: Location of undescended testes by CT Scanner CT Scanner was appointed for 83 patients (115 testes), undescended testes in high position in deep-groin hole and in abdomen accounted for 30.4% and 33.9%, respectively. Table 3.7: Location of undescended testes at operation In abdomen, undescended testes in high and low position accounted for 14.9% and 32.4% respectively, in deep-groin hole 18.9%. There were two testes having vestige. Table 3.8. Volume of Palpable undescended testes by Prader orchiometer: The proprotion of testis volume with 9-12ml, with 3-15ml and over 16ml was 27.3%, 67.3% and 5.4%, respectively. Table 3.9. Comparing mean volume of undescended testes in unilateral and bilateral cryptorchidism by ultrasound Volume of testis The right undescended testes /Unilateral The right undescended testes /Bilateral The left undescended testes /Unilateral The left undescended testes / Bilateral
Number of Mean±SD testis (cm3) 35 4.7+ 2.4 33 6.4 + 2.3 39 4.3+ 1.8 36 4.4 + 2.1
p 0.250 0.790
Table 3.10: Comparing mean volume of undescended testes in unilateral cryptorchidism and normal testis in the other scrotum Volume of testis The right undescended testes/Unilateral The left normal testis The left undescended testes/Unilateral The right normal testis
Number of testis
4.3 + 1.8
11.0 + 3.6
p < 0.001 < 0.001
Table 3.11: Volume of undescended testes in operation Number Mean±SD Volume of testis in operation of testis (cm3) The right undescended testes /Unilateral 36 5.1 + 2.1 The right undescended testes /Bilateral 34 4.5 + 2.3 The left undescended testes /Unilateral 40 4.2 + 1.7 The left undescended testes / Bilateral 36 4.6 + 2.0
p 0.669 0.414
12 Table 3.12. Palpable undescended testes: The proportion of soft density was 69.1%, of normal density was 29.1% Table 3.13: Density of testis in operation: There were two testes having vestige, 146 remain testes were assessed denssity in which the proportion of soft density accounted for the highest was 74.7%. Graph 3.7: Adhesion of epididymis and testis 47.3% normal, 45.9% part-adhension of epididymis and testis, 6.8% undefiend adhension of epididymis Graph 3.8: Characteristics of spermatic cord vessel after operation The proportion of stretchy vessels was 56.8%, of non-stretchy sperm vessels 41.1% There were 3/146 testes (2.1%) with stretchy sperm vessels so short that take down in scrotum. Table 3.14: Location of undescended testes and characteristics of spermatic cord vessel after operation Patient with stretchy vessel had always in undescended testes in abdomen, in which 3 testes with short sperm vessels to taking down in scrotum. Table 3.15. Testosterone and gonadotropin before operation Unilateral Bilateral cryptorchidism cryptorchidism Mean p (n=76) (n=36) Mean±SD Mean±SD LH (IU/l) 6.7±2.6 11.6±5.9 <0.001 FSH (IU/l) 8.8±6.9 22±13.7 <0.001 Testoterone (nmol/l) 17±5.9 14.5±7.3 0.049 Graph 3.9: Sperm concentration - Group of bilateral cryptorchidism: azoospermic 36/36 (100%) - 53 unilateral cryptorchidism patients were tested spermiogram: azoospermic 15.1%, cryptospermia 1.9%, oligozoospermia 15.1%, normozoospermia 36/53 patients (67.9%). Table 3.16: Spermiogram analysis in unilateral cryptorchidism Unilateral cryptorchidism Normal (n=44) proprotion by Spermiogram analysis WHO 1999 Mean±SD (Min-Max) Vitality (%) 49.7±12.8 (15-80) ≥75% Rapid progressive motility (A) (%) 14.3±10.4 (0-40) ≥25% Total of motility (A+B) (%) 37.3±12.8 (5-50) ≥50% Normal morphology (%) 37.8±17.8 (0-70) ≥ 30%
13 Table 3.17: Abnormality of spermiogram in unilateral cryptorchidism. 44 unilateral patients who have oligozoospermia and normozoosperm:Asthenozoospermia 72.7%, Teratozoospermia 27.3%. Table 3.18: There were 35 patients that were tested antibody of sperm. Mean of sperm antibody in two groups was normal. 3.3. Characteristics of cryptorchidism histopathology by biopsy in operation 46 undescended testes were biopsy during orchidopexy in which 20 palpable and 26 impalpable testes 3.3.1. The fibrosis of cryptorchidism Graph 3.10: The fibrosis of testis The proportion of non-fibrosis 0%, of part-fibrosis in seminiferous tubules was the highest (71.8%), of stiff-fibrosis in seminiferous tubules was 6.5%, of interstitial fibrosis was 21.7%. Table 3.19: The fibrosis and location of undescended testes before operation There was no significant difference between palpable and impalpable undescended testes group. The proportion of part-fibrosis in seminiferous tubules in two the groups, in which palpable undescended testes group was 70% (14/20 testes) and impalpable group was 73.1% (19/26 testes). Graph 3.11: Characteristics of spermatogenesis 23 testes
5 testes 0 testis
Sertoli cell only syndrome
Table 3.20: Spermatogenesis and location of undescended testes before operation
14 In impalpable undescended testes group, maturation arrest was the most popular accounted for 15/26 patients (57.7%). In palpable undescended testes group, hypospermatogenesis was the most popular 50% Table 3.21: The other changes of histology: one testis with calcification, 97.8% testes with no other changes of histology. 3.4. Results of taking down testis Average following-up time 14,3 ± 2,3 months (12 - 20 months). Table 3.22: Location of undescended testet after ochidopexy, reexamination: The proportion of testis in scrotum was 80.1%, of in scrotum root was 19.2%, of in shallow groin hole was 0.7%. Table 3.23: Comparing volume of testis by ultrasound before and after surgery Volume of testicle (cm3) The right undescended testes /Unilateral The left undescended testes/ Unilateral The right undescended testes / Bilateral The left undescended testes / Bilateral
Ultrasound before surgery Mean±SD 4.7 + 2.3 4.3 + 1.8 6.4+ 2.3 4.4 + 2.1
Table 3.24: Testosterone and gonadotropin after operation Unilateral Bilateral Mean hormone cryptorchidism cryptorchidism p (n=76) (n=36) LH (IU/l) 5.8±2.0 8.4±3.6 <0.001 FSH (IU/l) 7.2±5.3 15.6±9.8 <0.001 Testosteron (mmol/l) 18.8±4.9 16.2±5.8 0.149 Bảng 3.25: Testosterone and gonadotropin in patient with unilateral cryptorchidism Before surgery After surgery (n= 76) (n=76) Mean hormone p Mean±SD Mean±SD LH (IU/l)
15 Bảng 3.26: Testosterone and gonadotropin in patient with bilateral cryptorchidism Before After surgery surgery (n=36) Mean hormone p (n=36) Mean±SD
Graph 3.12. Sperm concentrate after operation Unilateral cryptorchidism group: azoospermic 0%, 4/53 patients (7.5%) with cryptospermia, 13/53 patients with oligozoospermia (24.6%), 36/53 patients with normozoospermia (67.9%) Bilateral cryptorchidism group: azoospermic 32/36 patients (88.9%), the proportion of cryptospermia was 11.1%. Table 3.27. Spermiogram analysis in unilateral cryptorchidism after operaion Before After Spermiogram analysis operation operation p (n = 44) Mean±SD Mean±SD Vitality (%) 49.7±12.8 50.8±12.5 <0.001 Rapid progressive motility (A) (%) 14.3±10.4 16.9±9.5 <0.001 Total of motility (A+B) (%) 37.3±12.8 40.9±11.9 <0.001 Normal morphology (%) 37.8±17.8 43.5±16.8 <0.001 Table 3.28: Abnormality of spermiogram in unilateral cryptorchidism after operation: 49 patients with normozoospermia or oligozoospermia, 69.4% patients with motility sperm was lower than WHO criteria, 26.5% patients with unormalized morphology of sperm was higher than WHO criteria. Table 3.29: Having baby after operation: 02 patients with having baby after operation. Table 3.30: Antibody of sperm after operation: increasing lightly but it belonged to normal range. The difference was unsignificant.
16 Table 3.31: The success of operation Operation outcome Very Good Good Average Bad Total
CHAPTER 4: DISCUSSIONS 4.1. The general characteristics Graph 3.1: The highest prevalence is in 20-29 years old (56,3%). This is the age that begins to be aware of the risks of undescended testes when preparing or getting married. Graph 3.2: Chief complaint: infertility reason of the adult cryptorchidism patient accounted for 23.2%. Table 3.1: 24.1% of cryptorchidism patients married for more than 1 year without children Table 3.2: There was no relationship between the erectile dysfunction and cryptorchidism. Only 14,3% patients with erectile dysfunction problem. Graph 3.3: 67,9% unilateral, 32,1% bilateral cryptorchidism affected. Le Minh Trac, in National hospital of Gynecology, 18,6% with bilateral cryptorchidism. Ho Minh Nguyet et al. bilateral cryptorchidism affected in 28,2% patients in Pediatric Hospital. Graph 3.4: The rate of infertility in the bilateral cryptorchidism group is 41.7%, in the unilateral cryptorchidism group is 14.5%. This result is consistent with many studies at home and abroad, the bilateral cryptorchidism will lead to infertility and have recently paid more attention to infertility in the unilateral cryptorchidism. Graph 3.5: The study found that the rate of normal sex was 67.1% in unilateral and 43.4% in bilateral cryptorchidism group. This result is consistent with many domestic and foreign studies that do not suggest that complications of cryptorchidism are erectile dysfunction.
17 Table 3.3: Normal physical development was 96,1% (unilateral cryptorchidism), 66,7% (bilateral cryptorchidism). This result fits in Thai Minh Sam research. Table 3.4: Comorbidities : inguinal herniation 10,7%; cyst of epididymis 4,5%. According to Le Minh Trac, 26,7% patients with other malformation, cordless cysts (19,1%) and inguinal herniation (2,7%). 4.2. Characteristics of cryptorchidism morphology and function 4.2.1. Location Graph 3.6: The proportion of palpable undescended testes was 37,2%, non-palpable was 62,8%. In other studies the proportion of nonpalpable was 20%. Table 3.5: Undetectable of 5 testes (3,4%) in ultrasound. The American Urology association, the ultrasound had the low specificity and sensitivity in term of diagnosis of non-palpable undescended testes. The difference could be explained by the clear anatomy of adult patients, and the more large volume of testis. The prevalence of testis in abdominal and inguinal was 23,6% and 25%. This results are different with Le Minh Trac study, non-palpable testis was 37,7%,and the authors conclude generally that most of the testicles are palpable Table 3.6: CT scanner showed the same result in comparison with ultrasound: The prevalence of abdominal testis was 33,9%; in the inguinal was 30,4%. According to Tasian G.E., CT scanner had no role in term of diagnosis. Table 3.7: In comparison with ultrasound, the prevalence of abdominal testis was higher in operation, According to us, some deep groin testicles have moved into the abdomen. 4.2.2. The volume of undescended testes Table 3.8: Prader orchidometer: the volume of affected testes was only in the adolescence (size 9-12, 27,3%, size 13-15, 67,3%). Testis volume reflects the spermatogenesis. Small testis represents the restriction in spermatogenesis. Table 3.9: Ultrasound measurement, in bilateral undescended testes affected, the average volume of right testes was 6,4 + 2,3 cm3; the left 4,4 + 2,1cm3. In unilateral undescended testes affected, the right volume 4,7±2,4cm3, the left volume 4,3+ 1,8cm3 . In comparison with the
18 average volume between unilateral and bilateral cryptorchidism , the difference was non significant statistical. Table 3.10: Ultrasound measurement, the comparison of unilateral undescended testis and normal testis (in scrotum) showed the smaller volume in affected undescended testis (p<0,001). This also fits in many studies which concentrate in histologic change and infertility in unilateral cryptorchidism patient. Table 3.11: Testis measurement during orchiopexy, the volume of undescended testis was characterized in ultrasound: unilateral affected: right 5,1 + 2,1 cm3, left 4,2 + 1,7 cm3; bilateral affected: right 4,5 + 2,3 cm3, left 4,6 + 2,0 cm3. 4.2.3. The density of undescended testes Table 3.12: Palpable testis density: soft (69,1%), normal (29,1%). According to many literatures, the soft testis signifies the mal-function testis, because the take seminiferous tubules part in 70-80 % testis. Table 3.13: The density of undescended testis in operation: soft 74,7%. This result differed than the Le Minh Trac study, in infants (1-2 years old): 92% normal density, 5% soft and fibrosis. It was supposed that delay treatment lead to size down the testis. 4.2.4. The characteristics of epididymis in operation Graph 3.7: 67 testes (45,9%) had epididymis with semilunar shape. The normal connection of epididymis in Le Minh Trac study was 95,7%, the higher undescended testis was, the more abnormal exist. 4.2.5. The characteristics of testicular vessels Graph 3.8: The stressed of testicular vessels was 56,8%, there were 2,1% testes only pulled down into proximal scrotum. It was caused by the high of undescended testis, it was characterized with testis in adulthood. There were difference with Thai Minh Sam study, the object was older and not count on the age, hence 95,8% wasn’t tender, 4,2% slight tender. Table 3.14: Almost stressed testicular vessels were high undescended testes 4.2.6. Male hormone before operation Table 3.15 There was a decrease of testosterone in bilateral cryptorchidism affected than unilateral group affected (14,5±7,3 mmol/l, 17±5,9 mmol, respectively, p = 0,049). Thai Minh Sam also showed the same result.
19 According to many researched, LH and FSH in the unilateral affected group was rarely changed. In contrast with bilateral affected, even if testosterone changes or not. In unilateral affected group, LH concentration was 6,7±2,6 IU/l (normal range), meanwhile FSH was 8,8±6,9 IU/l. In bilateral affected group, LH, FSH concentration increased (11,6±5,9 IU/l and 22±13,7 IU/l) meanwhile testosteron was normal (14,5±7,3 mmol/l). 4.2.7. The semen analysis test before operation Graph 3.9: 36 patients with bilateral cryptorchidism affected was azoospermic (100%), this results fits in many researches. Chilvers showed that non treatment with bilateral cryptorchidism could lead to azoospermic 75%, oligozoospermia 25%. Lains-Mota R., 83% to 98% of same group could azoospermic without treatment. In unilateral cryptorchidism affected group, 15,1% (8/53) was azoospermic. 67,9% (36/53) had normozoospermia. Chilvers showed 44% patients with unilateral undescended testes affected could lead to azoospermic or oligozoospermia. Table 3.16: In unilateral cryptorchidism, the mobility of sperm significantly decreased. The average rapid mobility was 14,3±10,4 %. The total of mobility (A+B) was 37,3±12,8 %. Table 3.17: Analyzing the result from 44 patients with normal sperm concentrate or oligozoospermia, 72,7% weak mobility, and 27,3% mal-formation sperm. . Scott L.S. showed, 21% completely azoospermic, 23% weak mobility and malformation of sperm shape. 4.2.8. The antibody of sperm Table 3.18: Normal range of antibody was shown in both unilateral and bilateral cryptorchidism affected group, only one patient was recorded with high concentration (120 mol/l). Kurpisz M. was supposed that the high concentration of antibody was a incidence for cryptorchidism without early treatment.. 4.3. The characteristics of undescended testes histology 4.3.1. The fibrosis Graph 3.10: None of testes signed fibrosis, the partial fibrosis seminiferous only in 71,8% testes. Stiff-fibrosis in seminiferous tubules 6,5% without spermatocyte. This results fits with Ho Minh Nguyet et al.: the histologic changes increase according aging. Hadziselimovic F. showed that fibrosis around ductus deferens could appeared in 2rd.
20 Table 3.19: 46 undescended testes were biopsy during operation in which 20 testes were palpable and 26 impalpable testes. According to Ho Minh Nguyet et al. showed that the histologic changes of undescended testis had no realtionship to location of testis. 4.3.2. The spermatogenesis of undescended testes Graph 3.11: The syndrome which only Sertoli cell, non spermatic cell in seminiferous tubules 10,9% had the optimist prediction after operation. Chung E. concluded that non spermatocyte at the operation point was important prediction of infertility. Maturation arrest was 50% testes in study. These patients could have a good outcome if early operation. The same outcome also happens in the group full of spermatogenesis stage, but lower spermatocyte count (39,1%). Table 3.20: The abnormal spermatogenesis happens same in both low and high undescended testis group. This could be a characteristic of undescended testis in adult, the change of histology appears no change in the position of testis. Therefore, the result of this study showed the difference that the different age leads to different the number of ductus deferens and primary spermatocyte. 4.3.3. The histologic change of cryptorchidism testis Table 3.21: One testis with calcification, no testis with malignancy change. 4.4. Assessing results of orchiopexy 4.4.1. Time of observation: Average 14,3±2,3 months (12 - 20 months). 4.4.2. The location of undescended testes after ochidopexy Table 3.22: The prevalence of testes in scrotum was 80,1%, 19,2% in the proximal of scrotum. In the study of Le Minh Trac, after 3 months after surgery, the testes were completely in the scrotum, 88.1%, higher because the group of patients had low age, before surgery was treated hormones, distance from testicles to scrotum. short. Vries A.M. evaluates 137 testicles for surgery to lower the testicles before puberty. 99.3% of testicles are lowered when the examination is again in the scrotum. In our opinion, this is a group of patients with late surgery in adulthood, a high incidence of stealth testicles, low cases often have short vascular stubs, stretched vessels. 4.4.3. The volume of undescended testes after orchidopexy
21 Table 3.23: The average volume of undescended testes on the right in the unilateral group is 5.1 + 2.1, compared with the preoperative rate, the growth rate is 1.08; on the left is 4,3 + 1,7 with a growth rate of 1.0. In the bilateral undescended testes group after surgery, the right testicular volume decreased slightly to 4.4 + 2.1cm3 compared to before surgery 6,4+ 2,3cm3 growth rate of 0.68; on the left is 4.5 ± 1.7cm3 with a growth rate of 1.02 compared to before surgery. According to Tseng C.S., when studying in the group of children aged 0-18 years, the volume of undescended testis is always smaller than normal testicles in scrotum in all research groups and in the years 1-5 years, there is a tendency to increase slowly volume. . After 2.5 years after surgery, there is a tendency to increase the volume compared to before surgery, but it is still smaller than the normal testicle in the scrotum. The growth rate of the unilateral is 1,780 and 1,049 on bilateral, and the total of two groups is 1,492. The growth rate of the normal testicular group (in the case of unilateral cryptorchidism) is 1,445. The result of testicular volume growth in this study is inferior to the above author because this is a group of patients in adulthood, a lot of undescended testis high, short vessel, risk of nourishing testicles After surgery, the failure of shrinking testicles after surgery is also a success. 4.4.4. Male hormones after orchidopexy Table 3.24: There are differences between the two groups of unilateral and bilateral cryptorchidism patients of the three hormonal indicators. The average LH, FSH in the bilateral groups were higher (LH: 8.4 ± 3.6 IU / l and 5.8 ± 2.0 IU / l, p <0.001; FSH: 15.6 ± 9.8 IU / l and 7.2 ± 5.3 IU / l, p <0.001). While the difference in testosterone in both groups was not statistically significant, although tetosteron in the bilateral group was still lower, this result was consistent with Lee P.A.’s research, the author also concluded in conclusion, postoperative elevated levels of LH and FSH indicate that the testicular function is still more severely impaired in the bilateral cryptorchidism Table 3.25: In unilateral affected group, LH and FSH pre and post operation was in decrease trend p<0,001. Similarly, the testosterone concentration could be increase (p=0,402). Table 3.26: The good outcome of gonadotropins pre and post operation, in term of FSH increase means the serious damage of
22 seminiferous tubules in comparison with unilateral affected. It also appeared in Chiba K. study. 4.4.5. The semen analysis test after operation Graph 3.12: Bilateral cryptorchidism: before surgery there were 36/36 patients (100%) azospermic, after surgery 32/36 (88.9%). However, it is worth noting that in some patients appear very little, scattered sperm on the field (4/36 patients, 11.1%), with current artificial insemination techniques, hope to have children for patients. This result is consistent with most of the researchs that show that the bilateral cryptorchidism are not treated, which is synonymous with adult infertility. Unilateral cryptorchidism, before surgery there were 15.1% azoospermic, 1.9% spermatozoa were very low, 67.9% patients had normal sperm density. After surgery, there were only 67.9% of patients with normal density, but the group of azzospermic patients before resurgery to test had sperm at the level of disability (24.6%) and very little (7.5%). This shows that unilateral cryptorchidism in adults although there is a low rate of azospermic, but after orchidopexy, the improvement of spermatogenesis is higher than the bilateral group. This result is consistent with the Virtanen H.E. study. Table 3.27: Comparing 44 cases with pre-operative and postoperative semen analysis, there was a significant, statistically significant improvement in sperm motility, and a fast motile sperm ratio (A) was 16.9 ± 9.5% compared to before surgery 14.3 ± 10.4%. Total mobility (A + B) was 40.9 ± 11.9% compared to 37.3 ± 12.8% before surgery. Unilateral or bilateral cryptorchidism and the timing of the surgery affects the mobility of spermatozoa reported in Lenzi A.'s research. Table 3.28: Even if the progression of spermatozoa mobility, after surgery, 34/49 (69,4%) patients have the lower mobility of spermatocyte than WHO standard. It also fits in Kraft K.H. et al. study. Table 3.29: Because of short time observation, 59,8% patients had not got married. At the re-examination 2/112 patients had babies. 4.4.6. Antibody of spermatocyte post operation Table 3.30: There was a slight increase in antibodies to sperm after surgery in patients with testicular biopsy, no statistically significant comparison (p> 0.05). This result is consistent with Patel