Nghiên cứu hình thái, chức năng, mô bệnh học và kết quả phẫu thuật điều trị tinh hoàn ẩn tt tiếng anh

MINISTRY OF

MINISTRY OF DEFENCE

EDUCATION AND TRAINING
VIETNAM MILITARY MEDICAL UNIVERSITY
=======

NGUYỄN MẠNH THẮNG

THE STUDY ON MORPHOLOGY, FUNCTION,
HISTOPATHOLOGY AND SURGERY RESULTS OF
CRYPTORCHIDISM

Speciality

: Surgery

Code

: 9720104

ABSTRACT OF THE THESIS FOR MEDICAL DOCTOR

HA NOI - 2019


THE THESIS WAS COMPLETED
IN VIETNAM MILITARY MEDICAL UNIVERSITY

Scientific Supervisors:

1. Prof.PhD. Trần Quán Anh
2. Assisstant Prof.PhD. Nguyễn Quang

The first Reviewer:

The second Reviewer:

The third Reviewer:

The Thesis approved by Council of scientist in Vietnam Military
Medical University.
At

On

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.

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
1.7.1.1. 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.
1.7.1.2. Infertility caused by unilateral cryptorchidism
Recently, some authors concern on the relation between infertility
and reduce spermatogenesis in unilateral cryptorchidism after
adolescence.
1.7.1.3. 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
1.7.2.1. 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.
1.7.2.2. 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.
1.8.2.1. Firor technique
It is archived by many stages.
1.8.2.2. Prentiss technique
Isolation of testicular vessels from the peritonea could help to
increase the length up to 12 cm, following Prentiss.
1.8.2.3. Jones technique

Isolation of testicular vessels is performed by the peritoneal
approach.
1.8.2.4. 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.
1.8.2.5. Kỹ thuật Walther-Ombredane
In case of inguinal testis: Isolation each components of inguinal
cord, tighten the hydrocele at the proximal
1.8.2.6. 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.
1.8.2.7. 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.
1.8.3.1. Orchidopexy by standard laparoscope techniques
Techniques were used to abdomial testis cryptorchidism with longstem vessel to take testis down scrotum.
1.8.3.2. 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.
1.8.3.3. 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
2.2.2.1. 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.
2.2.2.2. 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

Mean±SD
(cm3)

35

4.7+ 2.4

36

11.4+ 3.0

39

4.3 + 1.8

40

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

Testis

18 testes

5 testes
0 testis

No
seminiferous

Sertoli

cell only
syndrome

maturation
arrest

hypospermatogenesis

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

Ultrasound Increasing
after surgery proportion
(%)
Mean±SD
5.1 + 2.1
1.08
4.3 + 1.7
1.00
4.4 + 2.1
0.68
4.5 + 1.7
1.02

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)

6.7±2.6

5.8±2.0

<0.001

FSH (IU/l)

8.8±6.9

7.2±5.3

<0.001

Testosteron (mmol/l)

17.0±5.9

18.8±4.9

0.402


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

Mean±SD

LH (IU/l)

11.6±6.0

8.4±3.6

<0.001

FSH (IU/l)

22.0±13.7

15.6±9.8

<0.001

Testosteron (mmol/l)

14.5±7.3

16.2±5.8

<0.001

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

Unilateral
cryptorchidism
n
%
8
15.1
30
56.6
15
28.3
0
0
53
100

Bilateral
cryptorchidism
n
%
4
11.1
7

19.4
24
66.7
1
2.8
36
100

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