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A collective review of
cases with cryptorchidism managed
in a teaching hospital in
Sudan
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Awad Ali M. Alawad*, Walaa Amin Hussain, Faisal H.
Younis
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Department of Surgery, Faculty of Medicine,
University of Medical Sciences and Technology, Sudan
*Corresponding author E-mail:awadali82@hotmail.com
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Abstract
Background: Cryptorchidism is one of the most common urogenital
abnormalities in male children. Delayed diagnosis and treatment of
cryptorchidism lead to complications such as infertility, malignancy and testis
torsion.
Objective: To determine the cause
of delayed presentation, complications recorded, the surgical treatment offered
in a developing country.
Methods:A retrospective review of patients’ records from
December 2012 to December 2014 was carried out. Sixty one patients presented to
the University Charity Teaching Hospital during this period.
Results: Sixty one patients were included in the study. Age
ranged from 1-75 years with mean at surgery is 11 years. Twenty seven patients
(44%) presented after 24 months, 3 (4.9%) less than 12 months, and 23 (37.3%)
less than 1 month. Age at operation, 7 (13%) were £
2years, 15 (28%) were 2-5years, 39 (59%) were > 5 years.Fifty four (88.5%)
patients have undergone orchidopexy, 3(4.9%) orchidectomies, 1 (1.6%) biopsy, 1
(1.6%) exploratory laparotomy, and in 2 (3.3%) cases operation wasn’t done.
Conclusion:Late
presentation observed in this study is alarming and action should be taken by
spreading awareness in the community and ensuring adequate neonatal and
children examination in order to avoid the complications.
Keywords: Undescended
Testis; Urogenital Abnormalities; Delayed Diagnosis.
1. Introduction
The word cryptorchidism is obtained from the Greek word
“Kryptos” meaning “hidden" and “orchid'” meaning “testicles" (Khatwa & Menon 2000). It is one of the most common
urogenital abnormalities in newborn boys and very variable figures on its incidence
have been described in different type of studies. Several studies have
described risk factors such as low birth weight, being born as small for
gestational age, and preterm delivery as concerning newborns (Esposito et al. 2008, Khatwa & Menon 2000, Rubenwolf & Stein 2013).
The management of undescended testis (UDT) in children
poses a serious challenge to the urologist, in terms of management, which
depends on how early the patient present. Regardless of age; UDT represents a
true problem in Africa as it and its management is challenged by older
presentations, due to economic issue, illiteracy, or negligence, lack of
laparoscopic equipment and skills, few specialized pediatric centers, and
difficult follow-up. Given its high incidence and the few African researches,
particularly in Sudan where there is nothing available in the literature about
undescended testes, are reasons necessitating this study? The aim of this
research is to determine the cause of delayed
presentation; complications recorded, the surgical treatment offered in a developing
country.
2. Methods
A cross-sectional
descriptive study was conducted from December 2012 to December 2014 at
University Charity Teaching Hospital, affiliated to University of Medical
Sciences and Technology (UMST), Khartoum, Sudan.
All patients of undescended
testes who presented at this period were included in the study. Primary data
was collected through a questionnaire from medical records. The collected data
were computerized and statistically analyzed using SPSS (Statistical Package
for Social Science) version 19. Descriptive statistics were used to quantify
the categorical variables. Chi square was calculated to compare between gender
role in specialties and factors affecting specialty choices. P value (<
0.05) was considered significant difference. The ethical approval for this
study was obtained from the ethical committee at UMST. An informed consent was
obtained from the patients.
3. Results
Total number of patients was
61. Age ranged from 1-75 years with mean at surgery is 11 years. Regarding the
side of undescended testes; 28 (45.9%) were right, 21 (34.4%) were left, and 12
(19.7%) cases had bilateral UDT. There was an obvious variation in the
presentation where 27 (44%) cases presented after 24 months, 3 (4.9%) cases
less than 12 months, and 23 (37.3%) cases less than 1 month. In forty eight
(78.7%) of patients, the condition was noticed by their parents, 11 (18%) by
the patient himself, school camp and patients brother in individual cases
representing (1.6%) each. Table 1 showed the clinical presentation of the patients.
Regarding the management of
these patients, orchidopexy was the treatment of choice. Fifty four (88.5%)
patients have undergone orchidopexy for either unilateral or bilateral UDT,
3(4.9%) orchidectomies, 1 (1.6%) biopsy, 1 (1.6%) exploratory laparotomy, and
in 2 (3.3%) cases operation wasn’t done due to low haemoglobin (Tab 2). Of
these patients only 7 (13%) were£ 2yr, 15 (28%) were £
5yr, while 32 (59%) were > 5 yrs. Age ranged from 1-75 years with mean age
at surgery 11 to 12 years. Site of the testes as recorded intra-operatively 44
(72.1%) inguinal canal, 6 (9.8%) intra-abdominal, 3 (4.9%) not found, 1 (1.6%)
at external ring, 1(1.6%) peritoneal cavity, 1 (1.6%) under deep ring, and 5
(8.2%) not reported (Fig 1).
The size of the operated
testis could not be determined in 58 (95.1%) due to lack of data and 3 (4.9%)
were of normal size as found by ultrasonography. Complications mainly took the
form of 15 inguinal hernias, 3 hydrocele, 2 testicular torsion, and 2 testicular
tumors. Five associated anomalies were found in our patients 2 (3.3%) phimosis,
1(1.6%) meatal stenosis, 1(1.6%) hypospadias, 1(1.6%) micropenis. No records
about post operational growth or any follow-up were available.
4. Discussion
Undescended testis is a
condition of great concern to paediatric surgeons and urologists owing to the
risk of impaired spermatogenesis and consequent infertility later in life. The
risk of testicular cancer may be higher in these patients as noted by one
report in which ten per cent of patients with testicular cancer gave a history
of cryptorchidism(Shalaby 2012) even though there appears to be no conclusive proof
that correction of cryptorchidism protects against cancer, but renders the test
is easily accessible.
We noticed that 45.9% of
cases were right sided. This right side dominance came in consensus with most
of the studies reviewed except for one held at Nigeria by David et al. stating
that the left side was more affected with 34 (47.9%) involved in unilateral
cases than right side 22 (31.0%) (David & Iyekoretin 2008), which is
contrary to expectation as the left testis is usually lower than the right.
In this study, the condition
was noticed by the parents in 48 case (78.7%), more than that in study done by
Gasana et al. in Tanzania were only in 13 cases (43.3%) the condition was
discovered by the parent (Osifo & Osaigbovo 2009) which is quite
promising taking in account the level of parental education obtained by questionnaire
where 5/10 mothers attained high level education and only 3/10 fathers achieved
this level. In 11 cases (18%), UDT was discovered by the patient himself,
school camp and patients siblingin individual cases representing (1.6%) each,
compared to 9 (30%) cases noticed by the patient, and by health care staff in
eight cases (26.7%) in Tanzania (Mlay & Sayi 1994).
In this
study, the site of the UDT was inguinal in 72%. The UDT was atrophic in 26.7%
of cases overall. A study from Dar- Salaam reported that 80% of UDT were
inguinal and 29.8% were atrophied (Mlay & Sayi 1994). A study from Nigeria reported testicular atrophy in 28% of
patients with UDT (Adeoti et al. 2004). In contrast, another study from Nigeria found atrophy in
60.7% of UDT in adults, confirming the well-known fact that testicular atrophy
is associated with delayed surgery (David & Iyekoretin 2008). In this study, 16 patients (53.3%) had associated malformations,
of them 13 (43.3% of the total group of 30) had associated hernia sacs. In a
study from Nigeria associated hernia sacs were found in 52% (Sowande et al. 2015).
To avoid the risk of
testicular atrophy and infertility, it is now widely agreed that orchidopexy be
performed at age < 2 years (Ali et al. 2014). In
the present study, 13% of patients had orchidopexy before two years of age, but
60% had surgery after five years, by which time significant morphological
changes would have occurred in the testis. A study in Nigeria found that 11% of
patients with UDT had orchidopexy before two years, 42% before five years and
58% after five years of age (David & Iyekoretin 2008). A study from Tanzania reported that 50% of patients
presented for orchidopexy after five years of age. Another study from Nigeria
reported correction of UDT in 52.2% of patients after five years and in 26.9%
who presented as adults (Adeoti et al. 2004). A recent study from Ireland reported that only 29% of
patients with UDT proceeded to surgery before two years, and the mean age at
orchidopexy was 5.6 years (Sowande et al. 2015). In contrast, a study from the USA reported that the median
age at consultation and surgery was 20.3 and 28.9 months, respectively (Mlay & Sayi 1994). In our environment,
the current median age at surgery is 11 years; the reasons for this delay
include, late presentation, ignorance of initial attending doctors regarding
age at optimal treatment and lack of recognition by midwives. To improve on the
age at surgery, it is necessary to educate parents, midwives and doctors as suggested
before.
Orchidopexy represents the
gold standard treatment for UDT. Advances in laparoscopic surgery have led to
laparoscopy being used by most pediatric surgeons as both a diagnostic and
therapeutic tool. In our setting, laparoscopy is not available. In this study,
orchidopexy was the only mode of treatment available where 54( 88.5%) patient
have undergone orchidopexy for either unilateral or bilateral UDT,3(4.9%)
orchidectomies,1 (1.6%) biopsy, 1 (1.6%) exploratory laparotomy,and in 2 (3.3%)
cases operation was not done due to low haemoglobin.
5. Conclusion
The late presentation detected in this
study is alarming, because the majority of patients were diagnosed and treated
after two years of age.Health-care workers should perform neonatal examination
to detect UDT and inform parents that early correction of UDT will decrease the
risk of infertility and facilitate future examination to detect the development
of testicular malignancy.
References
[1] Adeoti ML, Fadiora SO, Oguntola
AS, Aderounmu AO, Laosebikan DA & Adejumobi OO (2004): Cryptorchidism in a
local population in Nigeria. West Afr J Med 23, 62-64. http://dx.doi.org/10.4314/wajm.v23i1.28085.
[2] Ali HAM, Alawad A, Ali AS &
Abdalla AAE (2014): Pattern of developmental sex disorders in a tertiary
hospital in Sudan. International Journal of Medicine 2, 53-55. http://dx.doi.org/10.14419/ijm.v2i2.2957.
[3] David OO & Iyekoretin E
(2008): Undescended testes in a developing country: a study of the management
of 71 patients. Afr J Paediatr Surg 5, 11-14. http://dx.doi.org/10.4103/0189-6725.41629.
[4] Esposito C, Caldamone AA, Settimi
A & El-Ghoneimi A (2008): Management of boys with nonpalpable undescended
testis. Nat Clin Pract Urol 5, 252-260. http://dx.doi.org/10.1038/ncpuro1102.
[5] Khatwa UA & Menon PS (2000):
Management of undescended testis. Indian J Pediatr 67, 449-454. http://dx.doi.org/10.1007/BF02859466.
[6] Mlay SM & Sayi EN (1994):
Undescended testis in paediatric patients at Muhimbili Medical Centre, Dar es
Salaam. East Afr Med J 71, 135-137.
[7] Osifo DO & Osaigbovo EO
(2009): The prevalence, postnatal descent, and complications of undescended
testes among children who underwent neonatal circumcision in Benin City,
Nigeria. J Pediatr Surg 44, 791-796. http://dx.doi.org/10.1016/j.jpedsurg.2008.06.009.
[8] Rubenwolf P & Stein R (2013):
[Diagnosis and management of the undescended testis--an update in the light of
the current guidelines]. Aktuelle Urol 44, 445-451. http://dx.doi.org/10.1055/s-0033-1358664.
[9] Shalaby MM (2012): Is there a role
for open surgery in the management of the undescended testis? Afr J Paediatr
Surg 9, 97. http://dx.doi.org/10.4103/0189-6725.99390.
[10]
Sowande
OA, Talabi AO, Etonyeaku AC & Adejuyigbe O (2015): Groin exploration for
the nonpalpable testes: a single center experience. Niger J Surg 21,
56-59. http://dx.doi.org/10.4103/1117-6806.153195.
