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

Zusammenfassung

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

Abstract

Cryptorchidism, or undescended testis (UDT), occurs in 1–3% of male term infant births. At least two-thirds of UDTs will descend spontaneously, typically during the first 6 months of life. UDTs are associated with loss of spermatogenic potential and testicular malignancy in the long term. Orchiopexy performed prior to puberty may significantly reduce the malignant potential by up to 4-fold. Neoadjuvant hormonal therapy starting at 6 months of life has been shown to potentially improve the testicle’s fertility index and should be part of the therapeutic concept. However, the use of hormonal treatment and HCG beyond the first year of life is to be challenged given a potentially negative impact on testicular function. Laparoscopic exploration and therapy is the method of choice for non-palpable testes. Ideally, surgical repair of the UDT should be completed by the age of 1 year.

Schlüsselwörter

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

Key words

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

• Literatur

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