Testicular Atrophy Risk after Orchidopexy Surgery in Children with Cryptorchidism in Isfahan Hospitals

Testicular Atrophy Risk after Orchidopexy Surgery in Children with Cryptorchidism in Isfahan Hospitals | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Testicular Atrophy Risk after Orchidopexy Surgery in Children with Cryptorchidism in Isfahan Hospitals Mehrdad Hosseinpour, Ali Zahed, Kimia Mirjalali This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4546212/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: This study was conducted to investigate testicular atrophy risk after orchidopexy surgery in children with Cryptorchidism. Method: "This prospective cross-sectional study , included 80 patients from Imam Hussein and Al-Zahra hospital in Isfahan. Children with endocrine disorders or retractable testes were excluded. Testicular measurements were taken before and 6 months after surgery using Lambert's criteria. The significance level was set at p ≤ 0.05. Results: A total of 70 children, with a mean age of 26.1 ± 67.1 months, participated in this study and were examined. A prevalence of 21.4% for testicular atrophy was reported. A statistically significant association was found between the variables of testicular torsion, initial inguinal testis position, and laparoscopic surgical method with the occurrence of atrophy. Logistic regression analysis revealed that testicular torsion prior to surgery, initial abdominal testicular position, and laparoscopic surgery increased the risk of testicular atrophy six months post-operatively. Conclusion: This study revealed that testicular torsion, laparoscopic surgery, and abdominal positioning of the initial testis were significantly associated with increased rates of atrophy. No significant correlation was found between atrophy and age. We recommend conducting future orchidopexy studies with larger sample sizes and conducting longer-term follow-up examinations to further elucidate these findings. Cryptorchidism testicular atrophy orchidopexy retractable testes Introduction Cryptorchidism, also known as undescended testis (UDT), is one of the most common congenital anomalies in male infants, affecting 1-4.6% of term infants and 1.1-45% of preterm infants (1). Cryptorchidism refers to the failure of the testis to descend permanently to its final position in the scrotum (2). Undescended testis is associated with an increased risk of testicular cancer, mortality, and infertility (3). Bilateral undescended testis leads to severe impairment of spermatogenesis, and if left untreated, it can result in infertility in adulthood. Orchidopexy for bilateral cryptorchidism improves the level of normal sperm. Findings suggest that the best outcome in terms of testicular growth after orchidopexy appears to be achieved when performed within the first two years of a child's life (4). Hormonal treatment for UDT is not recommended due to its low success rate (20%) (5). The globally accepted treatment for the aforementioned condition is orchidopexy, as stated in the guidelines of the European Association of Urology (EAU) and the American Urological Association (AUA), which recommend performing the surgery before 18 months of age (3). Nowadays, orchidopexy is the fourth most common general surgical procedure in children, following appendectomy, circumcision, and hernia repair (6). The most important aspect of this surgical procedure for true undescended testis is achieving the placement of a normal testis inside the scrotum (7). The first successful orchidopexy was reported by Thomas Annandale in Edinburgh in 1877. The technique reported by Bevan in 1899 involved four key principles: testicular mobilization, closure of the vaginal process, division of adhesions to the spermatic cord, and repositioning and fixation of the testis within the scrotum, which are the main components of orchidopexy (8). Orchidopexy is the standard intervention for undescended testes (UDTs) and is recommended to be performed at the age of 6-12 months or within the first 18 months of a child's life. Initial orchidopexy also reduces the risk of testicular cancer, preserves fertility, and improves testicular growth. Despite the benefits of orchidopexy, complications such as recurrence, hematoma of the scrotum, wound infection, and vascular injury, although relatively uncommon, are possible. Testicular atrophy (TA) is a serious complication that can occur during orchidopexy (9). Testicular atrophy refers to the partial or complete loss of spermatids from the lumen of the seminiferous tubules (10). In a study conducted in Toronto, Canada, in 2013, 1,400 undescended testes underwent orchidopexy, and testicular atrophy was reported in 111 cases (8%). Most of the cases were related to the right testis. Sixty-six cases (59%) resulted in atrophy due to the surgery, and 45 cases (41%) were found to have already undergone atrophy (11). In another study conducted in Southampton, England, in 2016, out of 208 cases of congenital undescended testes that underwent surgery at an average age of 1.8 years, 6 testes (2.9%) were found to have atrophy (12). Various factors can influence the occurrence of testicular atrophy after orchidopexy, and it appears that early surgery (before the age of two) leads to increased testicular growth (2). In some other studies, it has been observed that performing the surgery at a younger age result in improved spermatogonia maturation and thus increased fertility (13). Furthermore, in some studies, it has been suggested that the success of the surgery, in terms of atrophy, is significantly higher when performed at an age of three years and nine months compared to two years and four months (14). Additionally, the higher initial position of the testis, problems with hydrocele and torsion before the operation, have a significant association with postoperative atrophy (11). The results of other studies also indicate that laparoscopic and open orchidopexy procedures are almost similar, although laparoscopic surgery has fewer complications. In the mentioned study, out of 75 surgical cases, 5 testes were found to be atrophic, with three cases related to laparoscopy and two cases related to open surgery (15). According to the results of the study by Durell J et al., the occurrence of testicular atrophy is not influenced by the experience or expertise of the operating surgeon (12). Considering the above-mentioned issues and the importance of this matter in the sexual and reproductive life of children, as well as the limited and incomplete studies in Iran, it seems that understanding the risk factors for reducing postoperative atrophy and, consequently, reducing infertility in affected children would be influential. Therefore, our research team decided to conduct a study titled "Investigation of the incidence of testicular atrophy following orchidopexy surgery and its risk factors in children with cryptorchidism." Method This study was conducted as a descriptive-analytical, cross-sectional, prospective study with the aim of investigating the risk factors for testicular atrophy following orchidopexy surgery in children with undescended testes (UDT) who were referred to Al-Zahra and Imam Hossein hospitals in Isfahan. The study participants were selected through a census sampling method. All children who underwent orchidopexy surgery at these centers and whose parents consented to participate in the study were included. Children whose parents did not consent, had retractable testes, or had underlying endocrine disorders were excluded from the study. A total of 80 testes were initially included in the study. However, after consulting with a statistical advisor and considering the age range, 10 samples were excluded, resulting in a final sample size of 70 testes. A checklist was prepared to collect the necessary information, including the child's age at the time of surgery, type of surgery, initial location of the testis, and the presence or absence of hydrocele and testicular torsion. To initiate the study, necessary coordination was made with the officials of Imam Hossein and Al-Zahra hospitals. Subsequently, the medical records unit was visited, and contact numbers of children diagnosed with cryptorchidism who had visited these hospitals were extracted from the hospital records. The researcher contacted the parents of these children via telephone, explained the purpose of the study, and requested their participation if their child had undergone surgery at least 6 months prior. The parents were asked to attend a physical examination appointment, where they were provided with an informed consent form. According to the Lambert criteria and the following formula, the volume of both testes was measured by the specialist using an orchidometer: Volume = (Length x Width x Height) x 0.71 If there was a significant discrepancy in volume, indicating atrophy, the testis was considered atrophic (16). Other necessary information to determine the risk factors was obtained from the patients' medical records. Lambert formula and index calculation: Lambert testicular volume = width * length * height * 0.71/1000 Testicular atrophy index = Contralateral testicular volume * 100 / (Volume of affected testis - Contralateral testicular volume) The collected data were analyzed using SPSS software version 26. The following statistical tests were used: - Chi-squared test and Fisher's exact test for categorical variables. Independent t-test for continuous variables. Logistic regression analysis to assess the impact of different factors. The significance level was set at p-value ≤ 0.05 for all tests. Results A total of 80 individuals participated in this study, but 10 individuals were excluded due to their advanced age at the time of surgery, which could introduce bias into the statistical analysis. Therefore, a total of 70 children with a mean age of 1.26 ± 0.67 years were included in the study and analyzed. Table 1: presents the number of individuals and relevant percentages for variables such as torsion, affected testis side, initial position, and surgical approach. For example, out of the 70 examined samples, 11 individuals underwent laparoscopic surgery, while 59 individuals underwent open surgery. In this study, testicular atrophy was reported in 21.4% of cases. According to Table 1, there was a statistically significant association between variables such as torsion, initial testis position, surgical method, and the occurrence of atrophy. Based on Table 2: there was no linear significant relationship between the occurrence of atrophy and the mean and median age. (p < 0.516 and p < 0.706, respectively) In Table 3: age is categorized into four groups: less than 1 year, 1 to 2 years, 2 to 4 years, and over 4 years. The association between age groups and the occurrence of atrophy was examined. This statistical interpretation reported a significant relationship (p-value = 0.036). (It should be noted that in the descriptive analysis, lower rates of atrophy were observed in younger age groups, although logistic regression did not confirm this finding). Table 4: displays the logistic regression analysis of the study. From the overall results of this table, it can be inferred that preoperative testicular torsion, initial intra-abdominal testis, and laparoscopic surgery increase the risk of testicular atrophy 6 months after the procedure. Among these variables, laparoscopic surgery was found to have a significant impact. Age, when categorized, was reported to have a negligible difference, but it showed an increasing trend of atrophy with advancing age. In this table, the age groups between 2 and 4 years and over 4 years were combined. Examining the association between testicular side and age linearly, according to the crude model of logistic regression, no significant relationship with the occurrence of atrophy was observed. Regarding Model 1 in the logistic regression table, when considering the inclusion of other variables, the variable of interest was found to be statistically significant in relation to the measured atrophy. However, in all cases, this significance was reported as non-significant. Discussion This study aims to investigate the occurrence of testicular atrophy after orchidopexy in patients with undescended testis (UDT) and determine its risk factors. In the present study, testicular volume was accurately measured using an orchidometer through clinical palpation, and an overall atrophy rate of 21.4% was obtained. It should be noted that, according to the results of some studies, the rate of atrophy is usually underestimated due to the single-assessor size estimation by a surgeon (17). Despite this issue, Durl and colleagues achieved a similar overall atrophy rate of 6.2% using the clinical palpation method, which is consistent with the findings of most researchers in this field (12). It appears that the high reported rate of atrophy in the present study may be attributed to limitations in the sample size due to patient non-cooperation, exclusion of certain data during the study, lack of sufficient data, and other factors. However, this study demonstrated that testicular torsion, laparoscopic surgery, and initial intra-abdominal location of the testis are associated with higher rates of atrophy. In another study conducted in this field, testicular atrophy was generally associated with testicular volume, higher initial position of the testis, epididymal abnormalities, and complications of varicocele and two-stage Fowler-Stephen’s procedure. Since these factors had an AUC higher than 0.85, they can be used as predictive models. This model has the potential to assist surgeons in selecting the best surgical procedure for UDT patients and predicting testicular atrophy following orchidopexy. Severe testicular atrophy is the most significant complication of orchidopexy surgery (18). Upon reviewing various studies, the prevalence of atrophy after orchidopexy for UDT ranges from 8% to 32%. Testicular atrophy can lead to azoospermia and infertility in adulthood (11, 19-21). Additionally, smaller testicular volume (TV) is associated with oligospermia and increased risk of infertility (22). The European Association of Urology (EAU) Pediatric Urology Guidelines of 2020 indicate that male infants with unilateral UDT have lower fertility rates and similar paternity rates compared to boys with bilaterally healthy testes. Male infants born with bilateral UDT have lower fertility and paternity rates (23). The causes of atrophy include traction on the spermatic cord, resulting in testicular ischemia, torsion, or injury to the spermatic cord during the passage of testes towards the scrotum, and inadequate collateral vessels after ligation of the spermatic cord during surgery (1). Alagaratnam S et al. reported an atrophy rate of 8.8% in their study of two-stage orchidopexy in 94 patients with intra-abdominal testes (24). This study, conducted by In et al., retrospectively examined 1,400 children who underwent orchidopexy. The results indicated that the most significant risk factors associated with testicular atrophy were high undescended testis (UDT), preoperative hydrocele, and torsion (11). Another important risk factor to mention is the age of the infant or child at the time of surgery. According to the Nordic consensus, orchidopexy should be performed between 6 and 12 months of age (25). Numerous studies have shown that early orchidopexy for UDT results in sufficient testicular growth (4, 26). Carson et al. reported different findings suggesting a lower rate of testicular atrophy (5% testicular atrophy) when orchidopexy is performed before 13 months of age compared to when it is done between 13 and 24 months of age (12% testicular atrophy) (27). In the study by Shi et al., the rate of atrophy for orchidopexy performed before one year of age was not significantly lower (9%, p value=0.655) than for those performed between 1 and 2 years of age (8%). However, no atrophy was reported in patients who underwent surgery after 2 years of age, which may be attributed to the higher strength of the spermatic cord and better collateral blood supply to the testes in patients older than 2 years compared to those under 2 years. Nonetheless, orchidopexy is not recommended after two years of age since clinical and pathological evidence suggests that testes operated on after 2 years of age are smaller than those operated on before 2 years of age (9). Any treatment that results in testicular placement in the scrotum should be performed by 12 months of age or at most 18 months of age. Histological examinations of UDT indicate loss of germ cells and Leydig cells after that age (28). Michikawa T et al. demonstrated that orchidopexy performed before the age of 2 prevents any morphological changes in the testes of UDT patients (29). Some studies have shown that early orchidopexy is associated with better testicular growth (4, 26). In the present study, the rate of atrophy in patients over 2 years of age was reported to be lower than in patients aged 1-2 years and under 1 year (p-value=.940%,) in line with the results of most studies. In the study by Yang et al., elevated testis was reported as an independent risk factor for testicular atrophy (1). In another study, the rates of atrophy were reported as 3.3%, 9.6%, and 18.5% for supra-scrotal, inguinal canalicular, and high inguinal canal testes, respectively (9). In the present study, rates of 12.8% and 8.5% were obtained for canalicular and intra-abdominal testes, respectively. Despite the obtained percentages, in the logistic regression table of this study, the inguinal testis showed a lower probability of atrophy, which was consistent with previous findings. This is likely due to the higher temperature surrounding the testis in the inguinal canal and abdomen, which can damage testicular cells (1). A testis that does not properly descend is subjected to heat stress. When the testis is not in the low scrotal temperature (33 degrees), it interferes physiologically with the testis and hampers the development of germ cells into spermatogonia (30). In the present study, intra-abdominal testis in children with undescended testis (UDT) undergoing orchidopexy was found to be a strong risk factor, which is consistent with some of the aforementioned findings and can provide further evidence of the impact of high temperature on testicular atrophy. Some older studies report that the preoperative position of the testis for UDT has no effect on the final testicular volume in patients who have undergone preoperative hormonal therapy. However, it should be noted that the aforementioned study was conducted on a very small sample size and is not reliable. Therefore, it appears that the results of this study and other studies mentioned regarding the risk factor of the initial higher position of the testis are more reliable (31). According to the article by Yang Z et al., another important risk factor is the preoperative testicular volume (1). A smaller testis indicates damage to germ cells and Leydig cells (28). For this reason, smaller testes before the operation are more susceptible to postoperative atrophy (1). Unfortunately, due to the lack of measurement of this factor in most operating rooms and its absence in patient records, it was decided not to include this factor in the study. We have observed problems with vas deferens and epididymis, and another identified risk factor for atrophy after undescended testis (UDT) is intra-abdominal testis. Unfortunately, due to incomplete hospital records and operative reports, we were unable to make precise measurements in this regard. However, other studies have reported that problems with vas deferens can lead to testicular atrophy, for example Yang Z et al. reported that abnormalities in vas deferens and epididymis, such as looping, complete absence of vas deferens, and improper connection between testis and epididymis (including lack of fusion at the head and tail of epididymis), can result in testicular atrophy (1). Abnormalities in epididymis and vas deferens are considered important indicators of gonadal hypoplasia and can cause testicular atrophy (1). Furthermore, in cases of looping vas deferens, laparoscopic dissection of the spermatic cord can potentially damage the blood vessels of the vas deferens, which in turn can lead to testicular ischemia (32). The choice of surgical method is at the discretion of the surgeon and is influenced by anatomical factors, comfort with laparoscopic procedures, and the surgeon's preference. In the study by Yang et al., the rate of atrophy was higher in two-stage Fowler-Stephens orchidopexy compared to routine orchidopexy (1). Similar findings were reported in another systematic review, where two-stage Fowler-Stephens orchidopexy had a higher rate of atrophy compared to routine orchidopexy (33). In the present study, laparoscopic surgery was compared to open surgery, and the results strongly indicated that the rate of atrophy is significantly higher in laparoscopic surgery. Consistent with the findings of this study, a meta-analysis comparing laparoscopic and open surgery for UDT has recommended open surgery and discouraged laparoscopic surgery in non-essential cases (34). However, a Russian author has proposed a palpable laparoscopic model for UDT surgeries and achieved a higher success rate with it (35). Lastly, the final risk factor in the present study, which has been studied to a very limited extent and is not widely recognized by surgeons, as its overall prevalence is generally lower than other risk factors, is preoperative testicular torsion. In our study, testicular torsion before surgery was also found to be a significant and independent risk factor for post-orchidopexy testicular atrophy, similar to the study by Sigmund H. Ein. and colleagues (11). Conclusion Orchidopexy surgery leads to the proper descent of a normal testicle into the scrotum. Understanding the risk factors for reducing the occurrence of atrophy after surgery is of particular importance, and this study found a higher rate of atrophy associated with testicular torsion, laparoscopic surgery, and initial intra-abdominal location of the testicle. The study did not find a significant correlation between the variable of atrophy and age. It is recommended to perform orchidopexy with larger sample sizes and to conduct long-term follow-up investigations. Strengths: -Emphasis on the importance of timely orchidopexy surgery for undescended testicles, which ensures the proper descent of the testicle into the scrotum and has a significant impact on future sexual function and fertility. -This is the first study in Iran to comprehensively examine testicular atrophy following orchidopexy surgery and its associated risk factors. Limitation: Lack of cooperation and participation from some parents due to their unawareness of the importance of timely orchidopexy surgery and follow-up. Abbreviations undescended testis UDT European Association of Urology EAU American Urological Association AUA Declarations Ethics approval and consent to participate This study received the ethics committee of the Isfahan University of Medical Sciences approval. The Code of Ethics is IR.MUI.MED.REC.1401.198 'Informed consent' was obtained from all participants prior to conducting the educational intervention. The writing and oral consent procedure, was approved by the ethics committee of the Isfahan University of Medical Sciences approval. My submission was performed in accordance with the relevant guidelines and regulations (Declaration of Helsinki). All methods were carried out in accordance with [relevant guidelines and regulations].” Consent for publication They were ensured of the confidentiality of data, their right to withdraw from the study at any stage, and the researchers’ respect for privacy in analyzing and managing their data. It is not any applications for this study. Not applicable Availability of data and material Quantitative data are available in the form of an SPSS file. If someone wants to request the data from this study, by sending an email to the corresponding author should be contacted. Competing interests The authors declare that they have no competing interests. Funding This study was funded by University of Medical Sciences, Isfahan, Iran. All the authors have read and approved the final manuscript. Acknowledgments The authors of this manuscript would like to acknowledge and express their gratitude and appreciation to Dr. Shakiba Zahed, PhD in Health Education and Promotion, for her valuable editing, reviewing, and helping in submitting this manuscript and the staff of the Pediatric Surgery Department at Al-Zahra and Imam Hussein hospitals in Isfahan, as well as all the parents of the children who assisted us in this study Author contributions: M. H: is responsible for the supervision of the collection of data, the conception and development of the paper and the interpretation and discussion of the results. A.Z**: is responsible for the collection of data, the conception of the paper, the review of literature, the interpretation and discussion of the results and writing the article. K.M: is responsible for the critical review of the manuscript, Contributed to Data analysis & Statistical analysis Authors' information (optional) 1. Mehrdad Hosseinpour, MD . Associate Professor of Pediatric Surgery, Department of Surgery, School of Medicine, Imam Hossein Children’s Hospital, Isfahan University of Medical Sciences Email: [email protected] ORCID ID: 0000-0001-9242-2873 Cell phone: 989131294109 2. Ali Zahed**, MD. Isfahan University of Medical Sciences, Isfahan, Iran. Email: [email protected] ** Corresponding Author ORCID ID: 0000-0002-3673-5207 Cell phone: 989397655564 3. Kimia Mirjalali, MD, General Surgeon, Isfahan University of Medical Sciences, Isfahan, Iran. 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Open versus laparoscopic staged Fowler-Stephens orchiopexy: impact of long loop vas. The Journal of urology. 2009;182(5):2435-9. Penson D, Krishnaswami S, Jules A, McPheeters ML. Effectiveness of hormonal and surgical therapies for cryptorchidism: a systematic review. Pediatrics. 2013;131(6):e1897-e907. Mentessidou A, Gargano T, Lima M, Mirilas P. Laparoscopic versus open orchiopexy for palpable undescended testes: Systematic review and meta-analysis. Journal of Pediatric Surgery. 2022;57(4):770-5. VIu G. Surgical treatment of acute suppurative metapneumonic pleurisy. Klinicheskaia Khirurgiia. 1988(10):26-8. Tables Tables 1 to 4 are available in the Supplementary Files section Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4546212","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":315290020,"identity":"fd43d6e5-2c82-4439-be28-ccb39bf1316b","order_by":0,"name":"Mehrdad Hosseinpour","email":"","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mehrdad","middleName":"","lastName":"Hosseinpour","suffix":""},{"id":315290023,"identity":"5d36919d-9e33-4241-9658-9ee8dc9e9194","order_by":1,"name":"Ali Zahed","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4UlEQVRIiWNgGAWjYDCCA0DMY2Ajx8/eA+bz8BGnpSDNWLLnDJjDw0aclg+HEzfcyIFwCGrhu32A+cMbg8OJM2e+Pfj4Y46dDBsD88NHN/BokTyXwGA4xyDduF86L9ng4LZkoMPYjI1z8GgxAPogmcfAWnbm7BwziYPbmIFaeNikCWk5zGPAzLjh5hmQlnqitDA28xg4K264wQPScpiwFskzDMyMcwxAgZxjbHB223EeNmYCfuEDavnw5g8oKs8YPqjcVm3Pz9788DE+LQwM/B/QBJjxKh8Fo2AUjIJRQAwAACyRRuubMA/SAAAAAElFTkSuQmCC","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Ali","middleName":"","lastName":"Zahed","suffix":""},{"id":315290026,"identity":"6e33cc61-ddba-4f98-8bca-fc2bfcfd9b14","order_by":2,"name":"Kimia Mirjalali","email":"","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Kimia","middleName":"","lastName":"Mirjalali","suffix":""}],"badges":[],"createdAt":"2024-06-07 12:52:48","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-4546212/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4546212/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":61077315,"identity":"feaa4513-3bf2-450f-a062-9bd86e785dbe","added_by":"auto","created_at":"2024-07-25 09:47:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":320194,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4546212/v1/a78c9cb0-47cf-4162-895f-8b847aaffe8b.pdf"},{"id":58802212,"identity":"cbfa2b12-a3e6-4db4-951d-242012d941e8","added_by":"auto","created_at":"2024-06-21 09:58:41","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":19990,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-4546212/v1/21fb715ffa405f868deb82c0.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eTesticular Atrophy Risk after Orchidopexy Surgery in Children with Cryptorchidism in Isfahan Hospitals\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCryptorchidism, also known as undescended testis (UDT), is one of the most common congenital anomalies in male infants, affecting 1-4.6% of term infants and 1.1-45% of preterm infants (1). Cryptorchidism refers to the failure of the testis to descend permanently to its final position in the scrotum (2). Undescended testis is associated with an increased risk of testicular cancer, mortality, and infertility (3). Bilateral undescended testis leads to severe impairment of spermatogenesis, and if left untreated, it can result in infertility in adulthood. Orchidopexy for bilateral cryptorchidism improves the level of normal sperm. Findings suggest that the best outcome in terms of testicular growth after orchidopexy appears to be achieved when performed within the first two years of a child's life (4). Hormonal treatment for UDT is not recommended due to its low success rate (20%) (5). The globally accepted treatment for the aforementioned condition is orchidopexy, as stated in the guidelines of the European Association of Urology (EAU) and the American Urological Association (AUA), which recommend performing the surgery before 18 months of age (3). Nowadays, orchidopexy is the fourth most common general surgical procedure in children, following appendectomy, circumcision, and hernia repair (6). The most important aspect of this surgical procedure for true undescended testis is achieving the placement of a normal testis inside the scrotum (7). The first successful orchidopexy was reported by Thomas Annandale in Edinburgh in 1877. The technique reported by Bevan in 1899 involved four key principles: testicular mobilization, closure of the vaginal process, division of adhesions to the spermatic cord, and repositioning and fixation of the testis within the scrotum, which are the main components of orchidopexy (8). Orchidopexy is the standard intervention for undescended testes (UDTs) and is recommended to be performed at the age of 6-12 months or within the first 18 months of a child's life. Initial orchidopexy also reduces the risk of testicular cancer, preserves fertility, and improves testicular growth. Despite the benefits of orchidopexy, complications such as recurrence, hematoma of the scrotum, wound infection, and vascular injury, although relatively uncommon, are possible. Testicular atrophy (TA) is a serious complication that can occur during orchidopexy (9). Testicular atrophy refers to the partial or complete loss of spermatids from the lumen of the seminiferous tubules (10). In a study conducted in Toronto, Canada, in 2013, 1,400 undescended testes underwent orchidopexy, and testicular atrophy was reported in 111 cases (8%). Most of the cases were related to the right testis. Sixty-six cases (59%) resulted in atrophy due to the surgery, and 45 cases (41%) were found to have already undergone atrophy (11). In another study conducted in Southampton, England, in 2016, out of 208 cases of congenital undescended testes that underwent surgery at an average age of 1.8 years, 6 testes (2.9%) were found to have atrophy (12). Various factors can influence the occurrence of testicular atrophy after orchidopexy, and it appears that early surgery (before the age of two) leads to increased testicular growth (2). In some other studies, it has been observed that performing the surgery at a younger age result in improved spermatogonia maturation and thus increased fertility (13). Furthermore, in some studies, it has been suggested that the success of the surgery, in terms of atrophy, is significantly higher when performed at an age of three years and nine months compared to two years and four months (14). Additionally, the higher initial position of the testis, problems with hydrocele and torsion before the operation, have a significant association with postoperative atrophy (11). The results of other studies also indicate that laparoscopic and open orchidopexy procedures are almost similar, although laparoscopic surgery has fewer complications. In the mentioned study, out of 75 surgical cases, 5 testes were found to be atrophic, with three cases related to laparoscopy and two cases related to open surgery (15). According to the results of the study by\u0026nbsp;Durell J\u0026nbsp;et al., the occurrence of testicular atrophy is not influenced by the experience or expertise of the operating surgeon (12).\u003c/p\u003e\n\u003cp\u003eConsidering the above-mentioned issues and the importance of this matter in the sexual and reproductive life of children, as well as the limited and incomplete studies in Iran, it seems that understanding the risk factors for reducing postoperative atrophy and, consequently, reducing infertility in affected children would be influential. Therefore, our research team decided to conduct a study titled \"Investigation of the incidence of testicular atrophy following orchidopexy surgery and its risk factors in children with cryptorchidism.\"\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eThis study was conducted as a descriptive-analytical, cross-sectional, prospective study with the aim of investigating the risk factors for testicular atrophy following orchidopexy surgery in children with undescended testes (UDT) who were referred to Al-Zahra and Imam Hossein hospitals in Isfahan. The study participants were selected through a census sampling method. All children who underwent orchidopexy surgery at these centers and whose parents consented to participate in the study were included. Children whose parents did not consent, had retractable testes, or had underlying endocrine disorders were excluded from the study. A total of 80 testes were initially included in the study. However, after consulting with a statistical advisor and considering the age range, 10 samples were excluded, resulting in a final sample size of 70 testes. A checklist was prepared to collect the necessary information, including the child's age at the time of surgery, type of surgery, initial location of the testis, and the presence or absence of hydrocele and testicular torsion.\u003c/p\u003e\n\u003cp\u003eTo initiate the study, necessary coordination was made with the officials of Imam Hossein and Al-Zahra hospitals. Subsequently, the medical records unit was visited, and contact numbers of children diagnosed with cryptorchidism who had visited these hospitals were extracted from the hospital records. The researcher contacted the parents of these children via telephone, explained the purpose of the study, and requested their participation if their child had undergone surgery at least 6 months prior. The parents were asked to attend a physical examination appointment, where they were provided with an informed consent form. According to the Lambert criteria and the following formula, the volume of both testes was measured by the specialist using an orchidometer:\u003c/p\u003e\n\u003cp\u003eVolume = (Length x Width x Height) x 0.71\u003c/p\u003e\n\u003cp\u003eIf there was a significant discrepancy in volume, indicating atrophy, the testis was considered atrophic (16). Other necessary information to determine the risk factors was obtained from the patients' medical records.\u003c/p\u003e\n\u003cp\u003eLambert formula and index calculation:\u003c/p\u003e\n\u003cp\u003eLambert testicular volume = width * length * height * 0.71/1000\u003c/p\u003e\n\u003cp\u003eTesticular atrophy index = Contralateral testicular volume * 100 / (Volume of affected testis - Contralateral testicular volume)\u003c/p\u003e\n\u003cp\u003eThe collected data were analyzed using SPSS software version 26. The following statistical tests were used:\u003c/p\u003e\n\u003cp\u003e- Chi-squared test and Fisher's exact test for categorical variables. Independent t-test for continuous variables. Logistic regression analysis to assess the impact of different factors. The significance level was set at p-value ≤ 0.05 for all tests.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 80 individuals participated in this study, but 10 individuals were excluded due to their advanced age at the time of surgery, which could introduce bias into the statistical analysis. Therefore, a total of 70 children with a mean age of 1.26 ± 0.67 years were included in the study and analyzed.\u003c/p\u003e\n\u003cp\u003eTable 1: presents the number of individuals and relevant percentages for variables such as torsion, affected testis side, initial position, and surgical approach. For example, out of the 70 examined samples, 11 individuals underwent laparoscopic surgery, while 59 individuals underwent open surgery. In this study, testicular atrophy was reported in 21.4% of cases. According to Table 1, there was a statistically significant association between variables such as torsion, initial testis position, surgical method, and the occurrence of atrophy.\u003c/p\u003e\n\u003cp\u003eBased on Table 2: there was no linear significant relationship between the occurrence of atrophy and the mean and median age. (p \u0026lt; 0.516 and p \u0026lt; 0.706, respectively)\u003c/p\u003e\n\u003cp\u003eIn Table 3: age is categorized into four groups: less than 1 year, 1 to 2 years, 2 to 4 years, and over 4 years. The association between age groups and the occurrence of atrophy was examined. This statistical interpretation reported a significant relationship (p-value = 0.036). (It should be noted that in the descriptive analysis, lower rates of atrophy were observed in younger age groups, although logistic regression did not confirm this finding).\u003c/p\u003e\n\u003cp\u003eTable 4: displays the logistic regression analysis of the study. From the overall results of this table, it can be inferred that preoperative testicular torsion, initial intra-abdominal testis, and laparoscopic surgery increase the risk of testicular atrophy 6 months after the procedure. Among these variables, laparoscopic surgery was found to have a significant impact. Age, when categorized, was reported to have a negligible difference, but it showed an increasing trend of atrophy with advancing age. In this table, the age groups between 2 and 4 years and over 4 years were combined. Examining the association between testicular side and age linearly, according to the crude model of logistic regression, no significant relationship with the occurrence of atrophy was observed.\u003c/p\u003e\n\u003cp\u003eRegarding Model 1 in the logistic regression table, when considering the inclusion of other variables, the variable of interest was found to be statistically significant in relation to the measured atrophy. However, in all cases, this significance was reported as non-significant.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aims to investigate the occurrence of testicular atrophy after orchidopexy in patients with undescended testis (UDT) and determine its risk factors. In the present study, testicular volume was accurately measured using an orchidometer through clinical palpation, and an overall atrophy rate of 21.4% was obtained. It should be noted that, according to the results of some studies, the rate of atrophy is usually underestimated due to the single-assessor size estimation by a surgeon (17). Despite this issue, Durl and colleagues achieved a similar overall atrophy rate of 6.2% using the clinical palpation method, which is consistent with the findings of most researchers in this field (12). It appears that the high reported rate of atrophy in the present study may be attributed to limitations in the sample size due to patient non-cooperation, exclusion of certain data during the study, lack of sufficient data, and other factors. However, this study demonstrated that testicular torsion, laparoscopic surgery, and initial intra-abdominal location of the testis are associated with higher rates of atrophy. In another study conducted in this field, testicular atrophy was generally associated with testicular volume, higher initial position of the testis, epididymal abnormalities, and complications of varicocele and two-stage Fowler-Stephen’s procedure. Since these factors had an AUC higher than 0.85, they can be used as predictive models. This model has the potential to assist surgeons in selecting the best surgical procedure for UDT patients and predicting testicular atrophy following orchidopexy. Severe testicular atrophy is the most significant complication of orchidopexy surgery (18). Upon reviewing various studies, the prevalence of atrophy after orchidopexy for UDT ranges from 8% to 32%. Testicular atrophy can lead to azoospermia and infertility in adulthood (11, 19-21). Additionally, smaller testicular volume (TV) is associated with oligospermia and increased risk of infertility (22). The European Association of Urology (EAU) Pediatric Urology Guidelines of 2020 indicate that male infants with unilateral UDT have lower fertility rates and similar paternity rates compared to boys with bilaterally healthy testes. Male infants born with bilateral UDT have lower fertility and paternity rates (23). The causes of atrophy include traction on the spermatic cord, resulting in testicular ischemia, torsion, or injury to the spermatic cord during the passage of testes towards the scrotum, and inadequate collateral vessels after ligation of the spermatic cord during surgery (1).\u0026nbsp;Alagaratnam S\u0026nbsp;et al. reported an atrophy rate of 8.8% in their study of two-stage orchidopexy in 94 patients with intra-abdominal testes (24).\u003c/p\u003e\n\u003cp\u003eThis study, conducted by In et al., retrospectively examined 1,400 children who underwent orchidopexy. The results indicated that the most significant risk factors associated with testicular atrophy were high undescended testis (UDT), preoperative hydrocele, and torsion (11). Another important risk factor to mention is the age of the infant or child at the time of surgery. According to the Nordic consensus, orchidopexy should be performed between 6 and 12 months of age (25).\u003c/p\u003e\n\u003cp\u003eNumerous studies have shown that early orchidopexy for UDT results in sufficient testicular growth (4, 26). Carson et al. reported different findings suggesting a lower rate of testicular atrophy (5% testicular atrophy) when orchidopexy is performed before 13 months of age compared to when it is done between 13 and 24 months of age (12% testicular atrophy) (27). In the study by Shi et al., the rate of atrophy for orchidopexy performed before one year of age was not significantly lower (9%, p value=0.655) than for those performed between 1 and 2 years of age (8%). However, no atrophy was reported in patients who underwent surgery after 2 years of age, which may be attributed to the higher strength of the spermatic cord and better collateral blood supply to the testes in patients older than 2 years compared to those under 2 years. Nonetheless, orchidopexy is not recommended after two years of age since clinical and pathological evidence suggests that testes operated on after 2 years of age are smaller than those operated on before 2 years of age (9). Any treatment that results in testicular placement in the scrotum should be performed by 12 months of age or at most 18 months of age. Histological examinations of UDT indicate loss of germ cells and Leydig cells after that age (28).\u0026nbsp;Michikawa T\u0026nbsp;et al. demonstrated that orchidopexy performed before the age of 2 prevents any morphological changes in the testes of UDT patients (29). Some studies have shown that early orchidopexy is associated with better testicular growth (4, 26).\u0026nbsp;In the present study, the rate of atrophy in patients over 2 years of age was reported to be lower than in patients aged 1-2 years and under 1 year (p-value=.940%,) in line with the results of most studies. In the study by Yang et al., elevated testis was reported as an independent risk factor for testicular atrophy (1). In another study, the rates of atrophy were reported as 3.3%, 9.6%, and 18.5% for supra-scrotal, inguinal canalicular, and high inguinal canal testes, respectively (9). In the present study, rates of 12.8% and 8.5% were obtained for canalicular and intra-abdominal testes, respectively. Despite the obtained percentages, in the logistic regression table of this study, the inguinal testis showed a lower probability of atrophy, which was consistent with previous findings. This is likely due to the higher temperature surrounding the testis in the inguinal canal and abdomen, which can damage testicular cells (1). A testis that does not properly descend is subjected to heat stress. When the testis is not in the low scrotal temperature (33 degrees), it interferes physiologically with the testis and hampers the development of germ cells into spermatogonia (30). In the present study, intra-abdominal testis in children with undescended testis (UDT) undergoing orchidopexy was found to be a strong risk factor, which is consistent with some of the aforementioned findings and can provide further evidence of the impact of high temperature on testicular atrophy. Some older studies report that the preoperative position of the testis for UDT has no effect on the final testicular volume in patients who have undergone preoperative hormonal therapy. However, it should be noted that the aforementioned study was conducted on a very small sample size and is not reliable. Therefore, it appears that the results of this study and other studies mentioned regarding the risk factor of the initial higher position of the testis are more reliable (31). According to the article by\u0026nbsp;Yang Z\u0026nbsp;et al., another important risk factor is the preoperative testicular volume (1). A smaller testis indicates damage to germ cells and Leydig cells (28). For this reason, smaller testes before the operation are more susceptible to postoperative atrophy (1). Unfortunately, due to the lack of measurement of this factor in most operating rooms and its absence in patient records, it was decided not to include this factor in the study. We have observed problems with vas deferens and epididymis, and another identified risk factor for atrophy after undescended testis (UDT) is intra-abdominal testis. Unfortunately, due to incomplete hospital records and operative reports, we were unable to make precise measurements in this regard. However, other studies have reported that problems with vas deferens can lead to testicular atrophy, for example Yang Z\u0026nbsp;et al. reported that abnormalities in vas deferens and epididymis, such as looping, complete absence of vas deferens, and improper connection between testis and epididymis (including lack of fusion at the head and tail of epididymis), can result in testicular atrophy (1). Abnormalities in epididymis and vas deferens are considered important indicators of gonadal hypoplasia and can cause testicular atrophy (1).\u003c/p\u003e\n\u003cp\u003eFurthermore, in cases of looping vas deferens, laparoscopic dissection of the spermatic cord can potentially damage the blood vessels of the vas deferens, which in turn can lead to testicular ischemia (32). The choice of surgical method is at the discretion of the surgeon and is influenced by anatomical factors, comfort with laparoscopic procedures, and the surgeon's preference. In the study by Yang et al., the rate of atrophy was higher in two-stage Fowler-Stephens orchidopexy compared to routine orchidopexy (1). Similar findings were reported in another systematic review, where two-stage Fowler-Stephens orchidopexy had a higher rate of atrophy compared to routine orchidopexy (33). In the present study, laparoscopic surgery was compared to open surgery, and the results strongly indicated that the rate of atrophy is significantly higher in laparoscopic surgery. Consistent with the findings of this study, a meta-analysis comparing laparoscopic and open surgery for UDT has recommended open surgery and discouraged laparoscopic surgery in non-essential cases (34). However, a Russian author has proposed a palpable laparoscopic model for UDT surgeries and achieved a higher success rate with it (35). Lastly, the final risk factor in the present study, which has been studied to a very limited extent and is not widely recognized by surgeons, as its overall prevalence is generally lower than other risk factors, is preoperative testicular torsion. In our study, testicular torsion before surgery was also found to be a significant and independent risk factor for post-orchidopexy testicular atrophy, similar to the study by Sigmund H. Ein. and colleagues (11).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOrchidopexy surgery leads to the proper descent of a normal testicle into the scrotum. Understanding the risk factors for reducing the occurrence of atrophy after surgery is of particular importance, and this study found a higher rate of atrophy associated with testicular torsion, laparoscopic surgery, and initial intra-abdominal location of the testicle. The study did not find a significant correlation between the variable of atrophy and age. It is recommended to perform orchidopexy with larger sample sizes and to conduct long-term follow-up investigations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e-Emphasis on the importance of timely orchidopexy surgery for undescended testicles, which ensures the proper descent of the testicle into the scrotum and has a significant impact on future sexual function and fertility.\u003c/p\u003e\n\u003cp\u003e-This is the first study in Iran to comprehensively examine testicular atrophy following orchidopexy surgery and its associated risk factors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitation:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Lack of cooperation and participation from some parents due to their unawareness of the importance of timely orchidopexy surgery and follow-up.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eundescended testis UDT\u0026nbsp;\u003cbr\u003eEuropean Association of Urology EAU\u0026nbsp;\u003cbr\u003eAmerican Urological Association AUA\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003eThis study received the ethics committee of the Isfahan University of Medical Sciences approval. The Code of Ethics is IR.MUI.MED.REC.1401.198\u003c/p\u003e\n\u003cp\u003e\u0026apos;Informed consent\u0026apos; was obtained from all participants prior to conducting the educational intervention.\u003c/p\u003e\n\u003cp\u003eThe writing and oral consent procedure, was approved by the ethics committee of the Isfahan University of Medical Sciences approval. My submission was performed in accordance with the relevant guidelines and regulations (Declaration of Helsinki). All methods were carried out in accordance with [relevant guidelines and regulations].\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThey were ensured of the confidentiality of data, their right to withdraw from the study at any stage, and the researchers\u0026rsquo; respect for privacy in analyzing and managing their data.\u003c/p\u003e\n\u003cp\u003eIt is not any applications for this study.\u0026nbsp;\u003cbr\u003e\u003cstrong\u003eNot applicable\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuantitative data are available in the form of an SPSS file. If someone wants to request the data from this study, by sending an email to the corresponding author should be contacted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by University of Medical Sciences, Isfahan, Iran.\u003c/p\u003e\n\u003cp\u003eAll the authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors of this manuscript would like to acknowledge and express their gratitude and appreciation to Dr. Shakiba Zahed, PhD in Health Education and Promotion, for her valuable editing, reviewing, and helping in submitting this manuscript and the staff of the Pediatric Surgery Department at Al-Zahra and Imam Hussein hospitals in Isfahan, as well as all the parents of the children who assisted us in this study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eM. H:\u003c/strong\u003e is responsible for the supervision of the collection of data, the conception and development of the paper and the interpretation and discussion of the results.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA.Z**:\u003c/strong\u003e is responsible for the collection of data, the conception of the paper, the review of literature, the interpretation and discussion of the results and writing the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eK.M:\u003c/strong\u003e is responsible for the critical review of the manuscript, Contributed to Data analysis \u0026amp; Statistical analysis\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information (optional)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.\u003c/strong\u003e\u003cstrong\u003eMehrdad Hosseinpour, MD\u003c/strong\u003e. Associate Professor of Pediatric Surgery, Department of Surgery, School of Medicine, Imam Hossein Children\u0026rsquo;s Hospital, Isfahan University of Medical Sciences Email: [email protected] ORCID ID: 0000-0001-9242-2873 Cell phone: 989131294109\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Ali Zahed**,\u0026nbsp;\u003c/strong\u003eMD. Isfahan University of Medical Sciences, Isfahan, Iran.\u003c/p\u003e\n\u003cp\u003eEmail: [email protected] **\u003cstrong\u003eCorresponding Author\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eORCID ID: 0000-0002-3673-5207 Cell phone: 989397655564\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Kimia Mirjalali,\u003c/strong\u003e MD, General Surgeon, Isfahan University of Medical Sciences, Isfahan, Iran.\u003c/p\u003e\n\u003cp\u003eEmail: [email protected] ORCID ID: 0009-0004-6802-1681\u003c/p\u003e\n\u003cp\u003eCell phone: 989132672245\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eYang Z, Li S, Yin J, Bao J, Zeng H, Xu W, et al. A prediction model for risk factors of testicular atrophy after orchiopexy in children with undescended testis. Translational Pediatrics. 2021;10(4):882.\u003c/li\u003e\n\u003cli\u003eYu C, Long C, Wei Y, Tang X, Liu B, Shen L, et al. Evaluation of Fowler\u0026ndash;Stephens orchiopexy for high-level intra-abdominal cryptorchidism: A systematic review and meta-analysis. International Journal of Surgery. 2018;60:74-87.\u003c/li\u003e\n\u003cli\u003eEngeler DS, H\u0026ouml;sli PO, John H, Bannwart F, Sulser T, Amin MB, et al. Early orchiopexy: prepubertal intratubular germ cell neoplasia and fertility outcome. Urology. 2000;56(1):144-8.\u003c/li\u003e\n\u003cli\u003eKim S-O, Hwang EC, Hwang IS, Oh KJ, Jung SI, Kang TW, et al. Testicular catch up growth: the impact of orchiopexy age. Urology. 2011;78(4):886-9.\u003c/li\u003e\n\u003cli\u003ePy\u0026ouml;r\u0026auml;l\u0026auml; S, Huttunen N-P, Uhari M. A review and meta-analysis of hormonal treatment of cryptorchidism. The Journal of Clinical Endocrinology \u0026amp; Metabolism. 1995;80(9):2795-9.\u003c/li\u003e\n\u003cli\u003eBonney T, Southwell B, Donnath S, Newgreen D, Hutson J. Orchidopexy trends in the paediatric population of Victoria, 1999-2006. Journal of pediatric surgery. 2009;44(2):427-31.\u003c/li\u003e\n\u003cli\u003eHutcheson JC, Cooper CS, Snyder HM. The anatomical approach to inguinal orchiopexy. The Journal of urology. 2000;164(5):1702-4.\u003c/li\u003e\n\u003cli\u003eMcIntosh L, Scrimgeour D, Youngson G, Driver C. The risk of failure after primary orchidopexy: an 18 year review. Journal of Pediatric Urology. 2013;9(6):759-62.\u003c/li\u003e\n\u003cli\u003eTseng C-S, Huang K-H, Kuo M-C, Hong C-H, Chen C-H, Lu Y-C, et al. The impact of primary location and age at orchiopexy on testicular atrophy for congenital undescended testis. Scientific Reports. 2019;9(1):9489.\u003c/li\u003e\n\u003cli\u003eWoldemeskel M. Toxicologic pathology of the reproductive system. Reproductive and developmental toxicology: Elsevier; 2022. p. 1289-321.\u003c/li\u003e\n\u003cli\u003eEin SH, Nasr A, Wales PW, Ein A. Testicular atrophy after attempted pediatric orchidopexy for true undescended testis. Journal of pediatric surgery. 2014;49(2):317-22.\u003c/li\u003e\n\u003cli\u003eDurell J, Johal N, Burge D, Wheeler R, Griffiths M, Kitteringham L, et al. Testicular atrophy following paediatric primary orchidopexy: a prospective study. Journal of pediatric urology. 2016;12(4):243. e1-. e4.\u003c/li\u003e\n\u003cli\u003eHutson JM. Undescended testis: the underlying mechanisms and the effects on germ cells that cause infertility and cancer. Journal of pediatric surgery. 2013;48(5):903-8.\u003c/li\u003e\n\u003cli\u003eThorup J, Jensen C, Langballe O, Petersen B, Cortes D. The challenge of early surgery for cryptorchidism. Scandinavian journal of urology and nephrology. 2011;45(3):184-9.\u003c/li\u003e\n\u003cli\u003eAbolyosr A. Laparoscopic versus open orchiopexy in the management of abdominal testis: a descriptive study. International journal of urology. 2006;13(11):1421-4.\u003c/li\u003e\n\u003cli\u003eNiedzielski J, Pisarska K, Przewratil P. The usefulness of testicular atrophy index in the assessment of undescended testicle\u0026ndash;preliminary report. Rocz Akad Med Bialymst. 2003;48(112):4.\u003c/li\u003e\n\u003cli\u003eCastillo-Ortiz J, Mu\u0026ntilde;iz-Colon L, Escudero K, Perez-Brayfield M. Laparoscopy in the surgical management of the non-palpable testis. Frontiers in pediatrics. 2014;2:28.\u003c/li\u003e\n\u003cli\u003eCobellis G, Noviello C, Nino F, Romano M, Mariscoli F, Martino A, et al. Spermatogenesis and cryptorchidism. Frontiers in endocrinology. 2014;5:63.\u003c/li\u003e\n\u003cli\u003eLintula H, Kokki H, Eskelinen M, Vanamo K. Laparoscopic versus open orchidopexy in children with intra-abdominal testes. Journal of Laparoendoscopic \u0026amp; Advanced Surgical Techniques. 2008;18(3):449-56.\u003c/li\u003e\n\u003cli\u003eTaran I, Elder JS. Results of orchiopexy for the undescended testis. World journal of urology. 2006;24:231-9.\u003c/li\u003e\n\u003cli\u003eStec AA, Tanaka ST, Adams MC, Pope JC, Thomas JC, Brock JW. Orchiopexy for intra-abdominal testes: factors predicting success. The Journal of urology. 2009;182(4S):1917-20.\u003c/li\u003e\n\u003cli\u003eSakamoto H, Yajima T, Nagata M, Okumura T, Suzuki K, Ogawa Y. Relationship between testicular size by ultrasonography and testicular function: measurement of testicular length, width, and depth in patients with infertility. International journal of urology. 2008;15(6):529-33.\u003c/li\u003e\n\u003cli\u003eLee PA. Fertility after cryptorchidism: epidemiology and other outcome studies. Urology. 2005;66(2):427-31.\u003c/li\u003e\n\u003cli\u003eAlagaratnam S, Nathaniel C, Cuckow P, Duffy P, Mushtaq I, Cherian A, et al. Testicular outcome following laparoscopic second stage Fowler\u0026ndash;Stephens orchidopexy. Journal of pediatric urology. 2014;10(1):186-92.\u003c/li\u003e\n\u003cli\u003eMartin Ritz\u0026eacute;n E, Bergh A, Bjerknes R, Christiansen P, Cortes D, Haugen S, et al. Nordic consensus on treatment of undescended testes. Acta paediatrica. 2007;96(5):638-43.\u003c/li\u003e\n\u003cli\u003eTseng C-S, Chiang I-N, Hong C-H, Lu Y-C, Hong J-H, Chang H-C, et al. Advantage of early orchiopexy for undescended testis: Analysis of testicular growth percentage ratio in patients with unilateral undescended testicle. Scientific Reports. 2017;7(1):17476.\u003c/li\u003e\n\u003cli\u003eCarson JS, Cusick R, Mercer A, Ashley A, Abdessalam S, Raynor S, et al. Undescended testes: does age at orchiopexy affect survival of the testis? Journal of pediatric surgery. 2014;49(5):770-3.\u003c/li\u003e\n\u003cli\u003ePark KH, Lee JH, Han JJ, Lee SD, Song SY. Histological evidences suggest recommending orchiopexy within the first year of life for children with unilateral inguinal cryptorchid testis. International journal of urology. 2007;14(7):616-21.\u003c/li\u003e\n\u003cli\u003eMichikawa T, Matsufuji H, Araki Y, Nakamura A. Does early orchidopexy prevent morphological changes in undescended testes? A perioperative assessment using ultrasonography. Urologia Internationalis. 2008;81(2):210-4.\u003c/li\u003e\n\u003cli\u003eHutson JM. Cryptorchidism and hypospadias. 2015.\u003c/li\u003e\n\u003cli\u003eTaskinen S, Wikstrom S. Effect of age at operation, location of testis and preoperative hormonal treatment on testicular growth after cryptorchidism. The Journal of urology. 1997;158(2):471-3.\u003c/li\u003e\n\u003cli\u003eDave S, Manaboriboon N, Braga LH, Lorenzo AJ, Farhat WA, B\u0026auml;gli DJ, et al. Open versus laparoscopic staged Fowler-Stephens orchiopexy: impact of long loop vas. The Journal of urology. 2009;182(5):2435-9.\u003c/li\u003e\n\u003cli\u003ePenson D, Krishnaswami S, Jules A, McPheeters ML. Effectiveness of hormonal and surgical therapies for cryptorchidism: a systematic review. Pediatrics. 2013;131(6):e1897-e907.\u003c/li\u003e\n\u003cli\u003eMentessidou A, Gargano T, Lima M, Mirilas P. Laparoscopic versus open orchiopexy for palpable undescended testes: Systematic review and meta-analysis. Journal of Pediatric Surgery. 2022;57(4):770-5.\u003c/li\u003e\n\u003cli\u003eVIu G. Surgical treatment of acute suppurative metapneumonic pleurisy. Klinicheskaia Khirurgiia. 1988(10):26-8.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cryptorchidism, testicular atrophy, orchidopexy, retractable testes","lastPublishedDoi":"10.21203/rs.3.rs-4546212/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4546212/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e This study was conducted to investigate testicular atrophy risk after orchidopexy surgery in children with Cryptorchidism.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod:\u003c/strong\u003e \"This prospective cross-sectional study , included 80 patients from Imam Hussein and Al-Zahra hospital in Isfahan. Children with endocrine disorders or retractable testes were excluded. Testicular measurements were taken before and 6 months after surgery using Lambert's criteria. The significance level was set at p ≤ 0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e A total of 70 children, with a mean age of 26.1 ± 67.1 months, participated in this study and were examined. A prevalence of 21.4% for testicular atrophy was reported. A statistically significant association was found between the variables of testicular torsion, initial inguinal testis position, and laparoscopic surgical method with the occurrence of atrophy. Logistic regression analysis revealed that testicular torsion prior to surgery, initial abdominal testicular position, and laparoscopic surgery increased the risk of testicular atrophy six months post-operatively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e This study revealed that testicular torsion, laparoscopic surgery, and abdominal positioning of the initial testis were significantly associated with increased rates of atrophy. No significant correlation was found between atrophy and age. We recommend conducting future orchidopexy studies with larger sample sizes and conducting longer-term follow-up examinations to further elucidate these findings.\u003c/p\u003e","manuscriptTitle":"Testicular Atrophy Risk after Orchidopexy Surgery in Children with Cryptorchidism in Isfahan Hospitals","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-21 09:58:36","doi":"10.21203/rs.3.rs-4546212/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e517d1c4-a135-4a13-912a-6514476dcb9d","owner":[],"postedDate":"June 21st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-25T09:39:15+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-21 09:58:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4546212","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4546212","identity":"rs-4546212","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}