Cryptorchidism and testicular cancer

Prevalence of undescended testicles (UDT) is 3-4% at birth. The rate of UDT drops to 1% at 12 months, given that 2/3 of UDT demonstrate descent by age 3 months. The rate of UDT is higher in preterm infants, with no increased risk of malignancy in testes that descend spontaneously in the first 3-12 months. Infants (term or preterm) should be allowed to reach an adjusted gestational age of 12 months before orchidopexy is performed.

Using a meta analysis of current literature, the authors set out to answer 5 questions regarding cryptorchidism:

1. What is the RR of testicular cancer in a cryptorchid or formerly cryptorchid testis?

The historically quoted increased risk for testicular cancer (RR = 48) considered a substantial overestimate. The true RR for testicular cancer was found to be 4-6 in the undescended testes.

2. What is the relative risk for malignancy in the contralateral, normally descended testis?

Historically, it was believed that the contralateral, normal testis has a 5-10% chance of malignancy. Based on current literature, the authors identified no increased risk for malignancy in the contralateral testis.

3. Does relocating the testis affect the type of testicular cancer

Uncorrected cryptorchidism carries a higher risk for seminoma, while a corrected conditions carries a higher risk for non-seminomatous malignancies.

4. Does orchidopexy decrease the risk of malignancy

Relative risk of testicular cancer in the undescended testicle after operative correction depends on patient age at time of orchidopexy. When performed before the age of 10-12 years, the RR of testicular cancer is between 2 and 3. When orchidopexy is performed after age of 12, the RR is 2-6 times that of patients who undergo surgery before age 10-12 (this is comparable to the risk in uncorrected UDT).

5. Is there a risk of malignant degeneration in testicular remnants?

The risk of malignant degeneration from atrophic testes, resulting from perinatal spermatic cord torsion, is minimal.



Reference: Cryptorchidism and testicular cancer: Separating fact from fiction. Wood MW, Elder JS. Journal of Urology (2009);181:452-61

Stoma Complications in Infants with NEC

Up to 50% of infants with NEC require surgical intervention, which generally consists of exploration of the abdomen, bowel resection, and stoma formation. The bowel used for formation of the stoma is frequently of marginal viability, and the infants are usually systemically ill during this emergent procedure.

Aguayo et al [Journal of Surgical Research (2009) 157(2):275-8] performed a retrospective study to assess the factors associated with an increased risk of stomal complications in infants undergoing operative intervention for NEC. The authors noted a 43% rate of stomal complications (5% retraction, 5% Skin excoriation, 8% prolapse, 7% necrosis, 15% stricture, 3% parastomal hernias). They also noted a significant increase in risk of complications with lower gestational age and lower preoperative weight.

Intestinal stomas, although potentially life saving, have a surprisingly high rate of complications. They should be created with meticulous technique in order to help decrease the risk of morbid complications and need for revision.

When is prophylaxis against infectious endocarditis indicated?

Infectious endocarditis (IE) occurs when nonbacterial thrombotic endocarditis (NBTE) becomes infected after an episode of transient bacteremia. NBTE results from platelet/fibrin deposition at areas of abnormal and turbulent blood flow. Any event that can cause transient bacteremia (eg. violation of the GI tract) can transform NBTE to IE.

The AHA recommendations for endocarditis prophylaxis were modified in 2007 [Circulation (2007);116:1736-54) in light of the understanding that most IE results from random episodes of bacteremia not related to specific procedures and the concern for the potential harmful effects of unwarranted antibiotic administration

Only patients with specific cardiac IE risk factors [table] should be considered for prophylactic antibiotic administration.

Recommendations for respiratory tract procedures:
Single pre-procedure antibiotic dose (Cefazolin/clindamycin/ceftriaxone or Vanco if MRSA suspected) for any procedure expected to violate (incision/biopsy) the mucosa or for procedures intended to treat an existing infection (drainage of empyema/abscess).

Recommendations for GI or GU tract procedures:
Single pre-procedure antibiotic dose effective against enterococci should be used, when indicated, since these are the only organisms likely to cause IE.
Prophylaxis is NOT indicated for diagnostic GI/GU procedures (endoscopy, cycstoscopy etc..).

When patients are receiving antibiotics for a GI/GU infection or to prevent wound infection, it is suggested that the antibiotics used include an agent effective against enterococci (PCN, ampicillin, piperacillin, or Vanco).

Recommendations for infected skin/skin structure/musculoskeletal tissue
Only staph and B-hemolytic strep are likely causes of IE in this situation. Prudent to use antistaphylococcal agents.

Laparoscopic contralateral groin exploration: is it cost effective

The authors addressed the cost effectiveness of laparoscopic exploration of the contralateral groin in children undergoing inguinal hernia repairs. lap exploration identified a 10% (8/78) rate of contralateral patent processus vaginalis. Assuming all substantial PPV's (defined by the authors as those that could admit a scope, those whose distal aspect could not be visualized, and those that result in gas reaching the scrotum) eventually became hernias, the authors estimated the total cost of contralateral exploration/repair vs. repair when clinical hernias developed in the 8 patients with PPV to be $13,080 and $20,440, respectively. Thus they concluded that contralateral exploration and repair is a cost effective approach to inguinal hernias in children. This did not take into account the expense of the use of laparoscopic instruments.

Lee et al. Journal of Pediatric Surgery (2010);45:793-795

A picture is worth a "silk glove" sign?

How often do we make decisions to fix a hernia based on what the parents describe? have you ever ordered an u/s to check when you couldn't feel a hernia or a "silk glove"? How about just ask the parents to take a picture and email/text it to you to confirm?

A study by Kawaguchi et al (JPS 2009;44:2327-9) looked at 23 patients who underwent surgery based on history and a photograph sent by the parents showing the hernia. All patients underwent operative repair and were noted to have a hernia. two patients who's photographs were not consistent with an inguinal hernia were observed, and were not found to have hernias on follow up.

The use of digital photographs can potentially avoid unnecessary repeat office visits as well as wrong side surgery if the parents' description of a non palpable hernia is not correct.

Op or non-Op management of pancreatic injury

Operative vs nonoperative management of blunt pancreatic trauma in children.

Wood et al. J Ped Surg 2010;45:401-6

This article compared the difference in outcome between operative (distal pancreatectomy) and nonoperative management of grades 2-4 pancreatic injury. Based on 42 patients with pancreatic injury (18 of whom were grade 1; not included in the analysis since non underwent operative managment) the authors noted that the main difference between these two strategies was related to the type of complications. Patients who were treated nonoperatively had a higher rate of pancreatic complications while those that were treated with a distal pancreatectomy tended to have more complications not related to the pancreas.

Another retrospective study looking at 9 patients with pancreatic trauma and complete pancreatic transection confirmed the feasibility of non operative management. 4 patients developed pseudocysts, 3 of which required drainage. Follow up CT scans on 8 of the patients showed complete atrophy of the body/tail of the pancreas.
Wales et al. J Ped Surg 2001;36:823-7

Conversely, Meier et al. noted that patients with pancreatic transection had a quicker recovery and shorter length of hospital stay when treated operatively.
Meier et al. J Ped Surg 2001;36:341-4

Now that I reduced this baby's incarcerated hernia, can I send him home?

So what's the natural history of a truly incarcerated hernia after ED reduction and, subsequently, is it safe to send an infant home for an elective repair? I've had different experiences ranging from admitting infants and repairing their hernia after 24-48 hours (giving time for edema/tissue swelling to resolve) to discharging them home (to "reliable" parents) for a scheduled elective repair.

This subject was addressed by Baguley et al (Pediatr Surg Int 1992.7:366-7). The authors looked at 94 infants with incarcerated inguinal hernias and compared those who were admitted to those who were sent home. In 20% of patients admitted, the hernia reincarcerated prior to it's repair. A much higher rate of reincarceration (74%) in the discharged group reflected the longer time interval before operative repair (Mean 10 days compared to 2 days for the inpatient group). In comparison, 35% of infants with known inguinal hernias (but no history of incarceration), experience hernia incarceration while waiting for their elective operation, a median time of 22 days (Stylianos et al. J Ped Surg 1993;4:582-3).


The paper does not address the issue of potential bowel ischemia/necrosis and the need to monitor infants until that possibility is ruled out. This may have been a source of selection bias, where infants with hernias that were more difficult to reduce were admitted, while those who were reduced more easily were allowed to go home.

The way I see it, and based on this limited study, and given the 1/5 chance of reincarceration within a couple of days, it seems safest to keep patients inhouse until the hernia is repaired.

On the other hand, it is also reasonable to discharge patients home, as long as they live close enough to a center where the incarceration can be promptly treated if it recurs, have guardians who understand the signs and symptoms of incarceration and the need to address them promptly, perform the "elective repair" within 72 hours, and the patient is observed long enough to r/o the presence of compromised bowel after the hernia is reduced.

As to the issue of the 24 to 48 hour delay in repair resulting in a safer operation, secondary to resolution of tissue edema and inflammation, there does not seem to be any data to support or negate that concept.