Department of Paediatric Surgery, Surgical Clinic C, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
Department of Pathology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.
J Pediatr Urol. 2022 Dec;18(6):844.e1-844.e7. doi: 10.1016/j.jpurol.2022.10.031. Epub 2022 Nov 9.
Despite early surgery, many boys with bilateral cryptorchidism at surgery have a reduced number of germ cells per tubular cross-section (G/T) in testicular biopsies and/or low inhibin-B with no elevated follicle-stimulating hormone (FSH) as expected based on a normal gonadotropin feed-back mechanism. Such boys have a high risk of later infertility because of insufficient gonadotropin stimulation and may benefit from adjuvant hormonal treatment. Testicular biopsies are not always wanted or accepted. The study aim was to investigate the value of a low inhibin-B and normal FSH to identify patients that might benefit from adjuvant hormonal treatment avoiding the need for testicular biopsy.
A series of boys with cryptorchidism were evaluated with serum levels of inhibin-B and FSH in relation to G/T in testicular biopsies, which were compared to previously published age-matched normal control values.
A total of 365 boys who underwent bilateral orchidopexy between 0.4 and 7.8 (median: 2) years of age were included. Twenty-seven (7%) patients had increased FSH and low G/T, whereas 11 of these also had low inhibin-B indicating hypergonadotropic hypogonadism. Moreover, 85 (23%) patients between 0.75 and 7.5 (median: 2) years of age had both low G/T (median: 0.3) and low inhibin-B (median: 56 pg/ml) but normal FSH (median: 0.6 U/l) indicating a gonadotropin insufficiency. Three patients with normal FSH and low inhibin B had normal G/T.
Our study shows that if surgeons prefer to avoid testicular biopsies and only wish to rely on hormonal parameters (low inhibin-B and normal FSH) in order to diagnose a gonadotropin insufficiency as the cause of hypogonadism, they will identify only about 30% of such cases and overlook about 70% of patients sharing the same endocrinopathy. In addition, if surgeons treat patients for gonadotropin insufficiency only based on low inhibin-B and normal FSH they will solely treat patients with gonadotropin insufficiency and would not overtreat patients.
Adjuvant hormonal treatment was indicated by a gonadotropin insufficiency discerned in 23% of boys with bilateral cryptorchidism. Without histology, the clinicians are left with more difficult clinical judgments to identify patients for adjuvant hormonal treatment. The positive predictive value of low inhibin-B and normal FSH corroborated by low G/T was 0.97 (85/85 + 3), but the sensitivity was low (0.30).
尽管早期进行了手术，但许多双侧隐睾症男孩在睾丸活检中每个管状横截面上的生殖细胞数量（G/T）减少，并且/或抑制素-B 水平降低，而促卵泡激素（FSH）水平正常，这与正常的促性腺激素反馈机制不符。由于促性腺激素刺激不足，这些男孩以后有很高的不育风险，可能需要辅助激素治疗。但并非总是需要或接受睾丸活检。本研究旨在探讨抑制素-B 水平降低和 FSH 水平正常是否可以识别可能受益于辅助激素治疗的患者，从而避免进行睾丸活检。
对一系列隐睾症男孩进行血清抑制素-B 和 FSH 水平与睾丸活检中 G/T 的检测，并与之前发表的年龄匹配的正常对照组数据进行比较。
共纳入 365 名年龄在 0.4 至 7.8 岁（中位数：2 岁）之间接受双侧睾丸固定术的男孩。27 名（7%）患者 FSH 升高且 G/T 降低，其中 11 名患者也存在抑制素-B 水平降低，表明存在促性腺激素性性腺功能减退症。此外，85 名（23%）年龄在 0.75 至 7.5 岁（中位数：2 岁）之间的患者 G/T 降低（中位数：0.3）且抑制素-B 水平降低（中位数：56pg/ml），但 FSH 水平正常（中位数：0.6U/l），表明存在促性腺激素不足。3 名 FSH 和抑制素-B 水平正常的患者 G/T 正常。
本研究表明，如果外科医生更倾向于避免进行睾丸活检，仅依赖于激素参数（抑制素-B 水平降低且 FSH 水平正常）来诊断促性腺激素不足是性腺功能减退症的病因，那么他们仅能识别出约 30%的此类病例，而会忽略 70%具有相同内分泌异常的患者。此外，如果外科医生仅基于抑制素-B 水平降低且 FSH 水平正常来治疗促性腺激素不足的患者，那么他们仅会治疗促性腺激素不足的患者，而不会过度治疗患者。
双侧隐睾症男孩中有 23%存在促性腺激素不足，需要进行辅助激素治疗。如果没有组织学检查，临床医生在识别需要进行辅助激素治疗的患者时需要进行更困难的临床判断。抑制素-B 水平降低且 FSH 水平正常且 G/T 降低的阳性预测值为 0.97（85/85+3），但敏感性较低（0.30）。
