0022-5347/99/1623-0878/0

THF JOURNAL OF UROLOGY Vol. 162,878-880,September 1999

AS~OCUTION.hc.
UROLOCIC~L
Copyright 8 1999 by AMERICAN Printed in U.S.A.

PATHOLOGICAL DIFFERENCE BETWEEN RETRACTILE AND

CRYPTORCHID TESTES
SANG WON HAN, TACK LEE,* JANG HWAN KIM, SEUNG KANG CHOI, NAM HUN CHO AND
JI YOUNG HA"
From the Departments of Urology and Pathology, Yonsei University College of Medicine, Seoul and Inha University College of Medicine,
Inchon, Korea

ABSTRACT
Purpose: We compared testicular biopsies from retractile and cryptorchid testes to determine
the histological effect of testicular retraction and the necessity of treatment for retractile testes.
Materials and Methods: A total of 61 testicular biopsies were performed during orchiopexy in
36 boys 1.3 to 9.8 years old (mean age 5.4) with retractile testes (unilateral in 11, bilateral in 50)
and 115 testicular biopsies were done in 83 patients with cryptorchidism (unilateral in 51,
bilateral in 64) 0.5 to 14.9 years old (mean age 3.7). Parameters for germ and Sertoli cells were
determined in each group.
Results: Mean average spermatogonial number (SPT value) and Sertoli cell index were statis-
tically different between retractile and cryptorchid testes with values of 2.96 5 1.33 versus
0.61 2 0.87 and 26.81 5 6.75 versus 23.04 5 5.85, respectively. Average tubular degeneration
phase V to VII ratio was 0.23 2 0.18 for retractile testes and 0.22 2 0.17 for cryptorchid testes
which was not statistically different.
Conclusions: Similar tubular degeneration phase V to VII values between retractile and
cryptorchid testes indicate histological change in retractile testes and suggest the need for
hormonal or surgical therapy for those patients with retractile testes lacking spontaneous
descent.
KEY WORDS:testis, cryptorchidism,pathology

Despite familiarity with cryptorchidism there is still con-
fusion regarding prevalence, diagnosis and treatment of re-
tractile testes.'. * Furthermore, the prevalent view of retrac-
tile testes as a normal variant of descended testes, which is
based on the suggestion that testicular function and fertility
are normal with retractile testes, may be a cause of this
confusion. However, a few investigators have observed mor-
phological changes in retractile testes and suggested that it
can be a factor in infertility.3-5 Others have gone further and
stated the necessity of special observation and treatment for
retractile testes.6-8 We obtained testicular biopsies from re-
tractile and cryptorchid testes to compare changes in germ
and Sertoli cells, and determine the necessity of treatment
for retractile testes.
MATERIALS AND METHODS
A total of 61 testicular biopsies were performed during
orchiopexy on 36 boys with retractile testes (unilateral in 11,
bilateral in 50) 1.3 to 9.8 years old (mean age 5.4) and 115
testicular biopsies were done in 83 patients with cryptorchid-
ism (unilateral in 51, bilateral in 64) 0.5 to 14.9 years old
(mean age 3.7) between March 1994 and February 1996.
The criteria for the diagnosis of retractile testes were the
testis can be manipulated into a low scrota1 position, the tes-
tis can remain in the scrotum and does not retract immedi-
ately, the testis is of normal size and the testis resides in the
scrotum for a substantial part of the time.8 Orchiopexy was
performed in boys with retractile testes and parent consent
to operate after noting that the testes were in the scrotum
less than 50% of the time during a minimum 1-week period.
An impalpable or palpable testis that could not be pulled
Accepted for publication April 9, 1999.
*Requests for reprints: Department of Urology, Inha University
College of Medicine, Shinheungdong-3-ga,Jung-gu, Inchon, Korea
400-103.
878
down into the lower scrotum was considered cryptorchidism.
All patients were examined in a frog-leg or squatting position
and those who received prior hormonal therapy were ex-
cluded from the study.
Testicular biopsy was performed at the same least vascu-
larized site opposite the mediastinum of the testis in both
groups. The specimens were preserved in Bouin's solution
and paraffkized. Hematoxylin and eosin staining was per-
formed and observed under light microscopy by 2 patholo-
gists blinded to clinical information (N. H. C . , J. Y. H.). Pa-
rameters for germ and Sertoli cells were determined from
testicular biopsies. Average spermatogonial number (S/T val-
ue), the average number of germ cells per tubule in 50 tu-
bules,g was used as the germ cell parameter. Sertoli cell
index, the average number of Sertoli cells per tubule in 50
tubules,lO and tubular degeneration phase V to VII ratio, the
ratio of tubules with degeneration phase 5 or greater as
defined by Rune et al," were used as parameters for the
Sertoli cell. Each parameter was compared between retrac-
tile and cryptorchid testes. Statistical analysis was per-
formed using the unpaired, 2-tailed Student t test.
FIG. 1. Pathological findings of retractile (A) and cryptorchid (0
testes. Degenerated tubules in retractile testes were focally inter-
spersed within normal tubules in contrast to diffusely spread out
degeneration in cryptorchid testes. Reduced from x 100.
 PATHOLOGICAL DIFFERENCE BETWEEN RETRACTILE AND CRYPTORCHID TESTES 879

I0 ,

I.

FIG.2. Distribution of SPT values (A). Sertoli cell index tSCn values (B) and tubular degeneration phase (TDP)V to VII ( C )in retractile
and cryptorchid testes

RESULTS although randomly acquired, is usually counted from the

All patients with retractile testes had a well developed
scrotum on both sides, while some with cryptorchidism had
an ipsilateral underdeveloped or undeveloped hemiscrotum
as well as concomitant underdeveloped scrota1 rugae. The
histological pattern showed degenerated tubules focally in-
terspersed within normal tubules in retractile testes,
whereas diffusely spread out degeneration was seen in most
of the tubules from cryptorchid testes (fig. 1).
The mean SPT value was statistically different between
retractile (2.96 5 1.33) and cryptorchid (0.61 5 0.87) testes
(fig. 2, A, p <0.001). Of 61 retractile testes 25 (40.4%)had a
SPT value in the abnormal range as defined by Kleinteich and
Schickedanz.12 The difference in Sertoli cell index between
retractile (mean 26.81 2 6.75) and cryptorchid (mean
23.04 5 5.85) testes was statistically significant (fig. 2, B , p =
0.003). Average tubular degeneration phase V to VII was
0.23 5 0.18 for retractile testes and 0.22 5 0.17 for cryp-
torchid testes, which were not significantly different (fig. 2,
C, p = 0.420).
DISCUSSION
Retractile testis is generally conceived as a benign condi-
tion that does not require treatment, although this general
belief has been questioned by a few investigators. Recently,
in a followup study of 38 patients with a mean age of 18 years
who were treated for retractile testes before prepuberty
Caucci et a1 observed normal spermiograms in only 8
When the mean SPT value was compared to normal testes,
Cinti et a1 observed a significantly decreased value in retrac-
tile testes without prior hormonal treatment.5 Moreover,
Saito and Kumamoto noted decreased S/T values in 55% (16
of 29) of retractile testes and suggested that treatment may
be necessary since more than half showed testicular dysgen-
esis.l3 This finding is in accordance with our observation of
an abnormal SPT value in 40% of retractile testes. Our com-
parison of the mean S/T values between retractile and cryp-
torchid testes revealed a significantly higher SPT value in
retractile testes, corroborating with the findings of Rune et
al.11
Despite the fact that the SPT value of retractile testes is
significantly higher compared to cryptorchid testes, it is pos-
sible that the value itself may be providing a false prediction
of future fertility with retractile testes. We noted that retrac- esis that retraction of the testis is associated with histological
tile testes showed various phases of germ cell degeneration in change.3-8.l3 Since early surgical correction of cryptorchid
a single specimen compared to cryptorchid testes. Degener- testes is accepted, we suggest that hormonal or surgical
ated tubules were focally interspersed within normal tubules therapy be offered to patients with retractile testes lacking
in contrast to the diffusely spread out degeneration seen in spontaneous descent.
cmtorchid testes. Nistal and Paniama ., described this ~~~~-
find-
ing-as a mosaic pattern.4 Their explanation for the phenom-
enon was intratesticular excretory duct obstruction caused
by venous ectasia. The venous ectasia was thought to be
related to shortening of the spermatic cord and, therefore,
partial occlusion of the spermatic veins during retraction of
the testis. Considering the fact that the gem- cell number,
least damaged tubules horizontally sectioned while the dam-
aged tubules are not counted, it is possible that a significant
proportion of damaged tubules in a mosaic fashion were
ignored while calculating the SPT value. Thus, the SPT value
may only be providing a fraction of the total germ cell num-
ber, resulting in a false representation of the status of germ
cells in retractile testes. In this context, it is somewhat pre-
dictable that a significantly better Sertoli cell index, which is
determined similarly to the SPT value, was observed in re-
tractile compared to cryptorchid testes.
In contrast to germ cells, degeneration of Sertoli cells has
been somewhat overlooked in determining the extent of tes-
ticular damage, especially when one considers that the Ser-
toli cell increases in number, has an important hormonal
function after puberty and the effect of its degeneration at a
young age remains unclear. Sertoli cells give structural or-
ganization to the tubules and establish microenvironments
essential for the development and differentiation of the sper-
matogenic cells.14 They degrade the endocytotic vesicles and
cytoplasmic bodies released from prematurely sloughed dif-
ferentiating spermatids and germ cells. Rune et a1 proposed
that the reduction in germ cell number due to cryptorchidism
is also a consequence of Sertoli cell degeneration and that its
determination is at least as useful as the S/T value for pre-
dicting the extent of testicular damage." Our observation of
similar tubular degeneration phase V to VII values between
the retractile and cryptorchid groups could then indicate that
the state of testicular destruction in retractile testes is either
similar to cryptorchid testes or is somewhere in the spectrum
between normal and cryptorchid testes. Unlike the SPT value
or Sertoli cell index, tubular degeneration phase V to VII
represents the proportion of desloughed tubules that are in
phase V or greater among the total number of tubules. Thus,
the possibly overrated SPT and Sertoli cell index values in
conjunction with the tubular degeneration phase V to VII
ratio similar to cryptorchidism suggest that more active
treatment may be warranted in select patients with retrac-
tile testes. The questions of when and to whom should inter-
vention be given remain to be answered.
CONCLUSIONS
Our study is consistent with the former suggested hypoth-
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