Ascending testis: A congenital predetermined condition

About 0.8% of boys have undescended testes at 1 year of age. However, the overall rate of orchidopexy is 2.5 times that expected. While studies have shown ascending testes accounting for a proportion of such discrepancy, the aetiology of this ascent remains controversial. In this study, intra-operative findings of patients underwent orchidopexy for ascending testes are evaluated to infer aetiology.

Patients with confirmed ascending testes from a single paediatric surgery unit over a four-year period from June 2015 till June 2019 were included in this observational study. During orchidopexy procedure, intra-operative findings in terms of gubernacular attachment, and the degree of epididymal attachment to the upper pole of the testicle were primarily evaluated. Secondary findings including the presence and length of patent processus vaginalis (PPV), and the presence of any long looping vas or hydatid of morgangi were also noted.

Eighty-three children (median age = 79 months [range 38-149]) were included in this study. Two boys had bilateral ascending testes leading to a total of 85 orchidopexy cases performed. All patients were found to have a gubernacular attachment proximal to the junction between the upper lateral wall of scrotum and the medial part of the thigh. PPV was present in all cases, with its length measured from the deep inguinal ring after retracting the conjoint tendon ranging from 4 to 15 mm 84 cases (98.8%) demonstrated complete or partial separation between the head of epididymis and the upper pole of the testicle. Hydatid of morgagni was present in 82 cases (96.4%), and none of the operated testicles demonstrated looping vas.

The varying degrees of PPV length demonstrated during orchiodpexy for ascending testes in this study casts a doubt on the role of processus vaginalis in such ascent. Also, there is considerably a wide-range of reported incidence (13-78%) in literature for PPV in ascending testes. In this study, intra-operative findings demonstrated an abnormal gubernaculum attachment in all ascending testes in keeping with previous reports, and support the hypothesis that ascending testis has always been undescended, yet acquired more apparent undescended position with child age and growth.

Patients with ascending testes seem to share similar intra-operative findings with patients who have true undescended testes. The universal abnormal attachment of the gubernaculum and the omnipresent testicular-epididymal fusion anomalies may indicate that ascending testis is a congenital predetermined condition, and that these testes have always been congenitally undescended, yet obtained a more noticeable position with the child growth.