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La cryptorchidie et l’endocrinologue: conceptions récentes

Cryptorchidism and endocrinology: present approach

Resume

La cryptorchidie de l’enfant, qualifiée de commune par sa fréquence (qui oscille entre 0.8 et 1.6%), reste, en 1997, une endocrinopathie mystérieuse. Elle relève vraisemblablement d’un déficit néonatal de la sécrétion de testostérone secondaire à une insuffisance gonadotrope précoce et persistante jusqu’à la mi-puberté.

Son traitement par les gonadotrophines chorioniques entraîne une migration complète du testicule dans 1/3 des cas environ, une migration partielle ou asymétrique dans 1/3 des cas; il est inefficace dans 1/3 des cas. En cas d’échec, l’orchidopexie précoce est de règle. Le traitement par le LHRH est, quant à lui, tombé en désuétude.

Le pronostic de la cryptorchidie est dominé par les risques de stérilité et de cancer du testicule. Malheureusement, l’analyse des données de la littérature est particulièrement contradictoire du fait de l’absence de définition des groupes de patients étudiés. Néanmoins, l’atteinte de la spermatogénèse semble plus intense pour les cryptorchidies qui ont résisté au traitement hormonal et pour les cryptorchidies bilatérales. Quant au risque de dégénérescence, sans exclure une anomalie intrinsèque de la cellule germinale, il paraît être plus important après orchidopexie, après un traitement précoce, et apreès biopsie testiculaire.

A la lumière des travaux très récents, plusieurs questions essentielles se posent:

  • • Faut-il réaliser une orchidopexie systématique chez les enfants résistants au traitement hormonal?

  • • Faut-il privilégier la fertilité au détriment d’un risque de cancer du testicule en maintenant l’indication d’une orchidopexie précoce?

  • • Faut-il arrêter définitivement de biopsier les testicules cryptorchides?

Pour tenter de répondre à ces questions essentielles, seule une étude prospective impliquant la collaboration de pédiatres endocrinologues, biologistes de la reproduction, urologues, andrologues, permettrait de lever une partie du voile de la physiopathologie de cette endocrinopathie encore fort complexe.

Abstract

Cryptorchidism in che child is still a mysterious endocrinopathy in 1997, although it is considered to be fairly common because of its frequency, which varies between 0.8 and 1.6%. It appears to be due to a neonatal deficiency in testosterone secretion secondary to a neonatal gonadotropic insufficiency that persists into mid-puberty.

Treatment with chorionic gonadotrophins leads to the complete migration of the testes in approximately one-third of the cases; partial or asymetric migration in another third, and is ineffective in the remaining cases. In the case of failure, early orchidopexy is the rule. Treatment by LHRH has been abandoned.

The prognostic is dominated by the risks of sterility and testicular cancer. Unfortunately, an analysis of the literature shows marked contradictions in the data because patient groups have not been clearly defined. Nevertheless, spermatogenesis seems to be more affected in children who have resisted hormonal treatment and in bilateral cryptorchidism. Without excluding an intrinsic anomaly of the germinal cell, the risk of deterioration seems greater following orchidopexy, early treatment, and testicular biopsy.

In light of the most recent work, several essential questions arise:

Should orchidopexy be systematic in children resistant to hormone treatment?

Should concerns about fertility remain more important than the risk of testicular cancer —by maintaining the indication for early orchidopexy?

Should the biopsy of the cryptorchid testes be definitively dropped?

To respond to these questions, a prospective study is needed, with the collaboration of pediatric endocrinologists, reproductive biologists, urologists and andrologists, to further advance our understanding of the physiopathology of this highly complex endocrinopathy.

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Sultan, C. La cryptorchidie et l’endocrinologue: conceptions récentes. Androl. 7, 481–487 (1997). https://doi.org/10.1007/BF03035275

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