Management of Undescended Testes

Benefits and Risks of Orchiopexy

• The American Urological Association and European Association of Urology recommend orchiopexy to improve fertility potential and reduce cancer risk in individuals with undescended testes, with benefits including improved potential for fertility, reduced risk of testicular cancer, prevention of testicular torsion, and treatment of any associated inguinal hernia 1
• Orchiopexy has a high success rate (>96%) with very low risk of testicular atrophy (<2%) 1
• Prepubertal orchiopexy results in a 2-6 fold reduction in testicular cancer risk compared to postpubertal orchiopexy 1
• Unilateral cryptorchidism typically has minimal impact on overall fertility, while bilateral cryptorchidism is associated with a paternity rate of 35-53% 2, 1
• There is a 2.75-8 times increased relative risk of testicular cancer compared to the general population, but early orchiopexy (prepubertal) results in a 2-6 fold reduction in relative risk compared to postpubertal orchiopexy, as noted by the European Association of Urology 1

Diagnosis and Referral

• Infants with undescended testes should be referred to a surgical specialist (pediatric urologist) if testes remain undescended at 6 months of corrected gestational age, as recommended by the American Urological Association (AUA) guidelines 1
• The American College of Surgeons recommends against the use of ultrasound prior to referral due to poor sensitivity (45%) and specificity (78%) for non-palpable testes, and instead recommends a thorough physical examination under optimal conditions to confirm the non-palpable status of the testes 1
• The distribution of non-palpable testes is as follows:

1

• The following table summarizes the rates of cryptorchidism in premature and full-term infants:

1

Treatment and Outcomes

• Orchiopexy is the standard of treatment in the United States, with a success rate greater than 96% (range 89-100%) for open surgical intervention, and is recommended by the American Urological Association (AUA) guidelines 1
• Subsequent testicular atrophy is uncommon (<2%) after orchiopexy, and hormonal therapy has poor overall success rates, including human chorionic gonadotropin (hCG) 1, 2
• Early intervention (before 18 months) is recommended to preserve fertility potential, with secondary cryptorchidism typically requiring orchiopexy, as spontaneous re-descent is unlikely 1
• After 15-18 months of age, some cryptorchid boys begin to lack germ cells in the testes, with the number of boys without germ cells increasing with age, reaching about 40% in bilateral cryptorchid boys by 8-11 years, as noted by the American Urological Association (AUA) guidelines 1

Post-Operative Care and Recommendations

• Regular testicular self-examination after puberty is recommended to facilitate early cancer detection, as advised by the American Urological Association and the American Academy of Pediatrics 2, 1
• Parents should be informed about potential complications, including surgical risks, testicular atrophy, possibility of finding an abnormal testis requiring removal, and need for potential follow-up procedures if the initial surgery is not successful 1
• Patients should be counseled regarding potential long-term risks of infertility and cancer, and men with cryptorchidism may be at higher risk of hypogonadism, as recommended by the American Urological Association (AUA) guidelines 1
• Retractile testes are at increased risk for secondary ascent due to hyperactive cremasteric reflex, foreshortened patent processus vaginalis, and entrapping adhesions, and require annual monitoring to monitor for secondary ascent, with Grade B evidence 1