Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Pediatric Cryptorchidism Surgery Treatment & Management

  • Author: Marcos Perez-Brayfield, MD; Chief Editor: Marc Cendron, MD  more...
 
Updated: Jul 27, 2015
 

Approach Considerations

Engle proposed hormonal manipulation as a treatment for cryptorchidism in the 1930s. The main goals of treatment, whether hormonal or surgical, are as follows:

  • To allow the testicle to occupy a normal anatomic position
  • To preserve fertility and hormonal production
  • To diagnose potential testicular malignancies

Other putative benefits include correction of associated hernias and prevention of testicular torsion.

The risk of trauma and possible psychological effects of having a missing testis must be taken into account. Orchiopexy should be considered after 4 months of life; the rate of descent diminishes considerably after this point.

For postpubertal adolescents and men younger than 32 years who underwent unilateral orchiopexy, orchiectomy should be considered. For postpubertal men older than 32 years, close observation and routine physical examination should be considered. Any man with bilateral undescended testes should undergo bilateral testicular biopsy and orchiopexy.

Patients with bilateral anorchia or a disorder of sexual development (DSD) may benefit from a consultation with a pediatric endocrinologist.

No changes in diet are required after treatment. After surgery, patients should be advised to limit their activities for a week and refrain from straddling.

Next

Medical Care

Hormonal therapy should be considered in patients in whom the diagnosis of retractile testis is not certain. In patients who are not candidates for surgical interventions, hormonal therapy might be appropriate. Hormonal therapy has been employed in Europe for many years as a primary therapy for cryptorchidism; the main hormones used are human chorionic gonadotropin (hCG) and luteinizing hormone (LH)-releasing hormone (LHRH). In Europe, these two hormones have been given in combination, with initial success rates of 14-65%; however, some long-term studies have shown lower success rates.

Like LH, hCG acts on Leydig cells to stimulate the production of gonadal steroid hormones; however, its effects on testicular descent are not fully understood. In most patients with retractile testis, the condition responds to hCG. Studies have shown short-term success rates as high as 70%. Controlled studies have shown results less impressive than this, with rates around 14%. Multiple dosage schedules have been proposed. The authors' current protocol is 1000 IU/week for children who weigh less than 10 kg, 1500 IU/wk for children who weigh 10-20 kg, and 2500 IU/wk for children who weigh more than 20 kg. The duration of therapy is 4 weeks.

LHRH acts indirectly in the pituitary by stimulating the release of LH and follicle-stimulating hormone (FSH). LHRH may be more efficient in increasing testosterone than hCG is. LHRH is currently available only in Europe for use in cryptorchidism. Success rates are similar to those of hCG and are in the range of 10-15%.

Adverse effects from both hormonal therapies include increase in scrotal rugae, pigmentation, growth of pubic hair, increased penile size, and erections. LHRH has fewer adverse effects than hCG does.

A meta-analysis by Chua et al suggested that in a subset of children with cryptorchidism, gonadotropin-releasing hormone (GnRH) might be beneficial as an adjunct to orchidopexy in improving the fertility index; however, additional study will be required to identify specific characteristics of patient subgroups that will clearly benefit from such treatment.[4]

Previous
Next

Surgical Care

Several surgical approaches to the undescended testis have been described. The approach chosen is determined by the position of the testis and the surgeon's expertise.

The palpable testis can be approached via a scrotal, subinguinal, inguinal, or suprainguinal approach. The nonpalpable testis can be approached via an inguinal, suprainguinal, or laparoscopic approach.

During the period between January 2002 and July 2009, one study showed a shift in surgical approach toward more scrotal-approach procedures for palpable testes and fewer transinguinal abdominal orchidopexies for nonpalpable testes.[5]  In a prospective study of 200 patients with palpable undescended testis who underwent orchidopexy via either a two-incision inguinal approach or a single-incision scrotal approach between January 2011 and December 2013, Ben Dhaou et al found the latter approach to be safe and effective for undescended testicles palpable in the inguinal canal or in a high scrotal position.[6]

Routine testicular biopsy during orchiopexy is not recommended and should be considered only in cases involving prune belly syndrome, ambiguous genitalia, abnormal karyotypes, or postpubertal adolescents or men. Some authors have recommended that, if the biopsy reveals carcinoma in situ, repeat exploration and unilateral orchiectomy should be performed. In bilateral cases, radiation therapy may be useful.

Palpable testis

Look for the testis after incising the Scarpa fascia to avoid injuring a testis and its cord found outside of the external inguinal ring (ectopic testis in the superficial inguinal pouch).

Divide all attachments, including the gubernaculum, the cremasteric fibers, and the lateral spermatic fascia.

Identify the patent processus vaginalis in the anteromedial surface of the cord, separate it from the cord structures, and perform a high ligation; be careful not to trap the vas or vessels.

Place the testis in a subdartos pouch.

Nonpalpable testis

Diagnostic laparoscopy should be preferred to inguinal exploration.

Blind-ending vas and vessels confirm the diagnosis of a vanishing testis and do not warrant further therapy. Consideration should be given to exploring the contralateral scrotum and placing some anchoring stitches to prevent possible testis torsion on the other side.

Vessels entering the internal inguinal ring require further inguinal or scrotal exploration to identify the undescended testis or testicular nubbin.

In patients with findings of a vanishing testis or a testicular nubbin, fixation of the contralateral testis fixation should be considered but is controversial.

A small intra-abdominal testis or an abnormal testis requires orchiectomy.

Length-increasing maneuvers

The Prentiss maneuver involves rerouting the cord under the epigastric vessels or the division of epigastric vessels.[7]

The internal inguinal ring can be opened to perform more complete retroperitoneal mobilization.

The Fowler-Stephens principle involves dividing the testicular vessels to allow the blood supply to the vas deferens to keep the undescended testis viable. The testicular vessels should be divided away from the testis.

Testicular autotransplantation can be performed by transecting the testicular vessels and by performing a microvascular anastomosis to the inferior epigastric vessels.

Complications

Complications related to the surgical correction of the maldescended testis include the following:

  • Testicular atrophy (5%)
  • Injury to vas deferens (1%-2%)
  • Reascent of the testicle or abnormal anatomic position (< 10%)
  • Epididymoorchitis
  • Hydrocele
Previous
Next

Prevention

Early orchiopexy performed before age 2 years may prevent possible damage to the testis and may improve spermatogenetic viability. The data from one study noted that orchiopexy, when performed on patients younger than 2 years, resulted in significant recovery of testicular volume at follow-up.[8] These results suggest that time of surgery is a significant factory for recovery of delayed cryptorchid testicular growth.

Previous
Next

Long-Term Monitoring

The surgical procedure is done on an outpatient basis. Pain control medications should be prescribed as needed; minimal pain medication is required in the first 24-48 hours. The surgical incision site should be kept dry for 48 hours. If surgical buttons were used, consider removing them 7-10 days after the operation.

Children should avoid playing on straddle toys and participating in physical education for 1-2 weeks after surgery.

Office visits should be scheduled postoperatively and at 1 year to evaluate the location, size, and viability of the testis. Consideration should be given to seeing the patient again at the time of puberty. Discussions of fertility issues and the need for self-examination to detect cancer should be revisited.

Previous
 
 
Contributor Information and Disclosures
Author

Marcos Perez-Brayfield, MD Consulting Staff, HIMA-San Pablo; Assistant Professor, University of Puerto Rico School of Medicine

Marcos Perez-Brayfield, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Urological Association

Disclosure: Nothing to disclose.

Coauthor(s)

Andrew J Kirsch, MD, FAAP, FACS Clinical Professor of Urology, Chief of Pediatric Urology, Emory University School of Medicine, Children's Healthcare of Atlanta; Partner, Georgia Urology, PA

Andrew J Kirsch, MD, FAAP, FACS is a member of the following medical societies: American Academy of Pediatrics, American Urological Association, Society for Fetal Urology

Disclosure: Received consulting fee from Salix for speaking and teaching; Received royalty from Cook for device.

Adam G Baseman, MD Pediatric Urologist, North Texas Pediatric Urology Associates, Urology Clinics of North Texas

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Harry P Koo, MD Chairman of Urology Division, Director of Pediatric Urology, Professor of Surgery, Virginia Commonwealth University School of Medicine, Medical College of Virginia; Director of Urology, Children's Hospital of Richmond

Harry P Koo, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Urological Association

Disclosure: Nothing to disclose.

Chief Editor

Marc Cendron, MD Associate Professor of Surgery, Harvard School of Medicine; Consulting Staff, Department of Urological Surgery, Children's Hospital Boston

Marc Cendron, MD is a member of the following medical societies: American Academy of Pediatrics, American Urological Association, New Hampshire Medical Society, Society for Pediatric Urology, Society for Fetal Urology, Johns Hopkins Medical and Surgical Association, European Society for Paediatric Urology

Disclosure: Nothing to disclose.

Additional Contributors

Bartley G Cilento, Jr, MD Instructor, Department of Surgery, Division of Urology, Children's Hospital of Boston and Harvard Medical School

Bartley G Cilento, Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Urological Association, Massachusetts Medical Society

Disclosure: Nothing to disclose.

References
  1. Barthold JS, Redman JF. Association of epididymal anomalies with patent processus vaginalis in hernia, hydrocele and cryptorchidism. J Urol. 1996 Dec. 156(6):2054-6. [Medline].

  2. Nguyen MT, Showalter PR, Timmons CF, Nef S, Parada LF, Baker LA. Effects of orchiopexy on congenitally cryptorchid insulin-3 knockout mice. J Urol. 2002 Oct. 168(4 Pt 2):1779-83; discussion 1783. [Medline].

  3. Tasian GE, Copp HL, Baskin LS. Diagnostic imaging in cryptorchidism: utility, indications, and effectiveness. J Pediatr Surg. 2011 Dec. 46(12):2406-13. [Medline].

  4. Chua ME, Mendoza JS, Gaston MJ, Luna SL Jr, Morales ML Jr. Hormonal therapy using gonadotropin releasing hormone for improvement of fertility index among children with cryptorchidism: a meta-analysis and systematic review. J Pediatr Surg. 2014 Nov. 49 (11):1659-67. [Medline].

  5. Cuda SP, Srinivasan AK, Kalisvaart J, Kirsch AJ. Evolution of single practice trends in the surgical approach to the undescended testicle. J Urol. 2011 Jun. 185(6 Suppl):2451-4. [Medline].

  6. Ben Dhaou M, Zouari M, Zitouni H, Jallouli M, Mhiri R. [Comparison of the inguinal and scrotal approaches for the treatment of cryptorchidism in children]. Prog Urol. 2015 Jun 17. [Medline].

  7. Sfoungaris D, Mouravas V, Petropoulos A, Filippopoulos A. Prentiss orchiopexy applied in younger age group. J Pediatr Urol. 2011 Nov 1. [Medline].

  8. Kim SO, Hwang EC, Hwang IS, et al. Testicular Catch up Growth: The Impact of Orchiopexy Age. Urology. 2011 Oct. 78(4):886-9. [Medline].

  9. Banieghbal B, Davies M. Laparoscopic evaluation of testicular mobility as a guide to management of intra-abdominal testes. World J Urol. 2003 May. 20(6):343-5. [Medline].

  10. Bassel YS, Scherz HC, Kirsch AJ. Scrotal incision orchiopexy for undescended testes with or without a patent processus vaginalis. J Urol. 2007 Apr. 177(4):1516-8. [Medline].

  11. Breyer BN, DiSandro M, Baskin LS, Hsieh MH. Obesity does not decrease the accuracy of testicular examination in anesthetized boys with cryptorchidism. J Urol. 2009 Feb. 181(2):830-4. [Medline].

  12. Ferlin A, Simonato M, Bartoloni L, et al. The INSL3-LGR8/GREAT ligand-receptor pair in human cryptorchidism. J Clin Endocrinol Metab. 2003 Sep. 88(9):4273-9. [Medline].

  13. Giannopoulos MF, Vlachakis IG, Charissis GC. 13 Years' experience with the combined hormonal therapy of cryptorchidism. Horm Res. 2001. 55(1):33-7. [Medline].

  14. Hack WW, van der Voort-Doedens LM, Sijstermans K, Meijer RW, Pierik FH. Reduction in the number of orchidopexies for cryptorchidism after recognition of acquired undescended testis and implementation of expectative policy. Acta Paediatr. 2007 Jun. 96(6):915-8. [Medline].

  15. Hutson JM, Hasthorpe S, Heyns CF. Anatomical and functional aspects of testicular descent and cryptorchidism. Endocr Rev. 1997 Apr. 18(2):259-80. [Medline].

  16. Hutson JM, Southwell BR, Li R, Lie G, Ismail K, Harisis G, et al. The Regulation of Testicular Descent and the Effects of Cryptorchidism. Endocr Rev. 2013 May 10. [Medline].

  17. Kaleva M, Arsalo A, Louhimo I, et al. Treatment with human chorionic gonadotrophin for cryptorchidism: clinical and histological effects. Int J Androl. 1996 Oct. 19(5):293-8. [Medline].

  18. Koff SA, Sethi PS. Treatment of high undescended testes by low spermatic vessel ligation: an alternative to the Fowler-Stephens technique. J Urol. 1996 Aug. 156(2 Pt 2):799-803; discussion 803. [Medline].

  19. Law GS, Perez LM, Joseph DB. Two-stage Fowler-Stephens orchiopexy with laparoscopic clipping of the spermatic vessels. J Urol. 1997 Sep. 158(3 Pt 2):1205-7. [Medline].

  20. Lee MM, Donahoe PK, Silverman BL, et al. Measurements of serum müllerian inhibiting substance in the evaluation of children with nonpalpable gonads. N Engl J Med. 1997 May 22. 336(21):1480-6. [Medline].

  21. Lee PA, Coughlin MT. Fertility after bilateral cryptorchidism. Evaluation by paternity, hormone, and semen data. Horm Res. 2001. 55(1):28-32. [Medline].

  22. Lee PA, Coughlin MT. The single testis: paternity after presentation as unilateral cryptorchidism. J Urol. 2002 Oct. 168(4 Pt 2):1680-2; discussion 1682-3. [Medline].

  23. Lee PA, O'Leary LA, Songer NJ, et al. Paternity after bilateral cryptorchidism. A controlled study. Arch Pediatr Adolesc Med. 1997 Mar. 151(3):260-3. [Medline].

  24. Lenzi A, Gandini L, Lombardo F, et al. Unilateral cryptorchidism corrected in prepubertal age: evaluation of sperm parameters, hormones, and antisperm antibodies in adult age. Fertil Steril. 1997 May. 67(5):943-8. [Medline].

  25. Lewis AG, Pecha BR, Smith EP, et al. Early orchiopexy restores fertility in the Hoxa 11 gene knockout mouse. J Urol. 2003 Jul. 170(1):302-5. [Medline].

  26. Lim HN, Hughes IA, Hawkins JR. Clinical and molecular evidence for the role of androgens and WT1 in testis descent. Mol Cell Endocrinol. 2001 Dec 20. 185(1-2):43-50. [Medline].

  27. Lindgren BW, Darby EC, Faiella L, et al. Laparoscopic orchiopexy: procedure of choice for the nonpalpable testis?. J Urol. 1998 Jun. 159(6):2132-5. [Medline].

  28. Matthews LA, Abdul-Karim FW, Elder JS. Effect of preoperative human chorionic gonadotropin on intra-abdominal rat testes undergoing standard and Fowler-Stephens orchiopexy. J Urol. 1997 Jun. 157(6):2315-7. [Medline].

  29. Merry C, Sweeney B, Puri P. The vanishing testis: anatomical and histological findings. Eur Urol. 1997. 31(1):65-7. [Medline].

  30. Miller KD, Coughlin MT, Lee PA. Fertility after unilateral cryptorchidism. Paternity, time to conception, pretreatment testicular location and size, hormone and sperm parameters. Horm Res. 2001. 55(5):249-53. [Medline].

  31. Mirilas P, Mamoulakis C, De Almeida M. Puberty does not induce serum antisperm surface antibodies in patients with previously operated cryptorchidism. J Urol. 2003 Dec. 170(6 Pt 1):2432-5. [Medline].

  32. Nane I, Ziylan O, Esen T, Kocak T, Ander H, Tellaloglu S. Primary gonadotropin releasing hormone and adjunctive human chorionic gonadotropin treatment in cryptorchidism: a clinical trial. Urology. 1997 Jan. 49(1):108-11. [Medline].

  33. Palmer LS, Gill B, Kogan SJ. Endocrine analysis of childhood monorchism. J Urol. 1997 Aug. 158(2):594-6. [Medline].

  34. Penson D, Krishnaswami S, Jules A, McPheeters ML. Effectiveness of hormonal and surgical therapies for cryptorchidism: a systematic review. Pediatrics. 2013 Jun. 131(6):e1897-907. [Medline].

  35. Pettersson A, Richiardi L, Nordenskjold A, Kaijser M, Akre O. Age at surgery for undescended testis and risk of testicular cancer. N Engl J Med. 2007 May 3. 356(18):1835-41. [Medline].

  36. Pohl HG, Joyce GF, Wise M, Cilento BG Jr. Cryptorchidism and hypospadias. J Urol. 2007 May. 177(5):1646-51. [Medline].

  37. Radmayr C, Oswald J, Schwentner C, Neururer R, Peschel R, Bartsch G. Long-term outcome of laparoscopically managed nonpalpable testes. J Urol. 2003 Dec. 170(6 Pt 1):2409-11. [Medline].

  38. Sharma S, Sen A. Complete testicular epididymal dissociation in the abdominal cryptorchid testis. J Pediatr Urol. 2013 Jun 1. [Medline].

  39. Thorsson AV, Christiansen P, Ritzen M. Efficacy and safety of hormonal treatment of cryptorchidism: current state of the art. Acta Paediatr. 2007 May. 96(5):628-30. [Medline].

  40. Toppari J. Physiology and disorders of testicular descent. Endocr Dev. 2003. 5:104-9. [Medline].

  41. Wood HM, Elder JS. Cryptorchidism and testicular cancer: separating fact from fiction. J Urol. 2009 Feb. 181(2):452-61. [Medline].

 
Previous
Next
 
Hypoplastic right hemiscrotum in a patient with an undescended right testis.
Ectopic testis.
Diagnostic laparoscopy of a crossed ectopic testis.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.