Pediatric Cryptorchidism Surgery Workup
- Author: Marcos Perez-Brayfield, MD; Chief Editor: Marc Cendron, MD more...
Routine laboratory workup is not indicated with unilateral cryptorchidism.
Patients with bilateral nonpalpable testis and those with unilateral or bilateral undescended testis associated with hypospadias should undergo evaluation to rule out a disorder of sexual development (DSD). The evaluation should include chromosomal analysis and measurement of 17-hydroxylase progesterone, testosterone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH). For bilateral nonpalpable testis, abdominal-pelvic ultrasonography is advisable, mainly to determine if any müllerian structures, such as a uterus, are present.
Anorchia can be confirmed by means of hormonal stimulation with human chorionic gonadotropin (hCG), with baseline and poststimulation measurement of LH, FSH, and testosterone hormone levels. Many hCG stimulation protocols are described. The authors favor a single injection of hCG 2940 IU/m2 body surface area, with hormonal levels assessed at 72 hours. Anorchia is found in patients with elevated baseline LH and FSH levels and low testosterone levels without an increase in testosterone after stimulation.
Another marker of testicular function is müllerian-inhibiting substance (MIS; also known as antimüllerian hormone [AMH]). MIS levels that exceed 5 ng/mL suggest the presence of testicular tissue and are an indication for exploration. However, this study is rarely used and may not have any application in older children.
Imaging studies have little or no role in the diagnosis of cryptorchidism.
Ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and angiography have been used to detect undescended testes. However, these studies have unacceptable false-positive and false-negative rates. CT exposes the patient to high levels of radiation, and MRI requires sedation or anesthesia; both are costly.
Diagnostic laparoscopy (see the image below) is the most reliable technique for localizing the nonpalpable testis. It is performed in conjunction with definitive therapy (laparoscopic orchiopexy or open orchiopexy). Laparoscopic findings can be helpful in determining the need for inguinal exploration, for deciding between one-stage and two-stage repair, and for assessing gonadal viability. They can also help clarify the anatomy in complex DSD cases.
The histologic findings of an undescended testis range from normal histology to acquired germ-cell hypoplasia with Leydig cell hyperplasia. The severity of the histologic findings is correlated with an intra-abdominal testis, delayed orchiopexy, or both.
Carcinoma in situ is present in as many as 8% of infertile patients undergoing testicular biopsy with a history of orchiopexy. In children with undescended testis, the overall incidence of carcinoma in situ is approximately 0.4%. The clinical significance of these two findings is unclear.
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].
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].
Tasian GE, Copp HL, Baskin LS. Diagnostic imaging in cryptorchidism: utility, indications, and effectiveness. J Pediatr Surg. 2011 Dec. 46(12):2406-13. [Medline].
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].
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].
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].
Sfoungaris D, Mouravas V, Petropoulos A, Filippopoulos A. Prentiss orchiopexy applied in younger age group. J Pediatr Urol. 2011 Nov 1. [Medline].
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].
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].
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].
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].
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].
Giannopoulos MF, Vlachakis IG, Charissis GC. 13 Years' experience with the combined hormonal therapy of cryptorchidism. Horm Res. 2001. 55(1):33-7. [Medline].
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].
Hutson JM, Hasthorpe S, Heyns CF. Anatomical and functional aspects of testicular descent and cryptorchidism. Endocr Rev. 1997 Apr. 18(2):259-80. [Medline].
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].
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].
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].
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].
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].
Lee PA, Coughlin MT. Fertility after bilateral cryptorchidism. Evaluation by paternity, hormone, and semen data. Horm Res. 2001. 55(1):28-32. [Medline].
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].
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].
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].
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].
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].
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].
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].
Merry C, Sweeney B, Puri P. The vanishing testis: anatomical and histological findings. Eur Urol. 1997. 31(1):65-7. [Medline].
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].
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].
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].
Palmer LS, Gill B, Kogan SJ. Endocrine analysis of childhood monorchism. J Urol. 1997 Aug. 158(2):594-6. [Medline].
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].
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].
Pohl HG, Joyce GF, Wise M, Cilento BG Jr. Cryptorchidism and hypospadias. J Urol. 2007 May. 177(5):1646-51. [Medline].
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].
Sharma S, Sen A. Complete testicular epididymal dissociation in the abdominal cryptorchid testis. J Pediatr Urol. 2013 Jun 1. [Medline].
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].
Toppari J. Physiology and disorders of testicular descent. Endocr Dev. 2003. 5:104-9. [Medline].
Wood HM, Elder JS. Cryptorchidism and testicular cancer: separating fact from fiction. J Urol. 2009 Feb. 181(2):452-61. [Medline].