Pediatric Cryptorchidism Surgery Guidelines

Updated: Aug 09, 2017
  • Author: Marcos Perez-Brayfield, MD; Chief Editor: Marc Cendron, MD  more...
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Guidelines

AUA Guidelines

In 2014, the American Urological Association (AUA) issued the following statements regarding evaluation and treatment of cryptorchidism. [12]

Diagnosis

AUA diagnostic recommendations are as follows:

  • Providers should obtain a gestational history during the initial evaluation of boys with suspected cryptorchidism (standard; grade B evidence)
  • Primary care providers should palpate testes for quality and position at each recommended well-child visit (standard; grade B evidence)
  • Providers should refer infants with a history of cryptorchidism (detected at birth) who do not have spontaneous testicular descent by 6 months (corrected for gestational age) to an appropriate surgical specialist for timely evaluation (standard; grade B evidence)
  • Providers should refer boys with the possibility of newly diagnosed (acquired) cryptorchidism after 6 months (corrected for gestational age) to an appropriate surgical specialist (standard; grade B evidence)
  • Providers must immediately consult an appropriate specialist for all phenotypic male newborns with bilateral, nonpalpable testes for evaluation of a possible disorder of sex development (DSD) (standard; grade A evidence)
  • Providers should not perform ultrasonography (US) or other imaging modalities to evaluate boys with cryptorchidism prior to referral, in that these studies rarely assist in decision-making (standard; grade B evidence)
  • Providers should assess the possibility of a DSD when there is increasing severity of hypospadias with cryptorchidism (recommendation; grade C evidence)
  • In boys with bilateral, nonpalpable testes who do not have congenital adrenal hyperplasia (CAH), providers should measure müllerian-inhibiting substance (MIS; anti-müllerian hormone [AMH]) and consider additional hormone testing to evaluate for anorchia (option; grade C evidence)
  • In boys with retractile testes, providers should assess the position of the testes at least annually to monitor for secondary ascent (standard; grade B evidence)

Treatment

AUA therapeutic recommendations are as follows:

  • Providers should not use hormonal therapy to induce testicular descent; evidence shows low response rates and lack of evidence for long-term efficacy (standard; grade B evidence)
  • In the absence of spontaneous testicular descent by 6 months (corrected for gestational age), specialists should perform surgery within the next year (standard; grade B evidence)
  • In prepubertal boys with palpable, cryptorchid testes, surgical specialists should perform scrotal or inguinal orchidopexy (standard; grade B evidence)
  • In prepubertal boys with nonpalpable testes, surgical specialists should perform examination under anesthesia to reassess for palpability of testes; if testes are nonpalpable, surgical exploration and, if indicated, abdominal orchidopexy should be performed (standard; grade B evidence)
  • At the time of exploration for a nonpalpable testis in boys, surgical specialists should identify the status of the testicular vessels to help determine the next course of action (clinical principle)
  • In boys with a normal contralateral testis, surgical specialists may perform an orchiectomy (removal of the undescended testis) if a boy has a normal contralateral testis and either very short testicular vessels and vas deferens, dysmorphic or very hypoplastic testis, or postpubertal age (clinical principle)
  • Providers should counsel boys with a history of cryptorchidism, monorchidism, or both, as well as their parents, regarding potential long-term risks and should provide education on infertility and cancer risk (clinical principle)
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CUA-PUC Guidelines

In 2017, the Canadian Urological Association (CUA) and the Pediatric Urologists of Canada (PUC) formulated a guideline for the diagnosis, management, and follow-up of cryptorchidism. [13]  Recommendations included the following:

  • Imaging in cryptorchidism is not cost-effective, may delay referral and surgical treatment, and thus cannot be recommended as a standard adjunct to preoperative assessment of these children (level 3 evidence; grade B recommendation)
  • Routine karyotype or genetic workup of patients with undescended testis (UDT) is not recommended (level 4 evidence; grade D recommendation)
  • A karyotype should be performed in patients with at least one UDT and proximal hypospadias, especially in the setting of nonpalpable gonads (level 4 evidence; grade D recommendation)
  • Consideration should be given to include targeted WT1 genetic testing in patients with proximal hypospadias and at least one UDT (level 3 evidence; grade C recommendation)
  • When müllerian remnants are found incidentally during an inguinal orchidopexy, the proximal aspect of the fallopian tube can be transected and removed with the uterus, with the distal component left attached to the vas deferens, allowing the testis to be brought to a scrotal position (level 4 evidence; grade D recommendation)
  • Hormone therapy has a limited role in the management of cryptorchidism and should not be recommended as first-line therapy (level 2 evidence; grade B recommendation)
  • Orchidopexy is best performed between 6 and 18 months of age (level 2 evidence; grade B recommendation)
  • For palpable UDT undergoing surgery, both inguinal and prescrotal techniques are acceptable, depending on the surgeon’s preference and experience (level 2 evidence; grade B recommendation)
  • In uncertain cases or when tissue analysis is not consistent with atrophic testicular tissue, laparoscopic exploration should be strongly considered (level 4 evidence; grade C recommendation)
  • In the absence of literature strongly supporting or discouraging prophylactic orchidopexy, the decision should be made on the basis of informed discussion of options with the parents or legal guardian (level 5 evidence; grade D recommendation)
  • Given the reports of testicular cancer [8] (sometimes early) in these patients, orchidopexy is recommended when they are clinically fit for anesthesia for the purpose of surveillance (level 4 evidence; grade D recommendation)
  • Redo orchidopexy should be offered for cases where inadequate position is detected postoperatively (level 5 evidence; grade D recommendation)
  • Orchiectomy should be considered for postpubertal patients with hypotrophic/atrophic undescended testicles up to the age of 50 (level 4 evidence; grade D recommendation)
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