Pediatric Cryptorchidism Surgery Treatment & Management

Engle proposed hormonal manipulation as a treatment for cryptorchidism in the 1930s. Whether treatment is hormonal or surgical, the main goals 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.

Guidelines for management of pediatric cryptorchidism have been developed by the American Urological Association (AUA) ^[18]  and the Canadian Urological Association (CUA)–Pediatric Urologists of Canada (PUC) ^[19] (see Guidelines).

Hormonal therapy should be considered for patients in whom the diagnosis of retractile testis is not certain. For patients who are not candidates for surgical interventions, hormonal therapy might be appropriate. ^{[20, 21]}

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 less impressive results (~14%).

Multiple dosage schedules have been proposed. The authors' current protocol is 1000 IU/wk 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 would be required to identify specific characteristics of patient subgroups that would clearly benefit from such treatment. ^[22]

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. ^[23]

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. ^[24]

In a randomized study by Nazem et al, single-incision transscrotal orchiopexy (group I) was compared with traditional two-incision inguinal-scrotal orchiopexy (group II) in 100 children who required surgical treatment for undescended testis. ^[25] ​ Success rates were 98% in group I and 94% in group II, and the two groups did not differ significantly with respect to wound infection, testicular atrophy, testicular hypotrophy, and relapse. However, the single-incision transscrotal approach was judged more successful in terms of cosmetic results, patient satisfaction, and duration of hospitalization.

In a randomized controlled trial evaluating the effects of scrotal (n = 50) versus inguinal orchiopexy (n = 50) on the testicular function of children with clinically palpable inguinal undescended testis, Huang et al found no apparent differences between groups with respect to testicular volume, serum testosterone, or anti-müllerian hormone (AMH) and inhibin B (InhB) levels at 6 and 12 months after operation. ^[26] The groups also did not differ with respect to operating time and intraoperative blood loss. Although the overall complication rate was slightly lower in the scrotal group than in the inguinal group (2.0% vs 8.0%), the difference was not statistically significant.

Several studies reported successful treatment of cryptorchidism with laparoscopic techniques. ^{[27, 28]} A systematic review and meta-analysis of five studies (N = 705) by Anand et al concluded that laparoscopic orchiopexy was safe and effective in children with palpable cryptorchidism and was comparable to conventional open orchiopexy with respect to the rates of redo orchiopexy, early complications, and testicular atrophy. ^[29]

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 should be considered but is controversial. ^[30]

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. ^[31]

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.

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.

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%) - This can often be corrected by means of redo orchiopexy ^[32]
• Epididymo-orchitis
• Hydrocele

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.

Early orchiopexy performed before age 2 years may prevent possible damage to the testis and may improve spermatogenetic viability. The data from one study indicated that orchiopexy, when performed on patients younger than 2 years, resulted in significant recovery of testicular volume at follow-up. ^[33] These results suggested that the timing of surgery is a significant factor for recovery of delayed cryptorchid testicular growth.

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

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.