Pediatric Cryptorchidism Surgery Workup

Updated: Sep 30, 2019
  • Author: Marcos Perez-Brayfield, MD; Chief Editor: Marc Cendron, MD  more...
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Workup

Laboratory Studies

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 sex 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 (US) 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]). [11] MIS levels that exceed 5 ng/mL suggest the presence of testicular tissue and are an indication for exploration. However, this study is not yet in widespread use, and its applicability to older children remains to be defined.

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Imaging Studies

Imaging studies have little or no role in the diagnosis of cryptorchidism.

US, 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. [12]

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Diagnostic Laparoscopy

Diagnostic laparoscopy (see the image below) is the most reliable technique for localizing the nonpalpable testis. [13] 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.

Diagnostic laparoscopy of a crossed ectopic testis Diagnostic laparoscopy of a crossed ectopic testis.
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Histologic Findings

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.

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