Operative management of cryptorchidism: guidelines and reality--a 10-year observational analysis of 3587 cases

Mini-Puberty, Physiological and Disordered: Consequences, and Potential for Therapeutic Replacement

There are 3 physiological waves of central hypothalamic-pituitary-gonadal (HPG) axis activity over the lifetime. The first occurs during fetal life, the second-termed "mini-puberty"-in the first months after birth, and the third at puberty. After adolescence, the axis remains active all through adulthood. Congenital hypogonadotropic hypogonadism (CHH) is a rare genetic disorder characterized by a deficiency in hypothalamic gonadotropin-releasing hormone (GnRH) secretion or action. In cases of severe CHH, all 3 waves of GnRH pulsatility are absent. The absence of fetal HPG axis activation manifests in around 50% of male newborns with micropenis and/or undescended testes (cryptorchidism). In these boys, the lack of the mini-puberty phase accentuates testicular immaturity. This is characterized by a low number of Sertoli cells, which are important for future reproductive capacity. Thus, absent mini-puberty will have detrimental effects on later fertility in these males. The diagnosis of CHH is often missed in infants, and even if recognized, there is no consensus on optimal therapeutic management. Here we review physiological mini-puberty and consequences of central HPG axis disorders; provide a diagnostic approach to allow for early identification of these conditions; and review current treatment options for replacement of mini-puberty in male infants with CHH. There is evidence from small case series that replacement with gonadotropins to mimic "mini-puberty" in males could have beneficial outcomes not only regarding testis descent, but also normalization of testis and penile sizes. Moreover, such therapeutic replacement regimens in disordered mini-puberty could address both reproductive and nonreproductive implications.

Surgical treatment of cryptorchidism: current insights and future directions

Cryptorchidism presents with an incidence of 1-5% with potential long-term implications on future fertility and overall health. This review focuses on surgical treatment modalities, their impact on testicular development, and function while addressing the Nordic consensus statement as well as current European Association of Urology (EAU) and American Urological Association (AUA) guidelines. Congenital and acquired cryptorchidism present distinctive challenges in surgical management, with different implications for fertility. While congenital cryptorchidism entails a risk to fertility and warrants early intervention, both retractile testes and acquired cryptorchidism also pose risks to fertility potential, underscoring the importance of evaluating treatment options. Testicular location and the child's age form the basis of a practical classification system for undescended testicles. Early diagnosis by clinical examination enables timely treatment. Imaging is reserved for selected cases only. Following guidelines, orchidopexy is recommended between 6-12 months of age for congenital cryptorchidism. Evidence increasingly suggests the benefits of early surgery for promoting testicular health and fertility potential. Current surgical options range from open to laparoscopic techniques, with the choice largely determined by the location and accessibility of the undescended testicle. The advancement in laparoscopic approaches for non-palpable testes underscores the evolving landscape of surgical treatment. Sequential surgeries may be required depending on the mobility of the undescended testes. More research is needed to explore both the potential and limitations of hormonal therapy, which is secondary to surgical treatment and can selectively have a role as adjunct to surgery. Long-term follow-up is imperative to evaluate fertility outcomes, risk of testicular malignancy, and psychological impact. By integrating current guidelines with the latest evidence, this review intends to facilitate a comprehensive understanding of cryptorchidism, thereby optimizing patient management and outcomes.

Assessment of diagnostic accuracy for cryptorchidism and risk factors for delayed orchidopexy

OBJECTIVES

Cryptorchidism (CO) diagnosis by palpation is challenging. Patients with suspected CO are primarily referred to pediatric urologists by general pediatricians and urologists. Currently, surgical treatment for CO is recommended earlier than in previous guidelines. In this study, we evaluated factors that lead to diagnosis discordance and delayed orchidopexy in patients referred with suspected CO in addition to timing of initial screening.

METHODS

In total, 731 patients (1052 testes) with suspected CO were included. Risk factors for diagnostic discrepancy in CO diagnosis by pediatric urologists and risk of delayed orchiopexy were evaluated.

RESULTS

Herein, 659 (90%) patients were diagnosed during routine public health checkups for infants and young children, and 419 (57%) patients were referred by pediatric practitioners. Of 1052 testes, 374 (36%) were diagnosed with CO by pediatric urologists. In multivariate analysis, risk factors of diagnostic discrepancy for CO diagnosis by pediatric urologists were bilateral testis (odds ratio [OR] = 9.17, p < 0.0001), >6 months old at initial diagnosis (OR = 1.036, p < 0.0001), and pediatric referral (OR = 4.60, p < 0.0001). In total, 296 patients underwent orchiopexy for CO. In multivariate analysis, risk factors for delayed orchiopexy were presence of comorbidities (OR = 3.43, p = 0.003) and >10 months old at referral (OR = 12.62, p < 0.0001).

CONCLUSIONS

Pediatric referral is a risk factor for discordant CO diagnostics, and late age at referral brings a risk of delayed orchiopexy. It is necessary to enlighten pediatricians, who are mainly responsible for routine health checkups, in teaching CO diagnostic techniques to ensure early referral.

The Time of Diagnosis and Surgical Treatment of Congenital Cryptorchidism: A Single Center's Observational Study in Greece

PURPOSE

Congenital cryptorchidism or undescended testes (UDT) is one of the most common congenital abnormalities in newborns. Current guidelines recommend that surgical management should be scheduled by the 12th month and no later than the 18th month of the child's life. This is the first study to evaluate the age of diagnosis and surgical treatment of children with UDT in Greece, as well as the compliance with current guidelines worldwide.

METHODS

A retrospective analysis of patients with UDT who underwent orchidopexy from 2015 to 2019 was conducted. Patient age at diagnosis and orchidopexy and the meantime between were recorded. Patients were separated into groups, based on the diagnosis age: group A, diagnosis until the 11th month; group B, diagnosis between the 12th and 18th month; and group C, diagnosis at >18th month.

RESULTS

We identified 217 children who were diagnosed with UDT and underwent orchidopexy in our department. The majority of the patients (47.4%) had right-sided UDT, while 25.3% of them had UDT on both sides. There were 89 (41%) children in group A, 20 (9.2%) in group B, and 108 (49.8%) males in group C. The median age at diagnosis was 18 months (range: 1-164 months), while for groups A, B, and C, the median age at diagnosis was five, 15, and 71.5 months, respectively. The median age at orchidopexy was 23 months (range: 6-166 months), and for each aforementioned group, it was 11, 16.5, and 74 months. The median waiting time for the orchidopexy was 84 days (range: 1-692 days), and for each group, it was 157, 42, and 56 days, respectively. The delay between diagnosis and surgery was significantly greater for group A compared to groups B and C (p A versus B = 0.01 and p A versus C< 0.0001), while there was no difference in the delay between groups B and C (p > 0.05).

CONCLUSIONS

Patient age at diagnosis and applied orchidopexy was within the recommended range for almost half of the patients. The rest of them had delayed diagnosis and surgery due to delayed referral. In delayed cases, the time from diagnosis to treatment was significantly shorter. Early surgical referral leading to prompt treatment will increase compliance with the guidelines and improve the quality and the outcomes of the provided health-care services.

Orchidopexy for Ascending Testicles in Adulthood After Remote Hernia Repair: A Report of Two Cases

Testicular ascent to the inguinal region after hernia repair has been previously reported as a rare complication of this surgery in pediatric patients. This article presents two cases of adult patients with ascending testicles after inguinal hernia repair that was performed in childhood. Both men underwent orchidopexy through a combined inguinal and scrotal approach, the latter for the creation of a sub-dartos pouch. In both cases, this intervention was completed successfully without complication and resulted in a satisfactory post-operative position of the testicles in the scrotal sac. This surgical approach appears to be a safe management option for adult men with ascending testicles after inguinal hernia repair.

Are we still too late? Timing of orchidopexy

An undescended testis is the most common genitourinary disease in boys. The German guidelines, first published in 2009, proposed the timing of orchidopexy to be before 12 months of age. The aim of the study was to analyze the implementation of these guidelines 10 years after publication. The national cumulative statistics of hospital admissions, provided by the Institute for the Remuneration System in Hospitals (InEK), and the statistics concerning procedures performed in private pediatric surgical practices of the professional association of pediatric surgeons (BNKD) regarding the time of surgeries for the year 2019 were analyzed. Data from InEK included all German hospital admissions. Data from BNKD included data from 48 private pediatric surgical practices. The hospitals treated 6476 inpatients with undescended testis, and 3255 patients were operated in private practices. Regarding the age at treatment, 15% of the hospital patients and 5% of the private practice patients were younger than 1 year and fulfilled the guideline recommendations. Forty percent of the hospital patients and 29% of the private practice patients were 1 or 2 years of age. All other patients were 3 years of age or older at the time of orchidopexy.  Conclusions: The rate of orchidopexy within the first 12 months of life is remarkably low even 10 years after the publication of the guidelines. Awareness of the existing guideline must be increased for both referring pediatric and general practitioners. What is Known: • In Germany, orchidopexy is performed by pediatric surgeons and urologists either in hospital settings or in private practices. • Most international guidelines set the age for surgical treatment of undescended testis between 12 and 18 months of age. The German guidelines, published in 2009, sets the time-limit at one year of age. Until five years after publication of the German guidelines, the number of patients treated before the first year of life was low; studies show an orchidopexy ratebetween 8% and 19% during this time. What is New: • This study the first to cover all administered hospital patients in Germany and a large group of patients treated in private practices. It contains the largest group of German patients with undescended testis. • Although almost all children participate in the routine check-up at the age of seven months, which includes investigation for undescended testis, adherence to the orchidopexy guidelines is still low. Only 15% of the hospital patients and 5% of the patients in private practice were treated before their first birthdays.

Factors which delay surgery for undescended testis in Ontario: A retrospective population based cohort study on timing of orchidopexy between 2006 and 2012

BACKGROUND

Delays in performing orchidopexy (OP) for undescended testis (UDT) result in loss of germ cells. Despite practice guidelines recommending OP by 18 months of age, significant delays in OP occur. This delay may impact fertility and increase the risk of testicular malignancy in boys with UDT.

OBJECTIVE

The objective of this study is to identify factors associated with delayed OP with the goal of identifying modifiable risk factors.

STUDY DESIGN

A population-based, retrospective cohort study was conducted using linked databases held at ICES to evaluate factors associated with timing of OP in Ontario for 4339 male newborns undergoing their first OP between 2006 and 2012. Primary outcome was delayed OP (>18 months). Multivariable logistic regression analysis was performed to identify patient, physician, and hospital risk factors for delayed OP.

RESULTS

Median age at OP was 24 months, while median age at first surgical consult was 20 months (IQR 10-60 months). Older age at first surgical consult (>12 months vs. <9 months, OR 17.83) was identified as the primary risk factor for delayed OP, besides ICU hospitalization (OR 3.42), associated hypospadias (OR 2.30), higher hospital OP volume (OR 1.91), more healthcare visits in first year of life (OR 1.05), and older surgeon age (OR 1.02).

DISCUSSION

Our findings support reports that OP is often performed past guideline recommendations. Interventions that result in earlier referral for UDT (<6 months) may result in timely OP. Limitations for this study include potential misclassification or missing data within the utilized databases.

CONCLUSION

The most important barrier to timely OP is delay in first surgical consultation. Aiming for an earlier referral through guideline modifications or education to referring providers may help achieve the goal of timely OP.

Management of the undescended testis in children: An American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee Systematic Review

PURPOSE

Management of undescended testes (UDT) has evolved over the last decade. While urologic societies in the United States and Europe have established some guidelines for care, management by North American pediatric surgeons remains variable. The aim of this systematic review is to evaluate the published evidence regarding the treatment of (UDT) in children.

METHODS

A comprehensive search strategy and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were utilized to identify, review, and report salient articles. Five principal questions were asked regarding imaging standards, medical treatment, surgical technique, timing of operation, and outcomes. A literature search was performed from 2005 to 2020.

RESULTS

A total of 825 articles were identified in the initial search, and 260 were included in the final review.

CONCLUSIONS

Pre-operative imaging and hormonal therapy are generally not recommended except in specific circumstances. Testicular growth and potential for fertility improves when orchiopexy is performed before one year of age. For a palpable testis, a single incision approach is preferred over a two-incision orchiopexy. Laparoscopic orchiopexy is associated with a slightly lower testicular atrophy rate but a higher rate of long-term testicular retraction. One and two-stage Fowler-Stephens orchiopexy have similar rates of testicular atrophy and retraction. There is a higher relative risk of testicular cancer in UDT which may be lessened by pre-pubertal orchiopexy.

The fat anchor orchiopexy technique: results and outcomes from 150 cases surgical experience

PURPOSE

The purpose of the study is to evaluate results and outcomes in a long-time follow-up period, by performing a novel testicular fixation procedure, known as "fat anchor orchidopexy" (FAO), for the treatment of palpable low inguinal undescended testis.

MATERIALS AND METHODS

We retrospectively reviewed all patients who underwent scrotal orchiopexy technique, from May 2013 to May 2019, at the Pediatric Surgery Division of Department of Surgical Pathology, University of Pisa (Italy). FAO (Spinelli's technique) consists in anchoring the testicles to sub-scrotal fat with a single trans-scrotal incision. All the patients enrolled had history of unilateral or bilateral undescended testis. Data collected included patient's age, operative times and complications.

RESULTS

A total of 150 children with cryptorchidism were treated using a single trans-scrotal orchiopexy. Of them, 130 patients (86.7%) had unilateral undescended testis and 20 (13.3%) bilateral cryptorchidism. Mean patient's age was 21 months (range: 14-28 months). All the procedures were planned in a day-surgery setting. Trans-scrotal orchiopexy was successful in all cases and no patients required an additional groin incision. No intraoperatively and postoperatively major complications were observed. Patients' post-operative pain was mild (mean pediatric visual analog scale = 2). In all cases, the healing process was rapid and no surgical wounds infections were reported during the post-operative period, referring excellent cosmesis results. During a mean 48-month follow-up period, no testicular retraction, recurrence or testis atrophy was reported.

CONCLUSION

The original Spinelli's technique (FAO) proves to be a safe and effective method for the treatment of palpable or distal-to-external-inguinal-ring testes. No immediate and delayed post-surgery complications were reported. In all cases, the anchored testicle remained in the scrotal position with normal vascularization. This novel surgical technique could give better options for scrotal fixation in case of low-lying cryptorchid testes.

Delayed referral for orchidopexy: Scrutinising the causes

Orchidopexy for undescended testis is recommended at a younger age than heretofore; our study aimed to assess delays, and their causes, by retrospective analysis of data from a single tertiary care centre over one year (2015-2016). Almost 80% of children were brought after 1 year of age, mostly because of delayed referral by primary physicians (60%), or missed diagnosis by parents or primary physicians (20%). Misconception about the risk of surgery below 1 year was significant (15%). A timely referral is encouraged.

Laparoscopy for Abdominal Testes: Nationwide Analysis of German Routine Data

Introduction: Laparoscopy has been used for the evaluation of impalpable testes for more than 30 years. However, its use for intra-abdominal testes has never been evaluated in a population-based approach. Neither has the share of timely orchiopexies of intra-abdominal testes according to published guidelines. We aimed to provide this information by using nationwide administrative data for hospital reimbursements. Materials and Methods: We obtained data for procedures for exploration and orchiopexy of intra-abdominal testes in Germany from 2005 through 2018 and analyzed them with linear regression for the use of laparoscopy and timely repair. Results: In 2005, laparoscopy was already used in more than 60% of explorations, which composed 76% (95% confidence interval [CI]: 72 to 79) of children operated before their first birthday and 68% (95% CI: 65 to 70) of children up to 4 years of age. Throughout the study period, laparoscopy became increasingly popular for orchiopexy of intra-abdominal testes with a yearly increase of 1.8% (95% CI: 1.2 to 2.5, P < .001) in the first year of life and 1.3% (95% CI: 0.2 to 3.4, P < .001) until the age of 4. The share of patients treated before their first birthday increased yearly by 1.9% for explorations and 1.6% for orchiopexies (P < .001 for both) but did not exceed 30% in 2018. Conclusion: Laparoscopy is the method of choice for exploration of intra-abdominal testes and orchiopexy. In this study, more than 70% of boys were treated after their first birthday, thus not meeting the time limit set by guidelines.

Epidemiology, Diagnosis and Therapeutic Approaches of Cryptorchidism at the Panzi General Hospital, DR Congo: A 5-year Retrospective Study

Background

Cryptorchidism is a common congenital malformation characterized by unilateral or bilateral undescended testis in the scrotum. It is a common disease in pediatric urology although the prevalence is yet to be determined in the East DR Congo. The aim of this study was to describe the prevalence, clinical and therapeutic features of cryptorchidism at the Panzi General Hospital.

Methods

Medical records of patients who underwent pediatric surgery between January 2011 and December 2016 were reviewed. The prevalence of cryptorchidism, associated malformations, sociodemographic features of patients and therapeutic protocols were examined. Collected data were analyzed using SPSS software.

Results

A total of 5066 children were received during the study period in the service, of which 76 suffered from cryptorchidism giving a prevalence of 1.50% and an annual incidence of 12.70. Unilateral cases were found in 53(69.74%) patients among which 66.04% and 33.96% had unilateral right and left cryptorchidism respectively. Cryptorchidism was associated with other malformations in 71.1% of patients. The age of patients ranged from 0 to 15 years and 78.9% were older than two years. Surgery was the only therapeutic approach and fixation of cryptorchid testis in dartos through inguinal incision was the preferred therapeutic used method.

Conclusion

This study indicates that cryptorchidism is a relatively common and neglected disease in the Est-DR Congo, due to late consultation. Therefore, the local population and pediatricians should be sensitized on scrotal palpation techniques in order to shorten the consultation delay and prevent testis damages.

Multicenter Analysis of Acquired Undescended Testis and Its Impact on the Timing of Orchidopexy

OBJECTIVE

To assess whether late orchidopexy for undescended testis represents delayed treatment of primary undescended testis or later-occurring acquired undescended testis.

STUDY DESIGN

We examined boys undergoing orchidopexy for cryptorchidism regarding age at surgery and entity of undescended testis. We characterized differences between primary undescended testis and acquired undescended testis and evaluated the knowledge regarding the diagnosis and management of acquired undescended testis among practicing physicians. We conducted an observational study using a mixed-method multicenter cross-sectional design. A total of 310 consecutive boys undergoing orchidopexy for undescended testis at 6 pediatric medical centers in Germany between April 2016 and June 2018 were investigated regarding testicular position at birth and age at surgery. In addition, a survey on acquired undescended testis management was carried out in 1017 multidisciplinary physicians and final-year medical students.

RESULTS

Only 13% of all patients were operated on in their first year of life. Among patients with known previous testicular position (67%), primary undescended testis (n = 103) and acquired undescended testis (n = 104) were equally frequent. More than one-half (56%) of orchidopexies performed after the first year of life were due to acquired undescended testis. Remarkably, only 15% of physicians considered acquired undescended testis as an indication for late surgery.

CONCLUSIONS

Acquired undescended testis is more common than previously perceived and accounts for a significant proportion of "late" orchidopexies in patients with undescended testis. Acquired undescended testis needs to be better recognized in clinical practice and screening should continue in older children with previously descended testes.

TRIAL REGISTRATION

German Clinical Trials Registry: DRKS00015903.

Transscrotal transverse incision for the treatment of middle and low cryptorchidism in children: experience from 796 cases

BACKGROUND

The purpose of this study was to summarize our clinical experience with transscrotal transverse incision in the treatment of low and middle cryptorchidism in children.

METHODS

A total of 796 children with low or middle cryptorchidism participated in this study from March 2012 to May 2018. Transscrotal transverse incision was used to treat low and middle cryptorchidism. Symptoms and signs were followed up at 1 week, 1 month, 3months and every six to 12 months thereafter.

RESULTS

Testicular descent fixation through transverse scrotal incision was successfully performed in all 796 children. All patients were discharged 1-2 days after the operation. During hospitalization and follow-up, 35 patients had complications, including 7 cases of cryptorchidism recurrence, 5 cases of poor scrotal incision healing, and 23 cases of scrotal haematoma. There were no complications, such as bladder injury, testicular atrophy, inguinal hernia or hydrocele.

CONCLUSION

Transscrotal transverse incision is a safe and feasible method for the treatment of middle and low cryptorchidism. It has the advantages of less trauma and an aesthetic scar after operation.

Identifying and addressing training deficiencies in the examination of cryptorchidism-a quality improvement study

BACKGROUND

Accurate and timely diagnosis of cryptorchidism by primary care providers (PCPs) is critical to oncologic and fertility outcomes. Physical exam is the mainstay of diagnosis, but little is known about PCPs' skills in examining cryptorchid patients. Patients referred to surgeons for cryptorchidism often have normal or retractile testes on exam, and delayed or missed diagnosis of cryptorchidism may contribute to advanced age at surgical intervention. Previous studies on cryptorchidism have not investigated the baseline training, confidence, and/or exam skills of providers.

OBJECTIVE

The authors aimed to define baseline training and provider confidence in the exam of cryptorchid patients and to improve examiner confidence using bedside teaching with a pediatric urologist. Secondarily, baseline training and confidence were correlated to skill.

STUDY DESIGN

Medical students, family medicine, pediatrics, and urology residents, and pediatric attendings completed surveys on baseline training and self-reported confidence in the examination of cryptorchid patients at an academic institution from 2017 to 2018. N.G.K. (pediatric urologist) proctored examinations of cryptorchid patients and provided standardized grades and individualized feedback. Surveys were readministered after 3 months. Non-parametric comparison tests were performed to determine intervention effect and compare subgroups.

RESULTS

Ninety-two respondents participated. 62% reported little to no formal training on the scrotal exam, 50% were self-taught, and 20% defined undescended testis incorrectly. Confidence increased with level of training, comparing attendings to residents to students (P < 0.001). Those who learned from a mentor had higher baseline confidence than those who did not (P < 0.01). Baseline confidence and amount of formal training positively correlated with exam skill as graded during proctored sessions (n = 59, P < 0.01). Provider confidence was higher after proctored exams (Fig. 2, n = 32, P < 0.0001).

DISCUSSION

Significant training deficiencies exist in the examination of cryptorchid patients. A single proctored exam with a pediatric urologist can improve provider confidence and may improve exam skills. A rotation with pediatric urology, including proctored exams of cryptorchid patients, has become standard practice for pediatric trainees at the authors institution as a result of this study.

CONCLUSIONS

While further studies are required to assess the effectiveness of bedside teaching and its impact on accurate and timely diagnosis of cryptorchidism, implementation of the authors quality improvement recommendations at other teaching institutions would help address training deficiencies in the examination of cryptorchid patients.

The Diagnosis and Treatment of Impalpable Testes at King Salman Armed Forces Hospital, Tabuk, Saudi Arabia

Background

Impalpable testes may be caused by atrophy, congenital dysgenesis/agenesis, or the presence of testes at unusual sites. Early intervention can improve patient outcomes. The recommended age for surgery ranges from 6 to 18 months.

Objective

To investigate the diagnosis, treatment, and outcomes of impalpable testes and sensitivity and specificity of ultrasonography to diagnose impalpable testes at King Salman Armed Forces Hospital (KSAFH), Tabuk, Saudi Arabia.

Methods

We conducted a retrospective study to review cases of impalpable testes admitted to KSAFH, Tabuk, Saudi Arabia from January 1, 2015 to May 20, 2019. Fifty patients diagnosed with impalpable testes were treated surgically in our center during the period. Patients’ data were tabulated, and statistical analysis was performed using Statistical Package for Social Sciences software (SPSS, version 22; IBM, Armonk, NY). 

Results

We included 50 patients in our study, with a total number of 66 impalpable testes. The median age at diagnosis was 7 months, while the median age at surgery was 17.5 months. The median interval between diagnosis and surgery was 8.5 months, with 44% of cases undergoing surgery after the age of 1.5 years. Two-thirds of the cases were unilateral. The most common site was intracanalicular (57.6%) followed by intra-abdominal (34.8%). The testicular size was average in 36.4%, small in 42.4%, and atrophic in 21.2% of the evaluated cases. 

Conclusions

The overall sensitivity of ultrasonography was 56.1% (it correctly detected the location of 37 out of 66 impalpable testes). The sensitivity of ultrasonography for the detection of intra-abdominal testes was 43.5%, while that of intracanalicular testes was 71.1%.

Scrotal Ultrasound Is Not Routinely Indicated in the Management of Cryptorchidism, Retractile Testes, and Hydrocele in Children

Cryptorchidism, or undescended testes, is the most common congenital genitourinary anomaly. A failure or delay of treatment may result in reduced fertility or an increased risk of testicular cancer. The American Urological Association (AUA) recommends that a scrotal ultrasound (SUS) not be performed in the preoperative management of cryptorchidism. This study investigated how likely pediatricians were to perform SUS despite the AUA guidelines. We retrospectively studied 243 patients referred to a single pediatric urology practice for clinically diagnosed testis pathology including undescended testis, hydrocele, and retractile testis over a 4-year period (January 1, 2015, to December 30, 2018). A total of 72 patients (29.6%) underwent a SUS ordered by their pediatrician prior to the pediatric urology visit. Pediatricians should be aware that SUS performed prior to pediatric urological evaluation does not alter management and is associated with a significant financial cost in patients with cryptorchidism or hydrocele.

Variability among Canadian pediatric surgeons and pediatric urologists in the management of cryptorchidism in boys before the publication of major guidelines: a retrospective review of a single tertiary centre

Background

Before 2014, there was a lack of recommendations on managing cryptorchidism, or undescended testis (UDT), from a large pediatric urological or surgical organization. We assessed the variability in management of UDT among pediatric urologists and pediatric surgeons at a single tertiary pediatric referral centre before publication of major guidelines.

Methods

We performed a retrospective review of the electronic records of patients who underwent primary unilateral or bilateral orchidopexy at our centre between January 2012 and January 2014.

Results

A total of 488 patients (616 testes) were identified, of whom 405 (83.0%) and 83 (17.0%) were managed by pediatric urologists and pediatric surgeons, respectively. There was no difference in baseline characteristics, including age seen in clinic or at surgery, testis location/palpability and availability of preoperative ultrasonograms, of patients seen by the 2 groups. Pediatric surgeons ordered preoperative ultrasonography more often than pediatric urologists (25.3% v. 3.7%, p < 0.001). With palpable UDTs, although both groups used open approaches, pediatric urologists preferred a scrotal approach (56.9%), and pediatric surgeons approached most testes inguinally (98.8%). With nonpalpable UDTs, laparoscopic approaches were preferred by both groups; however, pediatric urologists used a 2-stage Fowler–Stephens approach more often than pediatric surgeons (48.4% v. 15.8%, p < 0.001).

Conclusion

There was wide variation in the management of primary UDT between pediatric urologists and pediatric surgeons before the publication of guidelines. The most prominent difference between the 2 groups was in the ordering of preoperative ultrasonography. Future assessment of change in practice patterns may elucidate whether guidelines are an effective tool for standardization of practice.

Utilization of scrotal orchidopexy for palpable undescended testes among surgeons

Introduction:

Scrotal orchidopexy for palpable undescended testicle (UDT) has received attention in the last decade due to its lower morbidity. This study was conducted to determine the frequency and factors related to the use of the scrotal approach in the surgical treatment of palpable UDT among surgeons.

Methods:

An observational cross-sectional study was carried out using an online survey, which was sent to different pediatric urologists, pediatric surgeons, and urologists groups. The survey consisted of questions on demographics as well as surgeons opinions and experience toward scrotal orchidopexy.

Results:

Of 163 respondents, 57 (35.0%) were pediatric surgeons, 98 (60.1%) were pediatric urologists, and 8 (4.9%) were urologists. There were 86 respondents (52.8%) who used the scrotal orchidopexy approach for UDT at any time in their practice. Pediatric urologists tended to use the scrotal orchidopexy approach for UDT more significantly than others (P < 0.001). There were significantly more scrotal orchidopexies for UDT performed by the pediatric urologists throughout their practice and per year compared to others, respectively (P < 0.001). Fifty-two respondents (31.9%) claimed that scrotal orchidopexy is not a good option for their patients, while seven respondents (4.3%) claimed that the procedure was hard to perform.

Discussion:

Based on the results of this study, we believe that there is a discrepancy in the reported advantages and success rate of scrotal orchidopexy in the published literature and the utilization of such an approach among surgeons managing palpable UDT in children.

Conclusion:

Scrotal orchidopexy is an underutilized approach in the management of palpable UDT in children. Only 52.8% of our respondents used it for UDT. One of the main reasons why scrotal orchidopexy is underutilized is due to the surgeons’ perception that scrotal orchidopexy is not the procedure of choice for their patients and their unfamiliarity with the procedure.

Guideline implementation for the treatment of undescended testes: Still room for improvement

BACKGROUND

Early orchidopexy (OP) around the age of 1 year is recommended in boys with congenital undescended testis (UDT) worldwide since decades. Former retrospectives studies did not distinguish congenital from acquired UDT with a consecutive negative bias concerning the age at surgery.

METHODS

In a retrospective analysis, data of all boys who underwent OP in eight pediatric surgery institutions from 2009 to 2015 were analyzed. Congenital or acquired UDT were differentiated. Patients were categorized into 3 groups of age at surgery: (1) <12 months, (2) 12-24 months, (3) >24 months. Data of one institution were analyzed in detail: exact age of first referral, exact age at surgery, intraoperative findings.

RESULTS

Out of 4448 boys, 3270 boys had congenital UDT. In 81% (2656 cases) surgery was performed beyond the age of 1 year, in 54.4% (1780) beyond the age of 2 years. chi-Square statistics showed a higher rate of early operations in hospitals compared to outpatient services and in Germany compared to Switzerland. In 694 congenital detailed cases, median age at referral was 13 months [range 0-196], median age at surgery was 15 months [range 0-202].

CONCLUSION

Delayed referral is the main reason for guideline non-conform delayed surgery in UDT.

TYPE OF STUDY

Clinical Research paper.

LEVEL OF EVIDENCE

Level III: Treatment Study.

Molecular Mechanisms of Syndromic Cryptorchidism: Data Synthesis of 50 Studies and Visualization of Gene-Disease Network

Background: Cryptorchidism is one of the most frequent congenital birth defects in male children and is present in 2-4% of full-term male births. It has several possible health effects including reduced fertility, increased risk for testicular neoplasia, testicular torsion, and psychological consequences. Cryptorchidism is often diagnosed as comorbid; copresent with other diseases. It is also present in clinical picture of several syndromes. However, this field has not been systematically studied. The aim of the present study was to catalog published cases of syndromes which include cryptorchidism in the clinical picture and associated genomic information. Methods: The literature was extracted from Public/Publisher MEDLINE and Web of Science databases, using the keywords including: syndrome, cryptorchidism, undescended testes, loci, and gene. The obtained data was organized in a table according to the previously proposed standardized data format. The results of the study were visually represented using Gephi and karyotype view. Results: Fifty publications had sufficient data for analysis. Literature analysis resulted in 60 genomic loci, associated with 44 syndromes that have cryptorchidism in clinical picture. Genomic loci included 38 protein-coding genes and 22 structural variations containing microdeletions and microduplications. Loci, associated with syndromic cryptorchidism are located on 16 chromosomes. Visualization of retrieved data is presented in a gene-disease network. Conclusions: The study is ongoing and further studies will be needed to develop a complete catalog with the data from upcoming publications. Additional studies will also be needed for revealing of molecular mechanisms associated with syndromic cryptorchidism and revealing complete diseasome network.

Disorders of sex development: timing of diagnosis and management in a single large tertiary center

BACKGROUND

We describe the phenotypic spectrum and timing of diagnosis and management in a large series of patients with disorders of sexual development (DSD) treated in a single pediatric tertiary center.

METHODS

DSD patients who had visited our tertiary center during the survey period (between 2004 and 2014) were identified based on an ICD-10 inquiry, and their phenotypic and molecular genetic findings were recorded from patient charts.

RESULTS

Among the 550 DSD patients, 53.3% had 46,XY DSD; 37.1% had sex chromosome DSD and 9.6% had 46,XX DSD. The most common diagnoses were Turner syndrome (19.8%, diagnosed at the mean age of 4.7 ± 5.5 years), Klinefelter syndrome (14.5%, 6.8 ± 6.2 years) and bilateral cryptorchidism (23.1%). Very few patients with 46,XY DSD (7%) or 46,XX DSD (21%) had molecular genetic diagnosis. The yearly rate of DSD diagnoses remained stable over the survey period. After the release of the Nordic consensus on the management of undescended testes, the age at surgery for bilateral cryptorchidism declined significantly (P < 0.001).

CONCLUSIONS

Our results show that (i) Turner syndrome and Klinefelter syndrome, the most frequent single DSD diagnoses, are still diagnosed relatively late; (ii) a temporal shift was observed in the management of bilateral cryptorchidism, which may favorably influence patients' adulthood semen quality and (iii) next-generation sequencing methods are not fully employed in the diagnostics of DSD patients.

Cryptorchidism in Sweden: A Nationwide Study of Prevalence, Operative Management, and Complications

OBJECTIVES

To review the cumulative prevalence, operative management, and complications of treatment for cryptorchidism in Sweden.

STUDY DESIGN

A nationwide observational study from longitudinal register data of all Swedish-born boys 0-18 years of age, diagnosed with cryptorchidism from 2001 to 2014. Primary outcomes were occurrence and age at primary surgery. Secondary outcomes included type of procedure and surgical site infection.

RESULTS

Of 20 375 boys diagnosed with cryptorchidism in 2001-2014, 12 766 were surgically treated. The cumulative childhood prevalence was 1.8% (95% CI, 1.5-2.0), with a higher prevalence in boys born prematurely, small for gestational age, or with low birth weight. The median age at treatment decreased from 6.2 years in 2001 to 3.4 years in 2014 (P < .001). Still, 94.1% (95% CI, 92.7-95.6) had surgery after the recommended 1 year of age in 2014. Variations in age at surgery between Swedish counties were great (range, 2.9-5.9 years of age). There were no deaths within 30 days after surgery and the frequency of surgical site infection was low (1.4%; 95% CI, 1.1-1.6).

CONCLUSIONS

The cumulative childhood prevalence of cryptorchidism was high, and complications were rare. Few boys underwent surgery in a timely manner according to clinical guidelines, and standards of care varied considerably across the country. Further research and collective actions are needed to improve the detection and management of congenital cryptorchidism.

Delayed treatment of undescended testes may promote hypogonadism and infertility

CONTEXT

Undescended testes at birth may be caused by testosterone deficiency during fetal development. It is unclear whether the process of failed descent contributes to permanent endocrine impairment.

OBJECTIVES

To evaluate the impact of age at treatment of undescended testes on endocrine and spermatogenic testicular function in middle-aged men.

PATIENTS AND METHODS

Reproductive hormone and semen data of 357 men with previously undescended testes were evaluated with respect to age at correction of testicular position and compared to those of 709 controls with eutopic testes at birth and normozoospermia.

RESULTS

Men with undescended testes had higher mean Luteinizing Hormone levels (p < 0.0001) and lower mean testosterone levels (p = 0.003) compared to controls. They also had lower bi-testicular volumes, higher Follicle Stimulating Hormone levels, and lower sperm concentrations (all p < 0.0001). Lowest mean sperm concentrations were found in subjects with bilateral undescended testes. Normal sperm concentrations were found in 21 % of cases (in 27 % of men with unilateral and in 12 % with bilateral undescended testes), while oligozoospermia was diagnosed in 44 %, and azoospermia in 35 % (in 28 % with unilateral, 46 % with bilateral undescended testes). Subjects with reduced semen quality had higher gonadotropin levels than those with normozoospermia. Age at correction (median: 6 years (1-39)) was inversely correlated with bi-testicular volumes and sperm concentrations, and positively correlated with FSH and LH, but not with serum testosterone.

CONCLUSION

Latent, rarely decompensated hypogonadism is a potential long-term consequence of undescended testes, besides infertility and testicular cancer, preferentially affecting subjects with delayed or unsuccessful correction of testicular position. Impaired Leydig cell function is likely to contribute to compromised fertility. These observations support correction of cryptorchidism during early infancy.

Acquired cryptorchidism: More harm than thought?

INTRODUCTION

Acquired cryptorchidism (AC) has been recognized as a subgroup of undescended testes (UDT). There is growing evidence that the compromising effect equals that of congenital UDT (cUDT). This prospective study included an extensive histological examination of biopsies taken from AC patients.

PATIENTS AND METHODS

From August 2013 to December 2014, 21 boys (3-12 years of age) underwent testicular biopsy during orchiopexy for AC. Patient and family histories were taken. The amount of germ cells (GC) per tubule (T) and the amount of adult dark spermatogonia (Ad-S) per T were determined by resin semi-thin sections examination. The samples were also scanned for signs of malformation. Immunohistochemical stains were performed as markers for atypical germ cells.

RESULTS

Four (19%) boys were born prematurely, two (9.5%) were small for gestational age (SGA), and nine (43%) had a positive family history of UDT. The median of GC/T was 1.06 in boys <9 years, and 0.60 in boys ≥9 years. The median of Ad-S/T was 0.02 in boys <9 years and 0.01 in boys ≥9 years. There were no signs for malformation and no atypical cells. The immunohistochemical stains were negative in all specimens.

CONCLUSIONS

Prematurity, SGA, and a positive family history appeared to be predictors for AC. Extensive histopathological examination of AC revealed a significant reduction of germ cell count and fertility markers, comparable with that in cUDT. The alterations were more severe in boys aged ≥9 years. It is unclear as to whether or not this was possibly caused by a longer duration of inguinal position, but this finding suggests that routine checks of testicular position throughout childhood are needed, and that there is a cause for continued efforts in educating parents and primary care physicians regarding AC. Current data support the notion of surgical correction once the diagnosis is made.

Undescended testes: an update

PURPOSE OF REVIEW

This article summarizes the latest evidence on the risk factors, management and outcomes of undescended testes (UDTs).

RECENT FINDINGS

UDTs remain common, with increasing evidence that acquired UDT or the ascending testis syndrome should be considered part of the spectrum of this disease. Prompt diagnosis and early referral for surgical evaluation and treatment would seem most likely to result in an optimal functional and cosmetic outcome. Hormonal treatment, rather than orchidopexy, remains popular in some centers, despite a lack of good evidence to support its efficacy, although it may have an important adjunct role in optimizing fertility. Although often performed, ultrasound does not generally assist in the diagnosis and management of UDT, with enhanced education of primary care physicians more likely to facilitate early referral. The testis, rather than quiescent, appears biologically active in the male infant, with increasing evidence of an adverse impact on future spermatogenesis and fertility in men with a UDT.

SUMMARY

Male infants with a UDT should be diagnosed and referred early for surgical evaluation. It seems likely that the optimal timing for surgery should be before the boy's first birthday. There remains a need for high-quality, long-term outcomes data to guide optimal management.