Surgical Management of the Undescended Testis: Recent Advances and Controversies

Abstract

Undescended testis (UDT) is the most common disorder of sexual development in boys and affects 3.5% of male newborns. Although approximately half of newborn UDTs descend spontaneously, some boys develop an ascending testis later in childhood. Recent guideline recommendations advocate orchiopexy by 18 months of age to maximize potential for fertility and perhaps reduce the risk for testicular carcinoma in the future. For palpable testes, a standard inguinal approach is appropriate. However, the prescrotal approach is often effective for low inguinal testes and reduces surgical time and patient discomfort with an equivalent success rate in boys with an ascending testis. Some advocate monitoring until adolescence to determine whether the testis will spontaneously descend into the scrotum, but data do not support this approach. Instead, prompt orchiopexy is recommended. In boys with a nonpalpable testis, approximately 50% are abdominal or high in the inguinal canal and 50% are atrophic, typically in the scrotum. Routine inguinal/scrotal ultrasound is not recommended, although in an older boy who is overweight, it is appropriate. If the patient has contralateral testicular hypertrophy, scrotal exploration is appropriate, and removal of the testicular remnant and contralateral scrotal orchiopexy to prevent future contralateral testicular torsion is recommended. In most cases, diagnostic laparoscopy is advised to determine whether the testis is abdominal. For the abdominal testis, there are numerous treatment options. If the testis is mobile or a peeping testis just distal to the internal inguinal ring, standard one-stage laparoscopic or open orchiopexy should be attempted using the Prentiss maneuver. If the testicular vessels are short or the testis is not mobile, a two-stage Fowler-Stephens orchiopexy is appropriate. The second stage can be performed laparoscopically or open. Another option is microvascular testicular autotransplantation, which is a technically demanding procedure. Surgical results of abdominal orchiopexy are highly variable, short term, and highly subjective. Prospective clinical trials with follow-up into adolescence and adulthood are necessary to assess the success of various surgical approaches.

Treatment of impalpable testis - one clinic's experience.

“…In 20% of patients with cryptorchidism, the testis is impalpable, and that group of patients is presently treated usually using laparoscopic techniques [2, 8, 10–12]. Therapy for undescended testis is recommended between 6 months and 1 year of life [1, 13, 14]. However, that is only possible when boys are under the control of a paediatric surgeon; in other circumstances, the age at surgery is usually much higher.…”

“…The value of laparoscopy in the diagnosis and treatment of impalpable testis is beyond doubt, and is the procedure of choice in many paediatric surgical and urological centres [1–4]. In most cases, ultrasonography (US) is able to localise impalpable testes, their viability and volume, which can then be compared to the gonad located in the scrotum [5, 6].…”

Surgical Management of Undescended Testis - Timetable and Outcome: A Debate

“…However, in larger published series of orchidopexies, the median and mean age is still often 3 years or more. The overall success rate of orchidopexy for inguinal testes at the level of the external annular ring is expected to be at least 90% [Taran and Elder, 2006;Elder, Prevalence, % Fig. 2.…”

“…Ascended testes contribute with 20-60% to operative series [Dahl et al, 1995;Mayr et al, 1995;Rabinowitz and Hulbert, 1997]. So, following guidelines for operative treatment of congenital cryptorchidism, the goal will never be to achieve that all orchidopexies are performed within the first years of life but that the proportion of late referrals might be diminished [Elder, 2016;Bergbrant et al, 2018]. The potential for this condition makes it mandatory that intra-scrotal testicular location must be confirmed by periodic physical examination up to and through puberty.…”

“…However, the overall success rate of surgical correction of intra-abdominal testes should not be expected to be higher than 80-85% [Taran and Elder, 2006;Elyas et al, 2010;Elder, 2016;Shepard and Kraft, 2017]. The success rate is highly dependent on whether the testis is located close or far from the internal inguinal annular ring and the collateral vascular supply.…”