Cryptorchidism: a general surgical perspective

A closer look to the timing of orchidopexy in undescended testes and adherence to the AWMF-guideline

BACKGROUND

To lower the risk of testicular malignancies and subfertility, international guidelines recommend orchidopexy for undescended testis (UDT) before the age of 12-18 months. Previous studies reported low rates of 5-15% of timely surgery. Most of these studies are based on DRG and OPS code-based data from healthcare system institutions that do not distinguish between congenital and acquired UDT.

METHODS

In a retrospective study data of all boys who underwent orchidopexy in a university hospital and two outpatient surgical departments from 2009 to 2022 were analyzed. The data differentiates congenital from acquired UDT.

RESULTS

Out of 2694 patients, 1843 (68.4%) had congenital and 851 (31.6%) had acquired UDT. In 24.9% of congenital cases surgery was performed before the age of 12 months. The median age at surgery for congenital UDT was 16 months (range 7-202). Over the years there was an increased rate of boys operated on before the age of 2 (40% in 2009, 60% in 2022). The median age fluctuated over the years between 21 and 11 months without a trend to younger ages.. The covid pandemic did not lead to an increase of the median age at surgery. The median time between referral and surgery was 46 days (range 1-1836). Reasons for surgery after 12 months of age were a delayed referral to pediatric surgeries (51.2%), followed by relevant comorbidities (28.2%).

CONCLUSION

Compared to recent literature, out data show that a closer look at details enables a more realistic approach. Still, there is no trend towards the recommended age for surgical treatment observable, but the rate of timely operated boys with congenital UDT is significantly higher than stated in literature.

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.

Management of undescended testis may be improved with educational updates and new transferring model

Background

To investigate whether management of undescended testis (UDT) may be improved with educational updates and new transferring model among referring providers (RPs).

Methods

The age of orchidopexies performed in Children’s Hospital of Chongqing Medical University were reviewed. We then proposed educational updates and new transferring model among RPs. The age of orchidopexies performed after our intervention were collected. Data were represented graphically and statistical analysis Chi-square for trend were used.

Results

A total of 1543 orchidopexies were performed. The median age of orchidopexy did not matched the target age of 6–12 months in any subsequent year. Survey of the RPs showed that 48.85% of their recommended age was below 12 months. However, only 25.50% of them would directly make a surgical referral to pediatric surgery specifically at this point. After we proposed educational updates, tracking the age of orchidopexy revealed a statistically significant trend downward.

Conclusions

The management of undescended testis may be improved with educational updates and new transferring model among primary healthcare practitioners.

A 22-year retrospective study: educational update and new referral pattern of age at orchidopexy

OBJECTIVES

To determine the current age at orchidopexy in China and whether changing targets have altered practice, as research suggesting progressive deterioration in an undescended testis (UDT) has led to the reduction in the target age for orchidopexy to 6-12 months but it is still unknown whether changing targets have altered practice.

PATIENTS AND METHODS

The demographics of orchidopexies performed in the Children's Hospital of Chongqing Medical University between 1993 and 2014 were reviewed. A survey of the general publics' awareness of UDT and survey of primary healthcare practitioners' current opinion on age at orchidopexy and referral patterns were performed.

RESULTS

In all, 3784 orchidopexies were performed over 22 years. The median age at orchidopexy fell between 1993 and 2014. There was an initial drop in the median age for orchidopexy between 2000 and 2010 (36 months) compared with 1993 and 2000 (48 months) (P < 0.05); however, beyond the corresponding target age (<18 months). The age for orchidopexy between 2010 and 2014 was also beyond the corresponding target age (6-9 months). The survey of the general public showed that 0.98% had knowledge of UDT and none of them knew about the target age for orchidopexy in the survey of 5393 cases. In all, 63.46% of them were told about the UDT by healthcare practitioners at the 1-4 months postnatal baby check. Furthermore, only 2% of the healthcare practitioners knew the recommended age for orchidopexy was 6-9 months and only 14.3% of them would directly make a surgical referral to paediatric surgery specifically at this point.

CONCLUSIONS

The recommended orchidopexy age is not being achieved and we recognise the national need to address this. The approach should include the right cognition of cryptorchidism among the general public and earlier primary care referral directly from the routine postnatal baby check to a specialist centre prepared to undertake surgery in this age group.

The timing of surgery for undescended testis - a retrospective multicenter analysis

BACKGROUND

n Germany, it is recommended that the surgical treatment of an undescended testis should be carried out between the ages of 6 months and 1 year to lower the risks of subfertility and testicular carcinoma. Although this recommendation has appeared in the German guidelines from 2007 onward, orchidopexy is still frequently performed at later ages.

METHOD

We retrospectively analyzed data from seven pediatric surgical services in the German state of Baden-Württemberg on all boys who underwent orchidopexy from 2009 to 2012. We classified the timing of surgery as Age Group I (before the first birthday), Age Group II (between the first and second birthdays), and Age Group III (after the second birthday). We determined whether preoperative hormonal treatment was given and distinguished primary from secondary undescended testis.

RESULTS

Among 2213 boys who underwent orchidopexy, 1850 had primary and 363 had secondary undescended testis. Of those with primary undescended testis, the percentages of boys who underwent surgery in Age Groups I, II, and III were (respectively, with 95% confidence intervals): 18.7% (17-20.6%), 24.4% (22.5-26.5%), and 57% (54.6-59.2%). A small percentage of boys in each group also received preoperative hormonal treatment. From 2009 to 2012, there was a secular trend favoring earlier orchidopexy. In 2012, 28 boys (14.2% [9.7-20.0%]) had orchidopexy in outpatient pediatric surgery practices before their first birthday, while 68 did on hospital inpatient services (40.7% [33.2-48.6%]).

CONCLUSION

Most of the patients studied had surgery at a later age than recommended. Adherence to the guidelines in this respect is nonetheless relatively good in Germany compared to other countries, as studies from abroad have yielded findings that are just as bad or worse.

Age at orchidopexy in the UK: has new evidence changed practice?

INTRODUCTION

Research suggesting progressive deterioration in an undescended testis has led to the reduction in the target age for orchidopexy to 6-12 months of age. This age was selected as normal testicular descent is unlikely after 3 months of age and it is timed to prevent early gonadocyte developmental delay as suggested by Hutson and Hasthorpe. This study aims to determine the current age at orchidopexy in one UK training centre and whether changing targets have altered practice.

METHODS

The demographics of orchidopexies performed at a single unit between 1998 and 2011 were reviewed.

RESULTS

A total of 1325 orchidopexies were performed over 13 years. The median age at orchidopexy fell between 1998 and 2011. There was an initial drop in the age for orchidopexy in 2000 corresponding with the change in target age to "less than 18 months". However, no subsequent improvement was seen over the following decade.

DISCUSSION

Early orchidopexy is not being achieved. We have identified how slowly such advice is implemented locally and recognise the national need to address this. The approach should include earlier primary care referral directly from the routine postnatal check to a centre prepared to undertake surgery in this age group.

Prise en charge de la cryptorchidie au centre hospitalier et universitaire de Brazzaville

But

contribuer à l’amélioration de la prise en charge de la cryptorchidie en milieu hospitalier.

Patients et méthodes

il s’agit une étude rétrospective descriptive réalisée dans les services de chirurgie pédiatrique et d’urologie-andrologie du centre hospitalier et universitaire de Brazzaville concernant les patients opérés pour cryptorchidie du 1er janvier 2000 au 31 décembre 2009. Les paramètres étudiés ont été: la fréquence, l’âge au moment du diagnostic et du traitement, les renseignements de l’examen physique, les données chirurgicales et évolutives.

Résultats

sur 8100 patients hospitalisés dans les deux services, 163 (2,7 %) l’étaient pour cryptorchidie dont 2,6 % chez les patients de 1 à 16 ans et 0,8 % chez les patients de 19 à 36 ans. L’âge moyen était de 9,6 ans avec des extrêmes de 1 à 36 ans. Les circonstances de découverte étaient: la vacuité de la bourse (77,3 %), la hernie inguinale étranglée (13,5 %), la hernie ombilicale étranglée (3,1 %), l’infertilité (3,1 %), les douleurs abdominales (1,8 %) et l’hypospadias (1,2 %). L’atteinte était unilatérale gauche (82 cas), droite (70 cas) et bilatérale dans 11 cas. À l’exploration chirurgicale, le testicule était intra-abdominal (26,5 %), inguinal profond (62 %), inguinal superficiel (11,5 %). Les testicules étaient d’aspect normal en peropératoire dans 129 cas, atrophiques dans neuf cas et d’aspect non précisé dans 25 cas. Les résultats du traitement après orchidopexie en un temps étaient bons dans 139 cas (92,6) et mauvais dans deux cas (1,3 %); pour l’orchidopexie en deux temps, les résultats étaient bon dans un cas et mauvais dans trois cas.

Conclusion

la cryptorchidie est encore diagnostiquée et traitée tardivement dans notre milieu hospitalier. Une prise en charge thérapeutique entre l’âge d’un et deux an(s) est nécessaire pour l’amélioration du pronostic fonctionnel.

Aspects cliniques, biologiques et thérapeutiques de la cryptorchidie diagnostiquée à l’âge adulte: analyse d’une série de 69 cas

But

Rapporter les aspects cliniques, biologiques et thérapeutiques de la cryptorchidie chez l’adulte et discuter de l’intérêt de l’abaissement du testicule non descendu (TND) chez l’adulte.

Patients et méthodes

Il s’agit d’une étude rétrospective colligeant 69 patients âgés de plus de 18 ans pris en charge au service d’urologie-andrologie du CHU Aristide-Le-Dantec pour cryptorchidie entre janvier 1999 et décembre 2007.

Résultats

L’âge moyen de nos patients était de 31,04 ± 8,4 ans (extrêmes 18 et 55 ans). Les principales circonstances de découverte ont été l’infertilité masculine (38 cas), la vacuité des bourses (21 cas) et la dégénérescence maligne du TND (six cas). La cryptorchidie était unilatérale dans 69,5 % et bilatérale dans 30,4 % des cas. Le spermogramme effectué chez 60 de nos patients a montré une azoospermie dans 46,6 % des cas, une oligozoospermie dans 38,3 % et une numération de spermatozoïdes normale dans 15 % des cas. Tous les patients ayant une cryptorchidie bilatérale avaient une azoospermie. À l’exploration chirurgicale, le TND a été retrouvé dans 95,6 % des cas (66 patients). Le principal type de traitement réalisé a été l’abaissement testiculaire. L’histologie des pièces d’orchidectomie sur testicule non tumoral (n = 7) a trouvé dans tous les cas une atrophie testiculaire sévère avec absence complète de cellules germinales. Les types histologiques des cancers étaient le séminome (n = 3) et le carcinome embryonnaire (n = 3). Parmi les patients ayant une azoospermie (n = 28), aucun cas d’induction de la spermatogenèse après abaissement testiculaire n’a été observé. Parmi les patients ayant consulté pour infertilité masculine, trois d’entre eux ont eu des enfants après abaissement testiculaire, soit un taux de paternité de 7,8 %.

Conclusion

Dans la cryptorchidie de l’adulte, l’abaissement du testicule a peu d’impact sur la fertilité masculine. Mais, vu les progrès actuels de l’assistance médicale à la procréation (AMP), le dogme d’orchidectomie systématique devant un TND diagnostiqué à l’âge adulte doit être reconsidéré.

Effect of cryptorchidism and retractile testes on male factor infertility: A multicenter, retrospective, chart review

This multicenter retrospective chart review study performed on 162 cryptorchid patients and on 34 subjects with retractile testes suggests that cryptorchidism and retractile testes can alter spermatogenesis, with more serious damage observed in bilateral cryptorchidism. This spermatogenetic impairment is probably related to the lack of an appropriate or timely surgical correction.