Undescended testis: Level of knowledge among potential referring health-care providers

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.

Mapping of referral patterns for undescended testes - Risk factors for referral of children with normal testes

BACKGROUND

Accurate referral of boys with suspected undescended testes (UDT) is of importance to preserve fertility and reduce risk of future testicular cancer. While late referral is well studied, there is less knowledge about incorrect referrals, hence, referral of boys with normal testes.

OBJECTIVE

To evaluate the proportion of UDT referrals that did not lead to surgery or follow-up, and to assess risk factors for referral of boys with normal testes.

STUDY DESIGN

All UDT referrals to a tertiary center of pediatric surgery during 2019-2020 were retrospectively assessed. Only children with suspected UDT in the referral (not suspected retractile testicles) were included. Primary outcome was normal testes at examination by a pediatric urologist. Independent variables were age, season, region of residence, referring care unit, referrer's educational level, referrer's findings, and ultrasound result. Risk factors for not needing surgery/follow-up were assessed with logistic regression and presented as adjusted odds ratios with a 95% confidence interval (aOR, [95% CI]).

RESULTS

A total of 378 out of 740 included boys (51.1%) had normal testes. Patients >4 years (aOR 0,53, 95% CI [0,30-0,94]), referrals from pediatric clinics (aOR 0.27, 95% CI [0.14-0.51]) or surgery clinics (aOR 0.06, 95% CI [0.01-0.38]) had lower risk of normal testes. Boys referred during spring (aOR 1.80, 95% CI [1.06-3.05]), by a non-specialist physician (aOR 1.58, 95% CI [1.01-2.48]) or referrer's description of bilateral UDT (aOR 2.34, 95% CI [1.58-3.45]), or retractile testes (aOR 6.99, 95% CI [3.61-13.55]) had higher risk of not needing surgery/follow-up. None of the referred boys that had normal testes had been re-admitted at the end of this study (October 2022).

DISCUSSION

Over 50% of boys referred for UDT had normal testes. This is higher or equal to previous reports. Efforts to reduce this rate should in our setting probably be directed towards well-child centers and training in examination of testicles. The main limitation of this study is the retrospective design and the rather short follow-up time, which however should have very modest effect on the main findings.

CONCLUSION

Over 50% of boys referred for UDT have normal testes. A national survey regarding the management and examination of boys testicles has been launched and directed at well-child centers to further evaluate the findings of the current study.

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.

Referral patterns for undescended testis: A 7 year comparative analysis of primary care providers

INTRODUCTION

Cryptorchidism, or undescended testis (UDT), is identified in 1% of boys by one year of age and carries long term risks of infertility and testicular neoplasia. In 2014, the American Urological Association (AUA) released a guideline statement stating that patients with UDT should be referred to a urologist by 6 months of age in order to facilitate timely surgical correction. This study is the follow-up to a 2010 study assessing referral patterns to our university center from primary care providers.

OBJECTIVE

In this new study, we aim to identify changes in referral patterns in response to the establishment of the 2014 AUA guidelines and to understand how our referring physicians stay abreast of current knowledge regarding UDT.

STUDY DESIGN

A 9 question anonymous survey regarding UDT referral patterns was sent to providers who had previously referred a patient to our pediatric urology practice. The results were categorized by specialty and were compared to the similar survey from 2010.

RESULTS

Surveys were sent to 500 physicians with 138 (27.6%) responses received. Less than half of respondents reported that they would refer a boy with unilateral or bilateral palpable UDT by 6 months of age (37.0% and 38.4% respectively). This was not significantly different than the 2010 survey (p = 0.68 and 0.27 respectively). Two-thirds of physicians would refer a patient with unilateral nonpalpable UDT within the recommended time frame (68.8%); this was also unchanged from 2010 (p = 0.87). There was an improvement in respondents who would refer immediately for bilateral nonpalpable testes from 49.8% in 2010 to 53.6% in 2017 (p = 0.01). Residency training was most commonly cited as the primary source of knowledge regarding UDT although 89.3% of respondents citing this were >5 years removed from residency training.

DISCUSSION

Delayed referral patterns were reported by the majority of providers for palpable UDT and by greater than one-third of providers for nonpalpable UDT. There was minimal change in referral patterns between 2010 and 2017 despite the release of the AUA cryptorchidism guidelines in 2014. In both 2010 and 2017, residency training was identified as the primary source of knowledge regarding management of UDT.

CONCLUSION

These findings suggest an unmet need for education regarding contemporary management of UDT for the primary care physicians in our community.

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.