Age at presentation of undescended testicles: a single-center study in Saudi Arabia

Knowledge and Awareness of Screening for Children With Cryptorchidism in the Al-Qunfudhah Governorate, Saudi Arabia

Background Undescended testis is a common pediatric surgical presentation condition with potential long-term consequences if left untreated. It is characterized by the failure of one or both testes to descend into the scrotum. This study aims to measure and enhance awareness and knowledge about undescended testis through comprehensive medical research and provide evidence-based recommendations. Objective The objective of this study was to evaluate participants' knowledge regarding undescended testes and assess the level of interest and awareness among individuals and parents about the importance of early examination and treatment. Methods It is a cross-sectional, nationwide study targeting the population of Al-Qunfudhah. The study was conducted in December 2023 using a validated questionnaire distributed through social media platforms. Results The study analyzed data from 459 participants to assess their knowledge and attitudes regarding undescended testis. Participants' knowledge was evaluated. In general, the mean ± SD score of knowledge was 3.61 ± 2.33. Higher education level, occupation, and having children were associated with greater knowledge. Attitudes were measured. The mean attitudes score was 2.37 ± 1.58. Higher education level, occupation, and marital status influenced attitudes. Conclusion This study provides valuable insights into the knowledge and attitudes of individuals regarding undescended testis. Participants displayed moderate levels of knowledge and positive attitudes, with educational attainment and occupation playing significant roles. These findings highlight the importance of targeted educational interventions to improve awareness and promote positive attitudes toward undescended testis.

Outcomes of Early vs. Late Surgical Intervention in Children With Undescended Testis

Background Undescended testis (UDT) is one of the most common urogenital abnormalities. International guidelines recommend performing orchidopexy no later than 18 months to decrease the risk of complications associated with UDT such as infertility and testicular malignancy. The aim of the study is to evaluate the outcomes of early versus late surgical intervention of UDT and to assess if the optimal age of orchidopexy is met. Methods This is a retrospective cross-sectional study that included 258 pediatric patients' testes with no prior UDT intervention from January 2016 to December 2020. A chart review was used to collect the patients' data. Children included were categorized into two groups based on their age at the time of surgery (group A ≤ 18 months and group B > 18 months). Statistical differences were explored using Pearson's chi-squared test or Fisher's exact test for categorical variables or a Wilcoxon rank sum test for numerical variables. A p-value of <0.05 indicated statistical significance. Results The median age at the presentation among the overall cohort was 14 months. The median age at the presentation for group A was six months and group B was 35 months. Group A included 109 children and group B included 149 children. At the time of the surgery, the median age of patients was 23 months. The median age at orchidopexy for group A was 12 months and the median age for group B was 38 months. The time between diagnosis and surgery was significantly shorter among older children with a median duration of one month versus a median of five months among patients in the ≤18 months group (p = 0.003). The follow-up interval was at three and 12 months. The change in testicular size before and after surgeries was statistically significant, as most small testicles before surgeries had become normal in size after surgeries among the overall cohort (76.6%), patients aged ≤18 months (72.4%), and those aged >18 months (79.2%) (p < 0.001). Conclusion Most of the patients included in this study did not undergo orchidopexy at the optimal age recommended by the international guidelines. However, there was a statistically significant improvement in testicular size following orchidopexy in children with small UDT regardless of age at the time of surgery.

Knowledge Level of Undescended Testis in Saudi Arabia: Why Are We Facing Delayed Presentation?

Background Undescended testis (UDT) or cryptorchidism is a common pediatric surgical presentation. The accepted time for surgical correction (orchidopexy) is when the patient is aged from six months, and should ideally be completed before one year of age. In Saudi Arabia, the median age at the time of orchidopexy is 25 months, exceeding the recommended surgery time. Objective The objective of the study was to determine the factors that cause delayed presentation of UDT among children in Saudi Arabia. Methods A cross-sectional, nationwide study targeting the general population of Saudi Arabia. The study was conducted in November 2022 using a validated questionnaire distributed through social media platforms. Results A total of 2360 participants were enrolled. Over half (54.92%) had not heard about UDT. Further, 48.5% of the participants did not know the age of UDT presentation, and 49.1% had no idea about the treatment modality. Moreover, 13.9% had known someone diagnosed with UDT, while 17.68% discovered UDT after more than a year. In addition, 1.5% had previous experience with UDT, and 22.86% were diagnosed after more than a year. There was a significantly high level of knowledge among participants who had experienced UDT. The three most common reasons for delaying the intervention for UDT patients were a lack of community awareness of UDT, parents' ignorance and neglect, and a lack of early screening programs (22.3%, 21.7%, and 19.7%, respectively). Conclusion Our data demonstrated a significant lack of awareness of UDT among the Saudi population since 1296 (54.92%) of the participants had not heard about UDT. The presence of such an awareness gap necessitates cultural education about the topic of UDT by all capable facilities, including medical schools, hospitals, and primary healthcare centers.

Trends in the treatment of undescended testes: a pediatric tertiary care center experience from Croatia

OBJECTIVE

Undescended testes (UDT) is the most common anomaly of the male genitourinary tract. The guidelines suggest that orchidopexy in congenitally UDT should be performed between 6 months and 18 months of age, while in acquired UDT, orchidopexy should be performed before puberty. Delay in treatment increases the risk of cancer and infertility. The main aim of this study was to determine whether we meet international standards in the treatment of UDT.

METHODS

The present study included all boys who underwent orchidopexy either due to congenital or acquired UDT in 2019 (from January 1 to December 31). For each group, laterality, location, associated anomalies, premature birth and in how many cases ultrasound was applied were determined. Additionally, for each group, the types of surgery, the number of necessary reoperations, and in how many cases atrophy occurred were determined. Finally, ages of referral, of clinical examination, and of orchidopexy were determined.

RESULTS

During this period, 198 patients with 263 UDT underwent orchidopexy. The median time of orchidopexy for the congenital group was 30 months, while that for the acquired group was 99 months. In the congenital group up to 18 months of age, orchidopexy was performed in 16 (16%) boys, while in the acquired group up to 13 years of age, orchidopexy was performed in 95 (96.94%) boys.

CONCLUSION

Given the well-known risks of late treatment of UDT, orchidopexy needs to be performed much earlier, especially in the congenital group.

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 value of an additional scrotal suture during orchidopexy

INTRODUCTION

Undescended testes present in 3-5% of male infants at birth. Orchidopexy is indicated to improve fertility and reduce the risk of testicular tumors. Guidelines recommend orchidopexy as early as six months of age, treatment should be finished within the age of 18 months. So far, no unequivocal proof demonstrated the superiority of one of the different surgical techniques.

OBJECTIVE

To evaluate the value of an additional scrotal suture between the tunica albuginea and the dartos fascia during orchidopexy in an outpatient setting. It is yet unclear, whether the suture influences the incidence of secondary cryptorchidism or recurrence.

STUDY DESIGN

This is a retrospective cohort study. Between 2010 and 2018 two experienced surgeons performed 561 inguinal orchidopexy-procedures in an open technique (375 boys). In group 1 (2010-2014) they managed 234 IOP (156 boys) without an additional scrotal suture. Since 2014, in group 2 an additional suture has been performed in 327 IOP (219 boys). Statistically, we compared both groups over a period of consecutive 4 years after the model of a life table analysis (Logrank).

RESULTS

The numbers of boys with complete follow-up were 118 of 156 in group 1 and 154 of 219 in group 2, demonstrating 7 (5.9%) and 7 (4.5%) recurrences, respectively. There was no statistically significant difference in recurrences between group 1 and group 2 (Logrank-Test, p = 0.97). Orchidopexie failure was detected between 0.9 and 23.1 months after the IOP in group 1 and between 3.2 and 17.7 months in group 2. Mean age in months at the operation in both groups was significantly higher than the recommended 6-18 months in the EAU/AUA-guidelines. Both groups showed similar rates of postoperative complications.

DISCUSSION

Orchidopexy is a safe procedure in an outpatient setting. So far there is no evidence that performing an additional scrotal suture decreases the operative failure rate in inguinal standard orchidopexy procedures.

Ambulatory Orchidopexy Is a Potential Solution to Improve the Rate of Timely Repair in Cryptorchid Boys: An 8 Year Retrospective Study of 4,972 Cases

Background: Cryptorchidism is the most common congenital anomaly in pediatric urology. Although early surgery on cryptorchid boys is recommended by pediatric urologists worldwide, the actual age at orchidopexy is often older than the recommended age. Our medical center has started performing ambulatory orchidopexy since March 2016 at the ambulatory surgery center. We aimed to investigate whether ambulatory orchidopexy can improve the timely repair rate. Methods: A retrospective analysis was conducted from 2012 to 2019 at our medical center. Ambulatory orchidopexy was started at our medical center on March 24, 2016. Boys born on or after September 24, 2015 were classified into the "with ambulatory medical resource" group, and boys born before September 24, 2014, were classified into the "without ambulatory medical resource" group. The timely repair rates were calculated and compared. Results: A total of 4,972 cryptorchidism cases were included in the final study. Approximately 33.0% of cryptorchid boys received timely surgery (orchidopexy by the age of 18 months), and only 6.8% of all cryptorchid boys underwent surgery before the age of 1 year. After the performance of ambulatory orchidopexy, the timely repair rate increased from 25.7 to 37.0% (P < 0.001), and the percentage of patients receiving surgery before the age of 1 year increased significantly from 3.5 to 8.6% (P < 0.001). The proportion of timely repair in patients with ambulatory medical resources was significantly higher than that in patients without ambulatory medical resources (15.6% vs. 58.2%, P < 0.001). Significant changes in the rate of surgery before 12 months of age were also found between the two groups (2.4% vs. 14.8%, P < 0.001). Conclusions: After the performance of ambulatory orchidopexy in our medical center, the rates of both timely repair and receiving surgery before the age of 1 year increased significantly. Ambulatory orchidopexy is a potential solution to improve the rate of timely repair in cryptorchid boys, and it is worthy of promotion in developing countries and regions.

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%.

Age at Surgery and Outcomes of Undescended Testes at King Salman Armed Forces Hospital, Tabuk, Saudi Arabia

Objective The aim of this study was to investigate the age at diagnosis and surgery of undescended testes and patients' outcomes. Methods This is a retrospective study that reviewed the files of patients who underwent orchidopexy at the King Salman Armed Forces Hospital (KSAFH), Tabuk, Saudi Arabia (SA), between January 1, 2015, and March 30, 2019. All children from birth until 13 years old who were admitted within the specified time frame and underwent orchidopexy were included in this study. The gathered data were analyzed through the Statistical Package for Social Sciences software (SPSS, version 23; SPSS Inc., Chicago, IL, USA). Results  A total of 175 patients were included in this study. The rate of orchidopexy at our institution was 12.2%. The median ages at diagnosis and surgery were 12 and 24 months, respectively. The median duration between diagnosis and surgery was eight months. The most common site of undescended testis was inguinal (80.6%). Bilateral undescended testes were recorded in 24.6% of cases, and 25.7% of cases were impalpable. The size of the undescended testis was average in half the cases, small in 44.6% and atrophic in 6.4% of cases. Postoperative complications were reported in 4.0% of cases. Cox regression analysis revealed that the age at diagnosis was a significant risk factor affecting the time of surgery. Conclusion The findings of this study revealed that most cases of undescended testes in Tabuk were operated beyond the age recommended by international guidelines. The age at diagnosis seems to significantly affect the time of surgery.

Timing of orchidopexy at a tertiary center in Saudi Arabia: reasons for late surgery

BACKGROUND

Orchidopexy should be performed during the first 18 months of life to decrease the risk of infertility and tumor formation. In our center, the timing of surgical correction varies depending on the availability of an operating room.

OBJECTIVES

Evaluate whether orchidopexy performed for patients referred to our center is done within the recommended time period and to determine causes for delay.

DESIGN

Retrospective descriptive study.

SETTING

Pediatric urology department of a tertiary care center.

SUBJECTS AND METHODS

We retrospectively reviewed the charts of patients charts who underwent orchidopexy at our center from 2000 to 2010. We assessed referral time and waiting list time, which were subdivided as follows: from referral to first visit and from first visit to surgery. We included patients younger than 14 years and excluded pa.tients with comorbidities that affected the timing of referral and surgi.cal treatment.

MAIN OUTCOME MEASURES

Referral time period and waiting list time for surgical correction of patients presented with undescended testis.

SAMPLE SIZE

128 RESULTS: After exclusion of 32 patients because of comorbidities, we describe 128 who underwent surgery for cryptorchidism at our center. The median (interquartile range, minimum-maximum) for age at sur.gery was 46.7 months (24.4-83.4, 3.1-248.6]). The median (IQR) referral occurred at an age of 25.3 months (4.1-65.5). The median (IQR) waiting list time was 15.2 months (8.1-23.3). The median (IQR) waiting time from referral to the first visit was 4.1 months (1.0-8.2). The median wait.ing time from the first visit to surgery was 8.1 months (3.8-17.5).

CONCLUSIONS

The age at the time of surgery at our center was far from ideal because of late referrals. A structured program offered by our National Health Service to educate referring physicians is necessary. Community health initiatives must emphasize prompt referral to reduce the impact of delayed surgery.

LIMITATIONS

Lack of data on the type of referring physician (i.e., general practitioner, pediatrician, surgeon, urologist).

CONFLICT OF INTEREST

None.