Complications of Cryptorchidism and management

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Elsevier ClinicalKey Clinical Overview

Synopsis Failure to immediately refer patients with bilateral cryptorchidism to pediatric urologist and pediatric endocrinologist for appropriate evaluation and treatment can result in increased morbidity and mortality from missed diagnosis (eg, disorders of sexual development, congenital syndromes) Refer any patients in whom there is difficulty differentiating between retractile testis and undescended testis to a pediatric urologist; expert examination, sometimes under anesthesia, is occasionally required to differentiate a retractile testis from an undescended testis to determine need for orchiopexy Avoid radiographic imaging before referral for expert examination or examination under anesthesia; imaging does not often contribute to management decisions Failure to adequately examine children yearly for acquired cryptorchidism can lead to increased morbidity and mortality, especially in children at high risk of acquired cryptorchidism (eg, retractile testis, history of delayed testicular descent, previous inguinal surgery, history of proximal hypospadias) Failure to adequately examine yearly and encourage patient monthly testicular self-examinations in patients after orchiopexy can lead to missed testicular malignancy, as surgical correction for cryptorchid testis diminishes but does not eliminate the increased risk of testicular malignancy

Complications and Prognosis Testicular cancer Risk for testicular cancer is 2.5- to 8-fold higher in patients with an unrepaired undescended testis compared with the general population Risk is greater overall for men with intra-abdominal or bilateral cryptorchidism Orchiopexy does not eliminate the risk of cancer in a previously undescended testis; risk of cancer is diminished to 2- to 3-fold higher than the general population if prepubertal orchiopexy is performed Earlier age at orchiopexy is associated with decreased relative risk of malignancy in the involved testis Children with acquired cryptorchidism are at risk of developing testicular malignancy; degree of increased risk is not definitively known Patients with ectopic and retractile testis are not at increased risk for malignancy Infertility Complete loss of germ cells is a risk if orchiopexy is not performed by age 18 months (corrected for gestational age) Children with acquired bilateral cryptorchidism are at risk of developing diminished fertility Formerly bilaterally cryptorchid men have an up to 6-fold increased risk of infertility Unilaterally cryptorchid men have paternity rates similar to the general population Inguinal hernia Over 90% of patients with disease have an associated hernia requiring repair at the time of orchiopexy Testicular torsion 10 times higher risk in patients with cryptorchidism; earlier age at orchiopexy decreases risk of torsion Testicular and genital trauma Risk of blunt trauma from compression against bony structures is increased if the location is in the inguinal canal

Synopsis A truly nonpalpable testis requires surgical exploration to determine location and best approach for surgical correction Orchiopexy is indicated within the first 18 months of life (corrected for gestational age) for congenital cryptorchidism or shortly after diagnosis in older patients Complications of untreated cryptorchidism include testicular cancer, testicular torsion, and infertility Normal testicular volume and function can be achieved if cryptorchidism is corrected before age 18 months (corrected for gestational age); risk for malignancy is diminished but not eliminated by orchiopexy

Treatment Subsubsection Title: Procedures: Subsubsection Title: Orchiopexy: Subsubsection Title: General explanation: Open or laparoscopic surgery to reposition the testes within the scrotal sac and secure in normal position Associated inguinal hernias are repaired Identify the status of the testis and testicular vessels during surgical exploration to ascertain the course of action Perform laparoscopic orchidectomy if testis has abnormal morphologic appearance or patient is postpubertal Perform laparoscopic orchiopexy if testis is normal in appearance and testicular vessels are adequate length for procedure Perform stage 1 of two-stage Fowler-Stephens orchiopexy if testis is normal in appearance and testicular vessels are inadequate length for laparoscopically assisted repair; occasionally, orchidectomy is required in patients with normal contralateral testis when vessels and vas deferens are very short Subsubsection Title: Indication: If the testes are present and do not descend spontaneously by age 6 months (corrected for gestational age), perform surgery within the next year In prepubertal boys with palpable undescended testes, perform scrotal or inguinal orchiopexy In prepubertal boys with nonpalpable undescended testes, examine under anesthesia to confirm nonpalpability; if confirmed, perform surgical exploration and orchiopexy Subsubsection Title: Contraindications: Uncorrected bleeding diathesis Subsubsection Title: Complications: Testicular retraction and atrophy in 0% to 2% Postoperative hernia in 2% to 3% Rarely injury to adjacent structures (eg, nerve, vessel, vas deferens) Subsubsection Title: Interpretation of results:

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Rodprasert W, Virtanen HE, Mäkelä JA, Toppari J. Frontiers in Endocrinology. 2019;10:906. doi:10.3389/fendo.2019.00906. Copyright License: CC BY

Publish date: February 4, 2020.

Congenital cryptorchidism (undescended testis) is one of the most common congenital urogenital malformations in boys. Prevalence of cryptorchidism at birth among boys born with normal birth weight ranges from 1.8 to 8.4%. Cryptorchidism is associated with a risk of low semen quality and an increased risk of testicular germ cell tumors. Testicular hormones, androgens and insulin-like peptide 3 (INSL3), have an essential role in the process of testicular descent from intra-abdominal position into the scrotum in fetal life. This explains the increased prevalence of cryptorchidism among boys with diseases or syndromes associated with congenitally decreased secretion or action of androgens, such as patients with congenital hypogonadism and partial androgen insensitivity syndrome. There is evidence to support that cryptorchidism is associated with decreased testicular hormone production later in life. It has been shown that cryptorchidism impairs long-term Sertoli cell function, but may also affect Leydig cells. Germ cell loss taking place in the cryptorchid testis is proportional to the duration of the condition, and therefore early orchiopexy to bring the testis into the scrotum is the standard treatment. However, the evidence for benefits of early orchiopexy for testicular endocrine function is controversial. The hormonal treatments using human chorionic gonadotropin (hCG) or gonadotropin-releasing hormone (GnRH) to induce testicular descent have low success rates, and therefore they are not recommended by the current guidelines for management of cryptorchidism. However, more research is needed to assess the effects of hormonal treatments during infancy on future male reproductive health.