From the Guidelines
The recommended management for an undescended testicle in a 50-year-old post-pubertal man is surgical removal (orchiectomy) rather than orchiopexy. This approach is based on the most recent and highest quality study available, which prioritizes the reduction of cancer risk and takes into consideration the patient's age and the increased risk of testicular cancer associated with undescended testicles 1.
The procedure for orchiectomy is typically performed as an outpatient surgery under general anesthesia, with the surgeon making an incision in the groin area to locate and remove the undescended testicle. Key considerations for the procedure include:
- Recovery usually takes 1-2 weeks with limited physical activity recommended during this time
- Pain management typically involves over-the-counter analgesics like acetaminophen or ibuprofen, though stronger medications may be prescribed for the first few days post-surgery
- A follow-up appointment should be scheduled 1-2 weeks after surgery to assess healing
It's also important to consider the potential need for testosterone replacement therapy after removal, particularly if the patient has only one testicle, to maintain secondary sexual characteristics and normal hormone levels 1. Additionally, psychological support may be beneficial as some men experience concerns about body image or fertility following the procedure. The American Urological Association guideline supports treating any post-pubertal male, regardless of age, according to adult treatment guidelines, which further emphasizes the importance of orchiectomy in this case 1.
In terms of specific treatment guidelines, the International Germ Cell Cancer Collaborative Group (IGCCCG) risk stratification is used to determine the chemotherapy regimen and number of cycles for patients with metastatic germ cell tumors (Stage IIC or III) requiring chemotherapy 1. However, for patients with an undescended testicle, the primary concern is the increased risk of testicular cancer, and orchiectomy is the recommended management approach.
From the Research
Management of Undescended Testicle in Post-Pubertal Men
The management of an undescended testicle in a 50-year-old post-pubertal man involves considering the risks and benefits of orchiectomy versus observation.
- The risk of developing a germ cell tumour (GCT) is increased in men with an undescended testicle (UDT) 2.
- However, the lifetime risk of dying from GCT decreases with increasing age, and the risk of perioperative mortality (POM) from orchiectomy exceeds the risk of death from GCT for men over 50 years with an American Society of Anesthesiologists (ASA) class 1, and over 35 years with an ASA class 2 2.
- A systematic review of post-pubertal UDT treatment found that management should be tailored individually, considering factors such as the condition of the contralateral descended testis, UDT location, serum testosterone level, patient's age, comorbidities, and interest in fertility 3.
- The U.S. Preventive Services Task Force recommends against routine screening for testicular cancer in asymptomatic men, but men with symptoms should receive a complete history and physical examination, and scrotal ultrasonography is the preferred initial imaging study 4.
- Orchiectomy may be considered in healthy patients with cryptorchidism who are between ages 12 and 50 years, but observation should be recommended in postpubertal males at significant anesthetic risk and all males older than 50 years 5.
Considerations for Orchiectomy
- Orchiectomy is both diagnostic and therapeutic for testicular cancer, and staging through chest radiography, chemistry panel, liver function tests, and tumor markers guides treatment 4.
- For patients desiring future fertility, sperm banking should be discussed early in the course of treatment 4.
- The risk of malignancy in testicular remnants is extremely low, suggesting that the risk of malignancy in these remnants is not a significant concern 5.
Recommendations
- Based on the available evidence, it is recommended that men with an undescended testicle over the age of 50 should undergo observation rather than orchiectomy, especially if they have significant anesthetic risk or comorbidities 2, 5.
- Individualized management should be considered, taking into account the patient's overall health, fertility desires, and other factors 3.