At what age is surgical intervention recommended for undescended testis (cryptorchidism)?

Surgical Intervention Timing for Undescended Testis (Cryptorchidism)

Surgical intervention for undescended testis should be performed between 6-18 months of age, with optimal timing being before 18 months to preserve fertility potential and reduce cancer risk. 1

Understanding Normal Testicular Descent

• Testicles normally descend into the scrotum between 25-30 weeks of gestational age 2
• 1-3% of full-term male infants and 15-30% of premature male infants have undescended testes at birth 2
• Spontaneous descent may occur in the first six months of life, but is unlikely after six months (corrected for gestational age) 2

Optimal Timing for Surgical Intervention

• Referral to a surgical specialist should occur by six months (corrected for gestational age) if testes remain undescended 1
• Orchidopexy should be performed between 6-18 months of age, with 18 months being the latest recommended time 1, 3
• The rationale for early intervention includes:
  • Preservation of fertility potential 1, 4
  • Reduction in the risk of testicular malignancy 1, 4
  • Prevention of progressive histologic damage to the undescended testis 1

Evidence Supporting Early Intervention

• After 15-18 months of age, some cryptorchid boys begin to lack germ cells in the testes 1
• By 8-11 years of age, approximately 40% of bilateral cryptorchid boys have no germ cells in testicular biopsies 1
• Prepubertal orchidopexy results in a two- to six-fold reduction in the relative risk of testicular cancer compared with postpubertal orchidopexy 1

Surgical Approach Based on Testicular Position

• For palpable testes: scrotal or inguinal orchidopexy should be performed 1, 5
• For non-palpable testes: exploration with identification of testicular vessels is necessary to determine the next course of action 1
• Success rates for open surgical intervention exceed 96%, with testicular atrophy occurring in less than 2% of cases 1

Special Considerations

• In postpubertal males with cryptorchidism, orchiectomy or biopsy may be considered rather than orchidopexy 1
• For boys with a normal contralateral testis and either very short testicular vessels, dysmorphic/hypoplastic testis, or postpubertal age, orchiectomy may be appropriate 1
• Bilateral non-palpable testes in newborns require immediate specialist consultation to evaluate for possible disorders of sex development 1

Long-term Risks and Follow-up

• Patients with a history of cryptorchidism have increased risks of:
  • Infertility (up to 10% in unilateral cases, higher in bilateral cases) 4
  • Testicular cancer (threefold increased risk compared to general population) 4
• Counseling regarding these risks should be provided to patients and parents 1
• Self-examination after puberty is recommended for early cancer detection 4

Common Pitfalls to Avoid

• Delaying referral beyond 6 months of age 1, 2
• Unnecessary imaging studies (ultrasound or other modalities) prior to specialist referral 1
• Monitoring until adolescence in hopes of spontaneous descent is not supported by data 5
• Hormonal treatment is not recommended due to low success rates (15-20%) and potential adverse effects on spermatogenesis 3

Despite recommendations for early intervention, studies show that only about 20-30% of boys receive surgery at the evidence-based age, highlighting the need for better adherence to guidelines 6.