What is orchidopexy?

Orchidopexy: Surgical Management of Cryptorchidism

Orchidopexy is the standard surgical treatment for cryptorchidism (undescended testis) and should be performed by 18 months of age to preserve fertility potential and reduce cancer risk. 1

Definition and Purpose

Orchidopexy is a surgical procedure that relocates an undescended testicle from its abnormal position into the scrotum. The primary goals of this procedure are:

• Preservation of fertility potential 1
• Reduction of testicular cancer risk 1
• Prevention of testicular torsion 2
• Repair of associated inguinal hernias 2
• Improved testicular monitoring for future cancer surveillance 1

Timing of Intervention

• Optimal timing: Surgery should be performed by 18 months of age 1
• Rationale: Progressive histologic damage occurs to undescended testes, particularly after the first year of life 1
• Referral guidelines:
  • Infants with cryptorchidism at birth should be referred if no spontaneous descent by 6 months 2
  • Boys diagnosed after 6 months should be promptly referred to a surgical specialist 2

Surgical Techniques

1. Standard Inguinal Orchidopexy (Two-Incision Technique)

• Indicated for: Most palpable undescended testes 1
• Procedure steps:
  • Inguinal incision to access the testis
  • Mobilization of spermatic cord and testis
  • Second scrotal incision to create a pouch
  • Placement of testis in scrotal position
• Success rate: >95% for inguinal testes 3

2. Single-Incision Scrotal Approach

• Indicated for: Low-lying palpable testes that can be manipulated to the scrotal neck 1, 4
• Variants include:
  • High scrotal orchidopexy (Bianchi procedure) 1, 4
  • Prescrotal orchidopexy 5
  • Transcrotal orchidopexy 6
• Benefits:
  • Less dissection of inguinal region 4
  • Excellent cosmetic results 4, 5
  • Shorter operative time 6
• Success rate: 80-98.8% depending on technique and patient selection 4, 5

3. Laparoscopic Orchidopexy

• Indicated for: Non-palpable testes 1
• Allows for:
  • Diagnosis (confirming presence/absence of testis)
  • Treatment in the same procedure
• Success rate: >85-90% for abdominal testes 3

4. Fowler-Stephens Orchidopexy

• Indicated for: High intra-abdominal testes with short testicular vessels 1, 7
• Procedure involves:
  • Division of testicular vessels
  • Reliance on collateral blood supply from vasal artery
• Can be performed as:
  • One-stage procedure (success rate ~82%) 7
  • Two-stage procedure (allows collateral circulation to develop) 1
• Can be performed via open or laparoscopic approach 1

Management of Non-Palpable Testes

• Identification of testicular vessels is the primary objective during exploration 1
• Surgical approach depends on findings:
  • If vessels end blindly: Indicates testicular absence or atrophy 1
  • If viable testis found: Orchidopexy attempted 1
  • If high intra-abdominal testis: Fowler-Stephens technique considered 7

Special Considerations

• Orchiectomy may be appropriate when:
  • Very short testicular vessels and vas deferens present 1
  • Testis is dysmorphic or hypoplastic 1
  • Patient is postpubertal with normal contralateral testis 1
• Bilateral nonpalpable testes in a phenotypic male newborn requires immediate specialist consultation to rule out disorders of sex development 2

Outcomes and Prognosis

Success Rates

• Overall success (viable testis in scrotum): >96% for open surgical intervention 1
• Testicular atrophy risk: <2% 1

Long-term Considerations

Cancer Risk

• Cryptorchidism increases testicular cancer risk by 2.75-8 times 1
• Prepubertal orchidopexy reduces this risk by 2-6 fold compared to postpubertal surgery 1
• Regular testicular self-examination should be taught after puberty 1

Fertility Impact

• Unilateral cryptorchidism: Paternity rates similar to general population (89.5% vs 94%) 1
• Bilateral cryptorchidism: Significantly reduced fertility (paternity rate ~62%) 1
• Time to pregnancy is substantially longer in men with history of bilateral cryptorchidism (33.9 months vs 11.1 months) 1

Post-Operative Follow-up

• Short-term: Monitor for complications such as hematoma, infection, or testicular atrophy 6
• Long-term: Regular monitoring of testicular position and development throughout childhood and adolescence 2
• Patient education: Counsel regarding long-term risks of infertility and cancer 1, 2

Common Pitfalls and Caveats

• Imaging studies before referral are generally not helpful due to poor sensitivity and specificity 2
• Hormonal therapy alone is not recommended as primary treatment 2
• Even with successful orchidopexy, increased risks of infertility and testicular cancer remain, though reduced 2
• Newborns with bilateral nonpalpable gonads should not be circumcised until workup is complete 2