Management of Undescended Testis in a 6-Year-Old Boy
The correct answer is (c): orchiopexy should be performed to improve spermatogenesis and prevent cancer, though it reduces rather than eliminates these risks. 1, 2
Why Orchiopexy is Indicated
Orchiopexy is the standard surgical treatment for cryptorchidism and should be performed promptly in this 6-year-old boy, ideally having been done by 18 months of age. 1, 2 While this child is beyond the optimal treatment window, surgery remains indicated because:
Fertility preservation: Progressive germ cell loss occurs in undescended testes, with approximately 40% of bilateral cryptorchid boys showing no germ cells by age 8-11 years 3. This boy is approaching this critical threshold.
Cancer risk reduction: Prepubertal orchiopexy reduces testicular cancer risk by 2-6 fold compared to postpubertal surgery 1, 2. At age 6, he is still prepubertal and can benefit from this risk reduction.
Improved surveillance: Bringing the testis into the scrotum allows for proper monitoring and self-examination after puberty 1.
Why Other Options Are Incorrect
Option (a) - Orchiectomy is NOT appropriate because this should only be considered when: 1, 2
- Very short testicular vessels and vas deferens are present
- The testis is severely dysmorphic or hypoplastic
- The patient is postpubertal
- A normal contralateral testis exists
None of these conditions are specified in this case.
Option (b) - Hormonal therapy is NOT recommended because the American Urological Association guideline explicitly states that hormonal therapy (hCG or GnRH) has low efficacy rates (<20%) and is not recommended as standard treatment 1, 4, 5. At age 6, the testis is unlikely to descend with hormones.
Option (d) is incorrect because orchiopexy DOES have beneficial effects on both spermatogenesis and cancer prevention, though it reduces rather than eliminates these risks 1, 2.
Option (e) is incorrect because leaving the testis undisturbed would allow continued germ cell degeneration and maintain elevated cancer risk 1, 3.
Critical Timing Considerations
While the optimal timing for orchiopexy is 6-18 months of age 2, 3, this 6-year-old still benefits from surgery because:
- Germ cell loss is progressive but not yet complete at this age 3
- Prepubertal surgery still provides cancer risk reduction 1, 2
- Success rates for open surgical intervention exceed 96% 1, 2
Expected Outcomes and Counseling
Parents must understand that orchiopexy reduces but does not eliminate long-term risks: 1
- Cancer risk: Cryptorchidism increases testicular cancer risk 2.75-8 times; prepubertal surgery reduces this but doesn't normalize it 2
- Fertility: Unilateral cryptorchidism typically has paternity rates similar to the general population (89.5%), while bilateral cases have significantly reduced fertility (62% paternity rate) 1
- Self-examination: The boy should be taught testicular self-examination after puberty 1
Common Pitfalls to Avoid
- Delaying surgery further: Every month of delay allows continued germ cell loss 3
- Ordering imaging studies: Ultrasound or other imaging rarely assists in decision-making for palpable testes and should not delay referral 1
- Considering hormonal therapy: This has been abandoned as standard treatment due to poor efficacy 1, 5