What is the recommended surgical procedure for a patient with undescended testis?

Surgical Management of Undescended Testis

Primary Recommendation

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

Age-Specific Surgical Approach

Prepubertal Patients (Optimal: By 18 Months)

• Perform orchidopexy at diagnosis once the child reaches 6 months of age, as progressive germ cell degeneration occurs after the first year of life and worsens during the second year 2, 1
• Prepubertal orchidopexy reduces testicular cancer risk by 2-6 fold compared to postpubertal surgery 2, 1
• Open surgical orchidopexy achieves >96% success rates with <2% risk of testicular atrophy 2, 1

Postpubertal and Adult Patients

For unilateral undescended testis with normal contralateral testis and normal hormonal function/spermatogenesis: offer orchidectomy 2

For unilateral or bilateral undescended testis with biochemical hypogonadism and/or infertility: offer orchidopexy if technically feasible 2

• Perform simultaneous testicular biopsy at the time of adult orchidopexy to detect intratubular germ cell neoplasia (formerly carcinoma in situ), which serves as a prognostic indicator for future testicular cancer 2
• Multiple biopsies of unilateral undescended testis are recommended to exclude germ cell neoplasia in situ 2

Surgical Technique Selection

Palpable Undescended Testis

• Standard inguinal orchidopexy is the primary approach for most palpable undescended testes 1
• Prescrotal (single-incision scrotal) orchidopexy is an alternative for palpable, mobile testes that can be drawn close to the scrotum on examination under anesthesia, with 98.8% success rate and superior cosmetic outcomes 3

Non-Palpable Undescended Testis

• Laparoscopic exploration with orchidopexy is indicated for non-palpable testes, allowing simultaneous diagnosis and treatment 1, 4
• The primary objective during exploration is identifying testicular vessel status to determine the next course of action 2
• Laparoscopic orchidopexy for abdominal testes achieves 85-90% success rates 5

Indications for Orchiectomy Instead of Orchidopexy

Orchiectomy should be performed when a normal contralateral testis is present AND any of the following conditions exist: 2

• Very short testicular vessels and vas deferens
• Dysmorphic or severely hypoplastic testis
• Postpubertal age (in the context of unilateral cryptorchidism with normal contralateral function)

Critical Pitfalls to Avoid

• Do not use hormonal treatment for cryptorchidism in postpubertal men - it is ineffective 2
• Do not delay surgery beyond 18 months in prepubertal boys - progressive histologic damage continues with delayed treatment 2, 1
• Do not perform orchidopexy in adults without concurrent testicular biopsy - the risk of occult germ cell neoplasia is substantial 2

Long-Term Counseling Requirements

• Testicular cancer risk remains elevated 2.75-8 times baseline despite orchidopexy 2, 1
• Teach monthly testicular self-examination after puberty for early cancer detection 2
• Unilateral cryptorchidism has near-normal paternity rates, while bilateral cryptorchidism significantly reduces fertility to 35-53% 6, 7
• Regular monitoring of testicular position and development throughout childhood and adolescence is necessary 1