What is the recommended treatment for a 25-year-old male with an undescended testis at the superficial ring: orchidectomy or orchidopexy?

Management of Undescended Testis in a 25-Year-Old Male

For a 25-year-old male with unilateral undescended testis at the superficial ring, orchidectomy is the recommended treatment if he has normal hormonal function and spermatogenesis, while orchidopexy should only be offered if he has biochemical hypogonadism or spermatogenic failure. 1

Decision Algorithm Based on Hormonal and Fertility Status

Step 1: Assess Hormonal Function and Semen Analysis

The treatment decision hinges entirely on two factors:

• Testosterone levels (to assess for biochemical hypogonadism)
• Semen analysis (to assess spermatogenic function/fertility status)

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Step 2: Apply Treatment Based on Results

If Normal Hormonal Function AND Normal Spermatogenesis:

Perform orchidectomy 1

• The 2025 European Association of Urology guidelines provide a strong recommendation for orchidectomy in adult men with unilateral undescended testis who have normal hormonal function and spermatogenesis 1
• This is because the undescended testis has already undergone significant germ cell degeneration by age 25, with progressive damage occurring after the first year of life and worsening during the second year 1, 2
• The contralateral descended testis provides adequate hormonal production and fertility potential 3, 4

If Biochemical Hypogonadism OR Spermatogenic Failure (Infertility):

Offer orchidopexy if technically feasible 1

• This carries a weak recommendation from the 2025 EAU guidelines, reflecting that the benefit is less certain in adults 1
• Orchidopexy in this scenario aims to preserve any remaining testicular function for hormone production or potential fertility 1
• Technical feasibility depends on vessel length and testicular viability 3, 4

Critical Additional Procedures Required

Mandatory Testicular Biopsy at Time of Surgery

Regardless of whether orchidectomy or orchidopexy is performed, simultaneous testicular biopsy must be done to detect intratubular germ cell neoplasia in situ (formerly carcinoma in situ). 1

• This is a strong recommendation from the 2025 EAU guidelines 1
• The risk of testicular cancer is elevated 2.75-8 times baseline in cryptorchidism, with the highest risk in intra-abdominal testes 3, 5
• Postpubertal orchidopexy does NOT reduce cancer risk, unlike prepubertal surgery which reduces risk by 2-6 fold 3, 6

Sperm Cryopreservation Before Orchidectomy

If orchidectomy is planned, perform sperm cryopreservation beforehand 1

• This is a strong recommendation to preserve future fertility options 1

Why Hormonal Treatment is NOT an Option

Do not use hormonal treatment (hCG or GnRH) for cryptorchidism in postpubertal men 1, 3

• This is a strong recommendation against hormonal therapy in adults 1, 3
• Hormonal treatment efficacy is less than 20% even in prepubertal boys and is ineffective in adults 2, 5
• hCG has been associated with inflammation-like reactions and increased germ cell apoptosis 2

Common Pitfalls to Avoid

Attempting Orchidopexy When Orchidectomy is Indicated

• If the patient has normal contralateral testicular function, attempting to preserve a severely damaged undescended testis provides no benefit and increases cancer surveillance burden 1, 3
• Orchidopexy in adults has limited success in improving fertility outcomes due to pre-existing germ cell damage 2, 5

Failing to Perform Cancer Screening Biopsy

• Omitting the testicular biopsy at the time of adult cryptorchidism surgery misses the opportunity to detect pre-malignant changes 1
• The cancer risk remains elevated regardless of surgical intervention performed in adulthood 3, 6

Not Counseling on Long-Term Cancer Risk

• Even after surgical correction, testicular cancer risk remains elevated 2.75-8 times baseline 3, 4
• Teach monthly testicular self-examination after surgery for early cancer detection 3, 4
• Most testicular cancers in cryptorchidism patients occur before age 40 7

Technical Considerations for Orchidopexy (If Indicated)

If orchidopexy is chosen based on hormonal/fertility status:

• Absolute contraindications to orchidopexy include: very short testicular vessels and vas deferens, dysmorphic testis, or severely hypoplastic testis 3, 4
• For testes at the superficial ring (as in this case), standard inguinal orchidopexy is the appropriate approach 3, 4
• A transscrotal approach can be considered for testes distal to the external ring that can be manually pulled into the scrotum, with success rates of 97.7% 8