Surgical Intervention is Mandatory for This 2-Year-Old with Palpable Intra-Abdominal Undescended Testes
This child requires immediate referral to a pediatric urologist or pediatric surgeon for orchiopexy, as the optimal surgical window (6-18 months) has already passed and further delay will cause irreversible testicular damage. 1
Why Immediate Surgery is Critical at Age 2
- Germ cell damage has already begun: Progressive loss of germ cells starts after 15-18 months of age, and by 8-11 years, approximately 40% of bilateral cryptorchid boys have no germ cells remaining in testicular biopsies 1
- The testis will not spontaneously descend: After 6 months of corrected age, spontaneous descent is extremely unlikely, and at 2 years old, this testis has been undescended well beyond the point where natural descent could occur 2, 1
- Cancer risk increases with delay: The relative risk of testicular cancer is 2.75-8 times higher in cryptorchid testes, but prepubertal orchiopexy reduces this risk by 2-6 fold compared to postpubertal surgery 3, 4
Surgical Approach for Palpable Abdominal Testis
For a palpable intra-abdominal testis, the surgical specialist will perform either open or laparoscopic orchiopexy with excellent success rates exceeding 96%. 3, 4
Technical Considerations:
- Standard inguinal orchiopexy is the primary approach for most palpable undescended testes 4
- Laparoscopic orchiopexy may be utilized for abdominal testes and allows simultaneous diagnosis and treatment 4, 5
- If the testis is mobile or just distal to the internal inguinal ring ("peeping testis"), a one-stage orchiopexy using the Prentiss maneuver should be attempted 6
- If testicular vessels are very short or the testis is not mobile, a two-stage Fowler-Stephens orchiopexy may be necessary 6
- Testicular atrophy occurs in less than 2% of cases, making this a very safe procedure 3, 4
What NOT to Do (Common Pitfalls)
- Do not order imaging studies (ultrasound, CT, MRI): These rarely assist in decision-making and should not delay surgical referral 2, 1
- Do not "watch and wait": Some advocate monitoring until adolescence, but data do not support this approach—prompt orchiopexy is recommended 6
- Do not delay referral further: This child is already past the optimal 18-month window, and every additional month increases the risk of permanent fertility impairment 1
Long-Term Counseling Requirements
Parents must understand that even with successful surgery, this child faces lifelong risks that require ongoing surveillance: 3, 4
- Fertility concerns: Unilateral cryptorchidism typically has normal paternity rates, but bilateral cases have significantly reduced fertility 4
- Cancer surveillance: The child will need lifelong testicular self-examination training after puberty and regular monitoring, as cancer risk remains elevated even after orchiopexy 3, 2
- Monthly testicular self-examination should be taught after puberty to facilitate early cancer detection 3
Special Circumstances to Consider
If during surgical exploration the specialist finds any of the following, orchiectomy (removal) may be more appropriate than orchiopexy (assuming the contralateral testis is normal): 3
- Very short testicular vessels and vas deferens that place the testis too high in the retroperitoneum
- Dysmorphic or severely hypoplastic (underdeveloped) testis
- Atretic vas deferens