Management of Undescended Right Testis in a 14-Month-Old
The correct answer is C: Right orchiopexy should be performed now, as this 14-month-old child is already within the recommended surgical window and should not be delayed further.
Rationale for Immediate Surgical Intervention
Orchiopexy should be performed by 18 months of age according to the American Urological Association, as progressive histologic damage occurs to undescended testes, particularly after the first year of life 1. This child at 14 months is already approaching the upper limit of the recommended treatment window.
Why Not Wait Until 3 Years?
- Spontaneous descent is extremely unlikely at this age, as testes that remain undescended by 6 months are unlikely to descend spontaneously 2
- Progressive testicular damage occurs with delay, with degenerative changes demonstrable histologically as early as 1-2 years of age 3
- Waiting until 3 years would miss the critical window for preserving fertility potential and reducing cancer risk, as the optimal timing is by 18 months 1, 2
Why Not Diagnostic Laparoscopy First?
- The testis location is already known - the examination reveals an empty right scrotum with (presumably) a palpable testis, making diagnostic laparoscopy unnecessary 1
- Laparoscopic orchidopexy is indicated for non-palpable testes, not for palpable undescended testes 1
- Standard inguinal orchiopexy is indicated for most palpable undescended testes and has a success rate >96% with testicular atrophy risk <2% 1
Why Right Orchiopexy (Not Left)?
- The clinical finding is an empty RIGHT scrotum, indicating the right testis is undescended [@question context]
- This is straightforward - treat the affected side
Surgical Approach Considerations
For a palpable undescended testis in this age group:
- Standard inguinal orchiopexy is the procedure of choice for palpable testes [@1@]
- A single incision approach is preferred over two-incision orchiopexy for palpable testes [@8@]
- Prescrotal orchiopexy may be considered if the testis is palpable and can be drawn close to the scrotum, with a 98.8% success rate 4
Critical Timing Considerations
- The child should have been referred by 6 months of age if spontaneous descent had not occurred [@2@]
- Boys diagnosed after 6 months should be promptly referred to a surgical specialist [@2@]
- At 14 months, this child is already overdue for referral and should proceed to surgery without further delay 1, 2
Long-Term Benefits of Timely Surgery
- Preservation of fertility potential is optimized with early intervention [@1@, 2]
- Reduction of testicular cancer risk by 2-6 fold compared to postpubertal surgery 1
- Improved testicular monitoring for future cancer surveillance 1
- Prepubertal orchiopexy reduces cancer risk, though it remains 2.75-8 times higher than the general population 1
Common Pitfall to Avoid
Do not delay surgery waiting for spontaneous descent - this is the most critical error in management at this age, as continued damage occurs to testes remaining in a non-scrotal location [@2@], and the window for optimal intervention is rapidly closing [@