Management of Left Inguinal Undescended Testis with Associated Cystic Lesions
This patient requires urgent referral to a urologic surgeon for orchidopexy of the left undescended testis, regardless of age, with the left inguinal cystic lesion likely representing a loculated hydrocele or cord cyst that will be addressed during the same surgical procedure. 1, 2
Primary Surgical Intervention: Orchidopexy
The undescended left testis is the critical finding requiring immediate surgical correction. The standard treatment is orchidopexy (surgical repositioning into the scrotum), which achieves >96% success rates with <2% risk of testicular atrophy. 2, 3
Age-Dependent Approach
If this patient is a child: Orchidopexy should be performed by 18 months of age to preserve fertility potential and reduce cancer risk, as progressive germ cell degeneration occurs after the first year of life and worsens during the second year. 1, 2
If this patient is an adult: Management depends on the contralateral (right) testicular function. 1, 4
- With normal right testicular function (normal testosterone, FSH, and semen analysis): Orchidectomy of the left undescended testis should be offered due to the 3.6-7.4 times higher risk of testicular cancer, with mandatory multiple biopsies at the time of surgery to exclude germ cell neoplasia in situ (GCNIS). 1, 4
- With impaired right testicular function (biochemical hypogonadism or infertility): Orchidopexy may be offered to preserve androgen production and fertility, with mandatory biopsies to exclude GCNIS. 1, 4
Surgical Technique Selection
- Standard inguinal orchidopexy is the primary approach for this palpable inguinal undescended testis. 2, 3
- The left inguinal cystic lesion (likely loculated hydrocele or epididymal/cord cyst) will be directly visualized and addressed during the same procedure—either excised if it is a cord cyst or drained/excised if it is a loculated hydrocele. 1
Management of Incidental Right-Sided Findings
The right testicle findings are benign and require no intervention:
- Small 0.3 cm epididymal head cyst: This is a common benign finding requiring no treatment, only reassurance. 5
- Minimal hydrocele (0.25 cc): This is physiologic and requires no intervention. 5
Critical Counseling Points
Cancer Risk (Applies to All Ages)
- Testicular cancer risk remains elevated 2.75-8 times baseline even after successful orchidopexy. 1, 4
- The patient should be taught monthly testicular self-examination after puberty for early cancer detection. 1, 4
- Men with cryptorchidism have a 2-6% lifetime risk of developing testicular tumors. 1, 4
Fertility Implications
- Unilateral cryptorchidism has near-normal paternity rates (nearly equivalent to men without cryptorchidism), so this patient should be reassured about future fertility potential. 1, 5, 4
- The contralateral normal descended testis may also have subtle structural abnormalities, but this does not typically affect overall fertility in unilateral cases. 1
What NOT to Do: Common Pitfalls
- Do NOT order imaging studies (ultrasound, CT, MRI) prior to surgical referral—they rarely assist in decision-making and do not change management. 1, 4
- Do NOT use hormonal therapy (GnRH or hCG)—meta-analyses demonstrate poor success rates at any age. 1, 4
- Do NOT delay surgery beyond 18 months in prepubertal boys—progressive histologic damage continues with delayed treatment. 2, 4
- Do NOT assume the right testis is completely normal—even the contralateral descended testis in unilateral cryptorchidism may have subtle abnormalities, though this rarely affects overall fertility. 1
Immediate Next Steps
- Refer to pediatric urologist or urologist immediately (timing depends on patient age). 1, 4
- If adult patient: Obtain serum testosterone, FSH, LH, and semen analysis to assess right testicular function before surgery to guide the decision between orchidopexy versus orchidectomy. 1, 4
- Schedule orchidopexy (or orchidectomy if adult with normal contralateral function) with simultaneous management of the left inguinal cystic lesion. 1, 2, 4