Timing of Surgery for Undescended Testicle
Surgery should be performed between 6-18 months of age, with 18 months being the absolute latest recommended time for orchidopexy. 1
Immediate Management Algorithm
The correct answer is C (Wait few months), but with critical caveats:
- Referral to a surgical specialist should occur by 6 months of corrected age if the testicle remains undescended, as spontaneous descent after this age is highly unlikely 2, 1
- The actual surgery (orchidopexy) is then performed between 6-18 months of age, not immediately at diagnosis 1
- This approach allows time to assess for spontaneous descent in the first 6 months while ensuring surgery occurs before the critical 18-month window closes 1
Why Not Immediate Surgery (Option A)?
- Spontaneous testicular descent can occur in the first 6 months of life, making immediate surgery unnecessary in many cases 1
- However, after 6 months of corrected age, spontaneous descent becomes extremely unlikely 2, 1
Why Not After 2 Years (Option B)?
Delaying surgery beyond 18 months causes irreversible damage:
- Germ cell loss begins after 15-18 months of age in cryptorchid boys 1
- By 8-11 years of age, approximately 40% of bilateral cryptorchid boys have no germ cells remaining in testicular biopsies 1
- Prepubertal orchidopexy (before puberty) results in a 2-6 fold reduction in testicular cancer risk compared to postpubertal surgery 1
- Surgery after 2 years significantly impairs fertility potential and increases cancer risk 1
Evidence-Based Rationale for 6-18 Month Window
The American Urological Association guidelines establish this timing based on:
- Preservation of fertility potential, which deteriorates after 18 months 2, 1
- Reduction in testicular cancer risk when surgery is performed prepubertally 2, 1
- Success rates for open surgical intervention exceed 96% when performed at this age 1
- Testicular atrophy occurs in less than 2% of cases with timely intervention 1
Critical Pitfalls to Avoid
- Do not order imaging studies (ultrasound) prior to referral - they rarely help with decision-making and should not delay specialist consultation 1
- Do not delay referral beyond 6 months - this is the most common error in management 1
- Do not wait for "watchful observation" beyond 6 months - the testis will not spontaneously descend and continues to sustain damage 1
Special Circumstances Requiring Immediate Action
Bilateral nonpalpable testes in a newborn require immediate specialist consultation to evaluate for possible disorders of sex development, including life-threatening conditions like congenital adrenal hyperplasia 1