At what age is orchidopexy (surgical procedure to move an undescended testicle into the scrotum) recommended?

Timing of Orchidopexy for Undescended Testis

Orchidopexy should be performed between 6-18 months of age, with referral to a pediatric urologist or pediatric surgeon by 6 months (corrected for gestational age) if the testis remains undescended. 1

Optimal Surgical Window

The critical timeframe for orchidopexy is before 18 months of age to preserve fertility potential and reduce testicular cancer risk. 2, 1 This recommendation is based on the following pathophysiologic timeline:

• Germ cell damage begins after 15-18 months of age, with progressive loss of fertility potential in cryptorchid boys. 2, 1
• By 8-11 years of age, approximately 40% of boys with bilateral undescended testes have complete absence of germ cells on testicular biopsy. 2, 1
• Prepubertal orchidopexy reduces testicular cancer risk by 2-6 fold compared to postpubertal surgery, though the overall relative risk remains elevated at 2.75-8 times baseline. 2, 1

Referral Timeline

The American Urological Association guidelines establish a clear referral pathway: 2, 1

• Spontaneous testicular descent may occur in the first 6 months of life (corrected for gestational age), but is unlikely after this point. 1
• Refer to a surgical specialist by 6 months if the testis remains undescended, as the probability of spontaneous descent after this age is minimal and continued damage to the cryptorchid testis occurs. 1
• This early referral allows adequate time for surgical planning and completion of orchidopexy within the optimal 6-18 month window. 1

Surgical Approach Based on Testicular Position

Palpable Undescended Testis

• Perform scrotal or inguinal orchidopexy for all palpable cryptorchid testes in prepubertal boys. 2
• Success rates exceed 96% with open surgical intervention, and testicular atrophy occurs in less than 2% of cases. 2, 1
• For low-lying palpable testes, a single scrotal incision approach is effective with mean operative time of approximately 23 minutes and 98% success rate. 3

Non-palpable Testis

• Identify the status of testicular vessels at exploration to determine the next course of action. 2, 1
• Approximately 50% of non-palpable testes are intra-abdominal or high inguinal, while 50% are atrophic remnants. 4
• Do not order imaging studies (ultrasound or other modalities) prior to specialist referral, as they rarely assist in decision-making and should not delay referral. 1

Special Clinical Scenarios

Bilateral Non-palpable Testes in Newborns

This is a medical emergency requiring immediate specialist consultation to evaluate for possible disorders of sex development, including congenital adrenal hyperplasia. 1 A genetic female (46,XX) with congenital adrenal hyperplasia can present with male-appearing genitalia and bilateral non-palpable gonads, representing a life-threatening condition. 1

Retractile Testis

• A retractile testis can be easily manipulated into the scrotum and remains there without traction. 5
• Annual monitoring is required because retractile testes carry a 2-45% risk of secondary ascent (acquired cryptorchidism) during childhood. 5
• If the testis cannot be manipulated into the scrotum and kept there without traction at 15 months, refer immediately for orchidopexy. 5

Acquired Cryptorchidism

• Previously descended testes that ascend and cannot be manipulated back into the scrotum face the same fertility and cancer risks as congenital undescended testes. 5
• Orchidopexy should be performed by 18 months once acquired cryptorchidism is diagnosed, as germ cell damage begins after 15-18 months. 5

Postpubertal Presentation

In postpubertal males with cryptorchidism, consideration should be given to orchiectomy or biopsy rather than orchidopexy, particularly when evaluating factors including associated medical conditions, anesthetic risk, and status of the contralateral testis. 2, 1

Common Pitfalls to Avoid

• Delaying referral beyond 6 months of age is the most common error, as this reduces the window for timely surgical intervention. 1
• Ordering unnecessary imaging studies (ultrasound, CT, MRI) prior to specialist referral delays appropriate care and provides minimal clinical benefit. 1
• Using hormonal therapy (hCG or GnRH) to induce testicular descent is not recommended, as evidence shows low response rates (6-38% in controlled studies) and lack of long-term efficacy with significant recurrence risk. 2
• Waiting beyond 18 months for spontaneous descent in true cryptorchidism results in irreversible germ cell loss. 2, 1

Evidence Regarding Early Surgery Safety

Recent data demonstrate that orchidopexy before 12 months of age does not increase the risk of postoperative testicular atrophy (3% in boys <1 year vs. 3.1% in older boys, p=0.999) or anesthetic complications. 6 However, there is a higher rate of wound infections in boys under 1 year (11% vs. 2.4%, p=0.025). 6 Despite guideline recommendations, only 11-25% of boys with congenital undescended testes currently undergo surgery before 12 months of age, with delayed referral being the primary reason for late surgery in 51% of cases. 7, 6