When should surgery be performed for a newborn with a non-palpable left testis confirmed by ultrasound to be in the inguinal canal?

Timing of Surgery for Undescended Testis in Newborn

Surgery should be performed between 6-18 months of age, with referral to a surgical specialist by 6 months (corrected for gestational age) and orchiopexy ideally completed before 18 months of age. 1

Immediate Management and Referral Timeline

• Refer to a pediatric urologist or surgical specialist by 6 months of corrected age if the testis remains undescended, as spontaneous descent is unlikely after this point 2, 1
• The testis confirmed in the inguinal canal by ultrasound will not descend spontaneously after 6 months, making early referral critical 2
• Perform orchiopexy between 6-18 months of age, with 18 months being the absolute latest recommended timing 2, 1

Rationale for Early Surgical Intervention

The evidence strongly supports early surgery based on fertility preservation and cancer risk reduction:

• After 15-18 months of age, germ cell loss begins in cryptorchid testes, with progressive damage occurring the longer surgery is delayed 1
• By 8-11 years of age, approximately 40% of boys with bilateral cryptorchidism have complete absence of germ cells on testicular biopsy 1
• Prepubertal orchiopexy reduces testicular cancer risk by 2-6 fold compared to postpubertal surgery 2, 1
• Continued damage to the testis occurs while it remains in a non-scrotal location 2, 1

Surgical Approach for This Case

For a palpable testis in the inguinal canal (as confirmed by ultrasound):

• Standard inguinal or scrotal orchiopexy is the appropriate surgical approach 2, 1
• Success rates exceed 96% for open surgical intervention, even for intra-abdominal testes 2, 1
• Testicular atrophy occurs in less than 2% of cases 2, 1
• For low-lying inguinal testes, a single-incision scrotal approach is also viable 2

Common Pitfalls to Avoid

• Do not delay referral beyond 6 months of age - this is the most critical error, as it reduces the window for optimal surgical timing 1
• Do not order additional imaging studies (ultrasound was already done) - these rarely assist in surgical decision-making and should not delay referral 2, 1
• Do not wait until after 2 years of age - this significantly increases the risk of permanent fertility impairment and does not reduce cancer risk as effectively 2, 1
• Do not consider hormonal therapy - it has low success rates, high re-ascent rates, and possible detrimental effects on spermatogenesis 3

Answer to Multiple Choice Question

The correct answer is D: After a few months - specifically, referral should occur by 6 months with surgery performed between 6-18 months of age. Options A (immediately) and C (after 2 years) are both incorrect based on current AUA guidelines 2, 1.