What is the optimal timing for orchiopexy in a newborn with an undescended testis located in the inguinal canal, as confirmed by ultrasound (US)?

Optimal Timing for Orchiopexy in Newborn with Undescended Testis

The correct answer is B: After few months—specifically, surgery should be performed between 6-18 months of age, with referral to a surgical specialist by 6 months (corrected for gestational age) if the testis has not descended spontaneously. 1, 2

Rationale for Timing

Why Not Immediately (Option A)

• Spontaneous descent is possible in the first 6 months of life but becomes unlikely after 6 months of corrected age 1, 2
• Immediate surgery in newborns with undescended testis and inguinal hernia shows no benefit and actually results in higher orchiectomy rates compared to delayed surgery 3
• Even in cases with hernia incarceration at presentation, readmission rates for complications in deferred cases are minimal (<1% for orchiectomy or hernia incarceration) 3

Why 6-18 Months is Optimal (Option B)

The window of 6-18 months balances allowing time for spontaneous descent while preventing irreversible testicular damage. 2

Key evidence supporting this timing:

• Germ cell damage begins after 15-18 months of age in cryptorchid testes 2, 4
• By 8-11 years, approximately 40% of bilateral cryptorchid boys have complete loss of germ cells on biopsy 2
• Prepubertal orchiopexy reduces testicular cancer risk 2-6 fold compared to postpubertal surgery 2, 4
• Success rates for orchiopexy exceed 96% with testicular atrophy occurring in less than 2% of cases 2

Why Not After 2 Years (Option C)

• Waiting beyond 18 months allows progressive, irreversible germ cell loss that compromises future fertility 2, 4
• The AUA guidelines explicitly state that testes remaining undescended by 6 months are unlikely to descend spontaneously and face continued damage in non-scrotal locations 1
• International guidelines uniformly recommend orchiopexy by 18 months at the latest 2, 5, 6

Clinical Algorithm

At Birth to 6 Months

• Monitor for spontaneous descent at each well-child visit 1, 2
• Document testicular position carefully 1
• Do NOT order ultrasound or imaging—these studies rarely assist in decision-making and should not delay referral 1, 2

At 6 Months (Corrected for Gestational Age)

• If testis remains undescended: refer immediately to pediatric urologist or pediatric surgeon 1, 2
• The rationale is low probability of spontaneous descent after this point and ongoing testicular damage 1

Between 6-18 Months

• Surgical specialist performs orchiopexy, ideally before 18 months 2, 5, 6
• For inguinal canal location (as in this case): standard inguinal or prescrotal approach is appropriate 2, 5

Critical Pitfalls to Avoid

• Never delay referral beyond 6 months waiting for spontaneous descent 2
• Never order ultrasound before referral—over 70% of cryptorchid testes are palpable on examination by experienced providers, and imaging rarely changes management 1, 2
• Never rush to immediate surgery in newborns unless bilateral nonpalpable testes are present (which requires emergency evaluation for disorders of sex development) 1, 2

Special Consideration for This Case

Since ultrasound has already confirmed the testis in the inguinal canal (though imaging was unnecessary), this represents a palpable undescended testis that should follow the standard pathway: referral by 6 months if not descended, with surgery between 6-18 months. 1, 2