What is the management of unilateral undescended testis (cryptorchidism)?

From the Guidelines

Management of a unilateral undescended testicle should begin with referral to a pediatric urologist or surgeon, ideally by 6 months of age, and surgical correction via orchiopexy is the standard treatment and should be performed before 18 months of age to preserve fertility potential and reduce the risk of testicular cancer. This approach is supported by the American Urological Association (AUA) guideline, which recommends against the use of hormonal therapy to induce testicular descent due to low response rates and lack of evidence for long-term efficacy 1.

Key Considerations

• The AUA guideline emphasizes the importance of early referral and treatment, as imaging for cryptorchidism is not recommended prior to referral, which should occur by 6 months of age 1.
• Orchidopexy is the most successful therapy to relocate the testis into the scrotum, and successful scrotal repositioning of the testis may reduce but does not prevent the potential long-term issues of infertility and testis cancer 1.
• Hormonal therapy with human chorionic gonadotropin (hCG) or gonadotropin-releasing hormone (GnRH) is generally not recommended as primary treatment due to low success rates, ranging from 6-38% 1.
• Early intervention is crucial because undescended testes have impaired spermatogenesis beginning around 6-12 months of age, and the risk of testicular malignancy is 4-10 times higher than in normally descended testes.

Treatment Approach

• During orchiopexy, the surgeon mobilizes the testicle and its blood supply, then places it in the scrotum with fixation to prevent retraction.
• The procedure is typically performed as outpatient surgery with minimal complications.
• Following successful orchiopexy, patients should receive long-term follow-up to monitor testicular growth and development, and they should be educated about testicular self-examination after puberty due to their increased lifetime risk of testicular cancer.

From the FDA Drug Label

Prepubertal cryptorchidism not due to anatomical obstruction. In general, HCG is thought to induce testicular descent in situations when descent would have occurred at puberty. HCG thus may help predict whether or not orchiopexy will be needed in the future. Although, in some cases, descent following HCG administration is permanent, in most cases, the response is temporary Management of unilateral undescended testicle may involve the use of human chorionic gonadotropin (HCG) to induce testicular descent in prepubertal cryptorchidism not due to anatomical obstruction.

• HCG may help predict the need for orchiopexy in the future.
• The response to HCG is usually temporary, but in some cases, descent may be permanent. 2

From the Research

Management of Unilateral Undescended Testicle

• The management of unilateral undescended testicle involves surgical intervention, with the goal of maximizing potential for fertility and reducing the risk of testicular carcinoma 3, 4, 5.
• The American Academy of Pediatrics recommends orchiopexy by 18 months of age to prevent degenerative changes and reduce the risk of infertility and testicular cancer 3, 4, 5.
• For palpable testes, a standard inguinal approach is appropriate, while the prescrotal approach may be effective for low inguinal testes, reducing surgical time and patient discomfort 3.
• In cases of non-palpable testis, diagnostic laparoscopy is often used to determine the location and viability of the testis, and to perform orchiopexy if possible 3, 6, 5.

Surgical Approaches

• The choice of surgical approach depends on the location of the testis, with options including:
  • Standard inguinal orchiopexy for palpable testes 3, 6
  • Prescrotal approach for low inguinal testes 3
  • Diagnostic laparoscopy for non-palpable testes, followed by orchiopexy if possible 3, 6, 5
  • Two-stage Fowler-Stephens orchiopexy for abdominal testes with short testicular vessels 3
  • Microvascular testicular autotransplantation, a technically demanding procedure 3

Risks and Complications

• Unilateral undescended testicle is associated with an increased risk of infertility, with rates up to 10% 5.
• There is also an increased risk of testicular cancer, with a threefold higher risk compared to the general population 5.
• Early correction, from 3 to 6 months of age, is currently advised to minimize these risks 7.