What is the recommended treatment and timing for orchidopexy (surgical procedure to move an undescended testicle into the scrotum) in a pediatric male patient diagnosed with cryptorchidism?

Orchidopexy: Treatment and Timing for Cryptorchidism

Orchidopexy should be performed between 6-18 months of age, with surgery optimally completed by 18 months to preserve fertility potential and reduce testicular cancer risk. 1, 2

Referral Timeline

• Refer to a surgical specialist by 6 months of corrected age if the testis remains undescended, as spontaneous descent after this age is unlikely 1, 2
• Do not order imaging studies (ultrasound, CT, or MRI) prior to referral, as they lack sensitivity and specificity for identifying cryptorchid testes and should not delay specialist consultation 1, 2
• Bilateral non-palpable testes in a newborn require immediate specialist consultation to rule out life-threatening disorders of sex development such as congenital adrenal hyperplasia 2

Surgical Approach Based on Testicular Position

For Palpable Testes

• Perform scrotal or inguinal orchidopexy with documented success rates exceeding 96% and testicular atrophy rates below 2% 1, 3
• Single-incision scrotal orchidopexy is equally effective as the traditional two-incision approach for low-lying palpable testes 1, 3

For Non-Palpable Testes

• Laparoscopic exploration is mandatory to identify testicular vessel status and determine whether the testis is intra-abdominal, absent, or vanished 1, 3
• The objective is to either locate the testis or identify blind-ending testicular vessels indicating testicular absence 1

Evidence Supporting Early Intervention

Fertility Preservation

• Germ cell loss accelerates after 15-18 months of age, with approximately 40% of bilateral cryptorchid boys lacking germ cells by 8-11 years of age 1, 2
• While 75% of cryptorchid boys have normal germ cell counts in the first 6 months of life, 25% are born with reduced germ cells, emphasizing the importance of early intervention 1
• There is no direct long-term data comparing early versus late orchidopexy on fertility outcomes, but progressive histologic damage occurs throughout the prepubertal period 1

Cancer Risk Reduction

• Prepubertal orchidopexy reduces testicular cancer risk by 2-6 fold compared to postpubertal surgery 1, 2, 3
• The overall relative risk of testicular cancer in cryptorchid testes is 2.75-8 times higher than in normally descended testes 1
• Cancer risk increases substantially after puberty, making prepubertal correction critical 4

Special Considerations for Postpubertal Patients

• In postpubertal males with cryptorchidism, consider orchiectomy or biopsy rather than orchidopexy, particularly when the contralateral testis is normal 1, 5
• Factors to consider include associated medical conditions, anesthetic risk, and status of the contralateral testis 1
• Orchiectomy is indicated when very short testicular vessels are present, the testis is dysmorphic/hypoplastic, or the patient is postpubertal with a normal contralateral testis 2, 3

Hormonal Therapy: Not Recommended

• Hormonal therapy with hCG or GnRH is not recommended due to poor long-term efficacy (6-38% success in controlled studies) and high recurrence rates 1
• Surgery remains the standard of care in the United States 1

Current Practice Gaps

Despite clear guidelines, only 56% of patients receive timely orchidopexy (by 18 months) in recent U.S. data, representing a modest improvement from 51% pre-2014 6. Health disparities exist, with Hispanic, African American, Native American, and uninsured males significantly less likely to receive timely surgery 6. The main contributing factor is delayed or neglected referral by primary care providers 7, 8.

Common Pitfalls to Avoid

• Delaying referral beyond 6 months in the hope of spontaneous descent 1, 2
• Ordering unnecessary imaging that delays specialist consultation 1, 2
• Failing to correct for gestational age in premature infants when determining the 6-month referral window 1, 2
• Missing bilateral non-palpable testes as a potential medical emergency requiring immediate evaluation 2

Long-Term Counseling

• Counsel patients and parents that successful orchidopexy reduces but does not eliminate risks of infertility and testicular cancer 1
• Lifelong testicular self-examination should be taught and regular follow-up maintained 1
• Formerly unilateral cryptorchid men have slightly reduced but not significantly different paternity rates compared to the general population 4