Surgical Management of Cryptorchidism with Patent Processus Vaginalis
In pediatric males with cryptorchidism and patent processus vaginalis, perform orchiopexy with concurrent high ligation of the processus vaginalis in a single operation by 18 months of age. 1, 2
Timing of Surgical Intervention
Surgery must be completed by 18 months of age to preserve fertility potential, as progressive germ cell loss accelerates after 15-18 months, with approximately 40% of bilateral cryptorchid boys lacking germ cells by 8-11 years if left untreated. 1, 2
Infants with cryptorchidism at birth should be referred to a surgical specialist by 6 months of corrected gestational age if spontaneous descent has not occurred. 3, 2
Testes that remain undescended by 6 months are unlikely to descend spontaneously and require surgical intervention. 3, 4
Surgical Approach Selection
For palpable cryptorchid testes, perform standard inguinal orchiopexy with concurrent closure of the patent processus vaginalis. 1, 2
The inguinal approach allows simultaneous mobilization of the spermatic cord, closure of the patent processus vaginalis (hernia repair), and placement of the testis into a scrotal dartos pouch. 2
Success rates for open surgical intervention exceed 96%, with testicular atrophy rates below 2%. 1, 2
A scrotal approach may be considered for low-lying palpable testes that can be manipulated to the scrotal neck under anesthesia, though the processus vaginalis must still be addressed if patent. 5, 6
Management of Patent Processus Vaginalis
High ligation of the patent processus vaginalis at the internal ring is essential during orchiopexy. 2, 7
All inguinal hernias in pediatric patients with undescended testes represent a patent processus vaginalis that must be addressed surgically. 2
Patent processus vaginalis is present in approximately 50% of cryptorchidism cases and must be ligated to prevent future inguinal hernia formation. 5, 7
More than 90% of pediatric inguinal hernias occur in boys due to the relationship between testicular descent and processus vaginalis formation. 2
High ligation is effective for successful orchiopexy and prevention of inguinal hernia in patients with undescended testes. 7
Surgical Technique Considerations
The processus vaginalis should be ligated at the internal ring during orchiopexy via either inguinal or scrotal approach. 2, 7
If a scrotal approach is attempted but the processus vaginalis is widely patent, conversion to an inguinal approach may be necessary for adequate high ligation. 5, 8, 6
Laparoscopic orchiopexy is indicated for non-palpable testes and allows for diagnosis and treatment in the same procedure, with the ability to address the processus vaginalis laparoscopically. 2, 9
Common Pitfalls to Avoid
Do not use hormonal therapy (hCG or GnRH) as primary treatment, as evidence shows low response rates (6-38% in controlled studies) and lack of long-term efficacy with significant recurrence risk. 1, 3
Do not obtain imaging studies (ultrasound) prior to referral, as they rarely assist in decision-making and have poor sensitivity (45%) for localizing non-palpable testes. 1, 3, 4
Do not delay surgery beyond 18 months of age, as this results in irreversible germ cell loss and reduced fertility potential. 1, 2
Failure to address a patent processus vaginalis during orchiopexy may result in subsequent inguinal hernia formation. 7, 9
Long-Term Outcomes and Counseling
Prepubertal orchiopexy reduces testicular cancer risk by 2-6 fold compared to postpubertal surgery, though the overall relative risk remains 2.75-8 times higher than the general population. 1, 2
Unilateral cryptorchidism has paternity rates similar to the general population, while bilateral cryptorchidism has significantly reduced fertility even with timely surgical correction. 2
Regular monitoring of testicular position and development is necessary throughout childhood and adolescence. 2, 4
Patients and families should be counseled that successful scrotal repositioning may reduce but does not completely prevent long-term risks of infertility and testicular cancer. 4