What is the optimal timing, peri‑operative management, surgical technique, and follow‑up for orchidopexy in a male infant with undescended testis?

Orchidopexy for Undescended Testis: Optimal Management

Timing of Surgery

All orchidopexy procedures must be performed by 18 months of age to preserve fertility potential, with the optimal window being between 6-18 months of corrected gestational age. 1, 2, 3

• Refer infants by 6 months of age if spontaneous testicular descent has not occurred, as testes remaining undescended after 6 months are unlikely to descend spontaneously 2, 3
• Progressive germ cell degeneration accelerates after 15-18 months of age, with approximately 40% of bilateral cryptorchid boys lacking germ cells by 8-11 years if left untreated 1
• The highest quality evidence from systematic reviews confirms that orchidopexy between 6-12 months optimizes fertility potential and reduces cancer risk 4
• While 18 months is the upper limit, there are still clear benefits to performing orchidopexy in all prepubertal boys at diagnosis, even if diagnosed later 1

Preoperative Assessment and Surgical Technique Selection

For Palpable Testes (approximately 70% of cases):

Standard inguinal orchidopexy is the gold standard approach, with documented success rates exceeding 96% and testicular atrophy rates below 2%. 2, 5

• The traditional inguinal approach involves mobilization of the spermatic cord and placement of the testis into a scrotal dartos pouch 5
• For low-lying palpable testes, single-incision scrotal orchidopexy is equally effective as the two-incision technique and has gained widespread acceptance 1, 5
• The scrotal approach allows for rapid postoperative recovery with minimal complications 6

For Non-Palpable Testes (approximately 30% of cases):

Laparoscopic exploration is mandatory for non-palpable testes, as radiologic imaging lacks both sensitivity and specificity for identifying testicular location. 2, 5

• The primary objective during exploration is identifying the status of testicular vessels to determine the next course of action 1, 5
• Approximately 55% of non-palpable testes are intra-abdominal, 30% are in the inguinal-scrotal area, and 15% are absent/vanishing 3
• Laparoscopic orchidopexy allows for both diagnosis and treatment in the same procedure with success rates of 85-90% 2, 7

Critical Technical Considerations

Early spermatic cord control at the internal inguinal ring is mandatory before any testicular manipulation to prevent potential tumor spread. 5

• If a patent processus vaginalis (inguinal hernia) is present, it must be ligated at the internal ring during orchidopexy 2
• This occurs in approximately 47% of cases and should be addressed concurrently in a single operation 2, 6

Indications for Orchiectomy Instead of Orchidopexy

Orchiectomy should be performed when a normal contralateral testis is present and any of the following conditions exist: 3, 5

• Very short testicular vessels and vas deferens preventing adequate mobilization
• Dysmorphic or severely hypoplastic testis
• Postpubertal presentation (though this should be rare given guideline adherence)

Postoperative Follow-Up

Regular monitoring of testicular position and development is necessary throughout childhood and adolescence. 2

• Assess for testicular re-ascent, which occurs in approximately 4-5% of cases and may require repeat surgery 6
• Monitor for testicular atrophy, though this complication occurs in less than 2% of cases 1, 5
• Evaluate testicular growth and development at regular intervals through puberty

Long-Term Counseling Requirements

Patients and families must understand that testicular cancer risk remains elevated 2.75-8 times baseline despite successful orchidopexy, though prepubertal surgery reduces this risk by 2-6 fold compared to postpubertal correction. 1, 3, 5

• Teach monthly testicular self-examination after puberty for early cancer detection 3
• Counsel that unilateral cryptorchidism has near-normal paternity rates (similar to general population), while bilateral cryptorchidism significantly reduces fertility to 35-53% 3, 7
• Explain that seminoma is the most common tumor type if the testis remains undescended, whereas nonseminomatous tumors are more likely following orchidopexy 7

Common Pitfalls to Avoid

Do not use hormonal therapy (hCG or GnRH) as primary treatment, as success rates are poor (6-38% in controlled studies) with significant recurrence risk. 1, 3

• Avoid delaying surgery beyond 18 months in prepubertal boys, as progressive histologic damage continues with each passing month 1, 2, 3
• Do not rely on imaging (ultrasound, CT, MRI) for non-palpable testes, as these modalities lack adequate sensitivity and specificity—proceed directly to laparoscopic exploration 1, 5
• Ensure proper informed consent regarding the 2-5% risk of testicular re-ascent requiring repeat surgery 6