Page 8 - CUA-PUC Canadian guideline for the diagnosis, management and followup of cryptorchidism

Braga et al.

strongly supporting or discouraging prophylactic orchido- Followup
pexy, the decision should be made based on informed dis-
cussion of options with the patient parents or legal guardian Although UDT are unquestionably associated with a higher
(Level 5 evidence, Grade D recommendation). risk for development of testicular cancer, the incidence rates
of this type of cancer are small and hence no screening
Testicular biopsy policy is justified. There is no need for formal long-term uro-
logical followup of patients with UDT. Nonetheless, periodic
Testicular biopsy is not indicated at the time of orchidopexy. self-exam after puberty is recommended with prompt referral
Recent evidence has shown that total germ cell histopathol- to an urologist if an abnormality is noted.
ogy at the time of orchiopexy was not predictive of significant
changes in hormone levels or semen analysis results in adult- Age at which orchiectomy is advisable over orchidopexy
49
hood. According to these authors, it may be clinically useful in
predicting fertility potential for those with bilateral undescended Data suggest that the risk of malignancy within a postpubertal
testicles, but this approach remains investigational. UDT is higher compared to those that underwent prepuber-
49
tal orchidopexy. Additionally, testicular cancer is exceed-
70
Orchiectomy ingly rare in older adults (i.e., after 50 years of age). 9,71 Hence,
we recommend considering orchiectomy for postpubertal
Orchiectomy remains the treatment of choice for the major- patients with hypotrophic/atrophic undescended testicles up
ity of postpubertal males presenting with unilateral crypt- to the age of 50. After that age, observation is likely appropri-
orchidism, especially when these testicles are small in size ate (Level 4 evidence, Grade D recommendation).
(hypotrophic/atrophic). Histological analysis of cryptorchid
testicles in postpubertal patients has shown that most of Acquired cryptorchidism
these testes have significant malignant potential and cannot
contribute to fertility (Sertoli only syndrome). 65 Acquired UDT are diagnosed at an average age of 8‒11
years. The reasons for this late diagnosis remain unknown.
Conservative management Careful serial physical examination is recommended to
accurately determine testicular position and identify cases
UDT is associated with a multitude of syndromes, some of acquired cryptorchidism in boys with retractile testes.
of which can lead to limited life expectancy and/or severe Some authors believe that acquired UDT represent a milder
developmental delay (e.g., Down’s, Prader-Willi, and subtype of congenital cryptorchidism that has escaped detec-
Noonan’s syndromes). Furthermore, there is evidence that tion in infancy. The percentage of retractile testicles that
72
in many of these patients, testicular function suffers pro- ascends and requires orchidopexy is difficult to estimate,
66
73
gressive deterioration over time. Nonetheless, given the ranging from 3‒30% in prepubertal children. Based on that,
67
reports of testicular cancer (sometimes at an early age ) in it is difficult to set a specific age for correction of these cases
these patients, we recommend orchidopexy when they are because it may vary from child to child.
clinically fit for anesthesia for the purpose of surveillance
(Level 4 evidence, Grade D recommendation). Competing interests: The authors report no competing personal or financial interests.
Previously failed orchidopexy
This paper has been peer-reviewed.
68
Overall orchidopexy failure rates are low (around 10%),
especially when only pediatric referral centre results are con-
sidered (1‒2%). When faced with a testicle in an inadequate References
69
(high) position after orchidopexy, redo surgery offers high
success rates in terms of bringing the testicle to a scrotal 1. Sijstermans K, Hack WWM, Meijer RW, et al. The frequency of undescended testis from birth to adulthood:
position. 68,69 Data on long-term (functional) outcomes of such A review. Int J Androl 2008;31:1-11.
testes are non-existent. We recommend offering redo orchi- 2. Berkowitz GS, Lapinski RH, Dolgin SE, et al. Prevalence and natural history of cryptorchidism. Pediatrics
1993;92:44-9.
dopexy for cases where inadequate position is detected post- 3. Cendron M, Huff DS, Keating MA, et al. Anatomical, morphological and volumetric analysis: A review of
operatively (Level 5 evidence, Grade D recommendation). 759 cases of testicular maldescent. J Urol 1993;149:570-3.
4. Hack WWM, van der Voort-Doedens LM, Goede J, et al. Natural history and long-term testicular growth of
acquired undescended testis after spontaneous descent or pubertal orchidopexy. BJU Int 2010;106:1052-
9. https://doi.org/10.1111/j.1464-410X.2010.09226.x
5. Health Canada. Fertility in Canada [Internet]. Government of Canada; [cited 2014 Nov]. Available from: http://
healthycanadians.gc.ca/healthy-living-vie-saine/pregnancy-grossesse/fert-eng.php. Accessed June 1, 2017.

E258 CUAJ • July 2017 • Volume 11, Issue 7