1. An undescended testis is a testis that fails to descend into the scrotum, and can occur at any point along its normal descent path. The most common locations are within the inguinal canal or just outside the external inguinal ring. 2. Complications of undescended testes include impaired fertility, increased risk of testicular cancer, and temperature-related damage to sperm production. Left uncorrected, nearly 40% of undescended testes lose their germ cells by age 2. 3. Diagnosis involves physical examination to locate the testis. Treatment is surgical orchiopexy between 6 months to 1 year of age to bring the testis into the sc

1. UNDESCENDED TESTIS
Presented by : Dr Rahul Goel
Moderator : Dr Anju Verma

2. Contents
• History
• Embryology
• Classification
• Incidence
• Complications
• Diagnosis
• Treatment
• Guidelines

3. History
• John Hunter - 1786 - dissected the human
fetus.
• Coined the word “Gubernaculum”
• Gubernacula (= pilot, steer) or caudal genital
ligament
• Gives rise to –
• Males - Gubernaculum testis
• Females - suspensory ligament of ovary,
• round ligament of uterus & ovarian ligament
Burgu, Berk; Baker, Linda A.; Docimo, Steven G. (2010-01-01), Gearhart, John P.; Rink, Richard C.; Mouriquand, Pierre D. E.
(eds.), "CHAPTER 43 - CRYPTORCHIDISM", Pediatric Urology (Second Edition), Philadelphia: W.B. Saunders, pp. 563–576

4. Embryology
• 32 days after ovulation genital ridge identified
• 6 wk primordial germ cells migrate to genital ridge
• 7 wk testicular differentiation
• The sex-determining region of the genome is located on the short arm of the
Y chromosome and is called the SRY
• Hormonal function critical - If lost embryo follows the default development
pathway

5. 5
• A 5th week Testis begins its primary
descent; kidney ascends.
• B 8th-9th weeks. Kidney reaches
adult position.
• C 7th month, Testis at internal
inguinal ring; gubernaculum (in
inguinal fold) thickens and shortens.
• D Postnatal life.
Embryology

6. Transabdominal Phase at 8 – 15 weeks
• Testis is held near the inguinal abdominal wall
during embryonic growth by enlargement of the
gubernaculum (G).
• Testicular hormones
• Insulin-like factor 3
• Mullerian-inhibiting substance (MIS)
• Cranial ligament regresses under the action of
testosterone.
Inguinoscrotal Phase at 28 - 35 weeks
• Gubernaculum migrates by elongation toward the
scrotum.
• Controlled by testosterone acting on the
genitofemoral nerve (GFN)
• Sensory fibers to release calcitonin gene-related
peptide (CGRP).
• CGRP controls growth and direction of migration of
the gubernaculum
Embryology

7. P
Dissection of 32-week human fetus
showing the testis (T) and gubernaculum
(G) migrating across the pubic region
toward the scrotum (S). A pair of forceps
holds the caudal end of the
gubernaculum
Embryology

8. 1. Insl3 - analogue of insulin and relaxin produced by Leydig cells. Insl3 is
made up of two peptide chains linked by a disulfide bond.
2. Testosterone and Mullerian-inhibiting substance.
3. Genitofemoral nerve. The signals initiating migration of the gubernaculum
out from the abdominal wall have many characteristics of an embryonic
limb bud. - Calcitonin Gene Related Peptide (CGRP)
4. The physical force for migration of the testis is probably provided by intra-
abdominal pressure acting through the patent processus vaginalis and the
cremaster muscle in the wall of the gubernaculum
Factors in Testicular Migration

9. An undescended testis is one which has filed to descend to the scrotum & is
retained at any point along the normal path of descent
Right side: 50% Left side: 30% Bilateral: 20%
M/C inguinoscrotal phase of descent is deranged - outside the inguinal canal
transabdominal phase is infrequently disrupted, so the intra-abdominal testes
are relatively uncommon - 5% to 10%
M/C location - neck of the scrotum, just outside or a little lateral to the
external inguinal ring, in the “superficial inguinal pouch”
Classification

10. Sites for UDT
60%

11. Retractile Testes
Transient retraction of the testis out of the scrotum - is a normal reflex
Caused by contraction of the cremaster muscle.
This muscle functions to regulate the temperature of the testis and
to protect it from extrinsic trauma.
Retraction occurs as a result of low temperature or stimulation of the cutaneous
branch of the genitofemoral nerve (inner thigh).
Theory of Goh and Hutson - acquired maldescent
Failure of the spermatic cord to elongate with age
Fenton, E. J. M., Woodward, A. A., Hudson, I. L., & Marschner, I. (1990). The ascending testis. Pediatric surgery international, 5,
6-9.

12. Ascending Testes
A newly described variant of the retractile testis is the ascending testis.
Ascent out of the scrotum later in childhood is often related to delayed
descent into the scrotum within the first 3 months after birth.
The difference between ascending and retractile testes is otherwise not
clear, and
Different names for developing acquired cryptorchidism

13. Incidence
Incidence 4.3% in infants but by 1 year of age, the incidence had fallen to 0.96%.
John Radcliffe Hospital Cryptorchidism Study Group - spontaneous descent
occurred postnatally in the first 3 months; beyond that time, it was rare
Age for surgery for congenital undescended testes - 6 months of age
Birth Weight < 1500 g - Incidence reaches 60% to 70%.
Cause - normal descent is not completed until about 35 weeks’ gestation.
If such children are examined at 12 weeks beyond their expected normal delivery
date, the incidence of cryptorchidism has fallen to more normal levels

14. • The majority of cases are isolated, ratio of non syndromic to syndromic
cryptorchidism >6 : 1 (Boyd et al, 2006).
• Risk factors of UDT:
– intrauterine growth restriction (IUGR)
– prematurity – incidence in premature infants 30%
– first- or second-born boys
– perinatal asphyxia
– Cesarean section
– toxemia of pregnancy
– congenital subluxation of hip
- MMC
- congenital abdominal wall conditions
Risk Factors

15. COMPLICATIONS

16. Temperature
• The scrotal testis in the human is maintained at 33C compared
with 34C to 35C in the inguinal region and 37C intra-abdominally
• The physiology of the testis is well adapted to this lower
temperature
• The testis undergoes progressive alteration –
1. increased germ cell apoptosis
2. DNA damage in sperm cells
3. Changes in gene expression
4. Increase in chromosome aneuploidy
5. Changes in Na+/K+-ATPase activity
Yuanyuan Gao, Chen Wang, Kaixian Wang, Chaofan He, Ke Hu & Meng Liang (2022) The effects and molecular mechanism of
heat stress on spermatogenesis and the mitigation measures, Systems Biology in Reproductive Medicine, 68:5-6, 331-
347, DOI: 10.1080/19396368.2022.2074325

17. Endocrine Effects
• Normal postnatal rise in plasma luteinizing hormone (LH) levels
and
Testosterone were found to be significantly lower than normal.
• Androgen receptor levels in scrotal skin fibroblasts and testicular
biopsy specimens taken at orchidopexy are normal in infants with
bilateral cryptorchidism.
• MIS levels are normally elevated between 4 and 12 months of
age, but in children with cryptorchidism this postnatal rise was
inhibited
Rodprasert W, Virtanen HE, Mäkelä JA, Toppari J. Hypogonadism and Cryptorchidism. Front Endocrinol (Lausanne). 2020 Jan
15;10:906. doi: 10.3389/fendo.2019.00906. PMID: 32010061; PMCID: PMC6974459.

18. Fertility
By the end of the second year of life, nearly 40% of undescended testes have
completely lost their germ cells.
evidence that germ cell maturation is already abnormal after 6 months of age -
early intervention may prevent it.
Paternity rates are not deficient in unilateral cryptorchidism - but with
bilateral cryptorchidism, fertility is significantly impaired
Hanerhoff BL, Welliver C. Does early orchidopexy improve fertility? Transl Androl Urol. 2014 Dec;3(4):370-6. doi:
10.3978/j.issn.2223-4683.2014.11.09. PMID: 26816793; PMCID: PMC4708134.

19. Malignancy
• RR - 3.7–7.5 times
• 5–10% of cases of testicular malignancy have cryptorchidism
• unilateral cryptorchidism is 15-fold or 33-fold for bilateral undescended
testes
• Malignant change typically peaks in 3rd to 4th decade of life
• Median Age - 32 years
• M/C - Seminoma 50–60%
• Occur at the same age as testis tumors in normally descended testes (i.e.,
20 to 40 years)
Gupta V, Giridhar A, Sharma R, Ahmed SM, Raju KVVN, Rao TS. Malignancy in an Undescended Intra-abdominal Testis: a
Single Institution Experience. Indian J Surg Oncol. 2021 Mar;12(1):133-138. doi: 10.1007/s13193-020-01262-9. Epub 2021 Jan
7. PMID: 33814843; PMCID: PMC7960876.

20. Risk Factors for Testicular Cancer
“Highly”
(1) Undescended Testis (Cryptorchidism) – LEVEL I EVIDENCE
(2) contralateral testicular germ cell tumor (GCT),
(3) familial testicular germ cell tumor,
(4) gonadal dysgenesis.
“Likely”
(1) Infertility
(2) twin-ship,
(3) testicular atrophy.
“Equivocal/Low”
(1) scrotal trauma,
(2) inguinal hernia,
(3) Mumps/ orchitis,
(4) testicular torsion,
(5) maternal estrogen exposure
(6) occupational exposure.
Coran’s 7 th ed

21. Risk Factors for Testicular Cancer
Cryptorchidism occurs in 2% to 5% of term infant males
however, by 12 months of age, this number is reduced to 1%.
overall relative risk of 4.8
underwent orchiopexy after 10 years of age had a 3.5-fold increased risk of
testicular cancer, compared with those that had the procedure at an earlier age
Pettersson et al –
n= 16,983
increased risk of testicular cancer for the entire cohort - 2.23 versus normal
population
incidence of cancer was significantly higher 5.4 after the age of 13 years
Pettersson A, Richiardi L, Nordenskjold A, Kaijser M, Akre O. Age at surgery for undescended testis and risk of testicular cancer. N
Engl J Med. 2007 May 3;356(18):1835-41. doi: 10.1056/NEJMoa067588. PMID: 17476009

22. Inguinal Hernia
Tanyel et al. and Davenport - although the processus vaginalis is patent in
boys with undescended testis, clinical inguinalhernia is only encountered in
10-15%
Higher risk of incarcerated hernia
Sepúlveda L, Gorgala T, Lage J, Monteiro A, Rodrigues F. Undescended Testis Presenting as Incarcerated Inguinal Hernia in Adults: A Rare Case
and Literature Review. Curr Urol. 2014 Oct;7(4):214-6. doi: 10.1159/000365680. Epub 2014 Aug 20. PMID: 26195955; PMCID: PMC4483298.

23. Torsion of a Cryptorchid Testis
• Incidence - 20% - in
unoperated undescended
testes
• Mobility of testis within the
tunica vaginalis in the
superficial inguinal pouch
Naouar S, Braiek S, El Kamel R. Testicular torsion in undescended testis: A persistent challenge. Asian J Urol. 2017 Apr;4(2):111-
115. doi: 10.1016/j.ajur.2016.05.007. Epub 2016 Jun 26. PMID: 29264215; PMCID: PMC5717970.
Case of an elderly male with
undescended testis associated with
a reactive inflammatory mass
incarcerated at the superficial
inguinal ring --
Findings - atrophic testis, enlarged edematous
epididymis, and prominent paratesticular mass
strangulated in the superficial inguinal ring
Testicular-Epididymal Fusion Abnormality

24. Trauma
Slightly increased risk of direct trauma
Cerebral palsy patients requiring wheelchair restraint

25. Diagnosis
Examination should be conducted in warm surroundings with the child relaxed.
Recumbent position , examine the genitalia
Inspect the scrotum before palpation
A hemiscrotum of normal size is more likely if the testis is retractile or ascending
80% to 90% of testes are palpable in the inguinal region or can be squeezed out
– pressing firmly on the abdominal wall laterally near the ASIS and pressing downward
and medially toward the scrotum
Examine ectopic sites
Truly impalpable testes in 5% to 28% of boys with undescended testes
If the testis cannot be palpated, this implies that it is either intra-abdominal (45%) or
within the inguinal canal (up to 25%)
Alternatively, it may be absent (45%) - vanishing testis due to intrauterine torsion of
the spermatic cord during migration of the gubernaculum to the scrotum.
Laparoscopy - intra-abdominal testis

26. • prematurity (incidence of UDT in premature boys is as high as
30%)
• Maternal use/exposure to exogenous hormones (estrogens)
• Lesions of the central nervous system (myelomeningocele)
• Previous inguinal surgery.
• Document a family history of cryptorchidism
• Important to know if the testes were ever palpable in the
scrotum at the time of birth or within the first year of life.
Diagnosis

27. Preterm and maternal history, including the use of gestational steroids
• Perinatal history, including documentation of a scrotal examination at birth
• The child's medical and previous surgical history
• Family history of cryptorchidism or syndromes
All boys with nonpalpable testes and normal serum gonadotropin levels must
undergo surgical exploration regardless of the results of the hCG stimulation test.
27
Diagnosis

28. • History & Physical exam
• Laboratory investigations
• Radiological imaging
• E U A
• Laparoscopy
Diagnosis

29. Certain anomalies are associated with increased risk of
cryptorchidism
– Classic prune-belly
– Spigelian hernia ,umblical haenia
– Cerebral palsy
– Arthrogryposis
– Myelomeningocele
– Omphalocele, gastroschisis
– Imperforate anus
– Posterior urethral valve
– Multicystic dysplastic kidney
– Prematurity, LBW , SGA, breech presentation, maternal diabetes
Cryptorchidism associated with syndromes and CNS
malformations is more commonly bilateral
Diagnosis

30. Imaging
• >70% of UDT are palpable by physical examination and need no
imaging.
• In the remaining 30% of cases with nonpalpable testis, the
challenge is to confirm absence or presence of the testis and to
identify the location of the viable nonpalpable testis
• USG is non-contributory; sensitivity and specificity - 45% and
78% respectively. Intra-abdominal testes are not detected by
USG
• CT - cost and ionizing radiation exposure
• MRI +/- angiography - low availability and need for anesthesia
Tasian GE and Copp HL: Diagnostic performance of ultrasound in nonpalpable cryptorchidism: a systematic review and meta-
analysis. Pediatrics 2011; 127: 119

31. • Gadolinium-enhanced magnetic resonance angiography (MRA)
& magnetic resonance venography (MRV) to identify 100% of
canalicular UDT and 96% of intra-abdominal UDT
• In current times the only indication for MRI is identification of
an ectopic abdominal testis not localized by laparoscopy.
• Laparoscopic or surgical documentation of anorchia is critical to
avoid leaving small or dysgenetic abdominal testes in situ.
Imaging

32. Hormone Therapy
Theory - deficiency of the hypothalamic pituitary-gonadal axis and that postnatal
treatment can induce the required migration of the gubernaculum.
Therapies used - Testosterone, hCG, and LHRH.
Direct androgen therapy was abandoned many years ago because excessive doses
caused precocious puberty.
hCG has been used commonly in Europe
LHRH has been tried more recently
Indications:
When the surgeon is not sure whether the case is one of retractile testis or
not
Bilateral incomplete descended testis

33. The overall efficacy of hormonal treatment is less than 20% for cryptorchid
testes and is significantly dependent on pretreatment testicular location.
Therefore, surgery remains the gold standard for the management of
undescended testes.
33
Hormone Therapy

34. Management of Cryptorchidism
Proper identification of the anatomy, position, and viability of the
undescended testis
• Identification of any potential coexisting syndromic abnormalities
• Placement of the testis within the scrotum in timely fashion to prevent
further testicular impairment in either fertility potential or endocrinologic
function
• Attainment of permanent fixation of the testis with a normal scrotal
position that allows for easy palpation
• No further testicular damage resulting from the treatment
Definitive treatment of an undescended testis should take place between 6
and 12 months of age

35. 35
Orchidopexy

36. 36
Orchidopexy

37. Orchidopexy
Prentiss Manoeuvre

38. Prentiss Manoeuvre

39. Prentiss Manoeuvre

40. Orchidopexy

41. The key steps in this procedure are ---
(1) Complete mobilization of the testis and spermatic cord
(2) repair of the patent processus vaginalis by high ligation of the
hernia sac
(3) skeletonization of the spermatic cord without sacrificing vascular
integrity to achieve tension-free placement of the testis within the
dependent position of the scrotum
(4) creation of a superficial pouch within the hemi-scrotum to receive
the testis.
Orchidopexy

42. WHEN LENGTH IS AN ISSUE
1. Medial transposition of the testis medial to the epigastric vessels
(Prentiss manoeuvre)
2. Divisionof lateral fascial bands along the cord
3. Cranial retroperitoneal dissection
4. Cranial extension of the incision.
Orchidopexy

43. Two stage procedures-
1. Fowler & Stephens “Long Loop Vas” Orchidopexy –
• Testicular vessels are ligated intra-abdominally.
• Testis is swung down on a long-loop vas.
• Supplied by collaterals from the artery to the vas and some cremasteric
vessels
Orchidopexy
FOWLER R, STEPHENS FD. The role of testicular vascular anatomy in the salvage of high undescended testes. Aust N Z
J Surg. 1959 Aug;29:92-106. doi: 10.1111/j.1445-2197.1959.tb03826.x. PMID: 13849840.

44. Fowler & Stephens “Long Loop Vas” Orchidopexy
Although the testicular vessels themselves
are short, the vas deferens and its
companion vessels are long
They run a recurrent course
The long vas and its accompanying vessels
emerge through the external ring and may
extend further either to the superficial
inguinal pouch or scrotum before looping
back to rejoin the testis.
This is the “long loop” type of vas.
FOWLER R, STEPHENS FD. The role of testicular vascular anatomy in the salvage of high undescended testes. Aust N Z
J Surg. 1959 Aug;29:92-106. doi: 10.1111/j.1445-2197.1959.tb03826.x. PMID: 13849840.

45. Fowler & Stephens “Long Loop Vas” Orchidopexy
The testicular artery (T.A. Lower) and sundry
anastomoses ( A ) are filled from the vasal artery
(V.A.), Testis (T.),Epidiciymis (E.).
The clamp is shown compressing the testicular
artery (t.A. Upper) and the pampiniform plexus
of veins (P.P.);
The dotted lines represent the unfilled segment
of testicular artery above and below the clamp
FOWLER R, STEPHENS FD. The role of testicular vascular anatomy in the salvage of high undescended testes. Aust N Z
J Surg. 1959 Aug;29:92-106. doi: 10.1111/j.1445-2197.1959.tb03826.x. PMID: 13849840.

47. Two stage procedures-
2. Dessanti etal(2009) novel two-stage technique .
• Spermatic vessels are not sectioned but are lengthened through
progressive traction of the spermatic cord
• Wrapped in polytetrafluoroethylene pericardial membrane.
• The first stage involves the mobilisation of the spermatic cord in the
retroperitoneal space and wrapping it in the polytetrafluoroethylene
membrane.
• The second stage, usually done after a period of 9–12 months, involves
the removal of the polytetrafluoroethylene membrane
Orchidopexy
Cryptorchidism with short spermatic vessels: staged orchiopexy preserving spermatic vessels ;Dessanti A, Falchetti D, Iannuccelli M, Milianti S,
Altana C, Tanca AR, Ubertazzi M, Strusi GP, Fusillo M ;Department of Pediatric Surgery, Azienda Ospedaliero-Universitaria, University of Sassari,
Sassari, Italy J Urol. 2009; 182: 1163-7

48. Two stage procedures-
2. Dessanti etal(2009) novel two-stage technique .
• Spermatic vessels are not sectioned but are lengthened through
progressive traction of the spermatic cord
• Wrapped in polytetrafluoroethylene pericardial membrane.
• The first stage involves the mobilisation of the spermatic cord in the
retroperitoneal space and wrapping it in the polytetrafluoroethylene
membrane.
• The second stage, usually done after a period of 9–12 months, involves
the removal of the polytetrafluoroethylene membrane
Orchidopexy
Cryptorchidism with short spermatic vessels: staged orchiopexy preserving spermatic vessels ;Dessanti A, Falchetti D, Iannuccelli M, Milianti S,
Altana C, Tanca AR, Ubertazzi M, Strusi GP, Fusillo M ;Department of Pediatric Surgery, Azienda Ospedaliero-Universitaria, University of Sassari,
Sassari, Italy J Urol. 2009; 182: 1163-7

49. Two stage procedures-
3. Cockery (1975) Sialisticbagtwo-stage technique .
• Anchor the testis to the pubic bone and 6-12
months later re-explore the wound – dense
adhesions
• A Silastic pouch encloses the spermatic
cord,epididymis, and most of the testis,
leaving a tiny lower pole of testis anchored
to the pubis
• The second stage, usually done after a period
of 12 months, involves the removal of the
sialistic bag and surgery proceeds as per
usual
Orchidopexy
Corkery JJ. Staged orchiopexy – a new technique. J Pediatr Surg. 1975;10(4):515–8. https://doi.org/10.1016/0022-3468(75)90194-3.

50. Complications of Orchiopexy
Testicular retraction
Hematoma formation
Ilioinguinal nerve injury
Postoperative torsion (either iatrogenic or spontaneous)
Damage to the vas deferens
Testicular atrophy
Devascularization with atrophy of the testis can result from skeletonization of
the cord, from overzealous electrocautery
50

51. Iatrogenic Undescended Testicle
After hernia repair
Rare but underreported complication.
Incidence of 0.2% - 0.4%
Reason - Failure to replace the testis back in the scrotum after the
procedure
OR
Testis subsequently trapped in a retracted location.
Rx - Secondary Orchidopexy
Abeş M, Bakal Ü, Petik B. Ascending testis following inguinal hernia repair in children. Eur Rev Med Pharmacol Sci. 2015
Aug;19(16):2949-51. PMID: 26367711.

52. American Urology Association
Guidelines 2014

54. (Retractile Testes)
• “In boys with retractile testes, providers should assess the
position of the testes at least annually to monitor for
secondary ascent.” (Standard; Evidence Strength: Grade B).
– Testicular examination is recommended at least
annually at every well-child visit in accordance
with Bright Futures AAP recommendations (2014).
– Etiology: presence of a hyperactive Cremasteric
reflex.
– Why: Retractile testes are at increased risk for
testicular ascent (34%)

55. (Ascending Testicle)
• “Providers should refer boys with the possibility of
newly diagnosed (acquired) cryptorchidism after six
months (corrected for gestational age) to an appropriate
surgical specialist.” (Standard; Evidence Strength: Grade B)
– Acquired or ascending testicle: Cryptorchid testicle that is
documented as in scrotal position at a previous examination.
– The prevalence of acquired cryptorchidism is (1-7%) and peaks
around 8 years of age
– Reason: fibrous persistence of the processus vaginalis, which
limits the growth of the spermatic cord.
– Risk Factor: Retractile testicles (34%), Hypospadias and Hx of
contralateral UDT.*
AUA guidelines, 2014

56. Gliding
• Testis can be manipulated into upper scrotum but retracts when
released.
• Emergent.
• Peeping.
Vanishing
• Bilateral anorchia, or embryonic testicular regression (vanishing
testis syndrome)
• Blind ending vessels
• Blind ending vas.

57. (UDT & DSD)
• “Providers must immediately consult an appropriate
specialist for all phenotypic male newborns with
bilateral, nonpalpable testes for evaluation of a possible
disorder of sex development (DSD).” (Standard; Evidence Strength:
Grade A)
– A newborn with a male phallus and bilateral
nonpalpable gonads is potentially a genetic
female (46 XX) with CAH until proven
otherwise.
– Karyotype, serum electrolytes and a hormonal
profile (LH, FSH, testosterone) should all be
done.
AUA guidelines, 2014

58. BILATERAL NON PALPABLE
• In patients ≤ 3 months with bilateral non-palpable UDT, LH, FSH, and
testosterone levels will help determine whether the testes are present;
• In patients >3 months of age, an hCG stimulation test will
aid in the diagnosis of the absent testes.
• A weight-based single injection of hCG (100 IU/kg) is usually sufficient to
detect a rise in serum testosterone 4–5 days later.
• A failure to see a measurable increase in testosterone in combination
with elevated LH and FSH is consistent with the diagnosis of anorchia

59. • Müllerian inhibiting substance MIS may be a more
sensitive and specific prepubertal marker for detecting the
presence of testes.
• A measurable value is predictive of non-palpable UDT,
whereas an undetectable value is highly suggestive of
anorchia
• Both MIS and testosterone levels may be misleading in
cases of UDT with intersex if the testes are severely
dysgenetic or if there is a mutation of the antimüllerian
hormone or receptor genes

60. “In boys with bilateral, nonpalpable testes who do
not have congenital adrenal hyperplasia (CAH),
providers should measure Müllerian Inhibiting
Substance (MIS or Anti- Müllerian Hormone [AMH])
and consider additional hormone testing to evaluate
for anorchia.” (Option; Evidence Strength: Grade C).
– Patient who has bil nonpalpable UDT with 46 XY
karyotype, may have hormonal workup or wait until
age 6 months to undergo laparoscopic exploration.
– Hormonal workup: Tes, LH, FSH, hCG stimulation test,
and MIS.
AUA guidelines, 2014

61. (Imaging)
• “Providers should not perform ultrasound (US) or other
imaging modalities in the evaluation of boys with
cryptorchidism prior to referral, as these studies rarely assist
in decision making.” (Standard; Evidence Strength: Grade B).
– At this time, there is no radiological test that can
conclude with 100% accuracy that a testis is
absent.
– Diagnostic laparoscopy is the gold standard with
high sensitivity and specificity.
AUA guidelines, 2014

62. (Hormonal Therapy)
• “Providers should not use hormonal therapy to induce
testicular descent as evidence shows low response rates
and lack of evidence for long-term efficacy.” (Standard;
Evidence Strength: Grade B).
– The overall review of all available studies fails
to document long-term efficacy.
– Success rates: 6-21% in randomized, blinded
studies (mostly distal inguinal UDT).
– Side effects of hCG treatment seen in up to
75% of boys include:
• Increased scrotal wrinkles, pigmentation, and pubic hair.
• Penile growth.
• Inducing epiphyseal plate fusion and retard future somatic growth.
AUA guidelines, 2014

63. (Time of Surgery)
• “In the absence of spontaneous testicular descent by six
months (corrected for gestational age), specialists
should perform surgery within the next year.” (Standard;
Evidence Strength: Grade B).
– Time of surgery: between age 6 and 18
months, to preserve available fertility
potential.
– After 15 to 18 months of age some
cryptorchid boys will have decreased number
of germ cells, Leydig and Sertoli cells in the
testes.
AUA guidelines, 2014

64. • The standard treatment for palpable testes is inguinal
orchidopexy with repair of an associated hernia if present
• The recommended age gradually declined over the years.
Presently age 6 months in full term males.
• An option for pubertal and post-pubertal boys is
orchiectomy, especially if the testis is abdominal or difficult
to mobilize.
• Success of the operative treatment of UDT is defined as
scrotal position and lack of atrophy of the testis. With
minimum 6 month follow up.

65. (Surgical Approach)
• “In prepubertal boys with palpable, cryptorchid testes,
surgical specialists should perform scrotal or inguinal
orchidopexy.” (Standard; Evidence Strength: Grade B).
– Outpatient procedure with minimal morbidity.
– There are cosmetic, fertility and cancerous
advantages.
– Success rate is greater than 96%.
AUA guidelines, 2014

66. SHOULD WE FIX. “IT IS A PEXY”
• Suture fixation of the testis is in any event not needed if
mobilization is adequate and a subdartos pouch technique is
used.
• If needed, additional absorbable fixation sutures can be
placed between the visceral tunica vaginalis and the dartos.
• Sutures through the tunica albuginea of the testis are not
recommended because of possible injury to the testis via
inflammatory or vascular insult.

67. • Generally not recommended.
• Biopsy is indicated in cases of sexual ambiguity or if
clinical evidence of testicular dysgenesis is present.
• Chromosomal disorders
• Clinical studies.
• Nevertheless, reports show that testicular biopsy in
prepubertal boys can predict future sperm count and identify
preinvasive CIS without causing damage resulting in presence of
antisperm antibodies or testicular microlithiasis in adulthood.
Role of Biopsy

68. (Surgical Approach to the
NON PALPABE Testis)
• “In prepubertal boys with nonpalpable testes, surgical
specialists should perform examination under
anesthesia to reassess for palpability of testes. If
nonpalpable, surgical exploration and, if indicated,
abdominal orchidopexy should be performed.” (Standard;
Evidence Strength: Grade B).
– Advantage: diagnostic and treatment
procedure at the same time.
AUA guidelines, 2014

69. • “At the time of exploration for a nonpalpable testis in boys,
surgical specialists should identify the status of the testicular
vessels to help determine the next course of action." (Clinical
Principle)
• Vanishing testicle: do nothing further.
• Intraabdominal viable testicle: Primary vs FS
orchiopexy.
AUA guidelines, 2014

70. (Orchiectomy)
• “In boys with a normal contralateral testis, surgical
specialists may perform an orchiectomy (removal of the
undescended testis) if a boy has a normal contralateral testis
and either very short testicular vessels and vas deferens,
dysmorphic or very hypoplastic testis, or postpubertal age.”
(Clinical Principle)
AUA guidelines, 2014

71. (Cancer & Infertility)
• “Providers should counsel boys with a history of
cryptorchidism and/or monorchidism and their
parents regarding potential long-term risks and
provide education on infertility and cancer risk.”
(Clinical Principle).
– UDT and testicular cancer:
• Risk of Testicular Ca in normal men is 1:500
• The increased incidence of malignancy in cryptorchid testes
varies from (0.05%) to (1%).
• The RR of testicular cancer in UDT is 2.75-8, which decreased
to 2-3 in patients who underwent orchiopexy before
puberty (age 10-12 years).
– UDT and fertility:
• Risk of infertility: normal men (7%), unilateral UDT (10%) and
bilateral UDT (33%).*
* 2009 Pediatric review Syllabus, volume 1 of 2, AUA publication

72. Why treat.
– to prevent the impairment of spermatogenesis,
– to prevent, or at least decrease, the risk of TGCN,
– to facilitate future examination of the testicle
(palpation, US),
– to correct the inguinal hernia frequently
accompanying UDT,
– to minimize the risk of torsion of the testis.
– to provide cosmetic benefits

73. THANK YOU