Overview
Definition:
Orchidopexy is a surgical procedure to bring an undescended testis (cryptorchidism) into its normal scrotal position
Undescended testis refers to a testis that has not descended into the scrotum by the age of 3-6 months
It is one of the most common congenital anomalies of the male genitourinary tract.
Epidemiology:
The incidence of undescended testis is approximately 3-5% in full-term neonates and up to 30% in premature infants
It is more common on the right side and often unilateral, though bilateral involvement occurs in about 10-20% of cases
Among infertile men, a significant proportion have a history of undescended testis.
Clinical Significance:
Undescended testis is clinically significant due to increased risk of infertility, testicular torsion, trauma, and malignancy (testicular cancer)
Early diagnosis and surgical correction are crucial to improve fertility potential, reduce the risk of torsion, and facilitate regular surveillance for malignancy.
Clinical Presentation
Symptoms:
Absence of one or both testes in the scrotum on routine physical examination
Parents may report a history of an absent or retractile testis
Other symptoms are generally absent unless complications like torsion or infection occur
Later, patients may present with infertility.
Signs:
A palpable but undescended testis may be felt in the inguinal canal, suprapubic region, or abdomen
The scrotum may appear underdeveloped or absent on the affected side
Absence of a palpable testis in the scrotum requires thorough examination of the groin and abdomen.
Diagnostic Criteria:
The diagnosis is primarily clinical, based on the physical examination finding of a testis not present in the scrotum by 6 months of corrected gestational age
Imaging is usually reserved for non-palpable testes to localize them within the abdomen.
Diagnostic Approach
History Taking:
Detailed birth history including gestational age, any antenatal abnormalities, and family history of cryptorchidism or genitourinary anomalies
History of retractile testis and any previous medical interventions should be noted
In older boys, inquire about symptoms of pain, swelling, or signs of puberty.
Physical Examination:
A systematic examination of the external genitalia in a warm environment is essential
Palpate the scrotum and inguinal regions carefully
For palpable testes, attempt to guide them into the scrotum
For non-palpable testes, examine the lower abdomen and perineum
Assess for other congenital anomalies.
Investigations:
For palpable undescended testes, no further investigations are usually required prior to surgery
For non-palpable testes, ultrasound may identify testes in the inguinal canal or abdomen, but accuracy is operator-dependent
MRI can be useful but is often reserved for complex cases
Hormonal assays (e.g., FSH, LH, testosterone) are not diagnostic of undescended testis but may be considered in cases of bilateral non-palpable testes to assess testicular function and differentiate from anorchia.
Differential Diagnosis:
Retractile testis (testis within the scrotum but can be pulled up into the inguinal canal due to cremasteric reflex, which is normal)
Ascended testis (testis that was previously descended but has moved upwards)
Absent testis (anorchia) due to testicular regression syndrome or congenital absence
Swollen lymph nodes or lipoma in the inguinal region can mimic a palpable undescended testis.
Management
Initial Management:
Referral to a pediatric surgeon or urologist for evaluation and management
Timing of intervention is crucial
surgical correction is generally recommended between 6 to 12 months of age to optimize fertility and reduce risks.
Medical Management:
Hormonal therapy (e.g., human chorionic gonadotropin - hCG) can induce testicular descent in some cases (approximately 20-30% success rate), particularly for palpable testes high in the inguinal canal
However, it is not a substitute for surgery in most cases and its efficacy is debated
The typical regimen involves intramuscular injections of hCG (e.g., 250 IU for infants <1 year, 500 IU for 1-5 years, 1000 IU for >5 years) given three times a week for several weeks.
Surgical Management:
Orchidopexy is the definitive treatment
For palpable testes, an inguinal incision is made to identify and mobilize the testis, followed by fixation into a created scrotal pouch
For non-palpable testes, laparoscopy is often used to locate the testis
if found, it can be mobilized and brought down into the scrotum via an inguinal or scrotal incision
If the testis is non-viable or atrophic intra-abdominally, it may be removed (orchiectomy)
Techniques include the tension-free fixation of the testis to the dartos pouch within the scrotum, often using sutures.
Supportive Care:
Postoperative care includes pain management, wound care, and monitoring for signs of infection or hematoma
Follow-up appointments are essential to assess scrotal position, monitor for complications, and evaluate testicular growth and function
Patients require lifelong surveillance for testicular cancer.
Complications
Early Complications:
Bleeding and hematoma formation in the scrotum or inguinal region
Wound infection
Injury to the vas deferens or testicular vessels
Testicular atrophy or necrosis due to compromised blood supply during mobilization
Persistent swelling.
Late Complications:
Recurrence of undescended testis (testis retracts or descends again)
Infertility (risk is increased even after successful orchidopexy, especially in bilateral cases)
Testicular torsion
Development of testicular cancer (risk remains higher than general population)
Chronic pain
Cosmetic dissatisfaction.
Prevention Strategies:
Meticulous surgical technique by experienced surgeons
Careful dissection to preserve testicular vasculature
Adequate mobilization of the spermatic cord
Secure fixation of the testis in the scrotum without excessive tension
Careful postoperative wound care
Regular surveillance for late complications.
Prognosis
Factors Affecting Prognosis:
The degree of testicular maldescent (intra-abdominal testes have poorer outcomes), presence of associated anomalies, age at surgery, and fertility status of the contralateral testis
Bilateral undescended testes and intra-abdominal testes have a worse prognosis for fertility.
Outcomes:
Successful orchidopexy leads to the testis residing in the scrotum, reducing the risk of torsion and facilitating cancer surveillance
Fertility outcomes are variable
early surgical correction (before 1-2 years) is associated with better preservation of spermatogenesis
The risk of testicular cancer is reduced but not eliminated, necessitating lifelong follow-up.
Follow Up:
Long-term follow-up is essential
This includes regular physical examinations to assess testicular position, size, and consistency, typically annually until adulthood
Semen analysis may be considered in adolescence if fertility is a concern
Patients and families should be educated about the signs and symptoms of testicular torsion and cancer.
Key Points
Exam Focus:
Understand the timing of diagnosis and surgical intervention for undescended testis (6-12 months)
Differentiate between palpable and non-palpable testes
Know the indications for laparoscopic versus open orchidopexy
Recall the hormonal therapy regimens and success rates
Recognize the long-term risks of infertility, torsion, and malignancy.
Clinical Pearls:
Always examine the scrotum and inguinal region in a warm environment
A retractile testis is normal and does not require orchidopexy
Consider the possibility of bilateral undescended testes if one is absent
Early intervention is key for optimizing fertility
Patients with a history of cryptorchidism are at increased risk for testicular cancer and require lifelong surveillance.
Common Mistakes:
Delaying surgery beyond 18-24 months of age
Relying solely on imaging for diagnosis of non-palpable testes without surgical exploration
Inadequate mobilization of the spermatic cord leading to tension on the testis
Failing to counsel patients and parents on long-term risks and follow-up requirements
Misdiagnosing a retractile testis as a true undescended testis.