Cryptorchidism
Why Treatment Is Recommended
Treatment Techniques
An undescended testicle, sometimes called a cryptorchid testicle, is a common problem in young boys. Up to 30 percent of premature boys will have at least one undescended testis, up to 5 percent of boys at term and up to 1 percent of one-year-old boys. As the numbers imply, most of these early undescended testicles will come down to the scrotum over the first year of life. Actually, most of them come down by three or four months and very few descend after that.
The testicle originally forms in the back of the abdominal cavity, similar to the position of the ovaries in girls. Near the end of pregnancy, the testis begins to descend to the scrotum. A path is cleared for the testis by a structure called the processus vaginalis-essentially a groin or inguinal hernia. The testicle follows the back wall of this hernia into the scrotum, and then the hernia closes. If the process is incomplete, the testicle might end up anywhere from inside the abdomen to just above the scrotum. Sometimes, the testis tries to descend but follows the wrong path and ends up in an "ectopic" location, usually not far from the scrotum.
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There are several reasons that we recommend treatment for persistently undescended testicles. First, it is well known that testicles are in the scrotum because this is a cooler location than other places in the body. Something about this minor temperature difference seems to have a dramatic influence on the ability of the testicle to make sperm, needed for fertility. This effect is not only important in adults, however, it has been demonstrated that the testicles begin to lose the cells that make sperm very early in life if they are not in the scrotum. This process has probably begun by one year of age. Bringing the testicle into the scrotum early might preserve these cells and, therefore, improve chances for fertility in the future.
Second, testicles that are undescended have a higher risk of developing testicular cancer than those that descended spontaneously. The overall risk of cancer is probably only 1-in-2,500, but this is still higher than the general population. Bringing the testis into the scrotum allows more accurate examination-both by doctors and by the young man himself-and, therefore, will result in earlier detection of these tumors if they should occur. We do not know if bringing the testicle into the scrotum decreases the risk of developing tumors.
A third reason to fix undescended testicles is because of the hernia that is often associated with them. As mentioned earlier, a hernia forms as a path for the testis to follow. If the testis does not descend completely, the hernia does not close and carries the same risks as any other hernia in the groin (or inguinal hernia).
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Treatment for the undescended testicle depends on the location of the testis. For testes which can be felt in the groin area, the usual recommendation is for an operation called anorchidopexy or orchidopexy. This literally means "fixing the testis." This operation is almost always performed as an outpatient. It is done through a small hernia incision in the groin and takes up to one and one-half hours to perform. Recovery is generally very rapid and success can be expected to be good. An alternative is hormonal treatment with HCG. This is a series of injections which stimulate the testicles to make male hormone. This puts in motion the mechanism of testicular descent and in a small number of boys will result in permanent descent of the testicle. We will sometimes recommend hormonal treatment if the testis is very close to the scrotum and it seems there is a good likelihood of success.
It is important to know that not all undescended testes are the same. In fact, some undescended testicles are ectopic, meaning that they have attached to the wrong place and this is the reason that they did not descend to the scrotum. Others are ascended testicles, meaning that they originally came down to the scrotum but at some point with the growth of the child were drawn up out of the scrotum into an abnormal position. Many of these testicles can be approached with a single incision through the scrotum, hopefully resulting in less post-operative discomfort as well as one less surgical scar. Work from this institution has demonstrated that 20% of these testicles will be associated with a hernia, which might require a second groin incision. On the other hand, 80% of these testicles can be brought down using a single incision.
If the testicle cannot be felt by the doctor, it is called an "impalpable" testis (which simply means "cannot be felt"). Impalpable testes may be inside the abdomen, too small to feel, or they may be absent. It is important to know, because we do not like to leave a testicle in the abdomen where it cannot be examined regularly. Unfortunately, there is no reliable X-ray which can tell us whether a testis is in the abdomen.
Generally, surgery is required to make that determination. The operation that is most accurate in locating these testicles is called a laparoscopy. This is a procedure in which a telescope is placed into the abdomen through a small incision near the navel. Using this telescope, the abdomen can be examined to see whether a testicle is inside. It may demonstrate evidence that there is no testicle, in which case the operation is over. It may indicate that there may be a small testicle in the groin, in which case a groin incision is made and the area is explored for a small testis, which must be removed. It may demonstrate a testicle inside the abdomen, in which case an operation can be done to either remove the testis or move it into the scrotum.
The operations to move these high testicles into the scrotum are more difficult than for the testicles which are in the groin. Because of this, the success rates are lower for these high testicles. Laparoscopic orchidopexy is an operation that has recently gained popularity for these difficult intra-abdominal testicles. Our faculty has been instrumental in the development and evaluation of laparoscopic orchidopexy. A recent multi-institutional study that we coordinated reveals that the success rates of laparoscopic orchidopexy are significantly higher than historical success rates for open surgery. Laparoscopic orchidopexy can follow diagnostic laparoscopy at the same sitting. The operation is performed by inserting two instruments through very small incisions which are used to free the testicle and pass it into the scrotum. A separate incision is made in the scrotum to create a pouch for the testicle. Laparoscopic orchidopexy, like the other procedures listed, is performed as an outpatient. Laparoscopic orchidopexy is an operation that can be done by experienced pediatric laparoscopic surgeons.
If you are an adult with an undescended testicle, the options are a bit different. Bringing the testicle down to the scrotum will probably not affect your fertility and, therefore, an undescended testicle might simply be removed. The ages of highest risk for testicular cancer are from 18 to 40, with most occurring in younger men. For this reason, and the increased risk of anesthesia with increasing age, it has been recommended that after age 32 or so, nothing needs to be done about these testicles. This is an individual consideration and you should consult with your physician if you are in this situation.
References:
- Schneck, F. X. and Bellinger, M. F.: Abnormalities of the Testes and Scrotum and Their Surgical Managemenet. In Walsh, P. C., Retik, A. B., Vaughan, E. D., Wein, A. J., eds.: Campbells Urology. Saunders, Philadelphia, 2002, pp. 2353-2394
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