Cryptorchidism is the most common malformation of male sexual development, with an overall prevalence rate of 3% in full-term newborn males. Most palpable UDT spontaneously descends within the first months of life, decreasing the prevalence to 1–2% for boys aged 6 months to one year [1, 2, 7, 14, 17]. The right side is affected more often than the left, occurring in 70% of cases. The majority of cases present with a palpable UDT, non-palpable testes accounting for approximately 20% of all cases [2]. This tendency was similarly reflected in the patient population of this study with right UDT occurring in 62% of cases, and no palpable testes were found in 29.8% of cases.
The undescended testis is a risk factor for both infertility and testicular malignancy. The histopathological and functional changes of the cryptorchid testis are well established with defective spermatogenesis and the loss of endocrine function being early consequences [2, 4, 5, 7, 8, 14,15,16, 18, 19, 26]. The histopathological hallmarks with degeneration of Sertoli cells, decreased numbers and defective maturation of germ cells, as well as hypoplasia of the Leydig cells, are evident from as early as one year of age [2, 4, 6, 15, 20]. Bilateral UDT is more significantly correlated with infertility, with azoo- or oligospermia reported in 66–87.5% of cases, compared to 33–35% of cases with unilateral UDT [4, 6, 11, 14, 15, 26]. Normal fertility rates are reported in 87–90% of patients undergoing repair within the first 2 years of life [4, 6, 8, 14,15,16, 26]. This figure is similar to fertility levels found in the general population [8]. Abnormal spermatogenesis is reported to be as high as 98% in the cryptorchid testis of post-pubertal men [10]. Fertility assessment was not part of routine investigative protocol in this cohort; however, the relevance is noted by the above percentages and should be included in future studies in refining management guidelines.
Besides the malignant potential and the loss of function of the cryptorchid testis influencing the approach to the management of UDT, other factors that have been recorded as fundamental are: the apparent increased risk of the UDT for undergoing torsion, the abnormal position predisposing it to trauma and the psychological benefit of having intrascrotal testes [14]. Early surgical correction is still the gold standard of the management of UDT [1, 3, 5,6,7,8, 14,15,16,17,18,19, 23]. Guidelines for the pre-pubertal patients are well defined; however, those applicable to the post-pubertal patient seem far more rudimentary and have remained unchanged for a number of years. The current AUA guidelines [8] with reference to the post-pubertal patients are as follows:
-
In the post-pubertal child with cryptorchidism, consideration should be given to performing an orchiectomy or biopsy.
-
In boys with a normal contralateral testis, surgical specialists may perform an orchidectomy (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 post-pubertal age.
The EAU guidelines [27] similarly state:
Little has been reported on patients presenting with UDT during adolescence or adulthood, particularly in developing countries [3, 7, 13]. The apparent loss of function and malignant potential of the UDT have swayed many authors towards doing orchidectomy for the adult patient, rather than orchidopexy [14, 15, 17, 23]. As mentioned previously, although standardised, uncertainty exists regarding the management of these patients and the current guidelines seem insufficient [14]. Several attempts have been made to refine these recommendations. Halachmi et al. [10] concluded that adult patients with unilateral UDT and a normal contralateral testis should be offered an orchidectomy. Patients with a single testis or bilateral UDT may be considered for testis-preserving management with regular follow-up. When comparing peri-operative mortality for UDT with mortality due to testicular germ cell neoplasia in post-pubertal patients, Farrer et al. recommended limiting surgical intervention to patients aged 32 years or younger [3]. With improvement of peri-operative care, OH et al. [23] demonstrated that in the American Society of Anaesthetists (ASA) class I and II groups, mortality from orchidectomy only began to exceed mortality from germ cell tumours at the age of 50 years. In accordance with these findings, the following recommendations were made:
-
For post-pubertal adolescents and healthy men younger than 50 years of age (ASA I/II) with unilateral UDT and normal contralateral testis, an orchidectomy should be offered.
-
Men older than 50 years of age or those with high anaesthetic risk (ASA III/IV) should be considered for close observation.
-
Men with bilateral UDT should undergo testicular biopsies, preservative management and close observation.
Earlier publications have reported the malignant risk to be 40 times higher than that of the general population [2]; however, more recent studies have estimated this to be much lower with a relative risk of 2.75–8 [7, 14, 15, 17, 19]. That, along with the improved oncological outcome of testicular germ cell neoplasia, may have caused a perceptual shift in clinicians and patients alike. There seems to be more consideration for testicular preservation, in spite of the malignant risk and the slim chance of improved fertility [28]. In the clinical setting, it is also difficult to determine the residual function of the cryptorchid testis. In two studies of post-pubertal men managed for UDT, Rogers and Koni et al. demonstrated germ cells at different levels of maturation in 31% and 51% of patients, respectively [15, 20]. Similarly, two separate studies by Shin et al. [24] and Lin et al. [25] reported cases which demonstrated commencement of spermatogenesis resulting in pregnancy, after late surgical correction of UDT. In a review article, Chung et al. [29] made a case for testicular preservation in patients who still desire parenthood, but also the elderly, where there is no further risk of malignancy. In his conclusion, he proposed guidelines for this specific group of patients which is similar to what OH et al. proposed, with the added recommendation: in post-pubertal patients with a non-palpable UDT, laparoscopic orchidectomy is preferred. All of this makes for a strong argument that in some instances there may be rationale for testicular preservation and that the decision to treat a post-pubertal patient with cryptorchidism must be made on an individual basis, rather than adhering to stringent recommendations.
In the pubertal group, 48 of UDT (92.3%) were treated by means of orchidopexy. In this group, two testes (4.5%) were described as atrophic with a normal contralateral testis; contrary to recommendations, these two testes were preserved. Three testes (5.7%) in the pubertal group were managed by orchidectomy. One of these was described as atrophic, and in another, there was inadequate length of the spermatic cord for orchidopexy. The reason for the orchidectomy in the third case was not stated.
Of the 124 units, 23 (18.5%) were described as being either atrophic or hypotrophic, with a normal contralateral testis. In accordance with AUA guidelines, the majority (60.9%) of these were managed by orchidectomy; however, nine (39.1%) units were preserved.
Eighteen patients had bilateral UDT, totalling 36 units. The majority of bilateral UDT (88.8%) were managed by orchidopexy in accordance with recommendations; however, three patients had undergone orchidectomy of whom one was for bilateral atrophic testes.
Based on the mean age of 25.4 years, with the oldest patient being 41.4 years of age, orchidectomy would have been indicated in the majority of patients, yet in only 30 units (24.2%) this was seen as the management of choice. Comparing the pubertal- and post-pubertal groups, orchidectomy was more often performed in the post-pubertal group, still the majority of UDT in this group (59.7%) were managed by preservative measures. Of these 43 testes, five (11.5%) were described as atrophic and 13 (30.3%) of cases were unilateral with a normal contralateral testis, all indications for orchidectomy rather than orchidopexy. A total of 14 surgeons were involved in the cases where orchidopexy was performed for the post-pubertal patient with an atrophic UDT, or UDT with normal contralateral testis. All of these surgeries were performed by trainees, while working under the close supervision of consultant Urologists and the decision to do orchidopexy, rather than orchidectomy, was not stated. Twenty-seven of UDT (37.5%) in the post-pubertal group were managed by orchidectomy; in 13 (48.1%) of these, the affected testes were described as atrophic and seven (25.9%) were not palpable with clinical examination. We concluded that in this setting there was a general tendency towards testicular preservation in this age group, despite guidelines recommending otherwise. Certain factors which seemed to sway the decision-making towards orchidectomy have been identified: age of the patient, an intra-operative finding of an obvious atrophic testis and if an orchidopexy was deemed practically impossible.
Certain limitations of this study have been identified; it was a single-centre study which may have biased the results and may not be generalisable to other institutions. It is a retrospective review, with some data lacking due to incomplete record keeping and different investigative protocols. On an individual, case-by-case basis, the reason of the preferred management option was not stated. Therefore, results are based on deductions from data analysis, rather than surgeons’ individual and clinical decision-making. Many patients were lost to follow-up, and there were limited data on these follow-up findings.
