Continuing Education Activity

Cryptorchidism is the most common congenital defect of the male genitalia, occurring in about 3% of full-term male births. Spontaneous resolution and testicular descent will occur in 80% of neonates by the age of three months. For testicles that remain undescended at 6 months of age or later, surgery is recommended. Diagnostic methods and imaging are reviewed, as well as the management of bilateral impalpable testes, which present a unique diagnostic and therapeutic challenge. Recent developments include laparoscopic orchiopexies, the use of internal abdominal testicular fixation techniques, and new recommendations regarding the optimal timing of corrective surgery

Participants in this activity gain insights into the indications and techniques of orchiopexy, including recent advancements such as laparoscopic procedures and internal abdominal testicular fixation techniques. To optimize care for infants and children with cryptorchidism, collaboration with an interprofessional team comprising pediatricians, pediatric surgeons or urologists, caregivers, and patients is emphasized. Through interdisciplinary collaboration, healthcare professionals enhance their ability to provide comprehensive care, ensuring timely diagnosis, appropriate intervention, and long-term management.

Objectives:

• Identify candidates for orchiopexy based on clinical assessment, including physical examination findings and diagnostic imaging results, to determine the need for surgical intervention in cases of cryptorchidism.
• Compare the different techniques for orchiopexy and identify the appropriate procedure based on the physical exam and imaging findings.
• Assess postoperative outcomes and complications following orchiopexy, monitoring for factors such as wound healing, testicular viability, and recurrence of cryptorchidism to guide postoperative management and follow-up care.
• Determine interprofessional team strategies with primary care physicians and pediatric surgeons to improve care coordination and communication about orchiopexies to improve long-term outcomes.

Introduction

Undescended testicles are a relatively common condition, occurring in about 3% of full-term male infants, and can be found in as many as 30% of premature male neonates.[1][2] This condition is the most common congenital defect affecting the male genitalia.[2] Testicular descent through the inguinal canal normally starts during the 28th week of gestation. About 80% of undescended testes noted at birth will migrate into the scrotum by 3 months.[2] Undescended testes that remain outside the scrotum by 6 months of age will likely require surgery.[2][3][4] Cryptorchidism can be unilateral or bilateral (10%).[2][5][2] 

In unilateral cryptorchidism, the left side is involved more often.[6] Testicular descent through the inguinal canal normally starts during the 28th week of gestation. Around 70% of undescended testes are palpable, with 90% identifiable in the inguinal canal.[7][8] More than 90% of patients with cryptorchidism will also have a concomitant patent processus vaginalis or indirect inguinal hernias. Long-term issues with untreated cryptorchidism include reduced male fertility (especially with bilateral cryptorchidism), testis atrophy, testicular torsion, increased risk of traumatic injury, and a higher risk of testicular cancer.[2] Although the exact cause is indeterminate, it is believed to be a combination of maternal factors, genetics, hormonal variations, mechanical effects, neurotransmitter levels, and toxic environmental exposures.[2]  Multiple known risk factors contribute to the development of undescended testes. The most significant appears to be prematurity, but low birth weight and a family history of cryptorchidism are also quite significant.[2][8][9][2] 

Other risk factors include the following:

• Associated congenital syndromes (Down, Noonan, and Prader–Willi)
• Cerebral palsy
• Cosmetics use
• Endocrine-disrupting drugs or toxins
• Exposure to phthalate, di(2-ethylhexyl) phthalate 
• Genetic disorders 
• Ibuprofen use
• In vitro fertilization
• Increased alcohol consumption (5 or more drinks per week, which triples the risk)
• Low testosterone disorders (Kallmann syndrome, Klinefelter syndrome)
• Low placental weight
• Maternal diabetes
• Maternal diethylstilbestrol use or exposure
• Maternal obesity
• Neural tube defects
• Pesticides exposure
• Persistent Müllerian duct syndrome
• Preeclampsia (especially severe)
• Small for gestational-age infants
• Smoking
• Twinning [1][2][3][4][5][6][7][8][9][10]

Anatomy and Physiology

Normal testicular descent begins as the testis forms on the posterior abdominal wall next to the kidney, beginning to travel towards the internal ring by the eighth week of gestation.[11][12] The cranial suspensory ligament regresses, and the gubernaculum shortens, pulling the testis towards the internal ring, accomplished by the 28th week of gestation.[11][12][13][14]

The next stage in testicular descent occurs as the testis begins its hormone-dependent passage into the inguinal canal.[11][12][15]The processus vaginalis, an elongated pocket of the peritoneum, forms during the third month of gestation and joins the gubernaculum.[11][12] Together, they enter and enlarge the inguinal canal for testicular passage.[11][12] The gubernaculum at this stage is about the same size as the testis.[16][14]

At gestational week 28, the gubernaculum contracts, pulling the testicle through the inguinal canal to the scrotum.[11][12] Passage of the testicle is aided by intraabdominal pressure superiorly, which helps push the testicle through the canal.[11][12][17] The processus vaginalis regresses in response to lower androgen levels during the third trimester and normally disappears before birth.[11][12][18] If the testis remains undescended, the processus vaginalis remains patent as an indirect hernia.[11][12][18]

The arterial supply to the testis must be considered when performing surgical orchiopexy. The primary artery is the testicular artery, which comes directly from the aorta. Two other arteries can generally maintain the viability of the testis if the testicular artery is damaged or ligated. These are the vasal and cremasteric arteries.[19][20] Skeletonizing the spermatic cord may provide some extra length, but it increases the risk of damage to one or more of these important vessels.[19][20]

Types of Undescended Testes 

Acquired: This occurs when the spermatic cord fails to grow in proportion to body growth.

Ascendant: This type is characterized by a testis that was in the scrotum but has since returned to the inguinal canal.

Dysgenetic: An embryological derangement of the seminiferous tubules and testis causes this type of undescended testes. 

Ectopic undescended testis: The testis is not along the natural descent path. They usually exit the external inguinal ring but then diverge to one of several possible locations, typically in about 1% of all cryptorchid testicles. Possible locations include the following:

• Femoral canal
• Opposite scrotum (least common)
• Perineum (most common)
• Superficial suprapubic or inguinal area

Hypoplastic: This is an underdeveloped or atrophic testis.

Retractile: A testis that moves in and out of the scrotum is retractile. This type does not require orchiopexy unless symptomatic. Yearly examinations are recommended as they may convert to an acquired or ascendant cryptorchid testicle.[1]

True undescended testis: The testis is located anywhere along the natural descent path in this condition. The testicle typically migrates from the abdominal cavity through the inguinal canal into the scrotum via the gubernaculum. Migration can become arrested at any point along its descent, or it can be ectopic.[1] Possible locations include the following:

• Retroperitoneal, intrabdominal, in the inguinal canal, or at the superior aspect of the scrotum
• Just outside the external ring (the most common location)

Vanished: This type is thought to be due to intrauterine testicular torsion in late gestation but may also involve testicular agenesis.

• Only 20% to 40% of non-palpable testes are truly absent at the time of surgery [1][4][11][21][22]

Indications

The indications for orchiopexy include:

• Failure of the testis to spontaneously descend into scrotum by 6 months [1][23]
• Acute or intermittent testicular torsion

Contraindications

The contraindications for orchiopexy include:

• Atrophic testis

  • If the testis is atrophic, perform an orchiectomy instead.
• Unable to tolerate anesthesia
• Active infection of the testicle or urinary tract
• Uncorrected bleeding diathesis or active anticoagulation

Personnel

The personnel needed to manage orchiopexy include:

• Pediatric surgeon or pediatric urologist
• Anesthesiologist
• Scrub tech/nurse
• Circulating nurse

Preparation

The American Urological Association (AUA) guidelines recommend neither ultrasonography nor computed tomography scanning as part of the diagnostic workup for undescended testes.[23] A careful physical exam by a skilled clinician can generally find cryptorchid testes in 70% of patients with undescended testicles.[23]

Hormonal therapy to facilitate testicular descent is not recommended by AUA guidelines due to low response rates and inadequate long-term efficacy, as demonstrated by numerous trials, reviews, and meta-analyses showing minimal efficacy.[23][24][25][26][27] This recommendation is consistent with the guidelines from the British Association of Pediatric Surgeons, the British Association of Pediatric Urological Surgeons, the Canadian Urological Association, the European Association of Urology (EAU), and the European Society for Pediatric Urology.[1]

Preoperative evaluation of patients with bilateral impalpable testes is recommended. This may include laboratory studies and imaging.

Bilateral impalpable testes and patients with unilateral cryptorchid with hypospadias will benefit from a chromosomal analysis for a possible disorder of sexual development.[28][29][30][31] An ultrasound can be considered to evaluate the pelvic anatomy and possible Müllerian structures. A laboratory evaluation for 17-hydroxylase progesterone, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and testosterone should be performed.[32][33][34]

Hormonal stimulation with human chorionic gonadotropin, hCG, can be used to verify the presence of functional testis tissue.[35][36][37] One technique is to administer 3 intramuscular injections of hCG on consecutive days at a dose based on age (younger than 1 year: 500 units; 1 to 10 years: 1000 units; older than 10 years: 1500 units).[35] LH, FSH, and testosterone are measured at baseline and 24 hours after the injection. Lack of testicular tissue (anorchia) would show no change in testosterone levels with elevation of the FSH and LH levels after 24 hours.[35][36][37]

Other laboratory indicators of anorchia include the following:

• Undetectable serum levels of anti-müllerian hormone and inhibin, together with an increased FSH, have been suggested as sufficient to diagnose anorchia.[38][39][40]
• Müllerian-inhibiting substance levels less than 5 ng/mL suggest a lack of functional testicular tissue.[38][39][41]
• Elevated serum gonadotropins also suggest anorchia.[34]

Imaging is not usually recommended for cryptorchid testes but may help in selected cases.[23][42][43][44]

Ultrasound delivers no ionizing radiation to the patient, is inexpensive and readily available, can increase the identification of a testis in the inguinal canal, and may be helpful as a first step in evaluating an impalpable testicle. For intraabdominal cryptorchid locations, it will not be useful.[43][45][46][47] Ultrasound can be helpful in the identification of inguinal testes in obese infants where the physical examination is difficult or equivocal and is reportedly accurate in up to 92% of cases. Magnetic resonance imaging and computed tomography scans can sometimes detect intraabdominal undescended testicles. Still, they are not therapeutic and have a high false negative rate due to the small size of the cryptorchid testis and interference from the intestines.[1][23][48][49][50]

Imaging is not considered sufficiently reliable in the 30% of patients with cryptorchid and impalpable undescended testes. Laparoscopy is suggested as the most dependable method to detect intraabdominal undescended testicles.[23] This also allows for a laparoscopic surgical orchipexy procedure to be performed simultaneously. However, it is invasive, costly, and requires anesthesia.

The evaluation of the patient with an undescended testicle is more fully described in the companion StatPearls reference article on "Cryptorchidism."[1] 

Technique or Treatment

The optimal recommended age for surgery has decreased over the past several decades. The AUA guidelines now recommend surgical orchipexy between 6 and 18 months.[23] Many specialists recommend surgery at around 6 months to minimize the distance the testis has to be moved, reduce long-term side effects, improve future fertility, and diminish the testicular cancer risk.[1][23] The corrected age is used for premature infants to guide optimal surgical timing.[1][23] 

Early surgery (at 6 months of age) is recommended as there is an increased loss of germ cells and an increase in potential future infertility problems the longer the orchiopexy is postponed.[1][51] On average, there is a drop in fertility of 1%, an increased need for assisted reproductive services of 5%, and an increase in testicular cancer risk of 6% for every 6-month delay in performing the surgery.[1][52] About 60% of boys with bilateral cryptorchidism will be infertile as adults, and up to 89% may be azoospermic.[53]

Many patients do not receive the necessary surgery within the recommended time period due to many factors, including reduced routine pediatric office visits, family issues, logistics, increased reliance on family practitioners instead of pediatricians for timely surgical referrals, ethnicity, insurance status, and a general lack of familiarity among primary care physicians of the current recommendations regarding the optimal age for surgical referrals.[52][54][55][56]

For older patients, an orchiopexy should be performed very shortly after diagnosis.[1][23] Consider an orchiectomy for males between puberty and 32 years of age. For untreated patients older than 32 years, close surveillance and regular physical examinations are recommended. Testicular appendages should be removed during surgery.

Additional information on undescended testes can be found in the companion StatPearls reference article on "Cryptorchidism".[1] 

Technique: 

A surgeon can perform an orchiopexy in several different manners.

If the testis are in the inguinal canal, an inguinal orchiopexy is performed. If the testis is at the top of the scrotum, a scrotal approach would be the procedure of choice. If in doubt, the inguinal approach is preferred as it provides access to the entire spermatic cord and inguinal canal, which may be necessary to achieve adequate length and optimal results.[56]

In bilateral cryptorchidism, only 1 teste is usually fixed and then allowed to heal. If the blood supply is lost or an infection develops, the patient still has a viable testis.[57][58][59] Some surgeons prefer to repair both undescended testes at the same time to reduce the infant's anesthesia risk.

Inguinal Approach 

This approach is generally preferred and the most common technique:

1. Make an incision over the inguinal canal, like an open hernia repair. Dissect through the subcutaneous tissue to expose the inguinal canal and external ring. 
2. Open the external oblique fascia over the inguinal canal along the direction of the fibers, including the external ring. Identify the ilioinguinal nerve so it can be isolated and preserved.
3. Identify the undescended testis and spermatic cord. 
4. Identify and dissect the processus vaginalis off of the spermatic cord, which is generally on the anteromedial aspect of the spermatic cord. (True undescended testicles will always have such a sac.)
5. Pass a penrose drain behind the proximal spermatic cord to use for traction.
6. Dissect the spermatic cord and testicle completely free of the inguinal canal and the gubernacular remnant.
7. Additional cord dissection will provide additional length if needed. Cremasteric muscles and restraining adventitial tissue may be safely dissected free to gain length.
8. Perform a high suture ligation of the sac to provide adequate length so the testis will reach the scrotum without tension. 
9. Ensure that the spermatic vessels lie anterior to the vas deferens.
10. If adequate length cannot be achieved through dissection of the spermatic cord, consider a one or two-stage Fowler-Stephens approach. (See below. Two-stage procedures are rarely needed except for abdominal testes.)
11. Develop the dartos pouch by making a small, superficial incision in the ipsilateral hemiscrotum.
12. Use a hemostat or Metzenbaum scissors to bluntly open and expand a superficial space or pouch under the skin that is superficial to dartos fascia and sufficient to hold the testicle.
13. An incision can be made in the dartos fascia, or a small opening can be created with a hemostat for the grasper.
14. Pass a nontraumatic grasper through the dartos fascia into the inguinal canal, grab the testis, and gently pull it into the pouch.
15. Tack the testis down to the dartos fascia using an absorbable suture (optional). Close the dartos fascia if it was incised. 
16. Before closing the skin, close the inguinal incision in multiple layers, including the inguinal canal and fascia of Scarpa.
17. When restoring the external inguinal ring, do not make the opening too tight to avoid ischemia of the cord and testicle.
18. A good general guide is to leave at least 1 cm of the external ring open.

Scrotal Approach

1. Make an incision in the ipsilateral hemiscrotum down to the dartos fascia.
2. Dissect up through the soft tissue toward the internal inguinal ring until the testis is identified.
3. If the ilioinguinal nerve is encountered, it should be isolated and protected.
4. Bring the testis down into the operative field with gentle retraction.
5. If necessary, dissection and detorsion of the spermatic cord should be performed.
6. Dissect out the gubernaculum and cremasteric muscles separate from the spermatic cord and tack to dartos fascia medially and laterally, allowing sufficient length of the spermatic cord for the testis to sit comfortably in the scrotum. 
7. If there is a hernia sac or patent processus vaginalis, it must be dissected free, given a high ligation, and resected.
8. At this point, there are two techniques for securing the testicle in the pouch:
9. Place a tacking suture, such as a 4-0 Vicryl, in the proximal Buck fascia and then run it (in pleats) toward the end of the fascia.
10. Then, turn the suture back to the tacked suture similarly. (Ensure that your bites do not go into the spermatic cord.)

     OR

• Suture or tack the testicle in place by placing four cardinal nonabsorbable sutures in the dartos fascia and into the very strong tunica albuginea (the whitish covering of the testis). 
• Place the testicle in the pouch and reapproximate the scrotum with interrupted absorbable sutures. This process should leave about 0.5 cm between bites. Cover the incision with a collodion. 

Laparoscopic Approach 

A laparoscopic approach is usually recommended if the testis is not palpable, although equivalent success rates are reported for open procedures.[60] The approach is usually determined by the surgeon's degree of laparoscopic skill and experience.

The procedure usually starts with an examination under anesthesia as a previously impalpable undescended testicle may now become detectable. If so, the procedure may be adjusted accordingly.

The next step is an exploratory laparoscopy to locate and identify the testis and its vascular supply.[61][62]

If no testicle is visualized on laparoscopy, it is important to identify blind-ending vessels and vas or a testicular nubbin to conclusively determine that an orchiopexy is unnecessary. A testicular nubbin (a small brown bump or nodule) will typically be found if blood vessels are noted to be entering a closed internal ring.[1] If the internal ring is open, pulling the testis into the abdomen may be possible.[1] The associated hernia sac is not usually ligated in a laparoscopic orchiopexy.

If the intraabdominal testis is clearly abnormal, small, or dysgenetic, an orchiectomy should be performed instead.

Laparoscopic orchiopexy can also be done on inguinal and palpable undescended testes with success rates comparable to conventional surgery.[63][64][65][66]

The optimal situation would be amenable to a straight laparoscopic orchiopexy with preservation of the gonadal vasculature in a single stage. This requires sufficient length to be developed without sacrificing gonadal vessels to allow tension-free placement of the testicle in the newly created dartos pouch. 

In general, if the cryptorchid testicle is within 1 cm of the ipsilateral internal ring, it can be moved to the contralateral internal inguinal ring without putting any strain or tension on its blood supply, a one-stage standard laparoscopic orchiopexy can be performed without vascular compromise or division.

The benefits of a laparoscopic procedure include improved visualization of abdominal structures with magnification, easy examination of the entire abdominal cavity (including the contralateral testicle), and any dissection superior to the internal ring performed under vision and not blindly.[64][67]

Standard laparoscopic orchiopexy: 

1. The patient is placed in a Trendelenburg position and rotated to raise the ipsilateral side. (This moves the bowel out of the field.)
2. The abdomen is entered in a controlled manner, with two additional ports placed under direct supervision, triangulating with the appropriate inguinal canal and the midclavicular line at the umbilical level. 
3. Identify the testicle location, viability, and vasculature.
4. During a laparoscopic approach, the vas deferens come medially to join with the lateral vasculature when viewing the internal ring of the inguinal canal. These then join together to travel through the inguinal canal into the scrotum.[68] 
5. Be aware that the vas may become separate from the testis and is, therefore, not a reliable guide to the location of the cryptorchid testicle.[1][69]
6. Dissection of the cord and testis in the inguinal canal is carried out.
7. Release gubernacular attachments carefully and mobilize the cord structure from the abdominal wall.
8. Mobilize the blood vessels by proximal dissection. 
9. The testicle, vas, and gonadal blood supply can be dissected free as a triangle-shaped pedicle.
10. The testicle and cord are brought into the abdomen to evaluate length and viability. 
11. Develop Dartos' pouch in the scrotum by making an incision in the ipsilateral hemiscrotum, placing a port under direct supervision, and then passing an instrument through the inguinal canal into the peritoneal cavity, grasping the testicle and pulling it down into the dartos pouch.
12. Fix the testis to the dartos fascia using absorbable sutures as described above.

If the testis cannot sufficiently mobilize to pass through the inguinal canal into the scrotum without tension, several options are available.

• During an inguinal orchiopexy, the peritoneal reflection can be mobilized and stripped from the spermatic cord, with extra care taken in the area of the epididymis.[70]
• The internal ring can be opened by incising and dividing the internal oblique fibers and cutting the fibrous bands running laterally from the cord to the abdominal wall; this allows for a straighter course for the vasculature and more extensive dissection, which can provide additional length.
• Dividing the transverse abdominal fascia, inferior epigastric vessels, and the lateral spermatic ligament allows additional retroperitoneal dissection as the spermatic vessels can now be moved medially, extending their effective length.[71] 
• Gentle dissection will separate the cord structures from their posterior retroperitoneal attachments. Injection of normal saline between the vessels and retroperitoneum can help with this.
• The spermatic cord can be routed to pass under the inferior epigastric vessels, or those vessels can be ligated and divided, giving the spermatic vessels a shorter, more direct path to the scrotum (the Prentiss maneuver).[72][73][74][75][76][77] This can provide 5.5 cm in additional spermatic cord length compared to just 2 cm from inguinal dissection alone.[76]
•  In the modified Prentiss maneuver, the internal ring is opened laterally, the testicle and spermatic cord are freed, and the retroperitoneal dissection is carried out as above.[74][76]
• • A small incision is made in the transversalis fascia above the pubic tubercle.
  • Forceps are advanced through this incision beneath the inferior epigastric vessels to the area of the internal ring.
  • The testicle and cord are then passed through this new passage, which totally avoids the inguinal canal.
  • The testicle now has sufficient length to place in the scrotum without tension easily.
  • The internal ring and external oblique fascia can then be repaired.
  • This technique preserves the posterior wall of the inguinal canal, does not require sacrificing the inferior epigastric vessels, and is generally less invasive than the original Prentiss maneuver.
  • This technique can be done laparoscopically or by an open inguinal incision.
• A 1- or 2-stage Fowler-Stephens approach and a two-stage internal fixation (Shehata) procedure are options.[1] 
• Microvascular surgical techniques can anastomose the testicular vessels (artery and vein) to the inferior epigastric vasculature. This eliminates the vascular supply from limiting the positioning of the cryptorchid testis into the scrotum but requires skill and experience in microvascular surgery.[78][79][80][81][82][83][84] The result is a microvascular autotransplantation of the cryptorchid testicle.

Selecting one of these modified laparoscopic surgical procedures depends on the surgeon's training, experience, skill level, personal choice, and individual patient characteristics.[1] 

There are several considerations when deciding between a 1-stage and 2-stage procedure; these include the distance from the testis to the internal ring (2-stage if >2.5 cm), mobility of the gonadal vasculature (2-stage if excessive tension), and age of the patient (>5 years of age, consider a 2-stage procedure).[60][85][86][87][88] Overall success rates are similar between 1- and 2-stage procedures, so a single-stage technique is recommended when technically feasible.

A testicular ischemia test has been suggested to determine the feasibility of a Fowler-Stephens approach to an intraabdominal testis.[1][89] A removable suture or vascular clamps temporarily block the blood supply to the intraabdominal testis. The testis is evaluated after 10 to 15 minutes. If no signs of ischemia are seen, then this is evidence that the testis can reasonably be expected to survive without the gonadal vessels (due to adequate collateralization), and they may be sacrificed as part of a Fowler Stephens procedure.[1][89] If not, then an internal fixation or Shehata technique is recommended.[1][89]

Everything else being equal, the Shehata technique is usually preferred whenever a single-stage procedure cannot be technically accomplished as it preserves the testicular blood supply, minimizes testicular atrophy, the second stage can be performed after just 3 months (compared to 6 months for the 2-stage Fowler-Stephens), and it has a better overall success rate of 84% to 100%.[1][88][89][90][91][92] This technique is also preferred if the testis fails the ischemia viability test.[69][89]

Laparoscopic 1-stage Fowler Stephens surgery sacrifices the primary gonadal vessels, relying on collateral vessels to preserve the testis.[89] The cryptorchid testis is then dissected and repositioned in the scrotum.[89] If this cannot be done without tension, a 2-stage procedure is recommended. The primary advantage of this surgery is that it avoids a second surgical procedure and anesthetic for the infant.[89]

Laparoscopic 2-stage Fowler Stephens procedures also sacrifice the testicular vascular supply, but there is minimal dissection of the testis and spermatic cord, which preserves the collateral circulation. After 6 months, additional collaterals have formed, and the testicle can be safely dissected with a large peritoneal section, which will now have substantial collateral circulation and be of adequate length to allow the testicle to be repositioned in the scrotal pouch in a tension-free manner.[58][93]

Laparoscopic 2-stage internal fixation or Shehata procedures are always performed in 2 stages but have the advantage of not sacrificing any of the testicular vascular supply.[88][94] The testis and cord are dissected, and the cryptorchid testicle is sutured with some traction to the abdominal wall about 2 cm medial and superior to the contralateral anterior superior iliac spine. After 3 months, a second laparoscopic procedure is performed to place the cryptorchid testicle in the prepared dartos pouch.[88][94]

The fixation provides additional length to the vascular pedicle, which is long enough to allow the testicle to be placed in the scrotum without tension and without sacrificing or ligating any of its primary blood supply.[88][94][95] The extra length comes not from actual surgical tension at the time of the original surgery but passively from the weight of the intestines on the fixed spermatic cord and the natural, frequent movements of the abdominal wall from normal daily activities and breathing. The Shehata procedure is generally preferred where the vascular supply is questionable, and the testicular ischemia viability test is poor or borderline, or a 2-stage procedure is performed.[88][89][92][94] 

There are suggestions that the Shehata technique is recommended if the abdominal testis is 4 cm or less from the internal ring, while the Fowler Stephens procedure should be performed if the testicle lies further away. Further study is needed to determine the optimal parameters and indications for choosing between these two laparoscopic techniques for orchiopexy of intraabdominal testes.[92]

Complications

Along with the complications that accompany any procedure (infection, bleeding, scarring), there are several severe complications related directly to orchiopexy. These include:

• Adhesions (This may interfere with the second stage of 2-stage laparoscopic procedures.)
• Ascent of the testis (This can occur if the testis has become fixed in the scrotum under excessive tension, usually due to not adequately dissecting and freeing the connective tissue around the testicle and spermatic cord.)
• Damage to or ligation of the vas deferens (The vas deferens can be devascularized during dissection and may be unintentionally ligated or transected.)
• Epididymitis and orchitis
• Herniation
• Hydrocele (Hydroceles are usually non-communicating, and their diagnosis is confirmed by ultrasound. They typically resolve themselves but can be drained if they persist for over a year.)
• Inadequate length
• Infection (Risks include infection of both testes with bilateral orchiopexy, which can result in the loss of both testes. For this reason, if the patient has bilateral undescended testes, each side is sometimes performed separately and several months apart.)
• Injury to the colon or bladder
• Ileus
• Issues regarding the inguinal hernia (1%)
• Testicular atrophy (Vascular compromise due to over-skeletonization of the testicle or cord during dissection (up to 20%) is generally caused by testicular atrophy, the most dreaded complication that can typically occur.)
• Volvulus [96][97][98][99][100][101][102]

Clinical Significance

Patients with undescended testes are at increased risk of infertility, testicular cancer (in both testes), and testicular torsion, especially if untreated.[1][23][103] The risk of testicular cancer is increased 40-fold compared to the general population, but it remains uncommon.[1][104] The contralateral testis, even if normally located in the scrotum, has about a 20% increased cancer risk compared to the general population.[1][103][104] 

For inguinal undescended testicles, additional length can be achieved by skeletonizing the spermatic cord, but be aware that this risks damaging the vascular supply to the testis. Seminoma is the most common malignant tumor associated with undescended testicles.[105] Early surgery appears to reduce the cancer risk, but not completely, although it allows for regular physical examination, which may not have been possible before the orchipexy.[106][107][108] Orchiopexy should be performed after 6 months of age and before 18 months of age to reduce the risks of infertility, torsion, and the development of cancer.[109][110] 

The risk of testicular torsion in a cryptorchid testis is estimated to be 10 times the risk in the general population. Testicular torsion may also rarely occur in an intraabdominal testis, which would present clinically as an acute abdomen.[111][112][113][114][115][116] There is evidence that the use of neoadjuvant gonadotropin-releasing hormone therapy before surgical orchiopexy may improve later fertility.[117][118][119] Testicular biopsies at the time of orchiopexy are not routinely recommended. They may be considered in patients with abnormal karyotypes, ambiguous genitalia, prune belly syndrome, adolescents (postpubertal), and previously untreated older men who do not get an orchiectomy. Retractile testicles do not carry the same risks as undescended testicles. There is no increased risk of infertility or cancer, and they do not require surgery unless they become symptomatic or ascendant, but they should be evaluated regularly.[23][120][121][122][123]

Enhancing Healthcare Team Outcomes

 Key points for the multi-disciplinary care of pediatric patients with undescended testes include the following: 

• The patient's pediatrician should perform regular testicular exams to ensure both testes are in the scrotum.
• If one or both testicles have not descended by 6 months of age, the pediatrician should refer the patient to a pediatric surgeon or pediatric urologist.
• Patients with a history of undescended testicles must learn how to perform regular self-exams, as they have a significantly higher risk of developing testicular cancer.[1][23][124]

Primary care and family practice physicians, pediatricians, and nurses should be aware of the recommended timing for surgical orchiopexy, between 6 and 18 months, as it otherwise increases the risk of testicular cancer and future male infertility. Effective collaboration and communication among healthcare professionals, including primary care and family physicians, nurse practitioners, physician assistants, pediatricians, nurses, pediatric surgeons, and urologists, are essential. Better communication and coordination lead to better outcomes, reduce unnecessary diagnostic testing, and increase the likelihood of timely surgeries within the recommended time period.

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References

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Leslie SW, Sajjad H, Villanueva CA. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): May 5, 2024. Cryptorchidism. [PubMed: 29261861]

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Disclosure: Anna Elseth declares no relevant financial relationships with ineligible companies.

Disclosure: Stephen Leslie declares no relevant financial relationships with ineligible companies.

Disclosure: Robyn Hatley declares no relevant financial relationships with ineligible companies.