Editing AUA: Cryptorchidism (2018) (section)

== Management ==

=== Benefits of Treatment ===
# '''<span style="color:#ff0000">Improve fertility potential'''
#'''<span style="color:#ff0000">Improve testicular growth'''
# '''<span style="color:#ff0000">Reduce risk of testicular malignancy'''
# '''<span style="color:#ff0000">Reduce risk of torsion'''
# '''<span style="color:#ff0000">Treat potential associated inguinal hernia'''

=== Timing ===

*'''<span style="color:#ff0000">Infants with a history of cryptorchidism (detected at birth) who do not have spontaneous testicular descent by 6 months (corrected for gestational age) should be referred to an appropriate surgical specialist for timely evaluation.'''
**'''<span style="color:#ff0000">Spontaneous descent of testes may occur in the first 6 months of life.'''
**'''<span style="color:#ff0000">Testes that remain undescended by 6 months (corrected for gestational age) are unlikely to descend spontaneously.'''
**Longer duration of testis undescent correlates with higher rates of germ cell loss and adult infertility
*'''<span style="color:#ff0000">In the absence of spontaneous testicular descent by 6 months (corrected for gestational age), surgery should be performed within the next year (first 18 months of life).'''
**'''<span style="color:#ff0000">While it is optimal to perform surgery for the cryptorchid testis by 18 months of age, there are clear benefits to performing orchidopexy in all prepubertal boys at the time of diagnosis of a cryptorchid testis'''
***Progressive and adverse histologic changes will occur in the cryptorchid testis prior to puberty
**'''<span style="color:#ff0000">In the post pubertal child with cryptorchidism, consideration should be given to performing an orchiectomy or biopsy, although there needs to be careful consideration of other factors including associated medical conditions, anesthetic risk, and status of the contralateral testis.''' 

=== Options ===

*'''Orchidopexy/orchiopexy''' 
** '''Refers to surgical repositioning of the testis within the scrotal sac'''
**'''Current standard of therapy in the United States'''
*'''Primary hormonal therapy'''
** Historically used for many years
** Using hCG or luteinizing hormone-releasing hormone (LHRH or gonadotropin-releasing hormone (GnRH))
** '''Should not be used to induce testicular descent'''
*** Evidence shows low response rates and lack of evidence for long-term efficacy. 

=== Approach ===

==== <span style="color:#ff0000">Palpable</span> ====
*'''<span style="color:#ff0000">Standard technique: two-incision (inguinal and scrotal) orchiopexy'''
**The inguinal portion of the procedure is performed to mobilize the cord structures and gain adequate length for repositioning the testis in the scrotum, along with closure of a patent processus vaginalis, when present. The secondary scrotal incision is performed to create a subdartos pouch for placement and fixation of the testis.
*If low lying, single incision orchidopexy is also a viable option. 
**Potential advantages with respect to enhanced recovery and cosmesis, as well as reduced operative time. This technique can be effective even when there is a patent processus/hernia sac present
*If a palpable nubbin is present, in the scrotum, potentially representing a vanishing testis, then scrotal or inguinal exploration can safely be performed.
**Regardless of the approach, the specimen should be sent for pathologic confirmation, to confirm a vanishing testis and no presence of malignancy.

==== <span style="color:#ff0000">Non-palpable ====
*'''<span style="color:#ff0000">Perform examination under anesthesia to reassess for palpability of testes'''
**If the testis is palpable, open orchidopexy should be undertaken
*'''If nonpalpable, surgical exploration (laparoscopic or open) and, if indicated, abdominal orchidopexy should be performed.'''
**'''<span style="color:#ff0000">Surgical options if an intrabdominal testis is found with anatomy that is felt to be appropriate for salvage (3):'''
**#'''<span style="color:#ff0000">Orchidopexy'''
**#'''<span style="color:#ff0000">One-stage Fowler Stephens (FS) orchidopexy'''
**#'''<span style="color:#ff0000">Two-stage FS orchidopexy'''
**'''The identification of the testicular vessels should be the end point of any exploration for a nonpalpable testis.'''
**'''If the testicle warrants salvage and tesicular vessels are long enough to reach into the scrotum, then the vascular supply should be spared and a primary orchidopexy is performed in preference to FS orchidopexy'''
**In the FS approach, the testicular vessels are divided and the blood supply to the testis is maintained through collaterals, including the artery of the vas deferens. 
***When the FS orchidopexy is done in one stage, the testicular vessels are ligated and the testicle is immediately moved down into the scrotum;
***In the two-stage approach, only ligation is done at the time of the first stage, without mobilization of the testis. The patient is then followed for three to six months, to presumably allow for improved collateral circulation to develop. A second stage repair is then undertaken with repositioning of the testis in to the scrotum.
***When a primary orchidopexy cannot be performed in cases where the testicular vessels are too short, the decision to perform a one-stage or two-stage FS orchidopexy is left to the discretion for the surgeon based on the location of the testis, associated vascular supply to the testis, and the anatomy of the peritesticular structures.

=== Special Scenarios ===

==== Retractile testes ====

*'''<span style="color:#ff0000">Do not require surgical correction'''
*'''Children with retractile testes should be monitored at least annually to assess for secondary "ascent" of the affected testis.'''
**Risk of testicular ascent (between 2-45%) may be higher in boys with retractile testes 
**Potential mechanisms related to ascent
***Hyperactive cremasteric reflex
***Foreshortened patent processus vaginalis
***Entrapping adhesions

==== Acquired cryptorchidism ====

* Risk factors
** History of proximal hypospadias
** History of retractile testes
* '''Children with a newly diagnosed non-scrotal testis found after six months of age should be referred to a surgical specialist.'''
** The same adverse histologic features (e.g. loss of germ cells) found in primary UDTs are also found in acquired cryptorchid testes.

==== Peeping testis ====

* May occur when a patent processus vaginalis prevents palpation of the testis. When the abdomen is insufflated with laparoscopy, the testis travels through the internal ring and can be palpated. 
* Can be managed safely with either laparoscopic orchidopexy or inguinal orchidopexy.