Editing CUA: Cryptorchidism (2017) (section)

== Management ==

* '''See Figure 1 from Original Guideline'''
* '''Hormone therapy has a limited role in the management of cryptorchidism and should not be recommended as first-line therapy'''
** '''Treatment of UDT with either hCG or LHRH does not seem to cause harm and may be effective; however, reported success rates are inconsistent'''
* '''Surgical exploration'''
** '''Timing'''
*** '''Orchidopexy is recommended between 6-18 months of age'''
**** '''Testicular descent is unlikely to occur in full-term babies after 6 months of age'''
*** '''Orchiopexy techniques'''
**** '''Surgical approach to the palpable testicle'''
***** '''Inguinal (most common) or prescrotal/scrotal'''
****** '''High (proximal) ligation of the processus vaginalis is an essential surgical step to allow placement of the testis in a sub-dartos pouch within the hemi-scrotum, without tension'''
**** '''Surgical approach for the non-palpable testicle'''
***** '''If the testicle is not palpable preoperatively, as may occur in up to 20% of UDT cases, examination under anesthesia (EUA) can sometimes allow identification of the testicle. Otherwise, diagnostic laparoscopy is the procedure of choice in most centres.'''
****** '''In certain non-palpable testicle (NPT) cases, confident palpation of an ipsilateral scrotal nubbin and identification of contralateral compensatory testicular hypertrophy may preclude diagnostic laparoscopy by means of initially performing a scrotal incision, which allows for testicular nubbin removal and confirmation of the vanishing testicle diagnosis'''. Inguinal exploration and/or laparoscopy can then be reserved for cases in which the initial scrotal approach is non-diagnostic.
******* '''It is critical to highlight the importance of confidently identifying atrophic testicular tissue with associated vas deferens and gonadal vessels if a scrotal or inguinal approach is chosen, as any doubt should trigger further exploration.''' Presence of a looping vas or incorrectly identifying non-gonadal tissue as a nubbin may lead to misdiagnosis, potentially leaving viable testicular tissue in the abdomen'''. In uncertain cases or when tissue analysis is not consistent with atrophic testicular tissue, laparoscopic exploration should be strongly considered'''
***** '''Diagnostic laparoscopy is the most useful modality for assessing NPT, as it permits identification of three surgical scenarios that will lead to different courses of action:'''
*****# '''Blind-ending vas and vessels indicate a vanishing intra-abdominal testicle (IAT), and no further exploration is necessary''' (10‒30% of cases).
*****# '''Testicular vessels and vas entering the inguinal canal through the internal inguinal ring.'''
*****#* '''Inguinal exploration may find a healthy palpable UDT amenable to standard orchidopexy, or a testicular nubbin either in the inguinal region or, most commonly, in the scrotum.''' Remnant cord structures are usually removed to confirm the diagnosis and because viable residual testicular elements are present in up to 14% of the cases. It should be noted that to date, no cases of intratubular germ cell neoplasia have been reported within these specimens.
*****# '''Peeping''' (just inside internal ring) '''or intra-abdominal testis (50%), which will require either an open or a laparoscopic orchidopexy in one or two stages.'''
***** '''Inguinal approach for the high inguinal canalicular, or intra-abdominal testis'''
******* '''Helpful maneuvers to bring a high testicle down to the scrotum while preserving its blood supply:'''
*******# '''Divide the lateral fibrous attachments of the cord at the internal inguinal ring'''
*******# '''Blunt dissection of the retroperitoneal spermatic vessels''' (which are usually the limiting factor) up to the lower pole of the kidney
*******# '''Mobilization of the cord medial to the inferior epigastric vessels (Prentiss maneuver)'''
*******# '''Despite these steps, if the testicle still does not reach the scrotum, a Fowler-Stephens (FS) orchidopexy may be performed.'''
***** '''Fowler-Stephens orchidopexy'''
****** Originally described as a single-stage open inguinal approach for the IAT in which the testicular artery and veins were too short to allow adequate testicular mobilization into the scrotum through standard orchidopexy
****** '''Principles:'''
******* '''Open approach'''
******** '''Ligating and dividing the testicular vessels'''
******** '''Preserving the''' '''distal gubernacular attachments and the collateral vessels on the floor of the inguinal canal, maintaining the cremasteric blood supply'''
******* '''Laparoscopic approach'''
******** '''Ligating and dividing the testicular vessels and cremasteric collaterals'''
******** '''Preserving the gubernaculum''', mimicking one of the surgical steps of the open FS technique, may help decrease the likelihood of testicular atrophy
******** '''Testicle is advanced medial to the inferior epigastric vessels or obliterated umbilical artery'''
******* '''When the testis is > 2 cm above the internal ring with no vascular redundancy, it is unlikely that the testis will be able to reach the scrotum without dividing the spermatic vessels. In this situation, staged Fowler-Stephens procedure with division of the gonadal vessels at the first stage has a significantly higher success rate than primary Fowler-Stephens procedure'''
**** '''Open vs. laparoscopic orchidopexy for NPT'''
***** Laparoscopic orchidopexy outcomes are comparable to those of open surgery
***** Laparoscopic approach is associated with shorter operative time, shorter return to normal activities, and reduced risk of atrophy at one year (10% laparoscopic vs. 19% open)
**** '''Complications'''
***** '''The most serious complication of inguinal orchidopexy is testicular atrophy, which occurs when the testicular vessels are damaged'''
***** '''Rare complications include''' '''testicular ascent''', where the testicle gets pulled to the entrance of the scrotum, '''and vas deferens injury'''. Other orchidopexy related complications might include those associated with any surgical procedure, such as wound infection, dehiscence, and hematoma.
**** '''Prophylactic contralateral orchidopexy'''
***** In the absence of literature strongly supporting or discouraging prophylactic orchidopexy, '''the decision should be made based on informed discussion of options with the patient parents or legal guardian'''
****** Preventive orchidopexy of the normally descended contralateral testicle in the setting of blind-ending spermatic vessels found upon exploration of a non-palpable testis has been advocated by some authors, based on the reported risk of bell-clapper deformity and abnormal testicular fixation found in the remaining solitary testis.
****** The risk of torsion is admittedly low, conceptually not different from the general population.
** '''Testicular biopsy is not indicated at the time of orchidopexy'''
* '''Conservative management'''
** '''UDT is associated with a multitude of syndromes, some of which can lead to limited life expectancy and/or severe developmental delay (e.g., Down’s, Prader-Willi, and Noonan’s syndromes)'''
** Given the reports of testicular cancer (sometimes at an early age) in these patients, '''we recommend orchidopexy when they are clinically fit for anesthesia for the purpose of surveillance'''
* '''Previous failed orchidopexy'''
** '''We recommend offering redo orchidopexy for cases where inadequate position is detected postoperatively'''