Bilateral undescended testes
First, intersex (females with adrenal hyperplasia) should be ruled out. If the boy is less than nine years old and he has bilateral undescended testes, hormonal work-up is needed. This work-up may lead to a diagnosis of bilateral anorchia which means the testes never formed on either side. If the hormonal work-up is normal, an HCG stimulation test is applied and testosterone is subsequently measured. Patients with bilateral anorchia will not make testosterone in response to HCG.
Retractile testis
This is a normal variant. This phenomenon usually disappears by 13 years of age.
Reasons to treat the undescended testicle
Most pediatric urologists recommend orchiopexy by 1 to 1.5 years of age or earlier. We recommend treatment of the undescended testicle before one year of age. There is evidence that early damage to the germ cells that produce sperm begins at this age. Other reasons to treat are psychological reasons and placement of testicle in position more amenable to physical examination to pick up testis cancer. The most effective treatment is surgery, which can be performed as an outpatient.
Pharmacotherapy has the advantages of avoiding anesthesia and being minimally invasive. HCG (human chorionic gonadotopin) is the drug of choice. HCG is thought to stimulate Leydig cells of testicle to produce male hormones. The precise mechanism of action is unknown. Injections of HCG are given several times per week over several weeks. This can produce descent in some children. However, the success rates have been reported to be as low as 10%. Unfortunately the results of hormone treatment have diminished success in children less than two years of age. Usually a maximum 5-week course is undertaken. Patients failing hormonal therapy should undergo surgical treatment.
Surgical Therapy
Surgery is immediately performed on ectopic testes, cryptorchids with coexisting hernias and boys at pubertal age. When a testis is felt in the groin area, we usually explore the area through a small incision made in the skin above the scrotum called the inguinal region. Most undescended testes are associated with a hernia that must be repaired. After this is done, the testis is brought down into the scrotum and anchored in a space created in the scrotum (orchiopexy). Both incisions (in the inguinal region and scrotum) are closed with absorbable sutures.
Concealed Laparoscopic Orchiopexy
Laparoscopy can be used to localize nonpalpable, undescended testes. The laparoscopy is performed first to find out if the testicle is located in the abdomen or if it is congenitally absent. If the testis is low in the abdomen, an orchidopexy is performed laparoscopically. A laparoscope is inserted through a small umbilical opening to locate the non-palpable testis. If the testis is healthy, a second instrument is placed through a small opening in the scrotum to move the testicle into its natural position. Sometimes the testicle is located too high in the abdominal cavity to reach in a one-step operation. In this setting, the testicle will be freed of its previous blood supply and placed in a location such that it can be brought down with a second operation. The second stage is performed in 6 months.
Follow-up
Long-term issues include infertility and tumorigenesis. After the initial post-operative visits, children should be seen 1 year after surgery to note the location and size of the testes. At puberty, boys should be taught how to perform monthly testicular self-examinations. The threshold for future ultrasound examinations is based on the type of tumor and physical exams. Once the boys reach adulthood, issues regarding fertility must be further explored with a urologist.
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