Operative management of cryptorchidism: guidelines and reality - a 10-year observational analysis of 3587 cases

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Abstract

Background

Undescended testis (UDT) is the most common disorder in pediatric surgery and one of the most important risk factors for malignancy and subfertility. In 2009 local guidelines were modified and now recommend treatment to be completed by the age of 1. Aim of this study was to analyze age distribution at the time of orchidopexy, whether the procedure is performed according to guideline recommendations and to assess primary care pediatricians’ attitude regarding their treatment approach.

Methods

We retrospectively analyzed 3587 patients with UDT regarding age at orchidopexy between 2003 and 2012 in 13 German hospitals. Furthermore, we conducted an anonymized nation-wide survey among primary care pediatricians regarding their attitude toward management of UDT.

Results

Before modification of the guideline 78 % ( n = 1245) of the boys with UDT were not operated according to guideline recommendations. After the modification that number rose to 95 % ( n = 1472). 42 % of the orchidopexies were performed on patients aged 4 to 17 years. 46 % of the primary care pediatricians were not aware of this discrepancy and 38 % would only initiate operative management after the first year of life. In hospitals with pediatric surgery departments significantly more patients received orchidopexy in their first year of life ( p < .001).

Conclusion

The guideline for UDT in Germany has not yet been implemented sufficiently. Timing of orchidopexy must be optimized in order to improve long-term prognosis. Both primary care providers and parents should be educated regarding the advantages of early orchidopexy in UDT. Prospective studies are needed to elucidate the high rate of late orchidopexies.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-015-0429-1) contains supplementary material, which is available to authorized users.

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Most cited references 50

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Prevalence and natural history of cryptorchidism.

Robert Lapinski, J Gazella, Elie S Dolgin … (1993)

A prospective hospital-based cohort study was conducted to determine the prevalence rates of cryptorchidism at birth, 3 months, and 1 year of age. A total of 6935 consecutive male neonates delivered at Mount Sinai Hospital in New York City between October 1987 and October 1990 were examined at birth for cryptorchidism. Standardized examination and classification criteria were used. Infants classified as cryptorchid at birth were reexamined at 3 months and 1 year after the expected date of delivery. Of 6935 neonates assessed at birth, 255 (3.7%) were found to be cryptorchid at birth. The rates were significantly elevated for low birth weight, preterm, small-for-gestational age, and twin neonates. The overall rate had declined to 1.0% by the 3-month assessment and 1.1% at the 1-year assessment. Although the rates at the 1-year assessment tended to be higher for low birth weight and preterm infants, no significant group differences were observed. Since the prevalence rates in this study are similar to those reported several decades ago, these data provide no evidence that the rate of cryptorchidism has increased either at birth or by 1 year of age. Furthermore, most testes that descend spontaneously do so within the first 3 months after the expected date of delivery.

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The frequency of undescended testis from birth to adulthood: a review.

K Sijstermans, W. Hack, R. W. Meijer … (2008)

We performed a systematic review and critique of the literature on the frequency of undescended testis (UDT) among boys from birth to adolescence. Special attention was given to whether previous testicular position was taken into account to distinguish between congenital and acquired UDT. We searched Medline, Embase, Cinahl and the Cochrane Library. Any study reporting on the frequency of UDT was included. Study population age, number of boys studied, period of examination, primary examiner, area of study, study design, ethnicity, definitions used and previous testicular position were analysed. A total of 46 studies met the inclusion criteria. Twenty-three of the 46 (50%) studies involved newborns. Definitions were described in half of the studies; however, the definitions used were heterogeneous. Previous testis position was described in 11% (5/46) of the studies. At birth, in term and/or birth weight >2.5 kg infants, the UDT rate ranged from 1.0 to 4.6%, and in premature and/or birth weight 2.5 kg infants was seen in 1.0-1.5%, at 6 years in 0.0-2.6%, at 11 years in 0.0-6.6% and at 15 years in 1.6-2.2% of boys. The frequency of UDT shows variable figures in the literature. The actual frequency of acquired UDT essentially remains unclear because of the shortage of studies performed at an older age, and of studies reporting on previous testicular position.

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The epidemiology of congenital cryptorchidism, testicular ascent and orchiopexy.

Julia Barthold, Ricardo Bonilla González (2003)

The frequency, significance and possible etiology of testicular ascent (acquired cryptorchidism) are characterized in light of the known incidence and natural history of congenital cryptorchidism, and data provided by longitudinal and epidemiological studies of ascended testes and orchiopexy rates. We comprehensively reviewed the literature addressing the epidemiology of congenital and acquired cryptorchidism and orchiopexy. The incidence of congenital cryptorchidism in full-term males at birth (2% to 4%) and at age 1 year (approximately 1%) has not increased in the last few decades. The risk of ascent may be as high as 50% in cases where 1 testis is significantly retractile. Ascended testes are typically unilateral (77%), identified in mid childhood and located distal to the inguinal canal (77%). Ascended and significantly retractile testes may be prone to the same germ cell maldevelopment seen in congenital cryptorchidism. Cumulative orchiopexy rates in defined populations are 2% to 4%, and mean age at orchiopexy remains higher than expected (greater than 4 years), despite a long held standard of care that includes recommendation for surgery by age 2. These data suggest that cryptorchidism may be acquired in a significant subset of cases. With close monitoring of young boys spontaneous ascent of testes from a scrotal to a suprascrotal position may be observed with time, due to either true or apparent testicular ascent, with possible adverse effects on germ cell development and fertility potential. Patients with significant testicular retractility appear to be at highest risk for acquired cryptorchidism, and should be followed closely at yearly intervals until puberty.

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Author and article information

Contributors

Kai O. Hensel: 0049-202-8963800 , kai.hensel@uni-wh.de

Tawa Caspers: tawa.caspers@uni-wh.de

Andreas C. Jenke: andreas.jenke@helios-kliniken.de

Ekkehard Schuler: ekkehard.schuler@helios-kliniken.de

Stefan Wirth: stefan.wirth@helios-kliniken.de

Journal

Journal ID (nlm-ta): BMC Pediatr

Journal ID (iso-abbrev): BMC Pediatr

Title: BMC Pediatrics

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2431

Publication date (Electronic): 10 September 2015

Publication date PMC-release: 10 September 2015

Publication date Collection: 2015

Volume: 15

Electronic Location Identifier: 116

Affiliations

[ ]Department of Pediatrics, HELIOS Medical Center Wuppertal, Children’s Hospital, Centre for Clinical & Translational Research (CCTR), Faculty of Health, Witten/Herdecke University, Heusnerstr. 40, D-42283 Wuppertal, Germany

[ ]Institute for Quality Management, HELIOS Kliniken GmbH, Berlin, Germany

Article

Publisher ID: 429

DOI: 10.1186/s12887-015-0429-1

PMC ID: 4566496

PubMed ID: 26357871

SO-VID: bc458ca2-e1da-439b-82fb-694641a81efa

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 11 September 2014

Date accepted : 20 August 2015

Custom metadata

ScienceOpen disciplines: Pediatrics

Keywords: undescended testis,testicular descent,primary cryptorchidism,maldescensus testis,retractile testis,acquired cryptorchidism,orchidopexy,timing of surgery,health services research,guideline implementation

Data availability:

ScienceOpen disciplines: Pediatrics

Keywords: undescended testis, testicular descent, primary cryptorchidism, maldescensus testis, retractile testis, acquired cryptorchidism, orchidopexy, timing of surgery, health services research, guideline implementation

Operative management of cryptorchidism: guidelines and reality - a 10-year observational analysis of 3587 cases

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Most cited references 50

Prevalence and natural history of cryptorchidism.

The frequency of undescended testis from birth to adulthood: a review.

The epidemiology of congenital cryptorchidism, testicular ascent and orchiopexy.

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