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Cryptorchidism: Treatment with Hormonal Therapy and Surgery

• Cryptorchidism: Definition and Causes
• Cryptorchidism: Signs, Symptoms and Diagnostik Workup
• Cryptorchidism: Hormonal Treatment and Surgery

Treatment Planning for Cryptorchidism

Current guidelines recommend to plan treatment of cryptorchidism six month after birth. Treatment should be finished with the end of the first year of life. The standard therapy for the vast majority of cases is early orchidopexy; it is safe and effective. There is insufficient evidence for hormone therapy to induce testicular descend; it is an option only in exceptional cases (Ritzen et al., 2007).

Goals of Therapy:

• Preserving fertility
• Reducing tumor risk
• Improving early detection of testicular cancer

Hormone Therapy of Cryptorchidism

Hormones (HCG, GnRH) stimulate testosterone and support the spontaneous testicular descent. In bilateral disease, there are better chances for the success of hormonal therapy.

The "Nordic Consensus Group on Treatment of undescended testes" does not recommend hormone therapy because of low efficiency and because of the potential harmful effect on fertility and recommends the surgical therapy as the sole treatment of choice (Ritzen et al., 2007). In contrast to studies with HCG, GnRH therapy demonstrated an improvement of the fertility index. However, these results are seen critical from the Nordic consensus group, and further studies are recommended (Thorsson et al., 2007). The EAU guideline is also cautious about hormone therapy to achieve testicular descent. However, hormone therapy is an option in bilateral cryptorchidism to improve fertility.

Contraindications for hormone therapy:

Ectopic testes, non-descended testes with inguinal hernia or after previous groin surgery.

Dosage of hormone therapy:

GnRH nasal spray

3 × 400 mg/d over a period of 4 weeks.

HCG therapy:

1 × / week i.m. injections over a period of 5 weeks, dosage per injection, depending on age: less than 1 year 250 IU, older than 1 year 500 IU. Many study groups do not recommend HCG treatment for undecended testes.

Combined hormonal therapy:

GnRH nasal spray for 4 weeks followed by HCG i.m. injections over 5 weeks.

Results of hormone therapy:

The results of hormone therapy (in randomized trials) are disappointing (<20% success). Studies with GnRH could demonstrate an improvement of the fertility index. HCG is suspected to impair fertility. Regular follow-up after successfull hormonal treatment is necessary, since testicular reascension is possible in 25%.

Side effects of hormone therapy:

Scrotal pigmentation, rarely penis enlargement and pubic hair (reversible), weight gain. HCG is suspected to impair fertility.

Surgical Treatment of Cryptorchidism

The goal of surgery is the transfer of the non-descended testis (tension-free) to a deep scrotal pouch before the end of the first year of life.

Inguinal orchidopexy:

For details see section surgical technique of Schoemaker orchidopexy.

• Inguinal incision to access the inguinal canal
• Mobilization of the spermatic cord up to the deep inguinal ring (funicolysis).
• Circular removal of the cremaster muscle
• Treatment of an open processus vaginalis, if present
• Deep ipsilateral subcutaneous scrotal pouch (dartos-pouch)
• Tension-free transfer of the testis to the dartos-pouch with orchidopexy

Two-stage surgical procedure:

A two-stage surgical procedure is necessary for an abdominal testis with low mobility of the testicular vessels. First, the testis is mobilized with laparoscopy and the testicular vessels are transsected as cranially as possible (Fowler-Stephens maneuver). The testis is transferred to the deep inguinal ring. In the second step (after 4–12 weeks of therapy with LHRH nasal spray), an inguinal incision is done and the testis is transferred to a deep Dartos pouch.

Microsurgical autotransplantation of the testis:

Testicular autotransplantation is a treatment option for an abdominal testis with a low mobility of the testicular vessels. After laparoscopic identification and explantation, the testis is anastomosed to the vasa epigastrica inferior.

Laparoscopic orchiectomy:

Laparoscopic orchiectomy is done due to hypoplastic abdominal testes.

Inguinal orchiectomy:

Inguinal orchiectomy is a treatment option in postpubertal patients with unilateral cryptorchidism, especially in hypoplastic testis or suspected testicular tumor.

Prognosis of Cryptorchidism

Spontaneous descent of the testis:

70–80% of undescended testicles at time of birth show a spontaneous descent, usually within 3 months. A high spontaneous descensus rate is associated with a low birth weight, bilateral cryptorchidism, normal scrotal anatomy and testes with already low inguinal position.

Fertility after orchidopexy:

87% of untreated men with unilateral cryptorchidism have children, but only 33% with bilateral cryptorchidism. Whether the (timely) surgery improves fertility is controversial.

References

Kolon u.a. 2004 KOLON, T. F. ; PATEL, R. P. ; HUFF, D. S.: Cryptorchidism: diagnosis, treatment, and long-term prognosis.
In: Urol Clin North Am
31 (2004), Nr. 3, S. 469–80, viii-ix

M. Ritzen, A. Bergh, R. Bjerknes, P. Christiansen, D. Cortes, S. E. Haugen, N. Jörgensen, C. Kollin, S. Lindahl, G. Läckgren, K. M. Main, A. Nordenskjöld, E. R.-D. Meyts, O. Söder, S. Taskinen, A. Thorsson, J. Thorup, J. Toppari, und H. Virtanen. Nordic consensus on treatment of undescended testes.
Acta Paediatr, 96 (5): 638–643, May 2007.

A. V. Thorsson, P. Christiansen, und M. Ritzen. Efficacy and safety of hormonal treatment of cryptorchidism: current state of the art.
Acta Paediatr, 96 (5): 628–630, May 2007.

  Deutsche Version: Kryptorchismus Therapie