Dr. med. Dirk Manski

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Cryptorchidism: Treatment with Hormonal Therapy and Surgery

Treatment Planning for Cryptorchidism

According to current guidelines, spontaneous testicular descensus should be awaited until the sixth month of life. In the case of persistent cryptorchidism, surgical treatment should be done within the next six months (EAU guideline) to 12 months (AUA guideline). The standard therapy for most cases is early orchidopexy; it is safe and effective. There is insufficient evidence for hormone therapy to induce testicular descent; it is an option only in exceptional cases (Ritzen et al., 2007).

Treatment goals:

Surgical Treatment of Cryptorchidism

The goal of surgery is the transfer of the undescended testis (tension-free) to a deep scrotal pouch.

Inguinal orchidopexy:

Inguinal orchidopexy is the surgical treatment of the palpable undescended testis. For details, see the section surgical technique of Schoemaker orchidopexy.

Laparoscopy for Abdominal Testes

Laparoscopy is indicated if abdominal testes are suspected. Before laparoscopy, the examination of the inguinal canal is repeated under anesthesia. If the testis is palpable, proceed with inguinal orchidopexy. Laparoscopy is indicated for unilateral nonpalpable testis or bilateral nonpalpable testes with positive HCG stimulation (see section diagnosis). When laparoscopy can identify testicular vessels and ductus deferens at the deep inguinal ring, the testis has to be in the inguinal canal; proceed with the inguinal approach. If blind-ending testicular vessels are identified, the blind end is removed. If no testicular vessels are identified, examine the path of descent up to the lower pole of the kidney.

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 transected 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. The risk of postoperative testicular atrophy is approximately 8% with a two-stage procedure.

Laparoscopic orchiectomy:

Laparoscopic orchiectomy is done for hypoplastic abdominal testes.

Microsurgical autotransplantation of the testis:

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

Inguinal orchiectomy:

Inguinal orchiectomy is a treatment option in postpubertal patients with unilateral cryptorchidism, especially for hypoplastic testes or suspected testicular tumors.

Hormone Therapy of Cryptorchidism

Hormone therapy stimulates testosterone and supports spontaneous testicular descent. Hormone therapy disappointed in randomized trials (<20% success). Studies with GnRH demonstrated an improvement in the fertility index, HCG is suspected to impair fertility. Regular follow-up after successful hormonal treatment is necessary, since testicular reascension is possible in 25%. The EAU guideline does not recommend hormone therapy to achieve testicular descent. However, hormone therapy with GnRH is an option in bilateral cryptorchidism to improve fertility.

Dosage of GnRH nasal spray:

3× 400 μg/d over four weeks.

Side effects of hormone therapy:

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

Prognosis of Cryptorchidism

Spontaneous descent of the testis:

70–80% of undescended testicles at the time of birth show a spontaneous descent, usually within three 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.






Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

References

Hutson und Hasthorpe 2005 HUTSON, J. M. ; HASTHORPE, S.: Testicular descent and cryptorchidism: the state of the art in 2004.
In: J Pediatr Surg
40 (2005), Nr. 2, S. 297–302

T. F. Kolon, A. Herndon, L. A. Baker, L. S. Baskin, and C. G. Baxter, “AUA Guideline: Evaluation and Treatment of Cryptorchidism,” 2018. [Online]. Available: https://www.auanet.org/guidelines-and-quality/guidelines/cryptorchidism-guideline.

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

C. Radmayr, G. Bogaert, H. S. Dogan, and Tekg&uuml, “EAU Guidelines: Paediatric Urology,” 2022. [Online]. Available: https://uroweb.org/guidelines/paediatric-urology/.

C. Radmayr, G. Bogaert, H. S. Dogan, and Tekg&uuml, “EAU Guidelines: Paediatric Urology,” 2022. [Online]. Available: https://uroweb.org/guidelines/paediatric-urology/.

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.



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