Medical Treatment
The AUA Guidelines state: "Providers should not use hormonal therapy to induce testicular descent as evidence shows low response rates and lack of evidence for long-term efficacy."
The American Pediatric Association Guidelines do recommend the use of hormones for cases of undescended testis associated with Prader-Willi Syndrome. Their reasoning is that a therapeutic trial of human chorionic gonadotropin (HCG) is indicated for treatment of undescended testes before surgery, because avoidance of general anesthesia is desirable for infants with low muscle tone and at high risk for underlying respiratory compromise.
The most commonly used hormone is human chorionic gonadotropin (HCG). A series of HCG injections is given, and the status of the undescended testicle is reassessed. The success rate is reported as 5% to 50%.
Hormone treatment also will confirm Leydig cell responsiveness and induce additional growth of a small penis due to a rise in testosterone levels.
The cost of hormone treatment is less than surgery, and the chance of complications are minimal. However, a recent meta-analysis of seven randomized clinical trials concluded that hormonal therapy was no more effective than placebo.
Surgery
Surgery is recommended for congenital undescended testes between the ages of 6 and 18 months (AUA Guidelines). Many experts are recommending surgery early, at around 6 months, to optimize testicular growth and fertility. For premature babies, corrected age is used to determine surgery timing. The longer the cryptorchid testis remains untreated, the greater the germ cell loss and the loss of fertility which is why early orchidopexy is the usual, standard remedy. Patients with bilateral undescended testes who receive orchidopexies as adults are almost always infertile and azoospermic; but there are now a few anecdotal reports of pregnancies achieved through assisted reproduction in this group.
For acquired (testis documented normal before diagnosis) and entrapped (after hernia repair) undescended testes, surgery is recommended shortly after diagnosis.
For retractile testes, a yearly physical examination is recommended because of the 2% to 50% reported risk of a retractile testis becoming an acquired undescended testis.
Technique of Orchiopexy
For palpable undescended testes, an inguinal or scrotal orchiopexy is recommended.
An incision is made in the high scrotum, median scrotal raphe, high edge of the scrotum, or groin. Many different type of retractors can be used depending of the size of the incision. Inguinal incisions can be as small as 1 cm. Scrotal incisions can be larger as they tend to heal concealed specially when in the median raphe.
The testis can be approached first or the cord first; for scrotal cases, the testis is found first. For an inguinal approach, the testis can be approached first or the external oblique fascia opened proximal to the external ring and the cord approached first.
When approaching the testis first, all the cremasteric muscles are divided as well as everything not going into the external ring.
The more difficult part of the case is separating the hernia sac from the vas and testicular vessels. This can be approached anteriorly or posteriorly. The posterior approach is much easier to teach and learn.
How the testis is positioned and secured in the scrotum varies. Most would agree that a sub-dartos pouch is desirable. Some surgeons do not suture the testis in place, others use absorbable sutures, others non-absorbable, and others just close the passage into the groin.
For nonpalpable testes under anesthesia, exploratory laparoscopy is recommended. If a testis is found during exploratory laparoscopy, the options are:
Laparoscopic orchiopexy preserving the vessels: the testis is dissected off a triangular pedicle containing the gonadal vessels and the vas.
Laparoscopic one stage Fowler Stevens (FS) orchiopexy: the gonadal vessels are divided and the testis is dissected off a pedicle of the vas and brought down in one stage.
Laparoscopic two stage Fowler Stevens orchiopexy: the vessels are divided with clips but dissection of the testis is postponed for 6 months to allow for optimal development of collaterals.
Laparoscopic two stage traction-orchidopexy (Shehata technique): the intrabdominal testis is fixed to a point one inch (2 cm) medial and superior to the contralateral anterior superior iliac spine, which provides traction. The testis is left there for 3 months after which a laparoscopy assisted ipsilateral subdartos orchidopexy is performed. This technique is an alternative to the two stage Fowler Stevens orchidopexy. Its main advantage is that it allows an intraabdominal testis to be relocated into the scrotum without the need to sacrifice the main testicular vessels. It should be considered whenever a single stage laparoscopic orchidopexy cannot be performed due to inadequate length. It provides a very high success rate with preservation of testicular vasculature without atrophy. Overall success with this technique is from 84% to 100%.
If no testis is found during exploratory laparoscopy, one has to determine the presence of either blind ending vessels or a testicular nubbin to completely rule out a missing testis. The vas can be dissociated from the testis and thus is not always a good guide to find the gonad.
If the internal ring is closed but vessels are going into it, a scrotal exploration usually will find a testicular nubbin. Look for a small structure with a brown spot.
If vessels are going into an open inguinal ring, one can usually push the testis into the abdomen but if not, an inguinal or scrotal exploration would be warranted.
Complications
Orchiopexy is associated with two major testicular complications: atrophy and testicular ascent. For palpable testes, these occur less than 5% of the time. For laparoscopic orchiopexies, the rate is also around 5%. For Fowler-Stephens orchiopexies (dividing the vessels) in one or two stages, the testicular atrophy rate is around 20% to 30% (worse for the one stage procedure).