Pediatric Urology

www.auajournals.org/journal/juro

JU Insight

Malignancy Yield of Testis Pathology in Older Boys and

Adolescents with Cryptorchidism
Rena Xu, Joseph W. McQuaid, Vera A. Paulson et al.
Correspondence: Rena Xu (email: rena.xu@childrens.harvard.edu).
Full-length article available at www.auajournals.org/10.1097/JU.0000000000002345.

Study Need and Importance: Cryptorchidism is

associated with an increased risk of testis cancer,
and the risk of malignancy has been shown to
increase with age at the time of orchiopexy. Data
on the prevalence of malignant changes in older
boys and adolescents, however, are limited. This
retrospective study aimed to characterize the
pathological findings of testis biopsy and orchi-
ectomy specimens from older boys and adolescent
males who underwent surgery for cryptorchidism.
What We Found: Seventy-one patients who un-
derwent orchiopexy with testis biopsy or orchi-
ectomy for cryptorchidism from 1994 to 2016 at
a pediatric hospital were included in the study.
All patients were age 10 years or older (median
age 15.3 years). None had a history of testicular
malignancy or differences of sexual development.
Malignancy was detected in 2 of 71 patients (2.8%);
both cases were in patients undergoing unilateral
orchiectomy for intra-abdominal testes. No evi-
dence of malignancy was observed in specimens
from the 55 patients with extra-abdominal testes Figure. Schematic of malignancy rate by testis location among
(see figure). older boys and adolescents with cryptorchidism.
Limitations: Our study is limited by its single-
institution, retrospective design. All patients
underwent tissue sampling, which introduces prospective studies with long-term followup will
some selection bias. Further, the study does not be valuable in this regard.
distinguish between primary undescended testes Interpretations for Patient Care: Our findings sug-
and ascending testes; these 2 populations likely gest that for older boys and adolescent males with
carry different malignancy risks. In practice, intra-abdominal testes, biopsy or orchiectomy should be
however, differentiating between these 2 groups considered, as these may demonstrate malignancy. In
is challenging, so aggregated data may be the contrast, for patients of comparable age with inguinal
most clinically relevant. Finally, this study does or scrotal undescended testes, biopsy is likely to be very
not predict future malignancy risk; additional low yield and may not be necessary.

0022-5347/22/2073-0694/0 https://doi.org/10.1097/JU.0000000000002345
THE JOURNAL OF UROLOGY® Vol. 207, , March 2022
Ó 2021 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC. Printed in U.S.A.

694 j www.auajournals.org/jurology

Copyright © 2022 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited.
 www.auajournals.org/journal/juro

Malignancy Yield of Testis Pathology in Older Boys and

Adolescents with Cryptorchidism
Rena Xu ,1,*,† Joseph W. McQuaid,2,* Vera A. Paulson,3 Michael P. Kurtz,1 Tanya Logvinenko,1
Richard N. Yu,1 Richard S. Lee1 and Caleb P. Nelson1
1
Department of Urology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
2
Department of Urology, University of Massachusetts Medical School, Worcester, Massachusetts
3
Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington

Purpose: We performed a retrospective, single-institution study to characterize

Abbreviations
the pathological findings of testis tissue specimens from older boys and adoles-
and Acronyms
cents with cryptorchidism.
DSD [ differences of sexual
Materials and Methods: With institutional review board approval, pathology development
reports were obtained for testicular specimens from patients age 10 years or
ITGCN [ intratubular germ cell
older at a pediatric hospital from 1994 to 2016. Reports were excluded if they
neoplasia
lacked clinical records, lacked testicular parenchyma, were from a descended
testis or were from a patient with differences of sexual development. Variables of UDT [ undescended testis
interest included age, testis location, procedure and pathological findings.
Accepted for publication November 6, 2021.
Presence of malignancy among intra-abdominal versus extra-abdominal unde- * Equal study contribution.
scended testes was compared using Fisher’s Exact Test. † Correspondence: Boston Children's Hospi-
tal, 300 Longwood Ave., Boston, Massachusetts
Results: Seventy-one patients met inclusion criteria. The median age was 15.3 02115 (telephone: 617-355-7796; FAX: 617-730-
years (range 10.1e27.7). None had a history of testicular malignancy. Forty-five 0474; email: rena.xu@childrens.harvard.edu).
unilateral orchiectomies, 22 unilateral orchiopexies with biopsy and 4 bilateral
procedures were performed. Seventeen testes (22.7%) were intra-abdominal, 42
(56.0%) were in the inguinal canal, 9 (12.0%) were at the external inguinal ring, 3
(4.0%) were in the superficial inguinal pouch and 4 (5.3%) were in the scrotum.
Malignancy was detected in 2/71 patients (2.8%). By location, 2/16 patients
(12.5%) with intra-abdominal testis and 0/55 patients (0%) with extra-abdominal
testis demonstrated malignancy (p[0.048).
Conclusions: Among males with cryptorchidism ages 10 years and older
without differences of sexual development, 2/16 patients with intra-abdominal
testis and 0/55 patients with extra-abdominal testis demonstrated malignancy.
In older boys and adolescents, orchiectomy or biopsy is indicated for intra-
abdominal testes but may not be necessary for extra-abdominal undescended
testes.

Key Words: cryptorchidism, testicular neoplasms, orchiopexy

CRYPTORCHIDISM is associated with a often performed at the time of orchi-

3- to 10-fold increased risk of malig-
nancy.1,2 Age at the time of orchi-
opexy matters; the risk of subsequent
testicular cancer among patients un-
dergoing orchiopexy at age 13 years
or older has been reported as twice
that of patients treated before the age
of 13.3 For this reason, testis biopsy is
opexy in older boys and adolescents
with cryptorchidism. Malignancy
rates of 0.3% to 1.3% have been re-
ported in boys with cryptorchidism
undergoing orchiopexy at a median
age of 11.7 years.4 Data on the prev-
alence of malignant changes in older
boys and adolescents, however, are

0022-5347/22/2073-0695/0 https://doi.org/10.1097/JU.0000000000002345
THE JOURNAL OF UROLOGY® Vol. 207, 694-700, March 2022
Ó 2021 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC. Printed in U.S.A.

www.auajournals.org/jurology j 695
Copyright © 2022 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited.
696 YIELD OF TESTIS PATHOLOGY IN OLDER CHILDREN WITH CRYPTORCHIDISM
limited. We performed a retrospective, single-
institution study to characterize the pathological
findings of testicular biopsy or orchiectomy speci-
mens from older boys and adolescent males under-
going surgery for cryptorchidism.
MATERIALS AND METHODS
With institutional review board approval, pathology re-
ports were obtained for all testicular specimens from pa-
tients 10 years of age or older who underwent orchiectomy
or orchiopexy with testis biopsy at a pediatric hospital
between 1994 and 2016 (IRB No. IRB-P00023685). Re-
ports were identified for review if they included the terms
“testis,” “testes,” “testicle,” or “testicular” (1,078). Reports
and their associated specimens were subsequently
excluded if they lacked operative or clinical records (31),
lacked testicular parenchymal tissue (688), were obtained
from a descended testis (251) or were obtained from a
patient with differences of sexual development (DSD),
defined as gonadal dysgenesis, ovotesticular syndrome,
androgen insensitivity syndrome or a disorder of testos-
terone biosynthesis (33; see figure). Clinical variables of
interest included history of cryptorchidism, laterality,
location of the undescended testis (UDT) and type of
procedure performed; pathology variables of interest were
the presence of malignancy, defined as testicular
neoplasia or intratubular germ cell neoplasia (ITGCN), a
precursor of testicular malignancy. The prevalence of
malignancy in intra-abdominal versus extra-abdominal
testes was compared using Fisher’s Exact Test, with
confidence intervals calculated separately for each group.
Analyses were performed using JMPÒ software, version
13.0 (SASÒ, Cary, North Carolina).
RESULTS
Seventy-one patients met inclusion criteria. The
median age was 15.3 years (range 10.1e27.7; IQR
12.9e16.5). None had a prior history of testicular
malignancy. Sixty-seven patients underwent uni-
lateral procedures, consisting of orchiectomy (45;
63.4%), single-stage orchiopexy (20; 28.2%) or 2-
stage orchiopexy (2; 2.8%). The remaining 4 pa-
tients underwent bilateral procedures, consisting of
bilateral single-stage orchiopexy (3; 4.2%) or uni-
lateral 2-stage orchiopexy with contralateral orchi-
ectomy (1; 1.4%). Of the 75 testes, 17 (22.7%) were
intra-abdominal, 42 (56.0%) were in the inguinal
canal, 9 (12%) were at the external inguinal ring,
3 (4%) were in the superficial inguinal pouch and
4 (5.3%) were in the high scrotum. Only 2/71 pa-
tients demonstrated malignancy upon pathology
review, for an overall malignancy rate of 2.8% (see
table).
By testis location, malignancy was found in 0/55
patients (0%, 95% CI: 0e6.5) with extra-abdominal
testes, as compared to 2/16 patients (12.5%, 95%
CI: 3.5e36.0) with intra-abdominal testes (p[0.048).
Both identified cases of malignancy were in patients
Copyright © 2022 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited.
undergoing unilateral orchiectomy. One patient, a
16-year-old male, had no documented past medical
history prior to referral for nonpalpable testis;
pathology from orchiectomy revealed intertubular
seminoma and ITGCN. The other patient, a 26-
year-old male with a history of developmental
delay, was referred to our institution for man-
agement of a fused pelvic kidney with left ure-
teropelvic junction obstruction discovered on
workup for hematuria after a fall. He was found
on examination to have a nonpalpable right testis,
and orchiectomy was performed at the time of pye-
loplasty. Pathology from the orchiectomy revealed
classic-type seminoma and ITGCN, with a single
microscopic focus of gonadoblastoma.
DISCUSSION
This retrospective study of testis pathological
specimens among adolescent males without a his-
tory of DSD who underwent surgical treatment for
cryptorchidism demonstrated a 2.8% prevalence of
testicular malignancy (2/71 patients). Both identi-
fied cases of malignancy were in patients under-
going unilateral orchiectomy for intra-abdominal
testes. No evidence of malignancy was observed
in specimens from the 55 patients with extra-
abdominal testes. These findings suggest that for
adolescent patients with intra-abdominal testes,
biopsy at the time of surgery (if orchiectomy is not
being performed) is appropriate. In contrast, for
patients with inguinal or high scrotal testes, biopsy
yield is likely to be very low.
Our results support and advance the existing
literature on the management of cryptorchidism in
older boys and adolescents. An association between
age at the time of treatment and malignancy rate
has been previously described. A meta-analysis by
Walsh et al found that testis cancer is nearly 3.5
times more likely to develop among boys undergoing
orchiopexy after age 10 to 11 years, as compared to
boys treated at a younger age.5 Pettersson et al re-
ported a sharp increase in the relative risk of sub-
sequent malignancy for boys undergoing treatment
at age 13 to 15 years as compared to those under-
going treatment at age 10 to 12 years or younger.3 A
secondary analysis of the Pettersson data by Hig-
gins et al demonstrated that at all ages, the cancer
incidence rate per 1,000 men with cryptorchidism is
higher for those who were treated at a later age,
and that the number needed to treat to prevent 1
case of testicular cancer decreases with age at the
time of orchiopexy.6 These findings underscore the
importance of understanding the risk of malignancy
specifically in older boys and adolescents with
cryptorchidism and of taking an evidence-based
approach to the management of these cases.
 YIELD OF TESTIS PATHOLOGY IN OLDER CHILDREN WITH CRYPTORCHIDISM
Flow diagram of study inclusion.
Our study deliberately focused on an older pa-
tient population to characterize this risk. Because
many previous studies included a large proportion
of prepubertal patients (in particular, of results
from routine biopsy of young boys undergoing
orchiopexy), their reported malignancy rates may
underestimate the true prevalence of malignancy
among older boys and adolescents.4,7 In a retro-
spective study by Cortes et al of 1,335 boys with
cryptorchidism who underwent orchiopexy with
concurrent biopsy between 1971 and 2000, for
example, the median age was 11.7 years, with a
range of 0.1e18.9 years.4 Testicular neoplasia was
identified in 0.3% of unilateral and 1.3% of bilateral
cases. Our study included only patients who were
age 10 years or older at the time of treatment. The
median age in our study was 15.3 years, with range
of 10.1e27.7 years. This may explain the higher
rate of malignancy that we report.
An added strength of our study is the categori-
zation of malignancies by testis location. Koni et al
reported a 2% malignancy risk based on 1 case of
ITGCN in a retrospective study of 52 patients with a
mean age of 21 years who underwent unilateral
orchiectomy.8 The location of the testis with the
positive finding was not specified. Ryang et al
similarly reported a 3.2% malignancy rate based on
1 case of ITGCN in a retrospective study of 31
postpubertal patients with a mean age of 34 years
(range 17e74 years) who underwent orchiectomy;
the location of the testis with the positive finding
was not specified.9 The authors concluded that
preventative orchiectomy should be performed in
Table. Description of subjects with identified malignancy
Subject Age (yrs) Procedure Location of Testis
16.2 Unilat orchiectomy (rt) Intra-abdominal
26.6 Unilat orchiectomy (rt) Intra-abdominal
Copyright © 2022 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited.
697
postpubertal patients with cryptorchidism because
of this risk of malignancy. Others have suggested
that testicular biopsy should be performed during
orchiopexy for all patients age 13 years or older.10,11
In our study, despite the overall increased ma-
lignancy rate of 2.8%, no cases of malignancy were
identified among testes in the inguinal or scrotal
regions. This is consistent with the results of prior
studies.4 Our finding suggests that even among
older boys and adolescents, UDTs that are inguinal
or scrotal may not need to be removed or even bio-
psied at the time of orchiopexy. Notably, this man-
agement approach does not apply to patients with
intra-abdominal testes, for whom biopsy at a mini-
mum is likely indicated. Nor does it apply to pa-
tients with DSD, which has been associated with an
increased risk of malignancy: prior studies have
reported aggregated malignancy rates for patients
with and without karyotype anomalies and external
genitalia abnormalities.12,13 Our study included
only patients without DSD in order to accurately
represent the risk of malignancy in the nonDSD
population.
Our study is limited by its retrospective, single-
institution design. Comprehensive assessment of
family history was not possible due to the study
design. The retrospective design also means that
some selection bias was introduced, since all
included patients underwent tissue sampling, while
all patients with UDT do not typically undergo bi-
opsy or removal. Additionally, the study does not
distinguish between primary UDTs and ascending
testes; these 2 populations likely carry different
Pathology
Multiple microscopic foci of intertubular seminoma (present as scattered single cells þ small clusters) with
ITGCN (unclassified type)
Seminoma, classic type, with ITGCN (unclassified type); single microscopic focus of gonadoblastoma
698 YIELD OF TESTIS PATHOLOGY IN OLDER CHILDREN WITH CRYPTORCHIDISM

malignancy risks and ideally could be identified and
managed separately. In practice, however, differ-
entiating between the 2 groups is challenging: pa-
tients and caregivers often cannot state definitively
whether a UDT was descended previously, and even
prior documentation by other providers is not al-
ways reliable. Therefore, aggregated risk data for
ascending and primary UDTs remain clinically
relevant, since clinicians must often counsel pa-
tients on their risk without knowing to which group
they belong.
Finally, this study of testis pathology findings
assesses the prevalence of malignancy at the time of
biopsy or orchiectomy but does not predict future
malignancy risk. Our findings suggest that the
approach outlined aboveddetermining the need for
biopsy based on testis locationdis reasonable;
however, additional prospective studies with long-
term followup will be valuable to further assess
the oncologic impact of this proposed clinical man-
agement strategy.
CONCLUSIONS
Among older boys and adolescent males age 10
years and older without a history of DSD or known
testicular malignancy, 0 out of 55 patients with
extra-abdominal UDTs were found to have evidence
of malignancy on biopsy or whole-testis specimens
while 2 out of 16 patients with intra-abdominal
testes demonstrated malignancy. These findings
suggest that testicular biopsy at the time of orchi-
opexy may not be necessary in patients older
than age 10 years with inguinal or scrotal UDTs.
Conversely, biopsy or orchiectomy should be
considered in older boys and adolescents with intra-
abdominal testes, as these may demonstrate
malignancy.

REFERENCES
1. Wood HM and Elder JS: Cryptorchidism and
testicular cancer: separating fact from fiction.
J Urol 2009; 181: 452.
2. Hutson JM, Li R, Southwell BR et al: Germ cell
development in the postnatal testis: the key to
prevent malignancy in cryptorchidism? Front
Endocrinol (Lausanne) 2012; 3: 176.
3. Pettersson A, Richiardi L, Nordenskjold A et al:
Age at surgery for undescended testis and risk of
testicular cancer. N Engl J Med 2007; 356: 1835.
4. Cortes D, Thorup JM and Visfeldt J: Cryptor-
chidism: aspects of fertility and neoplasms. A
study including data of 1,335 consecutive boys
who underwent testicular biopsy simultaneously
with surgery for cryptorchidism. Horm Res 2001;
55: 21.
5. Walsh TJ, Dall'Era MA, Croughan MS et al:
Prepubertal orchiopexy for cryptorchidism may
be associated with lower risk of testicular can-
cer. J Urol 2007; 178: 1440.
6. Higgins M, Smith DE, Gao D et al: The impact of
age at orchiopexy on testicular cancer outcomes.
World J Urol 2020; 38: 2531.
7. Cortes D, Visfeldt J, Møller H et al: Testicular
neoplasia in cryptorchid boys at primary surgery:
case series. BMJ 1999; 319: 888.
8. Koni A, Ozseker HS, Arpali E et al: Histopatho-
logical evaluation of orchiectomy specimens in
51 late postpubertal men with unilateral crypt-
orchidism. J Urol 2014; 192: 1183.
9. Ryang SH, Jung JH, Eom M et al: The incidence
and histological characteristics of intratubular
germ cell neoplasia in postpubertal cryptorchid
testis. Korean J Urol 2015; 56: 515.
10. Faure A, Bouty A, O'Brien M et al: Testicular
biopsy in prepubertal boys: a worthwhile minor
surgical procedure? Nat Rev Urol 2016; 13: 141.
11. Giwercman A, Bruun E, Frimodt-Møller C et al:
Prevalence of carcinoma in situ and other his-
topathological abnormalities in testes of men
with a history of cryptorchidism. J Urol 1989;
142: 998.
12. Wolffenbuttel KP, Hersmus R, Stoop H et al:
Gonadal dysgenesis in disorders of sex devel-
opment: diagnosis and surgical management.
J Pediatr Urol 2016; 12: 411.
13. Kathrins M and Kolon TF: Malignancy in disor-
ders of sex development. Transl Androl Urol
2016; 5: 794.

EDITORIAL COMMENTS

The management of undescended testes (UDTs) in
older children and adolescents can be difficult when
balancing the benefits of orchiopexy to preserve
endocrine and fertility function versus the risks of
malignancy in a retained gonad. Xu et al have shed
light on this topic by reviewing 71 patients from a
single institution who were age 10 years or older
with a UDT and who had a biopsy or orchiectomy.
Pertinently, patients with differences of sexual
development were excluded. The analysis revealed
that while none of the 55 patients with extra-
abdominal gonads harbored malignancy, 2 of the
16 (12.5%) who had intra-abdominal gonads were
noted to have malignancy on pathological review.
Interestingly, both cases had seminomatous germ
cell tumors.
There is inherent selection bias in studying only
patients who underwent pathological evaluation.
However, it would be impossible to know the pres-
ence of malignancy in those who did not have biopsy
or orchiectomy. Therefore, we are left with the
analysis as it is presented, given the acknowledged
constraints. I would argue, though, despite this
specific limitation, that this study informs clinical
practice. While recent work from Higgins et al notes
a large number of orchiopexies needed to prevent

Copyright © 2022 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited.
 YIELD OF TESTIS PATHOLOGY IN OLDER CHILDREN WITH CRYPTORCHIDISM
1 testicular cancer (reference 6 in article), the pop-
ulation studied by Xu et al is older in age, and when
selecting even further the intra-abdominal UDTs it
is clearly a high-risk cohort.
Surgical decisions are a balance of risks and ben-
efits that are best made after a full discussion with
the patient and family. These data help that con-
versation by allowing an objective assessment of the
malignancy risk in older children and adolescents
with intra-abdominal testes. While studies that
Xu and colleagues revisit the prevalence of neoplasia
in UDTs, finding that only 2 (12.5%) of boys with
intra-abdominal testes and no patients with extra-
abdominal testes had evidence of neoplasia at the
time of biopsy. Their findings ostensibly confirm
what many of us have long suspected: that not every
surgery for cryptorchidism at or after puberty needs
to be an orchiectomy. Importantly, however, their
findings raise questions about the generalizability of
recommendations surrounding gonadal management
in the pubertal and post-pubertal male. To para-
phrase Leo Tolstoy, every descended testicle is the
same, while every testicle located outside the
scrotum is malpositioned in its own way.1 Excluding
patients with incomplete records, inadequate tissue
for analysis (owing to anatomical findings and/or lack
of biopsy/orchiectomy) and differences of sexual
development, this retrospective series was comprised
of 71 patients over 22 years (or, on average, 3e4
patients/year) at a major academic pediatric referral
center. This observation alone suggests that this
patient cohort is highly selected. The rationale for
intraoperative clinical management (biopsy versus
orchiectomy versus orchiopexy) can be difficult to
REFERENCES
1. Tolstoy L: Anna Karenina. Moscow: The Russian 2. Kremen J, Chan Y-M and Swartz JM: Recent
Messenger 1878.
Older children presenting with an undescended
testis are a source of concern. We think of the
fertility potential lost and the malignancy risk
gained. We are further challenged when offered the
intra-abdominal testicle in a post-pubertal teen or
young man. These testicles can rarely be mobilized
to the scrotum or groin because puberty has pre-
cluded us from doing so. Testosterone has worked
against us, weighing down the testicle with cre-
masteric muscle deposition, confining it to the
Copyright © 2022 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited.
699
generate clinical data are never perfect, utilizing
data such as these from Xu et al allows us to practice
better medicine by making evidence-based decisions.
Nicholas G. Cost1
1
Department of Surgery, Division of UrologyePediatric Urology and
Urologic Oncology
Children’s Hospital Colorado and the University of Colorado
Cancer Center
Aurora, Colorado
determine with certainty in a retrospective review;
biopsies may miss neoplasia, and universal tissue
acquisition from all patients may raise ethical con-
cerns. Advances in genetic testing may identify pa-
tients with previously unrecognized differences of
sexual development.2 Some patients presenting with
a malpositioned testis at or after puberty may have
ascending testes rather than primary cryptorchi-
dism.3 Finally, this study lacked longer-term fol-
lowup evaluating the incidence of neoplasia in
preserved testes. Despite these limitations, Xu and
colleagues have identified at least 1 group of patients
for whom the prevalence of neoplasia in malposi-
tioned testes is zero. Understanding the pertinent
characteristics of these patients and whether their
findings hold true in a larger cohort will help inform
a nuanced approach to care in older boys with
cryptorchidism.
Kathleen Kieran1
1
Department of Urology
Seattle Children’s Hospital
University of Washington
Seattle, Washington
3. Alchoikani N and Ashour K: Ascending testis: a
findings on genetics of disorders of sex develop- congenital predetermined condition. J Pediatr Urol
ment. Curr Opin Urol 2017; 27: 1. 2021; 17: 192.e1.
peritoneal cavity. We are uneasy because surveying
an intra-abdominal testis for malignancy in perpe-
tuity is unreasonable.
This retrospective study offers some more clarity
in understanding the risk of malignancy in older
boys with a UDT, stratified by location (intra-
abdominal versus extra-abdominal). The strength of
the study lies in the selected sample. Boys were
older and those with differences of sexual develop-
ment were excluded. We assume that syndromic-
700 YIELD OF TESTIS PATHOLOGY IN OLDER CHILDREN WITH CRYPTORCHIDISM

cryptorchid children weren’t included either,
although both of those who developed malignancies
had developmental delay. By omitting those with a
known higher risk of gonadal malignancies, con-
clusions made from the research can better support
our clinical decision making for the majority we
treat (nonsyndromic and nondifferences of sexual
development cryptorchidism).
By testis location, malignancy was found in 0/55
patients (0%) with extra-abdominal testes as
compared to 2/16 patients (12.5%) with intra-
abdominal testes. The 2 subjects identified with
malignancy were much older (16.2 and 26.6) and
had elements of intratubular germ cell neoplasia
(ITGCN). Interestingly, ITGCN has been found in
up to 57% of syndromic cryptorchid cases.1
Based on the findings the authors make accurate
and simple conclusions. For adolescent patients with
intra-abdominal testes, biopsy at the time of surgery
is appropriate. In reality an orchiectomy may be
most practical considering an orchiopexy may not be
possible and the odds ratio that ITGCN will become
invasive increases considerably over a lifetime (ref-
erences 3 and 11 in article). In contrast, for patients
with inguinal or high scrotal testes, biopsy yield is
likely to be very low, and hence it just shouldn’t be
donedwe will rely on a lifetime of self-examination.
Michael C. Ost1
1
Department of Urology
West Virginia University Medicine
Morgantown, West Virginia

REFERENCE
1. Osterballe L, Clasen-Linde E, Cortes D et al: The diagnostic impact of testicular biopsies for intatubular germ cell neoplasia in cryptorchid boys and the subsequent risk of
testicular cancer in men with prepubertal surgery for syndromic or non-syndromic cryptorchidism. J Pediatr Surg 2017; 52: 587.

Copyright © 2022 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited.