Journal of Pediatric Surgery 57 (2022) 1293–1308

Contents lists available at ScienceDirect

Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg.org

Management of the undescended testis in children: An American

Pediatric Surgical Association Outcomes and Evidence Based Practice
Committee Systematic Review
Robert L Gates a, Julia Shelton b, Karen A Diefenbach c, Meghan Arnold d, Shawn D. St.
Peter e, Elizabeth J. Renaud f, Mark B. Slidell g, Stig Sømme h, Patricia Valusek i,
Gustavo A. Villalona j, Jarod P. McAteer k, Alana L. Beres l, Joanne Baerg m,
Rebecca M. Rentea e, Lorraine Kelley-Quon n, Akemi L. Kawaguchi o, Yue-Yung Hu p,
Doug Miniati q, Robert Ricca a,∗, Robert Baird r
a
University of South Carolina School of Medicine – Greenville, Greenville, SC, United States
b
University of Iowa, Stead Family Children’s Hospital, Iowa City, IA, United States
c
Ohio State University, Nationwide Children’s Hospital, Columbus, OH, United States
d
University of Michigan, C.S. Mott Children’s Hospital, Ann Arbor, MI, United States
e
Children’s Mercy Hospital, Kansas City, MO, United States
f
Alpert Medical School of Brown University, Hasbro Children’s Hospital, Providence, RI, United States
g
Comer Children’s Hospital, The University of Chicago Medicine, Chicago, IL, United States
h
Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, United States
i
Pediatric Surgical Associates, Children’s Minnesota, Minneapolis, MN, United States
j
Nemours Children’s Specialty Care, Jacksonville, FL, United States
k
Providence Pediatric Surgery, Sacred Heart Children’s Hospital, Spokane, WA, United States
l
University of California, Davis, Sacramento CA, United States
m
Loma Linda University Children’s Hospital, Loma Linda, CA, United States
n
Children’s Hospital Los Angeles, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
o
McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
p
Ann & Robert H. Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
q
Division of Pediatric Surgery, Kaiser Permanente Roseville Women and Children’s Center, Roseville, CA, United States
r
Division of Pediatric Surgery, BC Children’s Hospital, University of British Columbia, Vancouver, BC, United States

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: Management of undescended testes (UDT) has evolved over the last decade. While urologic
Received 21 August 2021 societies in the United States and Europe have established some guidelines for care, management by
Revised 31 December 2021
North American pediatric surgeons remains variable. The aim of this systematic review is to evaluate the
Accepted 8 January 2022
published evidence regarding the treatment of (UDT) in children.
Methods: A comprehensive search strategy and the Preferred Reporting Items for Systematic Reviews and
Keywords: Meta-Analysis (PRISMA) guidelines were utilized to identify, review, and report salient articles. Five prin-
Undescended testis/testes cipal questions were asked regarding imaging standards, medical treatment, surgical technique, timing of
Cryptorchidism operation, and outcomes. A literature search was performed from 2005 to 2020.
Orchiopexy
Results: A total of 825 articles were identified in the initial search, and 260 were included in the final
Testicular cancer
review.
Conclusions: Pre-operative imaging and hormonal therapy are generally not recommended except in spe-
cific circumstances. Testicular growth and potential for fertility improves when orchiopexy is performed
before one year of age. For a palpable testis, a single incision approach is preferred over a two-incision or-
chiopexy. Laparoscopic orchiopexy is associated with a slightly lower testicular atrophy rate but a higher

This work was completed by the authors while members of the American Pediatric Surgery Association Outcomes and Evidence Based Practice Committee. There are not
competing interests or financial disclosures. No financial support was provided for the completion of this manuscript.
Type of Study: Systematic Review
Levels of Evidence: Levels II – IV
∗
Corresponding author at: Division of Pediatric Surgery, 48 Cross Park Court, Greenville, SC 29605, United States.
E-mail address: Robert.ricca@prismahealth.org (R. Ricca).

https://doi.org/10.1016/j.jpedsurg.2022.01.003
0022-3468/© 2022 Elsevier Inc. All rights reserved.
1294 R.L. Gates, J. Shelton, K.A. Diefenbach et al. / Journal of Pediatric Surgery 57 (2022) 1293–1308
rate of long-term testicular retraction. One and two-stage Fowler-Stephens orchiopexy have similar rates
of testicular atrophy and retraction. There is a higher relative risk of testicular cancer in UDT which may
be lessened by pre-pubertal orchiopexy.
1. Introduction
Treatment of the undescended testis in children has evolved
over the last decade. Guidelines have been published by the Ameri-
can Urologic Association [1], the European Urologic Association [2],
and the Scandinavian Urologic Association [3], but these guidelines
do not include publications from the past 6 years. As pediatric sur-
geons evaluate and treat a large percentage of children with un-
descended testes in North America, this review seeks to provide a
comprehensive summary of recommendations that will allow pedi-
atric surgeons to develop and implement a consistent management
strategy based upon current literature.
2. Methods
2.1. Research questions
The APSA Outcomes and Evidence Based Practice (OEBP) com-
mittee vetted and selected the following questions a priori for this
systematic review. For children with undescended testes:
1. When is pre-operative imaging indicated and, if indicated,
which study is most appropriate?
2. What is the role of medical management of an undescended
testis?
3. What is the appropriate timing of intervention, and how is this
affected by associated clinical factors?
4. What is the evidence supporting choice of procedure?
5. What are the long-term outcomes after orchiopexy?
2.2. Search methods and data sources
The initial English language database search was conducted
with the assistance of a health librarian using the Medical Subject
Headings (MESH) terms “undescended testes/testis”, “undescended
testicle(s)”, “orchidopexy/orchiopexy”, “cryptorchidism”, “cryp-
torchid”, “intraabdominal testes/testis”, “nonpalpable/impalpable
testes/testis”, “pediatric”, “child”, “adolescent” with all publication
dates from January 2005 through June 2020. MEDLINE, Cochrane,
Embase Central, OVID, and National Guideline Clearinghouse
databases were queried. Inclusive and redundant clinical search
terms relevant to each question were applied to ensure complete-
ness of the literature search. Any additional articles identified from
the references of relevant articles were also included. The Pre-
ferred Reporting Items for Systematic reviews and Meta-analysis
(PRISMA) guidelines were followed [4]. The level of evidence was
assigned based on the Oxford Centre for Evidence-Based Medicine
(OCEBM) criteria (Table 1) [5,6].
Table 1
Grading classification scheme based on Oxford Center for Evidence.
Levels of Evidence
I. Randomized trial (N-of-1) or systematic review of randomized trials
II. Observational study or randomized trial
III. Non-randomized controlled cohort/follow up studies
IV. Case series, historically controlled studies or case control studies
V. Mechanism- based reasoning (expert opinion)
© 2022 Elsevier Inc. All rights reserved.
2.3. Study selection and data extraction
A list of 825 titles and/or abstracts was generated by the au-
tomated search, and these were reviewed independently by four
of the authors (JS, RG, MA, KD). Articles were excluded if they did
not address any of the study questions (Fig. 1). Single case reports,
reviews, expert opinions, and animal studies were also excluded.
The Oxford Centre for Evidence Based Medicine criteria guided
the recommendations generated for each question (Table 1). Pre-
existing consensus statements for relevant questions were identi-
fied through the search and incorporated into each individual sec-
tion for reference. Data compiled for each article included sample
size, description of the therapy or procedures performed, and out-
comes.
This review was not registered and a review protocol was not
prepared.
3. Results
3.1. Question 1: when is preoperative imaging indicated, and which
study is most appropriate?
A total of 32 studies were reviewed for this question. There
were 26 Level II or III studies appropriate for inclusion. Five
were prospective and 21 were retrospective [7–32]. Two consen-
sus guideline statements were identified [1,2]:
American Urological Association 2014 [1]
Providers should not perform ultrasound (US) or other imaging
modalities in the evaluation of boys with cryptorchidism prior to
referral, as these studies rarely assist in decision making.
European Association of Urology 2016 [2]
Use of Ultrasound or MRI is limited and only recommended in
specific and selected clinical scenarios.
Based upon the articles in this review, there is agreement that
no imaging should be performed prior to evaluation by the surgi-
cal specialist, however the consulting surgeon may decide to image
the child depending on clinical circumstance. When a primary care
provider orders imaging, it often does not contribute to decision-
making, is not cost-effective, and the results are frequently incon-
sistent with the physical examination findings by the pediatric sur-
geon or urologist. This step in management increases the time to
referral and delays definitive surgery [7-10,13,18,20,21,26,31,32]. A
Canadian database study in 2017 determined that before evalua-
tion by a pediatric surgeon or urologist, ultrasound (US) was used
in 33.5% of provincial referrals and 50% of institutional referrals
[19]. Definitive surgical management was delayed by about three
months in children who underwent US and the US correctly pre-
Grades of Recommendation
A – Consistent Level 1 studies
B – Consistent Level 2 or 3 studies or extrapolation from Level 1 studies
C – Level 4 studies or extrapolations from Level 2 or 3 studies
D – Level 5 evidence or inconsistent or inconclusive studies
 R.L. Gates, J. Shelton, K.A. Diefenbach et al. / Journal of Pediatric Surgery 57 (2022) 1293–1308
Fig. 1. Flow diagram showing study selection.
dicted physical examination findings in only 54% of patients. An-
other 2017 study found that pre-referral US findings disagreed with
pediatric urologic examination in 60% of patients. Specifically, 89%
of patients with a normal or retractile testis on physical examina-
tion had an US that reported an undescended testis in the inguinal
canal [13].
If a pediatric surgeon or urologist decides that imaging is indi-
cated, US is the most appropriate modality. Seven studies indicated
that US may be helpful for the surgeon in managing select patients
[14,15,18,22,23,25,31]. These select patients include those with a
non-palpable testis (unilateral or bilateral) in which location may
alter the operative approach or obviate the need for a diagnostic
laparoscopy [11,15,18,22,25]. The US may be valuable to evaluate
the comparative volume of the testes, predict viability, and assist
in discussions with the family. [14–16].
Cross-sectional imaging by CT or MRI is not required to local-
ize non-palpable testes and may lead to unnecessary exposures to
radiation and/or anesthesia. However, cross-sectional imaging may
1295
be considered when other associated urogenital anomalies are sus-
pected. [2,12,17,27,28,30]. One study noted a 5.6% incidence of ad-
ditional urogenital anomalies in boys with undescended testes that
could be further characterized using additional imaging [28], and
these included renal anomalies (2%), urethral duplications (3.2%),
posterior urethral valves, Prune belly syndrome (0.4%), and spina
bifida (0.4%).
The usefulness of MRI is inconclusive for the evaluation of non-
palpable testes. For testicular localization, MRI/MRA has an overall
accuracy of 62-67%; this accuracy increases to 92-97% with the ad-
dition of diffusion weighted imaging. However, if the testis is not
located by MRI, laparoscopy is still required to confirm the absent
testis, thus obviating the need for MRI [17,27,30]
1. Section summary and recommendations: When is preoper-
ative imaging indicated, and which study is most appropriate?
• Preoperative imaging should only be considered after physi-
cal evaluation by the consulting surgeon. US may be helpful
1296 R.L. Gates, J. Shelton, K.A. Diefenbach et al. / Journal of Pediatric Surgery 57 (2022) 1293–1308
in patients with a nonpalpable testis if the decision regard-
ing approach or the need for diagnostic laparoscopy will be
based on the results.
o Level II/III evidence, Grade C recommendation
Question 2: What is the role of medical management for an unde-
scended testis?
Out of a total of 18 studies initially reviewed to answer this
question, 12 were appropriate for inclusion (two Level I and ten
Level II or III studies) with six prospective and six retrospective
studies [33–44]. Three consensus guidelines were identified [1,2,3]:
American Urological Association 2014 [1]
Providers should not use hormonal therapy to induce testicular
descent as evidence shows low response rates and lack of evidence
for long-term efficacy.
European Association of Urology 2016 [2]
Endocrine treatment to achieve testicular descent is not recom-
mended.
Nordic consensus [3]
Hormonal treatment following orchiopexy has been proposed
to have beneficial effects on sperm count, but these findings need
confirmation by other groups before being incorporated into clini-
cal practice.
Hormonal therapy has been investigated as both a primary
therapy to induce descent and as an adjuvant to surgery to im-
prove fertility after orchiopexy. Results of hormonal therapy as pri-
mary management were discussed in three studies, and results var-
ied from 7% to 63% to induce successful testicular descent with
medical therapy alone [33,40,42,44]. In a prospective cohort study,
75 boys (mean age 1.6 years; 50 unilateral and 25 bilateral) were
treated pre-operatively for five weeks with hCG and followed for
6 months; only 7 testes descended, and these were palpated in a
high scrotal position after therapy [33]. It is difficult to compare
the results of these studies as the dose, treatment regimen, and
follow-up are different in each. An important observation regarding
the use of hormonal therapy found that side effects may be seri-
ous. One study evaluated 30 healthy boys treated with 5 weeks of
human chorionic gonadotropin (hCG) and found echocardiographic
evidence of increased left ventricular mass index in all patients (p
< 0.001) when compared to controls [42].
As an adjunct to surgical management, hormonal therapy was
discussed in eight studies [33,35-39,41,43]; its overall benefit is
unclear based on the results. Additional clinical information such
as imaging, endocrine evaluation, and biopsy were used to deter-
mine the appropriateness of adjuvant hormonal therapy. Studies
reviewed evaluated both pre- and post-operative use of hormonal
therapy. A small, randomized trial of patients compared the tes-
ticular atrophy index in post-orchiopexy patients with or with-
out hormonal therapy and demonstrated that hormonal therapy
decreased atrophy, but the impact on fertility was unclear [38].
The testicular atrophy index was calculated as: [(normative val-
ues of testicular volume from literature - affected testicular mean
volume) / normative values of testicular volume from literature]
X 100. A cross-sectional observational study in 77 boys treated
with hCG before surgery in childhood subsequently documented
sonographic testicular volume as well as serum levels of follicle-
stimulating hormone (FSH), luteinizing hormone (LH), and testos-
terone when they reached 18 years of age [37]. Scrotal descent
with hCG alone was 28.6% and the mean testicular volume was
11.8 mL, which was significantly higher (p=0.019) than the testic-
ular volume in patients who underwent orchiopexy after failure of
hormonal therapy (9.2 mL) and patients who underwent primary
surgery (8.6 mL). Hormone levels, however, were the same in all
groups. A retrospective review of 155 boys who underwent hor-
monal treatment, surgical treatment, or a combination of both, re-
ported that at the 9 to 12 months follow up, testicular volume was
higher following hCG therapy. In contrast, at the 24 to 39 months
follow up, there was no significant difference observed in percent-
age change in baseline testicular volume between groups [34].
While no study directly assessed ultimate fertility following
post-operative administration of hormonal therapy, multiple stud-
ies evaluated testicular mass, sperm production, and hormone
levels as surrogates. Thorup classified bilateral cryptorchid pa-
tients into three groups, (i) primary testicular failure, (ii) tran-
sient hypothalamus-pituitary-gonadal hypofunction, and (iii) nor-
mal endocrine and histopathologic evaluation [39]. They found that
those patients with hypothalamus-pituitary-gonadal hypofunction
may benefit from post-op adjuvant hormonal therapy. Another
small, randomized trial showed preoperative adjuvant hormonal
therapy improved the number of Type A dark (Ad) spermatogo-
nia per tubule based on biopsy performed at the time of or-
chiopexy, compared to patients with cryptorchidism without med-
ical therapy [41]. A small prospective trial of children with bi-
lateral undescended testes with no Ad spermatogonia on biopsy
at the time of surgery finding that those who received luteiniz-
ing hormone-releasing hormone (LH-RH) had a statistically signif-
icant increase in germ cells per tubule on a second biopsy com-
pared to the group that underwent surgery without hormonal ther-
apy [35]. In another trial, 45 patients with unilateral non-palpable
testis were randomized to hCG or no therapy administered after
one-stage Fowler-Stephens orchiopexy which showed that in 81%
of the treated group, the testicular size was comparable to the op-
posite descended testis, versus only 46% in the untreated group.
[36]. They also noted increased testicular vascularity in the treated
group. Finally, 30 patients with biopsy-proven impaired maturation
at the time of orchiopexy were randomized to receive either post-
operative hormonal therapy or no therapy. Post pubertal sperm
analysis showed all males in the untreated group were severely
oligospermic, with 20% demonstrating azoospermia as compared to
86% of the treated patients who had sperm counts in the normal
range [43]. They concluded that post-operative hormonal therapy
appeared to increase testicular mass and sperm production after
orchiopexy. The conclusion from these studies suggests that post-
operative hormone use may be beneficial in select populations,
however the studies are small and results are variable therefore
larger trials are needed in order to make convincing recommenda-
tions.
2. Section summary and recommendations: What is the role
of medical management for an undescended testis?
• There is no consistent evidence to support hormonal therapy
alone to manage an undescended testis.
o Level II evidence, Grade C recommendation
• Adjuvant hormonal therapy may improve sperm production in
patients undergoing orchiopexy however existing studies are
inconclusive for definitive recommendations.
o Level II evidence, Grade C recommendation
Question 3: What is the appropriate timing of intervention?
For this question, 82 studies were obtained from the initial
search, and 3 were added after further review. Although it is gener-
ally accepted that surgical correction of an undescended testis be
performed early, the recommended timing of the procedure dif-
fers among urologic associations and medical providers. Published
guidelines regarding timing of orchiopexy are as follows:
American Urological Association 2014 [1]
Under 18 months of age
European Association of Urology 2016 [2]
Treatment should be completed by 12 months or 18 months at
the latest
 R.L. Gates, J. Shelton, K.A. Diefenbach et al. / Journal of Pediatric Surgery 57 (2022) 1293–1308
Nordic consensus [3]
6-12 months
Despite these recommendations, there were 48 published stud-
ies that reported a majority of orchiopexies are done well out-
side of these age ranges. Reasons cited for non-adherence to es-
tablished guidelines include (i) a lack of knowledge in primary
care physicians [46,47,49,50,52,55,57,59,61-66,68-70,72-75,77,82-
84,86,88,89,91,92], (ii) children in lower socio-economic settings
with poor access to health care [67,85], (iii) children in ru-
ral areas where referral to subspecialty care is less available
[45,54,56,60,67,70,76,81,85], (iv) public insurance with poor health
care access [55,62,80,85], (v) children in whom testicular descent
was documented early in life but noted at a later age to have an
ascending testis [48,51,78,90,92], (vi) attempts at hormonal treat-
ment prior to surgical referral [44,71], and (vii) neurologically im-
paired children with less attention to testicular physical exam
[58,79,87]. Five studies demonstrated improved adherence to the
guidelines following intensive education to primary care providers
[48,53,59,61,83], while two studies showed no improvement in
early referral despite knowledge of the guidelines [84,86].
To answer the question regarding timing of orchiopexy, 23 stud-
ies were included in the final analysis. While three papers rep-
resented Level I evidence, these manuscripts were derived from
the same randomized controlled trial [93–95]. There were 8 other
prospective studies [96–103] and the remaining 12 were retrospec-
tive [16,104-114]. The two primary outcome measures evaluated
were testicular volume and testicular histology.
3.2. Orchiopexy timing and testicular volume
The relationship between the timing of orchiopexy and testic-
ular growth was assessed in 4 studies representing 3 distinct pa-
tient populations. In a prospective trial, 155 boys with a unilat-
eral, palpable undescended testis were randomized at 6 months of
age to undergo orchiopexy at either 9 months or 3 years [94,95].
Those who underwent orchiopexy at 9 months of age were more
likely to achieve testicular growth and size similar to their con-
tralateral side, compared to those who had orchiopexy at 3 years
of age. Similar findings were shown in a prospective cohort study
of 108 boys with unilateral, undescended testis [101] as well as in
a retrospective review of 134 boys, in which orchiopexy at <1 year
of age outperformed orchiopexy at 1-2 or > 2 years of age [105.]
Three retrospective studies suggested that initial testicular posi-
tion may be more important than age at orchiopexy. A single insti-
tution, retrospective review of 349 testes reported an overall 7.7%
incidence of testicular atrophy at 2 years, following orchiopexy at
any age and concluded that age at orchiopexy is not associated
with atrophy risk, when corrected for location [106]. A single sur-
geon retrospective review of 1400 orchiopexies over 35 years re-
ported that approximately 33% of inguinal and 67% of abdominal
testes were atrophic at the time of surgery and concluded that ini-
tial testis position noted at the time of surgery contributed signifi-
cantly to atrophy [107]. Another similar retrospective study of 182
boys who had undergone orchiopexy found that testicular atrophy
was higher when patients had a high primary location [104].
One study compared testicular volume in 129 boys with an un-
descended testis to 50 boys with normal descent but coinciden-
tal scrotal hydroceles [110]. The study found that testicular volume
was less in boys undergoing orchiopexy after 2 years of age com-
pared to orchiopexy under age 2 years; they also noted that av-
erage testicular volume in all children undergoing orchiopexy was
less than that in the hydrocele group, despite the age of repair. An-
other cross-sectional study of school-age children with a retractile
testis compared testicular volume of children who had undergone
orchiopexy (mean age 4.35 ±2.17 years at orchiopexy) and those
1297
who had never undergone orchiopexy [102]. They found that the
mean testicular volume for children with testes in normal loca-
tion was 2.47 mL, those undergoing orchiopexy was 2.35 mL and
those non-operated children with retractile testes was 1.82 mL. In
a retrospective study using ultrasound to follow 128 patients (184
testes), catch-up growth was seen to increase over time; specifi-
cally the testicular-volume was noted to increase compared to the
contralateral testis, and those operated on at an earlier age demon-
strated the most growth recovery [16].
A prospective study of 105 patients in the Netherlands looked
at testicular growth after pubertal orchiopexy [100]. They found
that the ultrasound- and orchidometer-assessed volume of unilat-
eral undescended testis (10.5 mL) was comparable with that of bi-
lateral undescended testes (9.5 mL); however, volume was lower
compared to the contralateral normally descended testis (14.1 mL).
A retrospective study of 155 boys (181 testes) who underwent or-
chiopexy at a median age of 7.7 years and an US at a median age
of 14.4 years demonstrated that the testicular volumes of all testes
fixed by orchiopexy were significantly smaller than normal val-
ues for age, and smaller than their counterparts in unilateral cases
[108].
Cryptorchid testes have also been noted to have morphologic
abnormalities including diffuse hypoechoic lesions within the tes-
ticular architecture, microlithiasis, and irregular surface. A retro-
spective study of 23 consecutive patients with unilateral unde-
scended testes who underwent orchiopexy were evaluated at 5
years postoperatively with scrotal ultrasound [111]. When compar-
ing mean testicular volume ratio (previously UDT to contralateral
unaffected testis), there was no difference between those who had
surgery under 2 years of age (mean age 1.4 years) and those who
had surgery at greater than 2 years of age (mean age 2.8 years).
However, the incidence of morphological abnormalities was lower
in the younger group (25.0% vs 83.3%; p = 0.05). Of note, no mor-
phologic abnormalities were seen in the contralateral testis, which
is consistent with a previous study [16].
3.3. Orchiopexy timing and testicular histology
In three prospective studies and one retrospective study, older
age at orchiopexy correlated with diminished germ cell develop-
ment. In one study, 228 testicular biopsies were obtained from 225
boys [93]; those who had been randomized to undergo orchiopexy
at 9 months of age had significantly larger numbers of germ cells
and Sertoli cells, a greater diameter of seminiferous cords and a
higher ratio of tubular to interstitial tissue than those whose or-
chiopexy had been randomized to orchiopexy at 3 years. In a study
where orchiopexy was performed from 5 months to 24.5 months
of age, the percentage of tubules with germ cells seen on histology
was significantly decreased with increasing age at orchiopexy [99].
In addition, the number of tubular cross-sections containing no
germ cells significantly increased with older age at orchiopexy. In a
prospective case-control study of 65 consecutive children with pal-
pable, unilateral UDT who underwent orchiopexy, increased age at
orchiopexy was associated with a reduction in the number of germ
cells and an increase in interstitial fibrosis [103]. Furthermore, in
patients who had undergone orchiopexy before their first birthday,
histologic parameters (mean tubular fertility index [MTFI], germ
cell count/tubules [GCC]) of the undescended testis were signifi-
cantly higher than those who underwent orchiopexy later. Finally,
compared to the controls, cryptorchid testes showed decreasing
MTFI and GCC values over time.
Several studies used serum markers to evaluate testicular func-
tion. A prospective group of 50 boys who underwent unilateral
inguinal orchiopexy at age 7 months to 2.5 years were noted to
exhibit an increase in serum inhibin-B after surgery, which may
reflect an improvement of the histological state of seminiferous
1298 R.L. Gates, J. Shelton, K.A. Diefenbach et al. / Journal of Pediatric Surgery 57 (2022) 1293–1308
tubules of the undescended testis after surgery [98]. They also
found that early orchiopexy had a beneficial effect on gonadotropin
levels. Another group evaluated 402 testicular biopsies from 33
boys with congenital (non-syndromic) cryptorchidism and found
that low serum inhibin-B correlated with low GCC as well as low
Ad spermatogonia per tubule (AdST); 25% of boys had reduced GCC
and 28% had reduced AdST [97]. They concluded that orchiopexy
prior to 9 months of age improved GCC and AdST. A study of testic-
ular biopsies of 274 children found a 2% risk per month of severe
germ cell loss and a 1% risk per month of Leydig cell depletion
for each month the testis remained undescended [109]. They also
noted more severe germ cell depletion with nonpalpable testes.
Another group performed testicular biopsies in 40 cryptorchid boys
undergoing orchiopexy at ages 4 to 36 months [96] and deter-
mined that GCC and AdST both decreased with increasing age (be-
tween 8-12 months) at time of orchiopexy (P < 0.0 0 01, P=0.0 085
respectively).
3.4. Orchiopexy and abdominal wall defects
Three retrospective case series considered the timing of or-
chiopexy in a population of boys with gastroschisis. Among 7
boys with cryptorchidism in the setting of either gastroschisis or
a congenital diaphragmatic hernia, spontaneous descent occurred
in only 1 of 9 undescended testes (11%), 2 underwent primary or-
chiopexy, and the remaining 4 required orchiectomies due to tes-
ticular atrophy [112]. Another study reported that 26 of 79 chil-
dren (33.0%) with gastroschisis, and 6 of 27 children (22.2%) with
omphalocele, had cryptorchidism [113]. Of the children with gas-
troschisis, 18 of 35 testes descended spontaneously, 2 required or-
chiectomy, and one had absent bilateral testes at exploration. Of
the children with omphalocele, only 1 of the 11 descended spon-
taneously. Finally, in 23 children (31 testes) with gastroschisis and
cryptorchidism who were given 10-12 months before considering
surgery, spontaneous descent occurred in 17 testes, 12 required or-
chiopexy (mean age 16.5 months), and 2 underwent orchiectomy
for testicular atrophy at surgery [114].
3. Section summary and recommendations: What is the ap-
propriate timing of intervention?
• Testicular growth is improved when orchiopexy is done be-
tween 6 months and 2 years of age but preferably prior to one
year of age. Germ cell number per tubule and other markers
of histologic normalcy are optimized when orchiopexy is done
early, although these children still remain at risk for infertility.
◦ Level II evidence, Grade B recommendation
• Morphologic changes in the cryptorchid testis may be pre-
vented by orchiopexy prior to one year of age.
◦ Level III evidence, Grade B recommendation.
• In children with abdominal wall defects, orchiopexy may be de-
layed up to 12 months as there is potential for spontaneous tes-
ticular descent in the first year.
◦ Level III evidence, Grade C recommendation
Question 4: What is the best type of operation?
For palpable testes, operations include open inguinal versus
single scrotal incision orchiopexy (SSIO); for non-palpable testes,
they include primary laparoscopy versus open inguinal, and laparo-
scopic Fowler-Stephens versus primary laparoscopy. Two related
questions were also addressed: Should a patent processus vaginalis
be closed at the time of orchiopexy? If no testis is found at the
time of exploration, should the nubbin be resected?
For these questions, there were 168 studies obtained from the
initial search and 18 were added after further review; 130 total
studies were found to be suitable for inclusion [18,115–224 Pub-
lished guidelines regarding choice of operation are as follows:
3.5. Choice of operation for an inguinal testis
American Urological Association 2014 [1]
Standard two incision (inguinal, scrotal) and single scrotal inci-
sion orchiopexy are both recommended.
European Association of Urology 2016 [2]
Standard two incision (inguinal, scrotal) and single scrotal inci-
sion orchiopexy are both recommended.
Nordic consensus [3]
Standard two incision (inguinal, scrotal) and single scrotal inci-
sion orchiopexy are both recommended.
3.6. Choice of operation for a non-palpable testis
American Urological Association 2014 [1]
Perform examination under anesthesia to reassess for palpabil-
ity of the testis. If nonpalpable, surgical exploration (open or la-
paroscopy) and, if indicated, abdominal orchiopexy should be per-
formed.
European Association of Urology 2016 [2]
Thorough re-examination under anesthesia; the easiest and
most accurate way to locate an intra-abdominal testis is diagnostic
laparoscopy.
Nordic consensus 2007 [3]
Diagnostic laparoscopy through an umbilical port to determine
surgical approach. The operative procedure is chosen according to
pathoanatomical findings related to the testis and vessels, and to
the surgeon’s preference.
3.7. Choice between one or two stage fowler-stephens orchiopexy
American Urological Association 2014 [1]
The decision to perform a one-stage or two-stage Fowler-
Stephens orchiopexy is left to the discretion of the surgeon based
on the location of the testis, associated vascular supply to the
testis, and the anatomy of the peritesticular structures.
European Association of Urology 2016 [2]
The two-stage approach may result in less testicular atrophy
and better testicular mobility.
3.8. Palpable inguinal testis
For the testis palpated within the inguinal canal, the predomi-
nant surgical approaches are the two-incision inguinal orchiopexy
and the single scrotal incision orchiopexy (SSIO) [237]. In order to
effectively evaluate the results of the large number of studies for
this topic, this systematic review combined the total number of or-
chiopexies reported from each of the reviewed studies [107,115,117,
120,122,124,126,133,135,139.145,146,149,152,155,159,161–163,165,
168,186–189,191–193,197–199,202,214,219,221,222,227,233]; a to-
tal of 857 inguinal orchiopexies and 2431 SSIO were performed.
The mean follow-up for inguinal orchiopexy was 18 months (range
6 to 60 months) and for SSIO, mean follow-up was 12 months
(range 6 to 46 months). Overall atrophy rates and retraction rates
were compared between the two procedures with 95% confidence
intervals to determine the superiority of one procedure over
another. The rate of post-operative testicular retraction was found
to be equivalent with both techniques; however, atrophy rate was
significantly lower in the SSIO approach (Fig. 2). SSIO is usually
more feasible when the testis is lower and the cord has more
length. As such, two small prospective randomized clinical trials
compared the two surgical procedures and suggested no statistical
difference in rates of atrophy or retraction (122,165). To evaluate
the difference in testicular function, one study measured postop-
erative inhibin B levels and found no difference between surgical
approaches [238]. In addition, five studies (Table 2) compared the
 R.L. Gates, J. Shelton, K.A. Diefenbach et al. / Journal of Pediatric Surgery 57 (2022) 1293–1308 1299

Fig. 2. Risk of Testicular Atrophy and Testicular Retraction in Open Inguinal Orchiopexy vs. SSIO (Single scrotal incision orchiopexy) Collective data for 35 open inguinal
orchiopexy (7 prospective and 28 retrospective) and 23 (2 prospective and 21 retrospective) SSIO studies.

Table 2
Length of Operation: Open Inguinal Orchiopexy vs. SSIO (Single scrotal incision orchiopexy).

Study N SSIO time (minutes) Inguinal time (minutes) p

Nazem 100 30 71 <0.001

Neheman 259 25 40 <0.05
Eltayeb (prospective) 35 18 25 <0.001
Takahashi (retrospective) 49 47 67 <0.0001
Al-Mandil (retrospective) 56 34 64 0.002

operative time, and all demonstrated that SSIO was faster than
the inguinal approach [122,124,165,214,219]. To determine the use
of SSIO, a study surveyed 163 pediatric surgeons and pediatric
urologists and found that only 52.8% use SSIO and that pediatric
urologists prefer SSIO [127].
3.9. Non-palpable testis
Studies were combined to aggregate the data
for a non-palpable testis [107,116,117,125,129,134,137-
139,141,143,144,147-149,156,158,162,164,166,169,172-
176,178,179,183,185,186,188,190,191,200,205-210,216-
218,220,221,223,224,226,229,233,235]. An open inguinal approach
for an abdominal testis was performed for 313 orchiopexies
and primary laparoscopic procedures were performed for 1434
orchiopexies; differing atrophy and retraction rates were noted
(Fig. 3). Open inguinal approach demonstrated lower testicular
atrophy and lower rate of retraction than primary laparoscopy.
There were two studies that found that age was an independent
risk factor for retraction [173,239]. Sfoungaris [181] evaluated the
addition of the Prentiss maneuver (ligation of the inferior epigas-
tric vessels to redirect the course of the testis into the scrotum)
and at mean follow up of 14 months the overall retraction rate
was 28%. Children undergoing orchiopexy under 19 months of
age (n=14) had no retraction, those age 19 to 36 months (n=18)
had retraction rate of 11%, and in children age 36-59 months
(n=18) the retraction rate was 22%. A retrospective review of 418
orchiopexies found that the mean age at surgery for boys with
failed orchiopexy was 28 months, compared to boys with suc-
cessful orchiopexy who had a mean age at surgery of 45 months,
and concluded that the difficulty of the procedure at a younger
age could result in a lower success rate, thus requiring a second
procedure, but that the importance of germ cell development
outweighed this risk [240].
Traditional teaching suggests that the success of orchiopexy for
an abdominal testis may be determined by the ability of the mobi-
lized testis to reach the opposite internal ring. However, one group
reported that distance from the contralateral internal ring, or the
ability of the testis to reach the contralateral internal ring, did not
consistently predict the incidence of long-term retraction [226].
Shehata described a laparoscopic two-stage traction technique: the
abdominal testis was temporarily fixed to the contralateral abdom-
inal wall, while maintaining the testicular blood supply [151]. Af-
ter 12 weeks, allowing for blood supply to develop and lengthen,
laparoscopy was again performed to detach the testis from the ab-
dominal wall, and bring it down into the scrotum through the ip-
silateral inguinal ring. This technique was used in 124 boys (140
units) and the study had a mean follow-up of 16 months (6 to 26
months) and reported scrotal testes in 105 cases with a success
rate of 84%, defined as less than 25% testicular volume loss and
the ability to place the testis in the lower scrotum. These results
have been validated in two subsequent studies [123,130].
3.10. Fowler-stephens orchiopexy (one- and two-stage)
A total of 53 studies were reviewed and aggregated
to evaluate one- vs two-stage Fowler-Stephens orchiopexy
[107,118,119,121,125,129,131,132,134,135,140,141,143,144,147,149,
152,156,158,160,164,166,167,169,170,171,172,174,176,178,180,183,
184,188,190,200,201,203,204,207,208,210,211,217,221,223,226,
229,230,231,233,234,236]. Combined, there were 147 one-stage
Fowler-Stephens orchiopexies and 1465 two-stage Fowler-Stephens
orchiopexies (Fig. 4). Atrophy and retraction rates were similar for
both approaches. Two prospective, randomized trials compared
the one-stage and two-stage approaches and found no significant
difference in percentage of atrophy or mean postop testicular
volume [132,156]. Two prospective and one retrospective study
described the gubernaculum-sparing technique for the second
stage of the Fowler-Stephens procedure and noted a decreased
1300 R.L. Gates, J. Shelton, K.A. Diefenbach et al. / Journal of Pediatric Surgery 57 (2022) 1293–1308

Fig. 3. Abdominal Testis: Open Inguinal Orchiopexy vs. Primary Laparoscopic Orchiopexy. Collective data for 35 open inguinal orchiopexy (7 prospective and 28 retrospective)
and 46 (6 prospective and 40 retrospective) Primary laparoscopic orchiopexy studies.

Fig. 4. Fowler Stephens Orchiopexy: One-stage vs. Two-stage. Collective data for 21 One-Stage (1 prospective and 20 retrospective) and 47 (9 prospective and 38 retrospec-
tive) Two-Stage studies.

atrophy rate when the gubernaculum was spared [118,125,184]. [143,146,148,155,163,165,175,178,179,182,184,194,199,218,220,228].

A comparison of primary laparoscopic orchiopexy and Fowler-
Stephens orchiopexy (combined one- or two-stage) is summarized
in Fig. 5. Both atrophy and retraction are decreased with the
primary laparoscopic approach.
3.11. Specialty training
There were a total of 1677 orchiopexies with a median follow-up
of 18.75 months, and no hernias were reported when the patent
processes vaginalis was not specifically closed at time of or-
chiopexy. One study reported an increased incidence of testicular
retraction when the patent processes was closed routinely in the
absence of an obvious hernia (4.3% versus 1.7%, P = 0.42) [163].

Specialty training also apparently influences the recurrence
rate. In an Australian 20-year, retrospective review, 3.4% of 25,984
orchiopexies required revision [63]. It documented that, despite a
15% increase in population, the rate of redo orchiopexy decreased
from 15.2% during 1995-1999 to 9.3% during 2010-2014. The au-
thors surmise this may be related to the increase in specialty-
trained pediatric surgeons, increased referral to pediatric surgery
centers, and decreased age at the time of initial surgical interven-
tion.
3.13. Scrotal fixation of the testis
In a randomized study from Iran, two surgical techniques com-
pared testis fixation with or without suture to the Dartos pouch.
Based upon pre- and post-operative ultrasound evaluation, they re-
ported no change in testicular volume between the two techniques
[241].
3.14. Timing of surgery with hernia repair

3.12. Should a patent processus vaginalis be closed at the time of
orchiopexy?
The decision to close a patent processus vaginalis if
no obvious hernia is present was evaluated in 16 studies
A single retrospective study investigated the timing of or-
chiopexy in boys with an ipsilateral inguinal hernia: 41 boys with
43 concurrent ipsilateral inguinal hernias and undescended testes
underwent surgical intervention, all before 6 months of age [265].
About 25% of the hernias were deemed symptomatic, requiring ur-
 R.L. Gates, J. Shelton, K.A. Diefenbach et al. / Journal of Pediatric Surgery 57 (2022) 1293–1308
Fig. 5. Laparoscopic Orchiopexy vs. Fowler-Stephens Orchiopexy. Collective data for 46 Primary laparoscopic orchiopexy (6 prospective and 40 retrospective) and 68 (10
prospective and 58 retrospective) Fowler-Stephens Collective data for 46 Primary laparoscopic orchiopexy (6 prospective and 40 retrospective) and 68 (10 prospective and 58
retrospective) Fowler-Stephens studies.
gent or emergent repair. Two-thirds of these boys underwent open
hernia repair with standard orchiopexy, while the remainder had a
hernia repair only with the plan for a future orchiopexy. Of those
who did not undergo orchiopexy at the time of hernia repair, 67%
of these did not descend and required orchiopexy. The overall tes-
ticular atrophy rate was 18% in both groups following orchiopexy
and was higher when the hernia was difficult to reduce (25%) or
unreducible (33%). When orchiopexy was performed at the time of
hernia repair, the retraction rate was 3%, requiring redo orchiopexy.
They concluded that orchiopexy in boys undergoing hernia repair
under age 3 months is feasible and likely does not statistically in-
crease the atrophy rate.
3.15. If no testis is found at the time of exploration, should the
atrophic testis (“nubbin”) be resected?
Often when exploration is performed, no testis is found,
but only a residual nubbin is identified. The question of-
ten arises whether to resect it or to leave it in place.
This is an important consideration as when abnormal tis-
sue is left in place, it may be functional and thus may be
at risk for malignant transformation. There were 15 stud-
ies that reviewed the pathology of the resected nubbin
[136,144,149,152,157,166,172,177,178,195,200,212,213,225,232].
The results of these studies were aggregated. A total of 329
units were evaluated, and 25.4% had calcifications, 23.5% had
hemosiderin deposits, and 6.7% had residual seminiferous tubules.
This correlates with a systematic review that included articles
published between 1980 and 2016. It confirmed that germ cells
may be found in up to 5.3%, and seminiferous tubules in 10.7% of
nubbins [242].
4. Section summary and recommendations: What is the best
type of operation?
• For a palpable inguinal testis, a single scrotal incision or-
chiopexy is likely associated with lower incidence of atrophy
and has a similar incidence of retraction.
◦ Level II evidence, grade C recommendation
• Single scrotal incisional orchiopexy is associated with shorter
operative time when compared to an open inguinal approach.
◦ Level II evidence, Grade B recommendation
• For an abdominal testis, laparoscopic orchiopexy is associated
with a slightly higher rate of testicular atrophy and a higher
rate of long-term retraction, compared to open inguinal ap-
1301
proach. Older patient age is associated with a higher rate of
testicular retraction when the testis is in the abdomen. The
Shehata technique may also be considered as an option since
several studies have validated its safety and efficacy with the
added benefit of testicular vessel preservation.
◦ Level II evidence, Grade B recommendation
• Both one-stage and two-stage Fowler-Stephens procedures have
similar rates of retraction and one-stage procedures likely have
a higher rate of testicular atrophy. A gubernaculum-sparing
technique for the second stage results in a decreased testicu-
lar atrophy rate.
◦ Level II/III evidence, Grade B recommendation
• In the absence of an obvious hernia, routine closure of a patent
processus vaginalis during orchiopexy is not indicated as symp-
tomatic hernias do not usually develop and also there are con-
cerns that this additional procedure may lead to increased inci-
dence of testicular retraction.
◦ Level II evidence, Grade B recommendation
• For concomitant UDT and inguinal hernia, orchiopexy should be
performed at the time of inguinal hernia repair because it is
safe, does not lead to increased testicular atrophy when per-
formed in infants, and future descent rate is low.
◦ Level IV evidence, Grade C recommendation
• During inguinal exploration for a non-palpable testis, an at-
rophic testis (nubbin) should be resected if found because it
may contain functional tissue and have potential for malignant
transformation.
◦ Level II evidence, Grade B recommendation
Question 5: What are the long-term outcomes after orchiopexy?
Recurrence rates and testicular atrophy have been addressed in
question 4 relative to the type of surgery performed. Testicular
function in terms of hormone and sperm production based upon
the timing of orchiopexy has been addressed in question 2. This
section, therefore, reviews the effects of orchiopexy on fertility and
the risk of testicular cancer associated with cryptorchidism. Pub-
lished guidelines regarding fertility and testicular cancer are as fol-
lows:
3.16. Effect of cryptorchidism on fertility
American Urological Association 2014 [1]
1302 R.L. Gates, J. Shelton, K.A. Diefenbach et al. / Journal of Pediatric Surgery 57 (2022) 1293–1308

Based upon testicular biopsy, for bilateral undescended testes, opment was the reason for the lower SRR in the bilateral group
infertility may be as high as 75-100%. For a unilateral undescended [253].
testis, infertility was approximately 33% Another study of 42 men found no significant differences in tes-
ticular volume, LSH, FH, testosterone concentration or sperm ex-
European Association of Urology 2016 [2]
traction between men who underwent orchiopexy before 10 years
Regarding preservation of fertility potential, early surgical cor-
of age and those who underwent orchiopexy after 10 years of age
rection of undescended testes is highly recommended before 12
[250]. However, those who had undergone orchiopexy prior to 10
months of age, and by 18 months at the latest.
years of age were able to achieve three live births in 13 attempted
From the initial search, 56 studies were obtained, and 13 stud-
pregnancies (23.1%), while those who had undergone orchiopexy
ies added after further review. Eleven studies were found suitable
after 10 years of age achieved four live births in 12 attempted
for review regarding the influence of cryptorchidism on fertility. In
pregnancies (33.3%; p=0.57).
a study of 357 men with undescended testes who underwent or-
No statistically significant difference was found in fertility be-
chiopexy there was noted to be a lower bi-testicular volume and
tween scrotal fixation of the testis or a “no-touch” approach [252].
sperm count than 709 controls, and they suggested that this was
perhaps due to impaired Leydig cell function [251]. In an evalu- 3.17. Risk of testicular cancer
ation of 51 men, ages 18-26 years, who had a unilateral or bi-
lateral orchiopexy in the first or second year of life, the authors American Urological Association 2014 [1]
found that total sperm count and motility were higher in those Orchiopexy performed before puberty decreases the risk of
men who had undergone operation before the age of one and that testicular cancer compared to those boys with cryptorchidism
there was no effect of pre-op hormonal therapy, position of the who undergo orchiopexy after puberty. The previously cryptorchid
testes, or bilaterality [243]. A Swiss cohort study compared semen boy should be taught how to perform a monthly testicular self-
analysis to testicular biopsy at the time of surgery and found that examination after puberty to potentially facilitate early cancer de-
boys with cryptorchidism who lacked Ad spermatogonia will de- tection.
velop infertility despite successful orchiopexy in childhood [244].
The results of this study were confirmed by a retrospective Lithua- European Association of Urology 2016 [2]
nian study that also found that Ad spermatogonia are essential for Early surgical intervention is indicated in boys with an unde-
fertility regardless of orchiopexy [245]. In contrast, in a prospec- scended testis and pre-pubertal orchiopexy may reduce the risk of
tive study of 85 men who had both testes biopsied at birth and testicular cancer.
underwent unilateral or bilateral orchiopexy (mean age 7.0 +/- 3.8
Nordic Consensus 2007 [3]
years and 8.3 +/- 3.2 years respectively), there were no statistically
Orchiopexy before two years of age may decrease the risk of
significant differences in semen volume, sperm density, or sperm
testicular cancer. Parents should be informed that the patient has
count when compared with normal controls [246]. They suggested
an elevated risk of testicular cancer after puberty.
that while significant differences in Ad spermatogonia count per
The risk of testicular cancer was evaluated in 21 studies, and
tubule may be found at orchiopexy, fertility potential, as defined
11 were chosen for this analysis. A retrospective, population-based
by future semen analysis and hormone results, may not be com-
study was conducted, identifying 56 cases of testicular cancer
promised in many cases. In addition, another study followed 65
among 16,983 Swedish men who had undergone orchiopexy be-
men over a 24-year period, comparing orchiopexy in both unilat-
tween 1964 and 1999 [254] at a mean age of 8.6±3.5 years (only
eral and bilateral undescended testes (median age at orchiopexy
4.2% underwent orchiopexy prior to two years of age). Compared
of 13.1 years) with normal controls [247]. They found that the 50
to the general Swedish population, the relative risk (RR) of testic-
men with unilateral UDT had smaller testicular volume compared
ular cancer was 2.23 (95% CI 1.58 – 3.06) among those who un-
to controls, however, endocrine function (LH, FSH, Inhibin B pro-
derwent orchiopexy before 13 years of age, and was 5.40 (95% CI
duction), sperm count and motility, and paternity studies were not
3.20 – 8.53) for those who underwent orchiopexy after 13 years
statistically different from controls. The 15 men with bilateral un-
of age. A within-cohort analysis of the effect of age at orchiopexy
descended testes had higher LH and FSH production with lower
on the risk of testicular cancer demonstrated that those treated
inhibin B, lower semen concentration and motility, and only 25%
at older ages had a higher risk of developing testicular cancer. A
had successful fatherhood compared to 86% in the control group.
subsequent analysis of the data from this study was performed to
An additional study of 68 men with prior orchiopexy found that
quantify how many patients must undergo orchiopexy to truly in-
those with bilateral orchiopexy had significantly decreased sperm
fluence testicular cancer outcomes, specifically for the purposes of
concentration, motility, and inhibin B levels in comparison to those
preoperative counseling [255]. They concluded that there is evi-
with unilateral orchiopexy [248]. They also noted that men who
dence supporting early orchiopexy in the prevention of testicular
had orchiopexy prior to age 8 had significantly increased inhibin
cancer and restoration of fertility, but the true impact that this
B levels and decreased FSH compared to subjects operated on at a
early intervention has specifically on testicular cancer outcomes is
later age.
low. Therefore, when counseling families in whom fertility preser-
Three retrospective studies assessed sperm count or sperm ex-
vation is not a central concern, delayed orchiopexy may have min-
traction in adulthood among those who had undergone orchiopexy
imal impact on later development of testicular cancer.
as children. The first study found that those undergoing orchiopexy
Testicular microlithiasis (TM) is more prevalent in boys with
in the first year of life were more likely to have a higher to-
history of cryptorchidism [256–258]. However, TM alone has not
tal sperm count and a greater number of mobile spermatozoa,
been shown to conclusively be a predictor of future testicular can-
compared to those who underwent orchiopexy in the second
cer [259–261]. Two studies evaluated children with cryptorchidism
year of life [249]. They concluded that age at surgery was in-
with microtubular damage from degenerating cells in the seminif-
versely related to the number of sperm cells and to the percent-
erous tubules, which has been associated with a higher rate of
age of highly mobile spermatozoa. A second study found a uni-
testicular germ cell tumor and precursor carcinoma. One group
lateral undescended testis was significantly more likely to be as-
[262] followed 2957 patients with scrotal ultrasound and found
sociated with a high sperm retrieval rate (SRR) compared to bi-
137 with TM, 8 of whom developed testicular cancer; two had had
lateral undescended testes (67.8% vs 35.2%, P = 0.031) [253] and
a history of cryptorchidism and two had testicular atrophy. In an-
suggested that the histologic outcome of the testis during devel-
other study [263], ultrasounds were performed on 3370 patients,
 R.L. Gates, J. Shelton, K.A. Diefenbach et al. / Journal of Pediatric Surgery 57 (2022) 1293–1308
and 83 with TM were identified; 20 of these later developed testic-
ular tumors. They noted that there was an increased prevalence of
preexisting conditions (Peutz-Jeghers, McCune-Albright, and Kline-
felter syndromes) in patients with TM and tumors compared with
patients with TM and no tumors (4 of 5versus 4 of 34, respectively;
P = .0039). There was no significant change when evaluated only
for cryptorchidism (1 of 5 versus 1 of 34, P = 0.52). Based upon
these studies, it is suggested that patients with documented ul-
trasound findings of testicular microlithiasis should be monitored
more closely for testicular cancer only if they have a history of
an undescended testis. Finally, an evaluation of histologic sections
of 1521 consecutive testicular biopsies in boys, aged one month
to 16.5 years, found persistence of undifferentiated spermatogonia
stem cells [264], which are sensitive to long-lasting high tempera-
tures, predisposing them to accumulation of mutations, which may
be prevented by early orchiopexy .
5. Section summary and recommendations: What are the
long-term outcomes after orchiopexy?
• Improved sperm counts are seen when orchiopexy is performed
at a younger age. To improve fertility, it is suggested that or-
chiopexy should be performed between the ages of 6 and 12
months . However, patients and families should be counseled
that successful orchiopexy may not mitigate infertility in all pa-
tients.
◦ Level I -III evidence, Grade B recommendation
• The risk of testicular cancer in cryptorchidism is higher than in
the general population and can be reduced by prepubertal or-
chiopexy, but not to the level of normal controls. Children with
a history of cryptorchidism and ultrasound findings of testicular
microlithiasis have an increased incidence of testicular tumors.
◦ Level III Evidence, Grade B Recommendation
3.18. Summary and conclusions
This systematic review was performed to answer five clinical
questions relevant to the care of patients with an undescended
testis. Based upon recent studies, it provides additional information
to previously established guidelines. Imaging is not recommended
for all patients but may be helpful when ordered after surgical
specialist evaluation to determine the operative approach or the
need for a diagnostic laparoscopy. Adjuvant hormonal therapy may
improve fertility in select patients undergoing orchiopexy, specif-
ically in those patients with endocrine hypofunction or biopsy-
proven impaired testicular maturation. Testicular growth is im-
proved when orchiopexy is performed before one year of age. For
a palpable testis, SSIO is associated with shorter operative times
and a lower incidence of atrophy. For a non-palpable testis, la-
paroscopic orchiopexy for the abdominal testis is associated with a
slightly higher testicular atrophy rate and has a higher rate of long-
term retraction when compared to the open approach. One and
two-stage Fowler-Stephens orchiopexy have similar rates of testic-
ular retraction but the one-stage procedure has higher incidence
of testicular atrophy. Orchiopexy should be performed between the
ages of 6 and 12 months to improve fertility. Testicular cancer has
a higher relative risk in those with a history of undescended testis,
which may be reduced by orchiopexy before puberty.
3.19. Glossary of terms
Ad Spermatogonia: Type A (dark cells) that represent the stem
cells for later spermatogenesis. They are derived from neonatal
gonocytes during the first 4-12 months of life. Development de-
pends on environmental conditions within the testis, which has a
lower core temperature when in the scrotum (33°C versus 37°C).
hCG: human chorionic gonadotropin. A primary hormonal ther-
apeutic agent used in the treatment of cryptorchidism. This acts
1303
like a luteinizing hormone to stimulate Leydig cells in the testis to
produce testosterone, which has been suggested to affect the sec-
ond phase of inguinal-scrotal descent.
LH: Luteinizing hormone. Produced by the pituitary gland. High
levels suggest low testosterone production by testes.
FSH: Follicle stimulating hormone. Produced by the pituitary
gland. High levels suggest low testosterone production by testes.
LH-RH: Luteinizing hormone releasing hormone. Also known as
GnRH (gonadotropin-releasing hormone). Produced by hypothala-
mus and stimulates the pituitary to release LH and FSH. Also used
as hormonal therapy to stimulate testicular descent.
Inhibin B: Produced by Sertoli cells and is a marker of sper-
matogenesis.
Fowler-Stephens Orchiopexy: The technique of ligating the tes-
ticular vessels and then allowing blood supply to the testes to de-
velop through the artery of the vas deferens and the gubernacular
or cremasteric vessels. Traditionally described as a two-stage pro-
cedure where the orchiopexy is performed in a separate operation
3-6 months after the initial vessel ligation. May also be performed
as a one-stage procedure where the orchiopexy is performed in the
same setting.
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