Cryptorchidism

What is cryptorchidism?

Cryptorchidism is a common congenital defect, where one of the testicles has not descended to his natural location in the testicular sack. This phenomena is known as undescended testis or cryptorchidism (Crypto = hidden, concealed in Greek). The surgical procedure of fixating the testicle in the testicular sack is called Orchiopexy.

What is the prevalence of cryptorchidism in children?

The prevalence in full term babies (more than 37 gestational weeks), is about 1-2%. The prevalence in the preterm population is much higher and rise up to 30%. You can usually identify the defect right after birth.
Usually it is just one testis, in less common cases – both testicles. Prevalence of bilateral undescended testicles can be up to 30% off all cases.
In 80% of all cases, you can feel the undescended testis in the inguinal canal (the groin area), and that way insure that the testis does exist. In the remaining 20% there is a question whether the testis is in the abdominal cavity or if it actually developed in the first place. This special situation requires an exploratory procedure of diagnostic laparoscopy.

What is the difference between undescended testis and a mobile testis?

During the pregnancy the testicles are developing in the abdominal cavity, and by the end of the seventh month, they travel to the inguinal area and settles in the testicular sack. This “relocation” is led by an anatomic structure known as “Gobernaculum Testis”. It leads the testes descend into the scrotum and anchors them to the testicular sack. In the case of an undescended testis, it finds its anchor in the groin area, and in the less common case – will stay in the abdominal cavity.
Another situation is when this migration process occurs, but the muscle that connects the testicle to the abdominal wall muscles (called the Cremasteric muscle), has a high contractility than usual, therefore the testicle will be mobile (or retractable). He will be in the groin when the Cremasteric muscle is relaxed (during sleeping hours for example), and then, as opposed to undescended testis, he will descend to the scrotum independently. Mobile testis is a normal testis (unlike undescended testis).

What to do when diagnosing cryptorchidism after birth?

Some of the undescended testis can complete the migration process into the testicular sack along the first 6 months of life. It will happen in about 50% of palpable testis in the groin area which stopped in the middle of the normal migration to the testicular sack. In these cases there is room for observation, and if there is no progress, then a decision about an operation must be made. The operation should be planed as of 6 months of age, in full term babies.
In cases of an undescended testis that went sideways and is not along the natural path of migration (the base of the hip, near the testicular sack or on the abdominal wall), the testis will not complete the migration in the first 6 months of life. This kind of cryptorchidism, also known as ectopic testis, will always require a surgical intervention.
In some cases of cryptorchidism, a diagnosis of inguinal hernia can be made along with cryptorchidism. This type of cryptorchidism is also in need of surgery.

Why is there a need to treat undescended testicle?

There are at least 6 very good reasons to operate on cryptorchidism:
1) The testicle can be simulated to a factory manufacturing testosterone and semen. This factory requires special conditions. The testicle needs a lower temperature than that of the body, and a bit of mobility. These two conditions are available at the scrotum so it is important to fix the testicle to the testicular sack and not leaving it somewhere else.
2) It is proven that the risk for malignancy in undescended testicle is higher compering with a normal testicle. This is a cause for concern, naturally, for parents to children with cryptorchidism. This is the place to reassure you that testicular cancer, prevalent between the ages of 15-35 years, is a rare type of cancer, even taking into account the higher prevalence amongst males with undescended testicles. Remember that after the operation and after fixating the testis in his rightful place, the prevalence of testicular cancer does not lower, but since it is in its natural place it is accessible for early diagnosis.
3) Most cases of undescended testis are accompanied by inguinal hernia (some can be diagnosed by the physician and some are discovered during the surgery), so during the surgery the surgeon will also take care of the inguinal hernia.
4) There is a higher probability for testicular torsion in undescended testicle than in a normal testicle. Testicular torsion is a condition where the testis rotates around itself, causing a problem with blood flow to the testis – which can cause necrosis and permeant damage to the testicle (even as much as losing the testicle).
5) In the testicular sack the testis is more protected from injuries or direct contusions. For example – an undescended testicle which was not fixated to the scrotum and is now in the groin with the pelvic bones behind it will be hit more easily if he would be hit directly – since he would crash on a hard surface such as the bone behind him. Placing the testis in the testicular sack would prevent that.
6) If you do decide not to operate the undescended testis, the presence of only one testis in the testicular sack can psychological and cosmetically effect the child. This is an important topic, since a large number of these children, growing with 1 testicle, will turn to surgery for insertion of a prostatic testis to the testicular sack.

When and how is Orchiopexy preformed?

As for today, this operation is done after 6 months of age, according to the opinion of the surgeon and with every case taking into account separately. The length of the operation is about an hour, and it is done under general and local anesthesia, mostly in the daycare surgical unit. The child will be discharged after a few hours in the recovery room.
During the operation the surgeon will make a small cut in the groin, identify the testis, and slide it through the inguinal canal to the scrotum and then fixating it. The fixation process will require a small incision in the testicular sack. The incision in the groin and the testicular sack will be closed with melting sutures, so there is no need for their removal in the next following days.
When the undescended testis is in the abdominal cavity, the exploration is done laparoscopically. The surgeon will insert a camera through a tiny incision in the umbilicus, so he can identify its location. If the testis is indeed in the abdominal cavity, the surgeon will release the blood supply and sperm duct from the abdomen and fixate the testis in the testicular sack. If the testis is not found during surgery, and instead there are remaining of the atrophied testis, than the remaining tissue will be removed.
There are unique cases where the testis is located in a very remote location, which will require the operation to be divided into 2 stages instead of one. These are very rare cases.

What to expect after the operation?

In most cases the pain that will appear after the local anesthesia wears off, will be tolerable. Off course you are more than welcome to use pain killers such as paracetamol of ibuprofen. Usually at-home rest of 5 days is recommended. The child needs to avoid physical activity (Gymboree, riding the minicar, playing in the playground, etc.) for 3 weeks after the operation so there will be a good healing of the area.

What are the possible complications?

Complications are not common. But, here are a few off the more common ones:
– Infection in the surgical wound: could appear after 3-4 days since the surgery, and will manifest as swelling and redness in the area. Sometimes with fever. In this case, you should turn to your surgeon for further instructions. Antibiotic treatment is often warranted. Opening of the wound for drainage is rarely done.
– Swelling and internal hematoma in the testicular sack: A rather common phenomenon which will go away on its own with no treatment needed.

What are the success rates and are there any future problems to expect?

In most cases – the surgical treatment is very successful. Children with one undescended testicle which went through surgical repair as infants will have fertility rate almost identical to children with normal testicles. Fertility rate is lower for children with two undescended testicles.

So what did we learn about cryptorchidism? Very common for children. A correct diagnosis and treatment by a specialist (pediatric surgeon) will fix most of the problems in these cases.