Statistics from Altmetric.com
Current guidelines recommend that orchidopexy for undescended testis (UDT) should be undertaken before 2 years of age because of the possible risks of torsion, infertility, and malignant transformation.1
We conducted a retrospective audit on eight consecutive orchidopexies for UDT over a three month period in 1996 at North Tees and Hartlepool general hospitals. Median age of orchidopexy was 7.8 years (range 15 months to 10.5 years), and only 12% of the children were operated on when under 2 years of age. Following this we introduced joint guidelines for UDT screening at birth, 6–8 weeks, 6–9 months, 12–15 months, and during the preschool check.
A re-audit was done after a five year period on all 99 children who underwent orchidopexy between January 2001 and January 2003. Median age (range) at orchidopexy was 5.2 years (15 months to 14.6 years) and was not significantly different to the first audit (p = 0.29). Only 14/99 (14.1%) of children were operated before the age of 2 years. The majority (54.5%) of the children had orchidopexy between the age of 5 and 15 years.
Reasons for delay in orchidopexy in the 85 children were categorised into six groups. Group 1: Suspected retractile testis: 23 (19.5%); testis was initially thought to be retractile, but later became undescended. Group 2: Surgical delay: 13 (11.1%). Group 3: Ascending testis: 16 (13.6%) (documented scrotal testis which subsequently became non-scrotal). Group 4: System failure: 9 (7.7%); failure to attend appointments or children were lost to follow up. Group 5: Late surgical referrals: 2 (1.7%). Group 6: Uncertain cause: 22 (18.7%); we could not ascertain the exact reason for delay in this group because of lack of documentation of testis position at birth and early infancy. Diagnosis of UDT was late in these children, which could be due to failure of screening or ascending testis.
Ascent of a previously scrotal testis appears to be the likely cause for late diagnosis of UDT, rather than a failure of screening. This would explain consistently high orchidopexy age reported from all over the world, despite introduction of aggressive UDT screening.2,3
There is increasing evidence to suggest ascending testis (primary acquired UDT4) is a common occurrence, outnumbering congenital UDT by a factor of two to three. Pathogenesis of primary acquired UDT is thought to be due to relative shortening of cord structures with respect to other tissues.5
Optimal management of primary acquired UDT is not known, but there is some evidence to suggest that most of these would descent spontaneously into the scrotum during puberty and the testicular volume is not affected. Moreover orchidopexy caries a 5–6% risk of damage to spermatic cord structures, resulting in gonadal atrophy.5
We conclude that late orchidopexies are possibly due to orchidopexies being carried out on ascending testes in prepubertal boys. Is likely that many of these orchidopexies are unnecessary and the testis might descend spontaneously during puberty. There is a need for a national testis registration at birth and to undertake large prospective cohort studies to establish the natural history of ascending testis.