Evidence-Based Resource

What is the ideal timing for orchiopexy?

Evidence Level I

Research has consistently reported that cryptorchidism is associated with poor fertility outcomes. Early orchidopexy may be protective against future infertility, but the optimal timing of this surgery remains controversial. Among the studies that we identified, the overall consensus is that orchidopexy performed in early childhood has the greatest benefits for future fertility. Most of these studies recommend orchidopexy before the age of two, although some have reported the best results when surgery is performed before one year of age. Specifically, an RCT by Kollin (2007) indicated that testicular catch-up growth was greater when orchidopexy was performed at nine months compared to three years of age. In addition, several non-randomized trials have reported greatest fertility (i.e., sperm count in adulthood) when orchidopexy is performed before one year of age (e.g., Kogan 1990, Canavese 2009, Tasian 2009).

The association between timing of orchidopexy and testicular cancer risk is less clear. There have been mixed findings regarding this outcome, with some studies reporting that orchidopexy in childhood is protective against cancer, while other studies report no association. We found that higher-quality studies tended to report a benefit of early orchidopexy. Specifically, findings from a systematic review (Walsh 2007) and several non-randomized trials (e.g., Forman 1994, Pettersson 2007) have indicated that the risk of testicular cancer is lower among patients who underwent orchidopexy before puberty compared with those whose surgery was performed postpubertally.

Another factor to consider when determining the optimal age for orchidopexy is the possibility of spontaneous testicular descent. In a study of 48 newborns with cryptorchidism, Thong (1998) found that 76% of infants achieved spontaneous testicular descent by one year of age. However, Wenzler (2004) found that if the testis was still undescended by two months of age, the chance of spontaneous descent decreased dramatically, with almost no chance of descent past six months of age. Thus, if the testis remains cryptorchid by six months of age, orchidopexy should be performed as soon as possible. This recommendation is consistent with that of a group of Nordic clinical specialists; after conducting a thorough literature review, these specialists reached a consensus that orchidopexy for cryptorchidism should be performed between 6-12 months of age (Ritzen 2007).

In summary, there is an overall consensus that early orchidopexy is beneficial for future fertility and may be protective against the increased risk for testicular malignancy in cryptorchid patients. In particular, optimal testicular function is most likely achieved when the surgery is performed before one year of age.

Acknowledgement: We thank Emily Chan for her work on this review.

The full systematic review can be found here.

Non-Randomized Trials: Comparison Studies

Canavese F, Mussa A, Manenti M, Cortese MG, Ferrero L, Tuli G, Macchieraldo R, Lala R. Sperm count of young men surgically treated for cryptorchidism in the first and second year of life: fertility is better in children treated at a younger age. European Journal of Pediatric Surgery 2009;19(6):388-91.

Cortes D, Thorup JM, Visfeldt J. Cryptorchidism: aspects of fertility and neoplasms. A study including data of 1,335 consecutive boys who underwent testicular biopsy simultaneously with surgery for cryptorchidism. Hormone Research 2001;55(1):21-7.

Coughlin MT, Bellinger MF, Lee PA. Age at unilateral orchiopexy: effect on hormone levels and sperm count in adulthood. Journal of Urology 1999;162(3 Pt 2):986-8.

Engeler DS, Hosli PO, John H, Bannwart F, Sulser T, Amin MB, Heitz PU, Hailemariam S. Early orchiopexy: prepubertal intratubular germ cell neoplasia and fertility outcome. Urology 2000;56(1):144-8.

Forman D, Pike MC, Davey G, Dawson S, Baker K, Chilvers CED, Oliver RTD, Coupland CAC. Aetiology of testicular cancer: association with congenital abnormalities, age at puberty, infertility, and exercise. United Kingdom Testicular Cancer Study Group. BMJ 1994;308(6941):1393-9.

Hadziselimovic F, Herzog B. The importance of both an early orchidopexy and germ cell maturation for fertility. The Lancet 2001;358(9288):1156-7.

Herrinton LJ, Zhao W, Husson G. Management of Cryptorchism and Risk of Testicular Cancer. American Journal of Epidemiology 2003;157(7):602-5.

Kim SO, Hwang EC, Hwang IS, Oh KJ, Jung SI, Kang TW, Kwon D, Park K, Bang-Ryu S. Testicular catch up growth: the impact of orchiopexy age. Urology 2011;78(4):886-9.

Kogan SJ, Tennenbaum S, Gill B, Reda E, Levitt SB. Efficacy of orchiopexy by patient age 1 year for cryptorchidism. Journal of Urology 1990;144(2 Pt 2):508-9.

Lee PA, Coughlin MT. Leydig cell function after cryptorchidism: evidence of the beneficial result of early surgery. Journal of Urology 2002;167(4):1824-7.

Lee PA, O'Leary LA, Songer NJ, Coughlin MT, Bellinger MF, LaPorte RE. Paternity after unilateral cryptorchidism: a controlled study. Pediatrics 1996;98(4 Pt 1):676-9.

McAleer IM, Packer MG, Kaplan GW, Scherz HC, Krous HF, Billman GF. Fertility index analysis in cryptorchidism. Journal of Urology 1995;153(4):1255-8.

Mengel W, Hienz HA, Sippe WG, Hecker WC. Studies on cryptorchidism: a comparison of histological findings in the germinative epithelium before and after the second year of life. Journal of Pediatric Surgery 1974;9(4):445-50.

Moller H, Prener A, Shakkebaek NE. Testicular cancer, cryptorchidism, inguinal hernia, testicular atrophy, and genital malformations: Case-control studies in Denmark. Cancer Causes & Control 1996;7(2):264-74.

Nagar H, Haddad R. Impact of early orchidopexy on testicular growth. British Journal of Urology 1997;80(2):334-5.

Park KH, Lee JH, Han JJ, Lee SD, Song SY. Histological evidences suggest recommending orchidopexy within the first year of life for children with unilateral inguinal cryptorchid testis. International Journal of Urology 2007; 14(7):616-21.

Pettersson A, Richiardi L, Nordenskjold A, Kaijser M, Akre O. Age at surgery for undescended testis and risk of testicular cancer. New England Journal of Medicine 2007;356(18):1835-41.

Pinczowski D, McLaughlin JK, Läckgren G, Adami HO, Persson I. Occurrence of testicular cancer in patients operated on for cryptorchidism and inguinal hernia. Journal of Urology 1991;146:1291-4.

Riebel T, Herrmann C, Wit J, Sellin S. Ultrasonographic late results after surgically treated cryptorchidism. Pediatric Radiology 2000;30(3):151-5.

Strader CH, Weiss NS, Daling JR, Karagas MR, McKnight B. Cryptorchism, orchiopexy, and the risk of testicular cancer. American Journal of Epidemiology 1988;127(5):1013-8.

Swerdlow AJ, Higgins CD, Pike MC. Risk of testicular cancer in cohort of boys with cryptorchidism. BMJ 1997;314(7093):1507-11.

Tasian GE, Hittelman AB, Kim GE, DiSandro MJ, Baskin LS. Age at orchiopexy and testis palpability predict germ and Leydig cell loss: clinical predictors of adverse histological features of cryptorchidism. Journal of Urology 2009;182(2):704-9.

Taskinen S, Hovatta O, Wikstrom S. Early treatment of cryptorchidism, semen quality and testicular endocrinology. Journal of Urology 1996;156(1):82-4.

Taskinen S, Wikstrom S. Effect of age at operation, location of testis and preoperative hormonal treatment on testicular growth after cryptorchidism. Journal of Urology 1997;158(2):471-3.

Trsinar B, Muravec UR. Fertility potential after unilateral and bilateral orchidopexy for cryptorchidism. World Journal of Urology 2009;27(4):513-9.

Wiser A, Raviv G, Weissenberg R, Elizur SE, Levron J, Machtinger R, Madgar I. Does age at orchidopexy impact on the results of testicular sperm extraction? Reproductive BioMedicine Online 2009;19(6):778-83.

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