Trends in the treatment of undescended testes: a pediatric tertiary care center experience from Croatia

Introduction

Undescended testes (UDT) is the most common congenital anomaly of the male genitourinary tract. In patients with UDT, testes can most often stop in the abdominal cavity or in the inguinal canal on their way.1 Congenital UDT occurs predominantly unilaterally in preterm infants. Most testes that do not descend at birth will complete the descent within the first 3 months of life, while spontaneous descent after the sixth month is extremely rare.2 3 After a series of studies reporting the negative effects of such laid testes, the recommendation from some associations is that treatment should begin as early as 6 months and end no later than 18 months.4–6 Acquired UDT occurred in a group of boys whose testes are palpable in the scrotum and can be observed during neonatal and infant life, but will ascend over time.7 8 In this group of boys, it is important to note that orchidopexy before puberty can significantly reduce the risk of testicular cancer.9 Due to low success rates, there are fewer and fewer proponents of hormone therapy. Since hormonal treatment can improve fertility indices, it is recommended as an additional tool in addition to orchidopexy, especially in boys who have UDT on both sides.10 11 The most common technique with a high success rate is Dartos pouch technique. For non-palpable intra-abdominal testes, the simplest and most accurate way of locating is diagnostic laparoscopy, after which Fowler-Stephens orchiopexy is most often used for testicular locating,12 13 but there are other techniques currently available that have not been used in our hospital.14 15 The severity of the outcome of untreated UDT, especially infertility and cancer, requires early referral of such boys for definitive treatment.

Methods

Results

During the 1-year period of 2019, a total of 204 children under the diagnosis of Q53 (undescended and ectopic testicle) were surgically treated at our institution. Six children were excluded because they had testicular agenesis or ectopy. A total of 198 children were included in the study. A total of 12 pediatric surgeons participated in the treatment of children with UDT.

Out of 198 children, 100 (50.51%) had congenital UDT, while 98 (49.49%) had acquired UDT (table 1). There were 31 (31%) bilateral cases in boys with congenital UDT, while in boys with acquired UDT, there were 34 (34.69%). As a result, a total of 263 orchidopexies were performed. In both congenital (62.32%) and acquired (67.19%) cases, the right side was predominantly affected. In the inguinal canal, there were 123 (93.89%) congenital and 126 (95.45%) acquired UDTs. Of the eight abdominal testes in the congenital group, four were within one side (two right and two left) of bilateral UDT, while of the six abdominal testes in the acquired group, two were within one side (one right and one left) of bilateral UDT. In the congenital group, 35.88% of patients with UDT had associated inguinal hernia or hydrocele, while in the acquired group, the prevalence was 21.21% (p=0.0084). In the congenital group, inguinal hernia or hydrocele was present bilaterally in seven boys (7%), while in the acquired group, it was present in only one boy (1.02%) (p=0.0326). Before the surgery, ultrasound was done in 67% of boys in the group of congenital UDT, while in the group of acquired UDT, 60.2% of cases underwent ultrasound. In the group of congenital UDT, 16% of boys were born before 37 weeks, while in the group of acquired UDT, 4.08% were born before term (p=0.0054). In both groups, patients were most often referred to pediatric surgeons by primary pediatricians (83% vs 40.82%), but parents themselves (23.47%) and school physicians (29.59%) played a significant role in the acquired group. In the congenital group, 19% of patients had associated anomalies, while in the acquired group, 11.22% had associated anomalies (p=0.1271) (table 2).

Out of a total of 263 orchidopexies performed, 249 (94.68%) were performed using the Dartos pouch technique (123 in congenital group and 126 in acquired group), while 14 (5.32%) were performed using the single-stage Fowler-Stephens procedure (eight in congenital group and six in acquired group). Within the congenital group, seven reoperations were performed due to inadequate position of the testis within the scrotum (six inguinal testis with four of the left side and two of the right side) and one abdominal left testis, while in the acquired group, three reoperations were performed (one inguinal right testis and two abdominal right testis). In total, 10 patients were reoperated and followed up for 2 years. During follow-up, all testes undergoing orchidopexy were palpated in the scrotum, but atrophy (>50% loss of volume after orchiopexy) was verified by ultrasound in nine (3.42%) testes (five in the congenital group and four in the acquired group).

The referral time to our institution, age at which the patient underwent clinical examination, and age at which the patient received surgery are summarized in table 1. The Mdn time from referral to clinical examination was 3.5 months in the congenital group and 6 months in acquired group (p=0.007). The Mdn time from clinical examination to orchidopexy was 12.5 months in the congenital group and 18.5 months in the acquired group (p=0.003) (figure 1). In the congenital group up to 18 months of age, orchidopexy was performed in 16 (16%) boys, while in the acquired group up to 13 years of age, orchidopexy was performed in 95 (96.94%) boys (figure 2).

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Discussion

Our single-center retrospective study aimed, in addition to general characteristics, to determine whether children with congenital and acquired UDT were surgically treated on time, as negative repercussions of untimely treatment were clearly identified.16 At the end of the 20th century, scientists made it clear that the optimal time for treatment of congenital UDT is within the first year of life and that there are no harmful effects or risks to the child.17 Although the first comprehensive research on this topic did not clearly distinguish the group of congenital from acquired testes, the researchers expressed concern, since in less than 50% of boys orchidopexy was performed by the age of 2 years.18 Already in the same year, it was considered necessary to determine whether there was a tendency to reduce the age at which orchidopexy was performed. For the Irish child population, the mean time of orchidopexy in one decade has been reduced by 3 years, while in the Danish population, for 6 years, the reduction was half a year, which instilled optimism.19 20 In two decades, the Mdn of orchidopexy performed in the Chinese population was reduced by 7 years, although only 2% of healthcare practitioners knew the recommended age for orchidopexy.21 Researchers in Germany have recognized that the theoretical knowledge of primary pediatricians and early referral is extremely important.22 Steckler et al reported in their study that only 30% of pediatricians and 14% of family physicians recommended orchidopexy between 6 months and 12 months of age.23 Gerber et al pointed out the suspicion that poor quality clinical examination by pediatricians may also be a factor that may influence the untimely diagnosis of this condition.24 The study by Cho et al showed that the intervention by an interactive survey aimed at general practitioners had positive effects on reducing referral time.25 We also believe that the time of referral to our institution must be significantly reduced, especially for the congenital group. In addition to the pediatrician’s and general practitioner’s theoretical knowledge, several other factors have been identified that are significantly related to the time to surgery, such as the age of the diagnosing physician, the age of the surgeon performing the surgery, and the urbanization of the patient’s residence.26–28 The study from the neighboring country also states that the residence of patients is extremely important, given that 28.13% of boys from urban areas underwent surgery by 18 months of age, while from rural areas, this percentage was only 15.46. A total of 22.6% of boys compared with our 16% underwent surgery before 18 months of age.29 Compared with our study, a New Zealand study showed that the Mdn waiting time from referral to clinical examination was only 1.84 months (vs 3.5 months), while the Mdn from clinical examination to orchidopexy was only 2.95 months (vs 12.5 months).30 At a single-center in Saudi Arabia, the Mdn waiting time for elective orchidopexy was 4.8 months, while in another center, the time was 8.1 months, but they had a slightly higher Mdn from referral to clinical examination (4.1 months).31 32 There is no doubt that we need to do orchidopexy for our patients faster than the day when the clinical examination was performed. It is interesting to note that even countries with a Mdn age for surgery of 1.05 and 1.49 years show a tendency towards a lower Mdn in the future.30 33 In a study by Chen et al, similar to our results, 32% of boys had an associated inguinal hernia, but in our study, we had more boys with bilaterally UDT (32.82% vs 11.3%).26 On the other hand, according to a study by Zhao et al, only 14% of boys had an inguinal hernia or hydrocele, while 15.2% had bilaterally UDT. Analogous to our results, only 16.9% of boys underwent surgery by 18 months of age.28 According to Marret et al, during the Mdn follow-up of 5.5 years, ultrasound verified atrophy in 11% of cases, while during our 2-year follow-up, atrophy was recorded in 3.42% of cases.34 Although in our study the rate is not high, according to Elzeneini et al, the rate of testicular atrophy is much lower in two-stage Fowler-Stephens orchiopexy, which should guide us in the future.35 Although meta-analysis concluded that ultrasound cannot reliably locate non-palpable testes and that ultrasound is unnecessary in preoperative evaluation of boys with UDT because it does not affect final surgical management, according to a study by Soto-Palou et al, 46.4% of boys underwent ultrasound preoperatively.36 37 In our study, as many as 63.6% of patients underwent ultrasound, which certainly extended the time to orchidopexy. Ultrasound was mostly requested by pediatric surgeons. This habit will certainly need to be reduced by adequate education of all stakeholders involved in treatment. Comprehensive studies that clearly distinguish congenital from acquired UDT began to appear only a few years ago. In the study of Boehme et al, almost identical results were observed in the proportion of congenital and acquired UDT, which is confirmed by our study. The study also found that there were more children born prematurely in the congenital group than in the acquired group (51% vs 34%), which was confirmed by our results (16% vs 4%). Regarding patients who had an associated inguinal hernia, a significantly higher number was recorded in the congenital group (50% vs 18%), which was confirmed by our study (36% vs 21%).38 It should be emphasized that the time interval, from diagnosis to orchidopexy, was only 3 months. Regarding the congenital UDT, a study by Zvizdic et al, analogous to our results, found that the right side is more often affected. An almost identical percentage of boys had an associated congenital inguinal hernia. Although we had a better Mdn referral time (14 months vs 23 months), the Mdn time of orchidopexy was far worse (30 months vs 24 months).39

In the future, we must strive to surgically treat children with congenital UDT much earlier, up to 18 months of age, in order to prevent long-term consequences of untimely treatment. Children with undescended testicles will have to get more priority appointments for surgery. Also, unnecessary referrals to ultrasound should be reduced, except in specific indications that require it. It will certainly be necessary to conduct extensive education and public health intervention for pediatricians and family physicians in order to move the time of referral to an earlier age. We will examine the real reasons for the delay in referral with a questionnaire that we plan to conduct and analyze soon.