Operative management of cryptorchidism: guidelines and reality - a 10-year observational analysis of 3587 cases
Hensel et al. BMC Pediatrics
Operative management of cryptorchidism: guidelines and reality - a 10-year observational analysis of 3587 cases
Kai O. Hensel 0 2
Tawa Caspers 0 2
Andreas C. Jenke 0 2
Ekkehard Schuler 1
Stefan Wirth 0 2
0 Department of Pediatrics, HELIOS Medical Center Wuppertal, Children's Hospital, Centre for Clinical & Translational Research (CCTR), Faculty of Health, Witten/Herdecke University , Heusnerstr. 40, D-42283 Wuppertal , Germany
1 Institute for Quality Management, HELIOS Kliniken GmbH , Berlin , Germany
2 Department of Pediatrics, HELIOS Medical Center Wuppertal, Children's Hospital, Centre for Clinical & Translational Research (CCTR), Faculty of Health, Witten/Herdecke University , Heusnerstr. 40, D-42283 Wuppertal , Germany
Background: Undescended testis (UDT) is the most common disorder in pediatric surgery and one of the most important risk factors for malignancy and subfertility. In 2009 local guidelines were modified and now recommend treatment to be completed by the age of 1. Aim of this study was to analyze age distribution at the time of orchidopexy, whether the procedure is performed according to guideline recommendations and to assess primary care pediatricians' attitude regarding their treatment approach. Methods: We retrospectively analyzed 3587 patients with UDT regarding age at orchidopexy between 2003 and 2012 in 13 German hospitals. Furthermore, we conducted an anonymized nation-wide survey among primary care pediatricians regarding their attitude toward management of UDT. Results: Before modification of the guideline 78 % (n = 1245) of the boys with UDT were not operated according to guideline recommendations. After the modification that number rose to 95 % (n = 1472). 42 % of the orchidopexies were performed on patients aged 4 to 17 years. 46 % of the primary care pediatricians were not aware of this discrepancy and 38 % would only initiate operative management after the first year of life. In hospitals with pediatric surgery departments significantly more patients received orchidopexy in their first year of life (p < .001). Conclusion: The guideline for UDT in Germany has not yet been implemented sufficiently. Timing of orchidopexy must be optimized in order to improve long-term prognosis. Both primary care providers and parents should be educated regarding the advantages of early orchidopexy in UDT. Prospective studies are needed to elucidate the high rate of late orchidopexies.
Undescended testis; Testicular descent; Primary cryptorchidism; Maldescensus testis; Retractile testis; Acquired cryptorchidism; Orchidopexy; Timing of surgery; Health services research; Guideline implementation
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Background
Primary undescended testis is the most common
congenital anomaly of the urogenital system and the most
common disorder in pediatric surgery, affecting up to
30 % of preterm and 3 % of term infants worldwide [1–3].
A synopsis of nomenclature and possible origins of
nonscrotal position of the testis is presented in Table 1. The
non-scrotal position of the testis bears a considerable risk
for the development of both uni- and contra-lateral
testicular malignancy as well as impaired fertility [4, 5].
Testicular decent takes place at two stages under
control of insulin-like hormone 3 between 8 and 15 weeks
of development [6] and androgens facilitating
inguinoscrotal migration afterwards [7]. While plenty of
research is dedicated to improve understanding of the
morphological complexity involved in the process of
testicular descent, the exact cause of cryptorchidism
currently remains elusive. Relevant risk factors include
prematurity, genetic predisposition, endocrine disorders
(e.g. disrupted hypothalamic-pituitary-gonad axis),
smallfor-gestational-weight (SGA), birth weight < 2500 g as well
as environmental factors (nicotine, alcohol, pesticides)
[2, 8–11]. 10 % of the cases are bilateral and are
commonly associated with complex syndromes or other
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Table 1 Synopsis of nomenclature and etiology for non-scrotal testes
Ascending testis, acquired
undescended testis
Incomplete descent of the testis, possible
positions: intra-abdominal, inside the inguinal
canal or supra-scrotal
Normal testicular position, periodic translocation
to a supra-scrotal position
No/delayed testicular descent
Immaturity, low birth weight [2, 8]
Hyperactive cremasteric reflex [47, 48]
Previously r (...truncated)