Detection and Treatment of Undescended Testicles

Joe Barber Jr, PhD

May 23, 2013

Undescended testicles can be effectively treated surgically in most cases, according to the findings of a systemic review. However, magnetic resonance imaging (MRI) has limited sensitivity for identifying absent testicles, according to a separate meta-analysis.

David Penson, MD, MPH, from the Department of Urology, Center for Surgical Quality and Outcomes, Vanderbilt University, Nashville, Tennessee, and colleagues, and Shanthi Krishnaswami, MBBS, MPH, from the Vanderbilt Evidence-based Practice Center, Vanderbilt Medical Center, and colleagues each published reviews online May 20 in Pediatrics.

"Clinical decision-making about treatment is influenced by factors including palpability, whether the condition is present unilaterally or bilaterally, age at presentation, and coexisting medical conditions," Dr. Krishnaswami and colleagues write. "Once cryptorchidism is diagnosed, treatment choices may include watchful waiting, hormonal treatment, or surgery."

In their systemic review, Dr. Penson and colleagues searched Medline and other databases between 1980 and February 2012 to identify studies that assessed the hormonal or surgical treatment of prepubescent boys with cryptorchidism. They limited their analysis to studies that had at least 1 comparison group and that provided data on the testicular position after surgery. In their meta-analysis, Dr. Krishnaswami et al searched Medline to identify studies published during the same time that investigated the efficacy of conventional MRI in identifying cryptorchidism in prepubescent boys.

Regarding treatment, surgical treatment typically resulted in satisfactory success rates (1-stage Fowler-Stephens procedure, 78.7%; 2-stage Fowler-Stephens procedure, 86%; primary orchiopexy, 96.4%), according to Dr. Penson and colleagues. Although descent rates were similar between open and laparoscopic surgery, laparoscopic surgery was associated with shorter operative times (P < .000), time to feeding (P = .004), hospital stay (P = .008), and return to normal activity (P = .000).

Conversely, among the studies that assessed hormonal treatment, the effectiveness of luteinizing hormone-releasing hormone in inducing testicular descent ranged from 9% to 62%, according to Dr. Krishnaswami and colleagues, and no study reported a statistically significant difference between luteinizing hormone-releasing hormone treatment and placebo. In addition, studies also did not identify a statistically significant difference in the effectiveness of luteinizing hormone-releasing hormone and human chorionic gonadotropin treatment.

The most common harmful effects after hormonal treatment included virilizing effects and behavioral changes, whereas a few cases of intestinal injury, none of which were specific to cryptorchidism repair, were observed after laparoscopic surgery.

Concerning the identification of undescended testicles, MRI identified nonpalpable testicles with a median sensitivity of 0.62 (95% Bayesian credible interval [BCI], 0.47 - 0.77) and a specificity of 1 (95% BCI, 0.99 - 1.0). Regarding the location of the undescended testicles, MRI detected inguino-scrotal testicles with a sensitivity of 0.855 (95% BCI, 0.672 - 1) and a specificity of 1 (95% BCI, 0.999 - 1), whereas intra-abdominal testicles were detected with a sensitivity of 0.549 (95% BCI, 0.094 - 1) and a specificity of 1 (95% BCI, 0.999 - 1), according to Dr. Penson and colleagues.

Moreover, the sensitivity of MRI for detecting atrophied testicles was low, ranging from 0% to 14%.

Both studies were supported by funding from the Agency for Healthcare Research and Quality. The authors have disclosed no relevant financial relationships.

Pediatrics. Published online May 20, 2013.

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