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Management of Undescended Testes: European Association of Urology Journal of Pediatric Urology (2016) 12, 335e343 Review Article Management of undescended testes: European Association of Urology/European Society for Paediatric Urology Guidelines aPaediatric Urology, Medical University of Innsbruck, Innsbruck, Austria Christian Radmayr a, Hasan S. Dogan b, Piet Hoebeke c, d e f g bHacettepe University, Faculty Radim Kocvara , Rien Nijman , Raimund Stein , Shabnam Undre , of Medicine, Department of Serdar Tekgul b Urology, Division of Paediatric Urology, Ankara, Turkey Summary of methodological and clinical heterogeneity. The cDepartment of Urology, Ghent risk of bias of each included study was assessed. University Hospital, Gent, Context Belgium Undescended testis is the most common endocrino- Evidence synthesis logical disease in the male newborn period. Inci- There is consensus that early treatment, by dDepartment of Urology, dence varies between 1.0% and 4.6% in full-term 18 months at the latest, for undescended testes is General Teaching Hospital in neonates, with rates as high as 45% in preterm ne- mandatory to avoid possible sequelae regarding Praha, and Charles University onates. Failure or delay of treatment can result in fertility potential and cancer risk. The current 1st Faculty of Medicine, Praha, reduced fertility and/or increased testicular cancer standard therapy is orchidopexy, while hormonal Czech Republic risk in adulthood. therapy is still under debate. However, in some in- dividuals the successful scrotal placement of previ- eDepartment of Urology, ously undescended testes may not prevent potential Division of Paediatric Urology, Objective negative long-term outcomes regarding fertility and University of Groningen, To provide recommendations for the diagnosis and testicular malignancy. Groningen, The Netherlands treatment of boys with undescended testes which reduce the risk of impaired fertility and testicular Conclusions f Division of Paediatric Urology, cancer in adulthood. There is good evidence for early placement of un- Department of Urology, Mainz descended testes in the scrotal position to prevent University Medical Centre, Johannes Gutenberg University, Evidence acquisition potential impairment of fertility and reduce the risk Mainz, Germany Embase and Pubmed were searched for all relevant of testicular malignancy. No consensus exists on the publications, from 1990 to 2015 limited to English various forms of hormonal treatment, which are gDepartment of Paediatric language. Data were narratively synthesized in light assessed on an individual basis. Urology, Great Ormond Street Hospital for Sick Children, London, UK Methodology and fertility were used. At least two reviewers Correspondence to: C. screened all 908 articles independently. Radmayr, Medical University The scientific literature on congenital diseases Disagreement was resolved by a third party. A Innsbruck, Department of is limited. Generally, the level of evidence is total of 73 full-text articles were included in Paediatric Urology, the final version. Key historical articles were Anichstrasse 35, 6020 poor, with most studies being retrospective Innsbruck, Austria with very heterogenous and not well-defined also included, for example [1]. The criteria patient groups and poor stratification of used for level of evidence (LE) and grade of christian.radmayr@i-med. quality. These guideline recommendations recommendation (GR) were defined according ac.at (C. Radmayr) were developed by the European Association to the widely adopted classification system from the Oxford Centre for Evidence Based Keywords of Urology (EAU)/European Society for Paedi- Undescended testis; Cryptor- atric Urology (ESPU) Guidelines Committee to Medicine [2] (Tables 1 and 2). chidism; Orchidopexy; provide a practical approach for treatment of Fertility; Testicular cancer children suffering from undescended testes. Background The Embase and Pubmed databases were Received 15 April 2016 searched for all relevant publications from Accepted 14 July 2016 Cryptorchidism or undescended testis is one of Available online 15 September 1990 to 2015. The terms cryptorchidism, un- the most common congenital malformations in 2016 descended testis, hormonal treatment, male neonates and is related to a multifacto- orchidopexy, laparoscopy, testicular cancer, rial process. Incidence varies and depends on http://dx.doi.org/10.1016/j.jpurol.2016.07.014 1477-5131/ª 2016 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. 336 C. Radmayr et al. Table 1 Summary of evidence. Table 2 Recommendations. LE LE GR An undescended testis justifies 2a Do not offer medical or surgical 2a A treatment early in life to treatment to boys with avoid loss of spermatogenic retractile testes but closely potential. follow-up until puberty. A failed or delayed orchidopexy 2a Offer surgical orchidolysis and 2b B may increase the risk of orchidopexy before the age testicular malignancy later of 12 months, and by in life. 18 months at the latest. The earlier the treatment, the 2a Evaluate male neonates with 1b A lower the risk of impaired bilateral non-palpable fertility and testicular testes for possible DSDs. cancer. In cases of non-palpable testes 1a A In unilateral undescended 1b and no evidence of DSDs, testis, fertility rate is offer laparoscopic reduced whereas paternity intervention because of its rate is not. excellent sensitivity and In bilateral undescended 1b specificity in identifying an testes, fertility and intra-abdominal testis, as paternity rates are well as the possibility for impaired. subsequent treatment in The treatment of choice for 1b the same session. undescended testis is Do not routinely offer hormonal 2a C surgical replacement in the therapy, either in an scrotum. adjuvant or neo-adjuvant The palpable testis is usually 2b setting for testicular treated surgically using an descent. Patients have to be inguinal approach. evaluated on an individual The non-palpable testis is most 2b basis. commonly approached In cases of bilateral 4C laparoscopically. undescended testes, offer There is no consensus on the 2b endocrine treatment to use of hormonal treatment possibly improve further for testicular descent. fertility potential. For an undescended testis in a 3B post-pubertal boy or older, gestational age, affecting 1.0e4.6% of full-term and with a normal contralateral 1.1e45% of preterm neonates. Despite spontaneous testis, discuss removal with descent within the first months of life, nearly 1.0% of all the patient/parents full-term male infants still have undescended testes at 1 because of the theoretical year of age [3]. This congenital malformation may affect risk of a later malignancy. both sides in up to 30% of cases [4]. In newborn cases with non-palpable or undescended testes on both sides and any sign of disorders of sex development (DSDs), such as documented as being scrotal after birth. Acquired unde- concomitant hypospadias, urgent endocrinological and ge- scended testes can be caused by entrapment after her- netic evaluation is required [5]. niorraphy or spontaneously referred to as ascending testis. Palpable testes include true undescended testes and ectopic testes. Non-palpable testes include intra- Classification abdominal, inguinal, absent, and sometimes also some ectopic testes. Most importantly, the diagnosis of a The term cryptorchidism is most often used synonymously palpable or non-palpable testis needs to be confirmed once for undescended testes. The most useful classification of the child is under general anaesthesia, as the first step of undescended testes is into palpable and non-palpable any surgical procedure for undescended testes. testes, and clinical management is decided by the loca- tion and presence of the testes (Fig. 1). Approximately 80% of all undescended testes are palpable [6]. Whether the Palpable testes condition is congenital or acquired can only be decided during a neonatal physical examination, documenting that Undescended testes the gonad is not in a proper scrotal position, compared with A true undescended testis is on its normal path of descent a testicle outside its normal position later in life, that was but is halted on its way down to the scrotum. Depending on Management of undescended testes 337 Figure 1 Classification of undescended testes. the location, the testes may be palpable or not, as in the undescended testes, emphasizing the importance of case of testes arrested in the inguinal canal. following patients with retractile testes on an annual basis till after puberty. Ectopic testes If the position of a testis is outside its normal path of descent and outside the scrotum, the testis is considered to Non-palpable testes be ectopic. Although the most common aberrant position is in the superficial inguinal pouch, modern terminology used Among the 20% of non-palpable testes, 50e60% are intra- in many publications reserves the term ectopic testis for a abdominal, canalicular, or peeping (right inside the internal testis that can be identified in a femoral, perineal, pubic, inguinal ring). The remaining 20% are absent and 30% are penile, or even contralateral position. Usually, there is no atrophic or rudimentary. possibility for an ectopic testis to descend spontaneously to a correct position; therefore, it needs surgical intervention. Intra-abdominal testes Additionally, an ectopic testis may not be palpable because Intra-abdominal testes can be located in different posi- of its position. tions, with most of them close to the internal inguinal ring. However, possible locations include
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