Undescended testicles: is surgery necessary?

Q:My 9 year old son has an undescended testicle. My doctor is urging me to allow him to have surgery to correct this. I have been told that there is a risk of cancer in later life, but wonder about the risks of the surgery and whether there is any ot

A:The testicles descend down the inguinal canal from the kidney to the scrotum shortly before birth. Up to 30 per cent of premature boys, and up to 5 per cent of boys at term, will have at least one undescended testis. Most of these testes will spontaneously descend during the first year of life, leaving fewer than one per cent of boys with an undescended testicle by their first birthday.

Although it is relatively rare, undescended testes (cryptorchidism) cause parents a great deal of anxiety. Surgery is usually recommended before the child is two (Curr Prob Pediatri, 1995; 25(7): 232-6). The usual rationales behind surgery are the effect on the child's future fertility, the possible development of cancer, and, not unnaturally, concern for the child's physical appearance.

The eventual positioning of the testis in the scrotum is very important because the cooler temperature of the scrotal sac encourages full spermatozoa production. A testicle which remains in the abdomen until late childhood may be too warm for normal development. Even when eventually brought into the cooler scrotum, it may never produce living sperm.

During the first year of life it can be easy to confuse a "retractile" testis with an undescended one which is why it may be better to "watch and wait" during the first year of life (Urol, 1996; 48: 458-60). A retractile testis is one which moves out of the scrotal sac and into a superficial "inguinal pouch" when the scrotal muscle contracts in response to cool air or a cool hand. If a patient and skilled practitioner can persuade the testicle to descend into a warmed hand you can assume your child is perfectly normal and his testicle will usually descend completely by puberty.

Genuinely undescended testicles then fall into two categories: incompletely descended testis and ectopic testis. The incompletely descended testis lies somewhere along the normal path of descent in the abdomen, the inguinal canal or at the neck of the scrotum. It cannot be manipulated into position and it will not descend at puberty. Hormone therapy or surgery, or both, is usually recommended. The affected testis will be smaller than usual, and there is virtually always an associated inguinal hernia. The hernia forms a path for the testis to follow; if the testis does not descend completely, the hernia does not close.

The ectopic testis has wandered from the normal line of descent and lies somewhere near the inguinal canal. It is usually of normal size, but its abnormal position leaves it open to greater damage. Again, the conventional view is that surgery is necessary.

There is also another less common condition called ascending testicles, which can be the result of a hernia operation (Br J Urol, 1994; 73(2): 204-6). Equally, in mid childhood it is normal for the testicles to ascend into the inguinal canal. This may be a variant on normal and require no therapy (Endocrinol Metabol Clin N Amer, 1993; 22(3): 479-90).

Hormone therapy is usually offered as a first line treatment. This is often administered as an injection or a nasal spray containing human chorionic gonadotrophin (hCG), luteinizing hormone releasing hormone (LHRH), follicle stimulating hormone (FSH) or gonadotrophin releasing hormone (GnRH), or a combination of these.

Hormone therapy does not have an impressive success rate. It appears that only around 32 per cent of testicles will descend with this treatment (Eur Urol, 1990; 17(3): 226-8), and no one has researched the long term consequences of giving these hormones to children.

Since hormonal therapy is often used in place of skilled hands to confirm a diagnosis of a retractile testis, it is hard to know how many of these testes would have descended naturally had they been left alone. In addition, research into hormone therapy has often been erratic both in its execution and in the way information is extrapolated from it (J Clin Endocrin Metabol, 1995; 80(9): 2795-9). It does appear, though, that hormone therapy is more likely to result in a retractile testis later in life (Human Rep, 1995; 10(3): 613-9). Hormone therapy seems to work best if the testicle is close to the scrotum.

Today, laparoscopic surgery is the main tool which doctors use to confirm a diagnosis of undescended testicles. Doctors are very enthusiastic about the use of microsurgery as a way of diagnosing the problem and then fixing it in the same operative session (J Urol, 1995; 154: 1513-5). Through laparoscopy doctors can tell where the testicle is, whether it is absent altogether, a "vanishing" testicle (the result of intra abdominal torsion), or atrophied.

Having gained this information, however, there is very little a surgeon can do but operate. If the child's vas deferens is of adequate length the testicle can be manoeuvred into position with relative ease. However some children require a two stage operation where the seminal vesicles are spliced and repositioned. Whatever the circumstances, in 3 per cent of cases the child will require a repeat operation (Br J Urol, 1992; 70(1): 84-9).

Conventional wisdom says that this surgery should be performed before the age of two. Many parents squirm at the idea of subjecting a baby boy to such a procedure. But at this age it is usually performed with a local anesthetic on an outpatient's basis, whereas in older boys and adults it is performed under a general anesthetic, which carries its own risk.

But does surgery prevent infertility? Half of all boys who undergo a bilateral orchiopexy will still end up infertile. Other studies into the fertility of men who have undergone orchiopexy are confused. There are very few studies which have long term follow up. Those that exist usually measure fertility by examining sperm count and motility rather than paternity (Eur J Pediatri, 1993; 152(Suppl 2): S25-7). Those studies which have looked at paternity have shown that men who had orchiopexy as children are just as likely to father a child as any other man. Remember that even if one testicle is atrophied, producing less sperm than the other or has been removed by orchiectomy, a man could still populate half the world with the other one.

Information about the development of cancer in testicles left inside the body is also vague. Orchiopexy does not prevent cancer, as is so often assumed though in some cases, particularly with older children and young men, it may permit earlier detection. At a rate of 1/2500, cancer in men with undescended testicles does not seem to be significantly greater than that in men with normal testicles. Also, in weighing up whether or not to have your child operated on you might also bear in mind that the risks from the surgery are at least equal to the potential of developing testicular cancer.

There is very little more than anecdotal evidence that therapies such as osteopathy can help with undescended testicles though there is little to lose by trying such measures as a first line. In one case, cranial osteopathy succeeded (Townsend, December 1991). We polled several of our panel members on this subject and all agreed that leaving the testicles in an undescended position is of no direct benefit to your child. This is one condition where the conventional approach may prove the best course, if only for psychological reasons.

For other parents of younger children, don't allow yourself to be pressured into allowing early surgery (before a year of age) if you don't want to. There is no evidence that this is necessary or desirable. And make sure to opt for a surgeon with a good deal of experience in this area.