It has been shown that undescended testicles at birth and throughout the first year of life have normal histology, and that includes a normal population of germ cells.
Huff et al. showed that beyond age of 18 months, both light microscopy and electron microscopy showed the development of abnormal histologic changes (15).
This was one factor that dictated timing of orchidopexy. Anesthesia risks also dictated timing of orchidopexy; however, infants aged four to six months have been shown now, with modern pediatric anesthesia techniques, to have risks similar to the healthy adult.
Recent studies would suggest that orchidopexy at six months is optimal as it capitalizes on the anatomic advantages conferred by the child's small size, while exhausting the real chances for spontaneous descent (16).
The role for orchidopexy in the older child, adolescent, and young adult is less well defined. Clearly, the undescended testicle will almost certainly have poor fertility potential; however, its usefulness for androgen production must be considered. There is then also the risk of malignant change, and as mentioned, relocation to the scrotum may not alter that risk at all. A recent analysis comparing anesthetic risks of orchiectomy versus the lifetime-adjusted risk of germ cell cancer was performed by Kibel and coworkers (17).
Kibel and coworkers recommend that healthy males with undescended testicles undergo orchiectomy until the age of 50 years. For patients with comorbid conditions [American Society of Anesthesiologists (> 2)] the risks of surgery might contraindicate orchiectomy even before the age of 50 years (17).
The preoperative diagnostic modalities used in the evaluation of the patient with a nonpalpable testicle include radiological tests and hormonal challenge. Medical management will not be discussed in this manuscript. However, radiologic evaluation will be discussed as many feel that a real alternative to laparoscopic localization. Virtually, all imaging modalities have been used. These would include ultrasound, venography, magnetic resonance imaging, and computed tomography. None of these modalities have been found to be sufficiently sensitive to answer the questions: (i) is there a testicle present, and (ii) where is that testicle (18-22)?
Radiographic imaging can be useful in some instances. One such instance is in the overweight boy with a nonpalpable testicle, which can be proven to be inguinal. Likewise, there is utility in adolescents for follow-up who are not surgical candidates because of comorbid conditions. One should not forget the examination under anesthesia at the time of orchidopexy or laparoscopic localization, because that oftentimes will reveal the location of the testicle (3).
In the young child, the peritoneum can be controlled and a trocar easily dilated into place under direct vision. Holding sutures placed in the fascia are helpful in elevating the fascia and peritoneum prior to peritoneotomy.
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