AUA Lesson 14

Update Series 2015 Volume 34

Cryptorchidism Learning Objective: At the conclusion of this continuing medical education activity, the participant will be able to apply the recent AUA guideline for the evaluation and treatment of cryptorchidism.

Thomas F. Kolon, MD Disclosures: National Institutes of Health: Scientific Study/Trial

Associate Professor of Urology (Surgery) Children’s Hospital of Philadelphia Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania

This self-study continuing medical education activity is designed to provide urologists, Board candidates and/or residents affordable and convenient access to the most recent developments and techniques in urology. Accreditation:The American Urological Association (AUA) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Credit Designation: The American Urological Association designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Evidence-based Content: It is the policy of the AUA to ensure that the content contained in this CME enduring material activity is valid, fair, balanced, scientifically rigorous and free of commercial bias. AUA Disclosure Policy: All persons in a position to control the content of an educational activity (ie, activity planners, presenters, authors)

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KEY WORDS: cryptorchidism, undescended testis, hormone, in-

fertility, testis cancer INTRODUCTION The American Urological Association guideline on the diagnosis and treatment of cryptorchidism is published and available unabridged at http://www.auanet.org/education/guidelines/cryptorchidism.cfm.1 Throughout this Update, this document will be referred to as the guideline. Cryptorchidism, or undescended testis, is one of the most common pediatric disorders of the male endocrine glands and the most common genital disorder identified at birth. It is defined as failure of a testis to descend into a scrotal position. This situation most commonly refers to a testis that is present but in an extra scrotal (usually suprascrotal) position, which may also lead to identification of an absent testis. In the latter situation the testis is most commonly referred to as vanishing (or vanished), consistent with evidence suggesting that it was present initially but disappeared during development most likely due to spermatic cord torsion or an unidentified vascular accident. The main reasons for treatment of cryptorchidism include increased risks of impairment of fertility potential, testicular malignancy, torsion and/or associated inguinal hernia. The current standard of therapy in the United States is orchiopexy or surgical repositioning of the testis within the scrotal sac, while hormonal therapy to induce descent has fewer advocates. However, successful scrotal relocation of the testis may reduce but does not prevent these potential long-term sequelae in susceptible individuals. The purpose of the AUA guideline is to provide physicians and non-physician providers (primary care and specialists) with a consensus of principles and treatment plans for the management of cryptorchidism (typically isolated, non-syndromic). An intensive discussion of disorders of sex development is beyond the scope of this guideline. The panel members were representative of various medical specialties (pediatric urology, pediatric endocrinology, general pediatrics). The guideline is divided into statements on diagnosis and treatment. METHODOLOGY The primary source of evidence for the AUA cryptorchidism guideline was the systematic review conducted as part of the Agency for Healthcare Research and Quality comparative effectiveness review on cryptorchidism.2 That report included systematic searches of MEDLINE®, Cumulative Index to Nursing and Allied Health Literature and Embase® for English language studies published from January 1980 through February 2012 relevant to cryptorchidism. To capture more recently published articles to augment and broaden the body of evidence provided in the original agency report, AUA conducted addi-

tional supplementary searches of PubMed® and Embase for relevant articles published between January 1980 and March 2013 that were systematically reviewed using a methodology developed a priori. These searches yielded 704 studies after exclusions which were used to inform the statements presented in the guideline as Standards, Recommendations or Options, and the treatment algorithm (see figure). When sufficient evidence existed, the body of evidence for a particular clinical action was assigned a strength rating of A (high), B (moderate) or C (low). In the absence of sufficient evidence additional information was provided as Clinical Principles and Expert Opinions. The AUA nomenclature system explicitly links statement type to body of evidence strength and the panel’s judgment regarding the balance between benefits and risks/ burdens. DIAGNOSIS GUIDELINE STATEMENTS 1. Providers should obtain gestational history at initial evaluation of boys with suspected cryptorchidism (standard, evidence strength grade B). Testicular descent occurs in the 2 phases of transabdominal descent and inguinoscrotal migration. Initial transabdominal descent occurs in the first trimester when at approximately 22 to 25 weeks of gestation the testes are at the internal ring. The inguinoscrotal phase of testicular descent, which is androgen dependent, occurs between 25 and 30 weeks.3, 4 Given the relatively late migration of testes through the inguinal canal into the scrotum, the prevalence of cryptorchidism is higher in premature boys in the first months of life (1% to 3% of full-term and 15% to 30% of premature male infants).5 Descent of the testes into the scrotum is probable in premature boys during the first months of life but is unlikely after 6 months of corrected age.6, 7 Thus, obtaining the gestational age is critical to the proper and timely referral of a child with persistent UDT to a surgical specialist. In addition to gestational age, low birth weight for gestational age has also been closely associated with cryptorchidism with approximately100% prevalence of cryptorchidism in infants