CUA Cryptorchidism 2017 GL

Question 1

What is the difference between congenital cryptorchidism, ascending testicle and retractile testicle?

Answer 1

Congenital: not present in scrotum in neonatal exam
ascending: was present in scrotum at some point but it is not present later in life
Retractile: brisk cremasteric reflex, travels up and down along normal path of descent. but if you pull it down in scrotum it will stay after releasing it

Question 2

Will an ectopic testicle respond to hormonal stimulation or spontaneously descend?

Answer 2

No, a True undescended testicle might though

Question 3

what is the differential diagnosis for non-palpable testicle?

Answer 3

Intra-abdominal testicle, inaccurate exam, testicular absence or atrophy ( so called nubbin)

Question 4

what percentage of patients with unilateral and bilateral cryptorchidism will father a child?

Answer 4

90% unilateral- same as general population

33-65% bilateral

Question 5

What are predictive factors for reduced fertility in patients with cryptorchidism?

Answer 5

bilateral, intra-abdominal/non-palpable testis, testis that remain undescended by 2 years of age. Associated with severe leydig and germ cell loss

Question 6

What does CUA recommend for undescended testicles discovered post-pubertally?

Answer 6

Consider orchiectomy ( not mandatory)

Question 7

what must you rule out in a newborn with male type genitalia and bilateral cryptorchidism?

Answer 7

Female with CAH must be ruled out

Question 8

what would be considered testicular hypertrophy in newborn and what does it mean>

Answer 8

> 1.8-2cm and it means higher likelihood of absent or atrophic nonpalpable gonad on the other side

Question 9

Is US useful in cryptorchidism?

Answer 9

nope, not a replacement for physical exam, does not add diagnostic accuracy to exam performed by a less experienced practitioner

Question 10

Is imaging ( in general) indicated in children with cryptorchidism?

Answer 10

NO, it is not cost effective, may delay referral and surgical treatment and therefore not recommended.

Question 11

Is routine karyotyping or genetic work up recommended for patients with UDT?

Answer 11

Nope, exception is bilateral undescended testicle with normal phallus and orthotopic urethral meatus. do a karyotype and then 17-hydroxyprogestrone levels

other setting is patients with at least one undescended testicle and PROXIMAL hypospadias. do a karyotype. (WT1 mutations, test for WT1 too)

Question 12

what is persistent Mullerian duct syndrome? how is it inherited?

Answer 12

presence of uterus, fallopian tube attached to an undescended testicle. Autosomal recessive. remove the Mullerian structures and do your orchidopexy. if you see this during inguinal orchidopexy, can just transect the proximal fallopian tube from uterus so you can do your orchidopexy. check AMH levels( made by Sertoli cells)

Question 13

what is the role of hormone therapy in management of cryptorchidism?

Answer 13

limited role and should not be recommended in first line. seem to work better for bilateral UDT

Question 14

when should orchidopexy be performed?

Answer 14

between 6-18 months of age

Question 15

what are surgical approaches to palpable UDT?

Answer 15

Inguinal and scrotal orchidopexy based on surgeon preference and experience

Question 16

What do you do in someone who has non palpable testicle, contralateral hypertrophy and ? a palpable nubbin in scrotum?

Answer 16

just do a scrotal incision, remove nubbin, send off for analysis, vanishing testicle diagnosis confirmed, if not proceed to make an inguinal incision or do laparoscopy

Question 17

what are three scenarios you may face while performing laparoscopy for NPT?

Answer 17

1- blind ending vas and vessels: Done
2- vas and vessels entering inguinal ring: inguinal orchidopexy or orchiectomy if you find a nubbin
3- peeping or intrabdominal testis: open or lap orchidopexy in one or two stages

Question 18

what are useful maneuver to bring a high testicle down to scrotum?

Answer 18

1-division of lateral fibrous attachments of the cord at internal ring
2- blunt dissection of retroperitoneal spermatic vessels up to lower pole of the kidney
3- mobilization of the cord medial to inferior epigastric vessels( Prentiss maneuver)

Question 19

what is the success rate of all approaches for NPT?

Answer 19

over 75%

primary>two stage FS>one stage FS

Question 20

From high to low. list testicualr atrophy rates

Answer 20

1 stage FS>2 stage FS> primary orchidopexy

Question 21

Does CUA recommend prophylactic contralateral orchidopexy?(particularly in the case of monorchidism)

Answer 21

No, shared decision making and do it if family wants it

Question 22

IS orchidopexy recommended for patients with Noonan, downs, prader-willi?

Answer 22

yes, do it if they are clinically fit for anesthesia to allow for the purpose of surveillance

Question 23

What do you do if the testicle is still too high post orchidopexy>

Answer 23

offer a redo, success aretes are high with a redo

Question 24

at what age do you stop doing orchidopexy/orchiectomy for UDT?

Answer 24

50, after this age, observation is appropriate

Question 25

what percentage of retractile testis become ascended testis?

Answer 25

3-30%, so ask GP to keep an eye on them in case they become UDT