Outcomes and Evidence Based Medicine Systematic Reviews Management - - PowerPoint PPT Presentation

Outcomes and Evidence Based Medicine Systematic Reviews

Meghan A. Arnold, Karen Diefenbach, Robert Gates, Julia Shelton

Management of the Undescended Testicle

APSA Outcomes and Evidence Based Medicine Committee

Discl closures

• We have no disclosures
• There is some discussion of non-FDA approved therapies as some

studies outside of the US have evaluated the use of LHRH analogs

Commonalities

• UDT = failure of the testis to

descend into a scrotal position

• Extrascrotal (prescrotal,

superficial inguinal pouch, external ring, canalicular, abdominal or ectopic) vs absent “vanishing”

• Congenital vs acquired

(ascending, entrapped, retractile, atrophic)

• Orchidopexy = Orchiopexy

https://uroweb.org/wp-content/uploads/EAU-Guidelines-Paediatric-Urology-2016-1.pdf

Questi tions s posed in t this s s systemati tic r review

For children with undescended testicle

• 1. When is pre-operative imaging indicated and if so,

which study is most appropriate?

• 2. What is the role of medical management in

undescended testicle?

• 3. What is the appropriate timing of intervention and

how is this affected by associated clinical factors?

• 4. What is the evidence supporting type of operative

intervention?

• 5. What are the long term outcomes after orchiopexy?

5

Sea Search Resu esult lts

• MeSH headings searched back to 2007:
• Cryptorchid/cryptorchidism, undescended testicle/testis, orchidopexy/orchiopexy,

intraabdominal testis, impalpable/nonpalpable testis,

• Infant, child or adolescent
• 417 articles total
• All abstracts reviewed and categorized
• Cross referenced between reviewers
• Snowballing technique used to obtain additional papers
• 388 chosen for full review
• 180 included in the review

Question 1 For children with undescended testicle:

When is pre-operative imaging indicated and if so, which study is most appropriate?

Sea Search Resu esult lts

• 19 studies obtained from initial search
• 5 added after further review
• 7 suitable for inclusion

– 3 prospective – 4 retrospective

• Imaging modalities: MRI, CT and US

Consensus us S Statements

• American Urological Association 2014

(http://www.auanet.org/guidelines/cryptorchidism-(published- 2014))

Providers should not perform ultrasound (US) or other imaging modalities in the evaluation of boys with cryptorchidism prior to referral, as these studies rarely assist in decision making

• European Association of Urology 2016

(https://uroweb.org/wp-content/uploads/EAU-Guidelines- Paediatric-Urology-2016-1.pdf)

Use of US, CT or MRI is limited and only recommended in specific and selected clinical scenarios

When i is pre-op

• per

erative e imagi ging g indicated ed?

• Ultrasounds should not be obtained prior to being seen by

surgeon (pediatric surgeon or pediatric urologist)

Wayne et al. 2017 (Level II) and Kanaroglou et al. 2017 (Level II)

• May not be necessary as >50% referrals were normal on exam by specialist

(Wayne)

• Children who had an US prior referral had an approximate 3 month delay in

definitive surgical management (Kanaroglou)

10

When p pre-operativ ive im imaging is is in indic icated, , which study i is most appropri riate?

• Cross-sectional imaging (CT/MRI) – no evidence that this is indicated

for locating testes

• May be helpful when evaluating for other anomalies associated with

undescended testes

When p pre-operativ ive im imaging is is in indic icated, , which study i is most appropri riate?

• Ultrasound may be helpful in select patients
• Moriya et al. 2017 (Level III)
• Berger et al. 2017 (Level II)
• Abdulrahman et al. 2016 (Level III)
• Vos et al. 2014 (Level II)
• Adesanya et al. 2013 (Level II)

When p pre-operativ ive im imaging is is in indic icated, , which study i is most appropri riate?

• Recommendations
• Ultrasound may be helpful in select patients:
• Patients with non-palpable testes (unilateral or

bilateral) in which location may alter operative approach or avoid diagnostic laparoscopy (Abdulrahman, Vos, Adesanya)

• Evaluation of volume of contralateral testis may predict

viability or increase accuracy of approach (Moriya, Berger) (Level II-III evidence, Grade B recommendation)

Question 2 For children with undescended testicle:

What is the role of medical management?

Sea Search Resu esult lts

• 12 studies obtained from initial search
• 1 added after further review
• 7 suitable for inclusion
• 4 prospective
• 3 retrospective
• Hormonal therapy investigated as
• Medical therapy alone to induce descent
• Adjuvant to surgery to improve fertility

Consensus us S Statements

• American Urological Association 2014

(http://www.auanet.org/guidelines/cryptorchidism-(published-2014))

Providers should not use hormonal therapy to induce testicular descent as evidence shows low response rates and lack of evidence for long-term efficacy.

• European Association of Urology 2016

(https://uroweb.org/wp-content/uploads/EAU-Guidelines-Paediatric- Urology-2016-1.pdf)

Endocrine treatment to achieve testicular descent is not recommended.

• Nordic consensus

(Ritzen et al, 2007)

Hormonal treatment following orchiopexy has been proposed to have beneficial effects on sperm count but these findings need confirmation by

• ther groups before being incorporated into clinical practice.

16

What i is the role of medical management t in undescended d testicle?

• Hormone therapy to induce descent of testes
• Aycan et al. 2006 (Level II), Marchetti et al. 2012 (Level III), Pirgon

et al. 2009 (Level III)

• Variable results from >65% successful descent into scrotum (Aycan)

to 25% (Marchetti)

• May have side effects including increased left ventricular mass

(Pirgon)

17

What i is the role of medical management t in undescended d testicle?

• Hormone therapy as an adjuvant to surgery to improve

fertility

• Spinelli et al. 2014 (Level II) – GnRHa effect on TAIn
• Thorup et al. 2012 (Level III) – endocrine and histopathology of

testis in determining possible improvement of fertility after

• rchiopexy
• Jallouli et al. 2009 (Level II) – GnRH effect on fertility index
• Hadziselimovic 2008 (Level II) – LH-RH Analogue (GnRH) effect on

sperm concentration after puberty

18

What i is the role of medical management t in undescended d testicle?

• Hormone therapy as an adjuvant to surgery to improve

fertility

• Additional clinical information may be required:
• Ultrasound of testes to determine volume and calculate TAIn
• Endocrine evaluation (serum levels of LH, FSH, and inhibin B)
• Histopathologic evaluation of testes (bilateral biopsy of testes)

19

What i is the role of medical management t in undescended d testicle?

• Recommendations
• Reserve consideration of hormonal therapy for select

patients as it may improve fertility after orchiopexy (Level II evidence, Grade C recommendation)

Question 3 For children with undescended testicle:

What is the appropriate timing of intervention and how is this affected by

• ther clinical factors?

Consensus us S Statements – Timing o

• f

f Orchi hiope pexy

• American Urological Association 2014

(http://www.auanet.org/guidelines/cryptorchidism-(published- 2014))

<18 months

• European Association of Urology 2016

(https://uroweb.org/wp-content/uploads/EAU-Guidelines- Paediatric-Urology-2016-1.pdf)

Treatment should be completed by 12 months or 18 months at the latest

• Nordic consensus

(Ritzen et al, 2007)

6-12 months

22

Sea Search resu esult lts

• 61 studies obtained from initial search
• 22 added after further review
• 16 suitable for inclusion
• 6 prospective
• 10 retrospective
• Data on timing related to
• Outcome
• Testicular growth
• Germ cell development
• [Sperm count/extraction and testicular cancer discussed elsewhere]
• Laterality
• Associated gastroschisis/omphalocele
• Concurrent inguinal hernia
• No data on timing related to
• Other comorbid conditions; associated torsion; palpable/non-palpable; symptoms; ascending/retractile

23

Timi ming o

• f Orchi

hiope pexy – Testicular G r Growth

• 4 papers representing 3 patient populations
• Prospective RCT
• Prospective case series
• Retrospective
• Kollin et al. 2006, 2007
• Kim et al. 2011
• Tseng et al. 2017

24

Timi ming o

• f Orchi

hiope pexy – Testicular G r Growth

• Kollin et al. 2006, 2007
• N = 155 boys with unilateral, UDT
• Randomized at 6 months to surgery at 9 months or 3 years
• Serial ultrasounds

25

Testicular volume ratio (undescended/descended)

Timi ming o

• f Orchi

hiope pexy – Testicular G r Growth

• Kim et al. 2011
• N = 108
• Divided by age at orchiopexy
• Group 1 = <2 years
• Group 2 = ≥2 to <5 years
• Group 3 = ≥5 years
• Serial ultrasounds

26

Timi ming o

• f Orchi

hiope pexy – Testicular G r Growth

• Tseng et al. 2017
• N = 134
• Divided by age at orchiopexy
• ≤ 1 year
• >1 to ≤ 2 years
• > 2 years
• Serial ultrasounds

27

Timi ming o

• f Orchi

hiope pexy – Testicular G r Growth

• Recommendation
• Orchiopexy should be performed between 9 months and 2

years of age to optimize testicular growth (Level II-III evidence, Grade B recommendation)

28

Timi ming o

• f Orchi

hiope pexy – Germ rm C Cell Development

• 3 papers
• All prospective
• 1 RCT
• Kollin et al. 2012
• Li et al. 2014
• Park et al. 2007

29

Timi ming o

• f Orchi

hiope pexy – Germ rm C Cell Development

• Kollin et al. 2012
• 228 biopsies from 225 boys randomized to orchiopexy at 9

months vs 3 years

• Those who had surgery at 9 months
• Significantly larger numbers of germ cells and Sertoli cells
• Greater diameter of seminiferous cords
• Higher ratio of tubular/interstitial tissue

30

Timi ming o

• f Orchi

hiope pexy – Germ rm C Cell Development

• Li et al. 2014
• N = 20
• Age at surgery 5-24.5 mo
• Testicular biopsy at OR

31

Timi ming o

• f Orchi

hiope pexy – Germ rm C Cell Development

• Park et al. 2007
• N = 65
• Mean age at OR 1.95 years
• Testicular biopsy at OR
• Divided by age at orchiopexy
• ≤1 year
• 1-2 years
• 2-4 years
• >4 years
• 15 age-matched controls

32

Timi ming o

• f Orchi

hiope pexy – Germ rm C Cell Development

• Recommendation
• Early orchiopexy should be performed to optimize germ cell

number and other markers of histologic normalcy in the cryptorchid testis (Level II evidence, Grade B recommendation)

33

Timi ming o

• f Orchi

hiope pexy – Based on Laterality

• Yardley et al. 2012
• Retrospective
• 32 boys with abdominal wall defect and 46 UDT
• Spontaneous descent in 10/17 R UDT = 58.8%
• Spontaneous descent in 9/29 L UDT = 31.8%

34

p=0.06

Timi ming o

• f Orchi

hiope pexy – Based on Laterality

• Recommendation
• Laterality should not determine the timing of orchiopexy

(Level IV evidence, Grade C recommendation)

35

Timi ming o

• f Orchi

hiope pexy – Concurr rrent Inguinal Hernia

• 1 paper
• Retrospective
• Wright et al. 2017
• N = 43
• OR in first 6 months of age
• 26% required urgent/emergent repair
• 67% required delayed orchiopexy
• 18% overall atrophy rate

36

67% 19% 9%

Timi ming o

• f Orchi

hiope pexy – Con

• ncurren

ent Ipsilater eral Inguinal Hern rnia

• Recommendation
• Both procedures should be performed at the same time and

according to standard guidelines for inguinal hernia repair (Level IV evidence, Grade C recommendation)

37

Timi ming o

• f Orchi

hiope pexy – Gastr troschisis and Omph phalocele

• 3 papers
• All retrospective case series
• Gastroschisis
• 24 boys with 31 UDT (Hill et al. 2012)
• 26 boys with 35 UDT (Yardley et al. 2012)
• 7 boys with 9 UDT (Berger et al. 2006)
• Omphalocele
• 6 boys wth 11 UDT (Yardley et al. 2012)

38

Timi ming o

• f Orchi

hiope pexy – Gastr troschisis and Omph phalocele

39

Gastroschisis Omphalocele Boys (n) 57 6 Undescended testes (n) 75 11 Spontaneous descent 36/75 = 48% 1/11 = 9.1% Orchiopexy 22/66 = 33% 5/8 = 62.5%

Timi ming o

• f Orchi

hiope pexy – Gastr troschisis and Omph phalocele

• Recommendation
• The decision regarding timing of orchiopexy in gastroschisis

and omphalocele should follow standard orchiopexy guidelines (Level IV evidence, Grade C recommendation)

40

Question 4 For children with undescended testicle:

What is the evidence supporting type of

• perative intervention?

Sea Search Resu esult lts

• 179 studies obtained from initial search
• 18 added after further review
• 98 suitable for inclusion

42

Procedure Articles Reviewed Prospective Retrospective Open Inguinal 27 6 21 Single Scrotal Incision 17 2 15 Single Stage Laparoscopy 42 5 37 1-Stage Fowler Stevens 18 1 17 2-Stage Fowler Stevens 39 6 33 No Closure of Patent Processus 19 3 16 Pathologic evaluation of Nubbin 14 14

Consen ensus S Statem emen ents – Cho Choice ce o

• f

Op Operation

• n for Inguinal T

Testicle

• American Urological Association 2014

(http://www.auanet.org/guidelines/cryptorchidism-(published-2014))

Standard two incision (inguinal, scrotal) and single scrotal incision orchiopexy are both recommended

• European Association of Urology 2016

(https://uroweb.org/wp-content/uploads/EAU-Guidelines-Paediatric- Urology-2016-1.pdf)

Standard two incision (inguinal, scrotal) and single scrotal incision orchiopexy are both recommended

• Nordic consensus

(Ritzen et al, 2007)

Standard two incision (inguinal, scrotal) and single scrotal incision orchiopexy are both recommended

43

Single scrotal incision orchiopexy (SSIO)

Ref: Endo M, 2011

Inguinal orchi hiopexy vs.

• s. SSI

SSIO

Open Inguinal SSIO N 640 2130 Atrophy, % (95% CI) 0.31 (0.12, 0.74) 0.23 (0.00, 0.43) Retraction, % (95% CI) 1.72 (0.71, 2.73) 1.50 (1.45, 1.55)

One RCT showed no difference in atrophy or retraction

(Eltayeb 2014)

Inguinal orchi hiopexy vs.

• s. SSI

SSIO

Study N SSIO time (minutes) Inguinal time (minutes) p Eltayeb (prospective) 35 18 25 <0.001 Takahashi (retrospective) 49 47 67 <0.0001 Al-Mandil (retrospective) 56 34 64 0.002

• Length of Operation

Inguinal orchi hiopexy vs.

• s. SSI

SSIO

• Recommendations
• SSIO may be associated with lower incidence of atrophy and

retraction (Level II-III Evidence, Grade C Recommendation)

• SSIO is associated with a lower operative time

(Level II Evidence, Grade B Recommendation)

Consensus us S Statements – Choice o

• f Operation for

r Non Non-palpable Testi ticle

• American Urological Association 2014

(http://www.auanet.org/guidelines/cryptorchidism-(published-2014))

Perform examination under anesthesia to reassess for palpability of testes. If nonpalpable, surgical exploration (open or laparoscopy) and, if indicated, abdominal orchidopexy should be performed.

• European Association of Urology 2016

(https://uroweb.org/wp-content/uploads/EAU-Guidelines-Paediatric-Urology- 2016-1.pdf)

Thorough re-examination under anaesthesia; the easiest and most accurate way to locate an intra-abdominal testis is diagnostic laparoscopy

• Nordic consensus

(Ritzen et al, 2007)

Diagnostic laparoscopy through an umbilical port to determine surgical approach. The

• perative procedure is chosen according to pathoanatomical findings related to the

testis and vessels and to the surgeons preferences.

48

Abdominal Testis Open I Inguinal v

• vs. Primary La

Laparoscopic

Open Inguinal Primary Laparoscopic N 313 1434 Atrophy, % (95% CI) 4.47 (2.18, 6.76) 4.15 (3.16, 5.16) Retraction, % (95% CI) 1.60 (0.21, 2.99) 3.05 (2.19, 3.91)

Factor

• rs A

Affec ecting R g Retraction

• n
• Increased incidence of retraction with inguinal
• rchiopexy in children age greater than 19 months

(Sfoungaris 2012)

• For abdominal testis (laparosopic orchiopexy)
• Distance from the internal ring, ability to reach contralateral ring

did NOT CONSISTENTLY predict incidence of long-term retraction (Yucel 2007)

• Patient age was an independent risk factor for retraction

(Bagga 2013)

Abdominal Testis Open I Inguinal v

• vs. Primary La

Laparoscopic

• Recommendations
• Either open or laparoscopic orchiopexy for abdominal

testis is appropriate based upon surgeon’s preference

• Perform orchiopexy at 6 to 12 months to achieve a lower

rate of testicular retraction (Level II Evidence, Grade B Recommendation)

Consen ensus S Statem emen ents – Choice b between one o e or two s

• stage F

e Fowler Stephen ens Or Orchiopexy

• American Urological Association 2014

(http://www.auanet.org/guidelines/cryptorchidism-(published- 2014))

The decision to perform a one-stage or two-stage FS

• rchiopexy is left to the discretion for the surgeon based on

the location of the testis, associated vascular supply to the testis, and the anatomy of the peritesticular structures.

• European Association of Urology 2016

(https://uroweb.org/wp-content/uploads/EAU-Guidelines- Paediatric-Urology-2016-1.pdf)

The two stage approach may result in less testicular atrophy and better testicular mobility.

52

Fow

• wler-Step

ephen ens Or Orchiop

• pexy

1-Stage 2-Stage N 147 1434 Atrophy, % (95% CI) 14.4 (9.34,19.5) 9.17 (7.49, 10.8) Retraction, % (95% CI) 3.72 (1.14, 6.30) 2.41 (1.55, 3.28)

Non-comparative data – groups had differing clinical presentations

Fowler-Stephens ns Or Orch chiopexy

• One RCT compared One-stage and Two-Stage
• Mean age – 21.6 months
• Compared Testicular volume before and six months after

surgery

Pre-op Volume Post-op Volume P 1 – stage 0.53 0.50 0.310 2 – stage 0.56 0.54 0.333

(Wang CY. Asian J Surg 2018)

Fowler-Stephens ns Or Orch chiopexy

• Recommendations
• Both One-stage and Two-stage procedures have similar

rates of retraction therefore choice of approach is left to the surgeon

• One stage procedures may have a higher rate of testicular

atrophy (Level II-III Evidence, Grade B Recommendation)

Closure o

• f Patent Proc
• ces

essus Vaginalis

• Total Patients without hernia repair: 1677 (19 studies)
• Median follow up: 18.75 months
• No hernias reported
• Ceccanti noted increased incidence of testicular

retraction with closure

• 4.3% vs. 1.7% (P = 0.42)

Closure o

• f Patent Proc
• ces

essus Vaginalis

• Recommendation
• Routine closure of the patent processus vaginalis during
• rchiopexy is not indicated

(Level II Evidence, Grade B Recommendation)

Resecti tion o

• f N

f Nubbin

• Total units with pathologic evaluation: 329
• Findings
• Calcification

25.4 %

• Hemosiderin

23.5%

• Seminiferous tubules

6.67%

Resecti tion o

• f N

f Nubbin

• Recommendation
• During exploration for non-palpable testicle, a nubbin

should be resected if found (Level II Evidence, Grade A Recommendation)

Question 5 For children with undescended testicle:

What are the long term outcomes of

• rchiopexy?

• 5. What a

are e the e lon

• ng ter

erm ou

• utcomes

es after er

• rchi

hiopexy?

• a. What is the failure/recurrence rate?
• b. Is testicular mass/size affected by orchiopexy?
• c. What is the effect on fertility?
• d. What is the risk of testicular cancer?

Sea Search Resu esult lts

• 56 studies obtained from initial search
• 13 added after further review
• 52 suitable for inclusion

62

Sub-question Articles Reviewed Prospective Retrospective Other Failure/recurrence rate 8 1 5 2 Testicular mass/size 24 9 7 4 + 4rct Effect on fertility 18 10 4 4 Risk of Testicular Cancer 10 2 2 6

Sea Search Resu esult lts

• 56 studies obtained from initial search
• 13 added after further review
• 53 suitable for inclusion

63

Sub-question Articles Reviewed Prospective Retrospective Other Failure/recurrence rate 8 1 5 2 Testicular mass/size 24 9 7 4 + 4rct Effect on fertility 18 10 4 4 Risk of Testicular Cancer 10 2 2 6

• American Urological Association 2014

(http://www.auanet.org/guidelines/cryptorchidism-(published- 2014))

Failure rate is less than 4%. Monitor for retractile testes and for testicular ascent at every well child check

• European Association of Urology 2016

(https://uroweb.org/wp-content/uploads/EAU-Guidelines- Paediatric-Urology-2016-1.pdf)

Overall success rates reported to be 88%-100%

64

Consen sensu sus S Statem emen ents s – Wha hat i is t the f he failure/rec ecurren ence e rate? e?

5a 5a -What is the failure re/re recurre rrence rate?

Title Level of evidence Findings McIntosh, et al. 2013 IV failure rate = 1.6% (uni 1.5%, bil 1.9%) Alagaratnam, et al. 2014 IV 8.8% ascent rate Lopes, et al. 2016 IV 1.8% of patients required reoperation Sijsterman, et al. 2009 II 88.7% unilateral, 88.9% bilateral testes were found to be low scrotal in position Vikraman, et al. 2017 IV 3.4% of 25,984 orchiopexies required revision Attalla, et al. 2017 IV 98% success rate of inguinal orchiopexies

5a 5a -What i is the failure/ e/rec ecurren ence e rate?

• Recommendation
• Annual testicular exams should be performed until

puberty to assess for retractile or ascending testes that may require operative fixation. (Level II-IV Evidence, Grade C Recommendation)

Sea Search Resu esult lts

• 56 studies obtained from initial search
• 13 added after further review
• 53 suitable for inclusion

67

Sub-question Articles Reviewed Prospective Retrospective Other Failure/recurrence rate 8 1 5 2 Testicular mass/size 24 9 7 4 + 4rct Effect on fertility 18 10 4 4 Risk of Testicular Cancer 10 2 2 6

Consen ensus S Statem emen ents – Is tes esti ticular mass/ ss/si size affected ed b by orchiop

• pexy?

y?

• American Urological Association 2014

(http://www.auanet.org/guidelines/cryptorchidism-(published- 2014))

Atrophy rates are less than 2%

• European Association of Urology 2016

(https://uroweb.org/wp-content/uploads/EAU-Guidelines- Paediatric-Urology-2016-1.pdf)

Atrophy rates ~1.8% for inguinal orchiopexy, 28.1% for one- stage F-S, and 8.2% for two-stage F-S.

68

5b 5b - Is s testicular mass/size a affec ected b by orchiopexy xy?

• Jedrzejewski, et al. The role
• f ultrasound in the

management of undescended testes before and after orchidopexy – an update

• 128 boys with UDT
• Annual ultrasound for 3 years
• Testicular volume ratio

(operated to scrotal testes volume) was noted to increase when compared to the contralateral testes. Catch up growth was noted to increase overtime

69

5b - Is testicular mass/size affected by orchiopexy?

5b 5b - Is s testicular mass/size a affec ected b by orchiopexy xy?

• Carson, et al. Undescended testes: does age at
• rchiopexy affect survival of the testes?
• Retrospective review, 349 testicles, primary outcome =

testicular survival without atrophy

• 7.7% atrophy rate
• Odds of atrophy were 15.6 times higher for intra-

abdominal testes

• Age was not associated with increased atrophy

71

5b 5b – Is testi ticular mass/size affect cted by y

• rchi

hiopexy?

• Recommendation
• Operation does not always reduce volume but is a known

complication (atrophy – reported in less than 2% to as high as 33% in two-stage F-S)

• UDT are smaller than non-cryptorchid controls and

contralateral testes in most cases

• Testicular size appears to benefit from earlier operation

allowing for catch up growth, increased atrophy risk has not been shown in younger patients

(Level I-IV Evidence, Grade C Recommendation)

Sea Search Resu esult lts

• 56 studies obtained from initial search
• 13 added after further review
• 53 suitable for inclusion

73

Sub-question Articles Reviewed Prospective Retrospective Other Failure/recurrence rate 8 1 5 2 Testicular mass/size 24 9 7 4 + 4rct Effect on fertility 18 10 4 4 Risk of Testicular Cancer 10 2 2 6

Consen ensus S Statem emen ents – Effec ects o s on fertility ty?

• American Urological Association 2014

(http://www.auanet.org/guidelines/cryptorchidism-(published-2014))

A 6-fold increase in infertility for bilateral UDT, unilateral infertility is similar to controls, pre-treatment testes location does not affect paternity/sperm count/hormones, biopsy of bilateral UDT may help predict fertility

• European Association of Urology 2016

(https://uroweb.org/wp-content/uploads/EAU-Guidelines-Paediatric- Urology-2016-1.pdf)

Medical therapy may increase fertility, biopsy of bilateral UDT may be indicated

74

5c 5c - What i is the effect o

• n f

fert rtility?

• Feyles, et al. Improved Sperm Count and Motility in

Young Men Surgically Treated for Cryptorchidism in the First Year of Life

• 51 young men (age 18-26 years) with unilateral or bilateral

undescended testicles underwent operation in the 1st or 2nd year of life

• Total Sperm Count and Motility were higher in those

patients operated on in the 1st year of life

• Not affected by pre-op hormonal therapy, position of the

testes, or bilateral disease

75

Feyles, et et al

5c 5c - What i is the effect o

• n f

fert rtility?

• Hadeziselimovic, et al. Infertility in cryptorchidism is

linked to the stage of germ cell development at

• rchidopexy
• Cryptorchid boys lacking Ad spermatogonia will develop infertility despite

successful orchiopexy in childhood

77

Ha Hadezisel elimovi vic, et et al

5c 5c - What i is the effect o

• n f

fert rtility?

• Bilius, et al. Incidence of High

Infertility Risk among Unilateral Cryptorchid Boys

• Cryptorchid boys lacking Ad

spermatogonia will develop infertility despite successful

• rchiopexy in childhood
• 2000-2001:
• mean age of surgery = 5.3 years
• No Ad spermatogonia were found

in 44% of samples

• 2012-2013
• mean age of surgery = 4.1 years
• No Ad spermatogonia were found

in 50% of samples

79

5c 5c - What i is the effect o

• n f

fert rtility?

• Canavese, et al. Sperm Count
• f Young Men Surgically

Treated for Cryptorchidism in the First and Second Year of Life: Fertility is Better in Children Treated at a Younger Age.

80

5c 5c – What is the effect o

• n f

fert rtility?

• Recommendations
• To improve fertility perform orchiopexy between 6 and 12

months

• Counsel patients and families that successful orchiopexy

may not mitigate infertility in all patients

(Level I-III Evidence, Grade B Recommendation)

Sea Search Resu esult lts

• 56 studies obtained from initial search
• 13 added after further review
• 53 suitable for inclusion

82

Sub-question Articles Reviewed Prospective Retrospective Other Failure/recurrence rate 8 1 5 2 Testicular mass/size 25 10 7 4 + 4rct Effect on fertility 18 10 4 4 Risk of Testicular Cancer 10 2 2 6

Consen ensus S Statem emen ents – Ri Risk o

• f tes

esti ticular cancer er?

• American Urological Association 2014

(http://www.auanet.org/guidelines/cryptorchidism-(published-2014))

Orchiopexy before puberty does decrease the risk of testicular cancer Close follow up and monthly self exam is indicated in boys with a history of cryptorchidism

• European Association of Urology 2016

(https://uroweb.org/wp-content/uploads/EAU-Guidelines-Paediatric- Urology-2016-1.pdf)

Failed or delayed orchiopexy may increase risk of malignancy, for unilateral UDT in post-pubertal boys or older, orchiectomy should be considered if the contralateral testes is normal

83

What i is the risk o

• f testicular c

r cancer? r?

Timi ming o

• f Orchi

hiope pexy – Risk o

• f T

Testicular r Cancer

• 1 paper
• Retrospective, population-based study
• Pettersson et al. 2007
• N = 16,983
• OR between 1964 and 1999
• Mean age of OR 8.6±3.5 years
• Only 4.2% were <2 years of age
• 56 cases of testicular cancer
• <13 years = RR 2.23 (95% CI 1.58 – 3.06)
• >13 years = RR 5.40 (95% CI 3.20 – 8.53)

85

What i is the risk o

• f testicular c

r cancer? r?

• Recommendations
• The risk of testicular cancer in cryptorchidism can be

mitigated by prepubertal orchiopexy but is not brought to the level of normal controls

• The risk of malignant degeneration in testicular remnants

exists; if in OR, perform nubbinectomy. (Level II evidence, Grade B Recommendation)

Questions?