AUA Guidelines on Undescended Testes
Brian Jumper, MD
The American Urological Association has recently come out with new guidelines regarding timing of surgery for undescended testes.
Experienced physicians at Maine Medical Partners – Urology have an informed opinion on this timing, and whether the effects of anesthesia on an infant’s central nervous system are effectively safe at such an early age.
Dr. Brian Jumper (Guest): The important thing to know is that I have looked at my own data over the last 25 years of practice and see that there is no change in the pattern of referrals that we’re getting referrals quite late in the process and that undescended testes are often found right at the time of birth, where 1 or 2 percent of normal boys have testes that are not palpable or not in the scrotum. The issue here for the AUA was come up with a set of guidelines that helped our primary care doctors know what our failings are and what the literature supports as far as following these patients and getting them as a proper referral to us so that we can evaluate them. What is known is that the cryptorchidism is the term meaning that you cannot see or feel the testes. And for one thing, imaging is not necessary to evaluate the children. It is just physical examination. We should be able to find the testes in the scrotum by six months of age. If they are not there on the well child visit by six months of age, they should be referred to a pediatric surgeon or a pediatric urologist so that we could evaluate them. The orchiopexy is a term we use for surgery to bring them into the scrotum, and through these 16 different recommendations that came out this August in the Journal of Urology, as far as our guidelines go, they make it obvious that we should be seeing them much sooner so that this is an ongoing problem for the testicle if it’s not in the scrotum. There are problems down the road with fertility, where they have much poorer sperm quality and numbers, and there’s an increased risk of cancerous changes later in life. The recommendations are for our pediatrician friends and family practitioners to send them to us if they do not palpate a testis in the scrotum by six months or what we consider their gestational age. Some children that are born prematurely are much younger because if they’re born at 34weeks and should be at 40 weeks, we take that six weeks into account. Six months of what would be their gestational age postpartum is when we would want to see those children if they do not feel the testes.
Melanie: Since this, Dr. Jumper, is one of the most common pediatric disorders of the male endocrine glands, are there certain risk factors that parents can know in vitro or before they get pregnant that would tell them you might be predisposed to having this situation?
Dr. Jumper: It’s a very complex set of risk factors, none of which are glaringly evident but one of which is smoking. There’s about a 13 percent increased risk in maternal smoking, but interestingly not for alcohol use. Another one that has come up as a risk factor—and this is very sad to hear—is Tylenol in the first and second trimester shows an increased risk. But none of these are very, very strong risk increases. It’s not like it doubles or triples it. It’s just in the order of a few percentage. It’s not just environmental, but there also is some multifactorial genetic issues, a couple that have been elucidative, but it only accounts for about 2 percent of all the boys with undescended testes. So it’s not recommended that you need genetic testing.
Melanie: What are the treatments involved? Parents hear surgery, they have an infant, they’re terrified. Tell us a little bit about what that surgery would entail, and what is the outcome? What happens afterward?
Dr. Jumper: Surgery is predicated on the testes needing to travel further, so it’s being held back typically by connective tissue and these muscles called the cremaster muscles. The cremaster muscles are an extension of our internal oblique muscles, which is a middle layer of muscles on our abdominal wall. Those need to be released and all the connective tissue freed up. So there’s is usually an inguinal incision, although you can do it all through a scrotal incision and move the scrotal incision around, then a second incision in the scrotum to make a little pouch for the testicle to reside. Ideally, this should be done before age two. That way, the child will have no memory of it. Their anesthetic risks are minimized and we can easily do the procedure. It gets more complicated if you cannot feel the testicle. That’s why there are 16 different recommendations, but I’m not going to go into all 16. But if you do not palpate the testes, you need to explore the abdomen, and that’s usually done with a laparoscopy. The children have a very great chance of having fertility if it’s just unilateral, just one testis is not down. Their fertility rates later on have been shown to be equal to the general population. However, bilateral undescended testes have a significant drop in parenthood and down to about maybe 50 percent. When you have bilateral undescended testes, it’s very, very important that they understand the risks of infertility later. The other big risk long-term is cancerous changes in the testes. If you bring them down before puberty, which is very late in the process, but if it’s done before puberty versus after puberty, you can reduce the risk of cancer by four or fivefold. We do not know exactly how much that would be reduced if we did all of our children before age two, but this presumption is that that would probably even confirm more protection than if they’re older. We do not recommend hormonal treatment, which is what they do in some places in Europe, for example, because there’s not enough evidence in the literature to suggest that hormones should bring down the testes.
Melanie: What about hernias after the surgery? Are they more predisposed to having hernia? Or how do parents care for this after treatment?
Dr. Jumper: Actually, they have a reduced risk of hernia because the hernia sac is typically associated with that undescended testis, which we fix at the same time. The second part of your question was what to expect. The children are amazing. They will recover within a day or two, acting as if nothing has happened. In fact, one of my colleagues did a video of his son later that same day running around, a two- or three-year-old. The point is, they can do very well as far as postoperative pain. Postoperative care is minimal. They usually are back to their own selves within one or two days.
Melanie: What’s the follow-up with the urologist, Dr. Jumper, after the fact?
Dr. Jumper: The follow-up is we see them about a week or two later to check on their incision and make sure everything is okay, and then six months later to reevaluate the testes to get an idea if they’re still where they should be, which 99.9 percent will. Occasionally, they may atrophy or shrink down if there has been damage at the time of surgery, which sometimes the blood vessels are not able to support the testes, especially if you have to do an abdominal testes which sometimes takes two procedures in order to get it safely into the scrotum. It’s recommended we see them six months later, and then counseling is one of the suggestions at the end of our recommendations so that by puberty and older, you’re never going to see that child’s testes again. They need to know about testicular self-exams for the risk of cancer, as I’ve mentioned.
Melanie: That was going to be my next question is explain to the parents just a little bit about teaching their children, their sons, about a testicular self-exam when they’re teenagers so that they know what they’re feeling for and what to look for. And then please tell the listeners why they should come to Maine Medical Center for their care.
Dr. Jumper: Well, the testes, to me, they are like hardboiled eggs. That’s what I counsel my adult patients when I go to do their vasectomies, when I’m examining them. I give this spiel. They should feel like hardboiled eggs, but if you were to palpate and squeeze the eggs slightly, if there was something inside that felt like a rock—let’s say the yolk of the egg was a rock—you would be able to feel that, much like the feel of your kneecap versus your thigh. Something that’s hard or irregular like that should be thought to be a testicular tumor until proven otherwise. The boys just have to kind of push the testes back and forth and slide it, make sure it feels uniform, it doesn’t feel hard in any way and feels soft and smooth. That should be done in about a monthly basis. Their risk for testicular cancer runs into the mid-50s, so it is something that they need to do for several decades and be aware of it. The reason that they should come to Maine Medical Center is we have fantastic pediatric anesthesiologists who are the most important thing as far as those parents are concerned because they are the ones that safely take the patient into surgery and bring them out of surgery safely. We do have three pediatric fellowship-trained urologists—myself, Dr. Thomas Kinkead, and we just hired a Dr. David Chalmers, who finished three years at Denver Children’s Hospital. Dr. Chalmers, for example, does a scrotal approach in some of his patients, whereas we do a standard two-incision approach, and all of us are trained to do it laparoscopically.
Melanie: Thank you so much, Dr. Jumper. You are listening to MMC Radio. For more information, you can go to mainemedicalcenter.org. That’s mainemedicalcenter.org, mmc.org. This is Melanie Cole. Thanks so much for listening and have a great day.