Current clinical guidelines recommend that orchidopexy be performed by the age of 1 in patients with congenital undescended testis. We sought to examine trends in surgical timing and to determine what factors are associated with age at surgery.
The Pediatric Health Information System (PHIS) is a national database of >40 freestanding children's hospitals. We searched the PHIS to identify boys with cryptorchidism who underwent orchidopexy between 1999 and 2008. Patient age at orchidopexy was evaluated, and we used multivariate models to determine factors associated with timing of surgery.
We identified 28 204 children who underwent orchidopexy at PHIS hospitals. Of these, 14 916 (53%) were white, and 17 070 (61%) had public insurance. Only 5031 patients (18%) underwent orchidopexy by the age of 1 year; only 12 165 (43%) underwent orchidopexy by the age of 2 years. These figures remained stable over time (P = .32). After adjusting for patient clustering, race (P < .001) and insurance status (P < .001) remained associated with patient age at orchidopexy; however, the treating hospital (P < .001) was the most important factor in predicting the timing of the procedure.
Only 43% had surgery by 2 years of age, which suggests that either significant numbers of boys with congenital cryptorchidism do not undergo surgery in a timely fashion or late-onset testicular ectopy is more common than generally recognized. Factors associated with the timing of orchidopexy include patient race, insurance status, and the hospital in which surgery is performed.
Dear Editor,
we welcome the recent article by Kokorowski et al. (1) which underlines the problem of delayed orchidopexy in boys with cryptorchidism and suggests that improvement is both needed and possible.
We have recently conducted an observational retrospective study to detect the current management of cryptorchidism in Italy, involving 140 Italian Family Pediatricians (FP) and 169 children with cryptorchidism. Our primary outcomes reflected those which have been identified as the best practices in cryptorchidism management by the Nordic Consensus (2): avoidance of hormonal therapy, a correct timing of orchidopexy and the use of a pediatric surgical team.
Our results confirmed an important delay of orchidopexy with a mean age at surgery of 22.8 months. The rate of surgery by 1 year of age was similar to the one reported in the US study (13% vs 18%), with only 50% who underwent orchiopexy under 2 years of age (vs 43%). Management resulted inhomogeneous with a mean age at orchidopexy which varied from 19,8 to 25,4 months among the Italian regions involved. In Italy the delay of orchidopexy cannot be imputable to insurance status as public insurance is ensured for all citizens or to race, as reported in the US (1). Primary pediatric care is entrusted to FP, therefore suggesting that the delay may be due to a lack in the knowledge of the new updated guidelines and of the problem of the acquired undescended testis.
With respect to the use of hormonal treatment our results showed that one out of 4 children with cryptorchidism have been treated with hormones as first line therapy. These findings reflect not only an unjustified wait -and-see approach but also a potential dangerous one. In fact, hormones are not formally recommended due to the unfavourable balance between benefits and dangers (3), and as they have been associated with an increased risk of testicular damage and consequent reduced spermatogenesis (4). In our study, hormones reported success rate was of only 15-20% compared to 95% of surgical treatment (3,4).
Optimal management of cryptorchidism represents a worldwide problem, not only specific to US. Efforts to ensure timely intervention to cryptorchid boys in order to prevent long term adverse health effects are warranted.
References
1.Kokorowski PJ, Routh JC, Graham DA, Nelson CP. Variations in timing of surgery among boys who underwent orchidopexy for cryptorchidism. Pediatrics. 2010;126(3):e576-82.
2.Ritzén EM, Bergh A, Bjerknes R, et al. Nordic consensus on treatment of undescended testes. Acta Paediatr. 2007;96(5):638-43.
3.Thorsson AV, Christiansen P, Ritzén M. Efficacy and safety of hormonal treatment of cryptorchidism: current state of the art. Acta Paediatr. 2007;96(5):628-30
4.Henna MR, Del Nero RG, Sampaio CZ, Atallah AN, Schettini ST, Castro AA, Soares BG. Hormonal cryptorchidism therapy: systematic review with metanalysis of randomized clinical trials. Pediatr Surg Int. 2004;20(5):357-9.
Federico Marchetti, MD (1), Jenny Bua, MD, MSc (2),Gianluca Tornese, MD (1), Giacomo Toffol, MD (3), Luca Ronfani, MD (4), on behalf of the Italian Study Group on Undescended Testes
(1) Department of Pediatrics, Institute of Child Health, IRCCS "Burlo Garofolo", Trieste, Italy (2) Department of Neonatology, Institute of Child Health, IRCCS "Burlo Garofolo", Trieste, Italy (3) Family Pediatrician, Associazione Culturale Pediatri, Italy (4) Service of Epidemiology and Biostatistics, Institute of Child Health, IRCCS "Burlo Garofolo", Trieste, Italy
Corresponding author: Federico Marchetti, MD Department of Paediatrics, Institute of Child Health, IRCCS Burlo Garofolo, Trieste Via dell'Istria 65/1, 34100 Trieste, Italy phone +39 040 3785454; fax +39 040 3785362 e-mail: marchetti@burlo.trieste.it
Conflict of Interest:
None declared