In our previous courses, I explained what an undescended testicle is and how we evaluate it.  In this pediatric surgeon’s journal, I explained when and how we treated the undescended testis.
Let’s first clarify our purpose in the treatment of undescended testis.  The aim is to fix the testis to the visible place where it should be normal, that is, inside the sack.
Why do we do this?
To reduce the risk of torsion, to prevent damage to the testis in case of possible blunt trauma, to reduce reproductive damage, to allow the person to self-examine in case of developing testicular cancer, and to increase psychological self-confidence by ensuring that both testicles are in the bag.
I will talk about two types of treatment: surgical and hormonal.
The treatment of true undescended testis is surgery.  Hormonal therapy can be used in between cases.
When will the surgery be performed?
After the birth of the accepted babies, the descent process of the testicles may continue for another 4-6 months.  In this case, we do not perform surgery before 6 months, unless there are conditions that may force us, such as hernia or torsion.  It is known that the growth and reproductive potential of the testicles of children who have had surgery before the age of two are increased.  In the testicular biopsies performed at the age of three, it was determined that there were permanent damages in some reproductive cells.  This means that after 6 months, before the age of two, it is necessary to lower the testicles into their proper position, which is inside the scrotum.  But if there is an inguinal hernia, at the first appropriate time, preferably within fifteen days after diagnosis.  If torsion has developed, it is appropriate to operate immediately.
What is our routine in our clinical practice?
We wait up to 9 months after birth.  If the testis does not come down, we definitely do the surgery between nine and twelve months.  In cases where the testis cannot go down enough despite all kinds of technical maneuvers, it is necessary to wait for a period of six months for the second surgery.  Even if there is a requirement for resurgery, with the timing I mentioned, we will have chance to lower the testicles at the age of 18 months at the latest.
Earlier, I told you about a problem called “ascending testis”.  The testicle of the patient, who is followed up for shy testicles, starts to stay higher and turns into an undescended testis.  In these patients, it is necessary to fix the testis by performing surgery within six months after the diagnosis.
What is undescended testicle surgery?  How is it done?  Do they need to be hospitalized?
We call the operation of fixing the testicle by lowering it into the bag, “orchidopexy”.  In this surgery, we make an incision on the skin fold line, in the groin area or from the sack, depending on the location of the testis, we free the testis, its vessels and the sperm-carrying duct from the surrounding tissues, and make the testis cord straight and extend it down.  I have told you before what an inguinal hernia is. In children with undescended testicles, the canal that causes hernia may be open.  In this operation we close this canal, and after repairing the existing hernia, we fix the testicle inside the scrotum.  So if we did this surgery by making an incision in the groin, there are going to be two small incisions; both  in both the groin and the sack.
It’s not always easy.  Sometimes, even if we straighten the cord as much as we want, the testicles cannot be released enough and go down.  Then we do technically different maneuvers, sometimes we release from the back of the peritoneum almost to the kidney, we pass it under the veins, we try to somehow lower it down.  The surgery can take about 45 minutes.  After the operation, we wait for a while and after the recovery is ensured, we discharge on the same day.  So there is no need for hospitalization.
Post-surgery is usually very comfortable.  We do not do any dressing.  Two days later, his bandages are removed at home and he begins to take a bath.  Five days later, the control time comes.  We look for infection in the wound.  Then, with the first, third, sixth month and 1-year controls, we look at whether there is a problem in the growth and position of the testis.  Young children do not have any movement restrictions, but older children should stay away from activities such as sports and cycling for three weeks.
The success rate of orchidopexy is about 96%.  Testicular atrophy, ie shrinkage, can develop at a rate of 2%, due to damage to the testicular vessels during surgery, edema, or not being able to feed in the testis after a serious effort.  Other possible problems are infection, bleeding, inguinal hernia and testicular retraction during the healing process.
Let’s move on to hormonal therapy.
As a surgeon, I don’t recommend it much.  We know that testosterone has a place in the descent journey of the testicles from the abdomen to the sack. Therefore, gonadotropin or gonadotropin-releasing hormones to be given externally may play a role in testicular descent.  There are publications stating that it can be 10-90 percent successful.  But the success is mostly for the testicles outside the canal, close to the sack.  As a matter of fact, it is written that hormone therapy is effective in shy testicles, not in real undescended testicles.  But I do not recommend treatment for shy testicles anyway.  Moreover, hormone administration has side effects such as hair growth, penis enlargement, erections, irritability.  Although these problems last up to six months, we do not know much about their long-term effects.
In summary, I do not think that hormone therapy has a place in the treatment of true undescended testicles.  Sometimes it can be difficult to distinguish between a shy testis and a true undescended testis.  We cannot be sure.  We follow up, we make follow up charts, still we can’t be clear.  In such cases, hormones can be used.  As a matter of fact, the 2014 American Urology Association statement is not in favor of hormone therapy, it is written in the 2016 European guidelines that it can be used as a supportive treatment before or after surgery.
I want to emphasize it again so that there is no misunderstanding. 
If there is a shy testis, that is, a retractile testis, what we need to do is to follow up.  In one study, these children were followed for 3 years and one-third turned to be normal;  one third of them turned to be the ascending testis;  and it turned out that one-third remained shy.  If it turns into an ascending testicle, we operate like an undescended testicle.  If it returns to normal, we will stop following.  If it continues to be shy, we will follow until we are sure or until puberty.
Yes, it has been a long journey.  But it is an important and very common issue.  Next time I’ll tell you what to do with the testicles that are never palpable.
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 And stay happy.
Prof. Dr. Egemen Eroğlu