1. Dropping the Ball The geopolitical management of cryptorchidism Wayne Brisbane, PGY-1 Department of Surgery

2. Overview Decline in the amount of orchiopexies performed by pediatric surgeons? What is the current state of treatment for cryptochidism. Europe – Hormonal treatment – Nordic consensus – Current practice United States – Guidelines – Current practice

3. Definitions Retractile Testis: can be “milked” into the scrotum, where it will remain, at least temporarily. Undescended Testis: absence of testis in the scrotum secondary to cryptorchid testis or vanishing testis.

5. Hormone Treatment B-hCG was originally introduced at a treatment in 1930. 1 Intranasal GnRH use began in 1975 2 Use has had varying degrees of enthusiasm over the last 30-40 years. Effective in about 20% of cases. 3 1.Schapiro B. [25 ears of hormonal treatment of cryporchidism]. Harefuah 1957; 53 198-9. 2.Bartsch G and Frick J. Therapeutic effects of luteinizing hormone releasing hormone (LH-RH) in cryptorchidism. Andrologia 1974; 6: 197-201 3.Pyorala S, Huttunen NP, Uhari M. A review and meta-analysis of hormonal treatment of cryptorchidism. J Clin Endocrinol Metab 1995; 80: 2795-9

6. Pyorala S, Huttunen NP, Uhari M. A review and meta-analysis of hormonal treatment of cryptorchidism. J Clin Endocrinol Metab 1995; 80: 2795-9

10. When to drop the ball 1950’s around age 10. 1 1975 age 4-6. 2 1996 age 1. 3 1.Gross, R.E. and Jewett, T.C., Jr.: Surgical experiences from 1,222 operations for undescended testis. J Am Med Assoc, 160: 634, 1956 2.The timing of elective surgery on the genitalia of male children with particular reference to undescended testes and hypospadias. Pediatrics, 56: 479, 1975 3.Timing of elective surgery on the genitalia of male children with particular reference to the risks, benefits and psychological effects of surgery and anesthesia. American Academy of Pediatrics. Pediatrics, 97: 590, 1996

11. Treatment window between 6 and 12 months of age, at least by 18 months. Medical therapy has success rates of 20% and is beneficial before or after surgical orchiopexy to increase fertility index. Lack long tern follow up data Palpable Testis: orchidofuniculoysis and orchiopexy Non palpable Testis: Inguinal surgical exploration, possible laparoscopy Intrabdominal testis for boys > 10 years old should be removed. If bilateral in boys < 10, Fowler-Stephens procedure is an option.

21. New York state health department maintains data on all operations performed in New York hospitals. Total of 36,484 patients underwent orchiopexy. – 26,575 outpatient – 9,909 inpatient

25. Baumracker, G.: Incidence of testicular pathology. Bull U S Army Med Dep, 5:312,1946

26. Summary Orchiopexy surgeries are occurring at relatively the same rate in some states. Unclear in WA. Ideally these surgeries are performed prior to age 1 yo, however this is difficult to accomplish on a global scale.