UroToday - The study concerned children with severe encephalopathy (SE). Cryptorchidism in these children is frequent and is often secondary to a spastic cremaster muscle provoking secondary retraction of an otherwise normal testis, without associated testicular dysplasia. The increased risk of testicular neoplasm observed in cryptorchid patients does therefore not exist in most of these patients. Indeed the 'common cause' theory or testicular dysgenesis syndrome, postulates that abnormal testicular descent happens in an abnormal testis, which is more likely to develop cancer. If this is so, secondary retracted testis are not at increased risk of cancer.
On the other hand, there have been several recent reports on the 'cause and effect' theory in which cryptorchidism and exposition to an abnormal testicular environment is carcinogenic in itself. Various studies credit early orchidopexy with a decreased risk of developing testicular cancer compared to children operated late, or not operated on at all. In a recent comprehensive review, Wood and Elder found that patients who undergo orchidopexy after the age of 12 (or no orchidopexy) were two to six times more likely to develop testicular cancer as those who undergo prepubertal orchidopexy. These results must still be regarded with caution, since it is probable that some boys who underwent early orchidopexy might have an inherently lower risk of cancer development because spontaneous testicular descent would have happened if given a chance.
The incidence of testicular cancer is still fairly low (5.1/100,000) and most often occurs in the third decade of life, which only one in five children with (SE) reaches. Whether orchidopexy decreases the risk of testicular cancer or not, it has the reputation of rendering the testicle clinically accessible for palpation. However, 25% of patients, whether operated or not, present with metastatic disease at the time of diagnosis, thus suggesting that surgery does not necessarily facilitate early diagnosis. Furthermore, the principle behind early diagnosis following orchidopexy relies mostly on self-examination, which is not relevant in children suffering from SE, in whom early detection would rely on frequent clinical examination.
Assuming a risk for testicular cancer in children with SE equal to that for the general population (approx 5.1/100,000), and taking into account relative risk of testicular cancer in cryptorchid patients with orchidopexy (about four times the general population) or without orchidopexy (about six times the orchidopexy group) and life expectancy for children with SE (approx 20% at age 30), it would probably require between 3,000 and 16,000 orchidopexies for one patient to benefit from surgery.
The question of improved fertility is irrelevant for these patients, and so is the psychological burden of the empty scrotum. The family, and sometimes the caregivers, feel strongly about the testicles being in the correct position, as for any other child. However, the benefit for the child is unclear and this raises questions about performing non-therapeutic treatments in severely disabled children. The predominant ethical issue is what is in the child's best interest.
Orchidopexy is performed under general anaesthesia, requires inguinal or intra-abdominal exploration, and is not without risk. These are fragile patients with an estimated morbidity and mortality which is superior to the normal population (ASA score 3). Unless the child is symptomatic, the medical justification for orchidopexy in these children unclear. From an ethical point of view, since there is no medical evidence of a benefit for the child, though there is clear evidence of risk, orchidopexy in these children is unwarranted. The results of this survey illustrate the unease on the subject. The 2 surgeons in our study who propose hormonal treatment for children with SE do not propose this treatment to the general population because they do not believe it to be effective enough. Thirteen recommend no treatment, but agree to perform surgery if the parents insist, though they do not believe the surgery to be justified. Five perform orchidectomy for impalpable cryptorchidism if the contralateral testis is present and orchidopexy is difficult, which has at least the advantage of truly preventing testicular cancer. Most perform orchidopexy for psychological reasons.
In conclusion, the risk/benefit ratio of orchidopexy for children with SE and crytporchidism is yet to be determined.
Written by Luke Harper, MD as part of Beyond the Abstract on UroToday. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations, etc., of their research by referencing the published abstract.
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