fertility potential in adulthood. A recent study

evaluating fertility potential in 65 men with ac-

quired and congenital UDT who had undergone

orchiopexy at puberty found abnormal testicular

consistency, smaller testes, lower sperm concentra-

tions and fewer motile sperm than in controls, por-

tending worse fertility potential, although without

evaluation of paternity.

In another study evalu-

ating long-term fertility potential via semen pa-

rameters in 78 men 18 to 26 years old who had

undergone orchiopexy during the ﬁrst 2 years of

life 96% of men had normal total sperm count

and motility if orchiopexy had been done within the

ﬁrst year of life, in contrast to 66% to 75% of those

who had undergone orchiopexy in the second year

of life, further supporting early intervention.

The number of germ cells per seminiferous tubule

is used as an indicator of fertility potential in

the developing testis. A recent study examining

testis samples from boys 5 to 25 months old using

germ and Sertoli cell markers demonstrated a

clear decrease in germ cell number with increasing

age at orchiopexy, suggesting a lasting impact on

fertility.

Overall, however, the fertility potential

of the cryptorchid testis is difﬁcult to determine

using single variables or even a combination of

variables. Recent work linking the number of adult

dark spermatogonia, which differentiate into pri-

mary spermatocytes, to other known fertility pa-

rameters,

including

serum

gonadotropin

and

inhibin B levels, and number of tubular germ cells,

has allowed further insight into the determination

of fertility potential in boys with a history of cryp-

torchidism. However, limiting the signiﬁcance of

this analysis was the fact that no evaluation of

pregnancy rates was available.

CRYPTORCHIDISM IN ADULTS

Early work demonstrated a higher risk of testicular

cancer in men with intra-abdominal testis but this

risk has been revised to 0.05% to 1%. Furthermore,

recent studies have demonstrated a lower risk of

cancer in boys undergoing orchiopexy before pu-

berty, with no increased risk of malignancy in a

contralateral normal testis.

23,24

However, fewer

studies have examined the role and risks of orchio-

pexy in postpubertal men. Given that the risk of

perioperative mortality has continued to decrease

and is now less than the risk of mortality from

germ cell tumors, some advocate for orchiectomy

postpubertally until age 50 years, at which point

observation

would

become

preferable

due

increased risk of perioperative morbidity.

Unfortunately, there is currently no consensus

and bilateral cryptorchidism in adults appears to

be rare, with few reports addressing management

in this situation. However, having an improved

understanding of the approach to such patients,

particularly with regard to balancing risk of malig-

nancy, fertility and endocrine function, should be

considered in the future.

In summary, the new AUA guideline is a signiﬁ-

cant step forward in synthesizing the existing data

on the diagnosis and management of cryptorchidism,

a daunting task in light of the volume of research

of variable quality performed in the last several de-

cades. Nevertheless, as evidenced by our ﬁndings,

continued progress in the ﬁeld is inevitable, with

numerous ﬁndings in the last year further contrib-

uting to our knowledge of the diagnosis and man-

agement of cryptorchidism, and largely supporting

the ﬁndings of the AUA guideline panel. Future

research remains necessary to better understand

numerous important aspects of cryptorchidism,

including the effects of the condition in adults.

Alexander W. Pastuszak and Larry I. Lipshultz

Scott Department of Urology

Center for Reproductive Medicine

Baylor College of Medicine

Houston, Texas

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348

DIAGNOSIS AND TREATMENT OF CRYPTORCHIDISM