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We assessed the effectiveness of imaging for identifying and correctly locating testicles, the use of hormonal stimulation for treatment planning and hormones for achieving testicular descent, and choices among surgical treatments, including surgical approach (open vs. laparoscopic).
We searched MEDLINE® via PubMed, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Embase, as well as reference lists of included studies.
We included studies published in English from January 1980 to February 2012. We included studies of prepubescent males with cryptorchidism. For treatment planning studies, we included all designs except case reports. Imaging studies needed to have confirmatory surgical data. For treatment studies, we required an appropriate comparison arm. We excluded studies of disorders of sexual development or ambiguous genitalia. Two reviewers independently assessed the quality (risk of bias) for each study and the overall strength of the evidence, with discrepancies adjudicated by a third reviewer.
We identified 60 unique studies meeting our review criteria; eight were of good, eight were of fair, and 44 were of poor quality. The accuracy of imaging to identify the presence or absence of testicles was 21 to 76 percent for ultrasonography (US), 42 to 92 percent for magnetic resonance imaging (MRI), 60 percent for computed tomography (CT) scan, and 100 percent for magnetic resonance angiography (MRA) and magnetic resonance venography (MRV). Both US and MRI failed to identify most cases of atrophied testicles. Two studies for a total of 44 boys accurately predicted anorchia using hormonal stimulation testing. Hormonal treatment is associated with testicular descent in some children, but rates generally do not exceed those seen with placebo by more than 10 percent. Surgical treatment for cryptorchidism is associated with success rates of testicular descent that range from 33 percent to 100 percent, depending on type of surgery. Weighted averages of success were 78.7 percent for one-stage Fowler-Stephens, 86 percent for two-stage Fowler-Stephens, and 96.4 percent for primary orchiopexy.
The body of the reviewed literature on cryptorchidism comprise primarily fair- and poor-quality studies, which limits our ability to draw definitive conclusions. No specific imaging technique is able to completely identify anorchia or position of the undescended testicles and thus eliminate the need for further surgical evaluation. Accuracy of imaging is related to location of the testicles, with less invasive methods demonstrating poor accuracy for abdominally located testicles and those that are atrophied. Hormonal stimulation testing may predict anorchia, but evidence is insufficient, with only two studies of fewer than 50 participants. Hormonal treatment is marginally effective relative to placebo, but it is successful in some children and has minimal side effects, suggesting that it may be an appropriate trial of care for some patients. Surgical options are effective, with high rates of testicular descent (moderate strength of evidence for Fowler-Stephens procedures, high for primary orchiopexy). Comparable outcomes occur with laparoscopic and open approaches.