Governments and health care systems across the world have recommended/mandated that elective surgery be postponed — as long as the delay does not cause harm to the patient. To better assist pediatric urologists addressing whether a delay could affect their patients, we reviewed the literature to provide evidence from which to base a decision to proceed with or postpone surgery. We start this guide with groin cases.
The American Urologic Association Guideline on the management of undescended testis recommends performing surgery in between 6-18 months of life “to preserve available fertility potential”.
In this study from Pittsburgh published in 2005, 65% of 86 men who had bilateral cryptorchidism were successful at paternity, compared to 90% of 609 with unilateral UDT and 93% of 708 men in the control group. Paternity rates were similar between the control group and patients who only had one testis or who had one testis removed. This study also showed some evidence of more favorable hormonal profiles and testicular volume for patients who had orchiopexy earlier (<9-18 months).
Another large study from Australia demonstrated a statistically significant decline in paternity and increased use of assisted reproductive technologies for every 6-month delay in orchiopexy.
Despite all these studies showing some statistically significant differences, at the end of the day, paternity rates in boys with a unilateral UDT are almost identical to controls, regardless of the age of orchiopexy. A delay in surgery is thus likely inconsequential.
On the other hand, for bilateral undescended testis, a delay could affect the potential for fertility. This 1995 study of testicular biopsies done at the time of orchiopexy, showed progressive deterioration in the testicular fertility index in the age groups of <2 years, 2-6 years, and >6 years. The study did not find a statistically significant difference in the fertility index of undescended testis less than 1-year-old compared to their contralateral normal testis. How would these data translate into paternity rates is unknown, but it would seem prudent to perform bilateral orchiopexies before the first year of life whenever possible.
In patients with multiple comorbidities or chromosomal abnormalities, the concern with regards to fertility would change depending on the severity of the disease, and thus it should be taken into account.
With regards to the risk of testicular cancer, the study by Patterson et al published in 2007 on the NEJM, found that the Standardized incidence ratio of testicular cancer did not increase significantly with age at orchiopexy until the age of 13:
- 0-6 years: 2.02
- 7-9 years: 2.35
- 10-12 years: 2.27
- >13 years: 5.40
Or in other words, if the only concern is that of testicular cancer, as long as the surgery is done before the age of 13 years, the risk does not appear to be increased in any clinically significant measure.
One last important consideration in patients awaiting orchiopexy is the risk of testicular torsion. From the AUA core curriculum:
A recent study identified 11 boys who were scheduled for orchiopexies which, while waiting for surgery, developed testicular torsion. These 11 cases corresponded to 10% of testicular torsion cases seen in between 2013 and 2018 at the authors institution. Median age was 9 months (range 1-22 months). Salvage rate was low at 18%. Clinically, 4/11 cases were thought to have an incarcerated hernia preoperatively. Over the same period, the authors performed 1440 orchiopexies, which translates to an incidence of torsion of 0.7% or 1/130 cases –much higher than the incidence of torsion of 1/5000 in the general population.
Hydroceles and Inguinal Hernias
Non-communicating hydroceles can be observed indefinitely as long as they are asymptomatic since there is no association with damage to the testis or any long term consequences. Christensen et al found a 75% chance of resolution for non-communicating hydroceles of new-onset in boys older than 1 year of age. They recommended an observation period of 6-12 months prior to repair. This is in contrast with the recommendation to operate on hydroceles that appear after the first 1-2 years of life made by the Canadian Association of Pediatric Surgeons.
Koski et al observed 174 infant boys presenting with an apparent communicating hydrocele (before 18 months of age) without surgery, noting 63% complete resolution at a mean age of 11.7 months. Six (5%) developed a hernia during observation, none of which had an episode of incarceration. They concluded that little risk is taken by initially observing communicating hydroceles in infants with the potential of spontaneous resolution in the majority. There are no reports with regards to communicating hydroceles of new-onset in boys older than 1 year of age.
Pediatric inguinal hernias have been typically repaired soon after they are diagnosed, even in premature or sick newborns, due to the higher risk of incarceration/strangulation reported in the literature for premature babies. The Canadian Association of Pediatric Surgeons recommends repair within a week of diagnosis in premature babies and “soon” after the diagnosis in full-term, healthy infants and older children. However, some centers have been postponing surgery for premature sick children until health has been optimized and the child can tolerate anesthesia better (i.e, after 3 months of corrected age). A retrospective review of 6361 children with hernias operated by a single surgeon over a 35 year period reported incarceration overall in 12% (39% of 191 preemies <36 weeks). Of 743 incarcerated hernias, only 8% could not be reduced before surgery and only 2 patients had bowel resection due to strangulation.
In another study of 172 premature infants diagnosed with inguinal hernias, outpatient elective repairs were done in 127 of the patients, none of which developed apnea. Eighty patients had a known inguinal hernia during their NICU hospitalization, 35 of which were discharged home with the hernia and none of them developed incarceration before elective repair. 45 patients had surgery before discharge from the NICU of which 13% required prolonged (>48 hrs) intubation after the surgery. Overall, 8 patients (4.6%) developed incarceration at a mean age of 11 weeks. All 8 patients were successfully reduced with no patient developing bowel or gonadal ischemia.
Another large study from Taiwan showed no difference in the rate of incarceration or strangulation between preterm and term babies. 2/231 preterm babies had bowel resection compared to 11/3650 term babies.
A several months delay in fixing a unilateral UDT is likely clinically inconsequential.
Bilateral UDT should probably be corrected before the age of 18 months as recommended by the AUA guidelines.
Hydroceles can be safely observed for several months in reliable families, after explaining the small risk of a hernia during observation.
Hernias can also wait a few weeks to be repaired in reliable families with quick access to medical care, after explaining the risks of observation to the family.