Ascending Testis (Acquired Cryptorchidism)

Definition

• Retractile testis - a scrotal testis that retracts easily but can be manually replaced in a stable scrotal position
• Recurrent cryptorchidism - testis that was undescended at birth, descended spontaneously, then became extrascrotal again
• Secondary cryptorchidism - suprascrotal testis after inguinal hernia repair or as a complication of orchidopexy

Mechanism / Pathogenesis

1. The testis is often located in a lateral (ectopic) position within the superficial inguinal pouch (SIP) - highly mobile and initially appearing descended
2. With somatic growth, the distance between the testis and scrotum increases relatively, making the incompletely descended testis appear to "ascend"
3. A fibrous remnant of the processus vaginalis tethers or foreshortens the cord over time
4. Mobility of the testis within an open sac

• Diagnosed at an average age of 8-11 years (vs. at birth for congenital)
• More likely in a lower position, distal to the inguinal canal
• Usually accompanied by a closed processus vaginalis and normal epididymis
• Campbell-Walsh-Wein Urology, p. 1226

Relationship to Retractile Testes

• Retractile testes present in 11%-15% of boys up to 11 years of age in population-based studies
• Up to 30% of boys at age 4 had suprascrotal testes on examination in one hospital-based cohort, but all were intrascrotal by age >12
• In prospective series, 2.6%-32% of boys with retractile testes developed ipsilateral cryptorchidism over 2.2-3.8 years of follow-up (retrospective series skewed higher due to referral bias)
• Serial examination is recommended for all boys with retractile testes to detect acquired cryptorchidism early
• Campbell-Walsh-Wein Urology, p. 1226

Prevalence

• True prevalence is incompletely defined due to limited longitudinal data
• One study of 742 infants found 1%-4% of testes rose to a high scrotal position at each follow-up visit
• In a cohort of 1072 boys followed from birth to 4.5-10 years, 1.6% acquired cases were observed, suggesting congenital and acquired forms may have similar prevalence
• More common in boys with proximal hypospadias

Associations

• Proximal hypospadias (increased incidence)
• Abnormal germ cell development
• Subfertility risk (though data is limited and largely retrospective)

Prognosis

Fertility

• Outcome data are difficult to interpret (retrospective, non-randomized studies)
• In limited series, spontaneous descent at puberty occurred in 57%-75% of acquired cryptorchid testes (Netherlands cohort)
• Subfertility risk is a concern, but prospective data are lacking
• Boys with retractile testes alone (uncomplicated) do not appear to have a clearly elevated infertility risk based on available evidence

Testicular Cancer

• Acquired cryptorchidism is associated with increased risk for testicular germ cell tumor (TGCT) - cases have been reported in older boys (mean age 18.9 years) followed for the diagnosis
• Population-based data from Australia showed increasing cancer risk for every 6-month delay in treatment beyond 18 months of age
• Seminoma predominates in persistently cryptorchid testes (74%), while nonseminoma predominates in scrotal testes
• Campbell-Walsh-Wein Urology, p. 1228, 1232

Management

Observation vs. Surgery

• Dutch investigators reported spontaneous descent in 57%-75% of acquired cryptorchid testes, most by mid-puberty, leading some to adopt an observational approach
• However, concern exists because descended testes in those series had reduced volume compared with controls, and the risk of delayed intervention on histology and malignancy risk is present

Surgical Treatment (Orchidopexy)

1. Optimize testicular function
2. Reduce risk of - and facilitate detection of - testicular malignancy
3. Provide cosmetic benefit
4. Prevent complications (torsion, hernia)

• For congenital cryptorchidism: surgery after 6 months but preferably by 12 months of age (per AUA guideline)
• For acquired cases: clinical judgment regarding timing; continued observation may be offered but serial examination is mandatory
• Operative approach is based on palpability and location of the testis

• Inguinal approach with mobilization of the spermatic cord
• Transverse scrotal incision and creation of a subdartos pouch
• Testis is passed through a dartos opening without twisting the cord
• Appendages excised; epididymis inspected
• Fixation by tension-free closure of the dartos around the cord

• Testicular retraction: <2% of primary open orchidopexies
• Testicular atrophy: approximately 1.9% in modern series
• Notably, in one series, all boys with acquired cryptorchidism had a successful result after orchidopexy, with a lower complication rate than congenital cases
• Campbell-Walsh-Wein Urology, p. 1235, 1243

Summary Table