Adult Orchidopexy for Undescended Testicle

Orchidopexy, also called orchiopexy, is surgery that moves an undescended testicle into the scrotum and fixes it in place.

Normally, the testicles descend into the scrotum before birth.

When one or both remain outside the scrotum, the condition is called:

• Cryptorchidism

• Undescended testicle

• Undescended testis

Most cases are diagnosed and treated during infancy.

A testicle that remains undescended until adulthood requires a different treatment strategy because years of abnormal temperature exposure can affect sperm production and increase malignancy risk.

Where can an undescended testicle be located?

An undescended testicle may be located:

• Near the upper scrotum

• In the inguinal canal

• Near the internal inguinal ring

• Inside the abdomen

Some testes are palpable during physical examination.

Others are non-palpable and may require laparoscopic exploration to determine whether the testicle is:

• Intra-abdominal

• Severely atrophic

• Absent

• Associated with abnormal anatomy

The location strongly influences the surgical approach.

Why treat an undescended testicle in adulthood?

Several issues must be considered.

These include:

• Testicular cancer risk

• Fertility

• Testosterone production

• Testicular pain

• Torsion risk

• Trauma

• Associated inguinal hernia

• Cosmetic appearance

• Ability to examine the testicle

Treatment therefore requires more than simply moving the testicle into the scrotum.

The surgeon must first decide whether preserving the testicle is appropriate.

Why is adult cryptorchidism different from childhood cryptorchidism?

In children, orchidopexy is ideally performed early because bringing the testicle into the scrotum can help protect future testicular function and facilitate examination.

By adulthood, an undescended testicle may have spent decades at an abnormally high temperature.

Long-standing cryptorchidism can result in:

• Germ-cell loss

• Reduced spermatogenesis

• Testicular atrophy

• Fibrosis

• Reduced fertility potential

The risk-benefit calculation is therefore different in adults.

Orchidopexy vs orchiectomy in adults

This is one of the most important parts of the page.

Adult patients should not be told that orchidopexy is automatically preferable because it “saves” the testicle.

Orchidopexy

Orchidopexy preserves the testicle.

It may be considered when:

• Both testes are undescended

• The patient has only one functioning testicle

• Hormonal function could benefit from preservation

• Fertility preservation is important

• Spermatogenic failure is already present

• The testicle appears potentially viable

• The patient strongly prefers preservation after counselling

Orchiectomy

Orchiectomy removes the undescended testicle.

It may be recommended when:

• Cryptorchidism is unilateral

• The opposite testicle is healthy

• The undescended testicle is severely atrophic

• The testicle appears abnormal

• Fertility benefit from preservation is unlikely

• Cancer-risk considerations favor removal

The decision should be individualized by an experienced urologist or andrologist.

What do current European guidelines say?

European guidance recognizes the important distinction between adult patients with preserved reproductive function and those with impaired testicular function.

For adult men with a unilateral undescended testicle and normal hormonal function or spermatogenesis, orchiectomy should be offered.

For selected adults with unilateral or bilateral undescended testes accompanied by hypogonadism or spermatogenic failure, orchidopexy may be offered when technically feasible.

This distinction is especially important for Andrology Abroad because presenting orchidopexy as the standard adult treatment without mentioning orchiectomy would be medically incomplete.

How is adult orchidopexy performed?

The exact operation depends on where the testicle is located.

For a palpable inguinal testicle, an incision is usually made in the groin.

The surgeon:

1. Identifies the testicle and spermatic cord.

2. Releases surrounding attachments.

3. Carefully mobilizes the spermatic vessels and vas deferens.

4. Creates sufficient length for the testicle to reach the scrotum without excessive tension.

5. Creates a pocket within the scrotum.

6. Positions the testicle inside that pocket.

7. Fixes it to reduce the chance of re-ascent or torsion.

The wounds are then closed.

What if the testicle is inside the abdomen?

A non-palpable testicle may require laparoscopy.

A small camera is inserted into the abdomen to locate the testicle and evaluate:

• Testicular size

• Blood supply

• Vas deferens

• Spermatic vessels

• Distance from the internal inguinal ring

Depending on these findings, the surgeon may perform:

• Standard laparoscopic orchidopexy

• Fowler-Stephens orchidopexy

• Staged orchidopexy

• Orchiectomy

What is Fowler-Stephens orchidopexy?

A high intra-abdominal testicle may not have enough vascular length to reach the scrotum safely using conventional mobilization.

Fowler-Stephens orchidopexy relies on collateral blood supply to obtain additional mobility.

It can be performed as:

• One-stage surgery

• Two-stage surgery

A staged approach allows collateral circulation to develop before the testicle is moved into the scrotum.

This should sit under your Techniques category rather than being another primary Procedure.

Is a testicular biopsy performed?

In adults undergoing orchidopexy, biopsy may be considered because of the increased risk of germ-cell neoplasia.

Current European guidance recommends simultaneous testicular biopsy for detection of germ cell neoplasia in situ (GCNIS) when undescended testes are corrected in adulthood.

This is an important difference between pediatric and adult orchidopexy.

Does orchidopexy reduce cancer risk?

Early childhood orchidopexy is associated with a lower cancer risk than correction after puberty.

However, adult orchidopexy should not be described as eliminating testicular cancer risk.

Moving the testicle into the scrotum makes it substantially easier to:

• Examine

• Monitor

• Ultrasound

• Investigate if a mass develops

The patient must therefore understand that repositioning the testicle does not reset cancer risk to that of a man who never had cryptorchidism.

How high is the cancer risk?

Cryptorchidism is an established risk factor for testicular germ-cell cancer.

Large cohort data have shown that men corrected after puberty have a substantially higher cancer risk than men corrected earlier.

This is one reason adult management may favor orchiectomy rather than preservation when the affected testicle is unilateral, abnormal or unlikely to contribute meaningfully to fertility or hormonal function.

Can adult orchidopexy restore fertility?

This requires careful wording.

Adult orchidopexy does not reliably restore fertility.

Long-standing exposure of the testicle to higher temperatures may already have caused irreversible damage to sperm-producing tissue.

However, isolated reports and small series demonstrate that spermatogenesis can sometimes persist or improve after post-pubertal orchidopexy.

Fertility assessment should therefore be individualized rather than assuming the testicle has either no function or normal function.

What if both testicles are undescended?

Bilateral adult cryptorchidism deserves particular attention.

Removing both testes would eliminate natural testosterone production and require lifelong testosterone replacement.

It would also eliminate any remaining potential for biological sperm production from those testes.

Testis-preserving strategies may therefore be considerably more important in bilateral disease.

Evaluation may include:

• Semen analysis

• Testosterone

• LH

• FSH

• Testicular imaging

• Fertility counselling

Orchidopexy may be considered if technically feasible.

What if only one testicle is undescended?

If the opposite testicle is normal and functioning, preserving a severely atrophic post-pubertal undescended testicle may offer limited reproductive or hormonal benefit.

In these circumstances, orchiectomy may be recommended.

The patient's:

• Age

• Testicular appearance

• Location

• Contralateral testicular function

• Fertility goals

• Hormonal status

• Cancer risk

• Personal preference

should all be considered.

Does orchidopexy improve testosterone?

Not necessarily.

An adult cryptorchid testicle may already have impaired Leydig-cell function.

Recent post-pubertal outcome data suggest that moving the testicle into the scrotum does not necessarily produce a substantial short-term improvement in testosterone, LH or FSH.

The main goals in selected adult patients may therefore be preservation, accessibility for examination and possible reproductive value rather than guaranteed hormonal improvement.

Can the testicle shrink after orchidopexy?

Yes.

The blood supply to the testicle must be carefully preserved.

If vascular supply is inadequate, postoperative testicular atrophy can occur.

This risk is particularly relevant for:

• High intra-abdominal testes

• Short spermatic vessels

• Fowler-Stephens procedures

• Previously operated testes

Why surgeon experience matters

Adult orchidopexy can be significantly more complex than routine pediatric orchidopexy.

Long-standing undescended testes may have:

• Short spermatic vessels

• Dense adhesions

• Abnormal anatomy

• Significant atrophy

• Associated hernia

• Increased oncologic concerns

The surgeon should therefore have experience in:

• Adult andrology

• Testicular surgery

• Laparoscopic urology

• Male infertility

• Testicular oncology assessment