Management of the postpubertal patient with cryptorchidism: an updated analysis

Management of the postpubertal cryptorchid testis depends on patient age at presentation. Based on the belief that the risk of death from surgery first exceeds the risk of death from testis cancer at age 32 years patients younger than 32 years are advised to undergo orchiectomy, while those older than 32 years are advised to remain under close observation. However, the data on which this recommendation is based are now a quarter-century old. During this interval significant improvements have been made in perioperative care and germ cell tumor therapy. We revisited the topic using contemporary data to determine whether and how recommendations on management of the postpubertal cryptorchid testis should be changed.

Contemporary data on germ cell mortality in the United States were obtained from the National Center for Health Statistics. From these data the lifetime risk of death from germ cell cancer in the general population was calculated for each 5-year interval between ages 15 and 60 years. Since the lifetime risk of germ cell tumor is believed to be higher in patients with cryptorchidism than in the general population, the lifetime risk of eventual death from germ cell tumor in the cryptorchid population was calculated by multiplying each 5-year lifetime risk by 9.7, which is the generally accepted relative risk of germ cell tumor in a cryptorchid testis. Contemporary literature on perioperative mortality was reviewed and we estimated the current mortality of orchiectomy based on American Society of Anesthesiologists (ASA) class. Mortality rates were plotted to determine the age when operative mortality exceeds the risk of mortality from germ cell malignancy.

While perioperative mortality and germ cell neoplasia mortality decreased in the last 25 years, the relative decrease in perioperative mortality was significantly greater. Thus, in ASA class I or II cases mortality from orchiectomy began to exceed mortality from germ cell cancer at age 50 years.

Improvements in therapy for germ cell neoplasia and perioperative care in the last 25 years have dramatically decreased the mortality of each cause. However, the decrease in perioperative mortality has been greater. In contrast to a generation ago, accidental death during routine elective surgery is now extremely rare in healthy patients. Thus, we advocate orchiectomy in all healthy males (ASA I and II) who present with postpubertal cryptorchidism until age 50 years.