Opinion: Comment on Evaluation and Treatment of Cryptorchidism: AUA/AAP and Nordic Consensus Guidelines

The ultimate goal in the treatment of cryptorchidism is to achieve normal fertility. However, in a substantial number of cryptorchid males, early and apparently successful orchidopexy does not improve fertility as it does not address the underlying pathophysiological cause, namely, the impaired transformation of gonocytes into Ad spermatogonia. It is important to realize that over half the patients presenting with unilateral cryptorchidism and the majority of those presenting with bilateral cryptorchidism have abnormal spermiogram which indicates that unilateral cryptorchidism is in fact a bilateral disease and therefore a serious andrological problem. More importantly, only testicular biopsy can nowadays determine which patient should benefit from hormonal therapy. This means that the rationale behind testicular biopsy is both diagnostic and therapeutic, particularly since LH-RHa hormonal therapy is a worthwhile solution to this andrological problem. In boys with a high risk of azoospermia development, adequate treatment with low doses of LH-RHa allowed 86% of subjects to achieve a normal sperm count. This strongly contrasts with the results of the 'surgery-only' group where not a single patient had a normal spermiogram and 20% suffered from azoospermia. Testicular biopsy is all the more justified that it allowed the detection of in situ carcinoma in 0.6% of all the cryptorchid boys studied. Even if hormonal pre-treatment only achieves successful epididymo-testicular descent in 20% of cases, this treatment should remain the first therapeutic choice because it may avoid resorting to surgery. In addition, it has no adverse effect on fertility and, in unsuccessful cases, facilitates orchidopexy and considerably helps reduce the incidence of post-surgical testicular atrophy, whether unilateral or, and this is a much more serious event, bilateral.