Anatomical position as a predictor of hormonal therapy failure in palpable undescended testes

Hormonal therapy for cryptorchidism shows limited long-term efficacy and is not routinely recommended by current guidelines, yet it continues to be used in practice. Evidence identifying anatomical subgroups with predictably poor outcomes remains limited. This study evaluated whether anatomical position predicts failure of hormonal therapy in palpable undescended testes.

This single-center retrospective cohort study included boys ≤ 14 years who received human chorionic gonadotropin (hCG) therapy for palpable undescended testes between 2015 and 2024. Testes were classified as high inguinal, low inguinal, external ring, or scrotal neck. The primary outcome was permanent testicular descent, defined as stable scrotal position for ≥ 6 months without re-ascent or orchidopexy. Multivariable logistic regression identified predictors of permanent descent.

A total of 170 testes in 154 boys were analyzed. Overall permanent descent was achieved in 21.8%, with re-ascent occurring in 39.3% of initial responders, underscoring the importance of assessing durable rather than immediate outcomes. Success varied significantly by anatomical position (p < 0.001): external ring 50.0%, scrotal neck 38.1%, low inguinal 16.7%, and high inguinal 3.6%. Testes above the external ring accounted for 77% of treatment failures; additionally, 78.2% of testes ultimately required orchidopexy. Anatomical position was the strongest predictor of permanent descent, with markedly reduced odds for low inguinal (adjusted OR 0.19) and high inguinal (adjusted OR 0.04) positions compared with external ring.

Hormonal therapy failure in palpable undescended testes is highly predictable based on anatomical position. High and low inguinal testes demonstrate negligible to poor durable benefit, and orchidopexy should generally be preferred over hormonal therapy trials in these positions, though shared decision-making with families remains appropriate. External ring and scrotal neck testes represent the only subgroups in which selective hormonal therapy may be considered through shared decision-making with families. These findings refine guideline-based management by identifying where hormonal therapy should generally be avoided to prevent futile treatment.