5th International Andrology Symposium
5th International Andrology Symposium
Dragana Živković
Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia.
The Institute for Children and Youth Health Care of Vojvodina, 21000 Novi Sad, Serbia. Correspondence; Prof Dr med. PhD Dragana Živković University of Novi Sad, 21000 Novi Sad, Serbia.
Accurate clinical distinction among undescended, ectopic, retractile and acquired/ascending testes underpins every subsequent decision in cryptorchidism. Misclassification drives both over- and under-treatment, with repercussions for fertility preservation, malignancy surveillance, resource use, and family counseling. This paper synthesizes practical pitfalls encountered from referral to definitive management, aligning bedside examination with contemporary guideline recommendations and translational insights. Drawing from our clinical program in Novi Sad and collaborative work with Faruk Hadžićselimović and colleagues, we emphasize five recurring traps: (1) equating any “empty” hemiscrotum with an undescended testis; (2) over-reliance on ultrasonography for palpable testes or to “rule in” non-palpable testes; (3) under-recognition of acquired/ascending testes and retractile physiology; (4) treating heterogeneous risk categories as homogeneous—particularly when biopsy interpretation is unavailable or suboptimal; and (5) ignoring environmental and systemic contexts that modulate risk and presentation. We propose a streamlined diagnostic pathway that privileges meticulous physical examination, judicious use of laparoscopy for non-palpable testes, selective adjunct testing, and context-aware counseling. Throughout, we integrate histological and molecular evidence (e.g., adult-dark [Ad] spermatogonia as a prognostic marker) to show how apparently “simple” diagnostic slips alter life-course outcomes.
Key words Cryptorchidism, pitfalls, treatment
Une distinction clinique précise entre testicules non descendus, ectopiques, rétractiles et acquis/ascensionnés conditionne toutes les décisions ultérieures en matière de cryptorchidie. Les erreurs de classification entraînent à la fois surtraitements et sous-traitements, avec des conséquences sur la préservation de la fertilité, la surveillance oncologique, l’utilisation des ressources et l’information des familles. Cette synthèse décrit les écueils pratiques rencontrés depuis l’orientation jusqu’à la prise en charge définitive, en alignant l’examen clinique bedside avec les recommandations contemporaines et les données translationnelles.
S’appuyant sur notre programme clinique à Novi Sad et sur les collaborations avec Faruk Hadžićselimović et collègues, nous identifions cinq pièges récurrents : (1) assimiler tout hémiscrotum « vide » à un testicule non descendu ; (2) surestimer l’utilité de l’échographie pour les testicules palpables ou pour « confirmer » un testicule non palpable ; (3) méconnaître les testicules acquis/ascensionnés et la physiologie rétractile ; (4) traiter des catégories de risque hétérogènes comme homogènes, surtout lorsque la biopsie est indisponible ou mal interprétée ; et (5) ignorer les contextes environnementaux et systémiques modulant les risques et les présentations.
Nous proposons un algorithme diagnostique rationalisé privilégiant un examen physique minutieux, une utilisation judicieuse de la laparoscopie pour les testicules non palpables, des examens complémentaires ciblés et un conseil contextualisé. L’intégration de données histologiques et moléculaires—notamment la valeur pronostique des spermatogonies adultes sombres (Ad)—montre comment des erreurs diagnostiques apparemment simples peuvent infléchir les trajectoires de vie.
Mots-clés: Cryptorchidie, pièges, traitement
For many trainees, orchiopexy is introduced as a “straightforward” pediatric case. Yet the clinical reality is knotty: the same child can be scheduled for surgery in one center and discharged with reassurance in another. That variability often reflects diagnostic pitfalls rather than genuine epidemiology. The consequences are not trivial. Perform an unnecessary orchiopexy on a retractile testis and you subject a child to anesthesia and create scar without benefit; miss an undescended or ascending testis and you delay the only intervention shown to optimize fertility potential and reduce malignancy risk when performed early.
Contemporary guidelines from both the American Urological Association (AUA) and the European Association of Urology (EAU) explicitly anchor management in accurate, exam-based classification, discourage pre-referral imaging, and recommend early orchiopexy for truly undescended testes—ideally by 12 months and no later than 18 months of age [1,2]. The rationale is not cosmetic: timely descent (surgical or, in selected contexts, hormonal) intersects with mini-puberty biology and the maturation of Ad spermatogonia, a determinant of adult spermatogenic capacity [3,4].
This paper is deliberately pragmatic. It is written from the perspective of a clinician who has stood at the operating table only to discover both testes in the scrotum of a child listed for “bilateral cryptorchidism,” and who has also seen non-palpable testes missed until school age—when salvage of fertility potential is less certain. It translates those lived clinic and operating-room tensions into five domains where diagnosis most commonly goes wrong.
Undescended testis (UDT) is an umbrella term encompassing true undescended (arrested along the normal path from abdomen to scrotum) and ectopic (deviated off the normal path). Retractile testis is a normally descended testis that can be manipulated to the scrotum and remain there without tension after cremasteric relaxation; it often rides high transiently due to an exuberant cremasteric reflex. Ascending (acquired) testis describes a testis documented in the scrotum earlier that later resides persistently supra-scrotal, likely due to an inelastic processus vaginalis or differential somatic growth. Finally, non-palpable testis includes intra-abdominal testes, canalicular testes hidden by body habitus, vanishing testes, or agenesis.
Failure to apply these labels rigorously begets algorithmic error. “Empty hemiscrotum → ultrasound → surgery” is a frequent but flawed chain. Pre-referral imaging is specifically discouraged by AUA/Choosing Wisely and international guidelines because it rarely changes management, can be misleading, and delays definitive care [1,2]. The diagnosis of cryptorchidism is, first and foremost, clinical.
A careful physical examination, performed in a warm room, with patience for cremasteric relaxation, and with the non-dominant hand sweeping from the anterior superior iliac spine along the inguinal canal, remains the most powerful diagnostic tool we have. In ~70% of referrals for “undescended testis,” a testis is palpable, and when palpable, management is largely determined without imaging [2]. Ultrasonography can “make” a retractile testis undescended, and it can’t reliably exclude a non-palpable testis; even in experienced hands, the testis may be missed in the canal or mistaken for lymph node or bowel. This is why AUA and EAU recommend against routine ultrasound prior to referral or surgery for palpable testes and against CT/MRI altogether [1,2].
Retractile testes do not require orchiopexy and, when truly retractile, carry fertility outcomes comparable to controls if left alone and monitored [6]. Conflating retractile with undescended drives unnecessary operations and parental anxiety. Conversely, labeling a true UDT as “retractile” delays orchiopexy beyond the window where germ cell maturation can be optimized (by ~12 months), risking poorer spermatogenic outcomes later in life [2–4].
Beyond operator variability, ultrasonography has limited sensitivity for localizing non-palpable testes and does not change the operative plan: if the testis is non-palpable, diagnostic laparoscopy both localizes and treats. Professional societies explicitly advise against ordering ultrasound, CT, or MRI for palpable or non-palpable testes during initial evaluation, because imaging rarely improves accuracy and often delays definitive management [1]. The EAU guideline reaches the same conclusion and prioritizes laparoscopy for non-palpable testes [2].
Common drivers include parental expectation (“We need a scan to be sure”), institutional habit, and referring-physician discomfort. Clear communication helps: family value prompt, confident, hands-on assessment and an explanation that laparoscopy is the most accurate—and often therapeutic—test when a testis is truly non-palpable [2].
An important subset of boys present with a history of previously scrotal testes that “ride up” over time. These acquired or ascending testes are not benign variants; their environmental and anatomical underpinnings differ from congenital UDT, but they still merit orchiopexy once ascent is established. Failing to recognize ascent—especially when earlier documentation exists—postpones repair and may erode fertility potential. Vigilant well-child examinations and accurate documentation of testis position at each pediatric visit are crucial; the AUA guideline underscores timely referral once ascent is identified [1].
Seminal work has shown that the presence or absence of Ad spermatogonia at orchiopexy correlates with later spermatogenic capacity; boys lacking Ad spermatogonia are a high-infertility-risk subgroup who may need intensified counseling and, in some protocols, adjuvant therapy [3]. Subsequent series—including national cohorts—have confirmed that a meaningful fraction of boys, even with unilateral UDT, lack Ad spermatogonia at typical ages of repair [3]. These data support the idea that “one size” counseling does not fit all.
Pathology services must be able to process small testicular biopsies and report beyond “juvenile testis” to germ-cell counts and the presence/absence of Ad spermatogonia. Without such capability, routine biopsy risks being uninformative, adding morbidity without guiding care—precisely the problem many centers face. Our Novi Sad experience mirrors others’: unless there is a committed and trained pathologist, biopsies rarely influence decisions (as discussed in our clinical reflections) [8]. When robust histologic reporting is available, biopsy during orchiopexy can stratify risk and refine follow-up; when it is not, biopsy should not be a ritual.
Hypospadias, ambiguous genitalia, bilateral non-palpable testes, or atypical genital anatomy warrant coordinated evaluation for differences/disorders of sex development (DSD) with endocrinology and genetics. Here, the mini-puberty window (weeks to months after birth) is a unique diagnostic moment to collect gonadotropin and testosterone data before the hypothalamic-pituitary-gonadal axis quiets [4]. A UDT work-up divorced from this context risks missing CHH or other endocrine disorders that change treatment entirely.
Cryptorchidism is a canonical endpoint in the “testicular dysgenesis syndrome” framework, where maternal smoking, certain pesticides and endocrine-disrupting chemicals have been variably associated with risk. While causal inference is complex, clinicians should be aware that regional exposures (including poorly regulated pesticides or post-industrial pollutants) can shape population-level histology and prevalence, as we observed when comparing Serbia with Switzerland and parts of the USA in different eras [6].
Step 1. History & context
Step 2. Physical examination (the crux)
Step 3. Decision node: palpable vs non-palpable
Step 4. Adjuncts—used selectively
Increased adiposity frustrates palpation; this is the rare case where ultrasonography can be pragmatically useful if it shows a canalicular testis that will be addressed via inguinal exploration, but the default remains examination and timely referral—not serial scanning [1].
This is an endocrine emergency until proven otherwise; evaluation should occur during mini-puberty to leverage physiologic LH/FSH/testosterone peaks. MRI/CT are not first-line; coordinated endocrine and surgical evaluation is.
Laparoscopy that reveals blind-ending vessels above the internal ring obviates further groin exploration; avoid the pitfall of “chasing” a testis that involuted antenatally [2].
Do not assume retractile status; acquired ascent is common. Prior documentation of scrotal position transforms the diagnosis to ascending testis requiring orchiopexy [1,2].
Mini-puberty—a physiologic postnatal surge in gonadotropins and testosterone—promotes transformation of gonocytes into Ad spermatogonia, seeding future spermatogenesis. In cryptorchidism, impaired testicular environment and hormonal signaling jeopardize this transition. Histologic series show that absence of Ad spermatogonia at orchiopexy predicts impaired adult sperm output; conversely, timely intervention aligns with more favorable maturation [3]. This biology is why guidelines press for early orchiopexy—by 12 months (and no later than 18 months)—and why protracted diagnostic pathways fueled by unnecessary imaging are not benign administrative detours but potential biologic harm [1,2].
The apparent simplicity of orchiopexy belies the diagnostic nuance required to decide who needs it, when, and how to counsel about future fertility. The most costly mistakes are often made before the first incision: labeling a retractile testis “undescended,” scanning instead of examining, or letting a non-palpable testis languish in a queue of imaging studies rather than proceeding to laparoscopy. When we align practice with evidence—exam-first classification, early referral and repair, selective adjunct testing, and center-appropriate use of biopsy—we respect both the biology of mini-puberty and the long-term interests of our patients. Cryptorchidism should be taught and practiced not as a routine, but as a disciplined exercise in developmental diagnosis.
With gratitude to Professor Faruk Hadžićselimović for mentorship that transformed my approach from certainty to curiosity, and to the teams in Novi Sad who continue working to improve access to timely evaluation and high-quality pathology reporting.
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