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Three Out of Every Five Referrals for Bilateral Undescended Testis are Unnecessary
Kathryn Trandem, MD PhD, Hillary Copp, MD MS, Laurence Baskin, MD.
University of California School of Medicine, San Francisco, San Francisco, CA, USA.

BACKGROUND: Approximately 3% of full term males are born with cryptorchidism with ~ 2/3 of these descending by 6 months of age. Evidence based recommendation is referral to pediatric surgical specialist for physical examination (without sonographic imaging) at 6-9 months of age. The goal is early surgical treatment for a truly undescended testis especially for children with bilateral cryptorchidism in the hope of facilitating future fertility. In our practice, we continue to see a large number of patients referred for undescended testis that on examination have retractile and/or simply normal testis in a dependent position in the scrotum, especially if the referral is for bilateral undescended testis. We hypothesize that patients referred for bilateral cryptorchidism have a higher rate of either normal testis or retractile testis than patients referred for unilateral cryptorchidism.
METHODS: To quantitate our referral practice for cryptorchidism, a retrospective cohort study of healthy boys newly referred to the division of pediatric urology for unilateral and bilateral cryptorchidism between 2012 and 2018 was performed using ICD-9 (752.51 and 752.52) or -10 codes (Q53 (all) and Q55 (all)). The age of the patient, associated medical conditions, testicular exam with documentation of testicular location and whether the patient had imaging studies were all extracted from the electronic medical record. Syndromic children and children with other genitourinary anomalies (i.e hypospadias) were excluded, as they often warranted referral to urology for other reasons and their conditions were often associated with cryptorchidism (i.e. Prader Willi Syndrome).
RESULTS: Of the 5176 referrals seen at the pediatric urology clinic for cryptorchidism during the study period, 928 referrals were randomly chosen for chart review. Of these boys, 381 were follow-up patients and 188 had genitourinary and/or chromosomal anomalies and were excluded. Ultimately, 359 boys met inclusion criteria with 228 and 131 boys referred for unilateral and bilateral cryptorchidism, respectively. Average age at referral was 3.2 years (range 0-16). At time of physical examination by the pediatric urologist, 167 (73%) of the unilateral cryptorchid referrals were found to be truly undescended. In contrast, only 51 (39%) of the bilateral cryptorchid referrals were found to be truly undescended. If a boy was referred for a bilateral undescended testis, he had a 4.3 (95% CI 2.72-6.79, p<0.0001) higher odds of having a truly descended testis than a boy referred for unilateral undescended testis. Additionally, older age at referral was significant in both univariate and multivariate analysis for an unnecessary referral. Sixty-nine boys (19%) had unnecessary testicular ultrasounds ordered by their referring physician.
CONCLUSIONS: Bilateral cryptorchidism referrals are more likely to be retractile or normal testis than unilateral cryptorchidism referrals. Many unnecessary testicular ultrasounds are still being performed, in spite of efforts to educate primary care physicians. The average age of referral for cryptorchidism is well above the recommended 6-9m of age. This knowledge should promote the referring physician to give pause and carefully perform the physical exam of the scrotum in infants with suspected bilateral cryptorchidism.


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