Utilization of ultrasound in patients undergoing orchidopexy: Impact of the 2014 AUA Guidelines
Ted Lee, MD, MSc, Andrea Balthazar, MD, Tanya Logvinenko, PhD, Caleb Nelson, MD, MPH, Hsin-Hsiao S. Wang, MD, MPH, MBAn.
Boston Children's Hospital, Boston, MA, USA.
BACKGROUND: Ultrasonography has a limited role in cryptorchidism management due to low sensitivity and specificity in localizing the non-palpable testis(es). In 2014, the American Urologic Association (AUA) guidelines for evaluation and treatment of cryptorchidism recommended against ultrasonography use prior to referral to a surgical specialist. Population based studies conducted before the publication of AUA guidelines demonstrated frequent use of ultrasonography in cryptorchidism management. The objective of this study was to assess whether trends of ultrasonography utilization for diagnosis of cryptorchidism have changed since the 2014 AUA guidelines were introduced. We hypothesized that trends of ultrasonography utilization have decreased since 2014.
METHODS: We queried the Pediatric Health Information System (PHIS) database to identify boys who underwent scrotal, abdominal, or retroperitoneal ultrasonography prior to undergoing orchidopexy, inguinal hernia repair, and hydrocelectomy between January 1, 2009 and December 31, 2019. Hospitals without outpatient surgery information were excluded. The cohort was divided into the orchidopexy group and inguinal hernia repair/hydrocelectomy group. The main outcomes were proportion of those undergoing ultrasonography prior to surgical intervention before and after the introduction of the AUA Guidelines (second quarter of 2019). Multiple group interrupted time series analysis (difference-in-difference) was performed with the introduction of the AUA Guidelines as the intervention time point.
RESULTS: We identified 110,450 individuals who underwent orchidopexy and 187,522 individuals who underwent inguinal hernia repair (n=165,593) or hydrocelectomy (n=21,929) between 2009 and 2019. Across all time periods, 1.4% (1,570/110,450) received ultrasonography prior to orchidopexy, opposed to 0.003% (550/187,522) who underwent ultrasonography prior to inguinal hernia repair and hydrocelectomy. Since 2014, there were significant increases in ultrasonography utilization trends in both the orchidopexy and inguinal hernia repair/hydrocelectomy groups (p < 0.001 and p = 0.001, respectively). However, the increase in trend was greater in the orchidopexy group compared to the inguinal hernia repair/hydrocelectomy group after the intervention time point (p = 0.005).
CONCLUSIONS:
Although overall utilization of ultrasonography prior to orchidopexy remains low within hospitals participating in the PHIS database, ultrasound utilization did not decrease after AUA guidelines on cryptorchidism were published in 2014. In fact, utilization prior to all groin surgeries increased after 2014. The largest limitation of this study is the inability of the PHIS database to capture ultrasonography performed at outside institutions. 
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