How Effective was the 2014 American Urological Association Cryptorchidism Guideline? - A Multi-Institutional Evaluation
Robert Thinnes, MD1, Hillary Weiner, BS2, Benjamin Pinsky, BS2, Charles Ferreri, BS2, Marquise Singleterry, BS2, Amanda Bahamonde, BS2, Sami Awadh, BS3, Jaqueline Tran, BS4, Alethea Paradis, MS5, Joel Vetter, PhD5, Anthony Brooks, MD5, Samantha Lund, MD5, Daren Kuwaya, MS1, Denise Juhr, MS1, Linder Wendt, MS1, Patrick Ten Eyck, PhD1, Erica Traxel, MD5, Kate Kraft, MD2, Jonathan Ellison, MD3, Douglas Storm, MD1.
1University of Iowa Hospitals and Clinics, Iowa City, IA, USA, 2University of Michigan, Ann Arbor, MI, USA, 3Medical College of Wisconsin, Milwaukee, WI, USA, 4Medical College of Wisconsin, Milwaukeee, WI, USA, 5Washington University, St Louis, MO, USA.
Background: In 2014, the American Urological Association (AUA) published guidelines regarding the evaluation and treatment of cryptorchidism. Recommendations from the guidelines included 1) referral for surgical management by 6 months of age if spontaneous testicular descent had not yet occurred and 2) the elimination of ultrasound or other imaging modalities in the routine evaluation of boys with cryptorchidism. The aim of this multi-institutional study is to determine if these guidelines reduced the age of referral and the utilization of ultrasound in boys with cryptorchidism. Our hypothesis is that the majority of boys with cryptorchidism are still being referred after 6 months of age and pre-referral utilization of ultrasound remains unchanged even after publication of these guidelines.
Methods: A retrospective review of boys referred for the evaluation of cryptorchidism was performed at four academic institutions, collecting data for 1 year prior to guideline creation (2013) and two non-consecutive years following guideline creation (2015 and 2019). We utilized the generalized linear mixed modeling framework to assess changes in (1) rates of patient comorbidities, orchiopexy, and pre-evaluation ultrasound and (2) mean ages at evaluation and at surgery. Models adjusted for institutional clustering (random effect). Comparisons (changes over time) of interest included 2013 vs. 2015 and 2013 vs. 2019. Appropriate distributions were specified for age outcomes (negative binomial distribution, log link) and rate outcomes (binary distribution, logit link). All comparisons with p-values ≤ 0.05 were considered significant. Analyses were conducted using R, version 4.1.0.
Results: A total of 2,848 patients were included in our analysis. Various patient co-morbidities which may delay referral were evaluated.
Over the duration of our study (2013-2019), there was a 6.8% (p = 0.200) increase in the mean age at time of first evaluation by a pediatric urologist, a 13.8% (p = 0.058) increase in the mean age at time of surgery and a 10.9% (p = 0.448) increase in the odds of utilizing ultrasound prior to referral (absolute increase = 3.7%).
| 2013 | 2015 | OR/MR (95% CI)2015 v. 2013 p-value | 2019 | OR/MR (95% CI)2019 v. 2013 p-value | ||
| Total Number of Patients Evaluated | 1,070 | 1,236 | - | 542 | - | |
| Patient Comorbidities | Number born prematurely (%) | 97 (9.1%)(N = 1,068) | 104 (8.5%)(N = 1,228) | 0.96(0.72-1.29)* 0.794 | 57 (10.6%)(N = 538) | 1.10 (0.77-1.56)* 0.583 |
| Number with Cardiac Disease (%) | 54 (5.1%)(N = 1,069) | 66 (5.4%)(N = 1,231) | 1.05 (0.73-1.53)* 0.788 | 24 (4.4%)(N = 541) | 0.86 (0.51-1.39)* 0.544 | |
| Number with Pulmonary Disease (%) | 66 (6.2%)(N = 1,070) | 70 (5.7%)(N = 1,232) | 0.97 (0.68-1.38)* 0.870 | 30 (5.5%)(N = 541) | 0.83 (0.52-1.29)* 0.421 | |
| Mean Age (months) at pediatric urology evaluation (SD) | 52.1 (45.8) | 56.0 (46.1) | 1.09 (1.00-1.17)# 0.042 | 53.6 (48.2) | 1.07 (1.00-1.18)# 0.200 | |
| Number of Patients evaluated by Pediatric Urology prior to 12 months of age (%) | 285 (77.7%)(N = 367) | 578 (78.7%)(N = 734) | 0.94(0.70-1.28)# 0.682 | 244 (76.2%)(N = 320) | 1.08 (0.75-1.55)# 0.670 | |
| Number of patients who underwent orchiopexy (%) | 641 (60.1%)(N = 1,067) | 668 (54.5%)(N = 1,226) | 0.76 (0.64-0.90)* 0.001 | 255 (47.0%)(N = 542) | 0.54 (0.44-0.67)* <0.001 | |
| Mean Age (months) at time of orchiopexy (SD) | 53.6 (48.3)(N = 640) | 60.1 (48.8)(N = 666) | 1.13 (1.02-1.25)# 0.016 | 59.2 (52.2)(N = 255) | 1.14 (1.00-1.30)# 0.058 | |
| Number of patients who underwent orchiopexy before 18 months of age (%) | 421 (65.8%)(N = 640) | 473 (70.8%)(N = 668) | 0.82 (0.65-1.04)* 0.095 | 173 (67.8%)(N = 255) | 0.87 (0.63-1.19)* 0.373 | |
| Number of patients with ultrasound evaluation prior to pediatric urology visit (%) | 222 (20.9%)(N = 1,056) | 257 (21.0%)(N = 1,209) | 0.91 (0.73-1.12)* 0.365 | 133 (24.6%)(N = 537) | 1.11 (0.85-1.45)* 0.448 | |
* Odds Ratio (OR)# Mean Ratio (MR)
Conclusions: Our data suggest that despite publication of the AUA Cryptorchidism Guidelines, there has been no reduction in the age of urologic evaluation or the utilization of imaging in boys with undescended testis. Perhaps the intended audience, namely pediatric primary care physicians, has not been reached by this 2014 publication. Finding alternative avenues to disseminate these evidence-based recommendations to referring providers and exploring barriers to guideline adherence will be necessary to improve evidence-based care for children with cryptorchism.
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