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It has been known for more than 20 years that early treatment of maldescended testicles can have a positive effect on fertility and a negative effect on the development of tumors. In certain circumstances, hormone therapy is still recommended in German-speaking countries. However, its benefit is still controversially discussed. Therapy is usually initiated by the pediatrician, who is usually the first to detect undescended testicles. Since therapy may involve early hormone therapy as well as surgery, acceptance among pediatricians and also the parents may be reduced. The question also arises as to how far the implementation is practicable. In patients with nonpalpable testis, there are many controversies concerning the value of ultrasound investigations. In the following two case studies, the treatment decisions for undescended testes in infancy are exemplified. Furthermore, the available evidence from the literature and guidelines is presented to provide assistance for daily routine care and to critically discuss potential fields of application and limitations of existing guidelines.

Background: Cryptorchidism is the most common genital malformation in male newborns. In recent years, guidelines concerning diagnosis and therapy have undergone considerable evolution with the implementation of recent knowledge in pathophysiology, diagnosis, and therapy., Objectives: The aim of this publication is to provide an overview of the current national and international guideline recommendations concerning diagnosis and treatment of cryptorchidism. Critical points are discussed in light of current scientific literature., Materials and Methods: The current guidelines of the European Association of Urology (EAU)/European Society for Pediatric Urology (ESPU), the American Association of Urology (AUA), the pediatric urologic task force of the Austrian Society of Urology (ÖGU), the international consultation on urological disease (ICUD) and the German Society of Urology (DGU)/German Association of Pediatric Surgery (DGKCh) have been analyzed concerning the most important aspects of treatment and diagnosis., Results: There is broad consensus concerning most steps and decisions for the treatment of cryptorchidism. However, some aspects of diagnostic imaging, the use of hormonal therapy, and surgical access in nonpalpable testis warrant further discussion and are the fields of considerable changes.

Evidence-based medicine is established by conducting high-quality, well-structured, and ideally prospective randomized trials. The initiation and performance of such studies pose a challenge to pediatric urology. Several randomized studies on vesicoureteral reflux, stone treatment, and urinary incontinence in childhood have been published in recent years. In addition, relevant guidelines on the topic of vesicoureteral reflux and phimosis were issued. Comprehensive up-to-date data are also available on undescended testicles and correction of hypospadias from which a recommended course of action can be derived.

Cryptorchidism is the most common genital disorder in boys. Early-born boys are affected in up to one third of the cases, while about 2-5% of full-term newborns suffer from at least one undescended testicle. As a result of short-term endogenous testosterone secretion after birth the prevalence decreases to 1-2% after 3 months. According to most studies, watchful waiting after 6 months is not justified because after this time spontaneous testicular descent only very rarely occurs. Even though the effects of testicular development and fertility in undescended testis have been extensively examined, the only fact that remains certain is that approximately 90% of untreated men with bilateral cryptorchidism develop azoospermia. The remaining scenarios of cryptorchidism (unilateral, ectopic, inguinal, treated or not treated) exhibit unpredictable fertility and likelihood of fatherhood.

Undescended testis (UDT) is the most frequent congenital malformation affecting 1% of 1-year-old mature birth boys. If untreated UDT leads to progressive histological changes with impaired spermatogenesis and an increasing risk of testicular cancer. For clinical reasons palpable testes should be differentiated from impalpable testes. Spontaneous testicular descent can be expected only before 6 months of age. Subsequently, treatment should start without delay and be finished before the child has reached the age of 1 year. Surgery is the cornerstone of treatment. Inguinal approaches are standard practice for palpable testes, whereas laparoscopy is used in non-palpable testes. Hormonal treatment is ineffective for inducing testicular descent but facilitates germ cell maturation and an improvement in fertility potential. Only early treatment of UDT reduces germ cell loss, improves fertility and reduces the risk of testicular cancer.

Cryptorchidism is a risk factor for testicular cancer and reduced fertility. Failure of critical maturation steps, with the persistence of gonocytes beyond 6 months, results in a decreased number of adult dark (A-dark) spermatogonia, which causes a deficiency of primary spermatocytes at 3 years of age. We evaluated the histological findings in boys older than 4 years who were diagnosed with a testis located in the inguinal channel. From September 2007 to September 2008, 15 boys (mean age 8 years) underwent orchidopexy with a biopsy taken from the undescended testis of one side. Sonograms were performed in all 15 boys. The incidences of spermatogonia, primary spermatocytes, and Leydig cells (semiquantitative) were estimated as well as the exclusion of intratubular carcinoma in situ cells (Department of Pathology, Central EM Lab, University Medical Center Regensburg, Germany). Orchidopexy was performed on the right side in eight boys, the left side in one, and both sides in six. Sonographically, no parenchymal echotexture abnormalities were found. A-dark spermatogonia could be detected in nine biopsies. The Leydig cell score was reduced in 11 boys. No carcinoma in situ cells were detected. Late diagnosis of undescended testis will have a poor prognosis for future fertility.

Laparoscopy and magnetic resonance imaging (MRI) are competetive tools in the diagnostic of non-palpable testis. Advantages and disadvantages of this methods will be demonstrate. 29 boys investigated for this indication with MRI. In case MRI failed to locate the testis laparoscopy was performed with a new miniaturized set of pediatric instruments (1.9 mm optic). The aim of laparoscopy was the identification of the spermatic duct and vessels and their topographic relation to the internal inguinal ring. All findings were verified by open surgical procedures. MRI revealed 10 inguinal and 7 abdominal testis. There was no false positive finding. In 12 boys MRI showed no testis. 4 cases were correct negative, 8 cases were false negative (32%). In these 8 MRI-negative patients laparoscopy revealed 7 inguinal and 1 abdominal testis. The optical quality of the mini-telescope was sufficient for a 100% correct diagnosis. Laparoscopy related complications did not occur. Laparoscopy proved to be a powerful low risk diagnostic method in non-palpable testis with high sensitivity and specifity (100% correct positive, 0% false negative). Therefore lapraroscopy is recommended as primary diagnostic access for this indication. In the same anesthesia a optimal therapy is possible. Nevertheless a positive MRI-finding locates the testis reliably, whereas a negative finding always needs further exploration because testis might have been missed.

The current world-wide experience with laparoscopy in the field of pediatric urology is summarized. Based on significant personal expertise, the operative technique and instrumentation of the different procedures are described. Herein standard indications (i.e., diagnosis and therapy of cryptochidism, bilateral varicoceles) can be distinguished from rather infrequent procedures (i.e., renal cyst resection, nephrectomy) and experimental indications (case reports) such as bladder "auto" augmentation, antirefluxplasty and pyeloplasty. At the referring centers, laparoscopic surgery in pediatric urology has significantly increased. Therefore, this minimally invasive, delicate technique is becoming more popular.

Between May 1987 and December 1991, laparoscopy was performed in 33 selected children with 40 nonpalpable testes, to localize the testes. Of 40 testes sought, 16 were present (14 intra-abdominal and 2 inguinal), and in 24 cases testicular aplasia was verified. The authors describe the technique of laparoscopy for unilateral and bilateral undescended testes. Exact anatomical localization of the testes by laparoscopy facilitated accurate planning of operative repair. The advantages of laparoscopy compared with ultrasound and MR imaging in 14 selected patients are described. In 3 patients with an intra-abdominal hypoplastic testis we performed laparoscopic orchiectomy. This new operative procedure is described. Laparoscopic orchiectomy is minimally invasive, offering a practicable alternative to orchiectomy in the case of an atrophic or hypoplastic abdominal testis. No complications were noted.

The importance of high-resolution sonography in the localization of undescended testes was displayed by an evaluation of 18 patients. In 15 patients the testis was not palpable on one side. In 3 cases, there was retention of the testis on both sides. Out of 17 testes in the inguinal region or in the external iliac region, 16 were located sonographically. There were 4 intraabdominal testes, and 2 were located sonographically. The retained and impalpable testes were in superficial positions in most cases. Hence, sonography proved to be the primary imaging method for localization. The importance of computed tomography, magnetic resonance imaging and phlebography of the internal spermatic vein are also discussed.

Failure of fusion between testis and epididymis will usually be encountered during operations for undescended testis in children and for infertility in adults. In 325 groin dissections for undescended testis monorchism was diagnosed in 3.7% and nonfusion of testis and epididymis in 1.2%. Case reports of three unilateral and one bilateral conditions are presented. Intraoperative misjudgement of this condition is likely to occur if the blind ending epididymis is mistaken for an atrophic testis. Careful search for the missing testis is mandatory.