Orchiopexy is surgery to move an undescended testicle from the abdomen or groin into the scrotum, where it is stitched into place. It is the standard treatment for cryptorchidism, a condition affecting roughly two to five percent of full-term male newborns, and current guidelines recommend completing the procedure between six and twelve months of age. The operation sounds straightforward, but the details matter: how it’s done, when it’s done, and why it’s done all shape a child’s long-term fertility and cancer risk in ways that were only clarified in the last few decades.
Why the Testicle Needs to Reach the Scrotum
During fetal development, the testes form near the kidneys and gradually descend toward the scrotum in two distinct phases. The first phase happens between roughly eight and fifteen weeks of gestation, when a hormone called insulin-like hormone 3 causes the gubernaculum, a ligament attached to the testis, to swell and anchor the testis near the groin as the fetus grows. The second phase occurs later, between about twenty-five and thirty-five weeks, when testosterone drives the gubernaculum to migrate through the inguinal canal and pull the testis into the scrotum.1PubMed. Regulation of testicular descent If something disrupts either phase, the testis stalls somewhere along the path.
The scrotum is not just a convenient endpoint. Mammalian testes function best at temperatures roughly four to five degrees Celsius below core body temperature.2PubMed. Amelioration of heat stress-induced damage to testes and sperm quality When a testis remains inside the abdomen or inguinal canal, chronic heat exposure damages the germ cells that produce sperm. Animal studies show this damage occurs through a process of programmed cell death, with the cells most involved in active sperm production being the most vulnerable.3Journal of Andrology. Heat Stress Causes Testicular Germ Cell Apoptosis in Adult Mice The longer a testis stays too warm, the worse the damage gets, which is why early surgical correction matters so much.
When the Surgery Should Happen
Multiple international guidelines agree on a window of six to twelve months of age for orchiopexy.4PubMed. Nordic consensus on treatment of undescended testes The reasoning is twofold: protecting future fertility and reducing cancer risk. German guidelines, for example, specifically recommend completing surgery between six months and one year to lower the chances of both subfertility and testicular cancer.5PubMed Central. The timing of surgery for undescended testis – a retrospective multicenter analysis
The cancer data are striking. A large Swedish study found that boys who had orchiopexy before age thirteen had about twice the testicular cancer risk compared with the general population, while those treated at thirteen or older had more than five times the risk.6PubMed. Age at surgery for undescended testis and risk of testicular cancer Even after successful orchiopexy, the risk never returns to the baseline of someone whose testes descended normally. But earlier surgery clearly brings the risk down compared with later surgery or no surgery at all.
In practice, many children still receive surgery well after the recommended window. Delays happen for various reasons: the condition is missed at early checkups, parents are told to “wait and see,” or the child is referred late. The evidence is clear enough, though, that pediatric guidelines now push hard for timely referral. If a testis has not descended on its own by six months of age, watchful waiting offers diminishing returns and the surgical consultation should begin.
Telling an Undescended Testis from a Retractile One
Not every testicle that seems absent from the scrotum during a diaper change actually needs surgery. A retractile testis sits in the scrotum most of the time but gets pulled temporarily into the inguinal canal by an overactive muscle reflex, especially when the child is cold, anxious, or being examined. The distinction matters because retractile testes are managed conservatively with follow-up, while truly undescended, ectopic, or ascended testes require surgical correction.7PubMed Central. Practical approach to evaluating testicular status in infants and children
An ascended testis adds a layer of confusion: it was once in the scrotum but has since migrated upward. This can happen months or even years after birth, and it requires surgery just like a primary undescended testis. Parents sometimes feel blindsided when a pediatrician says the testis was previously in normal position but now is not. Ascended testes are a real and recognized phenomenon, not a sign that something was missed at birth.
Do You Need Imaging Before Surgery?
If a doctor can feel the undescended testis in the groin during a physical exam, imaging is generally unnecessary before surgery. The real question arises when the testis cannot be felt at all. In those cases, ultrasound is commonly ordered but is surprisingly unhelpful: studies show it has a sensitivity of only about 45% and specificity of about 78% for locating a nonpalpable testis.8PubMed Central. Diagnostic Imaging in Cryptorchidism: Utility, Indications, and Effectiveness An ultrasound that does not find the testis does not mean it is absent; it may simply be too high for the ultrasound to reach.
MRI performs better at localization, but it is expensive and typically requires sedation in young children, making it impractical for routine use. The gold standard for nonpalpable testes is diagnostic laparoscopy, which has near-perfect accuracy and allows the surgeon to begin the repair during the same procedure.9PubMed Central. Unnecessary diagnostic imaging: a review of the literature on preoperative imaging for boys with undescended testes In other words, ordering an ultrasound before referring to a surgeon often adds cost and delay without changing the treatment plan.
How the Surgery Is Done
The specific technique depends on where the testis is sitting. For palpable undescended testes, which are the majority, the two main approaches are the traditional inguinal incision and the newer single scrotal incision.
The traditional approach uses two small cuts: one in the groin crease to find and free the testis and its blood supply, and one in the scrotum to create a pocket where the testis is placed and secured. The scrotal approach accomplishes the same thing through a single cut in the scrotum. A meta-analysis comparing the two found that the scrotal approach had a shorter operative time by roughly twelve minutes and a shorter hospital stay, with fewer analgesics needed and better cosmetic results, while complication rates were similar between the two methods.10PubMed Central. Comparison of Single-Incision Scrotal Orchiopexy and Traditional Two-Incision Inguinal Orchiopexy for Primary Palpable Undescended Testis in Children: A Systematic Review and Meta-Analysis An earlier meta-analysis of over 1,300 children confirmed that complication rates, including wound infection, testicular atrophy, reascent, and hernia, did not differ meaningfully between the two approaches.11PubMed. Single scrotal incision orchiopexy versus the inguinal approach in children with palpable undescended testis: a systematic review and meta-analysis
When the testis cannot be felt at all and is found high in the abdomen during laparoscopy, the surgeon faces a harder problem. If there is enough length in the blood vessels and spermatic cord, a one-stage laparoscopic orchiopexy can bring the testis down in a single operation. But when the testis is too high and the vessels are too short, a two-stage Fowler-Stephens procedure is used. In the first stage, the main blood vessels to the testis are deliberately clipped, forcing the testis to develop collateral blood supply. About six months later, the surgeon goes back in and moves the testis into the scrotum, now relying on those new blood vessels.12PubMed Central. Laparoscopic management of impalpable undescended testes: 20 years’ experience In one large series, none of the testes atrophied after the two-stage approach, while one out of 152 one-stage cases did. During laparoscopy, the surgeon may also discover that the testis is absent or has already atrophied on its own, which happens in a meaningful fraction of nonpalpable cases.13PubMed. Multi-incisional transumbilical laparoscopic surgery for nonpalpable undescended testes: a report of 126 cases
Complications and What Predicts Them
Orchiopexy is generally safe, but the two complications parents worry about most are testicular atrophy, where the testis shrinks significantly after surgery, and testicular reascent, where the testis migrates back upward out of the scrotum. In the ORCHESTRA study, a prospective cohort of over 400 children, about 3% had an atrophic testis at six-month follow-up, and about 2% experienced reascent.14BJS Open. Timing of orchidopexy and its relationship to postoperative testicular atrophy: results from the ORCHESTRA study Interestingly, the atrophy rate did not differ between children operated before twelve months and those operated later.
A larger study of over 1,600 orchiopexies found a higher atrophy rate of about 14%, but this series included many high-risk cases. The strongest predictors of atrophy were the testis being located higher up, structural abnormalities in the spermatic duct and epididymis, a smaller testis relative to the other side before surgery, and the need for a two-stage Fowler-Stephens repair.15PubMed Central. A prediction model for risk factors of testicular atrophy after orchiopexy in children with undescended testis In other words, the difficulty of the case matters more than the technique or timing in predicting atrophy.
Reoperation for reascent occurs in roughly 6% of cases overall, with the inguinal approach showing a higher reoperation rate than the scrotal approach in one analysis.16PubMed Central. Orchidopexy for undescended testis-rate and predictors of re-ascent Most reoperations are straightforward redo orchiopexies with good outcomes, but they obviously add another anesthetic and recovery period for the child.
Hormonal Treatment as an Alternative
Before surgery became the default, doctors tried hormonal injections to coax undescended testes into the scrotum. The idea was that since testicular descent depends partly on testosterone, giving hormones might finish the job. In practice, the evidence for this in typical childhood cryptorchidism has been weak, and some studies have raised concerns that hormone treatment (particularly with human chorionic gonadotropin) could actually harm germ cells through increased testicular pressure and inflammation-like changes.17PubMed Central. Epidemiology, classification and management of undescended testes: does medication have value in its treatment? Side effects during treatment can include penile growth, painful erections, and behavioral changes. Most current pediatric guidelines have moved away from hormonal therapy as a first-line treatment.
There is one notable exception. In adult men whose cryptorchidism is caused by a hormonal deficiency, specifically idiopathic hypogonadotropic hypogonadism, hormone replacement can be effective and safe for achieving testicular descent, along with puberty development and eventual sperm production.18PubMed Central. Hormonal therapy is effective and safe for cryptorchidism caused by idiopathic hypogonadotropic hypogonadism in adult males This is a specific population with a specific hormonal cause, not the same situation as a typical infant with an undescended testis.
Fertility After Orchiopexy
For men who had only one undescended testis corrected in childhood, fertility is close to normal. The other testis, having always been in the scrotum, carries most of the reproductive capacity. Bilateral cases are a different story: when both testes were undescended and required orchiopexy, fertility is significantly reduced in adulthood.19PubMed. Results of orchiopexy for the undescended testis This is one reason early surgery matters especially in bilateral cryptorchidism, since every month of heat damage to both testes compounds the future fertility deficit.
The fertility picture also connects back to the temperature issue. The longer germ cells sit at abdominal temperature, the more are lost. Surgery relocates the testis to its intended cooler environment, but it cannot reverse damage already done. This is why the recommended window of six to twelve months exists: it aims to minimize the cumulative injury before it becomes irreversible.
What Happens When Cryptorchidism Is Found in Adults
Most cryptorchidism is caught in infancy, but some men reach adulthood with an undescended testis that was either missed or ignored. The picture is grim when a testis has spent decades at the wrong temperature. One study found that 70% of undescended testes in adult patients showed no evidence of sperm production at all.20PubMed. The undescended testis in adult life At that point, the testis is not contributing to fertility, and its prolonged undescended position has substantially increased cancer risk.
For unilateral cases in adults, surgeons often recommend removing the undescended testis entirely rather than performing orchiopexy. The reasoning is that the testis has likely already lost its reproductive function, and removing it eliminates the elevated cancer risk. If the other testis is healthy and descended, the man retains normal hormone levels and fertility potential. A biopsy can help guide the decision: if germ cells are still present, the cancer risk is real, and removal is typically recommended. If the man has bilateral undescended testes, the situation requires more careful consideration to preserve whatever hormonal function remains.
Orchiopexy for Testicular Torsion
Cryptorchidism is not the only reason for orchiopexy. The procedure is also performed after testicular torsion, which occurs when the testicle twists on its spermatic cord, cutting off blood flow. This is a surgical emergency. If the torsion is caught in time and the testis can be saved, orchiopexy is performed on both sides to prevent it from happening again. A study of fifty patients who underwent bilateral orchiopexy for intermittent torsion reported a 100% success rate in preventing testicular loss over an average follow-up of nearly three years, with 88% of patients becoming completely pain-free.21PubMed Central. Bilateral orchidopexy for intermittent testicular torsion
In newborns with testicular torsion, a meta-analysis recommended urgent exploration of both sides with orchiopexy of the unaffected testis, even if the torsed testis cannot be saved. The concern is that whatever anatomical predisposition caused torsion on one side could just as easily affect the other, and losing both testes to sequential torsion events would result in complete absence of testicular function.22PubMed. Controversies in the management of neonatal testicular torsion: A meta-analysis The specific suture technique used to fix the testis in place varies, and a systematic review found limited evidence favoring any single method, though all aim to anchor the testis so it cannot twist again.23PubMed. Orchidopexy for Testicular Torsion: A Systematic Review of Surgical Technique
The Link Between Cryptorchidism and Inguinal Hernias
Parents of boys with undescended testes are sometimes told their child also has an inguinal hernia, and they may wonder whether the two conditions are related. They are. During normal development, a channel called the processus vaginalis opens to let the testis descend, then closes behind it. When the testis fails to descend, this channel often remains open, creating a pathway for abdominal contents to push into the groin. Reports suggest that cryptorchidism is associated with inguinal hernias in up to about 90% of cases.24PubMed Central. An adult right inguinal hernia and cryptorchidism treated simultaneously with laparoscopic transabdominal preperitoneal repair and laparoscopic orchiectomy: a case report Surgeons routinely check for and repair a patent processus vaginalis during orchiopexy, addressing both problems in the same operation.
Environmental Exposures and Cryptorchidism
The causes of cryptorchidism are not fully understood, but they go beyond random developmental glitches. Because testicular descent depends on precise hormonal signaling, chemicals that interfere with hormones can disrupt the process. Prenatal exposure to diethylstilbestrol (DES), a synthetic estrogen once prescribed to prevent miscarriage, was associated with higher rates of cryptorchidism in exposed sons. Epidemiological studies have also linked pesticide exposure during pregnancy to undescended testes, and some case-control studies have found associations between chemical levels in maternal breast milk and the condition.25PubMed. Cryptorchidism and endocrine disrupting chemicals These findings suggest that at least some cases of cryptorchidism may be preventable, though translating population-level chemical exposure data into individual-level prevention advice remains difficult.
Anesthesia and Pain Management During the Procedure
Orchiopexy in children is performed under general anesthesia, and regional anesthesia is commonly added for pain control during and after the procedure. A caudal block, which is an injection of local anesthetic near the base of the spine, is one of the most frequently used techniques for groin and scrotal surgeries in young children. Research has shown that a larger volume of more dilute anesthetic is more effective than a smaller volume of concentrated anesthetic at blocking the pain response during spermatic cord traction, which is the most stimulating part of the operation. Both approaches provided similar quality of postoperative pain relief, so the benefit of the higher-volume technique is mainly during surgery itself.
Most orchiopexies for palpable testes are day-surgery procedures, meaning the child goes home the same day. The scrotal approach tends to require fewer pain medications afterward. Parents can generally expect some swelling and discomfort for a few days, with a return to normal activity within one to two weeks. The two-stage Fowler-Stephens approach, by contrast, involves two separate anesthetics and recoveries spaced about six months apart, which is a larger commitment for the family.
Testicular Prostheses After Loss or Atrophy
When a testis is lost to torsion, removed due to cancer, or atrophied after orchiopexy, a silicone prosthesis can be placed in the scrotum to restore normal appearance. This is more than a cosmetic afterthought. A study of men who had a testicle removed for cancer found that those who received a prosthesis at the time of removal were significantly less likely to report decision regret, body-image shame, or the feeling that they were “still missing” the testicle. Partners of men without a prosthesis were more likely to comment on the change in body image.26PubMed. Decision Regret About Testicular Prosthesis After Radical Orchiectomy: Real-life Data to Improve Preoperative Patient Counseling
Prosthesis placement also works well in adolescents who lost a testis during childhood. Even in boys with an underdeveloped scrotum, the procedure has been reported as highly successful, with positive effects on self-confidence and intimate relationships.27Journal of Pediatric Urology. Testicular prosthesis insertion following testicular loss or atrophy during early childhood – Technical aspects and evaluation of patient satisfaction Bringing up the prosthesis option before surgery, rather than months or years later, seems to lead to better satisfaction outcomes and less regret. Surgeons who treat cryptorchidism increasingly include this discussion as a standard part of preoperative counseling, especially in cases where atrophy or removal is a possibility.