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Bilateral orchidopexies: synchronous or metachronous? Survey of BAPS and BAPU members and single-centre comparison
YJPSU-58948; No of Pages 3 Journal of Pediatric Surgery xxx (xxxx) xxx
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Bilateral orchidopexies: synchronous or metachronous? Survey of BAPS and BAPU members and single-centre comparison Ibrahim A. Mostafa a, Mohamed S. Shalaby a,b,⁎, Mark N. Woodward a a b
Department of Paediatric Surgery, Bristol Royal Hospital for Children, Bristol, UK Department of Paediatric Surgery, Ain Shams University, Cairo, Egypt
a r t i c l e
i n f o
Article history: Received 21 October 2018 Accepted 30 October 2018 Available online xxxx Key words: Undescended testes Undescended testis Testicular atrophy Cryptorchidism
a b s t r a c t Background/Aim: Approximately 20% of undescended testes (UDT) are bilateral. It is unclear whether bilateral orchidopexy (BO) should be undertaken synchronously (SBO) or metachronously (MBO). Our aim was to investigate current UK practice and the complications of SBO vs MBO. Materials & methods: Following approval of BAPS and BAPU ethics committee, a survey was circulated to UK consultant pediatric surgeons and urologists regarding practice. A departmental retrospective review was additionally carried out for patients undergoing BO between 2005 and 2017. Results: Forty-three consultant surgeons from 20 centres completed the survey. Overall, SBO was preferred by 70% for bilateral palpable UDT versus 30% for bilateral impalpable UDT. When one side was palpable and the other impalpable, 70% preferred SBO. Pediatric urologists were significantly more likely to undertake SBO than pediatric general surgeons. One hundred eighty-eight patients (376 testicular units) were identified who had undergone BO with a median follow up of 9 months. 144/188 (76.6%) underwent SBO, while 44 had MBO. There was no statistical difference in the complication rate between the two groups (7.6% in SBO vs 9.1% in MBO; p = 0.66). Conclusions: The majority of the responding UK consultants, in particular pediatric urologists, favor SBO. This potentially offers a reduction in cost, more rapid completion of treatment, and is not associated with additional complications by comparison to MBO. We recommend SBO to be standard practice for bilateral UDT whenever possible. Level of Evidence: Level III, Retrospective Comparative Study. © 2018 Elsevier Inc. All rights reserved.
Undescended testes (UDT) are reported in 1–5% of term and up to 45% of preterm boys, with approximately 20% being bilateral [1,2]. Postnatal descent occurs during the first 3 months in about 75% of full term and 90% of preterm infants with the incidence of UDT then being around 1% at 1 year of age [3]. Annually in England approximately 6000 elective orchidopexies are performed for UDT [4]. In those cases of bilateral UDT, some surgeons prefer to perform a synchronous bilateral orchidopexy (SBO), while others prefer to stage the operation. Metachronous bilateral orchidopexy (MBO) involves at least two hospital visits, two separate anesthetics, is more expensive as a consequence, and inevitably results in a delay in treatment completion. There are currently no publications in the literature that directly compare outcomes of SBO and MBO. In this report we survey preferences for
⁎ Corresponding author at: Department of Paediatric Surgery, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, BS2 8BJ. Tel.: + 44 1173428250; fax: + 44 1173428845. E-mail address: [email protected] (M.S. Shalaby).
SBO or MBO among consultant pediatric surgeons and urologists in the UK, and also assess our own outcomes for both surgical approaches.
1. Materials and methods Following ethical approval by BAPS and British Association of Pediatric Urologists (BAPU) Ethics and Research committees, a structured questionnaire was circulated. The responses were then analyzed anonymously. For analysis of our departmental outcomes, following ethical approval from the R&D team at University Hospitals Bristol NHS Foundation Trust (REC number: 4287), a retrospective review of our prospectively maintained surgical database was carried out. Boys undergoing either SBO or MBO between August 2005 and August 2017 in our tertiary centre were identified. Data were then analyzed to identify complication rates in each group and to correlate this to other variables, including the age at operation and position of the testis. Statistical analysis was undertaken using Fisher's exact test and Chi square test. A p value of ≤0.05 was regarded as significant.
https://doi.org/10.1016/j.jpedsurg.2018.10.088 0022-3468/© 2018 Elsevier Inc. All rights reserved.
Please cite this article as: I.A. Mostafa, M.S. Shalaby and M.N. Woodward, Bilateral orchidopexies: synchronous or metachronous? Survey of BAPS and BAPU members and single-centre compar..., Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2018.10.088
2
I.A. Mostafa et al. / Journal of Pediatric Surgery xxx (xxxx) xxx
Table 1 Preferences of UK consultants (Members of BAPS and/or BAPU). Position of the testes
Preference
Urologist (BAPU Member) (n = 18)
General surgeon (Non-BAPU) (n = 25)
Total (n = 43)
Both palpable
Synchronous Metachronous No preference Synchronous Metachronous Intraoperative decision Synchronous Palpable first Impalpable first
16 (89%) 1 (6%) 1 (6%) 10 (56%) 2 (11%) 6 (33%) 14 (78%) 3 (17%) 1 (6%)
14 (56%) 9 (36%) 2 (8%) 3 (12%) 18 (72%) 4 (16%) 16 (64%) 7 (28%) 2 (8%)
30 (70%) 10 (23%) 3 (7%) 13 (30%) 20 (47%) 10 (23%) 30 (70%) 10 (23%) 3 (7%)
Both impalpable
One palpable/one impalpable
2. Results Forty-three consultant surgeons from 20 centres completed the survey, of whom 18 (42%) were pediatric urologists (BAPU members) and 25 (58%) pediatric general surgeons. Overall, 30/43 (70%) surgeons preferred SBO in cases of bilateral palpable UDT, and also if one side was palpable and the other impalpable (Table 1). In contrast, if both were impalpable, only 13/43 (30%) preferred SBO, with another 10/43 (23%) deciding between SBO and MBO intra-operatively. Notably, a significantly greater proportion of pediatric urologists (74%) favored a synchronous approach compared to pediatric general surgeons (44%) (p b 0.001). Over 12 years, 188 patients had bilateral orchidopexies carried out in our centre, giving a total of 376 testicular units (Table 2). A hundred and forty-four patients (288 testicular units; 77%) underwent SBO while 44 (88 testicular units; 23%) had MBO. The median age at first operation was 26 (range 1–33) months and the median time-to-completion of the treatment was 7 (6–11) months for SBO compared to 13 (11–15) months for MBO. The overall complication rate was 8%, which appears comparable to the published data. Testicular atrophy occurred in 10/288 (3.5%) of the SBO group versus 3/88 (3.4%) of the MBO group; and recurrent UDT occurred in 7/288 (2.4%) of the SBO group versus 3/88 (3.4%) of the MBO group (Table 3). Differences were not statistically significant. 3. Discussion In most boys the testis reaches its normal settled scrotal position by about 3 months of age, and the incidence of UDT remains static at around 1% between 3 months and 1 year of age [1,5–8]. Park et al. have recommended that any treatment leading to a scrotal-positioned testis should ideally be finished by 12 months of age and no later than 24 months, as histological examination of undescended testes at 12–18 months has suggested a progressive loss of both germ cells and Leydig cells [9]. This recommendation has been adopted in the consensus paper of the Table 2 Analysis of patients according to surgical approach (SBO/MBO). Variable Approach • SBO • MBO Position of the testis at presentation • Low palpable • High palpable • Impalpable Age at presentation Age at first operation Time to completion of treatment • SBO • MBO Follow-up period ⁎ median(range).
№
%
288 88
76.6 23.4
178 142 56 22 (0–31)⁎ months 26 (1–33) months
47.3 37.8 14.9
7 (6–11) months 13 (11–15) months 9 (3–24) months
European Society of Pediatric Urologists (ESPU)/European Association of Urologists (EAU) [2]. The British Association of Pediatric Urologists (BAPU) consensus panel recommended the treatment to be completed prior to 12 months of age. In bilateral UDT, there is no generally accepted approach to synchronous or metachronous surgery and, to our knowledge, there is no evidence available in the literature to support the decision-making process. In the absence of real guidance, our survey shows that most surgeons aim for SBO by preference. In particular, those self-identified as pediatric urologists would be more likely to choose this option compared to the general pediatric surgeons surveyed. It may be that this group may have been more influenced by guidelines from organizations such as ESPU, EAU and BAPU with regards to the timing of surgery in UDT. Still, our survey was limited by a relatively poor response rate from the UK pediatric surgical community, so it is difficult to be sure of this finding. As about 6000 elective orchidopexies are undertaken for UDT [4] this is a not inconsiderable number and it is important to consider options that may reduce costs and/or waiting lists, provided that this does not affect clinical outcome. We believe that SBO with one operating theater visit seems more appropriate than MBO. In our series, the median age at first operation was 26 months, which is unfortunately well beyond the time-range recommended by specialist European and BAPU guidelines. We feel that this delay may have been multifactorial, with contributions related to delay in referral and to the long waiting lists to be seen in our clinics and then to actually secure a space on an operating list. In terms of complications, a recent meta-analysis demonstrated that post-orchidopexy testicular atrophy is reported in up to 4.9% of palpable UDT [10] and in up to 25% of impalpable cases and success rates are generally N 90% for inguinal orchidopexy and N 80% for one- or two-stage Fowler-Stephen's orchidopexy (either open of laparoscopic techniques) [11]. In our local series, the overall complication rate was comparable to that reported in the literature, and importantly there did not appear to be a statistically significant difference in complications rates between SBO and MBO. In conclusion, we have shown that most respondents to the questionnaire, particularly those identified as pediatric urologists, favor SBO. We would suggest that this option offers a potential reduction in cost, more rapid completion of treatment and is not associated with
Table 3 Complications by group (SBO/MBO). Complication
Atrophy Recurrence Wound infection Haematoma Total
SBO group (n = 288)
MBO group (n = 88)
p Value
Number
%
Number
%
10 7 3 2 22
3.5% 2.4% 1% 0.7% 7.6%
3 3 2 0 8
3.4% 3.4% 2.3% 0% 9.1%
1 0.70 0.33 1 0.66
Please cite this article as: I.A. Mostafa, M.S. Shalaby and M.N. Woodward, Bilateral orchidopexies: synchronous or metachronous? Survey of BAPS and BAPU members and single-centre compar..., Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2018.10.088
I.A. Mostafa et al. / Journal of Pediatric Surgery xxx (xxxx) xxx
additional complications by comparison to MBO. We recommend SBO to be standard practice for bilateral UDT whenever possible. Authorship contribution statement Ibrahim A. Mostafa: Data curation, Formal analysis, Writing - original draft. Mohamed S. Shalaby: Conceptualization, Writing - review & editing. Mark N. Woodward: Writing - review & editing. References [1] Ashley RA, Barthold JS, Kolon TF. Cryptorchidism: pathogenesis, diagnosis, treatment and prognosis. Urol Clin North Am 2010;37:183–93. [2] Radmayr C, Radmayr C, Dogan HS, et al. Management of undescended testes: European Association of Urology/European Society for Paediatric Urology Guidelines. J Pediatr Urol 2016;12:335–43. [3] Abaci A, Çatli G, Anik A, et al. Epidemiology, classification and management of undescended testes: does medication have value in its treatment? J Clin Res Pediatr Endocrinol 2013;5:65–72.
3
[4] Cochrane H, Tanner S. Trends in Children's Surgery 1994-2005: Evidence from hospital episode statistics data. Statistics (Ber) 2007:133–55. [5] Hutson JM, Clarke MCC. Current management of the undescended testicle. Semin Pediatr Surg 2007;16:64–70. [6] Hutson JM, Balic A, Nation T, et al. Cryptorchidism. Semin Pediatr Surg 2010;19: 215–24. [7] Khatwa UA, Menon PSN. Management of undescended testis. Indian J Pediatr 2000; 67:449–54. [8] Berkowitz GS, Lapinski RH, Gazella JG, et al. Prevalence and natural history of cryptorchidism. Pediatrics 1993;92:44–9. [9] Park KH, Lee JH, Han JJ, et al. Histological evidences suggest recommending orchiopexy within the first year of life for children with unilateral inguinal cryptorchid testis. Int J Urol 2007;14:616–21. [10] Allin BSR, Dumman E, Fawkner-Corbett D, et al. Systematic review and metaanalysis comparing outcomes following orchidopexy for cryptorchidism before and after 1 year of age. BJS Open 2018;2(1):1–12. [11] Niedzielski JK, Oszukowska E, Słowikowska-Hilczer J. Undescended testis current trends and guidelines: a review of the literature. Arch Med Sci 2016; 12:667–77.
Please cite this article as: I.A. Mostafa, M.S. Shalaby and M.N. Woodward, Bilateral orchidopexies: synchronous or metachronous? Survey of BAPS and BAPU members and single-centre compar..., Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2018.10.088
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Bilateral orchidopexies: synchronous or metachronous? Survey of BAPS and BAPU members and single-centre comparison Ibrahim A. Mostafa a, Mohamed S. Shalaby a,b,⁎, Mark N. Woodward a a b
Department of Paediatric Surgery, Bristol Royal Hospital for Children, Bristol, UK Department of Paediatric Surgery, Ain Shams University, Cairo, Egypt
a r t i c l e
i n f o
Article history: Received 21 October 2018 Accepted 30 October 2018 Available online xxxx Key words: Undescended testes Undescended testis Testicular atrophy Cryptorchidism
a b s t r a c t Background/Aim: Approximately 20% of undescended testes (UDT) are bilateral. It is unclear whether bilateral orchidopexy (BO) should be undertaken synchronously (SBO) or metachronously (MBO). Our aim was to investigate current UK practice and the complications of SBO vs MBO. Materials & methods: Following approval of BAPS and BAPU ethics committee, a survey was circulated to UK consultant pediatric surgeons and urologists regarding practice. A departmental retrospective review was additionally carried out for patients undergoing BO between 2005 and 2017. Results: Forty-three consultant surgeons from 20 centres completed the survey. Overall, SBO was preferred by 70% for bilateral palpable UDT versus 30% for bilateral impalpable UDT. When one side was palpable and the other impalpable, 70% preferred SBO. Pediatric urologists were significantly more likely to undertake SBO than pediatric general surgeons. One hundred eighty-eight patients (376 testicular units) were identified who had undergone BO with a median follow up of 9 months. 144/188 (76.6%) underwent SBO, while 44 had MBO. There was no statistical difference in the complication rate between the two groups (7.6% in SBO vs 9.1% in MBO; p = 0.66). Conclusions: The majority of the responding UK consultants, in particular pediatric urologists, favor SBO. This potentially offers a reduction in cost, more rapid completion of treatment, and is not associated with additional complications by comparison to MBO. We recommend SBO to be standard practice for bilateral UDT whenever possible. Level of Evidence: Level III, Retrospective Comparative Study. © 2018 Elsevier Inc. All rights reserved.
Undescended testes (UDT) are reported in 1–5% of term and up to 45% of preterm boys, with approximately 20% being bilateral [1,2]. Postnatal descent occurs during the first 3 months in about 75% of full term and 90% of preterm infants with the incidence of UDT then being around 1% at 1 year of age [3]. Annually in England approximately 6000 elective orchidopexies are performed for UDT [4]. In those cases of bilateral UDT, some surgeons prefer to perform a synchronous bilateral orchidopexy (SBO), while others prefer to stage the operation. Metachronous bilateral orchidopexy (MBO) involves at least two hospital visits, two separate anesthetics, is more expensive as a consequence, and inevitably results in a delay in treatment completion. There are currently no publications in the literature that directly compare outcomes of SBO and MBO. In this report we survey preferences for
⁎ Corresponding author at: Department of Paediatric Surgery, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, BS2 8BJ. Tel.: + 44 1173428250; fax: + 44 1173428845. E-mail address: [email protected] (M.S. Shalaby).
SBO or MBO among consultant pediatric surgeons and urologists in the UK, and also assess our own outcomes for both surgical approaches.
1. Materials and methods Following ethical approval by BAPS and British Association of Pediatric Urologists (BAPU) Ethics and Research committees, a structured questionnaire was circulated. The responses were then analyzed anonymously. For analysis of our departmental outcomes, following ethical approval from the R&D team at University Hospitals Bristol NHS Foundation Trust (REC number: 4287), a retrospective review of our prospectively maintained surgical database was carried out. Boys undergoing either SBO or MBO between August 2005 and August 2017 in our tertiary centre were identified. Data were then analyzed to identify complication rates in each group and to correlate this to other variables, including the age at operation and position of the testis. Statistical analysis was undertaken using Fisher's exact test and Chi square test. A p value of ≤0.05 was regarded as significant.
https://doi.org/10.1016/j.jpedsurg.2018.10.088 0022-3468/© 2018 Elsevier Inc. All rights reserved.
Please cite this article as: I.A. Mostafa, M.S. Shalaby and M.N. Woodward, Bilateral orchidopexies: synchronous or metachronous? Survey of BAPS and BAPU members and single-centre compar..., Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2018.10.088
2
I.A. Mostafa et al. / Journal of Pediatric Surgery xxx (xxxx) xxx
Table 1 Preferences of UK consultants (Members of BAPS and/or BAPU). Position of the testes
Preference
Urologist (BAPU Member) (n = 18)
General surgeon (Non-BAPU) (n = 25)
Total (n = 43)
Both palpable
Synchronous Metachronous No preference Synchronous Metachronous Intraoperative decision Synchronous Palpable first Impalpable first
16 (89%) 1 (6%) 1 (6%) 10 (56%) 2 (11%) 6 (33%) 14 (78%) 3 (17%) 1 (6%)
14 (56%) 9 (36%) 2 (8%) 3 (12%) 18 (72%) 4 (16%) 16 (64%) 7 (28%) 2 (8%)
30 (70%) 10 (23%) 3 (7%) 13 (30%) 20 (47%) 10 (23%) 30 (70%) 10 (23%) 3 (7%)
Both impalpable
One palpable/one impalpable
2. Results Forty-three consultant surgeons from 20 centres completed the survey, of whom 18 (42%) were pediatric urologists (BAPU members) and 25 (58%) pediatric general surgeons. Overall, 30/43 (70%) surgeons preferred SBO in cases of bilateral palpable UDT, and also if one side was palpable and the other impalpable (Table 1). In contrast, if both were impalpable, only 13/43 (30%) preferred SBO, with another 10/43 (23%) deciding between SBO and MBO intra-operatively. Notably, a significantly greater proportion of pediatric urologists (74%) favored a synchronous approach compared to pediatric general surgeons (44%) (p b 0.001). Over 12 years, 188 patients had bilateral orchidopexies carried out in our centre, giving a total of 376 testicular units (Table 2). A hundred and forty-four patients (288 testicular units; 77%) underwent SBO while 44 (88 testicular units; 23%) had MBO. The median age at first operation was 26 (range 1–33) months and the median time-to-completion of the treatment was 7 (6–11) months for SBO compared to 13 (11–15) months for MBO. The overall complication rate was 8%, which appears comparable to the published data. Testicular atrophy occurred in 10/288 (3.5%) of the SBO group versus 3/88 (3.4%) of the MBO group; and recurrent UDT occurred in 7/288 (2.4%) of the SBO group versus 3/88 (3.4%) of the MBO group (Table 3). Differences were not statistically significant. 3. Discussion In most boys the testis reaches its normal settled scrotal position by about 3 months of age, and the incidence of UDT remains static at around 1% between 3 months and 1 year of age [1,5–8]. Park et al. have recommended that any treatment leading to a scrotal-positioned testis should ideally be finished by 12 months of age and no later than 24 months, as histological examination of undescended testes at 12–18 months has suggested a progressive loss of both germ cells and Leydig cells [9]. This recommendation has been adopted in the consensus paper of the Table 2 Analysis of patients according to surgical approach (SBO/MBO). Variable Approach • SBO • MBO Position of the testis at presentation • Low palpable • High palpable • Impalpable Age at presentation Age at first operation Time to completion of treatment • SBO • MBO Follow-up period ⁎ median(range).
№
%
288 88
76.6 23.4
178 142 56 22 (0–31)⁎ months 26 (1–33) months
47.3 37.8 14.9
7 (6–11) months 13 (11–15) months 9 (3–24) months
European Society of Pediatric Urologists (ESPU)/European Association of Urologists (EAU) [2]. The British Association of Pediatric Urologists (BAPU) consensus panel recommended the treatment to be completed prior to 12 months of age. In bilateral UDT, there is no generally accepted approach to synchronous or metachronous surgery and, to our knowledge, there is no evidence available in the literature to support the decision-making process. In the absence of real guidance, our survey shows that most surgeons aim for SBO by preference. In particular, those self-identified as pediatric urologists would be more likely to choose this option compared to the general pediatric surgeons surveyed. It may be that this group may have been more influenced by guidelines from organizations such as ESPU, EAU and BAPU with regards to the timing of surgery in UDT. Still, our survey was limited by a relatively poor response rate from the UK pediatric surgical community, so it is difficult to be sure of this finding. As about 6000 elective orchidopexies are undertaken for UDT [4] this is a not inconsiderable number and it is important to consider options that may reduce costs and/or waiting lists, provided that this does not affect clinical outcome. We believe that SBO with one operating theater visit seems more appropriate than MBO. In our series, the median age at first operation was 26 months, which is unfortunately well beyond the time-range recommended by specialist European and BAPU guidelines. We feel that this delay may have been multifactorial, with contributions related to delay in referral and to the long waiting lists to be seen in our clinics and then to actually secure a space on an operating list. In terms of complications, a recent meta-analysis demonstrated that post-orchidopexy testicular atrophy is reported in up to 4.9% of palpable UDT [10] and in up to 25% of impalpable cases and success rates are generally N 90% for inguinal orchidopexy and N 80% for one- or two-stage Fowler-Stephen's orchidopexy (either open of laparoscopic techniques) [11]. In our local series, the overall complication rate was comparable to that reported in the literature, and importantly there did not appear to be a statistically significant difference in complications rates between SBO and MBO. In conclusion, we have shown that most respondents to the questionnaire, particularly those identified as pediatric urologists, favor SBO. We would suggest that this option offers a potential reduction in cost, more rapid completion of treatment and is not associated with
Table 3 Complications by group (SBO/MBO). Complication
Atrophy Recurrence Wound infection Haematoma Total
SBO group (n = 288)
MBO group (n = 88)
p Value
Number
%
Number
%
10 7 3 2 22
3.5% 2.4% 1% 0.7% 7.6%
3 3 2 0 8
3.4% 3.4% 2.3% 0% 9.1%
1 0.70 0.33 1 0.66
Please cite this article as: I.A. Mostafa, M.S. Shalaby and M.N. Woodward, Bilateral orchidopexies: synchronous or metachronous? Survey of BAPS and BAPU members and single-centre compar..., Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2018.10.088
I.A. Mostafa et al. / Journal of Pediatric Surgery xxx (xxxx) xxx
additional complications by comparison to MBO. We recommend SBO to be standard practice for bilateral UDT whenever possible. Authorship contribution statement Ibrahim A. Mostafa: Data curation, Formal analysis, Writing - original draft. Mohamed S. Shalaby: Conceptualization, Writing - review & editing. Mark N. Woodward: Writing - review & editing. References [1] Ashley RA, Barthold JS, Kolon TF. Cryptorchidism: pathogenesis, diagnosis, treatment and prognosis. Urol Clin North Am 2010;37:183–93. [2] Radmayr C, Radmayr C, Dogan HS, et al. Management of undescended testes: European Association of Urology/European Society for Paediatric Urology Guidelines. J Pediatr Urol 2016;12:335–43. [3] Abaci A, Çatli G, Anik A, et al. Epidemiology, classification and management of undescended testes: does medication have value in its treatment? J Clin Res Pediatr Endocrinol 2013;5:65–72.
3
[4] Cochrane H, Tanner S. Trends in Children's Surgery 1994-2005: Evidence from hospital episode statistics data. Statistics (Ber) 2007:133–55. [5] Hutson JM, Clarke MCC. Current management of the undescended testicle. Semin Pediatr Surg 2007;16:64–70. [6] Hutson JM, Balic A, Nation T, et al. Cryptorchidism. Semin Pediatr Surg 2010;19: 215–24. [7] Khatwa UA, Menon PSN. Management of undescended testis. Indian J Pediatr 2000; 67:449–54. [8] Berkowitz GS, Lapinski RH, Gazella JG, et al. Prevalence and natural history of cryptorchidism. Pediatrics 1993;92:44–9. [9] Park KH, Lee JH, Han JJ, et al. Histological evidences suggest recommending orchiopexy within the first year of life for children with unilateral inguinal cryptorchid testis. Int J Urol 2007;14:616–21. [10] Allin BSR, Dumman E, Fawkner-Corbett D, et al. Systematic review and metaanalysis comparing outcomes following orchidopexy for cryptorchidism before and after 1 year of age. BJS Open 2018;2(1):1–12. [11] Niedzielski JK, Oszukowska E, Słowikowska-Hilczer J. Undescended testis current trends and guidelines: a review of the literature. Arch Med Sci 2016; 12:667–77.
Please cite this article as: I.A. Mostafa, M.S. Shalaby and M.N. Woodward, Bilateral orchidopexies: synchronous or metachronous? Survey of BAPS and BAPU members and single-centre compar..., Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2018.10.088