Comparison of the perspectives of the pediatric surgeons and pediatric urologists in management of cryptorchidism in Saudi Arabia

Discussion

There are no standard national guidelines for the management of cryptorchidism. Moreover, there is a possibility that the difference in the training background between medical practitioners of different specialties could affect the cryptorchidism management. Therefore, we conducted this survey to evaluate the difference in cryptorchidism management between pediatric surgeons and pediatric urologists in Saudi Arabia.

International practice guidelines were developed according to the current evidence to standardize the management of cryptorchidism. However, there are several guidelines published with reference to the management of cryptorchidism, with possible dissimilarities.^10-13 A critical assessment of these guidelines suggested the similarity between them in terms of quality and overall recommendations.¹⁴ Still, the practice and approach used for the management of cryptorchidism could be affected by these multiple guidelines, especially in countries where medical practitioners of different specialties follow different guidelines.

We observed differences in the management of cryptorchidism between pediatric surgeons and urologists in Saudi Arabia. The survey included consultants of both the specialties with no significant difference in their practice years. However, the number of cases managed by the pediatric surgeons were significantly different, demonstrating the referral pattern of cryptorchidism.

According to the current recommendations, orchidopexy is typically performed within 6-12 months after the birth of male child. Pre-operative ultrasound is not essential for the diagnosis and open or laparoscopic approaches can be offered for the nonpalpable undescended testes.¹⁴ The participants’ practice or treatment approach in this survey was consistent with the previously published recommendations,^10-12,14,15 and most of them performed orchidopexy during the first year of the birth of the male child. However, we could not assess if the guidelines promoted a change in practice towards changing the age of orchidopexy to 18 months or not and whether the surgeons of both the specialties preferred the same treatment approach before the publication of the guidelines. Additionally, we observed that despite the recurrent recommendations, 30% of the surgeons still request for preoperative ultrasound and 4% for MRI. Preoperative imaging could improve the diagnosis in obese children or could be carried out for medicolegal reasons.

The approach used for the management of palpable testes differed significantly between the medical practitioners in both specialties. Pediatric surgeons preferred the inguinal approach, while pediatric urologists had no clear preference. Management approach used by pediatric urologists ‘depends on the testes’ position. They used the inguinal approach if the testes was below the deep inguinal ring and the laparoscopy was preserved for intra-abdominal testes. Despite the difference in response, it was found to be consistent with the current guidelines which indicated that both approaches are adequate. Moreover, the results obtained in this study were consistent with a previous study comparing the management of testicular torsion between pediatric surgeons and urologists in Saudi Arabia.¹⁶

On the other hand, both the groups agreed on the same approach for managing nonpalpable testes, and laparoscopy was their preferred approach for both unilateral and bilateral undescended testes. This response was found to be consistent with the American Urological Association guidelines which stated that laparoscopy is the preferred method; however, both laparoscopy and open approaches are acceptable options.¹³ This response was also consistent with the other guidelines, such as the Canadian Urological Association and British Association of Pediatric Surgeons guidelines which stated that both approaches are acceptable.^10,11,13 Unless the laparoscopist and equipment are unavailable, laparoscopy is the first choice for the nonpalpable testes and inguinal surgery is the first choice for palpable ones.

We investigated the timing for approaching bilateral cryptorchidism, whether synchronous or metachronous. Pediatric urologists preferred to approach bilateral cryptorchidism synchronously, but this did not reach a significant level. There are no guidelines recommendations for the management of timing for bilateral cryptorchidism. Therefore, it is not known whether a synchronous or metachronous approach could have different outcomes or costs. Additionally, the family perspectives about the timing have not been explored. All these issues should be considered when developing guidelines regarding the timing for the management of bilateral cryptorchidism.

Several suturing techniques and materials are used to fix the testes. The common practice in Saudi Arabia is the use of non-absorbable sutures. However, suturing through the testicular parenchyma may be associated with long-term complications. Coughlinet al¹⁷ found that the use of sutures to fix the testes was associated with infertility. Moreover, in animal studies, the use of sutures through the testes was associated with a local inflammatory reaction, which occurred irrespective of the type of the suture material or size.¹⁸ Therefore, it is recommended to assess the testicular function postoperatively by measuring the level of inhibin B.¹⁹ We did not find a significant difference in the management of cryptorchidism based on years in practice. This finding was in contrast with the Society of Pediatric Urology survey, which found a difference in the surgical approach based on the years in practice.⁶ Our results showed a significant difference in the management of complex and unusual scenarios based on the number of procedures performed per year rather than the number of years in practice.

Generally, the difference in the treatment approach used can exist between practitioners of different specialties. This difference can be attributed to the difference in training programs, the familiarity with surgical approaches, the number of cases performed per year and the “culture” in respective specialties. This study highlighted some of the factors that may affect the surgeons’ choices and practice patterns. Understanding these factors will help in development of a universal practice guide for the management of common surgical problems. This survey is not the first study to show a difference in practice patterns between pediatric surgeons and urologists in Saudi Arabia but a step towards development of a standard practice pattern.¹⁶