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UPJ INSIGHT How Effective Was the 2014 AUA Cryptorchidism Guideline? A Multi-Institutional Evaluation
By: Hillary Weiner, MD, MBE, Stanford University, Palo Alto, California; Julie R. Solomon, BS, Washington University, St Louis, Missouri; Robert Thinnes, MD, University of Iowa Hospitals and Clinics, Iowa City; Benjamin Pinsky, BS, University of Michigan, Ann Arbor; Charles Ferreri, MD, Vanderbilt University, Nashville, Tennessee; Marquise Singleterry, MD, University of Michigan, Ann Arbor; Amanda Bahamonde, BS, University of Michigan, Ann Arbor; Sami Awadh, BS, Medical College of Wisconsin, Milwaukee; Jacqueline Tran, BS, Medical College of Wisconsin, Milwaukee; Alethea G. Paradis, MS, Washington University, St Louis, Missouri; Joel Vetter, PhD, Washington University, St Louis, Missouri; Anthony Brooks, MD, Washington University, St Louis, Missouri; Samantha Lund, MD, Washington University, St Louis, Missouri; Daren Kuwaya, MS, University of Iowa Hospitals and Clinics, Iowa City; Denise Juhr, MS, University of Iowa Hospitals and Clinics, Iowa City; Linder Wendt, MS, University of Iowa Hospitals and Clinics, Iowa City; Patrick Ten Eyck, PhD, University of Iowa Hospitals and Clinics, Iowa City; Erica Traxel, MD, Washington University, St Louis, Missouri; Kate H. Kraft, MD, MHPE, University of Michigan, Ann Arbor; Jonathan S. Ellison, MD, Medical College of Wisconsin, Milwaukee, Children’s Wisconsin, Milwaukee; Douglas W. Storm, MD, University of Iowa Hospitals and Clinics, Iowa City | Posted on: 27 Nov 2023
Weiner H, Solomon JR, Thinnes R, et al. How effective was the 2014 AUA Cryptorchidism Guideline? A multi-institutional evaluation. Urol Pract. 2023;10(6):604-610.
Study Need and Importance
Cryptorchidism affects infertility and testicular cancer risks. The AUA updated its cryptorchidism guidelines in 2014 wherein the recommended age for referral to a urological specialist for boys with an undescended testicle was lowered to 6 months and the use of prereferral scrotal ultrasound was no longer recommended. However, the impact of these guidelines on general pediatrician practice patterns for cryptorchidism is not well known.
What We Found
On average, pediatricians and other general practitioners did not reduce the age at which they referred boys to surgeons for an undescended testicle after the release of the 2014 AUA cryptorchidism guidelines (Table). Furthermore, the use of prereferral ultrasound remained unchanged.
Table. Urologic Evaluation and Treatment Patient Characteristics
| Year | MR or OR (95% CI) | |||||
|---|---|---|---|---|---|---|
| Characteristic | Overall N = 3,293 | 2013 N = 1,070 | 2015 N = 1,236 | 2019 N = 987 | 2013 vs 2015 | 2013 vs 2019 |
| Age at referral visit | ||||||
| Median (IQR), mo | 37 (13, 88) | 37 (12, 88) | 38 (13, 86) | 36 (13, 94) | 1.03a (0.91, 1.17), P = .6 | 1.08a (0.95, 1.22), P = .2 |
| Missing data, No. (%) | 1,438 (43.7%) | 703 (65.7%) | 502 (40.6%) | 233 (23.6%) | ||
| Age at initial pediatric urology visit, median (IQR), mo | 39 (14, 92) | 37 (13, 88) | 42 (15, 92) | 38 (15, 97) | 1.07a (0.99, 1.16), P = .08 | 1.09a (1.01, 1.19), P = .03 |
| Patients evaluated by age 12 mo, No. (%) | 694 (21.1) | 241 (22.5) | 251 (20.3) | 202 (20.5%) | 0.88b (0.72, 1.07), P = .3 | 0.89b (0.67, 0.97), P = .2 |
| Patients evaluated by age 18 mo, No. (%) | 1,060 (32.2) | 386 (36.1) | 365 (29.5) | 309 (31.3%) | 0.74b (0.62, 0.88), P < .001 | 0.81b (0.67, 0.97), P = .02 |
| Prior ultrasound evaluation | ||||||
| No. patients (%) | 697 (21.2) | 222 (20.7) | 257 (20.8) | 218 (22.1) | 1.01b (0.83, 1.24), P = .9 | 1.08b (0.87, 1.33), P = .5 |
| Missing data, No. (%) | 49 (14.9) | 14 (13.1) | 27 (21.8) | 8 (0.8) | ||
| Patients undergoing operation, No. (%) | 1,738 (52.8) | 640 (59.8) | 668 (54.0) | 430 (43.6) | 0.79b (0.67, 0.93), P = .005 | 0.52b (0.44, 0.62), P < .001 |
| Age at operation | ||||||
| Median (IQR), mo | 40 (15, 100) | 29 (14, 92) | 45 (15, 99) | 51 (16, 113) | 1.72a (1.53, 1.92), P < .001 | 1.22a (1.08, 1.38), P = .002 |
| Missing data, No. (%) | 1,555 (47.2) | 430 (40.2) | 568 (46.0) | 557 (56.4) | ||
| Presence of comorbidities, No. (%)c | 705 (21.4) | 234 (21.9) | 273 (22.1) | 198 (20.1) | 1.01b (0.83, 1.23), P = .9 | 0.90b (0.72, 1.11), P = .3 |
| Premature birth | 292 (8.9) | 97 (9.1) | 104 (8.5) | 91 (9.3) | 0.93b (0.69, 1.24), P = .6 | 1.02b (0.76, 1.38), P = .9 |
| Pulmonary condition | 184 (5.6) | 66 (6.2) | 69 (5.6) | 49 (5.0) | 0.902 (0.64, 1.28), P = .6 | 0.802 (0.54, 1.16), P = .2 |
| Cardiac condition | 159 (4.8) | 54 (5.1) | 66 (5.4) | 39 (4.0) | 1.062 (0.74, 1.55), P = .7 | 0.782 (0.51, 1.18), P = .2 |
| Abbreviations: CI, confidence interval; IQR, interquartile range; MR, means ratio; OR, odds ratio. Bold text indicates statistical significance (P ≤ .05). Pulmonary and cardiac conditions were defined as congenital, structural cardiac diseases, and bronchopulmonary dysplasia or persistent oxygen requirement, respectively. a MR; continuous data were analyzed using a negative binomial model. b OR; categorical data were analyzed with a logistic model. c Some comorbidity data (0%-0.7% from each cohort) were unavailable in the electronic medical record. |
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Limitations
As a retrospective study, our review is limited to the data available in the electronic medical record. Thus, we have limited insight into the circumstances surrounding referral, including the frequency of testicular ascent. Additionally, all 4 centers are located in metropolitan centers of the Midwest, and the patients in this study are predominantly white and non-Hispanic. Therefore, our results may not be generalizable.
Interpretation for Patient Care
Our work calls for improved systems to promote awareness of updates to urological clinical guidelines, especially to general practitioners.
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