Clinical Outcomes of Orchiopexy and the Risk of Malignancy in Postpubertal Cryptorchid Patients

BACKGROUND: Postpubertal cryptorchidism remains clinically challenging, as patients often present with long-standing maldescent, impaired spermatogenesis, and an increased risk of testicular malignancy. However, the optimal management of this population remains controversial, and comprehensive data on clinical characteristics, surgical outcomes, endocrine changes, and spermatogenic damage are still limited. METHODS: We conducted a single-center retrospective cohort study of 194 patients (210 undescended testes) undergoing primary orchiopexy between January 2018 and June 2024. Clinical characteristics, testicular position, ultrasonographic volume, semen parameters, endocrine parameters, and histopathology findings were collected. Intraoperative biopsies were obtained in 200 testes (95.2%) and graded using the Johnsen score. Severe spermatogenic impairment was defined as a Johnsen score ≤3; analyses of spermatogenic impairment were performed in 164 patients with available histological and endocrine assessments. Surgical outcomes were assessed in 185 testes with ≥3-month follow-up, and oncologic events were assessed in 155 patients (161 testes) with available follow-up data. Univariable and multivariable logistic regression analyses were performed to identify predictors of severe spermatogenic impairment. RESULTS: Most undescended testes were in a high position (196/210, 93.3%), and the affected testis had reduced volume in unilateral cases (median 6 vs. 18 mL). Overall anatomical success at 3 months was 80.0% (148/185), with recurrence and atrophy rates of 9.7% and 10.3%, respectively. Among patients with available semen data, unilateral cases showed no azoospermia, but 16 of 44 patients (36.4%) had at least one abnormality in sperm concentration, progressive motility, or normal morphology; by contrast, bilateral cases frequently presented with azoospermia or extremely low sperm counts. In unilateral cases, testosterone, LH, and FSH remained within the normal range without significant perioperative change; in bilateral cases, testosterone was generally preserved whereas FSH was elevated and remained above normal at follow-up. Histologically, only 17 of 200 biopsied testes (8.5%) had a Johnsen score >8, and 71/164 (43.3%) showed severe spermatogenic impairment. High testicular position was strongly associated with severe impairment (univariable OR 6.50, 95% CI 2.15-19.64, p < 0.001) and remained an independent predictor in multivariable analysis (adjusted OR 6.01, 95% CI 1.95-18.49, p = 0.002); affected testicular volume was independently inversely associated with severe impairment (adjusted OR 0.78 per 1 mL, 95% CI 0.64-0.95, p = 0.013). During a median follow-up of 54.6 months (range 12-78), one patient (0.5%) developed ipsilateral seminoma 48 months after orchiopexy. CONCLUSIONS: In postpubertal cryptorchidism, histological and functional spermatogenic impairment is often established before surgery and is unlikely to be substantially reversed by orchiopexy. The main value of orchiopexy lies in anatomical repositioning, pathological assessment, and facilitation of long-term surveillance. High testicular position and smaller preoperative testicular volume identify a subgroup at particularly high risk of severe spermatogenic failure, and malignancy risk is not eliminated, supporting the need for long-term follow-up.