Management of undescended testis may be improved with educational updates and new transferring model

Ethical approval was not required as this research was conducted on previously collected non-identifiable information.

The age undergoing orchidopexy from 1 April 2010 to 1 February 2015 for undescended testes were included. Age at orchidopexy was calculated from date of birth and date of operation.

An anonymous questionnaire entitled “Cognition of cryptorchidism and referral patterns for children with undescended testes” was distributed to 373 RPs/ healthcare practitioners with a 100% response rate. The multiple choice questionnaire asked: how and at what age children with UDT were usually detected, the perceived optimal age for orchidopexy. Data were then collated and represented graphically.

The date diagnosed of UDT, the date referral to specialist center for outpatient appointment, the date of orchidopexy were collected from electronic appointment system.

We list the reasons why there may be a delay to orchidopexy for any given patients, then proposed educational updates and new transferring model.

All aspects of UDT management were addressed in our educational updates, and we chose to track the age of orchidopexy to determine if management could be improved. The following updates were provided: (1) A continuing medical education course on UDT management in January 2015 including lecture and training test in order to make them know about the issue, follow our suggested referral pathway for UDT. We proposed guideline for referral and management of undescended testes for early ochidopexy as follows: Healthcare practitioners help making referral of the given patients to specialist center for outpatient appointment before age 3 months if accurate diagnosis is performed. The cases diagnosed with undescended testis (not retractile testes) could undergo orchidopexy before age of 12 months; (2) Inserting a note that the recommended age of orchidopexy is 6–12 months, in August 2015; (3) An educational lecture named “referral as early as 3 months old” was held in February 2016. All providers who had referred a patient to our specialist center from April 2014 to January 2015 (Included the primary healthcare practitioners, and the providers from the other department of outpatient are educated.

The age undergoing orchidopexy for an UDT were then collected from 1 Feb 2015 to 30 July 2016 and 1 August 2016 to 1 August 2017 after our educational updates and new transferring model.

Data were represented graphically and statistic analysis Chi-square for trend were the statistic methods used to evaluate the change in age of orchidopexy over the study period.

On an individual level, there are many reasons why there may be a delay of orchidopexy for any given patient. By examining the referral pathway for our population and the data in the survey, we attempted to determine the main factors that may contribute to a delay of orchidopexy. A large number of patients accumulated in pediatric surgery center, therefore, it was felt that the reason for delay to surgery was due to long waiting list time. In our study, the total waiting list time of orchidopexy ranged from 79 days to 1032 days. Early orchidopexy would therefore require a referral before 3 months of age.

We then considered primary care. We notice the timing of referral to a surgical center. Our GP survey showed that the delay in referral pathway was likely to be a significant contributing factor. Since most infants with UDT were diagnosed when going for baby check, it is the reassessment and timing of referral that varies greatly between GPs. Only 25.50% of them would directly make a surgical referral to pediatric surgery specifically at this point. The majority of the primary healthcare practitioners would suggest to bring children back for reassessment, usually at around 1 year, and receive the operation before 2 years old if required. It is likely that delay in the referral pathway, and limited knowledge of current targets re significant contributing factors in the failure to reach the 12-month target.

The results of our healthcare practitioners survey demonstrated that the recognition of orchidopexy age and the delay in referral pathway were likely to be significant contributing factors [10, 15]. Catherine J have demonstrated only 25% of GPs would directly make a surgical referral at their first 6-week baby check: 20% to pediatric surgery specifically and only 5% to general surgery [10]. And only 2% of the healthcare practitioners knew the recommended age of orchidopexy was 6–9 months in our survey. 14.3% of them would directly make a surgical referral to pediatric surgery specifically at this point. Thus, the healthcare practitioners should continue to have education to strengthen the update knowledge of cryptorchidism, included the age of orchidopexy and the necessity to make a surgical referral to pediatric surgery [16, 17].

Most of Chinese babies are seen by their GP after birth. This is an ideal opportunity to identify infants with UDT and refer onwards [10]. It is suggested that infants should be provided a referral to a surgical outpatient clinic at around 3 months of age. Although a small number of testes will descend between GP visit and the outpatient clinic, delay in referral after 3 months is still likely to lead to late orchidopexy.

The median age at orchidopexy throughout this time period was analyzed every 2 months, and it decreased from 24 months (1 April 2014–1 February 2015) to 12 months (1 June 2016–31 July). Tracking the age of orchidopexy revealed a statistically significant trend downward after our educational update of new transferring model. Interestingly, there was a slight decrease in percentage of orchidopexies performed before the age of 24 months in the second stage study when compared with the first stage. It was considered to owing to the interrupted educational update, and it showed a risk that the healthcare practitioners could follow again the old timing system over 12 months. Which meas, it’s important to provide continuous learning courses for referring providers and healthcare practitioners.