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Management of Cryptorchidism: A Survey of Clinical Practice in Italy

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Marchetti et al.

BMC Pediatrics 2012, 12:4


http://www.biomedcentral.com/1471-2431/12/4

RESEARCH ARTICLE

Open Access

Management of cryptorchidism: a survey of


clinical practice in Italy
Federico Marchetti1*, Jenny Bua2, Gianluca Tornese1, Gianni Piras3, Giacomo Toffol3 and Luca Ronfani4, for
the Italian Study Group on Undescended Testes (ISGUT)

Abstract
Background: An evidence-based Consensus on the treatment of undescended testis (UT) was recently published,
recommending to perform orchidopexy between 6 and 12 months of age, or upon diagnosis and to avoid the use
of hormones. In Italy, current practices on UT management are little known. Our aim was to describe the current
management of UT in a cohort of Italian children in comparison with the Consensus guidelines. As management
of retractile testis (RT) differs, RT cases were described separately.
Methods: Ours is a retrospective, multicenter descriptive study. An online questionnaire was filled in by 140 Italian
Family Paediatricians (FP) from Associazione Culturale Pediatri (ACP), a national professional association of FP. The
questionnaire requested information on all children with cryptorchidism born between 1/01/2004 and 1/01/2006.
Data on 169 children were obtained. Analyses were descriptive.
Results: Overall 24% of children were diagnosed with RT, 76% with UT. Among the latter, cryptorchidism resolved
spontaneously in 10% of cases at a mean age of 21.6 months. Overall 70% of UT cases underwent orchidopexy at
a mean age of 22.8 months (SD 10.8, range 1.2-56.4), 13% of whom before 1 year. The intervention was performed
by a paediatric surgeon in 90% of cases, with a success rate of 91%. Orchidopexy was the first line treatment in
82% of cases, while preceded by hormonal treatment in the remaining 18%. Hormonal treatment was used as first
line therapy in 23% of UT cases with a reported success rate of 25%. Overall, 13 children did not undergo any
intervention (mean age at last follow up 39.6 months). We analyzed the data from the 5 Italian Regions with the
largest number of children enrolled and found a statistically significant regional difference in the use of hormonal
therapy, and in the use of and age at orchidopexy.
Conclusions: Our study showed an important delay in orchidopexy. A quarter of children with cryptorchidism was
treated with hormonal therapy. In line with the Consensus guidelines, surgery was carried out by a paediatric
surgeon in the majority of cases, with a high success rate.

Background
Undescended testicle (UT) is present at birth with a frequency varying from 2% to 8% [1]: in Italy the estimated
prevalence is 3.5% in term babies [2]. UT includes both
a non-palpable testis and a palpable supra-scrotal testis
which cannot be pulled down to the scrotum or does
not remain there by six months of age. UT should be
differed from retractile testis (RT), a condition where
the testis is palpable in the supra-scrotal region but,
once pulled down to the scrotum, remains there after
* Correspondence: marchetti@burlo.trieste.it
1
Institute for Maternal and Child Health IRCCS Burlo Garofolo, Department
of Paediatrics, Trieste, Italy
Full list of author information is available at the end of the article

the exhaustion of the cremasteric activity. In this case


RT should not be treated. Differential diagnosis between
a true RT and a supra-scrotal UT may not be easy [3].
The difficulty in achieving consensus on UT management depends largely on the long follow-up from diagnosis until the attainment of full testicular function in
adulthood. An up-to-date evidence-based Consensus on
the treatment of UT has been published [3] with the following recommendations: a) hormones are not recommended [4]; b) orchidopexy should be performed
between 6 and 12 months of age, or upon diagnosis, if it
occurs later; c) orchidopexy should be performed at centres with both paediatric surgeons or urologists and paediatric anaesthesiologists. These recommendations, in

2012 Marchetti et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.

Marchetti et al. BMC Pediatrics 2012, 12:4


http://www.biomedcentral.com/1471-2431/12/4

line with those by Swiss surgeons [5], are important in


order to avoid adulthood consequences of UT, such as
azoospermia or oligospermia [6,7], endocrine insufficiency [8,9] and possible tumoral degeneration [10-12].
Retractile testis (RT) may be more difficult to diagnose. According to the Consensus, RT should not
undergo surgery but should be followed-up once yearly
given the possible risk of reascent [13-15].
In Italy, current practices on UT management are little known and they appear to be heterogeneous. We
hypothesised a non-adherence to the Nordic Consensus
guidelines, with a delay in orchidopexy. We carried out
a retrospective observational study among Italian Family
Paediatricians (FP) on a cohort of children with UT in
order to describe the current management of cryptorchidism in Italy, before the Consensus publication [3].
Since the differential diagnosis between UT and RT can
be problematic [15], we decided to describe the management of RT cases separately.

Methods
Ours is a descriptive and multicenter study. It enrolled
FP from Associazione Culturale Pediatri (ACP), a
national professional association represented in all
Regions of Italy.
FP work independently in their offices, providing acute
and chronic care to all children from 0 to 14 years old.
They contract directly with the National Health System
for the care of patients through a capitated reimbursement system, ensuring free paediatric care at the point
of provision to all children.
ACP has been involved in previous studies and is
representative of the Italian paediatric primary care system [16,17]. FP were invited to participate at a national
ACP meeting, where the study protocol was first presented. Each FP was asked to fill out an electronic form
for each child with UT/RT diagnosis. The form was validated by a pilot study.
The study was approved by the Independent Bioethics
Committee of the Institute for Maternal and Child Health
IRCCS Burlo Garofolo (Prot. CE/V- 86, April 28, 2008).
The research was carried out in compliance with the Helsinki Declaration. Each FP asked the parents informed
consent before filling out the electronic data base.
Inclusion criteria and data collection

We included all children born between the 1st of January


2004 and the 1st of January 2006 with both diagnosis of
UT and RT. UT included both a non-palpable testis and
a palpable supra-scrotal testis which could not be pulled
down to the scrotum or did not remain there by six
months of age. RT was defined as a palpable supra-scrotal testis which could be pulled down to the scrotum and
remained there after exhausting the cremasteric activity.

Page 2 of 8

At the time of our survey (early 2008), enrolled children were aged between 24 and 56 months of age. We
excluded from the analysis all subjects with spontaneous
resolution of UT in the first 6 months of life.
An electronic data collection form (Additional files 1
and 2) was filled in directly by each participating FP for
each child with a diagnosis of cryptorchidism. Data
included: age at diagnosis, clinical type according to the
definitions above (non-palpable UT, palpable suprascrotal UT, RT), presence of a clinically significant concomitant disease, use of hormonal therapy, age at
orchidopexy, and centre at which orchidopexy was
performed.
Outcome variables

Primary outcome variables were: mean age at orchidopexy, prevalence of hormonal therapy and of referral to
a paediatric surgery centre. Secondary outcome variables
were: prevalence of reported success and failure of hormonal therapy and of surgery complications.
We analyzed the data from the 5 Italian Regions with
the largest number of children enrolled in order to
check for any regional difference for primary outcomes.
Data Analysis

Categorical variables are presented as absolute numbers


and percentages, continuous variables as means, standard
deviations, minimum and maximum range. Only means
are presented as their values essentially overlapped those
of medians. All data were analysed by the statistical package SPSS for Windows, version 11. Chi-square for trend
was calculated to detect significant differences among
regions. As a non-normal distribution of data were
shown both visually and with the Kolmogorov Smirnov
test, we used a non-parametric test (Mann-Whitney test
or Kruskal-Wallis test in case of more than 2 independent comparisons) to compare continuous data.

Results
One-hundred and sixty-two FP were enrolled in the
study; 140 (86%) responded to the questionnaire. Mean
age of enrolled FP was 51,7 years (SD 4,7), with a mean
of 26.3 years of clinical experience (SD 5.1) after medical degree. A mean of 895 (SD 148) patients were followed by each FP. Participating FP were representative
of the whole country as they came from 18 out of the
20 Italian administrative regions.
Eighty-three out of 140 FP (59%) followed at least 1
patient with UT or RT in the defined period, adding up
to a total of 177 children. After the exclusion of 3 cases
who did not meet the inclusion criteria and 5 cases with
spontaneous resolution of cryptorchidism in the first 6
months of age, 169 children were considered in the final
analysis: 127 with UT and 41 with RT (1 with unknown

Marchetti et al. BMC Pediatrics 2012, 12:4


http://www.biomedcentral.com/1471-2431/12/4

position). Figure 1 and Table 1 show the main results of


the study.

Page 3 of 8

non-palpable. In 18% of cases (n = 23) there was an associated disease or syndrome. The mean age at last follow-up
was 35.1 months (SD 13.1, range 4.8-58.8; 5 missing data).

Characteristics of children with UT

Mean birthweight was 3262 grams (SD 615) and gestational age 39 weeks (SD 2.1), with the majority of cases
(88%) born between 37 and 41 weeks.
Sixteen percent of children had bilateral cryptorchidism,
while 45% had right and 33% left cryptorchidism. Seventytwo (57%) were in inguinal position, while 55 (43%) were

Hormonal therapy

Overall 39 out of 127 children (31%) were treated with


hormones, of whom 29 before surgery and 10 after surgery (1 both pre- and post-surgery), although use of
hormones was not homogenous among regions (c2 for
trend, p = 0,001) (Table 2).

Figure 1 Data flow diagram describing children with a diagnosis of UT.

Marchetti et al. BMC Pediatrics 2012, 12:4


http://www.biomedcentral.com/1471-2431/12/4

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Table 1 Main outcome measures for children with cryptorchidism as a whole, and divided in UT and RT subgroups.
UT #

RT #

Spontaneous resolution

13/127 (10%)

14/41 (34%)

- Mean age at resolution, in months (SD; range)

21.6 (10.8; 9.6-40.8)

27.6 (13.2; 6-46.8)

Between 6 and 11 months

4 (31%)

2 (14%)

Between 12 and 23 months

3 (23%)

5 (36%)

24 months or more

6 (46%)

7 (50%)

29/127 (23%)

4/41 (10%)

16/29 (55%)
13/29 (45%)

2/4 (50%)
2/4 (50%)

Mean age at beginning of hormonal treatment, in months (md = 1) (SD; range)

20.4 (13.2; 6-50.4)

30 (7.2; 20.4-36)

- Mean age at beginning of hCG, in months (md = 1)

24 (13.2; 6-50.4)

30 (3.6; 43.2-33.6)

- Mean age at beginning of LHRH, in months

15.6 (10.8.; 6-42)

28.8 (10.8; 20.4-36)

Descend of testis after hormonal treatment

7/28 (25%)*

1/4 (25%)

Surgical treatment

88/126 (70%)

10/40 (25%)**

- Mean age at surgery, in months (md = 1) (SD; range)

22.8 (10.8; 1.2-56.4)

27.6 (10.8; 12-46.8)

- Age at surgery, categories (md = 1):


before 6 months

3 (3%)

between 6 and 11 months

9 (10%)

1 (10%)

between 12 and 23 months

44 (51%)

4 (40%)

24 months or more

31 (36%)

5 (50%)

- Carried out in paediatric surgery center

79/88 (90%)

8/10 (80%)

- Carried out in paediatric surgery center < 12 months

12/12 (100%)

1/1 (100%)

- Carried out in the Region where child lived (md = 4)

74/85 (87%)

8/9 (89%)

- Scheduled orchidopexy
Surgery outcome

7/126 (6%)

4/40 (10%)

- Descended testis

80/88 (91%)

10/10 (100%)

- Need for second surgery

2/88 (2%)

- Anorchia and prosthesis positioning

1/88 (1%)

- Outcome not clear/not specified

5/88 (6%)

11/126 (9%)

- Age at spontaneous resolution, categories:

Hormonal treatment (as pre-surgical or unique treatment)


- hCG
- LHRH

Post-surgery hormonal treatment


- hCG

10/11 (91%)

- LHRH

1/11 (9%)

Categorical variables are presented as percentages, continuous variables as mean (SD; range).
* 1 child lost at follow up from FP after beginning of treatment
** 1 child lost at follow up after sending to surgeon
17 children after hormonal treatment; 82 underwent surgery as first line treatment
# 1 child without indication of physical examination and clinical type

The mean age of initiation of pre-surgical hormonal


therapy was 20.4 months. Of 29 cases who underwent
hormonal treatment before surgery, 16 were treated
with human chorionic gonadotropin (hCG), 13 with
luteinizing hormone-releasing hormone (LHRH). No
child was treated with both drugs. Hormonal treatment
led to resolution in 7/28 cases (25%), of whom 5/15
(33%) treated with hCG and 2/13 (15%) treated with
LHRH; 1 was lost at follow up.
Orchidopexy

Overall 88 out of 126 children with UT (70%, missing


data = 1) underwent orchidopexy, 72 without previous

hormonal treatment, 16 with. The use of surgery varied


through regions (c2 for trend, p = 0,026) (Table 2) and
was not related to the age of FP (p = 0.3).
Mean age at intervention was 22.8 months. Mean age
of intervention did not differ between was those who
underwent surgery without receiving a previous hormonal treatment (mean of 21.6 months, SD 12, range 1,256,4 months) and those who received hormones before
surgery (mean of 24 months, SD 8.4, range 8.4-37.2) (p
= 0.2).
Overall only 13% of children underwent surgery
within the first year of life, while 36% at more than 2
years of age.

Marchetti et al. BMC Pediatrics 2012, 12:4


http://www.biomedcentral.com/1471-2431/12/4

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Table 2 Regional differences in the use of hormonal therapy, use of surgery and mean age at surgery
Hormonal therapy*

Surgery**

Mean age at surgery, in months (SD)

Friuli-Venezia Giulia

18.2% (2/11)

90% (9/10)

21,5 ( 8,0)

Veneto

9.4% (3/32)

71.9% (23/32)

23,9 ( 10,85)

Lombardy

30% (6/20)

75% (15/20)

21,2 ( 10,6)

Umbria

41.7% (5/12)

58.3% (7/12)

23,6 ( 18,7)

Sicily

53.3% (8/15)

46.7% (7/15)

25,0 ( 6,6)

* c per trend, p = 0,001; ** c per trend, p = 0,026; p = 0.7, 1 children lost at follow up after starting hormonal therapy
2

In 80 out of 88 cases (91%), surgery resulted in the


resolution of cryptorchidism (Figure 1). Only 2/16 children (12.5%) underwent surgery within the first year of
life. No surgical complications were reported.
Paediatric surgery centre

In 90% of cases, orchidopexy was carried out by a paediatric surgeon, in 100% of cases in children younger
than 12 months. The 2 cases who needed a second surgery came both from a paediatric surgery centre. In 87%
of cases, children underwent orchidopexy in the same
region from where they came.
Characteristics of children with RT

Among 41 children with diagnosis of RT, 14 had a


spontaneous resolution at a mean age of 27.6 months.
Four children were treated with hormones which was
started at a mean age of 30 months with a success rate
of 25%. Ten children with RT underwent orchidopexy at
a mean age of 27.6 months. In 9 cases surgery was conducted as first line treatment, in 1 it was carried out in
a paediatric surgery center, in 1 before the age of 12
months, with an overall success rate of 100%. Four children had scheduled surgery, 10 are followed up without
any treatment, 1 child was lost at follow-up (Table 1).

Discussion
Cryptorchidism is a relevant condition, with an estimated incidence in Italy of 3,5% yearly [2]. For unknown
reasons, UT prevalence appears to have increased in
some countries [18,19]. This increase is of concern
given the long term adverse health effects of UT, such
as altered semen quality [4,20], endocrine insufficiency
[8,21,22] and increased risk of testicular cancer
[11,23-27]. In fact cryptorchidism has been proposed to
be part of a testicular dysgenesis syndrome which
includes hypospadias, reduced semen quality and testicular cancer. These conditions are thought to have a
common origin in prenatal testicular maldevelopment,
which affects both Leydig and Sertoli cells and germ cell
differentiation [28]. The aim of an early orchidopexy is
to prevent the possible adulthood consequences on
spermatogenesis [3,29,30], while its effect on the risk of
testicular cancer remains to be established.

Our study aim was to describe the clinical practice of


cryptorchidism management in Italy before the publication of the Consensus [3] by selecting a cohort of children born and treated before then, with the additional
aim of divulgating the Consensus. In order to reflect the
Italian National Health System, we chose to draw our
study sample from the general population followed at
the primary care level from FP, retrieving a total of 169
cases, of which 127 with UT and 41 with RT.
Our study showed that one out of 4 children with UT
have been treated with hormones (55% of patients treated with hCG, 45% with LHRH) as first line therapy at a
mean age of 21,6 months. Success rate of both hormones was 25%, in line with those published in the literature [31]. According to the Nordic Consensus
Guidelines hormones are not formally recommended
[3,4]. Reported success rate for hormones is of 15-20%
compared to 95% for surgical treatment [3,4,31]. The
Nordic Consensus reservations over hormones use relate
to the fact that hCG has been associated not only with
an increased risk of testicular damage and consequent
reduced spermatogenesis [31-35] attributed to an
increased germ cells apoptosis, but also with systemic
effects, such as ventricular hypertrophy [36].
However, the aspect of hormonal use is still debated,
and the European Society of Paediatric Urologists
(ESPU) is in favour of using gonadotrophin releasing
hormone (GnRH) analogues to improve fertility in boys
UT, particularly in those with bilateral disorders [37].
Although the number of studies is limited and patient
numbers are relatively low, GnRH analogues (in some
studies used in combination with hCG) do appear to
have a statistically significant beneficial effect on fertility
indices both when used before orchidopexy [38,39] and
after [40,41]. Randomised controlled trials are warranted
to confirm the beneficial effect of the adjuvant GnRh
therapy [42].
We found a delay with regard to the recommended
timing of orchidopexy, as first line treatment (mean age
at surgery of 21.6 months) and even longer as secondary
treatment after hormones (mean age at surgery of 24
months), although the difference was not significant.
Only 13% of UT cases underwent orchidopexy before
one year of age; in 1 out of 3 cases surgery was

Marchetti et al. BMC Pediatrics 2012, 12:4


http://www.biomedcentral.com/1471-2431/12/4

performed after 2 years. The delay in the surgical


approach of UT is a common worldwide practice. An
Italian survey conducted in 2001 showed a mean age at
orchidopexy of 27,8 months, with 16% of not yet treated
children by the age of 32 months [43]. In UK between
1997 and 2005 the percentage of children with UT
undergoing surgery before 2 years of age increased
slightly from 15,8% to 28.5% [44]. In USA, a recent survey showed a rate of age at orchidopexy similar to our
study: 18% by 1 year of age, and 43% by the age of 2
[45]. This latter study found a significant association of
race and insurance payer with age at orchidopexy. In
Italy the delay of surgery cannot be imputable to insurance status, as all citizens have a public insurance or to
race, given that around 93% of Italian citizens are Caucasian. This suggests that in Italy the reasons for the
delay in orchidopexy rather reflect differences in the
knowledge and updating of the clinicians, as well as
organizational aspects at the national and regional level.
With this respect, we found significant differences in the
management of UT among Italian regions.
In line with the Consensus recommendations we
found a very high percentage of referral to a paediatric
surgeon: 9 out of 10 UT cases were treated in a tertiary
centre by a paediatric surgical team (100% under the
first year of life) with a high rate of success (91%), similarly to that reported by others [46]. Orchidopexy was
described as a safe surgical treatment as no complications were reported.
Our study also described 41 children with an initial
supposed diagnosis of RT. It showed a high percentage
of resolution of RT cases during follow-up, as it occurs
in RT natural history. Nevertheless, surprisingly 10 children with initial diagnosis of RT underwent surgery and
4 were treated with hormones. This may be explained
by two main reasons. Firstly, patients with significant
testicular retractility appear to be at a high risk for
acquired cryptorchidism [13]: for this reason according
to the Consensus an annual follow-up of RT cases
throughout childhood is recommended until puberty
due to the high risk of reascent [3,14,44]. Secondly, the
initial diagnosis, which distinguishes between a true
condition of UT from RT, still represents a diagnostic
dilemma, and the problem of misclassification is well
known [15] requiring specific training. The data that 13
children with a reported diagnosis of UT had a spontaneous resolution seems to confirm this difficulty in the
UT-RT differential diagnosis.
Other than the possible diagnostic problems mentioned above, our study is not without limitations. It is a
retrospective survey, the nature of which cannot rule
out a recall bias of the collected data. However, all FP
involved could retrieve data for all patients from an
electronical clinical file. Adhesion to the study was on a

Page 6 of 8

voluntary basis representing a possible bias as our


results may not be representative of the management of
cryptorchidism in the whole Italian reality. However,
there was a high response rate from the FP invited to
participate to the study (86%), and the participating FP
had a countrywide distribution. Differences according to
Italian regions were noted highlighting that current
practices on cryptorchidism management are not homogenous and that an update on cryptorchidism management is auspicable on a national basis.

Conclusions
The correct and timely management of children with
cryptorchidism is important to promote gonadal development and to avoid the adulthood consequences of
spermatogenesis defects. The results of our study
allowed for the first time to describe how was the management of cryptorchidism in Italy before the publication of the Consensus. Hormone therapy was used in
about one quarter of the cases. The average age at surgery was much higher than recommended in the Consensus, and only 13% of children underwent surgery
before 12 months of age.
Our results suggest that the spread of the Consensus
guidelines on the management of cryptorchidism among
all paediatricians is warranted in order to reduce age at
orchidopexy and to have a more homogenous approach
in the whole of Italy.
Additional material
Additional file 1: Italian data collection form. Data collection form in
Italian language as in the original electronic form.
Additional file 2: English data collection form. Data collection form
translated in English.

Abbreviations
UT: undescended testis; RT: retractile testis; FP: family paediatrician; hCG:
human chorionic gonadotropin; LHRH: luteinizing hormone-releasing
hormone.
Acknowledgements
This study was funded by the Italian Ministry of Health (research grant: 0208,
L 4). The sponsor had no role in design, data collection, analysis and
interpretation, or reporting of the study.
We thank the Italian Study Group on Undescended Testes (ISGUT): the
Scientific Committee (Francesco Chiarelli, Michele Gangemi, Jrgen Schleef,
Giorgio Tamburini, Alessandro Ventura) and all the Family Paediatricians who
participated to the data collection (Abadessa A, Accordini G, Aimini E, Alberti
A, Aloisio A, Amadio C, Amoroso B, Andreotti MF, Angelini P, Auriti L, Basilico
E, Belvedere L, Berardi C, Besoli G, Bianchi S, Binni O, Biolchini A, Bollettini S,
Bologna B, Bonin P, Bontempo F, Borghesani M, Brusadin L, Brutti P, Budassi
R, Cafaro C, Cajani M, Callegari M, Cambria R, Cammarota MS, Canfora G,
Capomolla D, Cappellani E, Casalboni R, Casiraghi EM, Cavallo R, Cazzuffi MA,
Cera M, Ciambra R, Clerici Schoeller M, Coltura E, Concas L, Conforti G, Conti
Nibali S, Corbetta D, Crupi I, De Angelis R, De Santi M, Degli Angeli M, Del
Bono GP, DellAntonia F, DellEdera L, Di Francesco C, Di Pietro ME, Donati D,
Faberi P, Faedi CM, Falasconi AM, Finco M, Fortunato V, Francano B, Frison E,

Marchetti et al. BMC Pediatrics 2012, 12:4


http://www.biomedcentral.com/1471-2431/12/4

Fusco F, Gaeta G, Gaiotti P, Gangemi M, Garrone G, Girotto S, Gorini S,


Gurnari AS, Gussoni C, Innocente M, Lambiase R, Lazzerini U, Lepre G,
Liberati M, Lisi V, Lixia G, Lo Cascio A, Lonardi S, Longaretti A, Lorenzon M,
Lucchi E, Madeddu E, Manetti S, Mantegazza M, Marolla F, Marolla L,
Marongiu F, Martello C, Martinati L, Martoccia M, Masala P, Materassi P,
Matteoli G, Mazzini F, Mittiga S, Molino O, Muzzolini C, Nardini P, Narducci
M, Neri P, Nicoloso F, Olimpi LM, Oliviero L, Pasinato A, Poggioli B, Portera G,
Primavera G, Primi A, Profiti V, Rafele I, Raimo F, Reali L, Rella F, Rimoldi R,
Rinaudo B, Rogari P, Rosi A, Salvadori R, Sambugaro D, Scala R, Scornavacca
G, Semenzato F, Servello R, Siracusano MF, Sonaglia F, Spanevello V, Speciale
S, Stazzoni A, Stocchero L, Toffol G, Tommasi M, Tulipano C, Valente M,
Vivaldi A, Zanetto F, Zanini S, Zarrilli S, Zini A, Zuccolo ML).
Author details
1
Institute for Maternal and Child Health IRCCS Burlo Garofolo, Department
of Paediatrics, Trieste, Italy. 2Institute for Maternal and Child Health IRCCS
Burlo Garofolo, Department of Neonatology, Trieste, Italy. 3Associazione
Culturale Pediatri, Italy. 4Institute for Maternal and Child Health IRCCS Burlo
Garofolo, Epidemiology and Biostatistics Unit, Trieste, Italy.
Authors contributions
FM, JB and G. Tornese conceived the study, participated to its design and
coordination, and wrote the first draft of the manuscript. LR participated to
the design of the study, its coordination and performed the statistical
analysis. GP designed the online questionnaire and carried out the data
collection. G. Toffol participated to the study design and promoted the
study among ACP. All authors read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 12 May 2011 Accepted: 10 January 2012
Published: 10 January 2012
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Pre-publication history
The pre-publication history for this paper can be accessed here:
http://www.biomedcentral.com/1471-2431/12/4/prepub
doi:10.1186/1471-2431-12-4
Cite this article as: Marchetti et al.: Management of cryptorchidism: a
survey of clinical practice in Italy. BMC Pediatrics 2012 12:4.

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