Baby Steps, Big Stakes: Early Surgery Leaves Testes Vulnerable to Atrophy

When a child is diagnosed with a testicular tumor in the first years of life, surgeons face an agonizing calculus. Remove the entire testicle, and the oncological risk drops to nearly zero. Spare it, and the child keeps an organ that may one day matter for hormone production and fertility. A new body of evidence, highlighted in a correspondence published in Pediatric Research by Jia You and Jun Wang of Wuhan Children’s Hospital, suggests that this calculus changes dramatically depending on one variable that surgeons cannot control: the age of the patient at the time of surgery.

The commentary centers on a retrospective study by Kwon and colleagues, published in World Journal of Urology, that followed children who underwent partial orchiectomy for prepubertal testicular tumors. Partial orchiectomy, also called testis-sparing surgery, involves carefully enucleating the tumor while preserving the surrounding healthy parenchyma. It has gained acceptance as a safe alternative to radical orchiectomy for benign lesions in children, on the logic that a preserved testis is better than a lost one. The new data complicate that logic in a specific and clinically important way. While the procedure proved oncologically sound, it came at a measurable cost to the affected testicle’s growth: testicular atrophy was observed in 21.7 percent of patients over a median follow-up of seven years.

The most striking finding, and the reason the Wuhan authors chose to weigh in, is the age effect. Children who underwent the operation before their first birthday faced a dramatically elevated risk of subsequent atrophy, with an odds ratio of 10.44 and a 95 percent confidence interval spanning 1.99 to 54.90, a statistically significant association at p equals 0.006. In plain terms, surgery in infancy was associated with roughly a tenfold increase in the odds that the spared testicle would fail to grow and instead shrink relative to expectations. For a procedure whose entire rationale rests on preserving function, that number demands attention.

Why would a one-year-old’s testicle be so much more fragile than a five-year-old’s? The answer lies in one of the most remarkable and underappreciated hormonal events in human development, a transient surge known as mini-puberty. In the first months after birth, the hypothalamic-pituitary-gonadal axis, dormant since fetal life, roars back into activity. The pituitary releases gonadotropins, the Leydig cells pump out testosterone at near-adolescent levels, and the testis undergoes a burst of proliferative activity. Sertoli cells, the nurse cells that will later support sperm production, multiply. Germ cells, the precursors of future sperm, expand their numbers. This window of endocrine activity is thought to be essential for laying down the cellular infrastructure of lifelong fertility, and it largely resolves by the end of the first year.

Mini-puberty is not merely a curiosity of developmental biology; it has measurable clinical correlates. Early testicular volume correlates positively with germ cell count, making infant testis size a window into reproductive potential. The importance of timing is already well established in a neighboring field of pediatric surgery: for boys with undescended testes, a systematic review by the American Pediatric Surgical Association’s outcomes committee found that orchidopexy performed before one year of age is associated with improved testicular growth, whereas surgery delayed beyond that window fails to achieve adequate compensatory growth. The developing testis, in other words, appears to have a critical period during which it responds robustly to intervention and, by implication, is most dependent on an undisturbed hormonal and vascular environment.

Animal experiments add a sobering layer of mechanistic plausibility to the new clinical data. Stampfli and Hadziselimovic demonstrated decades ago that even a needle biopsy procedure, a seemingly trivial insult, can cause tubular injury in prepubertal rat testes, producing unilateral testicular atrophy in up to 20 percent of cases. If a needle can do that, the argument goes, a tumor enucleation, which requires incising and dissecting within the delicate seminiferous tubules of a testis that may be only a centimeter or two across, is a far greater insult. The infant testis, in the midst of its mini-pubertal expansion, may be uniquely intolerant of such disruption.

Vascular compromise is the other prime suspect. Doğan and colleagues, writing in the Journal of Pediatric Urology, examined the effects of ischemia in a prepubertal rat model of testis-sparing surgery and reported that warm ischemia induces testicular injury within just 30 minutes, with significant atrophy following prolonged exposure. Warm ischemia, the deprivation of blood flow at body temperature, is an unavoidable feature of tumor enucleation, since the surgeon must temporarily control blood supply to excise the lesion cleanly. In a tiny infant testis, where the margin for error in clamping vessels and preserving collateral flow is vanishingly small, even a technically flawless operation may impose ischemic and traumatic costs that the organ cannot repay during its critical growth window.

The surgical reality of operating on infant anatomy compounds these biological vulnerabilities. Kwon and colleagues reported a postoperative hematoma rate of 13.3 percent, a figure that You and Wang argue underscores the technical challenges of parenchymal surgery in the small prepubertal testis. A hematoma, a collection of blood within or around the operated organ, is more than a cosmetic complication; it can compress delicate tissue, compromise microvascular perfusion, and set the stage for fibrosis and loss of volume. In an adult testis, such an insult might be absorbed. In an infant testis already navigating the hormonal turbulence of mini-puberty, it may be the difference between a gland that grows and one that withers.

None of this means that partial orchiectomy should be abandoned in infants. The oncological results remain reassuring, and for benign prepubertal tumors the alternative, radical removal of the testis, carries its own lifelong consequences for hormone production and fertility. What the data suggest instead is a more nuanced decision-making framework. Surgeons and families confronting a testicular tumor in the first year of life should understand that testis-sparing surgery in this age group carries a substantially higher risk of atrophy than the same operation performed later in childhood. That risk must be weighed against the tumor’s characteristics, the feasibility of a clean enucleation, and the availability of meticulous microsurgical technique to minimize both parenchymal trauma and ischemic time.

The findings also point toward future research priorities. If mini-puberty is the biological fulcrum on which outcomes turn, then studies that track gonadotropin and testosterone levels in infants undergoing testis-sparing surgery could clarify whether hormonal disruption, vascular injury, or direct parenchymal trauma dominates the atrophy pathway. Longer follow-up into adolescence and adulthood would reveal whether spared testicles that avoid atrophy genuinely preserve endocrine and reproductive function, or whether subtler damage lurks beneath a normal volume. For now, the message from Wuhan is a call for precision and humility: the infant testis is a small, busy, hormonally charged organ, and the window in which it builds its reproductive future is exactly the window in which surgery hurts it most.

Subject of Research: Risk of testicular atrophy after partial orchiectomy in infants with prepubertal testicular tumors

Article Title: Higher risk of testicular atrophy after partial orchiectomy performed before one year of age

Article References: You, J., & Wang, J. (2026). Higher risk of testicular atrophy after partial orchiectomy performed before one year of age. Pediatric Research. https://doi.org/10.1038/s41390-026-05585-1

Image Credits: AI Generated

DOI: 10.1038/s41390-026-05585-1

Keywords: partial orchiectomy, testicular atrophy, mini-puberty, pediatric surgery, prepubertal testicular tumors, testis-sparing surgery, hypothalamic-pituitary-gonadal axis, warm ischemia, Sertoli cells, orchidopexy, Pediatric Research, infant testicular development