Two-Stage Fowler-Stephens Orchiopexy With Laparoscopic Clipping of the Spermatic Vessels

Evaluation of two-staged Fowler-Stephens laparoscopic orchidopexy (FSLO) for intra-abdominal testes (IAT)

INTRODUCTION

The best operative intervention for intrabdominal testis (IAT) has not been standardized as yet. The question of whether to bring down an IAT with a single-staged vessel-intact laparoscopic orchidopexy (VILO) or a two-staged laparoscopic Fowler-Stephens orchidopexy (FSLO) is still undergoing debate, with both the procedures being popular. The present study has been designed to evaluate the factors predicting the success or failure of two-staged FSLO for (IAT).

METHODS

43 boys with 49 non-palpable testes underwent diagnostic laparoscopy out of which 35 underwent two-staged FSLO. Size of the testis was measured with a graduated probe in both stages. Independent variables such as age, height, testis-to-internal ring distance (T-IR), neo internal ring-to-midscrotal distance (NIR-MS), and mobility-to-contralateral ring (MCIR) were analysed. Postoperatively 34 IATs were followed up clinically as well as ultrasonologically after 6 months, to see for the size, position, and vascularity. Based on this, the patients were divided into two groups, Group A (successful) and Group B (Failed).

RESULTS

24 IATs had a successful outcome (Group A) and 11 were failure (Group B). The overall success rate of the study was 68.6%. The difference in mean age of patients in both groups was insignificant (p = 0.89) (Fig. 1), and similarly, the difference in mean height was insignificant (p = 0.61). The difference in mean T-IR in both the groups was insignificant (1.85 versus 2.77 cm; p = 0.09) and mean NIR-MS was 5.41 cm in Group A and 5.10 cm in Group B, and the difference again was insignificant (p = 0.23).

CONCLUSION

The success rate of FSLO was 68.6%. None of the above-described independent variables have any effect on the outcome of two-staged FSLO. While VILO remains the treatment of choice for IAT located at or near the ring, but IAT higher than this, two-staged FSLO gives a better chance for achieving intra-scrotal orchidopexy.

Testicular atrophy after attempted pediatric orchidopexy for true undescended testis

BACKGROUND/PURPOSE

A normal testis in the scrotum is the most important outcome of the attempted pediatric orchidopexy for a true undescended testis. The reports of post-orchidopexy testicular atrophy in the literature have ranged from non-existent to unclear. Our purpose in this study was to estimate the incidence of and associated risk factors for post-orchidopexy testicular atrophy.

METHODS

We performed a retrospective review of data from children who had an attempted orchidopexy for a true undescended testis from 1969 to 2003 inclusive. REB approval 1000011987.

RESULTS

There were 1400 attempted orchidopexies involving common (low) type (n=1135), ectopic type (n=174), and high type testes (n=91). There were a total of 111/1400 (8%) atrophic testes, mostly right-sided. 66/111 (59%) were MADE atrophic, and 45 (41%) were FOUND atrophic. Of the 1135 common type, 56 (5%) were MADE atrophic. In the ectopic and high types, the incidence of post-operative testicular atrophy was 1% and 9%, respectively. The most significant risk factors associated with testes MADE atrophic were high testicle, vas problems, and pre-operative torsion.

CONCLUSIONS

In this series, the incidence of post-operative testicular atrophy that was MADE was 5% in the common (low) type and 9% in the high type. These numbers and the above risk factors should be quoted to the caregiver during pre-operative informed consent.

Feasibility and safety of monopolar diathermy as an alternative to clip ligation in laparoscopic Fowler-Stephens orchiopexy

PURPOSE

The aims of the study were to study the effect of Fowler-Stephens orchiopexy (FSO) on testicular histology and to assess the feasibility of using monopolar diathermy as an alternative to clip ligation during laparoscopic FSO.

PATIENTS AND METHODS

The study included 20 patients with 20 intraabdominal testes and short vessels managed by laparoscopic-staged FSO. Biopsies were taken from intraabdominal testes during the first and second stages of the procedure for histologic comparison. The patients in the study were divided into 2 groups according to the method of dividing the testicular vessels in stage 1. The first 13 patients (group A) were managed by clip ligation of the vessels, whereas monopolar diathermy was used in the following 7 patients (group B).

RESULTS

Biopsy findings at stage 2 revealed an overall reduction in both the total number of germ cells per tubule and mean diameter of seminiferous tubules, whereas there was no statistically significant difference between the results in groups A and B.

CONCLUSION

The seminiferous cells can withstand (survive) dividing the main blood supply of the testis during FSO. The monopolar diathermy can be used as an alternative to clipping during laparoscopic procedures, having the advantages of lower expenses and using smaller instruments.

Laparoscopic orchiopexy for non-palpable testes: outcome of two techniques

OBJECTIVE

To assess the outcome of laparoscopic orchiopexy and the two-stage Fowler Stephens technique for managing patients with impalpable testis in terms of safety, feasibility and efficacy.

PATIENTS AND METHODS

This study included 78 patients who presented with 88 non-palpable testes to the outpatient clinic of Sohag university hospital in 2005-2009, and underwent laparoscopy by the same surgeon. Intra-abdominal testes were managed by laparoscopic orchiopexy if low, two-stage Fowler-Stephens technique if high, and orchiectomy if atrophic. Children were evaluated postoperatively to check the location and size of the testicle and to exclude any other complication.

RESULTS

Median age at presentation was 16 months (range 11-42 months). Four testes were absent while inguinal exploration was necessary for six testes with the vas entering the internal ring. Of the 78 intra-abdominal testes, 45 were identified as high (Fowler-Stephens in 43; orchiectomy in two atrophic testes) and 33 as low (orchiopexy). Follow up was 3-55 months (mean 34 months). Twelve patients (12 testes) were lost to follow up (7 Fowler-Stephens; 5 orchiopexy). On follow up, the testes were normal sized and well positioned in the scrotum in 28/28 and 32/36 testes in the orchiopexy and Fowler-Stephens groups with an overall success rate of 100% and 88.8%, respectively. Two testes showed testicular displacement and two showed testicular atrophy in patients of the Fowler-Stephens group.

CONCLUSION

Laparoscopy provides a safe and accurate modality for diagnosing and managing patients with non-palpable testes, with excellent outcomes.

Laparoscopic orchidopexy: the easy way to go

BACKGROUND/PURPOSE

Intraabdominal testes represent less than 10% of cryptorchid testicles, and yet, they are the most challenging to correct. In the last 15 years, the two-stage Fowler-Stephens orchidopexy has gained popularity. The traditional approach includes laparoscopic or open clipping of the testicular vessels (first stage) and open inguinal orchidopexy (second stage). We present our experience with 2-stage orchidopexy with both stages done through a laparoscopic approach.

MATERIALS AND METHODS

Over a recent 5-year period, we reviewed patients operated for intraabdominal testis using a two-stage laparoscopic orchidopexy with a minimum of 1-year follow-up. In this study, success is defined as a nonatrophic, intrascrotal testis. Fifteen patients met the inclusion criteria, and none were lost to follow-up.

RESULTS

In the 15 patients, 11 had a unilateral intraabdominal testis, and 4 had bilateral cryptorchidism, with one of the 2 testes intraabdominal. The first stage was done at a mean age of 32 months, and the average time between the two stages was 9.7 months. All procedures (31) were done on an outpatient basis. Only 2 complications occurred, one scrotal hematoma and one redo first stage because of unsuccessful clipping noted at the time of planned second stage. The success rate is 93.3% (14/15). All testicles are intrascrotal, and all but 1 have maintained preoperative volume.

CONCLUSION

Two-stage laparoscopic orchidopexy is a fairly easy surgical procedure with minimum morbidity and high short term success rate. A larger cohort of patients with long-term follow-up is needed to substantiate these findings.

Open versus laparoscopic staged Fowler-Stephens orchiopexy: impact of long loop vas

PURPOSE

There is a paucity of literature on factors associated with testicular atrophy following second stage laparoscopic Fowler-Stephens orchiopexy. We hypothesized that dissection of a long looping vas during this procedure could compromise testicular blood supply, leading to testicular atrophy.

MATERIALS AND METHODS

Following an initial laparoscopic testicular vessel ligation, a second stage Fowler-Stephens orchiopexy was performed in 73 testes (laparoscopic in 61, open in 12). The presence of a long looping vas was noted from the first stage operative notes. Doppler ultrasound was performed postoperatively to confirm testicular atrophy.

RESULTS

Atrophy rate at a mean followup of 13.5 months was 20.5% (15 of 61 in laparoscopic and 0 of 12 in open orchiopexy). None of the 5 long looping vas testes atrophied following open orchiopexy, compared to 5 of 6 (83%) following laparoscopic orchiopexy (p = 0.03). Analyzing the laparoscopic group alone, a long looping vas was significantly associated with risk of atrophy (p <0.01).

CONCLUSIONS

The presence of a long looping vas was associated with a higher atrophy rate following laparoscopic second stage Fowler-Stephens orchiopexy. Laparoscopic management of the long looping vas may be more challenging and, therefore, in such cases open Fowler-Stephens orchiopexy may result in better success rates by preserving the integrity of the collateral vessels.

Management of boys with nonpalpable undescended testis

Cryptorchidism is one of the most common genitourinary disorders in young boys. Although the management of boys with palpable testis is standardized, there are no formal guidelines for the management of boys with nonpalpable testis. In this Review we look at the current trends in the diagnosis and treatment of this disorder, as well as the indications for therapy and surgical procedures. On the basis of current evidence, we find that there is no optimum orchidopexy technique for the treatment of intra-abdominal testis, although it is preferable to adopt techniques that preserve the spermatic vessels. We also briefly examine the follow-up of patients with this disorder and its common complications. As yet, there are no data that assess the potential of laparoscopic orchidopexy being a risk factor for impaired fertility later in life.

Single stage Fowler-Stephens orchidopexy: a preferred alternative in the treatment of nonpalpable testes

In this present study we aimed to discuss the surgical efficacy of single stage Fowler-Stephens orchidopexy (FSO) technique, with an emphasis on its practical and logical application that may be kept in mind during a standard orchidopexy procedure. Twenty-two children have undergone a single stage FSO procedure for nonpalpable testes during the last 9 years in our department. Surgical procedure was initiated with a standard inguinal oblique incision keeping in mind that depending on the position and the anatomic features of the testes a FSO method might be needed. While an excellent result was defined as a testis with good scrotal position, size and adequate blood flow on Doppler sonogram, acceptable result was a palpably normal sized testis in a high scrotal position with adequate blood supply and lastly an unacceptable result was the atrophy of the testis with compromised blood supply. During regular follow-up visits although some cases revealed testicular atrophy; long-term examination (12 months) did show that majority of the testes maintained their normal position and tissue consistency (21/24, 87.5%). Due to the necessity of surgical approach either in the evaluation or the treatment of nonpalpable testes in most cases along with the unsatisfactory data of the time consuming and invasive radiological procedures; we believe that a classical orchidopexy approach together with further single stage FSO will be a rational and satisfactory algorithm in the majority of such cases.

Results of orchiopexy for the undescended testis

The undescended testis is one of the most common congenital abnormalities of the genitourinary system. Outcomes of orchiopexy include (1) having a viable, palpable testis in the scrotum, (2) fertility, as measured by paternity rates or semen analysis in adulthood and (3) risk of testicular cancer. Multiple operative techniques have been described and are associated with various success rates. In the past decade, success of orchiopexy for inguinal testes has been >95%. For abdominal testes, success for orchiopexy has been >85-90% in most series with single stage orchiopexy or two stage Fowler-Stephens orchiopexy, both with open surgical or laparoscopic technique. However, having a palpable testis in the scrotum does not assure fertility, as there are iatrogenic factors that may adversely affect the outcome. In adult men with a history of unilateral orchiopexy, fertility is nearly normal, but is significantly reduced following bilateral orchiopexy. The risk of testicular carcinoma is increased by a factor of 3.7 to 7.5 times. Tumor type is most commonly seminoma if the testis is undescended, whereas tumors that occur following orchiopexy are much more likely to be nonseminomatous.

Laparoscopy vs inguinal exploration for nonpalpable undescended testis

OBJECTIVE

The optimal initial surgical approach for nonpalpable undescended testis (UDT) is debated. The aim of the present study is to compare the results of initial laparoscopy and inguinal exploration in the management of unilateral nonpalpable undescended testes.

METHODS

The results of 20 children with unilateral nonpalpable UDT managed by initial laparoscopy (group I) were compared with 20 age-matched children managed by inguinal exploration (group II). The location of testes and results of orchiopexy were compared in both groups. A single surgeon performed all the operative procedures.

RESULTS

The majority of testes (16/20 group I, 17/20 group II) in both groups were canalicular or low abdominal. Vanishing testes accounted for one-third (13/40) of the testes, the majority (85%) of which were located in the inguinal canal. All children were discharged within 24 hours of the operation. The success of orchiopexy at 4-6 weeks post-operatively was 85% and 86% in the two groups respectively. Retrospectively, only 7/40 (18%) of the testes would benefit from laparoscopy.

CONCLUSIONS

Initial laparoscopic and inguinal approaches to nonpalpable UDT give comparable results. This report failed to demonstrate any specific advantage of initial laparoscopy in the majority of children with unilateral nonpalpable UDT.

Prepubertal unilateral spermatic vessel ligation decreases haploid cell population of ipsilateral testis postpubertally in rats

DNA flow cytometry is a sensitive and rapid technique to evaluate the germ cell maturation of testis. The haploid cell population of testis specifically denotes testicular maturation. High ligation of spermatic vessels (HLSV) and low ligation of spermatic vessels (LLSV) have been described in the surgical treatment of high undescended testis. Estimation of germ cell population of testis after these maneuvers has not been performed so far by DNA flow cytometry; hence this study was designed. Thirty male rats, aged 30 days, were randomized into three groups. Group I underwent sham surgery; group II underwent unilateral HLSV-ligation and division of main spermatic vessels, similar to the Fowler-Stephens technique; and group III underwent unilateral LLSV-ligation and division of main spermatic vessels close to the testis, similar to the Koff and Sethi technique. Thirty days later, the ipsilateral testes were harvested, and haploid, diploid, and tetraploid cells were counted by DNA flow cytometry. The mean (+/-SD) percentage of the haploid cell population was 68.7+/-4.8, 49.3+/-6.5, and 50.8+/-6.4 in groups I, II, and III, respectively. There was a significant (p<0.05) decrease in haploid cell population between groups I and II and between groups I and III. However, there was no significant difference between groups II and III. In conclusion, prepubertal HLSV as well as LLSV decreases the haploid cell population of ipsilateral testis in rats. LLSV has no advantage over HLSV.

SUCCESSFUL OUTPATIENT MANAGEMENT OF THE NONPALPABLE INTRA-ABDOMINAL TESTIS WITH STAGED FOWLER-STEPHENS ORCHIOPEXY

PURPOSE

Previous reports of orchiopexies have shown an 85.9% success rate for staged Fowler-Stephens orchiopexy (FSO). We review our experience with nonpalpable testes (NPTs).

MATERIALS AND METHODS

A total of 119 patients with 128 NPTs were treated at our institution between 1994 and 2001. Atrophic testes or "nubbins" were removed. Once an intra-abdominal testis was identified the peritoneum was opened and firm traction was placed on the gonad. If feasible, primary orchiopexy was completed. Otherwise, staged Fowler-Stephens orchiopexy was performed.

RESULTS

Primary orchiopexy was performed in 28 testes in 27 patients without division of the spermatic vessels. An atrophic nubbin was removed in 45 patients. All children with bilateral NPTs had at least 1 viable intra-abdominal testis found at surgery. Staged FSO was performed in 55 testes in 47 children. The second stage was performed at a median of 3.5 months after initial ligation of the spermatic vessels. Median followup was 1 year and mean followup was 9 months. Five patients were lost to followup. Successful surgery was defined as a dependent scrotal location and testis size equivalent to the contralateral mate. The overall success rate for the primary orchiopexy group was 100%. In the staged FSO group 1 patient had an atrophic testis at 1-year followup, yielding an overall success rate of 98%.

CONCLUSIONS

A high degree of success can be obtained for children with intra-abdominal testes. Mobility of the testis on exploration is a good indicator that the testis can be managed with primary orchiopexy without division of the vessels. If primary orchiopexy cannot be performed, excellent results are achieved with a staged FSO.

VOLUMETRIC AND HISTOLOGICAL FINDINGS IN INTRA-ABDOMINAL TESTES BEFORE AND AFTER DIVISION OF SPERMATIC VESSELS

PURPOSE

Increased use of video laparoscopy in the diagnosis and treatment of the impalpable testis has encouraged use of the 2-stage Fowler-Stephens orchiopexy. To date, however, few limited studies exist to indicate whether clipping and division of the spermatic vessels alone may cause histological abnormalities in the intra-abdominal testis.

MATERIALS AND METHODS

We evaluated histology and volume of 44 intra-abdominal testes in 35 patients between 4 months and 14 years old at stages 1 and 2 of the Fowler-Stephens procedure.

RESULTS

There was a significant reduction in the number of spermatogonia and seminiferous tubules 6 months after ligation and division of the spermatic vessels. No differences were found in the number of Sertoli cells or testicular volume before and after clipping and division of the spermatic vessels.

CONCLUSIONS

Ligation of the spermatic vessels during stage 1 orchiopexy for intra-abdominal testicles is associated with a significant reduction of spermatogonia. However, no significant changes were observed in the volumetric characteristics of the testicles. Further studies are necessary to evaluate the repercussions of these changes in future fertility.

Current concepts in minimal access surgery for children

Since the introduction of minimal access surgery to general surgeons in the 1980s, pediatric surgeons have been employing this innovative technology to perform surgery on children. Video technology and miniaturized instruments have brought the laboratory to the operating room; in many cases several small incisions are the only access necessary to perform complicated procedures that would otherwise require a large wound. Additional benefits of minimal access surgery may include reduced postoperative analgesic requirements, shortened length of stay, and faster resumption of normal activities. Increased operative costs offset some of these gains. The pediatric surgical community has embraced minimal access techniques for some operations; others remain controversial.

Germ cells may survive clipping and division of the spermatic vessels in surgery for intra-abdominal testes

PURPOSE

Laparoscopy is a well described modality that provides an accurate visual diagnosis upon which further management of intra-abdominal testes may be based. Laparoscopic ligation of spermatic vessels as stage 1 of the procedure is a natural extension of laparoscopy. A staged approach provides adequate viability of the intra-abdominal testis. However, it is uncertain whether the more sensitive germ cells survive this procedure in addition to the Sertoli and interstitial cells of the human testis. Survival of germ cells is a prerequisite of later fertility potential.

MATERIALS AND METHODS

We studied 17 nonpalpable testes in 10 patients 1 year and 7 months to 13(1/2) years old. Results of testicular biopsies of 13 intra-abdominal testes taken at stages 1 and 2 of surgery were available for histological comparison.

RESULTS

Median number of spermatogonia per tubular cross section of the biopsies taken at stage 2 was slightly lower (0.03) compared to the median number at stage 1 (0.06) of the operation but this difference was not significant (p = 0.2031).

CONCLUSIONS

Our study shows that the spermatogonia may survive clipping and division of the spermatic vessels, although the number of spermatogonia per tubular transverse section decreases slightly.