Robot-assisted Modified One-Stage Orchiopexy: Description of a Surgical Technique

Abstract

In recent years, robot-assisted laparoscopic procedures have gradually replaced standard laparoscopic procedures in the realm of pediatric urology. The potential advantages of the robot-assisted technique include a higher degree of dexterity, three-dimensional visualization, and reproducibility. Although laparoscopic orchiopexy is considered to be the gold standard approach in cases of intra-abdominal testes, it can be technically challenging. A crucial point in decision-making is choosing between preservation of testicular blood vessels or sacrificing the vessels in order to achieve sufficient length, as with the one and two-stage Fowler-Stephens orchiopexy (FSO). It is perceived that the one-stage FSO has lower success rates than the two-stage procedure. We present a modification of the one-stage FSO procedure for intra-abdominal testes, utilizing a robot-assisted laparoscopic orchiopexy (RAL-O) method. The key surgical maneuvers for the modified one-stage RAL-O include mobilization of the blood vessels and ligation of the artery as cranial as possible, maintenance of a wide flap of peritoneum between the vessels and vas deferens and employing the Prentiss maneuver. The cohort included 5 boys, all of which underwent RAL-O between April 2018 and May 2020. Median age at the time of surgery was 11 months (interquartile range [IQR] 8-16) and median weight was 9.6 kilograms (IQR 9.3-11.3). Median operating time and follow-up time were 97 minutes (IQR 77.5-109.5) and 8 months (IQR 4-14.5), respectively. All cases were completed as RAL-O and there was no conversion to a two-stage procedure. There were no cases of testicular atrophy. Modified one-stage Fowler Stephens RAL-O is safe and effective. It can be employed in all cases of intra-abdominal testis regardless of testis location, and eliminates the need for intra-operative decision-making, thus allowing for a standardized, one-stage approach.