Standardized single-stage laparoscopic Fowler-Stephens orchiopexy regardless of testis position: Modification of technique eliminates the need for intra-operative decision-making.

Abstract

It is generally perceived that a primary laparoscopic orchiopexy has superior outcomes due to preservation of the testicular artery, and thus should be the choice when achievable. The two-stage laparoscopic Fowler-Stephens orchiopexy (LFSO) is considered superior regarding success rate compared to the one-stage procedure when the artery must be transected. Outcomes can be jeopardized when a primary orchiopexy is ultimately realized to be the incorrect procedure due to insufficient testicular artery length. It is preferable to decide the approach before initiating dissection, however, in reality, this does not always occur. A single uniform approach to all intraabdominal testes (IAT) that takes into consideration the main challenges encountered when performing laparoscopic orchiopexy can simplify the approach and potentially achieve good outcomes. We present our experience with a standardized approach for IAT regardless of testicular position and describe the surgical modification needed to achieve good results with the one-stage LFSO. Key surgical maneuvers implicated in the modified one-stage LFSO (M-LFSO) include preservation of a wide peritoneal flap between the vessels and the vas deferens, dissecting the vessels as proximal as possible and avoiding manipulation of the epididymis and vessels between the vas and epididymis when transferring the testis to the scrotum. Our cohort included 55 boys (59 testes). Median age and weight at surgery were 13.3 months (interquartile range [IQR] 9.2-32.4) and 10.4 kg (IQR 9.2-12.6). The mean operative time was 70 min (IQR 60-85). The median follow-up was 11 months (IQR 7-12). There was one case of testicular atrophy (2%) and two cases of suboptimal testicular position in the scrotum at 6 months. M-LFSO is a standardized approach for all cases of IAT regardless of testicular position. Preservation of a wide peritoneal flap and proximal dissection of the vessels may contribute to the adequate testicular blood supply. The proposed approach eliminates the need for intra-operative decision-making and for ancillary procedures.