Two-Stage Fowler-Stephens Orchidopexy Preserving The Gubernacular Vessels And A Purely Laparoscopic Second Stage

Abstract

We describe a modification of the two-stage laparoscopic Fowler-Stephens technique in which the gubernacular vessels are preserved and the testis is brought down the canal via the internal ring. A purely laparoscopic second stage is performed. We report our outcomes with this technique. All laparoscopic Fowler-Stephens orchidopexies undertaken at our hospital from 1996 to July 2004 were identified from a prospectively collected database of all surgical procedures undertaken in the unit. A retrospective case-note review was undertaken. We identified 21 patients, 4 bilateral and 17 unilateral, giving a total of 25 intra-abdominal testes. Mean age at presentation was 21 months (range, 0-56 months). Mean age at the first stage was 36 months (range, 11-68 months). The testis position at initial laparoscopy was high in 5, close to the internal inguinal ring in 9, peeping in 6, and pelvic in 5. The testis size at this stage was either normal, good sized, or reasonable sized in 15, small or dysplastic in 5, and in 5 the size was not commented upon. The testicular vessels were mainly divided by diathermy at the first stage, but in 6 the vessels were clipped. The second stage was undertaken 6 months after the first, in order to allow the collateral blood supply to adapt. Twelve testes had changed position category during this interval, 2 having ascended to a higher position and 10 descended to a lower position; 12 were in the same position at both stages; and in 1 case the position was not commented upon at the second stage. A purely laparoscopic second stage technique was used in 21 cases; an assisted-open second stage was undertaken in 1 case. In 3 cases the testis was palpable in the groin at examination under anesthesia and so an open second stage orchidopexy was performed. Follow-up was at 6 and 18 months after the second stage. Eighteen of the 21 testes that underwent a purely laparoscopic second stage survived at 6 months, giving a success rate with this technique of 86%. The overall testis survival rate in the entire group at 6 months was 88% (22/25). Findings in those patients reviewed at 18 months were unchanged. The two-stage laparoscopic Fowler-Stephens orchidopexy, with preservation of the gubernacular vessels and predominantly using a purely laparoscopic second stage, provided a very good testis survival rate, approaching 90%.