Fowler-Stephens Procedure Research Articles

Scaphoid megalourethra associated with congenital urethrocutaneous fistula: a case report of a rare association

BackgroundCongenital megalourethra is a rare male genital malformation, with less than 100 cases reported in literature. Urethrocutaneous fistula, in turn, has only 65 cases described, which what makes the association between these two anomalies an even rarer condition.Case presentationThe patient was male and born at 37 weeks of gestational age. At birth, the testicles were impalpable, and he had a penile malformation compatible with scaphoid megalourethra associated with congenital urethrocutaneous fistula, with urine output exclusively through a small orifice in the ventral region of the penis. When the child completed 7 months and 22 days, underwent the first surgery, laparoscopically. The first Fowler-Stephens was performed, and the gonadal vessels were ligated, with reconstruction of the penis. Nine months later, the second Fowler-Stephens procedure was performed, with bilateral orchidopexy and penoplasty to improve penis aesthetics. The urethra region was not approached. The postoperative period of the second surgery progressed uneventfully. Nowadays, the patient presents adequate urinary stream.ConclusionThe scaphoid megalourethra associated with congenital urethrocutaneous fistula is an extremely rare pathology, with very few cases reported in the literature to date. The obstetric USG is important to increasing the chances of early diagnosis and treatment.

Laparoscopic Ist stage orchiopexy using antiadherent sheet for high abdominal testis

Abstract High undescended testes with short spermatic vessels are not treated with standard orchiopexy and are currently brought to scrotum prevalently after the section of spermatic vessels, according to the Fowler-Stephens procedure. The ischemic risk of that method is elevated and becomes unbearable in bilateral cases. In 2009 an original staged orchiopexy technique was proposed to elongate the whole cord with anti-adherent sheet preserving the spermatic vessels by which a normal scrotal position was successfully gained without any testis loss. Both stages were performed through inguinotomy. In the present article the successful procedure is updated with implementation of laparoscopy in the first stage in a case of extremely high bilateral 4a type abdominal testis. Laparoscopic access was confirmed as valuable both in terms of extended mobilization and coverage of the entire testis vascular supply. The method of progressive cord elongation by using an anti-adherent sheet avoids the excessive atrophy hazard deriving from the Fowler-Stephens procedure in bilateral high abdominal 4a type testes; based on our findings, the latter can benefit also of a laparoscopic approach in the first stage.

EFFICACY OF LAPAROSCOPY IN THE MANAGEMENT OF UNILATERAL NONPALPABLE TESTIS

Background:Undescended testis is one of the most common malformations seen in the field of pediatric surgery. The most problematic aspect of undescended testis is the diagnosis and treatment of nonpalpable testis. Laparoscopy has been widely used for the diagnosis and treatment of nonpalpable testis. Objective:To evaluate the role of laparoscopy in the diagnosis and treatment of unilateral nonpalpable undescended testis. Methods:This is a prospective study carried out in the period from December 2012 to December 2017 in the Pediatric Surgery Department of a tertiary hospital in Baghdad. We used laparoscopy in the diagnosis and treatment of 40 patients aged between one and 12 years (median age 4.9 years) with unilateral nonpalpable undescended testis. Boys with a palpable testis at any point were excluded from the study. Surgical procedure was individualized according to the laparoscopic findings either by one stage laparoscopic orchiopexy, two stage Fowler-Stephens procedure or laparoscopic orchiectomy. Results:Laparoscopy was able to diagnose the site of the nonpalpable testes in all the patients. Out of 40 nonpalpable undescended testes, 26 testes (65%) were intra-abdominal (12 testes were low intra-abdominal, 14 testes were high intra-abdominal). In 9 patients, (22.5 %), the vas deferens and spermatic vessels were found entering the internal inguinal ring. In 3 patients, (7.5 %), the testes were vanishing, and the testes were absent in 2 patients (5%). All patients with low intra-abdominal testes (n=12) were subjected to one stage laparoscopic orchiopexy through the normal inguinal ring. Out of 14 patients with high intra-abdominal testes, 7 patients underwent two staged Fowler-Stephens laparoscopic procedures, while three patients were treated by laparoscopic Prentiss maneuver and the remaining 4 patients underwent immediate laparoscopic orchiectomy due to presence of an atrophied testis. Patients with the vas deferens and spermatic vessels entering the internal inguinal ring (n=9) were treated by orchiopexy via conventional inguinal approach. Conclusion:Laparoscopy for unilateral nonpalpable testis has an excellent diagnostic yield combined with high success rate following repair. Keywords:Laparoscopy, nonpalpable undescended testis, Fowler-Stephens procedure Citation:Zain AZ, Mohammed NH, Fadil SZ, Abdul-Hassan BA. Efficacy of laparoscopy in the management of unilateral nonpalpable testis. Iraqi JMS. 2019; 17(3&4): 223-230. doi: 10.22578/IJMS.17.3&4.9

Staged laparoscopic traction orchidopexy for impalpable testes: a preliminary study

Laparoscopy is the gold standard to assess for presence of an intra-abdominal testis. However, techniques for the subsequent orchidopexy vary, and include the recently described staged laparoscopic traction orchidopexy (SLTO) (Shehata in Pediatr Surg 51(2):211–215, 2016). SLTO enables elongation of the testicular vessels without division, with initial success rates reportedly superior to Fowler–Stephens. We present the first UK data following a preliminary study using SLTO. 19 boys prospectively presenting with 22 intra-abdominal testes (IAT) underwent STLO in a single centre, with a median age of 2.5 years (IQR 1.4–5.2) at first stage. 3/19 (16%) boys had bilateral IAT and nine (41%) were left-sided. Pneumoperitoneum was established using 5 mm umbilical and 3 mm accessory ports in bilateral iliac fossae. The gubernaculum and lateral peritoneal attachments were divided prior to securing the intra-abdominal testis to the contralateral anterior abdominal wall with 2/0 Ti-cron™. Second-stage procedures were planned for 3–6 months later. The securing stitch was cut; an 11 mm STEP port was placed trans-scrotally to retrieve the testis and secured in a sub-dartos pouch. Outcome measures included palpable testes in the scrotum and surgical complications. 13/22 IAT have undergone follow-up. Twelve (92%) IAT were palpable in the scrotum following SLTO. There was one diathermy-related bladder injury necessitating laparoscopic repair, and 3/22 (13.6%) slipped sutures, requiring repeat first-stage procedures. Staged laparoscopic traction orchidopexy is a feasible technique, which can be performed as an alternative to Fowler–Stephens procedure, with potentially better outcomes for the testis. The complications described should be preventable as the technique evolves.

Role of Laparoscopy in Management of Non-Palpable Undescended Testis in Children

Background: Several techniques have been described for treatment of intra-abdominal testis including microsurgical autotransplantation, primary laparoscopic orchiopexy (VILO), one- and two-stage laparoscopic Fowler–Stephens procedures, and staged laparoscopic traction orchiopexy (Shehata technique). Aim of the work: To evaluate the role of laparoscopy in the treatment of non-palpable undescended testis. Patients and methods: This study was carried out in the Pediatric Surgery Unit, Tanta University Hospitals, during the period from April 2017 to October 2018, on 37 cryptorchid boys with 40 non-palpable testes. The mean age of the patients was 3.46 ± SD 3.1 years. Laparoscopic exploration was done for all cases, and if testes were found intraabdominally, with rough measurement of the length oftesticular vessels (TV), decision was taken either to do VILO or Shehata technique. Results: Out of 40 testes, 17 testes (42.5%) were vanishing, 3 intra-abdominal testes (7.5%) with long TV enough to undergo VILO, and 20 intra-abdominal testes (50%) with short testicular vessels underwent Shehata technique. Follow up for 3 -12 months postoperatively showed that all 3 testes underwent VILO were normal in size and vascularity. While the 20 testes underwentShehata technique, 19/20 (95%) testes were normal in size, while small testis was detected in 1/20 testis (5%). Conclusion: VILO has excellent results in management ofintra-abdominal testes with sufficient TV length while Shehata technique has excellent results in management ofintra-abdominal testis with short TV

Role of Laparoscopy in Management of Non-Palpable Undescended Testis in Children

Background: Several techniques have been described for treatment of intra-abdominal testis including microsurgical autotransplantation, primary laparoscopic orchiopexy (VILO), one- and two-stage laparoscopic Fowler–Stephens procedures, and staged laparoscopic traction orchiopexy (Shehata technique). Aim of the work: To evaluate the role of laparoscopy in the treatment of non-palpable undescended testis. Patients and methods: This study was carried out in the Pediatric Surgery Unit, Tanta University Hospitals, during the period from April 2017 to October 2018, on 37 cryptorchid boys with 40 non-palpable testes. The mean age of the patients was 3.46 ± SD 3.1 years. Laparoscopic exploration was done for all cases, and if testes were found intraabdominally, with rough measurement of the length oftesticular vessels (TV), decision was taken either to do VILO or Shehata technique. Results: Out of 40 testes, 17 testes (42.5%) were vanishing, 3 intra-abdominal testes (7.5%) with long TV enough to undergo VILO, and 20 intra-abdominal testes (50%) with short testicular vessels underwent Shehata technique. Follow up for 3 -12 months postoperatively showed that all 3 testes underwent VILO were normal in size and vascularity. While the 20 testes underwentShehata technique, 19/20 (95%) testes were normal in size, while small testis was detected in 1/20 testis (5%). Conclusion: VILO has excellent results in management ofintra-abdominal testes with sufficient TV length while Shehata technique has excellent results in management ofintra-abdominal testis with short TV

Laparoendoscopic Single-Site (LESS) Surgery in Pediatric Urology: A 4-Year Experience

Objective: The aim of the study was to assess the feasibility and outcomes of pediatric urological laparoendoscopic single-site (LESS) surgery. Materials and Methods: We retrospectively collected charts of all patients who underwent LESS procedures in our department from January 2013 to December 2016. Data included demographic characteristics, type of procedures, intraoperative details, hospital stay, and complications. The umbilicus was used as the surgical site in all cases. All procedures were performed with a homemade glove port and standard straight 3- or 5-mm laparoscopic instruments. Results: Seventy-three patients (55 males, 18 females) were identifed. Procedures included 46 orchidop-exies, 21 pyeloplasties, 8 varicocelectomies, 3 nephrecto-mies, 3 nephroureterectomies, 3 orchiectomies, and 1 renal hydatid cyst treatment. Median operative time for the entire cohort was 47 min (range 26-156 min). There was no signifcant intraoperative blood loss. No conversion to conventional laparoscopy or open surgery was needed. All patients required paracetamol postoperatively. The mean follow-up was 18 months. Two patients had testicular atrophy after a Fowler-Stephens procedure and 1 patient had testicular reascension. Cosmetic results were excellent. Forty-five (62.5%) patients were discharged on the day of surgery. Conclusion: Our study demonstrated that LESS surgery using our glove port technique and conventional laparoscopic instruments is a feasible and safe technique for the surgical management of various pediatric urological conditions.

Surgery for no palpable testis before the age of one year: a risk for the testis?

Surgery for undescended testisis now commonly recommended before the age of one year. However, the risk of testicular atrophy or miss location after surgery at a young age has not been clearly evaluated. The objective of this study is to evaluate the rate of testicular atrophy after surgery for non-palpable testis before the age of one year. Fifty-five patients operated between 2005 and 2014 for non-palpable testes were reviewed for clinical and ultrasound (US) evaluation. Median follow-up after surgery was of 68.5 months (range 26-130 months). The median age at surgery was ofmonths (5-12 months). Eight patients (14.5%) had bilateral non-palpable testis; thus, 63 testes were evaluated. At surgery, 38 (60%) testes were located in the high inguinal canal; 25 (40%), in the abdominal cavity. Orchiopexy was performed with preservation of the testicular vessels for 58 testes. Fowler-Stephens (FS) procedure was performed for 5 testes. Testicular location was clinically evaluated, and testicular volume was measured using a standard sonogram technique in our pediatric radiology department. Ratio comparing the volume of the descended testis to the spontaneously scrotal located testis was calculated in unilateral forms. After surgery, testes had scrotal location in 62 cases and inguinal location in one case. Seven cases of atrophy were confirmed after US control (11%), more frequently (odds ratio, OR 11.68 [1.9-72.5]) in abdominal testis (24%) than in inguinal testis (2.6%). Atrophy testicular was more frequent with FS technique (OR 7.1 [1.3-40.1]), but the population was weak (N=5). Median volume ratio for unilateral form was 0.88 [0-1.8]; 14 patients presented a ratio greater than 1. The influence of the young age at surgery and the risk of post operative testicular atrophy had not been clearly evaluated. The term of 'no palpable testis' supports an heterogeneous group mixing abdominal and extra-abdominal testis sharing a uniform clinical presentation. Our rate of atrophy in the group of abdominal testes (24%) and inguinal testes (2.6%) is similar to the literature, which concerns older patients. The long-term sonogram assessment demonstrated a good development of the testis after surgery, especially in inguinal cases. Surgery for no palpable testis before the age of one year does not lead to a superior risk of testicular atrophy compared with surgery at an older age and allows a good development of the testis.

Postoperative pain and analgesia administration in children after urological outpatient procedures

There are limited data about pain patterns, analgesic requirements and factors predicting opioid requirements of children undergoing outpatient urologic surgery. This prospective study aimed to assess recovery profiles and pain medication requirements. Patients between 6 months and 12 years of age were recruited prospectively between December 2013 and June 2014. Demographic and operative characteristics were collected. Following discharge home, the parents were asked to administer both acetaminophen and ibuprofen Q6H at a weight-adjusted dose, based on a schedule, until the end of postoperative day 2, and to administer the medication as required on postoperative day 3. Pain severity was recorded using validated pain scores (Face, Legs, Activity, Cry, Consolability/Parents' Postoperative Pain Measurement). A morphine prescription was provided for breakthrough pain. A Likert scale was used to assess parent's satisfaction with the pain management. A total of 249 patients were recruited, 111 patients (45%) returned appropriately completed surveys and were included in the final analysis. Mean age was 44.1 months (SD=37.3). The performed procedures were orchidopexy (31), hypospadias repair (26), hernia/hydrocele repair (15), Fowler-Stephens procedure (13), meatoplasty (7), phalloplasty (4), scrotoplasty (1), circumcision (7), and diagnostic laparoscopy (5). After discharge home 17 patients (15.3%) received morphine. Mean utilization of non-opioid analgesia was 79% on postoperative day 1, 67% on day 2, 36% on day 3, and 2% on day 4. Parental satisfaction was high (92.0% satisfied/very satisfied). No patient, anaesthetic or surgical factors were associated with opioid use or prolonged need for postoperative analgesia. The combination of scheduled non-opioid medications for maintenance and opioids for breakthrough pain provided satisfactory pain control after outpatient urologic surgery in children. There wereno specific patient, anesthetic or surgical factors that predicted postoperative opioid requirements.

MP66-12 PERCUTANEOUS EXTERNALLY ASSEMBLED LAPAROSCOPIC INSTRUMENTS FOR FOWLER-STEPHENS ORCHIOPEXY: THE FEASIBILITY OF A NEW SURGICAL SYSTEM

You have accessJournal of UrologyPediatrics: Testis, Varicocele & Stones1 Apr 2017MP66-12 PERCUTANEOUS EXTERNALLY ASSEMBLED LAPAROSCOPIC INSTRUMENTS FOR FOWLER-STEPHENS ORCHIOPEXY: THE FEASIBILITY OF A NEW SURGICAL SYSTEM Isaac Kelly, Samuel Abourbih, Minh Chau, Nazih Khater, Mohamed Keheila, Salim Cheriyan, Patrick Yang, Jim Shen, Matthew Pierce, and D. Duane Baldwin Isaac KellyIsaac Kelly More articles by this author , Samuel AbourbihSamuel Abourbih More articles by this author , Minh ChauMinh Chau More articles by this author , Nazih KhaterNazih Khater More articles by this author , Mohamed KeheilaMohamed Keheila More articles by this author , Salim CheriyanSalim Cheriyan More articles by this author , Patrick YangPatrick Yang More articles by this author , Jim ShenJim Shen More articles by this author , Matthew PierceMatthew Pierce More articles by this author , and D. Duane BaldwinD. Duane Baldwin More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2027AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Conventional laparoscopy is routinely used for the evaluation and management of the non-palpable testis but routinely requires three 5 mm ports that result in 9-10 mm scars. We have developed novel percutaneous externally assembled laparoscopic (PEAL) instruments which allow for nearly scarless laparoscopy. We present here a clinical series of six pediatric patients who underwent a Fowler-Stephens orchiopexy using these instruments. METHODS Using the PEAL instruments, one patient underwent a single stage, four patients underwent a first stage and one patient underwent a second stage Fowler-Stephens orchiopexy. In all cases, a 5 mm port was placed at the umbilicus for the camera. The PEAL instrument, which consists of a reusable handle and a 2.96 mm shaft was then introduced lateral to the rectus sheath at the level of the umbilicus using a special introducer tip under direct visualization. The introducer was then brought out through the camera port and switched to a 5 mm grasper tip. An additional 5 mm port was placed on the right at the same level for insertion of a hook electrode and clip applier. RESULTS The PEAL instruments functioned well for all dissection and grasping tasks, similar to 5 mm conventional instruments. Using these innovative new instruments, all patients underwent successful Fowler-Stephens procedures. Median operative time was 66 minutes (45-180 minutes). Blood loss was less then 5 mL in all cases. All six patients were discharged the day of surgery. The procedures were well tolerated without any perioperative or postoperative complications. At follow up, the average length of the PEAL scars was 3.25 mm, while the 5 mm port scars were 10 mm. CONCLUSIONS We describe a novel instrument paradigm for performing a pediatric laparoscopic Fowler-Stephens orchiopexy. These instruments offer improved cosmesis compared to conventional laparoscopy, and may show promise in other laparoscopic applications. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e866 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Isaac Kelly More articles by this author Samuel Abourbih More articles by this author Minh Chau More articles by this author Nazih Khater More articles by this author Mohamed Keheila More articles by this author Salim Cheriyan More articles by this author Patrick Yang More articles by this author Jim Shen More articles by this author Matthew Pierce More articles by this author D. Duane Baldwin More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Laparoscopy in the Evaluation of Impalpable Testes and Its Short-term Outcomes: A 7 Years' Experience.

Aims:The aim of this study is to report and analyze results of laparoscopy in impalpable testes performed between 2009 and 2016 and its short-term outcomes.Materials and Methods:Demographic data, laterality, laparoscopic findings, operative time, procedure, hospital stay, complications, and follow-up data of 76 patients with 79 impalpable testes from 2009 to 2016 were retrospectively collected and analyzed. Successful outcome was defined as maintenance of intrascrotal position with no atrophy at a follow-up of at least 6 months.Results:Impalpable testes constituted 24% of undescended testes in our series. Mean age was 3.9 years. Forty-two patients had left-sided, 31 right-sided, and three bilateral impalpable testes. Of the 79 clinically impalpable testes, on laparoscopy, 3 were vanishing testes, 52 were intra-abdominal (6 high-lying and 46 low-lying), 18 canalicular and 6 nubbin testes. Ultimately, 52 underwent laparoscopic orchiopexy: 46 single-staged orchiopexy and 6 two-staged Fowler–Stephens procedure. Mean operating time was 77 min. Complications were few and mostly minor. Eleven patients were lost in follow-up. On a mean follow-up of 23 months, one testis that underwent single-staged laparoscopic orchiopexy atrophied whereas good size and intrascrotal position were maintained in the rest.Conclusions:Laparoscopy in impalpable testes was safe, feasible, and effective. Overall outcome was good which was obtained by minimal use of electrocautery, dissection with wide strip of peritoneum and extensive retroperitoneal dissection for mobilization. There is a need for wide reporting of cases from high-volume pediatric surgery centers in India.

Early Experience with Laparoscopic Management of Nonpalpable Undescended Testes.

Background:Nonpalpable undescended testes (NPT) constitute 20%–30% of undescended testes, and its management has been a challenge both in diagnosis and treatment. Worldwide, laparoscopy is the current gold standard of management. In Nigeria, the management of NPT has largely been by open surgery with consequent high morbidity. In Nigeria, the trend is changing from a largely open management with its attendant high morbidity, to laparoscopic management which is the current worldwide gold standard of care.Aim:This study aims to classify the laparoscopic features of NPT and determine the outcome of managed cases in our center.Methodology:Prospective data were collected from consecutive patients who had laparoscopy for NPT at the Paediatric Surgical Unit of Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria from June 2014 to July 2016.Results:A total of 15 patients with 23 testes were treated. There were eight patients with bilateral NPT; four had left and the remaining three right NPT. The age ranged from 1.2 to 29 years with a median of 5 years. Eleven out of the 22 internal inguinal rings were open. The position of the testes was canalicular (2), peeping (2), low abdominal (6), high abdominal (6), blind-ended vas (1), absent vas and vessels (5). No further intervention was needed for the six agenetic/atrophic testes. Standard open orchiopexy was done for the two canalicular testes. Eight testes were brought down by one stage laparoscopic orchiopexy while four were brought down by staged laparoscopic Fowler-Stephens procedure. Laparoscopic orchiectomy was done in two patients (a grossly dysmorphic testes [nubbin] and a high abdominal testis in a 29-year-old). Orchiopexy was successful in 11 out of 15 fixed testes. Of the unsuccessful ones, three testes were atrophic (volume less than what it was initially) while two were high scrotal (one testes has both complications). There was no conversion to open abdominal surgery. All patients were discharged within 24 h of surgery.Conclusion:Laparoscopy provides for a better management of NPT by combining diagnosis and intervention in the same sitting with a good success rate and minimal postoperative morbidity.

Staged Fowler-Stephens and Single-stage Laparoscopic Orchiopexy for Intra-abdominal Testes: Is There a Difference? A Single Institution Experience

To compare single-stage laparoscopic orchiopexy (SSLO) and staged Fowler-Stephens (SFS) procedures in the management of intra-abdominal undescended testes, and to analyze postoperative atrophy and malpositioning as end points. A retrospective chart review identified laparoscopic orchiopexy patients with intra-abdominal testes between November 2006 and November 2014. Of 167 patients who had laparoscopic orchiopexy, 73 (85 testes) were identified as having laparoscopic orchiopexy. Baseline characteristics, as well as testicular scrotal position and size at follow-up, were recorded. Regression analysis was performed to compare outcomes between patients who underwent SFS and SSLO. Of the 85 laparoscopic orchiopexies, 35 underwent SFS and 50 had SSLO. Patient demographics were comparable in both groups. The median age at surgery was 12 months (5-151 months), and the average follow-up was 17.3 months. On follow-up, there were 0 recorded cases of SFS patients with abnormally positioned testes postoperatively, whereas there were 10 (20.0%) SSLO patients who had abnormally positioned testes (odds ratio: 0.05, 95% confidence interval: 0.01-0.44). Differences in atrophy rates were not significant. These results suggest that there may be no difference between the 2 approaches in terms of postoperative atrophy. However, the SFS appears to be more successful in securing a favorable scrotal position. Atrophy does not seem to be associated with other patient factors. Prospective, randomized studies are indicated to further explore outcome differences between the 2 approaches.

Use of laparoscopy as the initial surgical approach of impalpable testes: 10-year experience.

To review the experience in the management of impalpable testes using laparoscopy as the initial approach and the need for inguinal exploration. From January 2004 to June 2014, 339 patients with undescended testes underwent operation in our institute. Fifty patients (15%) had impalpable testes. All children with impalpable testes underwent initial laparoscopy. A retrospective review was conducted on this group of patients and the outcome was analyzed. Forty children had unilateral impalpable testis. Ten children had bilateral impalpable testes. Thirty-one children (78%) in the unilateral group underwent subsequent inguinal exploration while 4 children (40%) in the bilateral group underwent inguinal exploration (P < 0.05). Orchidopexy was performed in 16 children (40%) in the unilateral group and 9 children (90%) in the bilateral group (P < 0.05). Regarding the 24 children with unilateral impalpable testis and underwent orchidectomy for testicular nubbin (n = 19) or atrophic testes (n = 2) or has vanishing testes (n = 3); contralateral testicular hypertrophy was noticed in 10 (41%). No intra-operative complication was encountered. Two children after staged Fowler-Stephens procedure and 1 child after inguinal orchidopexy had atrophic testes. The use of laparoscopy in children with impalpable testes is a safe procedure and can guide the need for subsequent inguinal exploration. Children with unilateral impalpable testis were associated with an increased need for inguinal exploration after laparoscopy. Orchidopexies could be performed successfully in 90% of children with bilateral impalpable testes.

Mapping testicular blood supply in gubernaculum-sparing second-stage Fowler-Stephens procedure.

Testicular survival following second-stage Fowler-Stephens (FS) procedure depends upon adequate arterial supply. There is evidence that testicular survival rates are greater following gubernaculum-sparing second-stage FS procedure. The importance of collateral vessels in preservation of the testis has been hypothesised, but never shown in the literature. We aim to map the collateral blood supply to the testicle in gubernaculum-sparing, laparoscopic-assisted, second-stage FS procedure for intra-abdominal testicles. Selected patients undergoing a second-stage FS procedure were photographed prior to pexy in the Dartos pouch. Photographs were evaluated for the extent of vascular collateralisation between gubernacular, deferential and the ligated spermatic artery. Twenty-five patients with 28 undescended testicles underwent staged FS procedure over a 7.5-year period between 2005 and April 2013. Mean age at operation was 2.44 years, and all testicles were delivered to the scrotum. Mean follow-up was 3.29 years, and all patients were reviewed by the operating consultant. Testicular survival rate was 100 %. Representative photographs clearly demonstrate substantial cremasteric vessels running along the gubernaculum with robust collateralisation to the deferential vessel and the spermatic arterial stump. These images confirm the presence of robust collateral between the cremasteric and deferential vessels at second-stage FS procedure. Preservation of these collaterals in a gubernaculum-sparing approach may explain the excellent results seen in this series.

Role of laparoscopy and ultrasound in the management of “impalpable testis” in children

Undescended testes is one of the most common congenital abnormalities in boys. In cases of impalpable testes, ultrasound is often used to find the testis, which frequently provides false-negative results. Recently, laparoscopy has become popular in the management of impalpable testes. Retrospective study of all children with impalpable testes presenting for laparoscopy between August 2007 and July 2011 who had undergone ultrasound examinations without localizing the testes was conducted and the role of laparoscopy in diagnosing impalpable testes was evaluated. Twenty-three patients presented with impalpable testes for laparoscopy. All patients underwent ultrasound examinations in which the testes could not be identified. Of the 23 patients, Five patients were found to have palpable testes in the superficial inguinal pouch under anesthesia and proceeded to conventional open exploration during which the testes were brought into the scrotum. Eighteen patients were found to have impalpable testes in an evaluation under anesthesia (EUA) and proceeded to laparoscopy. Twelve patients were found to have intra-abdominal testes and underwent laparoscopic-assisted orchidopexy. Three patients underwent a two-stage Fowler-Stephens procedure, and two patients with "vanishing" testes with the vas and atrophic vessels entering a closed internal ring proceeded to open exploration and orchidectomy for atrophic testes. In addition, a teenager with atrophic testes underwent laparoscopic orchidectomy. Laparoscopy is superior to ultrasound in the management of impalpable testes when high-resolution ultrasound is not available during the diagnostic process, with respect to both the sensitivity of localizing the testis and being more time and cost effective.

LaparoEndoscopic Single Site Orchidopexy for Intra-Abdominal Testes in the Pediatric Population with a Multichannel Single Port and Flexible Tip Laparoscope

To assess the outcomes of pediatric LaparoEndoscopic Single Site (LESS) orchidopexy using a commercially available multi-channel single port (MCSP) and flexible tip laparoscope (FTL). A retrospective cohort study was performed of children who underwent LESS orchidopexy by a single surgeon at a pediatric institution. A commercially available MCSP was utilized at the umbilicus. A 5 mm FTL and 3 mm and 5 mm instruments were used for the dissection. Follow-up visits were performed 2-4 weeks and 6-12 months after surgery to assess position and size of the testes. A total of 17 patients were identified. Median age was 11 months (range 3-43). Sixteen patients underwent primary orchidopexy, including two bilateral procedures and five primary Fowler-Stephens (FS) procedures. One patient underwent a staged FS orchidopexy, with the LESS technique utilized during the second stage. Median laparoscopic dissection time for each testis was 35 minutes (range 22-40). There was no blood loss or intraoperative complications. All testes were noted to be in the scrotum without testicular atrophy. Our initial experience with this technique was favorable with excellent outcomes. LESS orchidopexy is facilitated with a MCSP and FTL.

Effectiveness of Hormonal and Surgical Therapies for Cryptorchidism: A Systematic Review

Controversy remains concerning the optimal treatment approach for cryptorchidism. The objective of this study was to assess effectiveness of hormone therapy or surgery for cryptorchidism. We searched Medline and other databases from 1980 to February 2012. Two reviewers independently assessed studies against predetermined criteria. Two reviewers independently extracted data and assigned overall quality and strength of evidence ratings using predetermined criteria. Fourteen studies addressed effectiveness of hormonal treatments, and 26 studies addressed surgical intervention outcomes. Hormonal treatment is associated with testicular descent in some children, but rates generally do not exceed those seen with placebo by >10%. Surgical treatment is associated with success rates of testicular descent ranging from 33% to 100%, depending on surgery. Weighted success averages were 78.7% for 1-stage Fowler-Stephens (FS), 86% for 2-stage FS, and 96.4% for primary orchiopexy. Descent rates were similar among studies comparing laparoscopic and open surgeries. Reported harms of hormonal treatments were mild and transient. Adverse effects specifically associated with surgical repair were rare. The body of the reviewed literature comprises primarily fair- and poor-quality studies, limiting our ability to draw definitive conclusions. Hormonal treatment is marginally effective relative to placebo but is successful in some children and with minimal harms, suggesting that it may be an appropriate trial of care for some patients. Surgical options are effective, with high rates of testicular descent (moderate strength of evidence for FS procedures, high for primary orchiopexy). Comparable outcomes occur with laparoscopic and open approaches.

Laparoscopic Orchiopexy for Intra-abdominal Testes—A Single Institution Review

To report success, complication, and atrophy rates, as well as cost analysis and surgeon preference, for standard laparoscopic versus laparoscopic Fowler-Stephens (FS) approaches to intra-abdominal testes. The records of children who underwent laparoscopic orchiopexy for impalpable testes at our institution were reviewed. Two groups were assessed: Group 1, who underwent a standard laparoscopic orchiopexy; and Group 2, who underwent either a single-stage or two-stage FS orchiopexy. Success was defined as an intrascrotal testis without atrophy. Cost analysis was performed by obtaining operating room charges for the procedures. Surgeon preference was evaluated by calculating the number of each type of orchiopexy performed. From 1998 to 2005, 61 laparoscopic orchiopexies were performed on 46 patients. In Group 1, 31 orchiopexies were performed on 22 patients. In Group 2, 30 orchiopexies were performed in 26 patients. Eight orchiopexies were performed on 7 patients in a single stage, whereas 22 orchiopexies in 19 patients were performed in two stages. Two patients underwent both unilateral FS and laparoscopic orchiopexy. Success rates for Groups 1 and 2 were 96.7% and 83.3%, respectively. There were three complications in Group 1 (9.7%) and nine complications in Group 2 (30%). Atrophy rates for the two groups were 6.5% (2/31) and 16.7% (4/24), respectively. The average operating room cost for a standard laparoscopic approach was $3686, $3604 for the first stage and $3909 for the second stage of a two-stage FS approach, and $3785 for a single-stage FS approach. Data from this series suggest that completing a laparoscopic orchiopexy in a single operation without ligating the testicular vessels has comparable, if not better, success rates to those of FS procedures, while reducing cost and potentially reducing complications. Outcomes between single- and two-stage FS approaches are similar, but the former can be accomplished at half the cost.

Laparoscopic Orchidopexy without Division of Spermatic Vessels using a Neoinguinal Canal Approach: A Single Center Experience

Introduction: About 1 to 2% of boys at age of 1 year have an undescended testis (UDT); almost 20% of UDT are nonpalpable. Several surgical procedures have been described but there are no formal guidelines for the management of boys with nonpalpable testis. We report our experience with laparoscopic orchiopexy performed without dividing the spermatic vessels in this case series over a period of 4 years stating that the Fowler-Stephens technique is no longer indicated for the treatment of the intra-abdominal testis. Materials and methods: Over a period of 7 years from 2005 to 2012, we carried out diagnostic laparoscopy on 50 nonpalpable intra-abdominal testis in 45 boys followed by laparoscopic orchiopexy without sectioning the spermatic vessels even in cases where testis was higher up (30 cases). The technique consisted in sectioning the gubernaculum, opening the peritoneum laterally to the spermatic vessels, and mobilizing the testicular vessels and the vas deferens in a retroperitoneal position for 8 to 10 cm. The testis was then brought down into the scrotum through a neo-inguinal ring created just lateral to medial umbilical ligament. Results: Out of 45 cases with 50 undescended testis, 30 testes were abdominal, away from the internal ring out of which we were able to bring 28 testis in the scrotum without dividing the spermatic vessels, using a neo-inguinal ring. The other two patients had to undergo orchidectomy because of atretic testis. In the remaining 20 cases, the testis was at the inguinal ring or close to it and mobilized easily through the neo-inguinal ring to scrotum. The mean follow-up period has been 14 months (6 months to 2 years) and all the testes were found to be in scrotum with no atrophy. Conclusion: On the basis of our experience, we believe that laparoscopic orchiopexy without division of the spermatic vessels should be the treatment of choice in the management of nonpalpable testes because it does not compromise the normal testicular vascularization. Creation of neo-inguinal canal lateral to the medial umbilical ligament has the advantage of gaining more length on the vessels and vas to bring the testis to scrotum and hence Fowler-Stephens procedure is no longer routinely indicated in management of high abdominal testis.