High Intra-abdominal Testes Research Articles

Comparative Outcomes of Single-Stage versus Two-Stage Laparoscopic Fowler-Stephens Orchidopexy: A Systematic Review snd Meta-Analysis.

Intra-abdominal testis (IAT) remains a challenging and controversial subset within the management of cryptorchidism. While Fowler-Stephens orchidopexy (FSO) is still being advocated as the gold standard for the treatment of this entity, there is new and conflicting evidence on the comparative outcomes between single- or two-stage laparoscopic FSO (LFSO). The aim of the study is to investigate whether staging has benefits in children receiving LFSO. We searched the PubMed, Medline, Embase, and Cochrane Trials databases for studies comparing single- with two-stage LFSO in children from January 1, 1995 to December 31, 2023. We assessed the identified studies for quality and performed a systematic review and meta-analysis in accordance with the Preferred Reporting of Systematic Reviews and Meta-Analyses. The main outcome measures examined were success rate (in terms of the scrotal position of the testis) and testicular atrophy, which were analyzed using fixed effect models. We included 17 eligible studies that involved a total of 499 operated testes. The overall success rates of single- and two-stage LFSO were 79.4 and 90.3%, respectively. The overall testicular atrophy rates of single- and two-stage LFSO were 17.3 and 11%, respectively. Fixed effect model analysis showed that two-stage LFSO is significantly superior to single-stage LFSO in overall success rate (odds ratio [OR: 2.57]; 95% confidence interval [CI]: 1.50-4.39, p = 0.0006) and testicular atrophy rate (OR: 0.48; 95% CI: 0.28-0.79, p = 0.004). There is no heterogeneity in the reports, and the funnel plot showed no publication bias. Two-stage LFSO remains the first choice of operation for children with a high IAT, with a significantly higher success rate and a lower testicular atrophy rate.

Comparison between staged laparoscopic technique in children with high intra-abdominal undescended testis: a systematic review and meta-analysis.

This study performed a systematic review and meta-analysis to compare the outcomes of the staged laparoscopic Fowler-Stephens Laparoscopic Orchiopexy (FSLO) and Staged Laparoscopic Traction Orchiopexy (SLTO) in patients with intra-abdominal testes (IAT). This study reviewed literature published from 2016 to 2024. A systematic literature search was conducted on three databases: PubMed, ScienceDirect, and Google Scholar, using keywords (High intra abdominal testis) AND (("Fowler Stephens laparoscopic orchiopexy" OR (FSLO)) OR (Staged Laparoscopic traction orchiopexy OR (SLTO)). Non-randomized trials and observational studies comparing staged laparoscopic FSLO and SLTO, without any time range restriction are included. Studies without FLSO orchidopexy as a control, case reports, case studies, duplicate publication, no full text and non-English studies are excluded. This study used the PRISMA protocol, the Jadad Scale, and the Newcastle Ottawa Scale (NOS) to evaluate the included studies. To analyze statistical data, the Review Manager (RevMan) software was used. The Chi-squared test was used to calculate statistical heterogeneity in the meta-analysis. There were 240 patients from 5 studies (109 in the SLTO group and 131 FSLO in group). The primary outcome of this study is testicular descent and atrophy. There were no significant differences in testicular descent (RR:1.08[0.96 - 1.23],p<0.20,I 2:0%) and atrophy rate (RR:0.45[0.19 - 1.09],p<0.08,I 2:0%). Secondary outcomes are the duration of operation in both the first and second stages. Statistical analysis reveals a significantly lower first-stage operation time in the FSLO group (MD:9.31[7.08,11.55], p<0.05;I 2:94%). At the same time, lower second-stage operation times are significantly reported in the SLTO group (MD:-4.05[-7.99,-0.12],p<0.05; I 2:60%). In terms of testicular descent and testicular atrophy the SLTO technique yields similar results to the FSLO technique. Both techniques have advantages and disadvantages, and we recommend SLTO as the first choice in children with a high IAT of <4 cm. CRD42023412407.

Laparascopic management of non-palpable testis

We present a new approach to high intraabdominal testis (IAT) for elongation of the testicular vessels without division. The technique entails fixation of the testis to a point one inch above and medial to the contralateral anterior superior iliac spine for 12 weeks. Subdartos orchiopexy is then done as the second stage. Both stages are laparoscopically assisted. The a new approach to high intraabdominal testis, two-stage laparoscopic traction-orchiopexy, is useful and resulted in significant elongation of the testicular vessels without atrophy. It is a safe and valid alternative to the two-stage laparoscopic Fowler–Stephens technique, which entails division of the main testicular vessels.

Comparison between staged laparoscopic technique in children with high intra-abdominal undescended testis: a systematic review and meta-analysis

Background: This study performed a systematic review and meta-analysis to compare the outcomes of the staged laparoscopic Fowler-Stephens Laparoscopic Orchiopexy (FSLO) and Staged Laparoscopic Traction Orchiopexy (SLTO) in patients with intra-abdominal testes (IAT). Methods: This study reviewed literature published from 2016 to 2023. A systematic literature search was conducted on three databases: PubMed, ScienceDirect, and Google Scholar, using keywords (High intra abdominal testis) AND (("Fowler Stephens laparoscopic orchiopexy" OR (FSLO)) OR (Staged Laparoscopic traction orchiopexy OR (SLTO)). Non-randomized trials and observational studies comparing staged laparoscopic FSLO and SLTO, without any time range restriction are included. Studies without FLSO orchidopexy as a control, case reports, case studies, duplicate publication, no full text and non-English studies are excluded. This study used the PRISMA protocol, the Jadad Scale, and the Newcastle Ottawa Scale (NOS) to evaluate the included studies. To analyze statistical data, the Review Manager (RevMan) software was used. The Chi-squared test was used to calculate statistical heterogeneity in the meta-analysis. Results: This study included four studies of 151 patients (72 SLTO group and 79 FSLO group). There was no significant difference between the two groups in terms of testicular descent (p=0.08), and there was no testicular atrophy in the SLTO group compared to the FSLO group (p=0.04). Statistical analysis revealed a significantly shorter first-stage operation time in the FSLO group (p 0.0001), whereas the SLTO group reported a significantly shorter second-stage operation time (p = 0.04). Conclusions: In terms of testicular descent, the SLTO technique yields similar results to the FSLO technique. The SLTO position is preferable to the FSLO position. Both techniques have advantages and disadvantages, and we recommend SLTO as the first choice in children with a high IAT of 4 cm. PROSPERO registration: CRD42023412407

Techniques of staged laparoscopic orchidopexy for high intra-abdominal testes in children: A systematic review and meta-analysis.

Laparoscopic exploration is currently considered the gold standard for managing nonpalpable intraabdominal testes. The problem of short vascular pedicle is addressed in Fowler-Stephen (FS) technique by the division of testicular vessels and in Shehata technique (ST) by traction on testicular vessels. There is a lack of the consensus among pediatric surgeons on the choice of one technique over other. This analysis compares the reported outcomes of staged laparoscopic orchidopexy by ST with the time tested FS technique in managing high intraabdominal undescended testis. The present systematic review and meta-analysis was conducted as per the preferred reporting items for the systematic review and meta-analyses guidelines. Only randomized controlled trials and comparative studies were included. The primary outcomes compared were the incidence of testicular atrophy, testicular retraction/ascent rate, and operative time of Stage I and Stage II orchidopexy. The present analysis was based on three randomized studies with a total of 119 undescended testes in 117 patients satisfying the inclusion criteria. The operative time was less in Stage I FS technique; however, there was no statistically significant difference in operative time of both procedures during the Stage II laparoscopic orchidopexy. Pooled analysis of postintervention testicular atrophy, testicular retraction rate, and duration of postoperative hospitalization showed no difference between both procedures. Both FS and STs are comparable in terms of postintervention testicular atrophy, testicular retraction/ascent; however, the mean operative time is significantly less with FS technique in Stage I laparoscopic orchidopexy.

Medium-Term Results of Staged Laparoscopic Traction Orchiopexy for Intra-abdominal Testes: A Multicenter Analysis

BackgroundStaged laparoscopic traction orchiopexy (SLTO) is a novel technique for the intra-abdominal testis (IAT) based on elongation of the testicular vessels without separating them. This multicenter study evaluated the medium-term results of this technique. MethodsData of SLTO performed in three pediatric surgical centers between 2013 and 2020 were analyzed retrospectively. In 2021, physical and Doppler ultrasound examinations were performed to determine the position and viability of testes. Success was defined as an intra-scrotal testicle without atrophy. ResultsSLTO was performed on 48 cases (55 testes, 7 bilateral). Mean age at first stage was 2.9 (0.8–12.6) years. High intra-abdominal testes were found in 16.4% and in 60% morphological abnormalities were observed. To fix the testes to the abdominal wall monofilament suture was used in 67.3%, braided in 29.1%. Mean time between the two stages was 16.4 weeks; three testes required redo traction.Perioperative complications occurred in 21 patients (38.2%) including insufficient fixation (11), testicular atrophy (4), wound complications (4), adhesion of the spermatic cords (1) and hydrocele (1). In case of insufficient fixation monofilament sutures were used in 90.9%.In 2021 38 patients (43 testes) had physical and 36 patients (41 testes) had ultrasound examinations. Mean follow-up was 2.7 (0.34–7.9) years. Altogether five atrophies were identified, and three testicular ascents (7.0%) occurred. The overall success rate was 82.2%. ConclusionsSLTO may be a feasible alternative to conventional treatments of IATs. Additionally, braided suture seems to be a better option to fix the testicle to the abdominal wall. Level of EvidenceLEVEL IV.

Open controversies on the treatment of undescended testis: An update.

Cryptorchidism is a common congenital malformation in pediatric urology. Although there have been many studies on the etiology of the disease, it has not been fully clarified, and while its diagnostic and treatment models have gradually approached standardization and systematization, some controversies regarding treatment remain. Additionally, although ultrasound is a non-invasive examination without ionizing radiation, its role in the evaluation of cryptorchidism remains controversial. The main basis for treating cryptorchidism is orchidopexy, and the main view on treatment age is that treatment should be performed between 6 and 12 months after birth, but no more than 18 months after birth. The view on hormone therapy is still controversial because most scholars believe that early surgery is the key to treatment. There are many surgical treatment methods for cryptorchidism, including traditional open surgery and laparoscopic surgery, which provide satisfactory results. In conclusion, the treatment of undescended testis (UDT) had been largely standardized, apart from the treatment of high intra-abdominal testis (IAT), which remains a matter of debate.

The role of laparoscopy in non-palpable undescended testicle: Analysis and review of the experience from two cities in Sudan.

Introduction:It is estimated that 1%–2% of male infants have undescended testicles. The reliability of ultrasound (US) to identify the non-palpable undescended testicles (NPUDT) is controversial. Laparoscopy remains the gold standard to diagnose and manage NPUDT.Objective:The objective is to highlight the role of laparoscopy in the management of NPUDT in 2 cities from Sudan over the past decade.Materials and Methods:Patients presented to Gadarif Teaching Hospital and Almak Nimir University Hospital with NPUDT were assessed by clinical examination and US. The testis, when found during laparoscopy, was either brought down to the scrotum in a single or two-stage or removed depending on the findings. Data were collected and analysed.Results:Patients covered the age range between 18 months and 65 years. The average was 12.4. The majority, 94 (67.2%) patients were older than 5 years. The main presenting symptom was either bilateral or unilateral empty scrotum. In 12 (8.4%) patients, the main presenting symptom was primary infertility. US was done in 120 (86.6%) of the patients and failed to see the testis in more than half of them. A single-stage procedure in the form of laparoscopic search assisted with orchidopexy was achieved in 90 (62.9%) patients and orchiectomy in 13 (9.1%) patients, while in 12 (8.4%) patients the testis was not found. Other procedures were applied on the 28 (19.6%) patients who needed staged operation in the form of Fowler Stephen's, in bilateral cases, in 6 (4.2%) patients. Shehata's operation in nine patients (64%) and open orchidopexy for 8 (5.6%) patients. The post-operative complication was encountered in 14 (9.8%) of the patients in this group in the form of bleeding, vassal injury and testicular atrophy.Conclusion:Laparoscopy provides the most accurate interventional option for managing patients with NPUDT. Laparoscopic orchidopexy, whether single stage for low or 2-stages for high intra-abdominal testis, is a proven and effective extension of lap-search with minimal complications.

Comparison of Two Types of Staged Laparoscopic Orchiopexy for High Intra-Abdominal Testes in Children: A Retrospective Study From a Single Center.

Background: To evaluate the efficacy and safety of 2nd-stage laparoscopic traction orchiopexy (Shehata technique) compared to Fowler-Stephens (F-S technique) for high intra-abdominal testes (IATs) in children.Patients and Methods: We performed a retrospective review of all children (<14 years old) who underwent laparoscopic treatment of high IAT in the pediatric surgery center of Yijishan Hospital of Wannan Medical College from April 2016 to April 2020. Participants were divided into the Fowler-Stephens (F-S) group and Shehata group according to the surgical method. We collected the medical records of all children and analyzed them statistically.Results: In this study, 43 patients in our center received 2nd-stage laparoscopic surgical treatment. The results showed that there were 23 high IATs in 22 patients in the F-S group and 22 IATs in 21 patients in the Shehata group. All patients completed the operation successfully. No significant difference in operation time was noted between the two groups. There was no significant difference in the testicular atrophy rate between the two groups (P = 0.323). The testicular retraction rate of the F-S group was greater than that of the Shehata group (P = 0.04).Conclusion:The results of this study indicate that the application of assisted laparoscopic testicular traction technology can effectively retain the main blood supply of the testis and vas deferens with a high survival rate and clear advantages. The preliminary results show that the Shehata technique is safe, reliable and effective in the treatment of high IAT in children.

Staged Fowler Stephens, Who Requires a Third Procedure?

The two-stage Fowler-Stephens orchiopexy is a well-described surgical approach for most pediatric urologists tackling the high intra-abdominal testis. Testicular ascent is a well-reported outcome of the surgery and a problem that could be fixed with a repeat procedure. The purpose of this review is to determine the rate of subsequent testicular ascent and repeat surgery after a two-stage Fowler-Stephens using best available evidence. We selected 16 studies that pertained to our topic. 0-13% of testicles were deemed to be in an inappropriate position on follow-up (6-37months). The definition of appropriate postoperative position varied between studies and rates of repeat procedures were sparsely available. Available data reports a repeat orchiopexy rate of 2.6-7.5% after two-stage Fowler-Stephens. Two-stage Fowler-Stephens orchiopexy is a highly successful surgical technique to manage high intra-abdominal testes. Rates of testicular ascent are difficult to ascertain due to varying definitions and small sample sizes. While repeat procedures are typically indicated, the actual rate of repeat orchiopexy is rarely reported and long-term outcomes following a third procedure is sparse.

Effect of dexmedetomidine on hemodynamics and recovery profile in children undergoing laparoscopic Stephen–Fowler's Stage-2 orchidopexy under general anesthesia: A prospective randomized controlled study

Background: Stephen–Fowler's Stage-2 (SF-2) orchidopexy for high intra-abdominal testes poses the challenge of both laparoscopic and open urogenital surgery to the pediatric anesthesiologist. Balanced anesthesia supplemented with regional analgesia remains the standard technique adopted. Studies involving intravenous (IV) dexmedetomidine as an adjuvant anesthetic in children are sparse. Aims and Objectives: The aim and objective was to study the effect of IV dexmedetomidine on intraoperative hemodynamic stability, airway reflexes, and hemodynamic responses to extubation and postoperative analgesia. Materials and Methods: This prospective randomized controlled study was conducted on thirty children undergoing laparoscopic SF-2 repair to receive balanced anesthesia with isoflurane. Group D patients received IV dexmedetomidine 1 μg/kg bolus over 10 min after induction followed by an infusion at 0.5 μg/kg/h and Group C patients received regional analgesia. Hemodynamic parameters, sedation, agitation, pain scores, time to rescue analgesia, and time to discharge were documented. Results: A significant change was discernible in the heart rate and systolic blood pressure with intraoperative hemodynamic stability in Group D patients, which was comparable to baseline values. Smoother extubation with better hemodynamic stability (P Conclusion: IV dexmedetomidine 1 μg/kg bolus followed by an infusion of 0.5 μg/kg/h gives better intraoperative hemodynamic stability with smoother extubation and prolonged postoperative analgesia without undue side effects in children undergoing SF-2 orchidopexy.

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&amp;4): 223-230. doi: 10.22578/IJMS.17.3&amp;4.9

Laparoscopic management of non-palpable un-descended testes: our experience

Background: The purpose of the study was to determine the sensitivity and specificity of laparoscopy in localizing non-palpable testes, its therapeutic role, mean operative time, conversion rate, complications and hospital stay.Methods: A total of 52 patients were included in the study and was conducted from June 2012 to June 2017. These boys were examined as outpatients, at the time of admission and after general anesthesia to exclude palpable testes and were subjected to diagnostic and operative laparoscopy.Results: We identified 52 patients with 66 non palpable un-descended testes. The most common age of presentation was 1-4 years. Majority of patients i.e. 27 were on the left side. Ultra-sound identified testis &gt;2 cm from deep inguinal ring in 20, near deep ring &lt;2 cm in 20 and at inguinal canal in 6 patients. In the diagnostic laparoscopy, high intra-abdominal testis found in 34, low intra-abdominal testis in 24, blind ending of vas and vessels in 2 patients. The operative procedures performed are diagnostic laparoscopy, laparoscopic orchidopexy, laparoscopic orchidectomy, conversion to open orchidopexy and open orchidectomy. The mean operative time was 53.67±2.37 for unilateral and 102.76±5.38 for bilateral cases. The postoperative complications include surgical emphysema, wound infection and scrotal haematoma. The mean hospital stay was 14.23±2.37 hours for unilateral and 16.27±5.38 hours for bilateral.Conclusions: Laparoscopic orchidopexy appears to be a feasible, minimally invasive, less postoperative pain and trauma, faster convalesce and return to normal activity and an effective technique for the management of low intra-abdominal testes.

PT019 - Laparoscopic orchiopexy for high intra-abdominal testes in adult patients, single vs two stages

PT019 - Laparoscopic orchiopexy for high intra-abdominal testes in adult patients, single vs two stages

What is the ideal surgical approach for intra-abdominal testes? A systematic review.

There is controversy regarding the ideal surgical management of intra-abdominal testes (IAT) to preserve fertility; we conducted a systematic review to address this problem. We performed a comprehensive electronic search of CENTRAL, MEDLINE, EMBASE, and CINAHL from 2008 to September 2014 (the date range was limited due to an abundance of literature), as well as reference lists of included studies. Two researchers screened all studies for inclusion, and quality assessed each relevant study using AMSTAR for systematic reviews (SRs), Cochrane 'Risk of bias' tool for randomized controlled trials (RCTs), and MINORS for non-randomized studies. We identified two relevant SRs and 29 non-randomized studies. Due to the heterogeneity of the data, meta-analysis was not possible. Ultrasound and magnetic resonance imaging are insufficient for identification or localization of IAT; laparoscopic or surgical exploration is necessary. Primary orchiopexy is effective for low IAT, and Fowler-Stephens orchiopexy (FSO) is effective for high IAT. There is no clear benefit of one- vs. two-stage FSO, or of open vs. laparoscopic technique. Several alternative or modified techniques also show promise. RCTs are needed to confirm the validity of these findings, and to assess long-term outcomes.

Laparoscopy-assisted orchiopexy versus laparoscopic two-stage fowler stephens orchiopexy for nonpalpable testes: Comparative study

Background/Purpose:To assess the outcome of the primary laparoscopy-assisted orchiopexy (LAO) and the laparoscopic two-stage Fowler Stephens orchiopexy (FSO) for managing patients with nonpalpable testis in terms of safety, feasibility and efficacy.Materials and Methods:This study included 94 patients (110 nonpalpable testes) who underwent laparoscopy at King Khalid University Hospital, Riyadh between July 1998 and June 2012. Patients were evaluated postoperatively to check the location and size of testes and to exclude any other complications.Results:Mean age at presentation was 24+/−19 months (9-96 months). Orchiectomy was done for 5 atrophic testes. 36 open orchiopexy was done for 29 canalicular testes and 7 peeping testes. 35 LAO were done for 1 canalicular testis, 5 peeping testes, 16 low intraabdominal testes and 13 high intraabdominal testes. 34 FSO were done for 23 high intraabdominal testes, 9 low intraabdominal testes and 2 peeping testes. Median follow up was 12 months (1-84 months) and 6 patients were lost to follow up. The overall success rates for LAO and FSO were 88% and 63%, respectively. Overall testicular atrophy rates were 3% and 30% for LAO and FSO, respectively (OR 0.08 [95% CI, 0.01-0.69], P = 0.006). For high intraabdominal testes, the atrophy rates were 3% and 20% for LAO and FSO, respectively (OR 0.14 [95% CI, 0.02-1.21, P = 0.049).Testicular displacement rates were 9% and 7% for LAO and FSO, respectively (OR 1.5, 95% CI, 0.24-9.59, P = 0.514).Conclusions:Laparoscopy provides a safe and accurate modality for diagnosing and managing patients with nonpalpable testes. LAO appears to be feasible and effective in management of high intraabdominal testes. Further well-conducted comparative studies are needed.

Role of Laparoscopy in Diagnosis and Management of Nonpalpable Testes

There is still a lot of controversy among urologists with regard to the treatment of nonpalpable (intra-abdominal) testes. This is a prospective randomized comparative study between open and laparoscopic orchidopexy for abdominally located testes. It is an assessment of the usefulness of laparoscopy in the diagnosis and definitive treatment of nonpalpable (abdominally located) testes. Methods: For a span of 5 years, orchidopexy was performed for 64 patients between the ages of 1 to 15 years (mean age of 4.6 years) with nonpalpable (intra-abdominal) testes. In all, 75 testes were involved in the study during which some had laparoscopic and open Fowler-Stephens orchidopexy while others had laparoscopic orchidectomy. One stage Fowler-Stephens orchidopexy was performed laparoscopically for 28 testes; 17 had two stage Fowler-Stephens orchidopexy. Laparoscopic orchidectomy was done for five testes. Postoperative follow-up consisted of clinical and color Doppler utrasonography. This was done for all who underwent orchidopexy. Results: The diagnostic convergence of US and laparoscopy was 16 out of 75 testes (21.3%). Laparoscopically 20 testes were located low intra-abdominally (26.6%), 17 were in the category of high intra-abdominal testes (22.7%). 18 testes had entered the inguinal canal (24%). Four of the patients had associated hernia. Mean follow-up period was 26 months (1 month to 5 years) during which the testes where found in their respective hemiscrotums except for two testes which had atrophied and three which were retracted up the

Is Staging Beneficial for Fowler-Stephens Orchiopexy? A Systematic Review

Fowler and Stephens showed that by dividing the spermatic vessels a high intra-abdominal testis could be placed in the scrotum. Testicular atrophy is a potential complication of this technique. We conducted a systematic review to determine whether single or 2-stage Fowler-Stephens orchiopexy results in better testicular viability. We searched electronic databases, clinical trial registries and gray literature. We included reports describing boys younger than 18 years with a primary outcome of "testicular viability and position." We performed a meta-analysis using random effects models. Heterogeneity was assessed using forest plot and I(2) statistic. We identified 1,807 citations and included 61 articles. Single stage Fowler-Stephens orchiopexy was discussed in 9 articles, a 2-stage procedure in 36 and both approaches in 16. There were no randomized controlled trials, and most studies were cohort or case series. The pooled estimate of success rates was 80% for single stage Fowler-Stephens orchiopexy (95% CI 75 to 86) and 85% for 2-stage Fowler-Stephens orchiopexy (95% CI 81 to 90). The pooled odds ratio of single stage vs 2-stage Fowler-Stephens orchiopexy was 2.0 (95% CI 1.1 to 3.9) favoring the 2-stage procedure. There was no difference in the success rate between laparoscopic and open techniques in either single or 2-stage Fowler-Stephens orchiopexy. There was no evidence of asymmetry on the funnel plot. There were no complications reported with single stage, while ileus, hematoma and infection were the most common complications with 2-stage Fowler-Stephens orchiopexy. Both techniques have a fairly high success rate but 2-stage Fowler-Stephens orchiopexy appears to carry a higher rate of success than the single stage approach (85% vs 80%, OR 2 in favor of 2-stage). Laparoscopic and open techniques had the same success rate. However, the level of evidence of the studies was low, and a study of a more robust design, such as a randomized controlled trial, should be performed.

Laparoscopic Stephen-Fowler Stage Procedure: Appropriate Management for High Intra-Abdominal Testes

The length of testicular vessels is the main length-limiting factor to bring down the testes in the scrotum. Fowler and Stephen proposed the division of testicular vessels, high and as far from the testes as possible to maintain collateral blood supply, to treat high intra-abdominal testes. Cortesi introduced the diagnostic laparoscopy and Jorden first did the laparoscopic orchiopexy for nonpalpable testes. We had done Fowler-Stephen staged orchiopexy for high intra-abdominal testes, in which both stages were done laparoscopically. In total, 17 testes of 13 patients had undergone laparoscopic staged Fowler-Stephen orchiopexy. The decision to perform a staged Fowler-Stephen orchiopexy was based on the distance of the testis from the deep inguinal ring on laparoscopy. If distance was more than 2.5 cm, then we proceeded to a laparoscopic staged Fowler-Stephen orchiopexy. In the first stage, testicular vessels were cauterized by bipolar diathermy. Laparoscopic second-stage Fowler-Stephen procedure was done 6 months after the first stage. Patients were regularly followed, and the success of the procedure was assessed by the size of the testes and the position in the scrotum. Testicular vascularity was assessed by color Doppler ultrasonography. There was no testicular atrophy on second stage and on follow-up. All testes were in the scrotum with good size on follow-up. There was no complication related to laparoscopy. In cases of high intra-abdominal testes, the staged Fowler-Stephen procedure should be the procedure of choice. This procedure yields a high success rate. Transaction of vessels by bipolar diathermy is a very safe, cost-effective method.

Laparoscopic manoeuvre for orchidopexy in high intra-abdominal testes when cremasteric artery is present

We report a case of high intra-abdominal testes (HIT) associated with the presence of the cremasteric artery (CA). The aim was to correlate the normal anatomy of the CA with the clinical finding in our patient and discuss its surgical implication. Left primary laparoscopic testicular descent by the Prentiss manoeuvre was performed in a 2 year-old boy with bilateral HIT. Cadaveric dissection was carried out focusing on the anatomical origin of the CA. Data obtained from cadavers and the clinical findings were analyzed. During laparoscopic orchiopexy a left HIT was found in the presence of the CA. Primary tension-free orchiopexy was achieved preserving the CA. Our cadaver study revealed that the CA arose more frequently (68%) from the medial aspect of the inferior epigastric artery. In the presence of HIT, surgeons should be aware of the CA as part of the testicular collateral circulation. Acquaintance with the normal anatomy of the CA is important to determine the most appropriate laparoscopic manoeuvre in orchiopexy when this artery is present. We believe that the Prentiss manoeuvre avoids compression and strangulation of the CA around the epigastric vessels while allowing testicular placement in the scrotum.