Laparoscopic Fowler-Stephens Orchiopexy Research Articles

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

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.

Clinical efficacy of two-staged Fowler-Stephens laparoscopic orchidopexy in the treatment of children with high cryptorchidism

Objective: To Evaluate the clinic effect of two-staged laparoscopic Fowler-Stephens orchiopexy in the treatment of high cryptorchidism, and compare it with laparoscopic orchiopexy treatment without disconnecting spermatic vessels. Methods: A retrospective analysis was conducted on 20 cases of children with high cryptorchidism who were treated with two-staged Fowler-Stephens orchiopexy from January 2015 to April 2019 (F-S group). All the children in this group had unilateral cryptorchidism, age 6 to 18 months. The average age was 13.5 months. Seven cases were on the left side, and 13 cases were on the right side. There were 20 control children in the same age group who were treated with testicular fixation without disconnecting spermatic vessels, age 6 to 18 months. The average age was 12.5 months. Six cases were on the left side, and 14 cases were on the right side. Testicular ultrasonography and sex hormone examination were conducted before operation. F-S group met the indications for Fowler-Stephens surgical. In the first stage, the testicular vessels were doubly clipped at a site away from the testis in laparoscopic, and the second stage was scheduled about 6 months after the first stage. The children in the control group were treated with laparoscopic orchiopexy without disconnect spermatic vessels. The two groups were followed up to 6 months after the operation, and the testicular volume and sex hormone indexes of the two groups were measured. The testicular volume and sex hormones before and after the operation of the F-S group and the control group were respectively subjected to a self-control study, and a hormone comparison study was carried out between the two groups of children. Results: Both the F-S group and the control group successfully fixed the testes in the scrotum without tension during the operation. In both groups, 20 cases of testicular positions were reexamined 6 months after the operation without retraction. All the patients had a viable testis in scrotum after operation. Two of F-S group had an atrophic testis in the scrotum, and the others had a good vascularization detected on echo color doppler ultrasound. The average testicular volume of F-S group was (0.34±0.16) ml before operation and the postoperative one was (0.38±0.13) ml, P=0.089, P>0.05. In control group, the preoperative average testicular volume was (0.40±0.14) ml, and postoperative one was (0.40±0.15) ml, P=0.933, P>0.05. The testicular volume of two group had no significant difference. Sex hormone reexamination: Testosterone (T), estradiol (E2) and luteinizing hormone (LH) did not change after operation. Prolactin (PRL) in F-S group was 13.44 μg/L before operation and 12.3 μg/L after operation, PRL in control group was from 15.45 μg/L to 10.34 μg/L, P=0.732, the change of prolactin (PRL) has no significant difference. The median preoperative follicle stimulating hormone (FSH) in the F-S group was 1.18 U/L preoperatively and 1.61 U/L postoperatively; the median FSH of the control group was 1.21 U/L preoperatively and 1.1 U/L postoperatively. Compared between the two groups, the postoperative increase in the FS group was higher than that before the operation, P=0.032, P<0.05, the difference was statistically significant. The median of progesterone (PROG) in the F-S group was 0.25 nmol/L before operation and 0.17 nmol/L after operation; the median PROG of the control group was 0.56 nmol/L before operation and 0.24 nmol/L after operation. It was lower after the operation than before the operation, P=0.034, P<0.05, the difference was statistically significant. Conclusions: (1) Laparoscopic Fowler-stephens staging operation is an effective method for the treatment of patients with high cryptorchidism, and it is worthy of further promotion. (2) Disruption of spermatic cord vessels does have an impact on hormones changes. The choice of this surgical procedure should be carefully and fully evaluated.

How far can one-stage laparoscopic Fowler-Stephens orchiopexy be implemented in intra-abdominal testes with short spermatic vessels?

The aim of the study was to compare the outcome of the prospective cohort who had one-stage laparoscopic Fowler-Stephens orchiopexy (LFSO) with an earlier, similar cohort who had a two-stage LFSO. Both cohorts included only intra-abdominal testes (IATs) with short spermatic vessels. The present study initially included all patients between the age of six months and preschool age, presenting with an IAT to the authors' tertiary clinic from January 2012 to December 2014. Only intra-abdominal testes with short testicular vessels, correlating to type 3A, 3B and 4A as per the updated Ain Shams classification, were included in this study. One-stage LFSO was performed on all patients. Patients with bilateral intra-abdominal testes had the procedure performed on the contralateral side 6-8 weeks later. Follow-up was performed at 6, 12 and 36 months postoperatively by means of Doppler ultrasound in the first two visits. A similar subgroup of the historical cohort from years 2002 to 2010 had a two-stage LFSO, with the second stage being performed 12-16 weeks later. In bilateral cases, a three-interval surgery based on two-stage LFSO was performed, with a follow-up at 6 months postoperatively. The recent cohort included 16 IATs (10 unilateral and 3 bilateral). The median age of the patients was 1.41 years. At 6-month follow-up, 4 testes were found atrophic (25%), whereas the remaining 12 testes (75%) were viable. In those viable, only half of them had a low scrotal position. No difference was found at 12- or 36-monthfollow-up. Doppler ultrasound confirmed adequate intratesticular blood flow at 6 and 12 monthspostoperatively.In the similar subgroup of the historical cohort, 3 of 25 (12%) testes were found atrophied at six months postoperatively, with only one testis (4%) having a high scrotal position. In a comparison of both cohorts, the two-stage LFSO was found to be associated with a halving of the testicular atrophy rate (p value=0.401) and a higher incidence of low scrotal position (p value=0.004). A comparison of both cohorts is shown in the summary table. Although one-stage LFSO may seem tempting, it still holds a higher rate of testicular atrophy, which is not justified. Level III (Case-control study).

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 ...

Feasibility and safety of monopolar diathermy as an alternative to clip ligation in laparoscopic Fowler-Stephens orchiopexy

PurposeThe aims of the study were to study the effect of Fowler-Stephens orchiopexy (FSO) on testicular histology and to assess the feasibility of using monopolar diathermy as an alternative to clip ligation during laparoscopic FSO. Patients and MethodsThe study included 20 patients with 20 intraabdominal testes and short vessels managed by laparoscopic-staged FSO. Biopsies were taken from intraabdominal testes during the first and second stages of the procedure for histologic comparison. The patients in the study were divided into 2 groups according to the method of dividing the testicular vessels in stage 1. The first 13 patients (group A) were managed by clip ligation of the vessels, whereas monopolar diathermy was used in the following 7 patients (group B). ResultsBiopsy findings at stage 2 revealed an overall reduction in both the total number of germ cells per tubule and mean diameter of seminiferous tubules, whereas there was no statistically significant difference between the results in groups A and B. ConclusionThe seminiferous cells can withstand (survive) dividing the main blood supply of the testis during FSO. The monopolar diathermy can be used as an alternative to clipping during laparoscopic procedures, having the advantages of lower expenses and using smaller instruments.

Spermatogenesis After 1-Stage Fowler-Stephens Orchiopexy in Experimental Cryptorchid Rat Model

To evaluate the validity of 1-stage Fowler-Stephens orchiopexy, we performed this procedure for intra-abdominal testes in an experimental cryptorchid rat model and assessed postoperative spermatogenesis. Cryptorchidism in rats was induced by injecting flutamide into the abdomen of pregnant Sprague Dawley rats for 7 days (days 14 to 20 of gestation). Four-week-old cryptorchid rats were divided into the 4 groups of sham operation (group 1, 7 rats), orchiopexy only (group 2, 7), spermatic vessel ligation only (group 3, 7), and spermatic vessel ligation and orchiopexy (1-stage Fowler-Stephens orchiopexy, group 4, 7). The testes were removed 12 weeks after birth in all groups, and testicular weight, testicular histopathological findings and presence of sperm in the epididymis were examined. All operated testes had reticulated vessels on the tunica albuginea. There were no statistically significant differences in the testicular weight between groups 1 (mean +/- SD 0.47 +/- 0.04 gm) and 4 (0.30 +/- 0.19), suggesting that Fowler-Stephens orchiopexy did not induce significant testicular atrophy. However, seminiferous tubule diameters in group 4 were significantly smaller than in group 1 (p <0.001), and no sperm was observed in the epididymis of group 4 rats, suggesting that Fowler-Stephens orchiopexy reduced seminiferous tubule diameters and did not improve spermatogenesis. Although Fowler-Stephens orchiopexy is a good procedure to maintain testicular size and correct cosmetic deformity of an absent scrotum, it may not significantly contribute to the improvement of spermatogenesis.

Open Versus Laparoscopic Staged Fowler-Stephens Orchiopexy: Impact of Long Loop Vas

There is a paucity of literature on factors associated with testicular atrophy following second stage laparoscopic Fowler-Stephens orchiopexy. We hypothesized that dissection of a long looping vas during this procedure could compromise testicular blood supply, leading to testicular atrophy. Following an initial laparoscopic testicular vessel ligation, a second stage Fowler-Stephens orchiopexy was performed in 73 testes (laparoscopic in 61, open in 12). The presence of a long looping vas was noted from the first stage operative notes. Doppler ultrasound was performed postoperatively to confirm testicular atrophy. Atrophy rate at a mean followup of 13.5 months was 20.5% (15 of 61 in laparoscopic and 0 of 12 in open orchiopexy). None of the 5 long looping vas testes atrophied following open orchiopexy, compared to 5 of 6 (83%) following laparoscopic orchiopexy (p = 0.03). Analyzing the laparoscopic group alone, a long looping vas was significantly associated with risk of atrophy (p <0.01). The presence of a long looping vas was associated with a higher atrophy rate following laparoscopic second stage Fowler-Stephens orchiopexy. Laparoscopic management of the long looping vas may be more challenging and, therefore, in such cases open Fowler-Stephens orchiopexy may result in better success rates by preserving the integrity of the collateral vessels.

Cryptorchidism With Short Spermatic Vessels: Staged Orchiopexy Preserving Spermatic Vessels

Patients with cryptorchidism can have such short spermatic vessels that it is impossible to place the testicle in a satisfactory scrotal position using conventional orchiopexy. In these cases the most commonly used operation is 1 to 2-stage Fowler-Stephens orchiopexy. We present our surgical experience using staged inguinal orchiopexy without section of the spermatic vessels in patients with short spermatic vessels. We used 2-stage inguinal orchiopexy in 38 children with intra-abdominal testis or testis peeping through the internal ring and short spermatic vessels (7 bilateral). Spermatic vessels were not sectioned, but were lengthened through progressive traction of the spermatic cord wrapped in polytetrafluoroethylene pericardial membrane (Preclude). In the first stage we mobilized the spermatic cord in the retroperitoneal space and then wrapped it in the polytetrafluoroethylene membrane. We subsequently attached the testis to the invaginated scrotal bottom. At 9 to 12 months we performed the second stage, which involved removing the polytetrafluoroethylene membrane. From the first to the second stage we observed progressive descent of the testicle toward the scrotum. At 1 to 8-year followup after the second stage all 45 testicles were palpable in a satisfactory scrotal position with stable or increased testicular volume. This technique represents an alternative to Fowler-Stephens orchiopexy, which can be associated with a greater risk of testicular ischemia.

Laparoscopic Fowler-Stephens Orchiopexy: The Westchester Medical Center Experience

The Fowler-Stephens orchiopexy is performed laparoscopically both as a single-stage as well as a two-stage procedure. We hypothesize that with the right technique, the single-stage procedure is just as successful as the two-stage procedure. The records of all boys who underwent a laparoscopic Fowler-Stephens orchiopexy (LFSO) for a nonpalpable testis at our institution from August 1995 to February 2007 were reviewed. Office charts and operative reports were reviewed for all patients. There were 48 testes that were brought down by a LFSO. Of these, 38 were performed in one stage and 10 were performed in two stages. The overall success rate was 91.1%. We conclude that both single-stage and two-stage laparoscopic Fowler-Stephens orchiopexies are effective treatment options for children with intra-abdominal testes. In this series, the overall success rate for one stage LFSO was 94.3%. Avoiding manipulation of the vas deferens and epididymis appears to be the key to a high success rate.

Laparoscopic diagnosis and treatment of nonpalpable testis

Treatment of the cryptorchid testicle is justified due to the increased risk of infertility and malignancy as well as the risk of testicular trauma and psychological stigma on patients and their parents. Approximately 20% of cryptorchid testicles are nonpalpable. In these cases, the videolaparoscopic technique is a useful alternative method for diagnosis and treatment. We present data concerning 90 patients submitted to diagnostic laparoscopy for impalpable testicles. Forty-six patients (51.1%) had intra-abdominal gonads. In 25 testicles of 19 patients, we performed a two stage laparoscopic Fowler-Stephens orchiopexy. The other 27 patients underwent primary laparoscopic orchiopexy, in a total of 29 testicles. We obtained an overall 88% success rate with the 2 stage Fowler-Stephens approach and only 33% rate success using one stage Fowler-Stephens surgery with primary vascular ligature. There was no intraoperative complication in our group of patients. In the laparoscopic procedures, the cosmetic aspect is remarkably more favorable as compared to open surgeries. Hospital stay and convalescence were brief. In pediatric age group, the laparoscopic approach is safe and feasible. Furthermore, the laparoscopic orchiopexy presents excellent results in terms of diagnosis and therapy of the impalpable testis, which is why this technique has been routinely incorporated in our Department.

Laparoscopic orchiopexy: report of 203 cases with review of diagnosis, operative technique, and lessons learned.

Proper management of the nonpalpable testicle requires an accurate diagnosis. Laparoscopic orchiopexy (LO) has become the standard for diagnosis and treatment. We classified the location of nonpalpable testicles, reviewed the technique of LO in detail, and report the results of our series, the largest described to date. We compiled the records of all cryptorchid patients seen between 1994 and 2002. Those with testicles located near the internal inguinal ring and those with nonpalpable testicles underwent laparoscopy and LO in the same session. The 173 patients underwent 203 procedures, all performed by the senior authors. The undescended testicles were right-sided in 33% of patients, left-sided in 53%, and bilateral in 14%. Six testicles were excluded because of hypotrophy (N=4) or agenesis of the vas deferens (N=2). At laparoscopy, 58% of the testicles were at the iliac vessels or higher (high intra-abdominal), 22% were between the iliac vessels and the internal ring (low intra-abdominal), 16% were peeping, 3% were intracanicular, and 1% were retrovesical. Standard LO was performed in 70.5% of the patients, with the remainder being treated by laparoscopic Fowler-Stephens orchiopexy. There have been four cases of testicular atrophy, all after Fowler-Stephens procedures. Two were virgin gonads, and the other two had previously been subjected to extensive orchiolysis. Only 3% of the patients required repeat surgery because of an unsatisfactory testicular location. The reported success rate for LO of intra-abdominal testicles has far exceeded that of open repair (95% v 76%). It is our belief that minimal manipulation of the testicle during dissection, a wider peritoneal window, and sparse use of electrocautery will result in adequate testicular position even for high intra-abdominal gonads with minimal risk of atrophy.

ARTERIAL SUPPLY OF THE HUMAN FETAL TESTIS DURING ITS MIGRATION

Irrespective of the surgical technique chosen to treat high undescended testis, preservation of an adequate arterial supply for the testis is crucial for successful orchiopexy with maintenance of normal testicular size and texture. To provide an anatomical background for such a procedure, we performed a systematic study on the number and origin of arteries supplying the fetal testis during its migration from the abdomen to the scrotum. We studied bilaterally 64 testes from 32 fresh human fetuses 13 to 33 weeks after conception. The fetuses were injected through the thoracic aorta with a microvascular silicone rubber red resin to fill in the arterial tree, thereby enabling identification and dissection of all arteries supplying the testes. Of the 64 testes 3 arteries (testicular, deferential and cremasteric) were found in 46 (71.9%), 2 (testicular and deferential) in 15 (23.4%) and 4 in 3 (4.7%). The fetal testis is always supplied by at least 2 arteries (testicular and deferential arteries) and by 3 or 4 arteries in nearly 80% of the cases.