Two-stage Fowler-Stephens Orchiopexy Research Articles

Testicular arteries anatomy applied to fowler-sthephens surgery in high undescended testis - a narrative review.

ABSTRACTObjectives:In this review we will describe the testicular vessels anatomy and the implications of these vessels in surgical treatment of high undescended testis.Material and Methods:We performed a narrative review of the literature about the role of the testicular arteries anatomy in the treatment of high undescended testis. We also studied two human testes to illustrate the testicular vascularization.Results:Each testis is irrigated by three arteries: testicular artery (internal spermatic artery), a branch of the right aorta; deferential artery (vasal artery), a branch of the inferior vesicle artery that originates from the anterior trunk of internal iliac artery and cremasteric artery (external spermatic artery), a branch of the inferior epigastric artery. There are important communications among the three arteries with visible anastomotic channels between the testicular and deferential arteries.Conclusions:Laparoscopic transection of the testicular vessels by dividing the spermatic vessels (Fowler-Stephens surgery) is safe in patients with high abdominal testis due to the great collateral vascular supply between testicular, vasal and cremasteric arteries; also, two-stage Fowler-Stephens orchiopexy appears to carry a higher rate of success than the single stage approach.

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.

A prediction model for risk factors of testicular atrophy after orchiopexy in children with undescended testis.

BackgroundThere have been limited studies with small sample sizes about risk factors of testicular atrophy. Thus, we aimed to investigate the risk factors for testicular atrophy after orchiopexy in male children with undescended testes and develop a prediction model based on clinical variables.MethodsWe performed a retrospective review of data on children who underwent orchiopexy for undescended testes from 2013 to 2017. The variables assessed included age, laterality, testicular location, preoperative testicular volume ratio, deferens and epididymis anomaly, hormonal treatment, comorbidities, type of surgical procedure, operating time, and complications as the outcome of testicular atrophy. A nomogram was constructed to predict the probability of testicular atrophy. We also validated our model based on a prospective cohort of patients who underwent orchiopexy from January 2018 to December 2018.ResultsA total of 1,608 patients undergoing orchiopexy were included in the training cohort. The median age was 2.8 years (range, 0.5−11.3 years). After follow-up for 12 to 18 months (median, 14 months), 228 (14.2%) cases of atrophic testes were recorded. The independent predictors of testicular atrophy were preoperative testicular volume ratio [odds ratio (OR) 0.001, P=0.001], testicular location (OR 1.903, P=0.001), deferens and epididymis anomaly (OR 6.470, P=0.001), and two-stage Fowler-Stephens orchiopexy (OR 2.613, P=0.04). Successful validation was achieved, and a receiver operating characteristic (ROC) curve was constructed. The sensitivity and specificity of the prediction model were 78.1% and 77.5%, respectively. The area under the ROC curve was 0.851.ConclusionsIn patients with undescended testes, excluding those with chromosomal abnormalities and testicular nubbin, the incidence of testicular atrophy after orchiopexy is higher in patients with a lower testicular volume ratio, higher testicular location, deferens and epididymis anomaly, and in two-stage Fowler-Stephens orchiopexy. Therefore, this prediction model provides useful evidence for surgeons to choose an appropriate surgical procedure for undescended testes and predict the probability of testicular atrophy.

Revisiting the success rate of one-stage Fowler-Stephens orchiopexy with postoperative Doppler ultrasound and long-term follow-up: a 15-year single-surgeon experience

The optimal management of a high undescended testicle (UDT) remains debated. When tethering is due to shortened spermatic vessels, a one-stage or two-stage Fowler-Stephens Orchiopexy (FSO) can be performed. Published series suggest a higher success rate with a two-stage FSO, though its superiority has not been ascertained. The authors examine patient and surgical factors associated with success of one-stage FSO and compare our outcomes with the established literature. We retrospectively reviewed the charts of 43 boys who underwent one-stage FSO for 45 testes from 2003 to 2018 by a single surgeon at our institution. Patient factors, surgical approach, and postoperative results were reviewed. Radiographic success was a testis with intact vascular flow or normal echotexture on scrotal ultrasound. Clinical success was a non-atrophic, intrascrotal testis at postoperative follow-up. Radiographic and clinical success was compared. Data analysis was performed with Fisher's exact test and t-test for categorical and continuous variables respectively. Follow-up (mean 29 months; 0.5 months-14.5 years) was available for 40 patients (42 testes; 21 bilateral, 21 unilateral). Average age at surgery was 21.8 months (4 months-10.4 years). Associated conditions were seen in 14 patients. Twenty-nine patients had postoperative scrotal Doppler ultrasound with radiographic success in 25/29 (86.2%). Overall clinical success was 34/42 (81%) with 4 (9.5%) each of atrophy and ascent. A second surgery to address ascent in four patients allowed correction in three for a success rate of 88%. Radiographic and clinical success was significantly associated (P=0.01). Clinical success was also significantly associated with inguinal rather than laparoscopic testis mobilization (P=0.03) but not to patient's age, associated conditions, unilaterality/bilaterality, or pre-operative hypoplasia or location. Greater than 3 years of follow-up was available in 11 (26.2%) cases, of which seven had successful results. All adverse outcomes occurred within 8 months after surgery. Success was otherwise durable. This is the largest series of one-stage FSO to date. The success rate of one-stage FSO in this series matches that published in the literature for two-stage FSO; equal success is achieved with fewer surgeries. Postoperative Doppler ultrasound demonstrating intact vascular flow or normal testis echotexture is significantly associated with clinical success and highlights the utility of postoperative ultrasound in patients with an equivocal exam.

Surgical Management of the Undescended Testis: Recent Advances and Controversies.

Undescended testis (UDT) is the most common disorder of sexual development in boys and affects 3.5% of male newborns. Although approximately half of newborn UDTs descend spontaneously, some boys develop an ascending testis later in childhood. Recent guideline recommendations advocate orchiopexy by 18 months of age to maximize potential for fertility and perhaps reduce the risk for testicular carcinoma in the future. For palpable testes, a standard inguinal approach is appropriate. However, the prescrotal approach is often effective for low inguinal testes and reduces surgical time and patient discomfort with an equivalent success rate in boys with an ascending testis. Some advocate monitoring until adolescence to determine whether the testis will spontaneously descend into the scrotum, but data do not support this approach. Instead, prompt orchiopexy is recommended. In boys with a nonpalpable testis, approximately 50% are abdominal or high in the inguinal canal and 50% are atrophic, typically in the scrotum. Routine inguinal/scrotal ultrasound is not recommended, although in an older boy who is overweight, it is appropriate. If the patient has contralateral testicular hypertrophy, scrotal exploration is appropriate, and removal of the testicular remnant and contralateral scrotal orchiopexy to prevent future contralateral testicular torsion is recommended. In most cases, diagnostic laparoscopy is advised to determine whether the testis is abdominal. For the abdominal testis, there are numerous treatment options. If the testis is mobile or a peeping testis just distal to the internal inguinal ring, standard one-stage laparoscopic or open orchiopexy should be attempted using the Prentiss maneuver. If the testicular vessels are short or the testis is not mobile, a two-stage Fowler-Stephens orchiopexy is appropriate. The second stage can be performed laparoscopically or open. Another option is microvascular testicular autotransplantation, which is a technically demanding procedure. Surgical results of abdominal orchiopexy are highly variable, short term, and highly subjective. Prospective clinical trials with follow-up into adolescence and adulthood are necessary to assess the success of various surgical approaches.

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.

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.

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.

Effect of Naloxone on Oxidative Stress and Testicular Injury due to Spermatic Vessel Ligation of Rat Testis

Aims: Two-stage Fowler-Stephens orchiopexy has been accompanied by testicular atrophy in some cases but neither of the mechanisms responsible for testicular injury are clear, nor is there an effective agent that might prevent this injury. In this study we aimed to investigate the long-term effects of naloxone, a morphine antagonist, on testicular histopathology and oxidative stress after spermatic vessel ligation (SVL) in rats. Methods: 32 prepubertal rats were randomly divided into four equal groups: group 1: control (only bilateral orchiectomies were performed); group 2: sham-operated group; group 3: SVL, and group 4: SVL+naloxone (1 mg/kg twice daily for 1 month). One month postoperatively, bilateral orchiectomies were performed to evaluate histopathologic findings and measurement of malondialdehyde (MDA) and nitric oxide (NO) levels. Results: Considering group 3, left SVL resulted in significant tissue damage in both testes, more severe in the ipsilateral testis. The SVL resulted in a significant increase in testicular MDA levels of both testes in this group (p < 0.05). While the ipsilateral testicular NO levels of groups 2 and 3 were significantly lower than of group 1 (p < 0.05), the contralateral testicular NO levels of all these groups were similar. After naloxone therapy, while there was no significant improvement in ipsilateral testicular histopathology (p > 0.05), the contralateral testicular histopathology improved significantly (p < 0.05). However, naloxone did not change either testicular MDA or NO levels. Conclusions: The SVL led to bilateral testicular injury, and oxidative stress may be a reason for this injury. Naloxone significantly improved contralateral testicular injury without showing any antioxidative effect.

The effects of one- and two-stage orchiopexy on postoperative serum testosterone levels and testicular volume in adult patients with bilateral nonpalpable testes.

In this study, we investigated the effects of one- and two-staged orchiopexy on testicular volume and serum testosterone levels in cases with high, abdominally localized, bilateral nonpalpable testes. Between March 1996 and April 2001, orchiopexy was performed on 46 testes in 23 patients with bilateral nonpalpable testes. In 15 of the 23 patients, a two-stage Fowler-Stephens orchiopexy was performed, and in 8 of the 23 patients, a one-stage laparoscopic orchiopexy was performed. For one patient who lacked both testes, bilateral prosthetic testes were inserted. The patients' ages were between 20 and 23 years (average, 21 years). In the first stage of the two-stage orchiopexy, the spermatic artery was ligated laparoscopically. Six months later, open surgery orchiopexy was performed. Patients were followed for 2 to 16 months (average, 10 months) and were evaluated for testicular atrophy, serum testosterone levels, and complications. In all the patients, the preoperative secondary sexual characteristics and serum testosterone levels were normal. Among the postoperative controls, evaluated at months 3 and 6, one patient's testes were found at the pubic area. Testicular atrophy was not observed in any of the patients, and the serum testosterone levels were in the normal range. In the two-stage orchiopexy group, 5 (33%) of the 15 patients had an average 30% volume decrease, and in the one-stage group, 2 (25%) of the 8 patients had an average 40% volume decrease. In this study, it was shown that either two-stage Fowler-Stephens orchiopexy or laparoscopic orchiopexy can be successfully performed in patients with bilateral abdominal testes, and that the testes can be fixed to their palpable original positions without interfering with the secretion of testosterone. Although the results are similar, our experience suggests that single-stage laparoscopic orchiopexy is the preferable method.

Laparoscopic diagnosis and treatment of nonpalpable testis.

Laparoscopy has become one of the important diagnostic modalities of nonpalpable testis and has been developed and applied in the treatment of this disease. In the present study, we investigated the usefulness of laparoscopy in the diagnosis and treatment of nonpalpable testis. Laparoscopy was carried out under general anesthesia on 21 patients (23 testes) from October 1991 to October 1999. If the internal spermatic vessels and vas deferens made their way into the internal inguinal ring, the inguinal canal was dissected with an incision in the inguinal region to look for the testis. Patients with intra-abdominal testis underwent laparoscopic orchiopexy or orchiectomy. If the internal spermatic vessels terminated with a blind end intraperitoneally, making it impossible to identify the testis, the case was judged to be vanishing testis and the operation was finalized without any further examination. In eight of 23 testes (35%), the internal spermatic vessels and vas deferens made their way into the internal inguinal ring. The inguinal region was examined in all the eight testes. Orchiopexy was carried out on two testes and orchiectomy was carried out on six testes. An intra-abdominal testis was detected in eight of 23 testes (35%). Laparoscopic orchiopexy was carried out on seven testes. One-stage orchiopexy was carried out on two of the seven testes and two-stage Fowler-Stephens orchiopexy was carried out on five of the seven testes. Orchiectomy was carried out on the remaining testis. Blocking or lack of the internal spermatic vessels and vas deferens was seen in seven of the 23 testes (30%) and this condition was diagnosed as vanishing testis. Laparoscopy for nonpalpable testis is considered to be the most effective technique for diagnosing the presence or absence of the testis and the location of the testis.

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.

Two-stage fowler-stephens orchiopexy with laparoscopic clipping of the spermatic vessels: G.S. Law, L.M. Perez and D.B. Joseph. J Urol 158:1205–1207, (September), 1997

Two-stage fowler-stephens orchiopexy with laparoscopic clipping of the spermatic vessels: G.S. Law, L.M. Perez and D.B. Joseph. J Urol 158:1205–1207, (September), 1997

Discussion: Two-Stage Fowler-Stephens Orchiopexy with Laparoscopic Clipping of the Spermatic Vessels

Discussion: Two-Stage Fowler-Stephens Orchiopexy with Laparoscopic Clipping of the Spermatic Vessels

Laparoscopic Evaluation and the Management of the Nonpalpable Testis

From June 1992 to December 1996, we performed laparoscopic evaluation for 28 nonpalpable testes in 22 patients (1–21, median 3 years old). The location of 28 testes were divided into 4 categories according to the classification by Malone et al.: canalicular in 17 testes, just canalicular in 2, abdominal in 7, and absent in 2. Two-stage Fowler–Stephens orchiopexy was performed in 3 abdominal testes and planned two-stage orchiopexy was performed in one abdominal testis, while one-stage standard orchiopexy was performed in 10 testes (canalicular 5, just canalicular 2, and abdominal 3). In 10 of 17 canalicular testes no testicular element was found on histological examination of the excised remnant tissue. In two completely absent testicular structures, as verified by vanishing spermatic vessels, no further exploration was done after laparoscopy. There was one complication in this series: jejunal injury which needed oversewing, otherwise there was no postoperative sequela in all cases. Laparoscopic evaluation in patients with nonpalpable testes gives us precise information as to the existence and location of the testicle which is helpful in determining subsequent appropriate procedure and avoiding unnecessary abdominal exploration.

Therapeutic laparoscopy for intra-abdominal testes

Fourteen laparoscopic surgical procedures were performed in 10 children with 11 intra-abdominal testes. In addition to localizing the testes, laparoscopy aided in the surgical approach. In 8 patients, the first phase of a two-stage Fowler-Stephens orchiopexy was performed. Five children underwent an open surgical procedure three months later and have a viable testis in the scrotum after at least nine months of followup. In 5 patients (6 testicles), laparoscopy was used to dissect the testis. Three patients underwent the second phase of the two-stage Fowler-Stephens procedure laparoscopically. In all 3 patients, the testicle could be easily mobilized into the scrotum. Two other testicles were mobilized by dissecting the spermatic vessels up to the renal hilum laparoscopically; this allowed the intra-abdominal testes to come into the scrotum without dividing the spermatic vessels. In one teenager with a small intra-abdominal testis and a normal contralateral testis, laparoscopic orchiectomy was performed. We believe laparoscopy has a role both diagnostically and surgically in the treatment of intra-abdominal testes.

Two-stage Fowler-Stephens orchiopexy in the management of intra-abdominal testes : J.S. Elder. J Urol 148:1239–1241, (October), 1992

Two-stage Fowler-Stephens orchiopexy in the management of intra-abdominal testes : J.S. Elder. J Urol 148:1239–1241, (October), 1992

Two-Stage Fowler-Stephens Orchiopexy in the Management of Intra-Abdominal Testes

Of 22 boys with an intra-abdominal testis 8 (12 testes) underwent the 2-stage Fowler-Stephens orchiopexy. During stage 1 the testicular artery and internal spermatic vein were ligated in situ 2 to 3cm. superior to the intra-abdominal testis. The testicular vessels were transected inferior to the ligatures 6 months later and the testis was brought to the scrotum with the standard Fowler-Stephens orchiopexy technique. Patient age ranged from 1 to 6 years (mean 3.2 years). At followup 11 of 12 testes (92%) are in the scrotum and have a normal consistency and size, while 1 (8%) is atrophic. In this preliminary series the 2-stage Fowler-Stephens orchiopexy has a success rate equal or possibly superior to the standard Fowler-Stephens orchiopexy. Whether ultimate testicular function is improved, however, remains to be determined.