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

Abstract

Objective: 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.

Study design: 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.

Results: 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-month follow-up. Doppler ultrasound confirmed adequate intratesticular blood flow at 6 and 12 months postoperatively. 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.

Conclusion: Although one-stage LFSO may seem tempting, it still holds a higher rate of testicular atrophy, which is not justified.

Level of evidence: Level III (Case-control study).

Keywords: Fowler-stephens; Impalpable testis; Intra-abdominal testis; Non-palpable testis; Orchiopexy; Spermatic vessels.