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Standardized single-stage laparoscopic Fowler-Stephens orchiopexy regardless of testis position: Modification of technique eliminates the need for intra-operative decision-making
Amos Neheman1, Andrew Shumaker1, Jack Grazi1, Eyal Kord1, Sergey Bondarenko2, Kobi Stav1, Amnon Zisman1, Paul Noh3
1 Department of Urology, Shamir Medical Center (Assaf Harofeh), Zerifin, Israel, Affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
2 Department of Pediatric Urology, Municipal Hospital, Volgograd, Russia
3 Department of Urology, Children's Hospital of Illinois, Peoria, Illinois, USA
|Date of Submission||07-Oct-2021|
|Date of Decision||20-Jan-2022|
|Date of Acceptance||26-Jan-2022|
|Date of Web Publication||02-Jun-2022|
MS, 4455 NW 27th Ave., Boca Raton, 33434 Florida
Source of Support: None, Conflict of Interest: None
Background/Purpose: 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.
Materials and Methods: 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.
Results: 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.
Conclusions: 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.
Keywords: Fowler-Stephens, laparoscopy, orchiopexy, undescended testis
|How to cite this URL:|
Neheman A, Shumaker A, Grazi J, Kord E, Bondarenko S, Stav K, Zisman A, Noh P. Standardized single-stage laparoscopic Fowler-Stephens orchiopexy regardless of testis position: Modification of technique eliminates the need for intra-operative decision-making. J Min Access Surg [Epub ahead of print] [cited 2022 Jul 3]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=346496
| ¤ Introduction|| |
Intraabdominal testes (IAT) are a subgroup of undescended testes diagnosed in approximately 0.1%–0.2% of term male newborns. Although the primary goal is to perform orchiopexy in a single procedure while preserving the testicular artery and vas deferens, this is not achievable in all cases. Fowler and Stephens described a technique that included transection of the testicular artery which allows extended mobility of the testis. The decision to perform primary orchiopexy or laparoscopic Fowler Stephens Orchiopexy (LFSO) is based on the length of the testicular artery, the ability to mobilize the testis sufficiently, distance between intraabdominal testicular location related to the internal ring, the presence or absence of looping ductal structures, age of the patient and surgeon preference. LFSO can be performed as a one-stage (transection of the artery and orchiopexy simultaneously) or a two-stage (in the first stage only transection of the artery is performed, and the second stage is performed 3–8 months later when the testis is brought down to the scrotum) procedure. In a meta-analysis, the two-stage LFSO is estimated to be more successful than the one-stage repair. The disadvantage of the two-stage approach is the need for two procedures many months apart., Developing a uniform surgical approach that can achieve equal success rates for all cases, regardless of testicular position, is ideal. We describe a surgical modification based on the one-stage LFSO. We hypothesize that the described approach will have good outcomes with a low testicular atrophy rate.
| ¤ Materials and Methods|| |
This is a bi-institutional study. Data from all cases who underwent orchiopexy due to IAT between March 2012 and September 2019 were retrospectively analyzed. We follow a standard approach for boys with nonpalpable testes. All cases with IAT underwent a modified one-stage LFSO (M-LFSO) and comprise the entirety of the study group. An institutional ethical board approved the study. Cases that were found to have an atrophic/vanishing testis upon explorative laparoscopy and those that eventually underwent standard orchiopexy were excluded.
The procedure was planned as an M-LFSO. The procedure is modified by distinct maneuvers: (1) Preservation of a wide peritoneal flap [Figure 1]. (2) Transection of the testicular artery as proximal as possible. This strategy is supported by the findings of Koyano, who recognized the significance of a smaller rate of testicular atrophy when the vessels are ligated farther from it between the testicular artery and vas deferens. (3) When mobilizing the testis from the abdomen to the scrotum, the gubernacular stump is grasped, thus avoiding mechanical trauma to the epididymis and vessels between the epididymis and vas deferens.
|Figure 1: Key surgical maneuvers in the M-laparoscopic Fowler-Stephens orchiopexy procedure: Transection of the testicular artery as proximal as possible and preservation flap between vas deferens and testicular artery|
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An initial assessment is made to verify that the vas deferens is robust and is not looping distally into the inguinal canal. Once verified, a 3-mm JustRight™ vessel sealer (stab incision without a trocar) or a 5-mm LigaSure™ is used to divide the gonadal vessels high in the retroperitoneum, leaving a long stump of vessels with the testis for development of collateral circulation. A wide berth of the peritoneum is also preserved with the stump of the gonadal vessels, using sharp dissection, as the testis and vas deferens are mobilized from the retroperitoneum. The indirect inguinal hernia sac, if present, is preserved by incising the peritoneum of the internal inguinal ring laterally with subsequent manipulation to pull the sac into the abdomen. The gubernaculum is divided. The peritoneal incision from the medial edge of the internal inguinal ring is continued parallel to the vas deferens, again preserving a wide margin of the peritoneum. A long clamp is delivered from the scrotal incision into the abdomen. Further maneuvers to provide an adequate length of the spermatic cord, such as medial transposition of the testis beneath the epigastric vessels (Prentiss maneuver) is routinely carried out. By controlling the gubernacular stump, trauma to the epididymis and vessels between the epididymis and vas deferens can be avoided during testis mobilization into the scrotum. Another intraabdominal inspection is performed to determine if additional peritoneal dissection is beneficial for tension-free positioning of the testis in the scrotum. The testis is secured in the scrotum based on the surgeon's preference, sometimes oriented with the upper pole in a caudal position, leaving the lower pole cranial in the scrotum to prevent tension on the vas deferens.
The M-LFSO procedure is performed regardless of testicular location. Operative time was measured from trocar placement to closure of scrotal skin. If a concomitant procedure was performed, the relative time for the other procedure was adjusted for in the calculation.
The primary endpoints of the study were testicular atrophy rate and success rate based on normal testicular position in the scrotum at follow-up. Patients were evaluated in the clinic 3, 6 and 12 months postoperatively. The estimated testicular volume of <50% of the contralateral testis, evaluated by physical examination, was considered to be atrophic. Testicular location outside of the normal position of the scrotum necessitating an additional procedure was considered a failure.
Continuous variables were described with medians and interquartile range (IQR). Categorical variables were described as frequency and percentage. Categorical variables were compared using the Chi-square test of independence. All statistical analysis was performed on SPSS statistics© v. 25 (IBM, Armonk, NY, USA) and statistical significance was set to P < 0.05.
| ¤ Results|| |
Our cohort included 55 boys (59 testes) with viable intraabdominal testis. Excluded were 21 cases with vanishing/atrophic testis and 11 cases that eventually underwent inguinal orchiopexy. Data regarding patient age and weight, laterality of the procedure, operative times, follow-up time and post-operative complications are outlined in [Table 1]. Concomitant procedures performed included 9 circumcisions and 1 circumcision revision, 5 inguinal hernia repairs, 1 nephroureterectomy and 1 urethral meatoplasty. Complications were defined by the Clavien-Dindo classification system. There were three cases of Grade 3/4 anesthesia-related complications involving respiratory distress, fever and broncho/laryngospasm.
All cases were completed laparoscopically. There were no cases of conversion to open surgery. The vas deferens was of sufficient length in all cases and orchiectomy was not performed in any of them.
At 3-month follow-up, there were 5 cases of high testicular position in the scrotum. At a median follow-up of 11 months (IQR 7–12), 2 cases were in a suboptimal position at the upper part of the scrotum, and follow-up was subsequently recommended.
There was one case of testicular atrophy (2%). There were 5 cases in which the cryptorchid testis had decreased volume, but more than 50% of the estimated volume compared to the contralateral testis. Doppler ultrasound demonstrated intact blood flow to these testes and normal echotexture.
| ¤ Discussion|| |
In the study, we present a uniform approach for all intraabdominal testes, regardless of testicular position. We describe a modification of the one-stage LFSO. The procedure demonstrates a high success rate with a low atrophy rate. The requirement for two different interventions 3–8 months apart to perform a two-stage LFSO, in addition to the lower success reported when performing laparoscopic primary orchiopexy that eventually required LFSO, was the impetus for developing a modification that will allow for a one-stage intervention with a higher success rate. Classically, the testicular distance from the inguinal ring is considered as a parameter for the surgical approach. The Ain Shams classification is a commonly employed system for this determination.
Wu and Kirsch reported on the success rate of one-stage LFSO with postoperative ultrasound and long-term follow-up. They reported an overall success rate of 88%. Their surgical approach is based on an attempt to perform a one-stage orchiopexy in every case, either as a laparoscopic procedure if the distance between the testis and the internal ring is more than 2 cm, or as an open groin approach if the testis is close to the ring. In cases that, after adequate manipulation, there is insufficient length, then a one-stage LFSO is pursued. The fact that although the testis is close to the internal ring, there is still insufficient length is important to acknowledge when performing orchiopexy for intraabdominal testis. We believe that this phenomenon is under-emphasized and more common than reported. We also believe, based on our prior experience, that the 2 cm cut-off is somewhat arbitrary and that other factors also influence the ability to bring the testis to the appropriate scrotal position. Our surgical approach differs from that reported by Wu in that we intend to perform a one-stage LFSO at the beginning of the procedure.
The available data regarding surgical treatment of intraabdominal testes are contradictory in many aspects. We speculate that leaving a long stump of the testicular artery reduces the rate of testicular atrophy. This is supported by the findings of Ellis et al. that performed mapping of testicular blood supply and clearly showed bridging vessels between gubernacular and spermatic vessels. On the other hand, Koff and Sethi proposed that ligation close to the testis is preferable.
We also speculate that transecting the vessels is to no extent inferior regarding success rates, and furthermore, regarding maintaining fertility. On the other hand, human studies involving testicular biopsies before and after spermatic vessel transection demonstrated a reduction in germ cell count, a finding that was significant in younger boys. This study concluded that in general, the preferred approach is avoidance of spermatic vessel transection whenever possible.
Although one-stage LFSO is considered to be inferior to the two-stage procedure, a few reports have contradicted this. Chang and Franco compared between a one-stage and a two-stage LFSO and determined a similar success rate of 94%.
The main determinant of testicular survival is hypothesized to be the blood supply to the testis. A pivotal study by Sampaio et al. studies 32 cadaveric fetuses. They demonstrated that all fetuses had at least two testicular vessels: A testicular artery originating from the abdominal aorta and a deferential artery originating from the internal iliac artery. A third cremasteric artery originating from the external iliac artery was present in 75% of cases. In our technique, the blood supply to the testis depends on the vasal artery and vasal-epididymal vessels. Leaving a wide leaf of peritoneum between the testicular artery stump and vas deferens and medial to the vas deferens minimizes the trauma to the vasal artery and is the cornerstone of this modification. Furthermore, the removal technique of the testis spares manipulation of the epididymis and inter-vasal-epididymal vessels.
Intraoperative decision-making today is based on the distance between the intraabdominal testis and the internal ring. It is believed that a distance of <2 cm is an indicator that the testis can be brought down to the scrotum without the need to transect the artery, whereas a distance of more than 2 cm is a negative prognostic factor for this to be achieved. Therefore, in these cases, a two-stage LFSO is performed. From our prior experience, this does not always stand true. At times, we have struggled with the so-called 'distal testis', and although the testis seems to be close to the internal ring, after dissection, it still could not be brought optimally to the scrotum, despite using the Prentiss maneuver. Furthermore, the ability to mobilize the testis to the opposite internal ring has been used as a measure of adequate length for placement in the scrotum, but it is not always predictable in some series. Our modified approach eliminates the need for intraoperative decision-making. Therefore, all testes can be treated with a single approach without compromising surgical outcomes.
Our only contraindication, for now, is a long looping vas deferens. In this scenario, we defer to the two-stage LFSO because of the concern of compromising blood supply to the vas deferens. Naycı et al. had described a modification in which the gubernaculum is not dissected. Combining both methods can potentially preserve an adequate testicular blood supply and should be further investigated in future studies.
This study is not without limitations. Although this is a retrospective review, it was performed independently in two different academic centers with similar success rates. Another limitation is this study being of a case series and not a comparative study. Nevertheless, compared to previously published data of the two-stage LFSO, the rate of testicular atrophy is not compromised.
Follow-up is relatively short, and a longer follow-up time may reveal a higher failure rate and inappropriate testicular volume at puberty. Doppler ultrasound was not performed routinely and was reserved for cases of small testis to verify viability. Nevertheless, it has been reported that radiographic and clinical success is significantly correlated. Testicular biopsies were not performed and data regarding future fertility is not yet available.
| ¤ Conclusions|| |
M-LFSO is a standardized approach for all cases of intraabdominal testes regardless of testicular position. It is reproducible with good outcomes.
The proposed approach alleviates the necessity for intraoperative decision-making and the need for ancillary procedures.
The authors have read and comply with the ethical guidelines stated in the “Guide to Authors.”
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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