(1)
Department of Paediatric Urology, Hospital Exequiel Gonzales Cortes and Clinica Santa Maria, Santiago, Chile
(2)
Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
Abstract
Undescended testis is the most frequent congenital genitourinary anomaly, affecting 1–2 % of boys [1]. About 20 % of them will have an impalpable testicle (IPT) [1, 2], situated intra-abdominally in nearly half. In the remainder, the testis may be absent, may have atrophied, or may be hidden in the inguinal canal or fat [2, 3]. For patients with IPT, laparoscopy is the gold standard for diagnosis, and it allows the surgical treatment to be performed in the same setting [4]. The laparoscopic surgical options for the intra-abdominal testis include single-stage orchidopexy, single-stage Fowler-Stephens procedure (FSP), and two-stage FSP. Intra-abdominal testes with sufficient vessel length may be mobilised into the scrotum in one procedure, but the gonadal vessels are too short in the vast majority of patients. In 1959, Fowler and Stephens [5] described division of the testicular vasculature to aid mobilisation, thereby leaving the testes to rely on collateral blood supply along the vas deferens. Twenty-five years later, Ransley et al. [6] advised a two-stage procedure with an interval between vessel ligation and testicular mobilisation to allow time for enhancement of the collateral blood supply along the vas deferens. Laparoscopy for division of the vessels was introduced 20 years ago, and more recently, it has been used for mobilisation during the second stage [7–9]. The FSP has been demonstrated to be an effective and safe technique with reported success rates consistently above 80 %; the complications of testicular atrophy and ascent are documented in about 10 % and 5 %, respectively. A systematic review comparing single-stage and two-stage FSP concluded that the staged approach has a higher rate of success, with better testicular viability [10]. This chapter describes the surgical technique of first- and second-stage Fowler-Stephens orchidopexy.
Keywords
CryptorchidismUndescended testisImpalpable testisIntra-abdominal testisLaparoscopyOrchidopexyFowler-Stephens procedure32.1 General Information
Undescended testis is the most frequent congenital genitourinary anomaly, affecting 1–2 % of boys [1]. About 20 % of them will have an impalpable testicle (IPT) [1, 2], situated intra-abdominally in nearly half. In the remainder, the testis may be absent, may have atrophied, or may be hidden in the inguinal canal or fat [2, 3]. For patients with IPT, laparoscopy is the gold standard for diagnosis, and it allows the surgical treatment to be performed in the same setting [4]. The laparoscopic surgical options for the intra-abdominal testis include single-stage orchidopexy, single-stage Fowler-Stephens procedure (FSP), and two-stage FSP. Intra-abdominal testes with sufficient vessel length may be mobilised into the scrotum in one procedure, but the gonadal vessels are too short in the vast majority of patients. In 1959, Fowler and Stephens [5] described division of the testicular vasculature to aid mobilisation, thereby leaving the testes to rely on collateral blood supply along the vas deferens. Twenty-five years later, Ransley et al. [6] advised a two-stage procedure with an interval between vessel ligation and testicular mobilisation to allow time for enhancement of the collateral blood supply along the vas deferens. Laparoscopy for division of the vessels was introduced 20 years ago, and more recently, it has been used for mobilisation during the second stage [7–9]. The FSP has been demonstrated to be an effective and safe technique with reported success rates consistently above 80 %; the complications of testicular atrophy and ascent are documented in about 10 % and 5 %, respectively. A systematic review comparing single-stage and two-stage FSP concluded that the staged approach has a higher rate of success, with better testicular viability [10]. This chapter describes the surgical technique of first- and second-stage Fowler-Stephens orchidopexy.
32.2 Working Instruments
5-mm Hasson port
Two ports of 5 mm or 3 mm
5-mm, 30° telescope
5-mm or 3-mm Kelly forceps
5-mm or 3-mm scissors
5-mm endoclips or bipolar coagulation forceps
Laparoscopic diathermy lead
32.3 Positioning, Port Siting, and Ergonomic Considerations
The patient is positioned supine and the IPT is confirmed on examination under anaesthesia. A 5-mm umbilical port is used as the primary port. Two additional 5-mm working ports are placed as shown in Fig. 32.1a. In bilateral cases, the working ports are placed in each flank, as illustrated in Fig. 32.1b. For small patients, 3-mm working ports may be used, but a 5-mm port will be necessary for clip placement.
Fig. 32.1
(a) Port placement for right impalpable testicle (IPT). (b) Port placement for bilateral IPT. Shown are a 5-mm umbilical port (1) and the two additional 5-mm working ports (2 and 3)
32.4 Relevant Anatomy and Diagnostic Laparoscopy Findings
After placement of the umbilical port, a diagnostic laparoscopy is carried out. The normal anatomy of the contralateral side is shown in Fig. 32.2. The laparoscopic assessment of the IPT has a number of possible outcomes:
The finding of an intra-abdominal testicle (Fig. 32.3)
The presence of a vas deferens and spermatic vessels running into the inguinal canal with the internal/deep ring closed or open (Fig. 32.4)
An atrophic intra-abdominal testicle or nubbin (Fig. 32.5)
A blind-ending vas deferens and spermatic vessels (Fig. 32.6).
Fig. 32.2
Contralateral normal side (right): the vas deferens (2) and spermatic vessels (3) exit through a closed deep/internal inguinal ring (1); 4 designates the caecum
Fig. 32.3
Intra-abdominal left testicle (1). Also shown are the gubernaculum (2), vas deferens (3), and spermatic vessels (4)
Fig. 32.4
Vas deferens and vessels exit through an open left deep ring into the inguinal canal (1)
Fig. 32.5
Right atrophic intra-abdominal testicular nubbin (2); also present is a vas deferens (1)
Fig. 32.6
Right blind-ending vas deferens (2) and atretic spermatic vessels (3), with a closed deep inguinal ring (1)
When the vas deferens and vessels are observed to run into the deep ring, we recommend an open inguinal exploration for a testis hidden within the inguinal canal/fat or a testicular nubbin or vanishing testis. An atrophic intra-abdominal testicle or nubbin should be removed and sent for histological analysis. If a blind-ending vas deferens is found, the spermatic vessels must be identified (Fig. 32.6), to ensure that a gonadal structure dissociated from the vas deferens-epididymis (for instance, located adjacent to the lower pole of the kidney) is not missed. When both the vas deferens and vessels are absent, testicular agenesis is diagnosed. No additional intraoperative procedure is indicated, but an ultrasound of the urinary tract should be undertaken subsequently, in view of the association with urinary tract anomalies, particularly renal agenesis.
Finding an intra-abdominal testis will prompt a brief assessment of the length of the testicular vessels, using the following guide: If an intra-abdominal testis can be brought to the contralateral deep inguinal ring without tension, the vessel length is likely to be sufficient to enable mobilisation to a scrotal position in a single procedure. For the vast majority of intra-abdominal testes, this is not the case, however, and a staged Fowler-Stephens procedure is carried out.
32.5 Surgical Technique: First-Stage Fowler-Stephens Procedure
- 1.
The patient is positioned supine; the laparoscopic insufflator is set to 10 mmHg of pressure and 2 L/min of flow. The umbilical port is placed using an open Hasson technique. A 5-mm 30° camera is used and two additional 5-mm ports are placed as shown in Fig. 32.1a (or Fig. 32.1b if bilateral) under direct vision.
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