Laparoscopic Stephen-Fowler Stage Procedure: Appropriate Management for High Intra-Abdominal Testes

Introduction

In high intra-abdominal testes, the length of testicular vessels is the main limiting factor to bring down the testicle in the scrotum. Division of testicular vessels for gaining length was first described by Beven in 1899, but the results were poor and had high testicular atrophy rates. ¹ Long after that, Fowler and Stephen, in 1959, reviewed the vascular anatomy of testis and popularized the division of testicular vessels, high and as far as possible from the testes to maintain collateral blood supply, to treat high intra-abdominal testes. ² Diagnostic laparoscopy for the management of the nonpalpable testis was first carried out by Cortesi et al. in 1976. ³ Long after that, in 1992, Jorden et al. introduced the therapeutic application of laparoscopy in boys with an undescended testis. ⁴ Since then, laparoscopy has been increasingly considered the procedure of choice for the diagnosis and treatment of the nonpalpable testis. Currently, Fowler-Stephen orchiopexy is performed laparoscopically both as a single-stage and as a two-stage procedure. In this series, we discuss our experience with the two-stage Fowler-Stephen orchiopexy, in which both stages were done laparoscopically.

Materials and Methods

From 2005 to 2008, 51 patients with 63 nonpalpable testes had undergone laparoscopy. Age range was from 1 to 14 years. Preoperatively, all patients underwent clinical examination and ultrasonography. We reexamined the patients under anesthesia. If the testes were palpable under anesthesia, we did an open inguinal orchiopexy. If not, we proceeded with laparoscopy. Patients with disorders of sexual differentiation were excluded. Patients with Prune Belly syndrome were included in the study. Three patients with Prune Belly syndrome had bilateral nonpalpable testes. The decision to perform either single-stage laparoscopic orchiopexy or staged Fowler-Stephen orchiopexy was based on the distance of the testis from the deep inguinal ring on laparoscopy; 2.5 cm was used as the criteria for the type of procedure (i.e., either standard or staged procedure). Laparoscopic second-stage Fowler-Stephen procedure was done 6 months after the first stage. Overall, 17 testes of 13 patients underwent a staged Fowler-Stephen orchiopexy.

Initially, all patients of nonpalpable testes underwent diagnostic laparoscopy. The patients were prepared the same as for standard laparoscopy. Laparoscopy was performed through an infraumbilical incision. We used the open technique for the first port placement. After the localization of the testes, the distance of the testes from the deep ring was assessed. Primary laparoscopic orchiopexy was done if the distance was less than 2.5 cm, and the first stage of staged Fowler-Stephen orchiopexy was done for patients who had a distance of more than 2.5 cm. With the additional ports, the testicular vessels were cauterized by bipolar diathermy.

The laparoscopic second-stage orchiopexy was performed 6 months after the first stage. Gubenaculum was dissected off from the pubic tubercle, and the lateral peritoneal fold was incised. The testes were mobilized with a wide strip of peritoneum maintained over the vas deferens. Care was taken to avoid injury to the ureter during dissection. After complete mobilization, a neohiatus was made lateral to the urinary bladder and medial to the inferior epigastric vessels. A dartos pouch was made and a 10-mm trocar was inserted from the scrotum to the neohiatus. Testes were brought down in the scrotum under vision and secured in dartos pouch. Patients were regularly followed up, and the success of procedure was assessed by the size and position of the testes in the scrotum. Color Doppler ultrasonography was also performed after 4 weeks.

Results

Overall, 17 testes of 13 patients underwent staged laparoscopic Fowler-Stephen orchiopexy. All testes were in the scrotum with good size and were well located in the scrotum on follow-up. There was no complication related to laparoscopy. On follow-up, there was no testicular atrophy (i.e., well placed in scrotum). Doppler ultrasonography showed normal testicular blood flow. Three patients with Prune Belly syndrome had bilateral high intra-abdominal nonpalpable testes and were treated by the laparoscopic Fowler-Stephen staged procedure successfully. During the first stage, testes were found just below the kidneys. Overall, the success rate in our series was 100% with the staged Fowler-Stephen orchiopexy.

Discussion

In 1959, Fowler and Stephen ² described the vascular anatomy of the testes. Based on this anatomy, they had given the concept of high ligation of testicular vessels to gain additional length of spermatic cord and bring the testes to the scrotum while maintaining the collateral vascular supply to the testes. The testes would be supplied by deferential and cremasteric arteries. The technique described by Fowler and Stephen was originally a single-stage procedure. In anticipation of the development of collateral blood supply and to allow greater mobility of the testes, the two-stage procedure was developed by Ransley et al., who introduced the practice of ligating the testicular vessels and waiting for 6–12 months before doing an orchiopexy. ⁵

Diagnostic laparoscopy was first advocated by Cortesi et al. in 1976. Their main aim was to locate the high intra-abdominal testes that could be missed from an inguinal approach. ³ Bloom, in 1991, extended the role of laparoscopy for the staged Fowler-Stephen orchiopexy by ligating the spermatic vessels laparoscopically. This was a simple extension of diagnostic laparoscopy. ⁶

The staged Fowler-Stephen procedure is a better alternative of the single-stage Fowler Stephen procedure as a staged procedure allowing the collateral blood supply to mature. This concept is supported by Pascle et al., ⁷ in which they used a xenon washout technique in rats to measure blood flow at 1 hour and 30 days after ligation of vessels. Results demonstrated an 80% reduction in blood flow at 1 hour after ligation. However, 30 days later, blood flow returned to its pretreatment level. In our series, all patients showed normal testicular blood flow at the end of 4 weeks.

There is great debate as to which undescended testes require testicular artery transaction. As a general guideline, a testis within 2 cm of the internal ring can be brought down without vessel transaction, and beyond 4 cm, vessel transaction should be considered. Distances between 2 and 4 cm is a gray area. ¹ It had been suggested that the ability of abdominal testes to reach the contralateral inguinal ring suggests that primary orchiopexy can be performed. ⁸ We use 2.5 cm from the internal ring as the criteria for staged Fowler-Stephen orchiopexy.

The success rate by various researchers for the staged Fowler-Stephen procedure was reported in ranges from 60 to 100%. ⁷ In their own series, Dhanani et al. reported a 98% success rate. ⁸ Chang et al. ⁹ reported 85% for Fowler-Stephen staged orchiopexy. Francis and Mark ¹ reported a success rate of 87.9% with the staged Fowler-Stephen orchiopexy, while only 74.1% with the single-stage Fowler-Stephen procedure. In our series, we had achieved a 100% success rate with the staged Fowler-Stephen procedure.

The testicular vessels were either ligated by sutures or clipped in most of the series, but we used bipolar diathermy for testicular-vessel transaction, and we did not find any complications related to diathermy. This is the cost-effective method. In most of the reported series, the second stage was performed by the open method, but recently, there are reports in which both the stages of the Fowler-Stephen procedure were performed laparoscopically for high abdominal testis with good results.^10,11 In our series, we had done both stages laparoscopically.

Conclusions

Laparoscopy is the procedure of choice for the diagnosis of nonpalpable testes. In cases of high intra-abdominal testes, the staged Fowler-Stephen procedure should be the procedure of choice. This procedure yields a high success rate. Color Doppler ultrasonography is a very good method for evaluating the results. Transaction of vessels by bipolar diathermy is a very safe, cost-effective method. Laparoscopy for the second stage is the safe method, without any additional risk for the patient.