Of the nonpalpable testes (NPT), 15–34.1% are inside the abdominal cavity and ∼29–44.8% of those testicles are considered ‘high.’ They are poorly identified, and they are not amenable for management by simple laparoscopic orchiopexy 1,2. Laparoscopy for NPT was accepted for the diagnosis of the disorder to confirm their absence and to detect their location, particularly in the absence of reliable imaging studies 3–5.
Laparoscopic or open exploration techniques are the conventional initial approaches to NPT as proposed by the American Urological Association guidelines 6. The shortness of testicular vessels may play a role in making the surgical approach in intra-abdominal testis (IAT) a technical challenge and can hinder the dragging of the testicles to the scrotum 7. Laparoscopic Fowler–Stephens orchidopexy (LFSO) entails the division of the testicular vasculature to gain adequate length, thus allowing for testis relocation in the ipsilateral hemiscrotum. Testicular viability depends on collateral circulation from the vessels of inguinal canal, hypertrophy of the artery of the vas, and gubernacular vessels 8,9.
It was only a matter of time before therapeutic laparoscopic orchidopexy became popular with the invention of the clip applicator for the stage I Fowler–Stephen procedure 10,11.
AbouZeid et al.12 reported the safety of monopolar diathermy and demonstrated no histological differences when using clip ligation in the first stage of the LFSO. We suppose that bipolar diathermy is safer than monopolar diathermy, reporting our experience with two-stage LFSO, and determining the safety and outcome of bipolar diathermy in vascular ligation.
Patients and methods
We conducted a retrospective study after approval from the Internal Review Board. All patients who had direct laparoscopic orchidopexy were excluded from analysis. We included all boys with IAT who underwent two-stage LFSO in the period from July 2010 to July 2017.
We reported demographic data, side, location, operative findings, and surgical complications. All the patients were examined again after the induction of anesthesia to ensure that the testis was nonpalpable. If the testis was nonpalpable, we proceeded to diagnostic laparoscopy. The urinary bladder was emptied by catheterization before the insertion of the trocars. The telescope was placed through a 5-mm open technique transumbilical port. When laparoscopy revealed an IAT, two 3-mm (if bipolar coagulation of the testicular vessels) or two 5-mm (if clipping of the vessels) working ports were placed under camera control in the midclavicular line at or just below the level of the umbilicus lateral to the rectus abdominis. The abdomen was inspected for the following structures: testicular vessels, vas deferens, testis, and internal inguinal ring.
We tried to test the mobility of the testis by pulling it toward the contralateral internal inguinal ring. All cases where the testis was at the ring or within 1 cm of the ring underwent vessel-intact laparoscopic orchidopexy, without division of the testicular vessels, whereas those testes which were 1 cm or more above the ring underwent a two-staged LFSO.
At the first stage, the spermatic vessels are mobilized minimally and doubly clipped proximally and distally at a site away from the testes using a 5-mm clip applicator or 3-mm bipolar diathermy, depending on the availability of each. With the bipolar diathermy, we induced coagulation in the same places where we put the clips. Then, we cut in between (Fig. 1).
The second stage of the surgery was scheduled ∼4–6 months after the first stage. Here again, the same three-trocar approach was used using 3-mm instrument. The testis was again examined for size and consistency, and the vas was also examined for adequate neovascularization. The gubernaculum was pulled and divided far from testis only after visualizing the entry of the vas into the testicular pole. The testis and the vas with their peritoneal coverings were subsequently mobilized, preserving a broad peritoneal flap, based inferiorly along the vas. Once we could reach the opposite internal inguinal ring along with the testicles, it usually means that we have gained enough length to allow for an easy descent. Then, an ipsilateral subdartos pouch was created in a standard fashion and a long hemostat was passed through the scrotal incision to the peritoneal cavity on top of the pubic symphysis medial to the epigastric vessels and lateral to the urinary bladder wall. Then, it opened to create a path for the testis. The testis was grasped by the hemostat under direct visualization then pulled down into the subdartos scrotal pouch avoiding any twists or kinks. The patients were discharged the next day in both the stages on analgesics.
Follow-up was performed at 1, 3, 6, and 12 months postoperatively. During the follow-up, the testicular volume, consistency, and position in the scrotal sac were documented by clinical examination. Atrophy was diagnosed when the testis became fibrotic and hard with no detectable testicular tissue or blood flow on duplex ultrasound.
Data were analyzed using statistical package for the social sciences software (Released 2009, PASW Statistics for Windows, Version 18.0.; SPSS Inc., Chicago, Illinois, USA). We calculated the relative risk (RR), as well as odds ratio (OR) and stated the level of statistical significance at P value less than 0.005, to prove if a null hypothesis subedited before the establishment of the research is to be rejected or accepted. It also enables the detection of any statistically remarkable findings. We also calculated the confidence intervals (CI) to provide all information about the range in which the real values lie, with a definite degree of probability, and also the direction as well as the strength of the demonstrated effect. This allowed us to draw conclusions about the statistical reasonability and clinical significance of the study.
The study included 31 boys with 39 IAT who underwent two-stage LFSO between July 2010 and July 2017. Their ages ranged from 6 to 96 months (mean, 32.18 months) at the first stage and 12 to 108 months (mean, 42.25 months) at the second stage.
Of all 39 testes, 13 were unilateral with normal contralateral sides, eight were unilateral (managed by two-stage LFSO) with contralateral intracanalicular testis (managed by inguinal orchidopexy), and 18 were bilateral IAT (one was vanishing so nothing was done, whereas two-stage LFSO was done for the other 17 testes) (Fig. 2).
Bladder perforation was recognized intraoperatively in one patient. All patients were admitted for 1 day postoperatively. Follow-up ranged from 1 to 72 months, with an average of 16 months. We found two methods of dividing the testicular vessels in first stage of the LFSO, which was clipping by metallic clips in 25 testes (20 patients, with mean age of 30.15 months), whereas bipolar diathermy was used in 14 testes (11 patients, with mean age of 35.58 months).
Preoperative volume was maintained in 38 (97.43%) testes. Moreover, 37 (94.87%) testes were at the intrascrotal level except two testes. There was an overall success rate of 92.30 and failure of 3/39 (7.69%). When we analyzed the outcome according to the method of dividing the testicular vessels and found one testicular atrophy in intrascrotal position (which was confirmed by color cobbler ultrasonography) in the clipping group (1/25, 4%), with RR of 1.7308, 95% CI of 0.0751–39.8654, and P value of 0.7318, whereas the OR was 1.7755, 95% CI of 0.0678–46.5242, and P value of 0.7304.
Two testicles were outside the scrotum with good size in the bipolar diathermy group (2/14, 14.28%), which was managed by redo inguinal orchidopexy, with RR of 0.1154, 95% CI of 0.0059–2.2472, and P value of 0.1540, whereas the OR was 0.0980, 95% CI of 0.0044–2.2002, and P value of 0.1434 (Table 1).
Of the NPT, 15–34.1% are inside the abdominal cavity and ∼29–44.8% of those testicles are considered ‘high.’ They were poorly identified and cannot be managed by simple laparoscopic orchiopexy 1,2. We found that left-side IAT was more prevalent than right-side IAT. Associated comorbidities were more likely among bilateral IAT, such as prune belly syndrome, cardiac anomalies, and genitourinary anomalies. This was identical to the reported findings 8,9.
The surgical approach for IAT is technically challenging because testicular vessels may be too short to allow the testicles to be dragged to the scrotum. In 1959, Fowler and Stephens 13 proposed a new technique, and their idea was based on dividing the testicular vessels to gain adequate length while getting the blood supply from collateral circulation, the ‘artery of the vas.’ In 1984, Ransley et al. 14 modified this technique and performed it in two stages.
For the past 30 years, laparoscopy has been considered as the gold standard procedure for the assessment and management of boys with NPT 15. Primary orchiopexy is preferred when the length of intra-abdominal testicular vessels is adequate. However, the presence of short intra-abdominal testicular vessels is a real challenge 16–20. Bagga and colleagues noted that the length of the vas is associated with a higher testicular position from the internal ring. This, in turn, will facilitate the success of the outcome of the LFSO procedure. Consequently, high testicular position is favored for successful scrotal placement in LFSO procedures 21.
The clipping of the testicular vessels in stage I has no effect on the size and vascularity of the testis in stage II, as long as adequate time has elapsed before the second stage, so that collateral supply can sufficiently take over 10,12,21–23. Law et al. 22 reported a 95% success rate in laparoscopically performed first-stage surgery, whereas the second stage was performed via an open approach. Our success rate with the two-stage LFSO was 92.3%, which was the same as that reported by many recent series (94–95%) 24–26.
The greatest risk for all forms of laparoscopic orchidopexy include relative or complete testicular atrophy and testicular ascent 1,8,9,27,28, which were found in three testes in our study (one atrophy and two assents in our study). The operated testis was always significantly smaller compared with the normal testis but was well vascularized 27. Parents should be cautioned that nearly a quarter of IAT are smaller than the contralateral descended testes before surgery, for them to understand that not all size discrepancies may be due to the surgery 9.
Although clipping remained the standard method for performing LFSO in most centers, few authors thought of changing this method. In their report, Law et al.22 explored techniques other than clipping for cosmetic and financial reasons, and they progressed to ligate the vessels with a free silk suture tied extracorporeally.
AbouZeid and colleagues reported that changing the method of transecting the testicular vessels did not alter the outcome (neither histologically nor macroscopically). They found no histologic differences between seven patients who underwent monopolar diathermy for ligation and 13 patients who underwent traditional clip ligation 12. The harmonic scalpel can be used as another alternative method, but it is not available in small sizes (3 mm) and it is expensive. We used a 3-mm bipolar diathermy to achieve the same effects as the harmonic scalpel with a smaller size. When we used the bipolar diathermy, two testicles were extrascrotal with good size (2/14, 14.28%), which were managed by redo inguinal orchidopexy. We did not find any testicular atrophy. As opposed to the case in the clipping group, there was one testicular atrophy in the intrascrotal position (which was confirmed by color cobbler ultrasonography). We did not find studies evaluating the use of 3-mm bipolar diathermy as an alternative in dividing the testicular blood vessels in the first stage of the LFSO. We found that bipolar diathermy can be a simple and safe alternative to clipping in LFSO and can be more suitable for younger patients. However, there was no significant difference in successful outcome rates between the clipping and bipolar methods used in testicular vascular division in two-stage LFSO. This observation reflects postprocedure testicular size (atrophy) and postprocedure testicular site (intrascrotal or extrascrotal). However, in terms of RR and OR, the bipolar modality showed superiority in postprocedure testicular size (atrophy) over the clipping method. In contrast, the clipping method showed excellence in postprocedure testicular site (intrascrotal or extrascrotal) over the bipolar method.
The incidence of complications associated with laparoscopy in boys with NPT is rare. A recent study reported only one (0.2%) complication of 412 boys who had surgery for this pathology 29. Bladder injury during creation of a transperitoneal tunnel for the testis medial to the medial umbilical ligament occurs in up to 3% of cases and may not always cause hematuria or be recognized intraoperatively 30. We had one case of bladder injury recognized intraoperatively and was managed by insertion of urethral catheter for 10 days.
The current study was limited by its small sample size, the low power of the study, and the short duration of follow-up. Longer periods of follow-up and larger series will be needed to further validate the two-stage LFSO using bipolar diathermy for dividing testicular vessels.
Two-stage LFSO is safe and feasible. Bipolar diathermy (3 mm) could be used as an alternative method of dividing testicular vessels.
Conflicts of interest
There are no conflicts of interest.
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