Objective To evaluate the usefulness of preoperative hormonal manipulation and the results of laparoscopic one-stage Fowler Stephens technique for high intra-abdominal testes.
Patients and Methods Eighty-five non-palpable testes in 74 children (1 – 11 years of age) were evaluated with regard to the management adopted. The site of the testes was localized by clinical examination, abdomino-pelvic ultrasound and laparo-scopy in all 74 children for an accurate diagnosis. In 42 children (Group I), pre-operative gonadotrophic hormonal treat-ment in a dose of 80 IU/kg body weight for six weeks was tried to increase the testicular vascularity. The remaining 32 children (Group II) were left without any hormonal manipulation. Laparoscopic one- stage Fowler Stephens technique was done in 22/42 children of Group I and in 10/32 children of Group II. Vanishing testes were encountered in 26/74 patients. They were subjected to laparoscopic excision of the end of the vas and the surrounding tissues in 10/42 cases of Group I and in 16/3

cases of Group II. Laparoscopic orchido-lysis and orchidopexy without inguinotomy as a one-stage procedure was performed in 10/42 cases of Group I and in 6/32 cases of Group II.
Results The success rate following the laparo-scopic one-stage Fowler Stephens proce-dure without preoperative gonadotrophine hormonal treatment was 80% (8/10 cases), while with additional hormonal treatment a success rate of 95.5% (21/22 cases) could be achieved representing a significant improvement (P>0.05).
Conclusion The one-stage laparoscopic Fowler Stephens technique for non-palpable undescended testes with pre-operative gonadotrophic hormonal treat-ment yields encouraging results in the pre-servation of high intra-abdominal testes. However, a larger group of children and a long-term follow up are needed for better evaluation.
Key Words undescended testes, one-stage Fowler Stephens technique, preoperative hormonal manipulation, laparoscopy

INTRODUCTION

In 1999, Radmayr et al. stated that a non-palpable testis had been the first indication for laparoscopy in urology1. Since then, this primarily diagnostic procedure has evolved to complete laparoscopic orchidopexy. Laparo-scopy is a useful and safe technique for an accurate diagnosis and may avoid additional intervention in treating non-palpable testes. Cortes et al. found that impalpable testes account for 20% of cases of undescended testes2. These testes can be intra-abdominal, intracanalicular, ectopic or absent. Moore et al. reported the use of the laparoscope for

The only choice for the treatment of high intra-abdominal testes is either vasal-based orchidopexy (Fowler Stephens technique) or microvascular transfer. In this study we tried to evaluate the results of the one-stage Fowler Stephens technique for high intra-abdominal testes using laparoscopy. Moreover, we tried to assess the usefulness of preoperative hormonal manipulation.

PATIENTS AND METHODS

This study was carried out between January 1996 and October 2001 over a period of 5 years at Al-Azhar University and health insurance hospitals in Egypt. It included 74 patients with non-palpable undescended testes selected from a group of 1028 patients with maldescended testes. The patients’ age rang-ed from 1 to 11 years. In 11 cases the non-palpable testes were bilateral resulting in a total number of 85 non-palpable testes. One patient had crossed testicular ectopia. All cases were evaluated clinically and by

Fig. 2: Rare case of transverse testicular ectopia on the right side after orchidolysis and surgical orchidopexy

In 26/74 cases (10/42 in Group I and 16/32 in Group II), laparoscopic exploration revealed obliteration of the deep inguinal ring and blind- ended vas (vanishing testes). These patients were subjected to laparoscopic excision of the end of the vas and surrounding tissues (Fig. 1).

We found in 16/74 cases that the non-palpable testes were located near the deep in-guinal ring and were associated with an open-ed deep inguinal ring and with a hernial sac, while the length of the testicular vessels was long enough to do laparoscopic orchidolysis and orchidopexy without division of the testi-cular vessels (Fig. 1). Five cases were bilateral, one of them had crossed testicular ectopia (Fig 2).

One-stage laparoscopic orchidopexy was performed in 10/42 children of Group I and in 6/32 cases of Group II. High impalpable testes were encountered in 32/74 children and 6 cases were bilateral. One-stage laparoscopic

laboratory examination as well as by abdo-mino-pelvic ultrasound in a trial to localize the site of the testis.

Preoperative gonadotrophine hormonal treatment in a dose of 80 IU/Kg body weight/ week for 6 weeks was tried in 42/74 children (Group I) to increase the testicular vascularity and open collaterals. The remaining 32/74 children (Group II) were left without hormonal treatment (Fig. 1).

Laparoscopy was used in 74 children for an accurate diagnosis and in treatment of 85 non-palpable testes.

vasal-based orchidopexy (Fowler Stephens technique) was applied in 22/42 children in Group I and in 10/32 cases in Group II. In all laparoscopic procedures, the testes were delivered through a scroto-peritoneal port (10 mm) and fixed in a dartos pouch (Fig.1).

Follow up using a brader orchimeter was done to detect the development of the testes. In addition, ultrasonic measurement of the testicular volume was done every 3 months.

A comparative study was done in 32/74 cases with 38 high impalpable testes. Laparo-scopic one-stage Fowler Stephens technique was performed in Group I (22 cases) and in Group II (10 cases) (Fig. 1).

RESULTS

In our study, impalpable testes were found in 74 out of 1028 children with maldescended testes. In 11 cases, the non-palpable testes were bilateral resulting in a total number of 85 testes (8.2%).

Successful laparoscopic one-stage orchido-lysis and orchidopexy without division of the testicular vessels and without inguinotomy was achieved in 16 children with a total of 21 testes, 10 cases in Group I and 6 cases in Group II.

One-stage laparoscopic Fowler Stephens technique was performed in 22/42 cases of Group I (28 testes) with a success rate of 95.5% (21/22 patients). In Group II, the suc-cess rate for laparoscopic one-stage Fowler Stephens technique without pre-operative hor-monal manipulation was 80% (8/10 patients).

The statistical analysis revealed a signify-cant difference between the results of treat-ment by laparoscopic one-stage Fowler Ste-phens technique with and without hormonal treatment. Without preoperative hormonal manipulation the success rate (viable, develop-ing testis along the follow-up course) was 80%, while with the use of preoperative hormonal treatment the success rate improved markedly rising to 95.5% (P> 0.05) (Table 1).

DISCUSSION

Laparoscopic examination of non-palpable testes has been considered the most effective,

rapid, accurate and least invasive procedure to localize impalpable testes and to make sure or preclude the location of the gonad3-5. In fact, the procedure can accurately determine the location of the gonad in a high percentage of patients approaching 95.3%6. Also the patency of the internal inguinal ring, determined laparo-scopically, is an accurate predictor of testicular salvageability7.
In our study, 74 of 1028 child-ren (7.2%) had non-palpable testes. Their age ranged from 1 to 11 years. The non-palpable testis was located on the right side in 36 and on the left in 38 patients. One case presented with crossed testicular ectopia (Fig.2).

The incidence of vanishing testes detected by laparoscopic exploration in boys with an intra-abdominal testis was reported in the literature to be ranging from 40% to 75%4,5 with 9.8% of the patients having intra-abdominal vanishing testes8. However, the incidence of identifying either blind-ending cord structures above the internal inguinal ring or intra-abdominal testes was reported to be around 50%1. The impalpable testis was absent in 77% of patients with a contralateral scrotal testis, and an associated inguinal hernia due to an open processus vaginalis was reported in 26% of cryptorchidism cases2.

In our study, laparoscopic exploration revealed obliteration of the deep inguinal ring and blind-ended vas (vanishing testis) in 26/74, (35%) cases of non-palpable testes.

In one series of cases of non-palpable testes, 64% had vascular pedicles long enough to reach the scrotum without dividing the testicular artery6. In another series 11% of the testes were located in the vicinity of the inguinal ring and were subjected to an imme-diate one-stage laparoscopic-assisted orchio-pexy without difficulty9. In our study, laparo-scopic orchidolysis and orchidopexy without

Staging the Fowler-Stephens orchiopexy with a preliminary ligation of the testicular vessels in situ followed by transection of the vessels and orchiopexy 6 months later may improve the success of this technique, since it allows a collateral arterial flow to develop with a minimal risk of arterial spasm5,14.

Laparoscopic orchidopexy was performed either as a two-stage Fowler-Stephens tech-nique or as a direct one-stage repair. In the two-stage Fowler-Stephens orchiopexy, the initial procedure was accomplished laparosco-pically by placing a clip on the testicular vessels; the second stage was performed 6 to 12 months later as an open operation. The preservation of the testicular blood supply is easier with laparotomy than with laparoscopy suggested by the well-developed collateral circulation.4,5,15 Once the testis trophism has been ascertained, the testis can be placed in the scrotum16. However, the second-stage Fowler-Stephens procedure or single-stage orchidopexy requires laparoscopic skills and may not necessarily provide a sufficient length to the testicular attachment.17 Testicular per-fusion could be revealed by flow Doppler sonography.2

The success rate of the Fowler-Stephens procedure was reported in the literature to be as high as 97%4,18. Some authors claim that it ranges only between 50% and 70% based on palpation. Nevertheless, it is considered now the most common method of treating high-positioned undescended testes.19

The incidence of impalpable testes after the complete Fowler-Stephens procedure or atro-phic testicles observed in the scrotal area was reported to be around 3.4%9,20, while the incidence of testicular atrophy after two-stage Fowler-Stephens operation was reported to be around 2.5%. Thus, the good results reported in most series have proven the laparoscopic management of non-palpable testes to be superior to the open technique regarding mor-bidity, complication rate and length of hospital stay9.

way for localizing the site of a non-palpable testis. Obliteration of the deep ring indicates a vanishing testis. The wider the opening of the deep ring, the more developed is the testis and the better is the chance for a one-stage orchio-pexy. The one stage laparoscopic Fowler Stephens technique for non-palpable undes-cended testes with preoperative gonado-trophic hormonal
treatment has shown the best results for preserving the high
intra-abdominal testes. The use of a scroto-peritoneal port has facilitated the extraction of the dissected testis under vision, and in the shortest pathway.

REFERENCES

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8. Cisek LJ, Peters CA, Atala A, Bauer SB, Diamond DB, Retik AB. Current findings in diagnostic lapa-roscopic evaluation of the nonpalpable testis. J Urol 1998, 160:1145-1149.

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division of the testicular vessels was suc-cessful in 16/74 (21.6%) testes of the non-palpable group, where they were associated with an opened deep inguinal ring and a hernial sac, and found near the deep inguinal ring. The length of the testicular vessels was long enough. The opening of the deep inguinal ring indicated that the testis was formed and present elsewhere in the abdominal cavity, while obliteration of the deep inguinal ring, in addition to attenuation of the testicular vessels indicated that the testis was atrophic (vanish-ing). Clinically, this can be suspected, when the testes in unilateral cases are larger than considered normal in the age group in question due to compensatory hypertrophy. We have noticed that, the wider the opening of the deep ring the more developed are the testes, and the better are the chances for a one-stage descent without division of the testicular vessels. An early choice of the type of the technique to be applied in cases of non-palpable testes is mandatory to avoid injury of the collateral vessels between the artery of the vas and the testicular vessels.

Transverse testicular ectopia (TTE) is evidently a rare anomaly. It was Chen et al. who reported the first case of TTE described in Taiwan10. In our study, the single case of right TTE was encountered in the group of imme-diate laparoscopic surgical correction without division of testicular vessels. Both testes were found on the left side.

It is agreed that the preferred management of intra-abdominal testes with short vessels may be transection of the spermatic vessels rather than a planned two-stage inguinal technique, where 80.9% success was reported in re-orchiopexy11. Testicular vessel tran-section allows a one-stage orchiopexy for high undescended testes12. Jordan and Winslow reported no evidence of testicular loss or acute

Some authors advocated a medial displace-ment of the testicular vessels as an important principle for a successful operation of high undescended testis, involving the division of the fascia transversalis, but this was not favoured by other surgeons as it is more invasive21. Some authors suggested the use of a fourth "scroto-peritoneal" port to facilitate a complete laparoscopic orchiopexy, a step which is safe and easy to perform22. In our study we used the medial displacement of the testicular vessels in 38 cases, 12 by Prentis maneuver, and through scrotoperitoneal port no. 10 in 26 cases. The scroto-peritoneal port allowed a meticulous extraction of the dissect-ed testes under vision, without much trauma to the testis and without the need of inguinotomy.

The literature poses the question whether or not to divide the testicular artery in order to bring the testicle into the scrotum. The results confirm that preservation of the testicular col-laterals will often allow the testicle to survive in a normal scrotal location and the need for testicular autotransplantation with microvas-cular anastomosis should rarely arise.6

In our study the preoperative gonadotrophic hormonal treatment was noted to increase the size and number of the posterior peritoneal collateral vessels, in addition to its role for elongation of the testicular vessels, thus obviating the need for division of testicular vessels. These results were found comparable to those reported by Myles and Holmes23, who added that 13% would descend to the inguinal canal and 47% would become close to the deep ring. They also noted a significant im-provement of the success rate following pre-operative administration of gonadotrophic hor-mones before Fowler Stephens’s technique, performed either in one stage or in two stages. The success rate of the laparoscopic one-stage Fowler Stephen’s technique with pre-operative hormonal manipulation is nearly equal or better than that of the microvascular technique. It reaches as high as 95%24. To our knowledge, only one case of a testicle with venous infarction following microsurgery carried out on 7 intra-abdominal testicles has been reported in the literature25. Our study has confirmed that the results of the one-stage Fowler Stephens technique with preoperative hormonal treatment is better than the reported results of the microvascular technique (95.5%).

In conclusion, we have found in our study that laparoscopy is the most accurate practical

10. Chen KC, Chu CC, Chou TY. Transverse testicular ectopia: preoperative diagnosis by ultrasono-graphy. Pediatr Surg Int 2000, 16:77-79.

11. Livne PM, Savir A, Servadio C. Re-orchiopexy: advantages and disadvantages. Eur Urol 1990, 18:137-139.

12. Bachy B, Bawab F, Mitrofanoff P, Borde J. Undescended testicles: 2-stage reduction of Fowler’s technique. A propos of 2 comparative series. Chir Pediatr 1987, 28:310-313.

13. Jordan GH, Winslow BH. Laparoscopic single stage and staged orchiopexy. J Urol 1994, 152: 1249-1252.

14. Bloom DA. Two-step orchiopexy with pelviscopic clip libation of the spermatic vessels. J Urol 1991, 145:1030-1033.

15. Andze G, Homsy Y, Laberge I, Desjardins JG, Kiruluta HG. The role of therapeutic laparoscopy in the surgical treatment of intra-abdominal testes in children. Chir Pediatr 1990, 31:299-302.

16. Montanari E, Trincheri A, Zanetti G et al. Andro-logical laparoscopy. Ann Urol (Paris), 29:106-112.

17. Humphrey GM, Najmaldin AS, Thomas DF. Laparoscopy in the management of the impalpable undescended testis. Br J Surg 1998, 85:983-985.

18. El-Gohary MA. The role of laparoscopy in the management of impalpable testes. Pediatr Surg Int 1997, 12:463-465.

19. Huang EJ, Liu HW, Shen KL, Ma CP. Testicular morphological and biochemical changes after Fowler-Stephens orchiopexy in rats. J Formos Med Assoc 1990, 89:829-834.

20. Teyschl O, Tuma J. Laparoscopy in the diagnosis, classification and therapy of nonpalpable undes-cended testes. Rozhl Chir 2000, 79:557-560.

21. Ayub K, Williams MP. A simple alternative tech-nique of orchiopexy for high undescended testis. Ann R Coll Surg Engl 1998, 80:69-71.

22. Jawad AJ. Scroto-peritoneal port for laparoscopic orchidopexy. Pediatr Surg Int 13:460-461.

23. Myles LM, Holmes SJ. Human chorionic gonado-trophin and laparoscopy in treatment of impalpable testes. J Pediatr Surg 1994, 29:551-552.

24. Bukowski TP, Wacksman J, Billmire DA, Sheldon DA. Testicular autotransplantation for the intra-abdominal testis. Microsurgery 1995, 16:290-295.

25. Wacksman J, Dinner M, Handler M. Results of testicular autotransplantation using the micro-vascular technique: experience with 8 intra-abdominal testes. J Urol 1982, 128:1319-1321.