THE IRAQI POSTGRADUATE

LAPAROSCOPIC MEDICAL JOURNAL

ORCHIDOPEXY VOL.8, NO.3, 2009

Laparoscopic Orchidopexy: Current Surgical Opinion.

Saad Dakhil F
ABSTRACT:
BACKGROUND:
With the use of diagnostic laparoscopy widely accepted in the setting of the non palpable testes,
now day's laparoscopic orchidopexy is an efficient and logical alternative to open orchidopexy.
OBJECTIVE:
We reviewed the efficacy of laparoscopy for diagnosing the intra abdominal testes.
Also we review the efficacy of primary orchidopexy, one stage and two stages laparoscopic
orchidopexy for the management of the intra abdominal testes.
PATIENTS AND METHODS:
Prospective Study includes 20 boys with 23 impalpable testes (3 patients were bilateral). underwent
laparoscopy for a non palpable testes at urosurgical department between June 2007 and February
2009.
Their age ranged between 3years and 7 years. Eight patients had primary laparoscopic orchidopaxy
without division of spermatic vessels .twelve patients had one stage Fowler Stephen method, and
Two patients had two stages Fowler Stephen method.
RESULTS:
During diagnostic laparoscopy: Bilateral abdominal testes was found in 3 patients, Left intra
abdominal tests was found in 10 patients, while right intra abdominal testes was found in 7
patients .With the use of laparoscopic orchidopexy : twenty two testes were brought down to the
scrotum: sixteen testes (72.7%) brought down to the normal scrotal site, while six testes (27.2 %)
were placed at high scrotal position. Orchidectomy was done for one (4.3%) intra abdominal testis.
CONCLUSION:
Laparoscopy is extremely effective for diagnosis and treatment of patients with non palpable testes.
Laparoscopic orchidopexy is the logic extension of diagnostic laparoscopy for intra abdominal
testes.
KEY WORDS: laparoscopic orchidopexy, undescended testis.

INTRODUCTION:
Laparoscopy has attained its greatest degree of There are three distinct possible findings,and
general acceptance, both diagnostically and courses of action,when laparoscopy is used to
therapeutically, in the realm of pediatric urology assess a non palpable testis. Findings include :
for the management of a non palpable testis. Since Blind-ending vessels above the internal ring
the earliest reported cases over a quarter of a (vanishing testis), Cord structures entering the
century ago, there are now several thousand cases internal ring (viable intracanalicular testis versus
in the literature documenting the impact that an intracanalicular or scrotal atrophic testis),and
laparoscopy has made in the management of a non Intra-abdominal testis (4).
palpable testis (1). An intra-abdominal testis is usually found within 1
The principles of surgery for a non palpable testis to 2 cm of the internal ring, which is usually patent
are equal to, if not enhanced by a laparoscopic and primary orchidopexy without division of the
approach; exposure, lighting, and magnification spermatic vessels can be performed (5).
remain critical to this pediatric procedure (2). If the testis is immobile and beyond 2.5 cm from
However, the advantages of laparoscopy over a the internal ring, it may be prudent to perform a
conventional “open” surgical approach to a non staged orchidopexy consisting of clipping the
palpable testis include accurate anatomic internal spermatic vessels and returning 6 months
assessment of testicular position and viability and, later to mobilize the testis with collateral vessels
when necessary, optimal accessibility to the crux of and the deferential artery (6).
the surgical problem (3). Laparoscopic Fowler-Stephens Orchidopexy
The spermatic vessels are usually the length-
College of Medicine, Baghdad University limiting factor in accomplishing a tension-free

THE IRAQI POSTGRADUATE MEDICAL JOURNAL232 VOL.8, NO.3, 2009

 LAPAROSCOPIC ORCHIDOPEXY

orchidopexy. The decision whether to divide these Group A: Where the testis located within 2 cm
vessels needs to be made early in the course of from the internal inguinal ring.
laparoscopic orchidopexy (7). There are no absolute Group B: Where the testis located between 2-4 cm
criteria for when transection needs to be from the internal inguinal ring.
performed, but the obvious maxim is the further the Group C: Where the testis located more than 4 cm
distance that the testis is from the scrotum, the from the internal inguinal ring.
greater the likelihood that vessel transection will be Eight patients (with group A) had primary
necessary (8). As a general guideline, a testis within laparoscopic orchidopaxy without division of
2 cm of the internal ring can be brought down spermatic vessels:
without vessel transaction, between 2 and 4 cm is a The testis was mobilized by division of
gray area, and beyond 4 cm vessel transaction gubernaculums and making an incision on the
needs to be seriously considered before any posterior peritoneum lateral to testicular vessels.
peritoneal dissection (4). The testicular vessels and the vasdeferens were
Keeping in mind that staged orchidopexy carries mobilized for a length of 6-8 cm using blunt
risk rate with regard to testicular atrophy (9). dissection.
However, if a single-stage Fowler-Stephens An adequately mobilized testis is the one that reach
orchidopexy is the intended or possible procedure, the opposite internal ring without tension, and there
the peritoneum between the spermatic vessels and are no limiting spermatic vessels.
the vas diference needs to be carefully preserved to Twelve patients (All patients with group B and
prevent disruption of the collateral vasculature (10). four patients with group A) had one stage fowler
Vessel transaction may not be as necessary in Stephen procedure because, the presence of
children younger than 1 year because the critical limiting spermatic vessels after complete
distance of the testis to the scrotum is not dissection, The testes managed by laparoscopic
significantly more than that for an intracanalicular mobilization followed by laparoscopic vessel
testis (8). clipping , transaction and orchidopexy in one
PATIENTS AND METHODS : stage,
During the period between June 2007 and February Two patients( with group C) had been managed by
2009, We have performed laparoscopy on 20 boys two stages Fowler Stephen procedure .The first
with 23 impalpable testes (3 cases were bilateral), stage include clipping and transaction the
at urosurgical department, surgical specialties spermatic vessels and meticulous mobilization of
hospital in medical city. the testis near the internal inguinal ring, the second
Their age ranged between 3years and 7 years. stage performed 6 months later to enhance
All operations were performed under general formation of collateral vessels and testes mobilized
anesthesia. to the scrotum by open technique.
All patients (scrotal and inguinal regions) were Seven testes were brought down through a new
examined under general anesthesia. opening created in the anterior rectus sheath medial
Laparoscopy was performed through a 10mm infra to inferior epigasteric vessels (Closed internal
umbilical port for 0 degree telescope and two iliac inguinal ring); the other fifteen testes were brought
fossa ports of 5 mm size for the operative down through the patent inguinal canal. All testes
instruments. were placed in subdartos pouchs.
The patient was positioned head down with a right Transfer of the testis into the scrotum has been
or left tilt depending on the side being operated done by making small scrotal incision and passing
upon. a curved hemostat from the subdartos pouch over
A Folly's catheter was introduced into the urinary the symphysis pubis into the peritoneal cavity
bladder at the initiation of the procedure and was where the laparoscope can guide its path medial to
removed at night of surgery. the obliterated umbilical artery ,The testis then
Pneumoperitonum was created using a Veress grasped and placed into subdartos pouch, an
needle, and Laproscopy was performed at 8-10 mm external nylon fixation button is useful in
pressure. maintaining testicular position securely in the
Diagnostic Laparoscopy was done first, and scrotum when tension is present.
assessment of the testes location, size, and One testis located in higher location (group C) was
proximity to the internal inguinal ring. atrophied and was removed laparoscopically
We classified the laparoscopic findings according ( laparoscopic orchidectomy):
to the testis location into three groups:

THE IRAQI POSTGRADUATE MEDICAL JOURNAL 233 VOL.8, NO.3, 2009

 LAPAROSCOPIC ORCHIDOPEXY

By clipping of the spermatic vessels and vas The operating time for laparoscopic procedures
difference and testis extraction through 10 mm iliac ranged between 45 minutes to 104 minutes.
fossa port (which replace the already inserted 5 All patients required analgesia in the post operative
mm iliac fossa port). period.
Most patients were fit to go home the next day.

A-Laparoscopic view of intra abdominal testis.

B-Laparoscopic dissection of the spermatic vessels.

RESULTS:
We have performed laparoscopy on 20 boys with Bilateral abdominal testes was found in 3 patients,
23 impalpable testes. Their age ranged between Left intra abdominal tests was found in 10 patients,
3years and 7 years. while right intraabdominal testes was found in 7
patients.(Table 1).
Table 1: Break-up of patients

3 years 3
4 years 10
ِAGE 5 years 7
6 years 2
7 years 1
Total No. 23
BILATERAL 3
SIDE LEFT 10
RIGHT 7
Total No. 23
The laparoscopic findings during diagnostic laparoscopy was mentioned on (Table 2).

THE IRAQI POSTGRADUATE MEDICAL JOURNAL 234 VOL.8, NO.3, 2009

 LAPAROSCOPIC ORCHIDOPEXY

Table 2: Laparoscopic finding

Testis location Group No. %

A
ِAdj.to int. ing .ring 12 52.1

2-4cm from the int. ing. Ring. B 8 34.7

More than 4 cm from the int. ing. C 13.2

3
Ring.
total 100
23

Ten boys had left empty scrotum and 7 had right Two patients with high intra abdominal testes
empty scrotum, while the other 3 had bilateral (group C) were managed by two stages Fowler
empty scrotal sacs. Stephen procedure.
Eight patients(group A) had primary laparoscopic One testis located in higher location (group C) was
orchiopaxy without division of spermatic vessels . found to be atrophied and was removed
Twelve patients (group B and four patients of laparoscopically ( laparoscopic orchidectomy).
group A) had one stage Fowler Stephen procedure. (Table 3).

Table 3: Types of Surgical procedures

Type of Procedure No. Of Patients

%
Primary Orchidopexy 8
34.8
One stage Fowler
12 52.2
Stephen method.

Two stages Fowler

2 8.7
Stephen method.

Orchidectomy 1
4.3
Total 23
100

Of the 22 testes brought down to the scrotum 16 site, 6 (27.2%) are at high scrotal position. (Table
testes (72.7%) brought down to the normal scrotal 4).

Table 4: Percentage of testicles brought down to the scrotum

Type of the procedure No. of the testicles No. of the testicles brought down to
operated the scrotum %
Primary orchidopexy 8 7 87.5%

one stage Fowler-Stephens 12 8 66.6 %

procedure
Two stage Fowler-Stephens 2 1 50%
procedure

Total 22 16 72.7%

THE IRAQI POSTGRADUATE MEDICAL JOURNAL 235 VOL.8, NO.3, 2009

 LAPAROSCOPIC ORCHIDOPEXY

The complications encountered with the Stephens procedure had decrease vascularity and
laparoscopic orchiopaxy were listed on (table 4). testis size (testicular atrophy).
On Doppler study was performed one month post Difficult dissection was observed in one patient
operatively, two patients with one stage Fowler- with two stages Fowler-Stephens procedure
(operative time about two hours) because of
fibrosis.

Table 4: Complications with the laparoscopic orchidopaxy

Complications No. % Management

Port infection 1 4.3 Local dressing and antibiotic treatment

Gaseous swelling of the scrotum. 1 4.3 Resolved spontaneously within 48 hours.

Prolonged illus for 24-36 hours. 2 8.6 Resolved spontaneously
Testicular atrophy (one stage Fowler-Stephens 2 8.6 Follow up
procedure).
Difficult dissection 1 4.3 Meticulous dissection
(Two stages Fowler-Stephens procedure).

DISCUSSION :
Laparoscopic orchidopexy is now standard in the groups depend on the distance of the abdominal
urologists' armamentarium of management for an testis from the internal inguinal ring, and we
intra-abdominal testis. performed eight (66.6%)primary laparoscopic
A laparoscopic approach in the management of an orchidopaxy on group A .Other testes had not been
intra-abdominal undescended testis has advantages brought to the scrotum with out clipping and
over open orchidopexy performed through either transaction of the spermatic vessels, for whom, we
an extended inguinal incision or a high inguinal performed one stage Fowler-Stephens orchidopexy
incision (11). Laparoscopy accurately assesses the for the testes located up to 4 cm from the internal
presence, absence, viability, and entire anatomy of inguinal ring to avoid the morbidity of the second
an intra-abdominal testis. Success in testicular procedure. Testis located more than 4 cm from the
mobilization may require complete and proximal internal inguinal ring had not been brought to the
dissection of the spermatic vessels and redirecting scrotum with out staged procedure.
the line of “descent” to the shortest distance to the Success rates of laparoscopic orchidopexy were
scrotum. comparable to the published results for
Laparoscopic orchidopexy allows accessibility to laparoscopic orchidopexy and are based on
the entire course of the spermatic vessels to their postoperative testicular position and viability (13).
origin, usually the limiting factor in tension-free In present study we successfully replaced 16
mobilization of an intra-abdominal testis. testicles (72.7%) to their normal lower scrotal
Dissection close to the origin of the spermatic positions while other six testicles (27.2%) were
vessels is possible because the surgeon's range of placed in higher scrotal position. Success rates
motion with laparoscopic instrumentation extends were dependent on the nature of surgical method
across the entire abdominal cavity. Magnification (87.5%) for “primary” laparoscopic orchidopexy,
of these delicate vessels aids in dissection and (66.6 % ) for one-stage Fowler-Stephens
preservation of the main and collateral blood orchidopexy, (50%) for two-stage Fowler-Stephens
supply. Primary laparoscopic orchidopexy orchidopexy), with an overall atrophy rate of
(without division of the spermatic vessels) is the 8.4%. Although testicular atrophy is a well-
procedure of choice for intra abdominal testis recognized complication of orchidopexy, especially
located adjacent or within 2 cm from the internal for an intra-abdominal testis, it has been more apt
inguinal ring because the preservation of the to occur in patients who have undergone previous
spermatic vessels. (12). surgery, presumably because of dissection around
We classify the laparoscopic findings into three the vas deferens. Atrophy rates were found to be

THE IRAQI POSTGRADUATE MEDICAL JOURNAL 236 VOL.8, NO.3, 2009

 LAPAROSCOPIC ORCHIDOPEXY

highest in the single-stage Fowler Stephens 4. Takahashi,Abdallah A, Abdel moneim A,Gad

orchidopexy(16.6%). In one study by ( Baker et El-MoulaM,El-Anany F: Laparoscopy for
al ), Success rates were (97.2% for “primary” impalpable testis: classification based
laparoscopic orchidopexy, 74.1% for one-stage management - Surg. Endosc.2007;21,449-5.
Fowler-Stephens orchidopexy, 87.9% for two-stage 5. Castilho L N. Laproscopy for non palpable
Fowler-Stephens orchidopexy), with an overall testis :how to interpret the endoscopic
atrophy rate of 6.1%. Atrophy rates were found to findings.J Urol 1995;154,1148-1152.
be highest in the single-stage Fowler-Stephens 6. Yucel,Wilcox D,Harrison C,Ziada A ;Decision
orchidopexy at 22%, whereas atrophy occurred in making during laparoscopic orchiopexy for
only 2% of testes after a straightforward intra-abdominalt abdominal testes near internal
laparoscopic orchidopexy (14). ring.J Urol 2007;178,1447-50.
(Chang et al ) reported a large single-group 7. Linndgren BW,Franco I,Blick S,levitt
experience with similar success rates for all SB,Brock WA,Friedman SC,Reda EF.;
laparoscopic techniques of orchidopexy, Laparoscopic Fowler-Stephens orchiopexy for
specifically, an overall 85% success rate for one- or the high abdominal testis .J urol 1999;162,990-
two-stage Fowler-Stephens procedures with a 4% 3.
failure rate as a result of atrophy (15). 8. Esposito C,Garipoli V: The value of two-step
The results of this study represent the initial Iraqi laparoscopic Fowler-Stephens orchiopexy for
experience with laparoscopic orchidopaxy and intra-abdominal testes J Urol.1997;158,1952-
actually it will be more promising in future with 5.
the improvement of our experience with such 9. Lane S palmer,Jonathan D Kaye: Single
laparoscopic techniques. setting bilateral laparoscopic orchiopexy for
CONCLUSION: bilateral intra-abdominal testicles, J Urol.
1-Laparoscopic is extremely effective for 2008;180,1795-9.
diagnosing and treating patients with non palpable 10. Canavase F,Cortese MO,Gennari F,etal.
testis. Nonpalpable testis :Orchiopexy at single stage.
2-Laparoscopic orchidopexy is the logic extension Eur. J Pediatr. Surg. 1995;5,104-105.
of diagnostic laparoscopy for intra abdominal 11. Chui CH, Jacobsen AS. Laparoscopy in the
testes. evaluation of non palpable testes. Singapore
3-Primary laparoscopic orchidopexy (without Med J 2000;41,206-8.
division of the spermatic vessels) is the procedure 12. Esposito C,Vallone G,Settimi A ,et al :
of choice for intra abdominal testis located adjacent Laparoscopic orchiopaxy without division of
or within 2 cm from the internal inguinal ring. the spermatic vessels :can it be considered the
4-For high intra abdominal testes in wih vessel procedure of choice in cases of intra-
length prevents the testis from reaching the abdominal testis ? Surg. Endosc. 2000;
scrotum, Fowler-Stephens procedure (one stage or 14,658-660.
two stage) can be used. 13. Baker et al., 2001. Baker LA, Docimo
REFERENCES: SG, Surer I, et al: A multi-institutional
1. Kirsch AJ,Escala J,Duckett Jw,et al .Surgical analysis of laparoscopic orchidopexy ,
management of nonpalpable testis :The BJU 2001; 87,484-489.
children Hospital of Philadelphia experience. J 14. Chang B ,Palmer LS,Franco L. : Laparoscopic
Urol 1998;159,1340-1344. Orchiopexy: A review of large clinical series.
2. Biswas A, Mukhopadhaya B. : Role of Br J Urol Int 2001;87,409-493.
diagnostic laparoscopy in impalpable testis .J 15. Chang et al., 2001. Chang B, Palmer
Indian Pediatric Surgery 2002;7,64-66. LS, Franco I: Laparoscopic orchidopexy: A
3. Franco I,Levitt SB,Reda EF,,Brock review of a large clinical series. Br J Urol
WA,Faiella L,Darby EF,Lindgren Bw: Int 2001; 87,490-493.
Laparoscopic orchiopexy: procedure of choice
for the non palpable testis? J Urol
1998 ;159,2132-5.

THE IRAQI POSTGRADUATE MEDICAL JOURNAL 237 VOL.8, NO.3, 2009