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Laparoscopy for the impalpable testes: Experience with 80 intra-abdominal testes
Journal of Pediatric Urology (2009) 5, 389e392
Laparoscopy for the impalpable testes: Experience with 80 intra-abdominal testes G.M. Hvistendahl*, E.U. Poulsen 1 Department of Urology, Aarhus University Hospital e Skejby, DK-8200 Aarhus N, Denmark Received 3 January 2009; accepted 6 April 2009 Available online 19 May 2009
KEYWORDS Laparoscopy; FowlereStephens orchidopexy; Two stage; Intra-abdominal testes
Abstract Objective: To evaluate two-stage laparoscopic FowlereStephens (FS) orchidopexy for intra-abdominal testes. Materials and methods: A retrospective analysis was performed of the clinical findings, interventions and outcomes in 111 boys undergoing laparoscopy for 132 impalpable testes. Results: The median age was 5.7 years (1.1e14.6 years). Twenty-seven testes were absent. Eighty testes were intra-abdominal, of which 10 were removed laparoscopically due to anatomical anomalies (4), short spermatic cord (5) or atresia (1). Twenty-five testes were located in the groin. Laparoscopic FS procedure was performed for 65 intra-abdominal testes: 60 two-stage operations and five where the testes were removed during FS second stage due to short vas or testicular atrophy. Outcome was successful in 80%. One-stage laparoscopic orchidopexy without vessel division was performed in five intra-abdominal testes with satisfactory results in three. In general, the success rate is higher in boys with bilateral intra-abdominal testes, probably due to younger age at operation. Conclusions: At our centre two-stage laparoscopic FowlereStephens orchidopexy for intraabdominal testes showed results comparable to most other studies, but less satisfactory than a couple of recent studies. The median age at referral was higher than recommended. Operation at an earlier age may further improve the results. ª 2009 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction Failure of one or both testes to descend into the scrotum affects about 3% of full-term newborns and up to 30% of preterm infants; two thirds of undescended testes will descend spontaneously within the first few months of life. By age 6 * Corresponding author. Tel.: þ45 8949 5566; fax: þ45 8949 6006. E-mail addresses: [email protected] (G.M. Hvistendahl), [email protected] (E.U. Poulsen). 1 Tel.: þ45 8949 5566; fax: þ45 8949 6006.
months the prevalence of undescended testes is 1e2% and unilateral cryptorchism accounts for about 85% of all cases [1]. Cryptorchidism is associated with infertility and testicular neoplasms. Cryptorchid boys have been shown to lack germ cells from age 15e18 months [2e4] and the lifetime risk of testicular neoplasia in maldescended testes is increased 5e10 fold [5,6]. To avoid ongoing testicular degenerative changes the latest recommendation is to perform surgery before the age of 12 months or upon diagnosis, if that occurs later [7,8]. Furthermore, prepubertal orchidopexy for cryptorchidism may lower the risk of testicular cancer [9].
1477-5131/$36 ª 2009 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2009.04.004
390
Materials and methods We retrospectively reviewed the records of boys who underwent a diagnostic laparoscopy for non-palpable testes at Aarhus University Hospital e Skejby between 2000 and 2006. A 5-mm port was placed through a sub-umbilical incision and the child was put into the Trendelenburg position to facilitate inspection of the pelvic region. If necessary, two accessory 5-mm instrument ports were inserted. When vas and testicular vessels entered the internal ring we performed an open exploration of the groin with a standard orchidopexy in cases with a normal testicle missed on palpation or an orchiectomy in cases with a testicular nubbin. In cases with no testicle, evidenced by blind-ending vas and vessels, the operation was terminated. The finding of a small and atrophic intra-abdominal testicle led to a laparoscopic orchiectomy. A few cases went through a one-stage laparoscopic orchidopexy if the vas and vessels had sufficient length. In the rest of the cases judged to be suitable for a two-stage laparoscopic FowlereStephens orchidopexy, the first stage with low clipping of the testicular vessels, without further dissection of the vessels or vas, was performed. Six months later the second stage took place using the same laparoscopic access as previously. The testicular vessels were divided and the testicle mobilized on its vasal pedicle flap. Via a scrotal port through a neohiatus medial to the medial umbilical ligament the testicle was brought to the scrotum and placed in a subdartos pouch. The child was discharged later the same day. In cases with bilateral intra-abdominal testes the contralateral procedure was performed 3 months later. The child was seen 3 months later in the out-patient clinic where location and size (atrophic or unchanged) of the testicle were registered.
(1.1e14.6 years) (Fig. 1). One hundred and seven testicles were either intra-abdominal (80) or absent (27) as evidenced by blind-ending vas and vessels. The surgical management of the intra-abdominal testis was laparoscopic orchidopexy without vessel division as a one-stage procedure (5); laparoscopic FowlereStephens orchidopexy (65); or laparoscopic orchiectomy in 10 cases with anatomical anomalies (4), short vas (5) or atresia (1) after clipping of the spermatic vessels (Table 1). Standard orchidopexy was performed in 13 of 25 cases with vas and vessels running to the inguinal canal, where we found a testicle missed on palpation and groin exploration/orchiectomy in 12 with blind-ending vessels or hypoplastic testis. A total of 10 patients (15%) were lost to follow up. In the group of laparoscopic FowlereStephens orchidopexies the testis was in a scrotal position and of normal size/ unchanged in 80%. Atrophy and displacement was found in 14% and 6% respectively with an age distribution as shown in Fig. 2. Comparison of unilateral and bilateral laparoscopic FowlereStephens procedures showed a success rate of 69% and 85% respectively (Fig. 3). Median age at the primary operation was 6.1 years (1.1e14.6 years) versus 4.8 years (1.3e13.5 years) in unilateral and bilateral cases. The group of laparoscopic orchidopexies without vessel diversion had a success rate of 60% (three out of five). Complications were few and minor: two port hernias which were re-operated and three conservatively managed scrotal haematomas.
Discussion Orchidopexy is a relatively minor operation. However, the preoperative position of the undescended testis seems to influence outcome since the success rate in canalicular testes is higher than in those located intra-abdominally [12,13]. There is no generally accepted management protocol regarding when and how to operate according to the position of the testis. Different centres tend to have their own strategy dependent on a ‘local’ classification, which makes it difficult to compare results. Some perform twostage operations on all intra-abdominal testes [12,14], 18 16 14 12
number
The undescended testes may be palpable or nonpalpable. Surgical therapy for the palpable undescended testis is orchidopexy through a transverse groin incision. When the testis is non-palpable, diagnostic laparoscopy will determine which surgical approach should be taken. If the laparoscopy reveals an intra-abdominal testis, several options are available depending on the exact location of the testicle, low or high intra-abdominal [10], and the length of the vas deferens. The operation may be performed laparoscopically or by laparotomy, either as a onestage procedure with (FowlereStephens orchidopexy) or without diversion of the spermatic vessels, or as a staged procedure with vessel diversion [11]. Recently laparoscopy has replaced many open procedures, because it is a minimally invasive procedure and seems to have fewer complications. However, it is important that the overall results are comparable to those achieved using other procedures. The aim of this study was to evaluate the two-stage laparoscopic FowlereStephens orchidopexy for intraabdominal testes.
G.M. Hvistendahl, E.U. Poulsen
10 8 6 4 2 0
Results A total of 111 boys presented with 132 non-palpable testes. At diagnostic laparoscopy the median age was 5.7 years
0
1
2
3
4
5
6
7
8
age
9
10 11 12 13 14 15 16
Figure 1 Age distribution at diagnostic laparoscopy for impalpable testis.
Laparoscopy for the impalpable testes
391 100
Table 1 Results of diagnostic laparoscopy in boys with non-palpable testes, and treatment followed. No. of patients (%) (100) (61) (20)
80
60
%
Laparoscopic findings Non-palpable testis 132 Intra-abdominal testis 80 Intra-abdominal vanishing testis 27 Procedure Laparoscopic FowlereStephen 65 Laparoscopic orchidopexy (one-stage) 5 Laparoscopic orchiectomy 10 Open orchidopexy 13 Open orchiectomy 12
successful atrophy displacement
40
(81) (6) (13) (52) (48)
20
0 All
others distinguish between high and low position of the testis [15e19], whereas the decision between one- or two-stage operation in some series is taken after complete dissection of the vessels and vas [20,21]. Also, the age at operation is of importance for the final result as the chance of bringing the testis successfully to the scrotum seems to be higher in boys under 6 years of age [13]. It has been reported that early orchidopexy results in a significantly larger testicular volume at follow-up after 12 months, if the operation is performed at age 9 months compared to 3 years [22]. Therefore, a recent Scandinavian consensus report on treatment of undescended testes recommends orchidopexy before age 1 year to preserve spermatogenesis [7]. Our patients had a median age of 5.7 years at operation. They were all operated before the new Scandinavian consensus, which changed the recommended age at operation from 4 years to 1 year for unilateral undescended testis. Several determinants may influence this relatively high age; for instance, late referral from general practitioner, long waiting lists and, for some, other more important chronic diseases being treated first. Typically, the oldest were boys with congenital genetic disorders requiring a lot of attention in other aspects. The older age of our patients may explain the high number of two-stage operations performed together with our different approach, as we decide on which operative procedure to perform after intraabdominal inspection to avoid primarily dissection of vessels and vas if a two-stage procedure is chosen. The bilateral cases were treated at an earlier age (median 4.8 years) than boys with unilateral non-palpable
14 Total Failures
Number
12 10 8
Unilateral
Bilateral
Figure 3 Results after two-stage laparoscopic Fowlere Stephens orchidopexy in the whole group (all), and divided into unilateral and bilateral cases.
testis and the success rate was higher, supporting the fact that age influences the short-term outcome in terms of scrotal position and lack of atrophy. The failures were in boys younger than 8 years, but the number of Fowlere Stephens orchidopexies was much higher in this age group, as diagnostic laparoscopy revealed more cases with testicular agenesis, hypoplasia and short vas/vessels in the group of older boys resulting in orchiectomy. In a meta-analysis by Docimo a 76.8% success rate was noted for staged FowlereStephens orchidopexy [13]. Chang and Franco reported a success rate of 80% after two-stage laparoscopic FowlereStephens orchidopexy [21] and Radmayr et al. had a long-term success rate of 93% after twostage laparoscopic orchidopexy [20]. We report a success rate of 80% in staged laparoscopic FowlereStephens orchidopexy, which is very close to the result of the metaanalysis and Chang and Franco. Others report similar results [12,14] or an even better outcome [15,17e20,23]. Comparisons are difficult since most of the data are from retrospective analyses with a variety of operative procedures, median ages and follow-up periods. Many of the staged procedures have been performed openly or with second stage as an open procedure, and the numbers are small. However, Radmayr et al. showed excellent results in 27 of 29 two-stage procedures, in younger patients. Also, one-stage laparoscopic orchidopexy with [21] or without [20] clipping of the testicular vessels seems to be a good alternative with success rates between 94% and 100%. Typically, these patients are younger than the patients treated with a two-stage laparoscopic orchidopexy. Hence, classification-based management and strict procedures are needed to evaluate the results of the staged FowlereStephens procedure for the impalpable testis.
6 4
Conclusion
2 0 1
2
3
4
5
6
7
8
9
10
11
12
13
Age
Figure 2 Age distribution (total number and failures) of twostage laparoscopic FowlereStephens orchidopexy.
At our center, two-stage laparoscopic FowlereStephens orchidopexy for intra-abdominal testes shows less satisfactory results compared to some recent studies. The median age at referral in our study was higher than what is now recommended in Scandinavia, and hopefully operation
392 at a younger age will improve our results in the future. Furthermore, with operation at an earlier age the number of two-stage procedures will probably drop and one-stage laparoscopic orchidopexy take over.
Conflict of interest/funding None.
References [1] Berkowitz GS, Lapinski RH, Dolgin SE, Gazella JG, Bodian CA, Holzman IR. Prevalence and natural history of cryptorchidism. Pediatrics 1993;92:44. [2] Hadziselimovic F, Herzog B, Buser M. Development of cryptorchid testes. Eur J Pediatr 1987;146:S8. [3] Kogan SJ, Tennenbaum S, Gill B, Reda E, Levitt SB. Efficacy of orchiopexy by patient age 1 year for cryptorchidism. J Urol 1990;144:508. [4] Schindler AM, Diaz P, Cuendet A, Sizonenko PC. Cryptorchidism: a morphological study of 670 biopsies. Helv Paediatr Acta 1987;42:145. [5] Swerdlow AJ, Higgins CD, Pike MC. Risk of testicular cancer in cohort of boys with cryptorchidism. BMJ 1997;314:1507. [6] Giwercman A, Grindsted J, Hansen B, Jensen OM, Skakkebaek NE. Testicular cancer risk in boys with maldescended testis: a cohort study. J Urol 1987;138:1214. [7] Ritzen EM, Bergh A, Bjerknes R, Christiansen P, Cortes D, Haugen SE, et al. Nordic consensus on treatment of undescended testes. Acta Paediatr 2007;96:638. [8] Gill B, Kogan S. Cryptorchidism. Current concepts. Pediatr Clin North Am 1997;44:1211. [9] Walsh TJ, Dall’Era MA, Croughan MS, Carroll PR, Turek PJ. Prepubertal orchiopexy for cryptorchidism may be associated with lower risk of testicular cancer. J Urol 2007;178:1440. [10] Hay SA, Soliman HA, Abdel Rahman AH, Bassiouny IE. Laparoscopic classification and treatment of the impalpable testis. Pediatr Surg Int 1999;15:570.
G.M. Hvistendahl, E.U. Poulsen [11] Fowler R, Stephens FD. The role of testicular vascular anatomy in the salvage of high undescended testes. Aust N Z J Surg 1959;29:92. [12] Baillie CT, Fearns G, Kitteringham L, Turnock RR. Management of the impalpable testis: the role of laparoscopy. Arch Dis Child 1998;79:419. [13] Docimo SG. The results of surgical therapy for cryptorchidism: a literature review and analysis. J Urol 1995;154:1148. [14] Heiss KF, Shandling B. Laparoscopy for the impalpable testes: experience with 53 testes. J Pediatr Surg 1992;27:175. [15] Esposito C, Garipoli V. The value of 2-step laparoscopic FowlereStephens orchiopexy for intra-abdominal testes. J Urol 1952;158:1997. [16] El-Anany F, Gad El-Moula M, Abdel MA, Abdallah A, Takahashi M, Kanayama H, et al. Laparoscopy for impalpable testis: classification-based management. Surg Endosc 2007; 21:449. [17] Lindgren BW, Franco I, Blick S, Levitt SB, Brock WA, Palmer LS, et al. Laparoscopic FowlereStephens orchiopexy for the high abdominal testis. J Urol 1999;162:990. [18] Dhanani NN, Cornelius D, Gunes A, Ritchey ML. Successful outpatient management of the nonpalpable intra-abdominal testis with staged FowlereStephens orchiopexy. J Urol 2004; 172:2399. [19] Abolyosr A. Laparoscopic versus open orchiopexy in the management of abdominal testis: a descriptive study. Int J Urol 2006;13:1421. [20] Radmayr C, Oswald J, Schwentner C, Neururer R, Peschel R, Bartsch G. Long-term outcome of laparoscopically managed nonpalpable testes. J Urol 2003;170:2409. [21] Chang M, Franco I. Laparoscopic FowlereStephens orchiopexy: the Westchester Medical Center experience. J Endourol 2008;22:1315. [22] Kollin C, Karpe B, Hesser U, Granholm T, Ritzen EM. Surgical treatment of unilaterally undescended testes: testicular growth after randomization to orchiopexy at age 9 months or 3 years. J Urol 2007;178:1589. [23] Elder JS. Two-stage FowlereStephens orchiopexy in the management of intra-abdominal testes. J Urol 1992;148: 1239.
Laparoscopy for the impalpable testes: Experience with 80 intra-abdominal testes G.M. Hvistendahl*, E.U. Poulsen 1 Department of Urology, Aarhus University Hospital e Skejby, DK-8200 Aarhus N, Denmark Received 3 January 2009; accepted 6 April 2009 Available online 19 May 2009
KEYWORDS Laparoscopy; FowlereStephens orchidopexy; Two stage; Intra-abdominal testes
Abstract Objective: To evaluate two-stage laparoscopic FowlereStephens (FS) orchidopexy for intra-abdominal testes. Materials and methods: A retrospective analysis was performed of the clinical findings, interventions and outcomes in 111 boys undergoing laparoscopy for 132 impalpable testes. Results: The median age was 5.7 years (1.1e14.6 years). Twenty-seven testes were absent. Eighty testes were intra-abdominal, of which 10 were removed laparoscopically due to anatomical anomalies (4), short spermatic cord (5) or atresia (1). Twenty-five testes were located in the groin. Laparoscopic FS procedure was performed for 65 intra-abdominal testes: 60 two-stage operations and five where the testes were removed during FS second stage due to short vas or testicular atrophy. Outcome was successful in 80%. One-stage laparoscopic orchidopexy without vessel division was performed in five intra-abdominal testes with satisfactory results in three. In general, the success rate is higher in boys with bilateral intra-abdominal testes, probably due to younger age at operation. Conclusions: At our centre two-stage laparoscopic FowlereStephens orchidopexy for intraabdominal testes showed results comparable to most other studies, but less satisfactory than a couple of recent studies. The median age at referral was higher than recommended. Operation at an earlier age may further improve the results. ª 2009 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction Failure of one or both testes to descend into the scrotum affects about 3% of full-term newborns and up to 30% of preterm infants; two thirds of undescended testes will descend spontaneously within the first few months of life. By age 6 * Corresponding author. Tel.: þ45 8949 5566; fax: þ45 8949 6006. E-mail addresses: [email protected] (G.M. Hvistendahl), [email protected] (E.U. Poulsen). 1 Tel.: þ45 8949 5566; fax: þ45 8949 6006.
months the prevalence of undescended testes is 1e2% and unilateral cryptorchism accounts for about 85% of all cases [1]. Cryptorchidism is associated with infertility and testicular neoplasms. Cryptorchid boys have been shown to lack germ cells from age 15e18 months [2e4] and the lifetime risk of testicular neoplasia in maldescended testes is increased 5e10 fold [5,6]. To avoid ongoing testicular degenerative changes the latest recommendation is to perform surgery before the age of 12 months or upon diagnosis, if that occurs later [7,8]. Furthermore, prepubertal orchidopexy for cryptorchidism may lower the risk of testicular cancer [9].
1477-5131/$36 ª 2009 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2009.04.004
390
Materials and methods We retrospectively reviewed the records of boys who underwent a diagnostic laparoscopy for non-palpable testes at Aarhus University Hospital e Skejby between 2000 and 2006. A 5-mm port was placed through a sub-umbilical incision and the child was put into the Trendelenburg position to facilitate inspection of the pelvic region. If necessary, two accessory 5-mm instrument ports were inserted. When vas and testicular vessels entered the internal ring we performed an open exploration of the groin with a standard orchidopexy in cases with a normal testicle missed on palpation or an orchiectomy in cases with a testicular nubbin. In cases with no testicle, evidenced by blind-ending vas and vessels, the operation was terminated. The finding of a small and atrophic intra-abdominal testicle led to a laparoscopic orchiectomy. A few cases went through a one-stage laparoscopic orchidopexy if the vas and vessels had sufficient length. In the rest of the cases judged to be suitable for a two-stage laparoscopic FowlereStephens orchidopexy, the first stage with low clipping of the testicular vessels, without further dissection of the vessels or vas, was performed. Six months later the second stage took place using the same laparoscopic access as previously. The testicular vessels were divided and the testicle mobilized on its vasal pedicle flap. Via a scrotal port through a neohiatus medial to the medial umbilical ligament the testicle was brought to the scrotum and placed in a subdartos pouch. The child was discharged later the same day. In cases with bilateral intra-abdominal testes the contralateral procedure was performed 3 months later. The child was seen 3 months later in the out-patient clinic where location and size (atrophic or unchanged) of the testicle were registered.
(1.1e14.6 years) (Fig. 1). One hundred and seven testicles were either intra-abdominal (80) or absent (27) as evidenced by blind-ending vas and vessels. The surgical management of the intra-abdominal testis was laparoscopic orchidopexy without vessel division as a one-stage procedure (5); laparoscopic FowlereStephens orchidopexy (65); or laparoscopic orchiectomy in 10 cases with anatomical anomalies (4), short vas (5) or atresia (1) after clipping of the spermatic vessels (Table 1). Standard orchidopexy was performed in 13 of 25 cases with vas and vessels running to the inguinal canal, where we found a testicle missed on palpation and groin exploration/orchiectomy in 12 with blind-ending vessels or hypoplastic testis. A total of 10 patients (15%) were lost to follow up. In the group of laparoscopic FowlereStephens orchidopexies the testis was in a scrotal position and of normal size/ unchanged in 80%. Atrophy and displacement was found in 14% and 6% respectively with an age distribution as shown in Fig. 2. Comparison of unilateral and bilateral laparoscopic FowlereStephens procedures showed a success rate of 69% and 85% respectively (Fig. 3). Median age at the primary operation was 6.1 years (1.1e14.6 years) versus 4.8 years (1.3e13.5 years) in unilateral and bilateral cases. The group of laparoscopic orchidopexies without vessel diversion had a success rate of 60% (three out of five). Complications were few and minor: two port hernias which were re-operated and three conservatively managed scrotal haematomas.
Discussion Orchidopexy is a relatively minor operation. However, the preoperative position of the undescended testis seems to influence outcome since the success rate in canalicular testes is higher than in those located intra-abdominally [12,13]. There is no generally accepted management protocol regarding when and how to operate according to the position of the testis. Different centres tend to have their own strategy dependent on a ‘local’ classification, which makes it difficult to compare results. Some perform twostage operations on all intra-abdominal testes [12,14], 18 16 14 12
number
The undescended testes may be palpable or nonpalpable. Surgical therapy for the palpable undescended testis is orchidopexy through a transverse groin incision. When the testis is non-palpable, diagnostic laparoscopy will determine which surgical approach should be taken. If the laparoscopy reveals an intra-abdominal testis, several options are available depending on the exact location of the testicle, low or high intra-abdominal [10], and the length of the vas deferens. The operation may be performed laparoscopically or by laparotomy, either as a onestage procedure with (FowlereStephens orchidopexy) or without diversion of the spermatic vessels, or as a staged procedure with vessel diversion [11]. Recently laparoscopy has replaced many open procedures, because it is a minimally invasive procedure and seems to have fewer complications. However, it is important that the overall results are comparable to those achieved using other procedures. The aim of this study was to evaluate the two-stage laparoscopic FowlereStephens orchidopexy for intraabdominal testes.
G.M. Hvistendahl, E.U. Poulsen
10 8 6 4 2 0
Results A total of 111 boys presented with 132 non-palpable testes. At diagnostic laparoscopy the median age was 5.7 years
0
1
2
3
4
5
6
7
8
age
9
10 11 12 13 14 15 16
Figure 1 Age distribution at diagnostic laparoscopy for impalpable testis.
Laparoscopy for the impalpable testes
391 100
Table 1 Results of diagnostic laparoscopy in boys with non-palpable testes, and treatment followed. No. of patients (%) (100) (61) (20)
80
60
%
Laparoscopic findings Non-palpable testis 132 Intra-abdominal testis 80 Intra-abdominal vanishing testis 27 Procedure Laparoscopic FowlereStephen 65 Laparoscopic orchidopexy (one-stage) 5 Laparoscopic orchiectomy 10 Open orchidopexy 13 Open orchiectomy 12
successful atrophy displacement
40
(81) (6) (13) (52) (48)
20
0 All
others distinguish between high and low position of the testis [15e19], whereas the decision between one- or two-stage operation in some series is taken after complete dissection of the vessels and vas [20,21]. Also, the age at operation is of importance for the final result as the chance of bringing the testis successfully to the scrotum seems to be higher in boys under 6 years of age [13]. It has been reported that early orchidopexy results in a significantly larger testicular volume at follow-up after 12 months, if the operation is performed at age 9 months compared to 3 years [22]. Therefore, a recent Scandinavian consensus report on treatment of undescended testes recommends orchidopexy before age 1 year to preserve spermatogenesis [7]. Our patients had a median age of 5.7 years at operation. They were all operated before the new Scandinavian consensus, which changed the recommended age at operation from 4 years to 1 year for unilateral undescended testis. Several determinants may influence this relatively high age; for instance, late referral from general practitioner, long waiting lists and, for some, other more important chronic diseases being treated first. Typically, the oldest were boys with congenital genetic disorders requiring a lot of attention in other aspects. The older age of our patients may explain the high number of two-stage operations performed together with our different approach, as we decide on which operative procedure to perform after intraabdominal inspection to avoid primarily dissection of vessels and vas if a two-stage procedure is chosen. The bilateral cases were treated at an earlier age (median 4.8 years) than boys with unilateral non-palpable
14 Total Failures
Number
12 10 8
Unilateral
Bilateral
Figure 3 Results after two-stage laparoscopic Fowlere Stephens orchidopexy in the whole group (all), and divided into unilateral and bilateral cases.
testis and the success rate was higher, supporting the fact that age influences the short-term outcome in terms of scrotal position and lack of atrophy. The failures were in boys younger than 8 years, but the number of Fowlere Stephens orchidopexies was much higher in this age group, as diagnostic laparoscopy revealed more cases with testicular agenesis, hypoplasia and short vas/vessels in the group of older boys resulting in orchiectomy. In a meta-analysis by Docimo a 76.8% success rate was noted for staged FowlereStephens orchidopexy [13]. Chang and Franco reported a success rate of 80% after two-stage laparoscopic FowlereStephens orchidopexy [21] and Radmayr et al. had a long-term success rate of 93% after twostage laparoscopic orchidopexy [20]. We report a success rate of 80% in staged laparoscopic FowlereStephens orchidopexy, which is very close to the result of the metaanalysis and Chang and Franco. Others report similar results [12,14] or an even better outcome [15,17e20,23]. Comparisons are difficult since most of the data are from retrospective analyses with a variety of operative procedures, median ages and follow-up periods. Many of the staged procedures have been performed openly or with second stage as an open procedure, and the numbers are small. However, Radmayr et al. showed excellent results in 27 of 29 two-stage procedures, in younger patients. Also, one-stage laparoscopic orchidopexy with [21] or without [20] clipping of the testicular vessels seems to be a good alternative with success rates between 94% and 100%. Typically, these patients are younger than the patients treated with a two-stage laparoscopic orchidopexy. Hence, classification-based management and strict procedures are needed to evaluate the results of the staged FowlereStephens procedure for the impalpable testis.
6 4
Conclusion
2 0 1
2
3
4
5
6
7
8
9
10
11
12
13
Age
Figure 2 Age distribution (total number and failures) of twostage laparoscopic FowlereStephens orchidopexy.
At our center, two-stage laparoscopic FowlereStephens orchidopexy for intra-abdominal testes shows less satisfactory results compared to some recent studies. The median age at referral in our study was higher than what is now recommended in Scandinavia, and hopefully operation
392 at a younger age will improve our results in the future. Furthermore, with operation at an earlier age the number of two-stage procedures will probably drop and one-stage laparoscopic orchidopexy take over.
Conflict of interest/funding None.
References [1] Berkowitz GS, Lapinski RH, Dolgin SE, Gazella JG, Bodian CA, Holzman IR. Prevalence and natural history of cryptorchidism. Pediatrics 1993;92:44. [2] Hadziselimovic F, Herzog B, Buser M. Development of cryptorchid testes. Eur J Pediatr 1987;146:S8. [3] Kogan SJ, Tennenbaum S, Gill B, Reda E, Levitt SB. Efficacy of orchiopexy by patient age 1 year for cryptorchidism. J Urol 1990;144:508. [4] Schindler AM, Diaz P, Cuendet A, Sizonenko PC. Cryptorchidism: a morphological study of 670 biopsies. Helv Paediatr Acta 1987;42:145. [5] Swerdlow AJ, Higgins CD, Pike MC. Risk of testicular cancer in cohort of boys with cryptorchidism. BMJ 1997;314:1507. [6] Giwercman A, Grindsted J, Hansen B, Jensen OM, Skakkebaek NE. Testicular cancer risk in boys with maldescended testis: a cohort study. J Urol 1987;138:1214. [7] Ritzen EM, Bergh A, Bjerknes R, Christiansen P, Cortes D, Haugen SE, et al. Nordic consensus on treatment of undescended testes. Acta Paediatr 2007;96:638. [8] Gill B, Kogan S. Cryptorchidism. Current concepts. Pediatr Clin North Am 1997;44:1211. [9] Walsh TJ, Dall’Era MA, Croughan MS, Carroll PR, Turek PJ. Prepubertal orchiopexy for cryptorchidism may be associated with lower risk of testicular cancer. J Urol 2007;178:1440. [10] Hay SA, Soliman HA, Abdel Rahman AH, Bassiouny IE. Laparoscopic classification and treatment of the impalpable testis. Pediatr Surg Int 1999;15:570.
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