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Journal of Pediatric Surgery (2009) 44, 1999–2003

Review

Is the Fowler-Stephens procedure still indicated for thetreatment of nonpalpable intraabdominal testis?☆

Paul Daher a, Philippe Nabbout b, Jawad Feghali b, Edward Riachy a,⁎

aDepartment of Pediatric Surgery, Hotel-Dieu de France University Hospital, Saint Jospeh University, Faculty of Medicine,PO Box: 16-6830, Beirut, LebanonbDepartment of Urology, Hotel-Dieu de France University Hospital, Saint Jospeh University, Faculty of Medicine,PO Box: 16-6830, Beirut, Lebanon

Received 4 May 2009; revised 5 June 2009; accepted 5 June 2009

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Key words:Undescended testis;Nonpalpable testis;Intraabdominal testis;Orchidopexy;Fowler-Stephenstechnique

AbstractPurpose: There are no formal guidelines for the management of boys with nonpalpable testis. In thisarticle, we report our experience in treating all nonpalpable intraabdominal testis (NPIT) with standardinguinal orchidopexy without dividing the spermatic vessels stating that the Fowler-Stephens techniqueis no longer indicated for the treatment of the intraabdominal testis.Methods: Between June 2003 and April 2008, we treated 23 boys with NPIT confirmed by ultrasound orlaparoscopy. All cases were treated through an inguinal orchidopexy without division of the spermaticvessels by fixing the testis to the scrotum by 2 absorbable stitches even if there was an upward retractionof the scrotal skin. Location and size of testis were reported at 1 week, 1 month, 3 months, and 6 monthsthrough physical examination.Results: Average age at presentation was 24 months. Ten patients (43%) had the NPIT on the right side,8 (35%) on the left side, and 5 (22%) were bilateral. We had no intraoperative complications. Allpatients were discharged on the same day. In all cases, the testis was normal in size and found in thescrotum after 6 months of follow-up.Conclusion: On the basis of our experience, we believe that the Fowler-Stephens procedure is notindicated anymore in the management of NPIT. Orchidopexy without division of the spermatic vesselsshould be the treatment of choice even for the cases of very high intraabdominal testis because it doesnot affect normal testicular vascularization and is minimally invasive.© 2009 Elsevier Inc. All rights reserved.

At the age of 1 year, approximately 1% to 2% of boys system in young boys, the disorder being unilateral in

have an undescended testis, making it one of the mostcommon congenital abnormalities of the genitourinary

☆ Presented at the VIIth Congress of the Mediterranean Association ofediatric Surgery, Tunis, Tunisian Republic, October 11, 2008.⁎ Corresponding author. Tel.: +961 3 998923; fax: +961 1

15300x9704.E-mail address: eddy_riachy@msn.com (E. Riachy).

022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved.oi:10.1016/j.jpedsurg.2009.06.012

about 90% of cases and bilateral in about 10% [1,2]. Mostcryptorchid testes are palpable but incompletely descendedinto the scrotum. In approximately 20% of cases, the testis isnot palpable; half of these cases are nonpalpable intraab-dominal testes (NPIT), and the remainder are either absent oratrophic [2-4]. Computed tomographic scan, magneticresonance imaging, and other diagnostic modalities havebeen proposed for the assessment and diagnosis of

2000 P. Daher et al.

nonpalpable testis, but only ultrasonography and laparo-scopy have been adopted [3,5-9]. Although several researchstudies have been conducted, the management of boys withNPIT is still controversial [2,4,10]. In this article, we reportour successful experience in treating all NPIT by an inguinalorchidopexy without division of the spermatic vessels, whichled us to raise the question if the Fowler-Stephens techniqueis truly indicated.

ig. 1 This figure illustrates the testis attached to the scrotumith 2 stitches, one in the frontal plane to the inner face of thecrotal skin (F) and the other in the sagittal plane to the interscrotalscia (S). One can understand why a dimple (D) is created on thecrotal skin secondary to the centripetal tension of the shortpermatic vessels.

1. Materials and methods

Between June 2003 and April 2008, we reviewed therecords of all boys with undescended nonpalpable testis whounderwent orchidopexy at Hotel-Dieu de France Hospital(Beirut, Lebanon). Nonpalpable intraabdominal testis wasdefined as (1) an absence of palpable testis in the scrotum orother ectopic position such as inguinal canal, pubis,perineum, or the upper thigh during normal physicalexamination and under anesthesia and (2) failure to identifythe testis in the inguinal canal upon inguinal incision. Datacollected included patient age, date of procedure, operativetime, affected side, associated anomalies/comorbidities, pastsurgeries, diagnostic modalities, presence or absence oftestis, location of testis, surgery-related complications, andhospital stay. Before surgery, the nonpalpable testis wasevaluated using ultrasonography. If the testis was detected,the surgery was done systematically through an inguinalincision; otherwise, we performed a laparoscopic explorationthrough the umbilicus to assess the presence of a testis: if thetestis was found on laparoscopy, the surgery was resumedthrough an inguinal incision and, if it was absent (confirmedby absence of the testis at the end of spermatic vessels), weperformed a fixation of the contralateral testis in the scrotum,as we consider it to be precious. The size of the testis wasmeasured with a ruler and recorded perioperatively. Locationand size of testis were reported at 1 week, 1 month, 3 months,and 6 months through a physical examination. A good resultwas defined as a palpable normal size testis with normalscrotal position, whereas an unacceptable result was a testisof abnormal size or position.

2. Operative technique

The same surgeon treated all patients. A standard inguinalincision was used; a lateral extension was done if necessary.Because the testis was not found in the inguinal canal andthe internal inguinal ring, the peritoneum was immediatelyopened. The operation consisted of (1) dividing thegubernacular attachment once the vas was completelyidentified; (2) a good dissection of the vas and vesselsfrom the posterior peritoneum and repair of the patentprocessus vaginalis with very high ligation that providedadditional length once the testis, vas, and vessels are freed

Fwsfass

from attachments to the posterior abdominal wall, whereasthe tissue between the spermatic vessels and the vas deferensremained intact; and (3) transperitoneal mobilization of thevas and vessels without clipping or transecting the spermaticvessels. The inferior epigastric vessels were not routinelydivided. At the end of the dissection, a pouch was created inthe scrotum between the skin and the tunica dartos. Thetestis was then attached without any bolster to the scrotumwith 2 PDS 5.0 stitches, one in the frontal plane to the innerface of the scrotal skin and the other in the sagittal plane tothe interscrotal fascia, even if there was traction on thespermatic vessels and upward retraction of the scrotal skinbecause of the short length of the vessels (Fig. 1). In case ofbilateral nonpalpable testis, orchidopexy was performed onboth sides simultaneously.

3. Results

Twenty-three patients underwent operations for nonpalp-able testis. The right testis was affected in 10 boys (43%), theleft in 8 (35%), and both in 5 (22%), making a total of 28nonpalpable testes to be treated. Patient age ranged from 3months to 6 years (mean, 2 years). No case of sexualambiguity was noted.

Abdominal ultrasound was capable of identifying 13patients (57%) with nonpalpable testis. In case of its failureto identify the testis, an intraoperative laparoscopy wasperformed (8 patients, 35%). One patient had a computedtomographic scan and another had a magnetic resonanceimaging. In 2 patients (9%), the testis was absent, and the 26remaining testes were intraabdominal. Three patients hadalready undergone operations in other hospitals without

2001Fowler-Stephens procedure

success. Other associated pathologic conditions were presentin 5 patients: 2 contralateral inguinal hernias, a diaphrag-matic hernia, a scrotal bifidity, and a hypospadias.

In the 21 patients with an identifiable testis (26 testis), anorchidopexy without division of the spermatic vessels wasperformed even if there was initially an excessive traction onthe spermatic pedicle and upward retraction of the scrotalskin, which was the case in all. Associated proceduresincluded ligation of a contralateral patent processus vaginalisin 2 patients, circumcision in 1, and contralateral scrotalorchidopexy in 3. In all cases, an ipsilateral patent processusvaginalis was identified and ligated. Mean operative timewas 1 hour, and all cases were discharged home on the sameday of surgery. No complications were reported.

At 1 week, the testis that was in a high scrotal positionpostoperatively was found in an acceptable scrotal positionand the scrotal skin was not retracted anymore. At 1, 3, and 6months follow-up, all testes were clinically assessed andwere found to be normal in size and location.

4. Discussion

The management of boys with NPIT is still a controversialsubject [2,11]. On the basis of an extensive literature review,we found that different techniques are used for the treatmentof NPIT. Hormone therapy (hCG - “Human chorionicgonadotropin" or GNRH1 - “Gonadotropin-releasing hor-mone 1") has generally shown poor results with a successrate that varies between 6% and 75% [2,12]. Microsurgicaltesticular autotransplantation has a success rate of about80% but has not been adopted by many surgeons forseveral reasons, including the long duration of theoperation and the need for microsurgical skills and specialinstrumentation [13,14].

Fig. 2 On the left, a perioperative photo shows a scrotal dimple on thetension of the short spermatic vessels. However, this upward retractioexamination after 3 months on the same patient shows that the testicule

The Fowler-Stephens procedure is recommended by somein the case of very high intraabdominal testis defined as adistance between the testis and the internal inguinal ringgreater than 3 cm [15]. It involves clipping and transectingthe testicular vessels and then mobilizing the testis in whichvascularization will become dependent on collateral defer-ential (vasal) artery [16,17]. The success rate of the one-stepFowler-Stephens procedure is between 67% and 100%[10,17-19], but most studies report good results in lessthan 85% of patients [2,20]. Although some surgeons prefera 2-step Fowler-Stephens procedure, the disadvantage is thatduring the second stage the reproductive tract (including thevas deferens and epididymis), as well as the testicular bloodsupply, might be injured [4]. Moreover, a review by Docimo[10], as well as many others, revealed the success rate of the2-step Fowler-Stephens procedure to be around 77%,although it should theoretically have a higher success ratethan the 1-step procedure [2,10]. In the absence of long-termresults on the fertility of patients who have undergone theFowler-Stephens procedure [2], we think it is preferable tochoose procedures that spare the spermatic vessels, whichshould reduce the risk of damaging germ cell lines as a resultof reduction in testicular vascularity. One comparativeretrospective study stated that a standard surgical orchido-pexy without spermatic vessel ligation is preferable to theFowler-Stephens 2-step procedure with less failure, atrophy,or incomplete testicular descent [21].

At our center, we do not perform the Fowler-Stephenstechnique even in the cases of very high intraabdominaltestis. By using a standard open inguinal orchidopexy, wewere able to successfully manage all of the 28 NPIT. Theshort operative time (1 hour) and hospital stay (outpatient),the absence of procedure-related complications, and theexcellent results on 6-month follow-up makes thisapproach the treatment of choice irrespective of thelocation of the NPIT.

scrotal skin where the testicule is fixed secondary to the centripetaln enables this tension to be released. On the right, the physicalis of normal size and regained a normal location.

2002 P. Daher et al.

In agreement to other authors [11,17,22], we believe thatchecking the position and size of the testis on follow-upphysical examination is a reliable sign of a good vascularsupply to the testis. We are persuaded that the testes shouldtotally disappear within 2 months from the surgery if anecrosis should occur; thus, a follow-up of 6 months is fairenough to spot such an event. Therefore, we did not find itnecessary to use Doppler ultrasonography or testicularbiopsies to evaluate our results. However, one limitation ofour study is the absence of long-term follow-up to assessfertility and risk of testicular cancer.

We think that the keys for our success are as follows: first,a good dissection of the vas and vessels from the posteriorperitoneum and repair of the patent processus vaginalis,which provides additional length once the testis, vas, andvessels are free from attachments; and second, fixation of thetestis to the scrotum even if there is upward centripetalretraction of the scrotal skin manifested as a dimple. Thisupward retraction permits the tension on the spermaticvessels to be released. One should expect this temporaryevent to happen because all testes were found in a normalposition in the scrotum after a 3-month period of follow-up(see Fig. 2).

We believe that by expanding our experience with thistechnique to other centers, increasing the size of the sample,and a longer follow-up period would confirm our statementthat the Fowler-Stephens technique is not indicated anymorefor the treatment of the intraabdominal testis, especially thatopting for this procedure, either in 1 or 2 steps, is apreconceived decision not based on the feasibility of theordinary orchidopexy.

Laparoscopic-assisted orchidopexy without division ofthe spermatic vessels has become the procedure of choice formany practitioners because it reproduces the same techniqueas in open surgery while preserving the original vascularityof the testis [15,23-25]. However, only a surgeon who hasmastered laparoscopic skills can freely choose whether toperform the orchidopexy by laparoscopy or by open surgery[2]. In our center, we chose to perform standard openorchidopexy because we think that the key to success is agood dissection and very high ligature of the processusvaginalis, which would be difficult to achieve laparoscopi-cally in a patient between 9 and 12 months of age. We onlyused laparoscopy for diagnosis when abdominal ultrasoundfailed to demonstrate the nonpalpable testis preoperatively.

5. Conclusion

Management of boys with NPIT is still a controversialsubject despite years of experience and research on the topic.Multiple approaches exist for the management of thenonpalpable testis.

Many surgeons perform the Fowler-Stephens technique incase of very high intraabdominal testis. In the absence of

long-term results of the Fowler-Stephens procedure and itseffects on testicular vascularity and fertility, we believe thatpreservation of the testicular vessels should always beattempted. In our series, we were able to manage all cases ofexisting NPIT (n = 26) through a standard open inguinalorchidopexy without transaction of the testicular vessels. Ourearly results revealed that testicular vascularization isunaffected and its trophicity is conserved, which iscompatible with other reports in the literature [4,21]. Onthe basis of our experience, we believe that the Fowler-Stephens technique is no longer indicated for the treatment ofNPIT. Orchidopexy without division of the spermatic vesselsshould be the treatment of choice even for the cases of veryhigh intraabdominal testis.

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