SECOND STAGE GUBERNACULUM SPARING LAPARASCOPIC ORCHIDOPEXY (GSLO)
Luis H. Braga, M.D., MSc., PhD., Smruthi Ramesh, BSc, Melissa McGrath, BASc.
McMaster University, Hamilton, ON, Canada.
BACKGROUND: Laparoscopic staged Fowler-Stephens Orchidopexy (LFSO) is commonly performed when vessel length limits a tension-free testicular descent however, atrophy rates up to 30% have been reported. To improve testicular survival rates, a modified second-stage LFSO technique is presented, in which the cremasteric/gubernacular vessels are not divided and the testis is anatomically delivered into the scrotum through the internal ring and inguinal canal.
METHODS: Initial access is obtained with a Hasson technique through an umbilical incision. After identifying the area of previous testicular vessel ligation, mobilization is started laterally and superiorly towards the internal inguinal ring (IIR), and extended along the superior margin of the IIR, continuing beyond the inferior epigastric vessels medially, extending medially beyond the obliterated umbilical artery. After identifying the vas, dissection is continued medially towards the bladder and then performed proximally, near the bifurcation of the iliac vessels. Effectively, a wide strip of peritoneum between the testis and the gubernaculum is preserved, allowing free mobilization over a peritoneal triangle containing a rich collateral blood supply to the testis. Next, a laparoscopic grasper is advanced through the IIR alongside the gubernaculum, and into the most dependent aspect of the scrotum. A small scrotal incision is made and a 5-mm port introduced over the laparoscopic grasper into the abdominal cavity. The distal gubernacular attachments and preserved gubernaculum/cremasteric vessels, along with the testis, are advanced through the IIR with the assistance of a laparoscopic grasper, following the anatomical testicular descent route into the ipsilateral scrotum. The testis is fixed to the scrotum in a sub-dartos pouch with a single 4-0 polydioxanone stitch.
RESULTS: This 4.5-minute video demonstrates the GSLO technique. Since its inception at the site in 2008, 196 testes have successfully undergone this procedure with only one reported case of testicular atrophy.
CONCLUSION: GSLO is feasible and appealing alternative to the classic LFSO. Further comparative studies with classic LFSO are needed to establish if this modification truly improves testicular survival rates.
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