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Luis H. Braga, MD, MSc, PhD, Armando Lorenzo, MD, Jorge DeMaria, MD.
McMaster University, Hamilton, ON, Canada.

Although Conventional Laparoscopic Fowler-Stephens Orchidopexy (CLO) is widely used as a 1 or 2-stage procedure for intra-abdominal gonads, testicular atrophy rates can be as high as 30%. We had previously described an alternative laparoscopic technique, which involves advancing the testicle through the internal inguinal ring (IIR), without dividing the gubernaculum and sparing the cremasteric vessels, aiming to reduce testicular atrophy. Herein, we compared the outcomes of CLO to those of Gubernaculum Sparing Laparoscopic Orchidopexy (GSLO).
We prospectively collected data on all patients who had GSLO from 2008-13 and compared their results with a historical cohort of patients who had CLO between 2005-08. We excluded children with missing follow-up ultrasound data (n=16), resulting in 212 boys to form our study sample. Primary outcome was atrophy rate (nubbin or non-palpable testis confirmed by postop Doppler US), and testicle position in the scrotum (entrance/high vs low/normally positioned). Variables captured were age at surgery; location of intra-abdominal testicle (IAT) [defined as peeping vs true IAT (>2cm from IIR)]; surgical technique (CLO vs GSLO); number of stages (1 vs 2); and patency of IIR. Uni and multivariable analyses were performed.
Mean patient age at surgery was 28.7±16.3 mos and mean F/U was 28.6±20.5 mos. Of the 212 boys, 1-stage laparoscopic orchidopexy was performed in 44 (21%) cases and 2-stage in 168 (79%). CLO was done in 46 (22%) and GSLO in 166 (78%). The overall atrophy rate was 6.6% (14/212): 13/46 testicles atrophied after CLO vs 1/166 following GSLO (28.3% vs 0.6%, p<0.01). Eight of 44 testicles had atrophy after 1 stage vs 6 of 168 following 2-stage procedure (18.2% vs 3.5%, p<0.01). Two of 46 testicles were located in the upper part (entrance) of the scrotum after CLO vs 15 of 166 following GSLO (4.3% vs 9.0%, p=0.3). On multivariable analysis, CLO was the only factor associated with higher atrophy rates (OR=15, 95%CI: 6-44).
Our findings suggest that GSLO was significantly associated with lower testicular atrophy rates compared to CLO, after adjusting for number of stages and testicular position. Preserving the cremasteric vessels by not dividing the gubernaculum at the level of the IIR should be considered as part of the technical steps for laparoscopic orchidopexy.

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