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Comparison of Laparoscopic Approaches for Correction of Undescended Testis
Iqra Nadeem, MD, Curran Uppaluri, MD, Alice Xiang, MD, John Weaver, MD, Katherine Fischer, MD, Christopher J. Long, MD, Thomas F. Kolon, MD, Sameer Mittal, MD, Aseem R. Shukla, MD, Arun K. Srinivasan, MD.
Children's Hospital of Philadelphia, Philadelphia, PA, USA.

Background:Undescended testis (UDT) is a commonly encountered congenital anomaly in pediatric urology. For those patients with nonpalpable UDT, laparoscopic orchiopexy has been described as an effective surgical management option. Our study focused on a modern cohort undergoing laparoscopic correction for nonpalpable UDT with an emphasis on comparison of intraoperative findings and postoperative outcomes between simple laparoscopic orchiopexy and Fowler-Stephens orchiopexy (FSO).
Methods:We reviewed our prospective institutional nonpalpable testis database to identify pediatric patients that underwent a laparoscopic procedure from February 2015 to October 2021. Laparoscopic procedures were defined as diagnostic laparoscopy, laparoscopic FSO, and simple laparoscopic orchiopexy; laparoscopic FSO further consisted of patients that underwent one-stage or two-stage FSO, including both the first and second stage. Our analysis focused on laparoscopic correction for UDT with patients that underwent diagnostic laparoscopy excluded. Baseline characteristics, intraoperative details, and follow-up outcomes were collected and analyzed. Procedural success for a procedure was defined as a palpable and nonatrophic testis in the scrotum upon follow-up visit.
Results: Our cohort included 235 patients, of which 114 (48%) underwent laparoscopic simple orchiopexy and 60 underwent laparoscopic FSO (Figure 1). The median age of surgery for the simple orchiopexy cohort was 18.4 months (IQR=8.0-16.4) and 26.1 months (IQR=8.1-19.8) for the FSO cohort (Table 1). 17% of the simple orchiopexy cohort had a prior abdominal surgery compared to 60% of the FSO cohort. 6% of the laparoscopic orchiopexy group were intraoperatively found to have a testis greater than 2 centimeters above the internal inguinal ring versus 18% of the FSO group. Complication rates based on cohort were similar at 6% for simple orchiopexy and 7% for FSO. Follow-up procedural success was 98% for laparoscopic orchiopexy and 86% for laparoscopic FSO.
Conclusion:Our study from a large contemporary single-institutional cohort noted higher success rates than in reported literature for both simple laparoscopic orchiopexy (98%) and laparoscopic FSO (86%). Both techniques were associated with low rates of morbidity. Laparoscopic correction for nonpalpable testis is additionally safe and effective to perform in patients with a prior abdominal history.

Table 1. Patient characteristics and outcomes by surgical approach
Laparoscopic OrchiopexyFowler-Stephens Orchiopexyp-value
11460
Age of Diagnosis (months) 4.96.4
Age at Surgery (months), median (IQR) 18.4 (8.0, 16.4)26.1 (8.1, 19.8)
Previous Abdominal Surgical History 19 (16.7%)36 (60.0%)<0.001
Redo Procedure 1 (0.9%)0 (0.0%)0.29
Single Site Port 17 (14.9%)9 (15.0%)0.92
Intraoperative Location of TestisAt level of internal ring or within 2cm of ring105 (92.1%)46 (76.7%)
Greater than 2cm above internal ring7 (6.1%)11 (18.3%)
Intraoperative Finding Small Testicular Size32 (28.0%)15 (25.0%)
First Stage FSOVessels clipped51 (85.0%)
Vessels clipped and cut9 (15.0%)
Conversion to Open1 (0.9%)0 (0.0%)0.47
Operative Time (min), median (IQR)103 (68, 125)118 (68, 128)0.64
Same Day Surgery99 (86.7%)51 (85.0%)0.67
ComplicationsOverall7 (6.1%)4 (6.7%)0.36
Clavien I-II7 (100.0%)3 (75.0%)
Clavien III0 (0.0%)1 (25.0%)
Readmissions1 (0.9%)2 (3.3%)0.22
Follow-up Duration (months), median (IQR)19.3 (5.7, 27.2)30.4 (6.0, 27.4)<0.001
Palpable, Nonatrophic Testis in Scrotum on Follow-up97 (98.0%)24 (85.7%)


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