Skip to main content

Staged Fowler Stephens, Who Requires a Third Procedure?

Current Urology Reports volume 22, Article number: 32 (2021) Cite this article

Abstract

Purpose of Review

The two-stage Fowler-Stephens orchiopexy is a well-described surgical approach for most pediatric urologists tackling the high intra-abdominal testis. Testicular ascent is a well-reported outcome of the surgery and a problem that could be fixed with a repeat procedure. The purpose of this review is to determine the rate of subsequent testicular ascent and repeat surgery after a two-stage Fowler-Stephens using best available evidence.

Recent Findings/Result

We selected 16 studies that pertained to our topic. 0–13% of testicles were deemed to be in an inappropriate position on follow-up (6–37 months). The definition of appropriate postoperative position varied between studies and rates of repeat procedures were sparsely available. Available data reports a repeat orchiopexy rate of 2.6–7.5% after two-stage Fowler-Stephens.

Summary

Two-stage Fowler-Stephens orchiopexy is a highly successful surgical technique to manage high intra-abdominal testes. Rates of testicular ascent are difficult to ascertain due to varying definitions and small sample sizes. While repeat procedures are typically indicated, the actual rate of repeat orchiopexy is rarely reported and long-term outcomes following a third procedure is sparse.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 39.95

Price includes VAT (USA)
Tax calculation will be finalised during checkout.

Fig. 1

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Barthold JS, Gonzalez R. The epidemiology of congenital cryptorchidism, testicular ascent and orchiopexy. J Urol. 2003;170(6 Pt 1):2396–401.

    Article  Google Scholar 

  2. Papparella A, Romano M, Noviello C, Cobellis G, Nino F, Del Monaco C, et al. The value of laparoscopy in the management of non-palpable testis. J Pediatr Urol. 2010;6(6):550–4.

    CAS  Article  Google Scholar 

  3. Fowler R, Stephens FD. The role of testicular vascular anatomy in the salvage of high undescended testes. Aust N Z J Surg. 1959;29:92–106.

    CAS  Article  Google Scholar 

  4. Ransley PG, Vordermark JS, Caldamone AA, Bellinger MF. Preliminary ligation of the gonadal vessels prior to orchidopexy for the intra-abdominal testicle world. J Urol. 1984;2:266–8.

    Google Scholar 

  5. •• Yu C, Long C, Wei Y, Tang X, Liu B, Shen L, et al. Evaluation of Fowler-Stephens orchiopexy for high-level intra-abdominal cryptorchidism: a systematic review and meta-analysis. Int J Surg (London, England). 2018;60:74–87 Meta-analysis evaluating outcomes for 1 and 2-stage Fowler-Stephens orchiopexy. The authors found that the 2-stage Fowler-Stephens has a higher overall success rates for high intra-abdominal cryptorchidism.

    Article  Google Scholar 

  6. • Elyas R, Guerra LA, Pike J, DeCarli C, Betolli M, Bass J, et al. Is staging beneficial for Fowler-Stephens orchiopexy? A systematic review. J Urol. 2010;183(5):2012–8 Systematic review comparing success rates after a 1-stage and 2-stage Fowler-Stephens orchiopexy, showing higher success with the 2-stage procedure.

    CAS  Article  Google Scholar 

  7. • Abdelhalim A, Chamberlin JD, Young I, Fahim M, Chuang KW, McAleer IM, et al. Testicular volume changes in laparoscopic staged Fowler-Stephens orchiopexy: studying the impact of testicular vessel division. Urology. 2019;127:113–8 Study with re-ascent outcomes after a 2-stage Fowler-Stephens orchiopexy. This study also published data on repeat procedures after initial surgery.

    Article  Google Scholar 

  8. Alagaratnam S, Nathaniel C, Cuckow P, Duffy P, Mushtaq I, Cherian A, et al. Testicular outcome following laparoscopic second stage Fowler-Stephens orchidopexy. J Pediatr Urol. 2014;10(1):186–92.

    Article  Google Scholar 

  9. Alam A, Delto JC, Blachman-Braun R, Wayne G, Mittal AG, Castellan M, et al. Staged Fowler-Stephens and single-stage laparoscopic orchiopexy for intra-abdominal testes: is there a difference? A Single Institution Experience. Urology. 2017;101:104–10.

    Article  Google Scholar 

  10. Baker LA, Docimo SG, Surer I, Peters C, Cisek L, Diamond DA, et al. A multi-institutional analysis of laparoscopic orchidopexy. BJU Int. 2001;87(6):484–9.

    CAS  Article  Google Scholar 

  11. •• Casanova NC, Johnson EK, Bowen DK, Kraft KH, Wan J, Bloom DA, et al. Two-Step Fowler-Stephens orchiopexy for intra-abdominal testes: a 28-year single institution experience. J Urol. 2013;190(4):1371–6 Large series with outcomes after a 2-stage Fowler-Stephens orchiopexy using a strict and specific definition of adequate postoperative position (“dependent part of the scrotum").

    CAS  Article  Google Scholar 

  12. Wang CY, Wang Y, Chen XH, Wei XY, Chen F, Zhong M. Efficacy of single-stage and two-stage Fowler-Stephens laparoscopic orchidopexy in the treatment of intraabdominal high testis. Asian J Surg. 2017;40(6):490–4.

    Article  Google Scholar 

  13. Dhanani NN, Cornelius D, Gunes A, Ritchey ML. Successful outpatient management of the nonpalpable intra-abdominal testis with staged Fowler-Stephens orchiopexy. J Urol. 2004;172(6 Pt 1):2399–401.

    Article  Google Scholar 

  14. Roy C, Cullis PS, Clark C, Munro FD. Retrospective analysis of testicular outcomes following laparoscopic two-stage Fowler Stephens orchidopexy. J Pediatr Surg. 2020;55(2):300–3.

    Article  Google Scholar 

  15. • Samadi AA, Palmer LS, Franco I. Laparoscopic orchiopexy: report of 203 cases with review of diagnosis, operative technique, and lessons learned. J Endourol. 2003;17(6):365–8 Large series with re-ascent outcomes after a 1-stage and 2-stage Fowler-Stephens orchiopexy. This study also reports the rate of a third procedure.

    Article  Google Scholar 

  16. • Stedman F, Bradshaw CJ, Kufeji D. Current practice and outcomes in the management of intra-abdominal testes. Eur J Pediatr Surg. 2015;25(5):409–13 Study with re-ascent outcomes after a 2-stage Fowler-Stephens orchiopexy. This study also reports the rate of a third procedure.

    PubMed  Google Scholar 

  17. • Wu CQ, Kirsch AJ. Revisiting the success rate of one-stage Fowler-Stephens orchiopexy with postoperative Doppler ultrasound and long-term follow-up: a 15-year single-surgeon experience. J Pediatr Urol. 2020;16(1):48–54 One of the only investigations of outcomes looking specifically at 1-stage Fowler-Stephens orchiopexy.

    Article  Google Scholar 

  18. Alzahem A. Laparoscopy-assisted orchiopexy versus laparoscopic two-stage fowler stephens orchiopexy for nonpalpable testes: comparative study. Urol Ann. 2013;5(2):110–4.

    Article  Google Scholar 

  19. Burjonrappa SC, Al Hazmi H, Barrieras D, Houle AM, Franc-Guimond J. Laparoscopic orchidopexy: the easy way to go. J Pediatr Surg. 2009;44(11):2168–72.

    Article  Google Scholar 

  20. Moursy EE, Gamal W, Hussein MM. Laparoscopic orchiopexy for non-palpable testes: outcome of two techniques. J Pediatr Urol. 2011;7(2):178–81.

    Article  Google Scholar 

  21. Ismail KA, Ashour MHM, El-Afifi MA, Hashish AA, El-Dosouky NE, Negm M, et al. Laparoscopy in the management of impalpable testis (series of 64 cases). Afr J Paediatr Surg. 2017;14(4):65–9.

    Article  Google Scholar 

  22. Bagga D, Prasad A, Grover SB, Sugandhi N, Tekchandani N, Acharya SK, et al. Evaluation of two-staged Fowler-Stephens laparoscopic orchidopexy (FSLO) for intra-abdominal testes (IAT). Pediatr Surg Int. 2018;34(1):97–103.

    Article  Google Scholar 

  23. Mahomed A, Adams S, Islam S. Initial success with gubernacular-sparing laparoscopic-assisted Fowler-Stephens orchidopexy for intra-abdominal testes. J Laparoendosc Adv Surg Techn A. 2012;22(2):192–4.

    Article  Google Scholar 

  24. Bassel YS, Scherz HC, Kirsch AJ. Scrotal incision orchiopexy for undescended testes with or without a patent processus vaginalis. J Urol. 2007;177(4):1516–8.

    Article  Google Scholar 

  25. Al-Mandil M, Khoury AE, El-Hout Y, Kogon M, Dave S, Farhat WA. Potential complications with the prescrotal approach for the palpable undescended testis? A comparison of single prescrotal incision to the traditional inguinal approach. J Urol. 2008;180(2):686–9.

    Article  Google Scholar 

  26. •• Pesce C, d'Agostino S, Costa L, Musi L, Manzi M. Reoperative orchiopexy: surgical aspects and functional outcome. Pediatr Surg Int. 2001;17(1):62–4 Pesce et al. provided valuable data from 40 boys who underwent re-operative orchiopexies specifically. This study noted that the re-operated testes were significantly smaller than control testes but fertility was only impaired in 19% of the patients.

    CAS  Article  Google Scholar 

  27. Lee PA, Coughlin MT. The single testis: paternity after presentation as unilateral cryptorchidism. J Urol. 2002;168(4 Pt 2):1680–2 discussion 2-3.

    Article  Google Scholar 

  28. • Gracia J, Sánchez Zalabardo J, Sánchez García J, García C, Ferrández A. Clinical, physical, sperm and hormonal data in 251 adults operated on for cryptorchidism in childhood. BJU Int. 2000;85(9):1100–3 This study found that sperm count in adults who underwent surgery for cryptorchidism in their childhood showed some abnormalities. The biggest factor influencing sperm counts was if the subject had bilateral cryptorchidism or unilateral.

    CAS  Article  Google Scholar 

  29. Hay SA. Collateral circulation after spermatic vessel ligation for abdominal testis and its impact on staged laparoscopically assisted orchiopexy. J Laparoendosc Adv Surg Techn A. 2007;17(1):124–7.

    Article  Google Scholar 

  30. Braga LH, Farrokhyar F, McGrath M, Lorenzo AJ. Gubernaculum testis and cremasteric vessel preservation during laparoscopic orchiopexy for intra-abdominal testes: effect on testicular atrophy rates. J Urol. 2019;201(2):378–85.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Urology, Oregon Health & Science University, Portland, OR, USA

    Mitchell Hayes, Amir Patel & Casey Seideman

  2. Department of Pediatric Urology, Doernbecher Children’s Hospital, Portland, OR, USA

    Mitchell Hayes, Amir Patel & Casey Seideman

Authors
  1. Mitchell Hayes
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Amir Patel
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Casey Seideman
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Amir Patel.

Ethics declarations

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Conflict of Interest

The authors declare no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Pediatric Urology

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Hayes, M., Patel, A. & Seideman, C. Staged Fowler Stephens, Who Requires a Third Procedure?. Curr Urol Rep 22, 32 (2021). https://doi.org/10.1007/s11934-021-01049-7

Download citation

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s11934-021-01049-7

Keywords

  • Fowler-Stephens
  • Outcomes
  • Testicular ascent
  • Orchiopexy
  • Cryptorchidism
  • Undescended testicle