Staged orchiopexy in low intra-abdominal undescended testis with short spermatic cord: Open traction vs. Laparoscopic Fowler-Stephens - A matter of surgeon preference.

INTRODUCTION: Among techniques for short spermatic vessels in nonpalpable undescended testis (UDT), the Fowler-Stephens (F-S) procedure is the most favored. However, traction methods have regained popularity with gradual testicular tension for elongation to avoid ligating the spermatic vessels.

OBJECTIVE: To compare two techniques for low intra-abdominal UDT with a short spermatic cord: staged laparoscopic F-S and a modified staged open traction technique, and to determine if long-practicing surgeons should change their preferred method.

STUDY DESIGN: Seventy boys under six with nonpalpable low intra-abdominal UDT and short cords underwent either staged laparoscopic F-S or staged open traction orchiopexy. Based on surgical exploration and the surgeons' opinions, the included patients had vessels too short for one-stage orchiopexy. Two expert pediatric surgeons performed the surgeries, each using their preferred technique. Surgeon 1 used staged open traction, anchoring the testis to the pubic tubercle with low tension, followed by canal mobilization and fixation in the scrotum, while Surgeon 2 performed staged laparoscopic F-S. Post-operative ultrasonography at six months assessed success based on the absence of testicular atrophy and correct testis location.

RESULTS: Of the 70 boys, 36 (51.4 %) underwent staged open traction, and 34 (48.6 %) underwent staged laparoscopic F-S. The median age was 1.7 years. No intra- or post-operative complications occurred, and all testes were correctly placed in the scrotum. Testicular atrophy occurred in 6 patients (8.6 %): 2 (5.6 %) in the traction group and 4 (11.8 %) in the F-S group (p-value: 0.422). Atrophy was more common in bilateral cases, but all instances were unilateral (p-value: 0.022).

DISCUSSION: Both techniques had comparable results with no post-operative complications, and all testes were correctly positioned in the scrotum during follow-up. Although 5.6 % of patients in the traction group and 11.8 % in the F-S group experienced testicular atrophy, the difference was not statistically significant. Surgeon 1 performed all open traction surgeries, and Surgeon 2 performed all F-S operations due to their preferences and over 10 years of experience. Acceptable and comparable outcomes in both techniques show that both are safe when performed by an expert surgeon. We suggest that surgeons continue using their preferred technique if they are experts in it for the treatment of UDT. Although we assume our modified open traction method has an acceptable learning curve for less experienced surgeons, this needs further study.

CONCLUSIONS: Both staged traction and F-S techniques, performed by expert surgeons, yielded comparable outcomes, supporting the continued use of preferred methods.