stephen fowler orchidopexy

STEPHEN FOWLER ORCHIDOPEXY

• Cryptorchidism is the absence of one or both the testis from scrotum

• Testis undergoes intra-abdominal descent up to 28 weeks of intrauterine development

• Normally found in inguinal canal from 28-32 weeks onwards

• Should be expected to be found in scrotum from 30 weeks onwards

• In full-term infants incidence of cryptorchidism is 4%

• A high incidence of cryptorchidism is seen in premature infants

• In 80% of patients with cryptorchidism the testis is palpable

• 90% of impalpable testes are either high in inguinal canal or abdomen

• Types1. Lumbar2. Iliac3. Inguinal4. External ring5. Scrotal

• Complications

• Malignancy (10%)• Sterility• Torsion• Trauma• Epidydemo-orchitis on right side can mimic

as appendicitis

TREATMENT• ORCHIDOPEXY

• Palpable testis

• Testis is mobilised and brought down to scrotum

• Fixed in a subdartos pouch

STEPHEN FOWLERS ORCHIDOPEXY• Treatment for intra-abdominal testis

The operative options which are available for management of the high inguinal and the intra-abdominal testis have always had to contend with the short testicular vascular pedicle and the residual blood supply to the transferred testis.

• The sources of testicular blood supply are limited to the main testicular vessels and to a collateral circulation from the delicate vasal and cremasteric vessels

• In 1963 Fowler and Stephens presented an account of the collateral blood supply to high undescended tests and the results to be expected from division of the spermatic vessels

• In essence, testicular transfer to the scrotum is achieved by division of the short main vascular pedicle.

• The testis is left to survive on the collateral circulation from the vessels accompanying the vas

• Stephens fowler technique is of 2 types• Single stage• Two stage

• The single-stage Fowler-Stephens procedure must be planned ahead to avoid devascularisation of the secondary blood supply from the vas deferens and the cremaster muscles.

• It can be performed using open or laparoscopic technique.

• The success rate is 67%

• Two stage operation• Allows improved collateral blood supply,

but a second stage is required• It may also be performed with an open or

laparoscopic technique.• success rate is 77% At the first of this two

stage procedure, the main testicular vessels are completely occluded, either at open operation or by clipping at laparoscopy

• Subsequently, after a period of six months, the testis is transferred to the scrotum.

• The high testis on a 'long loop' vas has been considered to have a well-developed testiculo-vasal circulation, and as such should be the ideal anatomical indication for the Fowler-Stephens procedure

•  A literature review reveals no statistically significant difference between success rates of 1-stage versus 2-stage Fowler-Stephens orchidopexies.

• Disadvantages• Two stages are required• Inadequacy of collateral circulation• Testicular venous congestion and infarction

REFLOU TECHNIQUE • Proposed by Domini and Lima as a

fallback position in the event of a failed arterial anastomosis.

• This procedure followed on their observation that the testicular loss after the Fowler-Stephens approach was largely due to testicular venous congestion and infarction.

• They considered the arterial inflow from the vasal collaterals to be adequate for testicular survival, but the venous drainage to be poor and insufficient, thus compromising testicular survival.

• The 'Refluo' approach therefore aims to provide full venous drainage by micro vascular anastomosis of the testicular to the inferior epigastric vein(s), but continues to rely on the arterial input from the vasal collaterals.

MICROVASCULAR AUTOTRANSPLANTATION

• The idea of micro vascular autotransplantation was first given by Hodges and associates when they speculated on the possibility of transplanting the origin of spermatic artery to a lower position in abdominal aorta

• The first micro vascular autotransplantaion for undescended testis was done by Silber and Kelly in 1975

• This method solves the problem of testicular ischaemia that results due to ligation of spermatic vessels during orchidopexy of abdominal testis

• Microanastomosis of spermatic vessels to inferior epigastric vessels is done

• The anastomosis is done under operating microscope using 16x to 25x magnification

• 10-0 monofilament nylon suture and BV2 needle is used

• Before anastomosis dissection and clearing of vessels is done under loup magnification

• The success rate is around 80%