Evidence-Based Resource

What is the ideal management strategy for intra-abdominal testes?

Evidence Level III

Controversy exists regarding the ideal surgical approach for intra-abdominal testis (IAT).  Surgeons disagree regarding whether a primary orchiopexy, one- or two-stage Fowler-Stephens (FS) orchiopexy, or an alternate technique is superior; their opinions also differ regarding the ideal surgical method (i.e. laparoscopic or open).  We limited our search to the past 5 years due to abundance of literature.

There appears to be a consensus regarding how to best diagnose IAT.  Both ultrasound (Nijs 2007, Sharifiaghdas 2008) and MRI with or without arteriography/venography (Desireddi 2008) are insufficient for identification or localization of non-palpable testes (NPT), including IAT.  Inguinal canal exploration is effective for identifying most NPT, but for high IAT, surgical exploration is necessary (e.g., Gapany 2008, Papparella 2010, Snodgrass 2007, Tang 2009).

In general, higher-quality studies report that the one- or two-stage FS procedure is often performed successfully for high IAT, while primary orchiopexy is effectively used for low IAT (e.g., Gatti 2007, Papparella 2010, Stec 2009, Tang 2009).  Higher rates of success are reported for primary orchiopexy compared to the FS procedure (e.g., Moursy 2011, Stec 2009), but this is likely because primary orchiopexy is usually performed exclusively to repair low IAT, which are easier to correct than high IAT.

We only identified one systematic review comparing the one- and two-stage FS procedures for IAT (Elyas 2010), although this review was fairly low quality and contained no randomized controlled trials (RCTs).  Both one- and two-stage procedures were found to be quite effective, with the two-stage procedure demonstrating a significant advantage as far as testes viability following surgery. The 2-stage procedure was, however, associated with ileus, hematoma, and infection while no complications were observed with the one-stage procedure. An additional study by Chang (2008) supported these findings.  Furthermore, the long-term success rate of the two-stage FS orchiopexy has been reported at 83% (Esposito 2009); we did not identify any studies examining long-term success for the one-stage procedure.

We identified one additional systematic review (Guo 2011), which compared laparoscopic versus open orchiopexy for treatment of NPT. This review included 2 RCTs and 5 observational studies. They reported no significant advantages of laparoscopy over open procedure with regards to overall success rate, recurrence, and testicular atrophy.

There were several studies examining alternate or modified techniques for the surgical management of IAT (e.g., gradual traction rather than division of the testicular vessels; e.g., Shehata 2009, laparoscopic orchiopexies performed with a single trocar; Noh 2012) or classification systems to guide treatment (e.g., El-Anany 2007), however all were relatively small non-controlled trials.

Based on the available evidence, we recommend primary orchiopexy for low IAT and FS orchiopexy for high IAT.  It is unclear whether one-or two-stage FS is superior as there are no RCTs on this topic.  It is also unclear whether there are advantages of laparoscopic vs. open FS, but the available evidence suggests that the success rates are equivalent. For identifying and localizing IAT, the existing literature reports that ultrasound and MRI are not effective; instead, laparoscopy should be performed, followed by inguinal canal exploration if necessary.

Well-conducted RCTs are needed to clarify if there is a benefit to either one- or two-stage FS orchiopexy, and if there is a benefit to conducting open or laparoscopic surgery for intra-abdominal testes.

Acknowledgement: We thank Emily Chan for her work on this review.

The full systematic review can be found here

Non-Randomized Trials: Comparison Studies

AbouZeid AA, Mousa MH, Soliman HA, Hamza AF, Hay SA. Intra-abdominal testis: histological alterations and significance of biopsy. Journal of Urology 2011;185(1):269-74.

Alagaratnam S, Nathaniel C, Cuckow P, Duffy P, Mushtaq I, Cherian A, Desai D, Kiely E, Pierro A, Drake D, De Coppi P, Cross K, Curry J, Smeulders N. Testicular outcome following laparoscopic second stage Fowler-Stephens orchidopexy. Journal of Pediatric Urology 2014;10(1):186-92.

Bagga D, Teckchandani N, Kumar V, Grover SB, Yadav DK, Acharya SK. Predictive factors for successful vessel-intact laparoscopic orchiopexy for intra-abdominal testes. Journal of Pediatric Urology 2013;9(4):453-7.

Castillo-Ortiz J, Muñiz-Colon L, Escudero K, Perez-Brayfield M. Laparoscopy in the Surgical Management of the Non-Palpable Testis. Frontiers in Pediatrics 2014;2:28.

Chang M, Franco I. Laparoscopic Fowler-Stephens orchiopexy: the Westchester Medical Center experience. Journal of Endourology 2008;22(6):1315-9.

Dave S, Manaboriboon N, Braga LH, Lorenzo AJ, Farhat WA, Bagli DJ, et al. Open versus laparoscopic staged Fowler-Stephens orchiopexy: impact of long loop vas. Journal of Urology 2009;182(5):2435-9.

Lintula H, Kokki H, Eskelinen M, Vanamo K. Laparoscopic versus open orchidopexy in children with intra-abdominal testes. Journal of Laparoendoscopic and Advanced Surgical Techniques 2008;Part A.18(3):449-56.

Singh RR, Rajimwale A, Nour S. Laparoscopic management of impalpable testes: comparison of different techniques. Pediatric Surgery International 2011;27(12):1327-30.

Stec AA, Tanaka ST, Adams MC, Pope JC, Thomas JC, Brock JW, III. Orchiopexy for intra-abdominal testes: factors predicting success. Journal of Urology 2009;182(4 Suppl):1917-20.

Non-Randomized Trials: Non-Comparison Studies

Agrawal A, Joshi M, Mishra P, Gupta R, Sanghvi B, Parelkar S. Laparoscopic Stephen-Fowler stage procedure: appropriate management for high intra-abdominal testes. Journal of Laparoendoscopic and Advanced Surgical Techniques 2010;Part A. 20(2):183-5.

Ang CW, Forrest J. Diagnostic laparoscopy and management of the impalpable testis--a review of 10 years' practice at a non-paediatric specialist centre. Journal of Pediatric Urology 2008;4(3):214-7.

Atawurah H. Role of laparoscopy in diagnosis and management of nonpalpable testes. World Journal of Laparoscopic Surgery 2011;4(2):73-5.

Burjonrappa SC, Al HH, Barrieras D, Houle AM, Franc-Guimond J. Laparoscopic orchidopexy: the easy way to go. Journal of Pediatric Surgery 2009;44(11):2168-72.

Canavese F, Lala R, Valfre L, Vinardi S, Bianco E, Cortese MG. Effectiveness of primary inguinal orchiopexy as treatment of non-palpable testes in the first two years of age. Minerva Pediatrica 2010;62(3):245-8.

Daher P, Nabbout P, Feghali J, Riachy E. Is the Fowler-Stephens procedure still indicated for the treatment of nonpalpable intraabdominal testis? Journal of Pediatric Surgery 2009;44(10):1999-2003.

Denes FT, Saito FJ, Silva FA, Giron AM, Machado M, Srougi M. Laparoscopic diagnosis and treatment of nonpalpable testis. International Brazilian Journal of Urology 2008;34(3):329-34.

Desireddi NV, Liu DB, Maizels M, Rigsby C, Casey JT, Cheng EY. Magnetic resonance arteriography/venography is not accurate to structure management of the impalpable testis. Journal of Urology 2008;180(4 Suppl):1805-8.

Dessanti A, Falchetti D, Iannuccelli M, Milianti S, Altana C, Tanca AR, et al. Cryptorchidism with short spermatic vessels: staged orchiopexy preserving spermatic vessels. Journal of Urology 2009;182(3):1163-7.

Esposito C, Vallone G, Savanelli A, Settimi A. Long-term outcome of laparoscopic Fowler-Stephens orchiopexy in boys with intra-abdominal testis. Journal of Urology 2009;181(4):1851-6.

Hvistendahl GM, Poulsen EU. Laparoscopy for the impalpable testes: experience with 80 intra-abdominal testes. Journal of Pediatric Urology 2009;5(5):389-92.

Kaye JD, Palmer LS. Single setting bilateral laparoscopic orchiopexy for bilateral intra-abdominal testicles. Journal of Urology 2008;180(4 Suppl):1795-9.

Kelley BP, Higuera S, Cisek LJ, Friedman J, Heller L. Combined laparoscopic and microsurgical techniques for testicular autotransplantation: is this still an evolving technique? Journal of Reconstructive Microsurgery 2010;26(8):555-8.

Kojima Y, Mizuno K, Kamisawa H, Kato T, Kohri K, Hayashi Y. Laparoscopic management of nonpalpable testis: new treatment strategy. Journal of Endourology 2011;25(4):635-40.

Mahomed A, Adams S, Islam S. Initial success with gubernacular-sparing laparoscopic-assisted Fowler-Stephens orchidopexy for intra-abdominal testes. Journal of Laparoendoscopic and Advanced Surgical Techniques 2012;Part A. 22(2):192-4.

Moursy EE, Gamal W, Hussein MM. Laparoscopic orchiopexy for non-palpable testes: outcome of two techniques. Journal of Pediatric Urology 2011;7(2):178-81.

Noh PH, Kalyanaraman B. Single trocar skin puncture laparoscopic orchidopexy. Urology 2012;80(3):695-7.

Papparella A, Romano M, Noviello C, Cobellis G, Nino F, Del MC, et al. The value of laparoscopy in the management of non-palpable testis. Journal of Pediatric Urology 2010;6(6):550-4.

Sharifiaghdas F, Beigi FM. Impalpable testis: laparoscopy or inguinal canal exploration? Scandinavian Journal of Urology and Nephrology 2008;42(2):154-7.

Shehata SM. Laparoscopically assisted gradual controlled traction on the testicular vessels: a new concept in the management of abdominal testis. A preliminary report. Eur Journal of Pediatric Surgery 2008;18(6):402-6.

Tang PMY, Leung MWY, Chao NSY, Wong BPY, Kwok WK, Liu KKW. Use of laparoscopy in the management of impalpable testis in children. Hong Kong Journal of Paediatrics 2009;14(3):172-6.

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