What are the types of orchidopexy (surgical procedure to move an undescended testicle into the scrotum)?

Types of Orchidopexy

For palpable undescended testes, perform either standard inguinal orchidopexy or single-incision scrotal orchidopexy, while non-palpable intra-abdominal testes require laparoscopic approaches including standard laparoscopic orchidopexy or staged Fowler-Stephens procedures. 1

Standard Approaches for Palpable Testes

Inguinal Orchidopexy (Two-Incision Technique)

• This is the traditional gold standard approach for most palpable cryptorchid testes, with documented success rates exceeding 96% and testicular atrophy rates below 2%. 1
• The procedure involves an inguinal incision with mobilization of the spermatic cord and placement of the testis into a scrotal dartos pouch. 1

Single-Incision Scrotal Orchidopexy (Bianchi Approach)

• For low-lying palpable testes, this primary scrotal approach is equally effective as the two-incision technique and has gained widespread acceptance. 1
• High scrotal orchidopexy successfully places 87% of palpable maldescended testes in the scrotum through a single high scrotal incision, with 80% showing excellent anatomical and cosmetic results. 2
• This technique requires less dissection of the inguinal region and provides superior cosmesis compared to traditional inguinal approaches. 2
• The key advantage is avoiding unnecessary inguinal dissection when the spermatic cord length is adequate, which is the case in most palpable undescended testes. 2

Laparoscopic Orchidopexy for Palpable Testes

• Recent evidence demonstrates that laparoscopic orchidopexy achieves better final testicular position (89.3% lower position rate) compared to open inguinal orchidopexy (77.9%), with comparable 100% success rates. 3
• This advantage is particularly pronounced in children aged 3 years or older, where laparoscopic surgery achieved 88.1% lower position rate versus 69.6% with open surgery. 3
• Laparoscopic approach for palpable testes has minimal complications and no testicular atrophy, making it an emerging alternative to traditional approaches. 3

Approaches for Non-Palpable Intra-Abdominal Testes

Diagnostic Laparoscopy

• Laparoscopy is mandatory for non-palpable testes to identify testicular vessel status and determine the next course of action, as radiologic imaging lacks both sensitivity and specificity. 1, 4
• Laparoscopy accurately defines intra-abdominal anatomy in 99% of cases (90 of 91 patients). 4

Standard Laparoscopic Orchidopexy (One-Stage)

• For intra-abdominal testes with adequate vascular length, standard laparoscopic orchidopexy preserves the testicular vessels and achieves 96% overall success rates. 5
• This approach is preferred when the testicular vessels can reach the scrotum without tension, avoiding the need for vessel division. 4, 5

Fowler-Stephens Orchidopexy (Staged Procedure)

• For high intra-abdominal testes where vessels are too short, the two-stage Fowler-Stephens procedure involves laparoscopic clipping of testicular vessels (first stage) followed by orchidopexy 6-12 months later (second stage). 6, 4
• The staged approach allows collateral blood supply through the vasal artery to develop before moving the testis. 6
• Two-stage laparoscopic Fowler-Stephens achieves 93.3% success rates with both stages performed laparoscopically, compared to higher atrophy rates when the second stage is performed open. 6, 4
• The average interval between stages is 9.7 months. 6

One-Stage Fowler-Stephens Orchidopexy

• One-stage Fowler-Stephens (immediate vessel division and orchidopexy) has significantly higher testicular atrophy rates, with 67% atrophy in some series (2 of 3 testes). 4
• One-stage Fowler-Stephens should be avoided given the superior outcomes of staged procedures. 4, 5
• When excluding patients with previous testicular surgery or extensive vasal dissection, staged Fowler-Stephens achieves 96% success rates. 5

Critical Technical Considerations

Avoiding Testicular Atrophy

• Never perform extensive dissection around the vas deferens, as this almost inevitably leads to testicular atrophy by compromising collateral blood supply. 5
• Patients with previous testicular surgery have significantly higher atrophy risk and should be counseled accordingly. 5
• Early spermatic cord control at the internal inguinal ring is mandatory before any testicular manipulation to prevent tumor spread. 7

When to Perform Orchiectomy Instead

• Orchiectomy is indicated when a normal contralateral testis exists and the patient has very short testicular vessels and vas deferens, dysmorphic or severely hypoplastic testis, or postpubertal age. 1, 8
• In postpubertal males with cryptorchidism, orchiectomy or biopsy should be strongly considered given limited fertility benefit and elevated cancer risk. 1

Timing Considerations

• All orchidopexy procedures should be performed by 18 months of age to preserve fertility potential, as progressive germ cell loss accelerates after 15-18 months. 1, 8
• Prepubertal orchidopexy reduces testicular cancer risk by 2-6 fold compared to postpubertal surgery. 1, 8