Fowler–Stephens Orchiopexy: Single-Stage and Two-Stage Technique

The testicle has three sources of blood supply: the main testicular vessel originating at kidney level, the deferential vessel running along the vas deferens, and fine branches from the gubernaculum (guiding ligament). When the main vessel is short, it cannot carry the testicle to the scrotum; but if the other two sources are strong enough, the testicle can survive on them alone.

The technique has two forms. In the single-stage version, the vessel is divided and the testicle is brought down into the scrotum in the same session. In the two-stage version, only the vessel is divided or clipped in the first session; the testicle is left in place and brought down in a second session about six months later.

The first session is performed under the same anesthesia, as a continuation of the diagnostic laparoscopy. Once the testicle is found high within the abdomen and the vessels are determined not to reach the scrotum, the plan already discussed with the family is put into action.

• The main testicular vessel is identified as far from the testicle as possible, higher up, so that the collateral connections near the testicle are preserved.
• The vessel is clipped, ligated, or sealed and divided. The testicle, vas deferens, and surrounding peritoneum are left untouched.
• The ports are closed; the procedure usually takes 30–45 minutes, and the child goes home the same day.

• In this session, the testicle is not mobilized; it is deliberately left in place. Mobilization could disrupt the collateral circulation, so it is reserved for the second session.

During the interval, the child continues normal daily life; no special check-ups or medication are needed. About six months later, the second session is planned, again usually laparoscopically.

• On laparoscopy, the testicle’s viability and size are assessed; the adequacy of the collateral circulation is judged from the testicle’s color and texture.
• The testicle is mobilized while the peritoneum around the vas deferens is preserved as a wide triangle of tissue; this peritoneum carries the collateral vessels, and keeping it intact is critical.
• The gubernaculum attachments are divided, preserving the vessels where possible.
• The testicle is routed through a short path medial to the inferior epigastric vessels, leading directly to the scrotum.
• A subdartos pocket is created in the scrotum; the testicle is placed without tension, and the ports are closed.

• The second session may take 60–90 minutes; the child goes home the same day or the following morning. Mild pain, swelling, and bruising at the port sites and in the scrotum are normal in the first days. In our practice, both sessions are performed jointly by two pediatric urology specialists.

Success is defined as the testicle remaining in the scrotum and viable. The risk is higher than for a palpable testicle; the most important possible complication is testicular atrophy (shrinkage of the testicle when the collateral circulation is insufficient). This risk is lower with the two-stage technique, but it is not zero.

• Even when the testicle is in the scrotum, it may remain smaller than the other side. For this reason, after the second session, follow-up occurs several times in the first year and then yearly until adolescence; evaluation continues at adolescence with size, hormone levels, and, if needed, semen analysis. Self-examination is taught from adolescence onward; follow-up continues with the same team into adult urology.