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PEDIATRIC
UROLOGY
doi: 10.1590/S1677-55382010000600031
Is
staging beneficial for Fowler-Stephens orchiopexy? A systematic review
Elyas R, Guerra LA, Pike J, DeCarli C, Betolli M, Bass J, Chou S, Sweeney
B, Rubin S, Barrowman N, Moher D, Leonard M
Queens University, Kingston, Ontario, Canada
J Urol. 2010; 183: 2012-8
- Purpose:
Fowler and Stephens showed that by dividing the spermatic vessels a
high intra-abdominal testis could be placed in the scrotum. Testicular
atrophy is a potential complication of this technique. We conducted
a systematic review to determine whether single or 2-stage Fowler-Stephens
orchiopexy results in better testicular viability.
Materials and Methods: We searched electronic databases, clinical trial
registries and gray literature. We included reports describing boys
younger than 18 years with a primary outcome of “testicular viability
and position.” We performed a meta-analysis using random effects
models. Heterogeneity was assessed using forest plot and I(2) statistic.
Results: We identified 1,807 citations and included 61 articles. Single
stage Fowler-Stephens orchiopexy was discussed in 9 articles, a 2-stage
procedure in 36 and both approaches in 16. There were no randomized
controlled trials, and most studies were cohort or case series. The
pooled estimate of success rates was 80% for single stage Fowler-Stephens
orchiopexy (95% CI 75 to 86) and 85% for 2-stage Fowler-Stephens orchiopexy
(95% CI 81 to 90). The pooled odds ratio of single stage vs 2-stage
Fowler-Stephens orchiopexy was 2.0 (95% CI 1.1 to 3.9) favoring the
2-stage procedure. There was no difference in the success rate between
laparoscopic and open techniques in either single or 2-stage Fowler-Stephens
orchiopexy. There was no evidence of asymmetry on the funnel plot. There
were no complications reported with single stage, while ileus, hematoma
and infection were the most common complications with 2-stage Fowler-Stephens
orchiopexy.
Conclusions: Both techniques have a fairly high success rate but 2-stage
Fowler-Stephens orchiopexy appears to carry a higher rate of success
than the single stage approach (85% vs 80%, OR 2 in favor of 2-stage).
Laparoscopic and open techniques had the same success rate. However,
the level of evidence of the studies was low, and a study of a more
robust design, such as a randomized controlled trial, should be performed.
- Editorial
Comment
This study
is a meta-analysis of the English literature regarding Fowler-Stephens
orchiopexy. The authors sought to determine if either a one-stage or
a two-stage procedure had better outcomes. Out of over 1,800 citations
they were able to include 61 articles. As one might imagine, their were
no randomized controlled trials and the overall quality of these studies
was average. Despite this, the statistical analysis demonstrated a slight
advantage to a staged Fowler-Stephens orchiopexy with a success rate
of 85% versus an 80% success rate in the single stage procedure. There
was no significant difference noted between laparoscopic or open repair
for either a single stage or a staged Fowler-Stephens orchiopexy. Those
studies that looked at both a one-stage versus two-stage Fowler-Stephens
orchiopexy were pooled together and favored a two-stage procedure with
an odds ratio of 2, although the numbers in many of these studies were
quite small.
Although the strength of the data in this metaanalysis is not particularly
strong it certainly favors a two-stage approach for these patients.
Location of the testis and anatomy of the vas and vessels will vary
from patient to patient. In addition, surgeon experience and comfort
level with each of these procedures has to be taken into account. Having
said that, however, this meta-analysis of the available literature gives
the advantage to a staged procedure.
M.
Chad Wallis
Division of Pediatric Urology
University of Utah
Salt Lake City, Utah, USA
E-mail: chad.wallis@hsc.utah.edu
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