One Stage vs. Two Stage Gubernaculum Sparing Laparoscopic Orchidopexy (GSLO)
One Stage vs. Two Stage Gubernaculum Sparing Laparoscopic Orchidopexy (GSLO)
Undescended Testis (UDT) is the most common congenital anomaly of the genitalia in boys and
 it is commonly managed by surgical intervention. Patients with intra-abdominal or non
 palpable testis, specifically, are often managed using a laparoscopic assisted orchidopexy, a
 common surgical technique to bring undescended testes down into the scrotum. Evidence in the
 medical literature to support the superiority of either one stage or two stage gubernaculum
 sparing laparoscopic orchidopexy (GSLO) is lacking. Due to this reason, this study focuses on
 the effects of one stage versus two stage GSLO on a patient important outcome: testicular
 atrophy.
The principal research question to be addressed is: what is the feasibility of a randomized
 controlled trial to assess whether in boys, 1-5 years of age, diagnosed with intraabdominal
 UDT, two-stage GSLO results in fewer postoperative testicular atrophies when compared to
 single-stage GSLO? The results of this study will be used to assess the feasibility of a
 randomized controlled trial on this topic. If our protocol does not require significant
 modifications, then participants assessed in this pilot trial will be included as
 participants in the definitive multicenter trial.

 To the best of our knowledge, the full-scale trial will be the first prospective,
 multicenter, randomized controlled trial to study the success rates of single-stage and
 two-stage GSLO. The results of the definitive multicenter trial will inform guidelines both
 locally and nationally, regarding the efficacy of staged techniques for orchidopexy. The
 results of this study will also inform and improve current care for children with IAT, as
 atrophy rates can be as high as 33% using the traditional laparoscopic approach.

 Furthermore, if it is shown that a single stage approach is more efficacious than a two-stage
 approach, it will limit unnecessary exposure of young children to general anesthetic, which
 may be associated with an increased risk for learning disability or behavioral problems

 The control group will receive single-stage GSLO procedure, while the intervention group will
 receive a two-stage GSLO technique. The first stage of the two-stage technique involves the
 ligation of testicular vessels laparoscopically, or transection of these vessels using
 cautery. Approximately 3-6 months following the completion of the first stage, the patient is
 seen again and the second stage of the procedure is performed. Access is obtained with a
 Hasson technique through an umbilical incision. Dissection begins laterally and proceeds
 along the superior margin of the internal inguinal ring (IIR), extending medially beyond the
 obliterated umbilical artery, while preserving a wide strip of peritoneum between the testis
 and the gubernaculum. Further dissection is then performed proximally, near the bifurcation
 of the iliac vessels, which allows free mobilization of this peritoneal triangle containing
 collateral blood supply to the testis. Next, a laparoscopic grasper is advanced through the
 IIR alongside the gubernaculum, and into the most dependent aspect of the scrotum. The distal
 gubernacular attachments and preserved cremasteric vessels, along with the testis, are pulled
 through the IIR with the assistance of a laparoscopic grasper, following the normal
 testicular descent route into the ipsilateral scrotum. Upon completion of dissection and
 descent, the testis is fixed to the scrotum in a sub-dartos pouch with a single 4-0
 polydioxanone (PDS) stitch. If the patient is randomized to receive single-stage GSLO
 procedure, it is important to note that both the ligation of testicular vessels and the
 mobilization of the testis occur during the same operation.
Inclusion Criteria:

 -  boys 1-5 years of age at presentation to Pediatric Urology Clinics

 -  patients diagnosed with intraabdominal UDT

 -  patients who require one- or two-stage repair performed by fellowship-trained
 Pediatric Urologists

 Exclusion Criteria:

 -  patients who have undergone previous laparoscopic orchidopexy

 -  patients with palpable testes

 -  patients requiring orchiectomy