Effectiveness of laparoscopic varicocelectomy

15-Year varicocelectomy outcomes in pediatric age: Beware of genitofemoral nerve injury

BACKGROUND

Varicocele affects 15% of adolescents. The main postoperative complications are recurrence and hydrocele; nerve injury is rarely reported.

OBJECTIVE

The aims of this study are: to assess the complications after laparoscopic varicocelectomy, namely nerve injury; and to assess if nerve injury is more frequent using "hot" or "cold" ligation.

STUDY DESIGN

Retrospective study of varicocele cases submitted to laparoscopic correction in our department from April 2006 to March 2020. Parameters analyzed were: age, clinical findings, surgical indication, operative technique, and outcomes. Comparison was done between the "cold" versus "hot" vessel section technique.

RESULTS

110 patients, with median age 14-years-old, were included. Most cases were on the left side and grade 3. Fifty patients (45%) presented complications: 21% recurrence; 18% hydrocele; and 3% genitofemoral nerve injury. Nerve injury was independent of the technique used.

DISCUSSION

Genitofemoral nerve injury is a complication with unknown cause and all cases are related to laparoscopic technique. It was suggested that "hot" methods of ligation of the vessels can lead to higher incidence of the lesion, but that was not corroborated in our analysis. Possible explanations for its occurrence are: a wide peritoneal window opening created with electrocautery near the internal inguinal ring; and additional dissection required to isolate the testicular veins from the artery. Prospective studies are needed to clarify the real incidence of genitofemoral nerve injury and its causes.

CONCLUSIONS

Laparoscopic varicocelectomy seems to be safe and effective, although complications remain frequent regardless of the technique used. Genitofemoral nerve injury is a complication rarely described that may require rehabilitation, and so awareness for this problem is of paramount importance.

Successful outcomes in adolescent varicocele treatment with high-level laparoscopic varicocelectomy

PURPOSE

In this study, we aimed to compare the effects of testicular vein ligation level on complications encountered; i.e. high-level ligation cranial to the linea terminalis vs ligation caudal to the linea terminalis.

METHODS

A total of 47 unilateral adolescent patients, treated with laparoscopic varicocelectomy between January 2004 and December 2017, were reviewed retrospectively. Patients were divided into two groups in terms of ligation level: caudal to the linea terminalis as group 1 and cranial to the linea terminalis as group 2. Symptoms, varicocele grades, preoperative testicular growth arrest, operative method, hydrocele formation, postoperative recurrence and testicular catch-up growth were recorded.

RESULTS

The mean operation time was 38.6 ± 10.2 min (34-53 min) in group 1 and was 33.6 ± 6.4 min (29-42 min) in group 2. Single hydrocele occurred in the laparoscopic nonselective varicocelectomy in group 1 (4.5%) and was successfully treated with open hydrocelectomy. Single varicocele recurrence was observed in the laparoscopic selective varicocelectomy in group 1 (4.5%) and treated with laparoscopic nonselective varicocelectomy cranial to the linea terminalis.

CONCLUSIONS

The high-level ligation of the spermatic veins cranial to the linea terminalis during laparoscopic varicocelectomy, independent of the technique applied, may contribute to reasonable low hydrocele and recurrence rates.

LEVEL OF EVIDENCE

Level III.

Recurrent varicocele

Varicocele recurrence is one of the most common complications associated with varicocele repair. A systematic review was performed to evaluate varicocele recurrence rates, anatomic causes of recurrence, and methods of management of recurrent varicoceles. The PubMed database was evaluated using keywords “recurrent” and “varicocele” as well as MESH criteria “recurrent” and “varicocele.” Articles were not included that were not in English, represented single case reports, focused solely on subclinical varicocele, or focused solely on a pediatric population (age <18). Rates of recurrence vary with the technique of varicocele repair from 0% to 35%. Anatomy of recurrence can be defined by venography. Management of varicocele recurrence can be surgical or via embolization.

Surgical approaches for varicocele in pediatric patient

BACKGROUND

Varicocele represents one of the most common surgically correctible urologic anomalies in adolescent males. The best procedure for the treatment of adolescent varicocele has not been established, but with recent advances in minimal access surgery, there have been many reports praising the safety and efficacy of laparoscopy and retroperitoneoscopy for the surgical correction of varicocele in adolescent. The aim of this review is to compare the results of Palomo's technique, with retroperitoneoscopic and transperitoneoscopic approaches in adolescent, analyzing recurrence, testicular growth and complications.

METHODS

A literature search on PubMed and Cochrane Database was conducted with regard to management of varicocele in adolescent population. Twenty two English language studies that compared outcome of different minimally invasive treatments or outcome of minimally invasive and traditional surgical treatments for adolescent diagnosed with varicocele were included.

RESULTS

Intraoperative complications of minimally invasive approaches occur in early cases, but in pediatric urology these procedures would become more efficient with experience and these approaches continue to increase in number. Postoperative hydrocele is the most postoperative compliance of Palom technique, and reports have shown a wide range of variability for his incidence, depending on the technique used for surgical treatment. Literature showed an increase of testicular volume for real growth of testis after surgery, and an intratesticular improvement in sperm quality after minimally invasive approach. In laparoscopic approach reports have showed very low recurrence because allows better vision of collateral veins, and a lymphatic sparing technique permit to identify lymphatic vessels in 100% of cases.

CONCLUSIONS

The literature has shown that laparoscopic varicocelectomy is the surgical approach most commonly reported in adolescent patients, and that its use is increasing for better training for surgeons and the ability to avoid operational hydrocele that is a main complication after technical Palomo's technique.

Laparoscopic varicocelectomy in the management of chronic scrotal pain

Background and Objectives:

To evaluate the usefulness of laparoscopic varicocelectomy in the management of chronic scrotal pain.

Methods:

Between 2009 and 2011, 48 patients in total were treated with laparoscopic varicocelectomy for dull scrotal pain that worsened with physical activity and was attributed to varicoceles. All patients were followed up at 3 and 6 months and biannually thereafter with a physical examination, visual analog scale score, and ultrasonographic scan in selected cases.

Results:

The mean age was 38.2 years (range, 23–54 years). The mean follow-up period was 19.6 months (range, 6–26 months). Bilateral varicoceles were present in 7 patients (14.6%), and a unilateral varicocele was present in 41 (85.4%). The varicocele was grade 3 in 27 patients (56.3%), grade 2 in 20 (41.6%), and grade 1 in 1 (2.1%). The mean preoperative visual analog scale score was 4.8 on a scale from 0 to 10. The mean postoperative visual analog scale score at 3 months was 0.8. After the procedure, 42 patients (87.5%) had a significant improvement in the visual analog scale score (P < .001); 5 (10.4%) had symptom improvement, although it was not statistically significant; and 1 (2.1%) remained unchanged. During follow-up, we observed 5 recurrences (10.4%) whereas de novo hydrocele formation was identified in 4 individuals (8.3%).

Conclusion:

Laparoscopic varicocelectomy is efficient in the treatment of symptomatic varicoceles with a low complication rate. However, careful patient selection is necessary because it appears that individuals presenting with sharp, radiating testicular pain and/or a low-grade varicocele are less likely to benefit from this procedure.

Leg ischemia post-varicocelectomy

Varicocelectomy is the most commonly performed operation for the treatment of male infertility. Many surgical approaches are used as each of them has advantages over the other and is preferred by surgeons. Vascular injury has never been reported as a complication of varicocelectomy apart from testicular artery injury. We present a 36-year-old male who developed leg ischemia post-varicocelectomy due to common femoral artery injury. He was successfully treated by using a vein graft.

The evolution and refinements of varicocele surgery

Varicoceles had been recognized in clinical practice for over a century. Originally, these procedures were utilized for the management of pain but, since 1952, the repairs had been mostly for the treatment of male infertility. However, the diagnosis and treatment of varicoceles were controversial, because the pathophysiology was not clear, the entry criteria of the studies varied among centers, and there were few randomized clinical trials. Nevertheless, clinicians continued developing techniques for the correction of varicoceles, basic scientists continued investigations on the pathophysiology of varicoceles, and new outcome data from prospective randomized trials have appeared in the world's literature. Therefore, this special edition of the Asian Journal of Andrology was proposed to report much of the new information related to varicoceles and, as a specific part of this project, the present article was developed as a comprehensive review of the evolution and refinements of the corrective procedures.

Effects of anthocyanin extracted from black soybean seed coat on spermatogenesis in a rat varicocele-induced model

Varicocele is the most common cause of primary male infertility and is associated with oxidative stress. The aim of the present study was to investigate the effects of anthocyanin on a rat model of varicocele. Twenty-four male rats were divided into four experimental groups: a normal control group, a varicocele-induced control group and two varicocele-induced groups treated with either 40 or 80mgkg(-1), p.o., anthocyanin for 4 weeks. Varicocele was induced by the partial obstruction of the left renal vein. After 8 weeks, the testes and epididymides from rats in all groups were removed, weighed and subjected to histological examination and semen analysis. Apoptosis in the testes was determined by terminal deoxyribonucleotidyl transferase-mediated dUTP-digoxigenin nick end-labelling (TUNEL) and oxidative stress was assessed by measuring 8-hydroxy-2'-deoxyguanosine (8-OHdG) levels. Although no significant differences in sperm counts were observed among the groups, anthocyanin treatment of the varicocele-induced groups resulted in significantly increased testes weight, sperm motility and spermatogenic cell density (P<0.05). Anthocyanin treatment also significantly decreased apoptotic body count and 8-OHdG concentrations (P<0.05). We suggest that the antioxidant effect of anthocyanin prevented the damage caused by varicocele-induced reactive oxygen species.

Genitofemoral nerve injury after laparoscopic varicocelectomy in adolescents

PURPOSE

Genitofemoral nerve injury is an underappreciated complication after laparoscopic varicocele ligation in teenage boys. We describe the incidence according to ligation instrument and the pattern of spontaneous symptom resolution.

MATERIALS AND METHODS

Patients who underwent laparoscopic varicocele ligation between 2004 and 2007 were retrospectively grouped by ligation modality (clipping or cautery by ultrasonic shears). The incidence of iatrogenic genitofemoral nerve injury was assessed and compared. To illustrate the pattern of resolution, 1 affected patient documented the decreasing area of paresthesia through time on a topographic map.

RESULTS

During the study period laparoscopic varicocele ligation was performed using ultrasonic shears in 12 boys and endoscopic clips/cold dissection in 15. Genitofemoral nerve injury occurred in 2 patients using ultrasonic shears (17%) and no patient in the clip/cold dissection group (p = 0.10). In both patients the paresthesias resolved completely by 8 months.

CONCLUSIONS

Genitofemoral nerve injury may be more frequent when the dissection is performed using "hot" methods such as cautery by ultrasonic shears. Preoperatively, patients should be made aware of the relatively high incidence and the usually self-limiting nature of this complication.

Laparoscopy in paediatric urology: present status

The spectrum of laparoscopic surgery in children has developed dramatically; what was initially used as a diagnostic method to identify an impalpable testis is now commonly used for complex reconstructive procedures such as pyeloplasty. Laparoscopic orchidopexy and nephrectomy are well established and are used at many centres. Laparoscopic partial nephrectomy, adrenalectomy and dismembered pyeloplasty series have reported shorter hospital stays and operative times that are comparable with that of open techniques, and/or decreasing with experience. The initial experiences with laparoscopic ureteric re-implantation and laparoscopically assisted bladder reconstructive surgery are reported, with encouraging results for feasibility, hospital stay, and cosmetic outcome.

Two-trocar laparoscopic varicocelectomy: cost-reduction surgical technique

OBJECTIVES

To describe the technique of two-trocar laparoscopic varicocelectomy and compare it with the standard three-trocar laparoscopic technique in terms of effectiveness, morbidity, and cosmesis.

METHODS

Two matched groups of patients with left varicocele were recruited. Each group included 30 patients. One group underwent three-trocar and the other two-trocar laparoscopic varicocelectomy. The results of the two approaches were compared.

RESULTS

No significant differences were found in terms of mean hospital stay or morbidity between the two-trocar and three-trocar techniques. A significant difference was found in the operative time and proportion of patients needing postoperative parenteral narcotic analgesia in favor of the two-trocar technique. In both approaches, the previously infertile patients had a significant improvement in sperm count and motility (P <0.05). Cosmetically, the trocar wound scars were aesthetically superior using the two-trocar technique.

CONCLUSIONS

No significant difference was found between two-trocar and three-trocar laparoscopic varicocelectomy in terms of effectiveness and morbidity. The cost of an extra 5-mm disposable trocar in the three-trocar technique and the improved cosmesis after the two-trocar technique have made us prefer the latter technique.

Minimal invasiveness and effectivity of subinguinal microscopic varicocelectomy: a comparative study with retroperitoneal high and laparoscopic approaches

AIM

The standard management of varicocele repair is the subject of ongoing controversy. We retrospectively evaluated three surgical methods of varicocele treatment to determine the minimally invasive and most effective procedure.

METHODS

We performed 144 varicocelectomies on infertile patients with left clinical varicocele. Of the patients, 50 were treated with retroperitoneal high ligation under lumbar anesthesia, 33 with laparoscopic ligation under general anesthesia, and 61 with subinguinal microscopic ligation under local anesthesia. Operative time, hospital days, and clinical outcomes were compared between these techniques.

RESULTS

The operating time and hospitalization period required for subinguinal microscopic ligation was signi fi cantly shorter compared to those for the other procedures. All patients treated with subinguinal microscopic ligation could achieve normal activity as soon as they returned to their rooms. Postoperative complications were observed in fi ve (10.0%) cases treated with high ligation and three (9.1%) laparoscopic cases, but were not observed after the subinguinal procedure. There were six cases (12.0%) of recurrence in the high ligation group and six (6.1%) in the laparoscopic group, but none in the subinguinal group. Sperm density was signi fi cantly improved in all procedures postoperatively, but sperm motility was not improved. The two-year pregnancy rate calculated by the Kaplan-Meier method was 35.8% for high ligation, 40.4% for laparoscopic ligation and 50.9% for subinguinal microscopic ligation, although there were no statistical differences between the three groups.

CONCLUSION

We concluded that subinguinal microscopic varicocelectomy could be a minimally invasive procedure compared to the other two techniques and a worthy method for treating male infertility due to clinical varicocele.

Improvement in the fertility rate after placement of microsurgical shunts in men with recurrent varicocele

OBJECTIVE

To evaluate the effectiveness of microsurgical shunts for secondary varicocele repair after ligation-like procedures, focusing on long-term functional outcomes.

DESIGN

Long-term survey (mean follow-up, 8.5 years) of infertile men after secondary microsurgical reconstructive varicocelectomy.

SETTING

University-based medical center.

PATIENT(S)

Thirty-four infertile men (group A, <30 years of age; and group B, >30 years) with recurrent palpable varicocele after varicocelectomy, according to Ivanissevich (n = 28), or after angiographic vein occlusion (n = 6). Ten patients presented bilateral recurrence.

INTERVENTION(S)

Microsurgical shunts between spermatic vein and inferior epigastric vein.

MAIN OUTCOME MEASURE(S)

Sperm count, pregnancy rate, and ultrasound evaluation of varicosity.

RESULT(S)

Complete disappearance of varicosity was achieved in 97.06% of patients, while in 2.94%, a consistent reduction in size was observed. In patients with severe infertility, a significant postoperative increase in seminal parameters was observed. Pregnancy rates were 43.75% in group A and 22.22% in group B.

CONCLUSION(S)

Microsurgical drainage in patients with recurrent varicocele after ligation-like procedures was shown to be an effective minimally invasive treatment, with immediate hemodynamic recovery of testicular venous outflow and excellent long-term results in patients with left or bilateral recurrences.

Nerve injury after laparoscopic varicocelectomy

PURPOSE

Laparoscopic varicocelectomy is a minimally invasive option for varicoceles in children. Occasional reports of nerve injury after inguinal laparoscopic procedures have been published. There is anatomical variation in the sensory innervation of the anterior thigh and variable branching patterns of the nerves involved. We report a retrospective analysis of our patients, focusing on the incidence of sensory changes on the ipsilateral anterior thigh after laparoscopic varicocelectomy.

MATERIALS AND METHODS

The medical records of all patients who underwent laparoscopic varicocelectomy at 1 institution performed by 2 of us (YR and DV) from 1997 to 2002 were retrospectively reviewed. Demographics, outcomes and any postoperative sensory complications were obtained by chart review and telephone interview.

RESULTS

A total of 58 patients underwent laparoscopic varicocelectomy during this 5-year analysis and 51 with a total of 62 varicoceles were available for review. Three patients (4.8%) experienced transient numbness of the ipsilateral anterior thigh, which resolved or improved in an average of 8.0 months (range 6 to 9). Symptoms were not always noticed immediately postoperatively (range 0 to 10 days). In affected patients the sensory distribution was usually consistent with injury to the genitofemoral nerve.

CONCLUSIONS

Laparoscopic varicocelectomy is a minimally invasive procedure that still has the potential for complications. Cautery or harmonic dissection of the peritoneum overlying the spermatic cord and excessive traction on the tissues surrounding the cord should be avoided intraoperatively. Patients and surgeons should be aware of the possibility of nerve injury and the resultant sensory deficit.

Applications of laparoscopic surgery in urology: impact on patient care

From its first use as a diagnostic tool, urologic laparoscopy has developed into a complex therapy for both benign and malignant disease. Most procedures are still performed at large centers with experienced laparoscopists but nonacademic urologists are starting to gain the necessary training and skills. With the clear advantage that laparoscopy shows over open procedures in terms of decreased perioperative morbidity and quicker recovery times, patients are increasingly asking for this approach. The urologic community must meet this challenge and train future urologists to meet the expected demand.

[Laparoscopic spermatic vessel ligation in the treatment of varicocele: report of 129 procedures]

With the improvement of laparoscopic techniques in the hands of urologists, a minimally invasive therapy can be offered to patients. We report retrospectively our experience in the laparoscopic treatment of varicoceles. A total of 93 patients with 129 varicoceles were treated by a laparoscopic approach, the mean age was 29 years (12-47), with 57 left varicoceles and 36 bilateral varicoceles. Indications for treatment were infertility in 51 patients and pain in 42 cases. The mean duration of the operation was 40 min (25-85) for bilateral varicoceles, and 24 min (15-65) for left varicoceles. All our patients were operated the day of their admission and 52 patients left the hospital 8 h after the intervention. We report 2 incidents with conversion to open surgery in one case. The pregnancy rate after surgery in patients with infertility was 21%, the recurrence rate was 4%. Laparoscopic spermatic vein ligation in the treatment of varicocele is a minimally invasive procedure, simple, fast and is not a contraindication for other procedures in case of recurrence.

Laparoscopic surgery for pediatric varicoceles: Randomized controlled trial

BACKGROUND/PURPOSE

The purpose of this investigation was to evaluate the advantages and the shortcomings of laparoscopic varicocelectomy compared with open traditional treatment of varicoceles.

METHODS

A total of 654 patients were operated on for left-sided varicoceles over 5 years from 1995 to 2000. To evaluate the clinical efficiency of the treatment, the patients were divided randomly into 2 groups. Laparoscopic varicocelectomy (LV) was performed on 434 patients, and open varicocelectomy (OV) in 220 patients. Outcome data looked at relapse rate, presence of hydrocele, wound complications, and testicular or scrotal edema. Operating time, postoperative length of stay, and pain control also were compared. In both groups, the operations were performed by Palomo's technique with preservation of lymphatics and mass ligation of the artery and veins in the retroperitoneum above the internal inguinal ring.

RESULTS

In LV versus OV, relapse rates were 1.84% versus 1.36 (P < 0.5), hydrocele occurrence was 0.23% versus 1.82% (P < 0.1), wound complication was 0.23% versus 7.73%, and testicular or scrotal edema was 3.9% versus 13.1%. LV hospital stay was an average of 3 days versus 7 days for OV. Operating time was 15 minutes for LV versus 26 minutes in open. Postoperative analgesic use was almost cut in half with LV.

CONCLUSION

The clinical efficacy of LV is superior to traditional OV.

Laparoscopic ultrasonography

The use of laparoscopic ultrasonography (LUS) allows visualization of tissues beyond the two-dimensional laparoscopic picture, enhancing the amount and quality of information available to the surgeon. Linear-array transducers with frequencies of 7.5 to 10 MHz are typically used for LUS, employing B-mode scanning and color Doppler capability on probes with articulating tips. In general surgery, LUS has become a common adjunct to the intraoperative staging of upper gastrointestinal malignancy to determine resectability, avoiding unnecessary laparotomy. In urology, LUS appears to be a promising adjunct for four current procedures: difficult pelvic lymphocele marsupialization, renal cyst decortication, nephrolithotomy and other renal stone surgery, and cryotherapy of renal masses. The role of LUS during varicocelectomy is limited, and enthusiasm for this procedure is waning. Laparoscopic ultrasonography is a critical adjunct to renal cryoablation, a developmental procedure that currently lacks long-term data but is promising as therapy for small, incidentally detected renal masses. It appears that as laparoscopic urologic procedures continue to expand, so will the application of this promising operative imaging modality.

Incidence and pattern of varicocele recurrence after laparoscopic ligation of the internal spermatic vein with preservation of the testicular artery

OBJECTIVES

To determine the incidence and pattern of recurrence of varicocele after laparoscopic internal spermatic vein ligation with testicular artery preservation.

METHODS

In a prospective study, 16 patients who underwent 20 laparoscopic varix ligation were evaluated postoperatively for recurrence by clinical physical examination and percutaneous spermatic venography.

RESULTS

No significant complications were encountered with the surgical or radiological procedure. Clinical recurrence was detected by physical examination in 20% of cases, while percutaneous spermatic venography detected recurrence in 45% of cases. The sensitivity and specificity of clinical physical examination for detecting varicocele recurrence was 33% and 90.9%, respectively with an accuracy rate of 65%. Recurrences were through parallel collaterals or medial transverse collaterals in 88.8% and 11.2%, respectively. Parallel collaterals joined the spermatic vein in mid or high retroperitoneum in seven patients while it joined the renal vein in one patient. There were no low retroperitoneal parallel collaterals.

CONCLUSIONS

Laparoscopic ligation of internal spermatic vein with preservation of testicular artery is a procedure that is associated with low morbidity and quick recovery. It is able to achieve its surgical objective in only 55% of cases, however. Such information should be taken into consideration during patient counselling when selecting the operative technique of choice for varicocele ligation.

Laparoscopic adrenalectomy: the preferred choice? A comparison to open adrenalectomy

PURPOSE

We compare the effectiveness and efficiency of laparoscopic adrenalectomy to open surgical management of adrenal disorders.

MATERIALS AND METHODS

A retrospective comparison was undertaken of 21 patients who underwent transperitoneal laparoscopic adrenalectomy between April 1996 and May 1997 with 17 patients who underwent open adrenalectomy between October 1994 and January 1996. Any patient suspected of having primary adrenal carcinoma and/or an adrenal lesion larger than 6 cm. was excluded from the study.

RESULTS

Patient demographics were matched well. Mean laparoscopic surgical time was 79 minutes longer than for open surgery. After overcoming the learning curve, the surgical time decreased by 59 minutes in the last 10 laparoscopic adrenalectomies. All laparoscopic intraoperative complications were managed without the need for open surgical conversion. Postoperative characteristics demonstrated significant benefits in the laparoscopic group (p=0.001) with respect to days to return to full diet (1.7 versus 4.6), analgesic pain requirements and days of hospitalization (2.7 versus 6.2).

CONCLUSIONS

Laparoscopic adrenalectomy offers significant postoperative benefits to patients with benign adrenal disease requiring surgical intervention. The surgical time is longer than that for open adrenalectomy but there was an encouraging reduction in time after overcoming the laparoscopic learning curve. Laparoscopic adrenalectomy is an excellent choice for tumors smaller than 6 cm. Its role for larger lesions and/or primary adrenal carcinoma is currently under investigation.

Comparison of Laparoscopic and Open Ligation of the Testicular Vein in Bilateral Varicocele

In this study, we aimed to compare the advantages and disadvantages of open varicocelectomy with Kelami's incision versus laparoscopic varicocelectomy in bilateral varicoceles. We performed bilateral varicocelectomy by infrapubic incision in 43 patients with bilateral varicocele in our clinic between November 1995 and June 1997. The results of this method were compared with laparoscopic varicocelectomy results taken from literature. Open surgery has been found more advantageous in relation to the type of anesthesia, duration of the operation, complications and cost-effectiveness. There is no significant difference between the two methods with regard to the time of returning to normal activity. But, postoperative analgesic requirement in open surgery is more than in laparoscopic varicocelectomy. It is not fully known which method is best in varicocele treatment. In our clinic, however, open surgical ligation with Kelami's incision is preferred in bilateral varicocelectomies until a certain concensus is held about this treatment.

Stationary mechanical-assist technology for single-surgeon laparoscopic bilateral varicocelectomy

One potential detraction from the continued application of laparoscopy in the management of varicoceles is the requirement for a skilled assistant, which increases the cost of performing this surgery. This report describes the clinical application of a simple stationary mechanical-assist device to allow a single surgeon to perform bilateral varicocelectomies. The device is attached to the surgical table with a rotary adjusting stem-arm. A cross-mounted sidearm stretches over the patient and forms the attachment to the friction-jointed elbow and wrist attachment to the laparoscope, providing the range of motions similar to a human arm (shoulder, elbow, and wrist). By adjusting the tension at all three levels, changes of the laparoscopic camera portal are possible. Both of the surgeon's hands are then free to work through two operating trocars. The Laprotract arm (Minnesota Scientific, St. Paul, MN) costs $3000 and is autoclavable for quick reutilization. The average time needed to set up the device for bilateral varicocelectomy during eight cases was 2 minutes. The mean procedure time was 65.0 (+/-23.1) minutes, reflecting its ease of use. The electronic image obtained from the stationary mechanical assistant was always steady, and there was no inadvertent wandering from the surgical field. Statistical comparison with 63 open left and 22 open bilateral varicocelectomies during the same time period demonstrated no significant differences in the procedural times. Mechanical-assist technologies can facilitate laparoscopic bilateral varicocelectomies, allowing a single surgeon to perform this operation as quickly as left and bilateral open procedures.

Blue venography in adolescent varicocelectomy: a modified surgical approach

BACKGROUND/PURPOSE

Conventional varicocelectomy is often complicated by postoperative recurrences. When failure occurs, it is likely to be caused by incomplete interruption of the testicular vein, which is divided into multiple branches, or by the parallel collaterals, and to incompetence of the cremasteric vein(s). Occasionally it is caused by reversed flow in the deferential vein(s).

METHODS

The author reports his experience with 172 consecutive corrections of varicocele in adolescents (mean age, 13.4 years) by means of a personally modified technique. This technique is characterized by ileoinguinal access to all venous areas such as the retroperitoneum and the inguinal canal; ligature and transection of the internal and external spermatic veins, the parallel collaterals, and the deferential vein(s), if dilated and tortuous, with spermatic artery preservation; control of the interruption of flow in these veins by injection of methylene-blue solution in a vein of the pampiniform plexus (blue venography). Optical magnification (4x) and papaverine solution were also used. The rationale for this surgical approach is twofold: interruption of all testicular veins incompetent and potentially incompetent; easy and effective intraoperative control of venous interruption.

RESULTS

No varicocele recurrences or postoperative controlateral varicoceles were detected (follow-up, 6 to 24 months). The complications include a postoperative testicular atrophy by intraoperative methylene-blue extravasation with large hematoma of the cord and three postoperative hydroceles.

CONCLUSION

The surgical approach reported here is a simple, safe, artery-sparing technique.

Comparison of inguinal and laparoscopic approaches in the treatment of varicocele

To determine the pros and cons of inguinal and laparoscopic varix ligation techniques, we reviewed 53 patients who underwent inguinal (n = 35) and laparoscopic (n = 18) varicocelectomy at two centers. Intraoperative complications were not observed in either of the groups. There was 1 recurrence and 1 persistence in the laparoscopically treated patients. The inguinal approach had the advantage of shorter operating time (19.1 versus 52.8 min), ability to ligate the external spermatic veins, and it could be performed as an outpatient procedure. However, the laparoscopic approach seemed superior for preserving the spermatic artery (88.8% versus 68.5%) and had lesser postoperative morbidity.

Long-term results of microsurgical drainage for idiopathic varicocele

The long-term results of microsurgical shunts for idiopathic varicocele are reported in the present paper. Sixty-two patients with a total of 65 varicoceles (three were bilateral) were followed up for 1 to 8 years. Pre- and postoperative ultrasonographic evaluation of varicocele size was considered of great importance in order to reduce the bias of subjective clinical diagnosis and to achieve a reliable and objective follow-up. Microsurgical shunts were tailored to the type of reflux: renospermatic (76.9%), iliospermatic (10.8%) or mixed type (12.3%), 94% of patients experienced a complete morphologic disappearance of varicosities, while in 6% of the cases a consistent reduction of size was objectified although varicosities were still detectable at ultrasonographic examination. In patients with severe infertility a significant increase of seminal parameters was observed postoperatively and this improvement showed a higher statistical significance in patients aged < 30 years.

Laparoscopic surgery for adolescent varicocele: preliminary report on 80 patients

Laparoscopic clipping and division of the internal spermatic vessels was performed without complications in 80 adolescents to treat varicocele. In four cases the procedure had to be converted to open surgery. Two of the cases were converted because of technical errors during CO2 insufflation and in two cases because dissection of the vessels was impossible owing to abnormal adhesion of sigmoid colon. At 6 months' follow-up there was only one relapse. Only one hydrocele was noted postoperatively, and testicular size did not decrease in any patient. The authors believe that laparoscopic varicocelectomy is a simple, safe, and effective surgical procedure, which could be proposed as an alternative to open surgical or percutaneous embolization approaches. However, much more experience is needed to obtain a definitive conclusion.

Incidence of external spermatic veins in patients undergoing inguinal varicocelectomy

OBJECTIVES

To determine the incidence of external spermatic veins at inguinal varicocelectomy.

METHODS

A prospective study was performed by making intraoperative observations on 78 varicocelectomies (47 patients) performed by a single surgeon. All patients were referred for evaluation of male infertility and had a palpable varicocele present when examined while performing a Valsalva maneuver in the upright position. Varicocelectomies were performed via the inguinal approach using x 2.5 loupe magnification. Presence of external spermatic veins was defined as visualization (with x 2.5 loupe magnification) of veins on the floor of the inguinal canal traveling posterolateral to the spermatic cord that then subsequently exited the spermatic cord before passing through the internal inguinal ring. Age, anesthetic technique, and need for incision of the external inguinal ring were also recorded for each patient.

RESULTS

One third of patients had undergone left-sided varicocelectomies, while two thirds had undergone bilateral procedures. External spermatic veins were identified in 15% of left-sided varicoceles and 19% of right-sided ones. Of 31 patients undergoing bilateral varicocelectomies, 19% had at least 1 external spermatic vein. Of these patients, only 2 (7%) had a unilateral right external spermatic vein, none had a unilateral left external spermatic vein, and 4 (13%) had bilateral external spermatic veins. Overall, of all patients studied, 16% had at least 1 external spermatic vein. Follow-up at 1 year showed no evidence of clinical recurrence in any patient.

CONCLUSIONS

These results emphasize the importance of distal gonadal venous anatomy in the surgeon's choice of the proper approach to varicocele repair, since external spermatic veins are only accessible via an inguinal approach.