Two decades of experience with laparoscopic varicocele repair in children: Standardizing the technique

A systematic review and meta-analysis on the efficacy of internal spermatic artery ligation during laparoscopic varicocelectomy in children and adolescents: Is it safe?

INTRODUCTION

Challenges in identifying small testicular arteries and lack of microscopic experience have led to a rising trend in the use of laparoscopic technique for pediatric and adolescent varicocele. The controversy over artery ligation (AL) and artery preservation (AP) during laparoscopic varicocelectomy (LV) is still debatable. This study investigates the effectiveness of AL and AP during LV in pediatric and adolescent varicocele cases.

METHODS

The systematic searches based on PRISMA guideline were conducted in PubMed, Scopus, ScienceDirect, Web of Science and ProQuest databases with pre-defined keywords. Both quantitative and qualitative analyses were performed to assess catch-up growth, persistence, recurrence, hydrocele, operative time, post-operative testicular volume, and sperm analysis.

RESULTS

A total of 1512 patients from 9 eligible studies were included. There were no significant differences in catch up growth (OR 0.89; 95%CI 0.53, 1.51; p = 0.68) or hydrocele incidence (OR 0.59; 95%CI 0.28, 1.24; p = 0.16). The recurrence rate and persistence rate in AP group is significantly higher compared to AL group (OR 2.95; 95%CI 1.53, 5.68; p = 0.001 and OR 5.13; 95% CI 2.04, 12.88; p = 0.0005, respectively). The mean operative time during laparoscopic varicocelectomy is significantly longer when arteries are preserved as opposed to when they are ligated (OR 5.33; 95%CI 2.05, 8.60; p = 0.001). AL and AP both improved testicular volume and post-operative sperm analysis.

CONCLUSIONS

AL showed higher efficacy and comparable safety to AP. We recommend using AL with lymphatic sparing to minimize hydrocele complications.

Outcome following the surgical management of varicocele in children and adolescents: a systematic review and meta-analysis

Background

The ideal surgical approach for the management of varicocele in children and adolescents remains controversial. Several techniques are available including artery- or lymphatic-sparing with optical magnification (via open inguinal or sub-inguinal approach), laparoscopic, antegrade and retrograde embolization/sclerotherapy.

Objectives

We aimed to appraise the clinical outcomes of these techniques in children and adolescents.

Data Sources and Methods

A systematic review was conducted (1997-2023). Meta-analysis or proportional meta-analysis for non-comparative studies (Freeman-Tukey transformation) using the random effects model was conducted. Results are expressed as overall proportion % and 95% confidence interval (CI).

Results

We identified 1910 studies; 632 duplicates were removed, 1278 were screened, 203 were reviewed and 56 were included, with 12 reporting on 2 different techniques (total of 68 data sets). Optical magnification via inguinal approach (498 cases): recurrence 2.5% (0.6-5.6), hydrocele 1.6% (0.47-3.4), testicular atrophy 1% (0.3-2.0), complications 1.1% (0.2-2.6); optical magnification via sub-inguinal approach (592 cases): recurrence 2.1% (0.7-4.4), hydrocele 1.26% (0.5-2.3), testicular atrophy 0.5% (0.1-1.3), complications 4% (1.0-8.8). Laparoscopic with mass-ligation/division (1943 cases): recurrence 2.9% (1.5-4.6), hydrocele 11.4% (8.3-14.9); complications 1.5% (0.6-2.9); laparoscopic with lymphatic-sparing (974 cases): recurrence 2.4% (1.5-3.5), hydrocele 1.2% (0.45-3.36), complications 1.2% (0.05-3.9); laparoscopic with artery-sparing (228 cases): recurrence 6.6% (2.3-12.9), hydrocele 6.5% (2.6-12.0). Antegrade embolization/sclerotherapy (403 cases): recurrence 7.6% (5.2-10.4), hydrocele 0.8% (0.17-1.9), technical failure 0.6% (0.1-1.6), complications 4.0% (2.3-6.1); retrograde embolization/sclerotherapy (509 cases): recurrence 6.9% (4.6-9.5), hydrocele 0.8% (0.05-2.5), technical failure 10.2% (4.6-17.6), and complications 4.8% (1.0-11.2).

Conclusion

The recurrence rate varies between 2.1% and 7.6% and is higher with the embolization/sclerotherapy techniques. Post-operative hydrocele rate varies between 0.8% and 11.4% and is higher with the laparoscopic mass-ligation/division technique. Testicular atrophy has not been reported with the laparoscopic and embolization/sclerotherapy techniques. The retrograde embolization technique is associated with 10% technical failure (inability to complete the procedure). The laparoscopic lymphatic-sparing technique is characterized by the lowest recurrence rate, incidence of hydrocele and other complications, and no reports of testicular atrophy.

Recent Advances in Treatment of Recurrent Spontaneous Abortion

Importance

Recurrent spontaneous abortion (RSA) is a distressing condition experienced by approximately 1% of women trying to conceive. However, the treatment of RSA is a challenge both for clinicians and patients.

Objective

The aim of this review is to discuss the medical and surgical approach to the management of RSA, including those caused by anatomical, genetic, male, infectious, endocrine, and immune factors.

Evidence Acquisition

A literature search using MeSH terms for each topic was undertaken using PubMed, supplemented by hand searching for additional references. Retrieved articles were reviewed, synthesized, and summarized.

Results

Available treatments target hypothetical risk factors for RSA, although the effectiveness of many treatment options is controversial. Intervention should depend on the benefit-to-risk ratio of the proposed treatment.

Conclusions and Relevance

The etiology of RSA is heterogeneous, and patients often lack specific clinical manifestations, which has hindered the progress in predicting and preventing RSA to some extent. Despite intensive workup, at least 50% of couples do not have a clear underlying pathology. In addition, an evidence-based treatment is not available in most patients even if abnormal test results are present. Many new treatment directions are also still actively exploring; empirical and combined multiple treatments are still the main methods.

Target Audience

Obstetricians and gynecologists, family physicians.

Learning Objectives

After completing this activity, the learner should be better able to describe common risk factors for RSA; formulate individualized treatment plans to improve pregnancy outcomes; and propose supportive treatment recommendations for patients with unclear causes.

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.

Laparoscopic varicocelectomy in male infertility : Improvement of seminal parameters and effects on spermatogenesis

Background

The suitability of laparoscopic varicocelectomy for assisted reproductive technology depends on the improvement of semen parameters. The present study analyzed the improvement of semen parameters following laparoscopic varicocele ligation.

Material and methods

A retrospective study of the laparoscopic varicocele clippings at the Department of Urology of University Hospital of Kiel between the years 2007 and 2019 was conducted. The semen analyses according to WHO standards (sperm count, density, motility and morphology) were conducted before and 12 months after surgery. Screening for surgical complications took place at the time of the follow-up seminal analysis. Included were patients with oligozoospermia, asthenozoospermia and/or teratozoospermia (group 1, OAT) or with nonobstructive azoospermia (group 2, NOA).

Results

This study included data of 27 patients and 22 patients presented preoperative OAT (81%, group 1). Another 5 patients showed NOA (19%, group 2). Data of group 1 showed that semen parameters normalized in 32% of the patients after surgery. Significant improvement in total sperm count (p < 0.005), sperm density (p < 0.005) and total motile sperm count (p < 0.005) was observed. No deterioration of semen parameters was observed. In group 2 we detected spermatozoa in 1 case in the postoperative ejaculate. None of the patients showed complications according to the Clavien-Dindo classification, postoperative hydrocele formation or recurrence of varicocele at the time of control spermiogram.

Conclusion

Laparoscopic varicocelectomy is a valid therapeutic approach to improve semen parameters for further assisted reproductive techniques. Spermatogenesis may be induced for patients with NOA. Normalization of semen parameters can be achieved for patients with OAT.

Near-Infrared fluorescence imaging using indocyanine green (ICG): Emerging applications in pediatric urology

BACKGROUND

Near-infrared fluorescence (NIRF) imaging with indocyanine green (ICG) has been recently adopted in pediatric minimally invasive surgery (MIS) in order to improve intra-operative visualization of anatomic structures and facilitate surgery.

OBJECTIVE

This study aimed to report our preliminary experience using ICG technology in pediatric urology using laparoscopy and robotics.

STUDY DESIGN

ICG technology was adopted in 57 laparoscopic or robotic urological procedures performed in our unit over a 24-month period: 41 (38 laparoscopic - 3 robotic) left varicocele repairs with intra-operative lymphography and 16 renal procedures (12 laparoscopic - 4 robotic) including 9 partial nephrectomies, 3 nephrectomies and 4 renal cyst deroofings.

RESULTS

The ICG solution was injected intravenously in renal procedures or into the testis body in case of varicocele repair. Regarding the timing of the administration, the ICG injection was performed intra-operatively in all cases and allowed the visualization of the anatomic structures in a matter of 30-60 s. The dosage of ICG was 0.3 mg/mL/kg in all indications. All procedures were completed laparoscopically or robotically without conversions. No adverse and allergic reactions to ICG and other complications occurred postoperatively.

DISCUSSION

This paper describes for the first time in pediatric urology that ICG-guided NIRF imaging may be helpful in laparoscopic and robotic procedures. In case of varicocele repair, ICG-enhanced fluorescence allowed to perform a lymphatic-sparing procedure and avoid the risk of postoperative hydrocele. In case of partial nephrectomy, ICG-guided NIRF was helpful to visualize the vascularization of the non-functioning moiety, identify the dissection plane between the two moieties (Fig. 1) and check the perfusion of the residual parenchyma after resection of the non-functioning pole. In case of renal cyst deroofing, ICG-guided NIRF aided to identify the avascular cyst dome and to guide its resection. No real benefits of using ICG-enhanced fluorescence were observed during nephrectomy.

CONCLUSION

Our preliminary experience confirmed the safety and efficacy of ICG technology in pediatric urology and highlighted its potential advantages as adjunctive surgical technology in patients undergoing laparoscopic or robotic urological procedures. Use of NIRF was also cost-effective as no added costs were required except for the ICG dye (cost 40 eur per bottle). The most common and useful applications in pediatric urology included varicocele repair, partial nephrectomy ad renal cyst deroofing. The main limitation is the specific equipment needed in laparoscopy, that is not available in all centers whereas the robot is equipped with the Firefly® software for NIRF.

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.

Image-Guided Pediatric Surgery Using Indocyanine Green (ICG) Fluorescence in Laparoscopic and Robotic Surgery

Background: Indocyanine green (ICG)-guided near-infrared fluorescence (NIRF) has been recently adopted in pediatric minimally invasive surgery (MIS). This study aimed to report our experience with ICG-guided NIRF in pediatric laparoscopy and robotics and evaluate its usefulness and technique of application in different pediatric pathologies. Methods: ICG technology was adopted in 76 laparoscopic and/or robotic procedures accomplished in a single division of pediatric surgery over a 24-month period (January 2018-2020): 40 (37 laparoscopic, three robotic) left varicocelectomies with intra-operative lymphography; 13 (10 laparoscopic, three robotic) renal procedures: seven partial nephrectomies, three nephrectomies, and three renal cyst deroofings; 12 laparoscopic cholecystectomies; five robotic tumor excisions; three laparoscopic abdominal lymphoma excisions; three thoracoscopic procedures: two lobectomies and one lymph node biopsy for suspected lymphoma. The ICG solution was administered into a peripheral vein in all indications except for varicocele and lymphoma in which it was, respectively, injected into the testis body or the target organ. Regarding the timing of the administration, the ICG solution was administered intra-operatively in all indications except for cholecystectomy in which the ICG injection was performed 15-18 h before surgery. Results: No conversions to open or laparoscopy occurred. No adverse and allergic reactions to ICG or other postoperative complications were reported. Conclusions: Based upon our 2 year experience, we believe that ICG-guided NIRF is a very useful tool in pediatric MIS to perform a true imaged-guided surgery, allowing an easier identification of anatomic structures and an easier surgical performance in difficult cases. The most common applications in pediatric surgery include varicocele repair, difficult cholecystectomy, partial nephrectomy, lymphoma, and tumors excision but further indications will be soon discovered. ICG-enhanced fluorescence was technically easy to apply and safe for the patient reporting no adverse reactions to the product. The main limitation is represented by the specific equipment needed to apply ICG-guided NIRF in laparoscopic procedures, that is not available in all centers whereas the ICG system Firefly® is already integrated into the robotic platform.

Clinical application and technical standardization of indocyanine green (ICG) fluorescence imaging in pediatric minimally invasive surgery

PURPOSE

We reported our preliminary experience using ICG fluorescence in pediatric minimally invasive surgery (MIS) with the aim to standardize indications, dose, timing, and modality of administration of ICG according to different organs.

METHODS

ICG technology was adopted in 46 MIS procedures performed in our unit over the last 18 months: 30 left varicocele repairs; 5 cholecystectomies in obese adolescents; 3 tumor excisions; 3 nephrectomies; 2 partial nephrectomies; 3 lymphoma excisions. ICG solution was injected intravenously in all cases except for varicocelectomy in which it was injected into the testis. The ICG injection was performed intra-operatively in all cases except for cholecystectomy in which it was injected 18 h prior to the procedure.

RESULTS

All procedures were completed laparoscopically without conversions or intra-operative complications. No adverse or allergic reactions to ICG were reported.

CONCLUSION

Our preliminary experience showed that ICG fluorescence is a safe, useful, and versatile technique to adopt in pediatric MIS to achieve a better identification of anatomy and an easier surgical dissection or resection in challenging cases. Currently, the main indications are varicocelectomy, difficult cholecystectomy, tumor excision, nephrectomy, and partial nephrectomy. The main limitation is the needing of a special equipment to use ICG technology.

Single-Site Laparoscopy and Robotic Surgery in Pediatric Urology

PURPOSE OF REVIEW

In this review, we summarize research that has evaluated the role of laparoendoscopic single-site (LESS) and robotic surgery in pediatric urology, highlighting new and/or controversial ideas.

RECENT FINDINGS

The newest research developments over the last several years are studies that address generalizability of these techniques, ideal patient factors, extrapolation to more complex surgeries, and comparative studies to more traditional techniques to define the associated costs and benefits, as well as patient-centered outcomes. Specifically in the field of LESS, addressing the limitations of suboptimal vision, instrument crowding, and loss of triangulation have been a focus. The literature is now replete with new applications for robotic surgery as well as descriptions of the specific technical challenges inherent to pediatrics. Robotic surgery and LESS are areas of growth in pediatric urology that allow continual innovation and expansion of technology within a surgeon's armamentarium.

Adolescent varicocele: Efficacy of indication-to-treat protocol and proposal of a grading system for postoperative hydroceles

BACKGROUND

Varicocele is a common urologic anomaly in adolescent males; however, evidence-based treatment guidelines do not exist. Hydroceles are known to be a common complication after surgical therapy, with a wide variation in the reported incidence between 1 and 40%.

AIM

This study aimed to introduce a standardized indication-to-treat protocol and prove its efficacy by analyzing the outcome of patients. Secondly, it aimed to better define postoperative hydroceles because the wide variation of reported incidence is attributed to a lack of definition.

METHODS

Our standardized treatment protocol included an initial assessment with clinical grading of varicoceles, ultrasound evaluation of testicular volume, and calculation of the atrophy index. Indications for surgical treatment were testicular volume asymmetry >20%, discomfort and pain, or bilateral varicocele. The Palomo procedure (laparoscopically since 2005) was the standard procedure. Postoperative hydroceles were graded according to clinical findings and symptoms: Grade I, sonographic chance finding without clinical correlate; Grade II, palpable but clinically insignificant; Grade III, symptomatic. All patients treated according to the defined protocol were prospectively monitored between January 2001 and December 2015.

RESULTS

A total of 129 patients with left varicocele were referred to our institution; 70 fulfilled the indication criteria for surgical treatment. Twenty-eight of these patients were treated for volume asymmetry, 26 of these showed catch-up growth. Forty-two patients were treated for discomfort and pain; the symptoms subsided in all of them. Postoperative hydroceles were detected in 36 patients (51%). In 29 patients this was a sonographic chance finding (Grade I). Three patients showed a palpable but clinically insignificant postoperative hydrocele (Grade II) and four patients (5.7%) showed symptomatic hydrocele (Grade III) where treatment was recommended.

DISCUSSION

The treatment protocol allowed judicious indication for surgery and postoperative outcomes similar to previous reports. The high rate of catch-up growth in operated cases represents a proxy for successful treatment in cases where more precise parameters, like semen quality or paternity rate, were not yet detectable. The introduced grading system for postoperative hydroceles provs to be a valid and appropriate instrument, and promises to be a standardized method for comparing outcomes in future studies.

CONCLUSION

The indication-to-treat protocol proved to be easily applicable, highly efficient, and have outcomes comparable to international literature. The necessity for a standardized grading of postoperative hydroceles was underscored in the data.