Intraoperative spermatic venography during varicocele surgery in adolescents

An Analysis of Major Causes of Surgical Failure Using Bähren System in Intraoperative Venography During Varicocelectomy

PURPOSE

In young patients with varicocele, preservation of the internal spermatic artery may be advantageous for catch-up growth, but it may also increase the likelihood of treatment failure. Intraoperative venography reduces the likelihood that unsealed veins will remain after varicocelectomy. We analyzed the characteristics of remnant veins visualized through intraoperative venography to investigate the cause of surgical failure in artery-sparing varicocelectomy (ASV).

MATERIALS AND METHODS

We retrospectively analyzed clinical characteristics and outcomes of patients aged 18 years or younger who underwent varicocelectomy with intraoperative venography from January 2005 to December 2017. During varicocelectomy, intraoperative venography was performed to distinguish veins from other structures. Any unsealed veins that were discovered were ligated and classified using the Bahren system.

RESULTS

One hundred and sixty-two patients underwent intraoperative venography: 153 cases (94.4%) were for primary varicocelectomy, and 9 cases (5.6%) were for repeat varicocelectomy. Open varicocelectomy was performed in 105 cases (64.8%), and laparoscopic varicocelectomy was performed in 57 cases (35.2%). Venography revealed remnant veins after the first ligation in 51 cases (31.2%), 46 (90.2%) and 5 (9.8%) of which were Bähren types 3 and 4, respectively. Five patients (3.1%) experienced varicocele recurrence, classified as persistence in 1 patient (0.6%) and relapse in 4 patients (2.5%).

CONCLUSION

Remnant collateral veins of the internal spermatic vein (ISV) (Bahren type 3) are the most common cause of failure in ASV. In a few patients, an external spermatic vein merges with the ISV at a higher level (Bahren type 4) and is unidentifiable without venography.

The value of ultrasonography in the diagnosis of varicocele

A varicocele is described as pathologically enlarged, tortuous veins of the pampiniform plexus, leading to an increased testicular temperature and adrenal metabolite reflux into the testes. Varicocele can impair spermatogenesis and is considered to be the most common cause of male infertility. Patients may palpate a thickening in the scrotum or complain of dull scrotal or inguinal pain, which increases when standing or during erection. In the case of a sudden onset of varicocele in elderly men, it is necessary to exclude renal tumor and extend diagnostic ultrasound with the assessment of the abdominal cavity. The diagnosis of varicocele is based on medical history and physical examination, which involves palpation and observation of the scrotum at rest and during the Valsalva maneuver. Ultrasound is the imaging method of choice. The width and the number of vessels in the pampiniform plexus as well as the evaluation and measurement of regurgitation during the Valsalva maneuver are typical parameters analyzed during ultrasound assessment. However, diagnostic ultrasound is still a controversial method due to numerous and often divergent classification systems for varicocele assessment as well as its poor correlation with clinical manifestations. As a result of introduction of clear ultrasound criteria as well as the development of elastography and nuclear magnetic resonance, diagnostic imaging can play an important role in assessing the risk of damage to the testicular parenchyma, qualifying patients for surgical treatment and predicting the effects of therapy.

The role of testicular artery in laparoscopic varicocelectomy: a systematic review and meta-analysis

PURPOSE

We performed this meta-analysis to evaluate the efficacy and safety of artery preserving versus artery non-preserving in laparoscopic varicocelectomy.

METHODS

All publications up until October 2015 were searched in PubMed, EMBASE, Ovid, Web of Science, and Cochrane library. Randomized controlled trials (RCTs) and cohort studies (CSs) that compared the difference in two operative approaches in laparoscopic varicocelectomy were included. Statistical analysis was performed using Stata version 12.0.

RESULTS

A total of four RCTs and ten CSs involving 503 cases with artery preserving and 911 cases with artery non-preserving met our inclusion criteria. Meta-analysis showed that artery preserving had higher recurrence rate [risk ratio (RR) = 2.91, 95 % confidence interval (CI) 1.83-4.61; P = 0.000], lower incidence of hydrocele formation (RR = 0.18; 95 % CI 0.08-0.42; P = 0.000), and prolonged operating time [standard mean difference (SMD) = 1.27; 95 % CI 0.17-2.37; P = 0.023], compared with artery non-preserving in laparoscopic varicocelectomy. The results were similar in postoperative catch-up growth (RR = 1.00; 95 % CI 0.86-1.17; P = 0.985) and testicular atrophy (RR = 0.36; 95 % CI 0.09-1.54; P = 0.169). Besides, no significant difference was found in sperm concentration, motility, and normal morphology between two groups, as well as on postoperative pregnancy rate (RR = 0.95; 95 % CI 0.65-1.40; P = 0.809).

CONCLUSION

With the advantages of less recurrence, easier operating and less time spending, and comparable results in other respects, artery non-preserving is preferable to artery preserving in laparoscopic varicocelectomy, although there is a relatively high incidence of hydrocele formation. Considering the limitation of included studies, more large-scaled RCTs are required to confirm the present findings.

Effect of varicocelectomy on testicular volume in children and adolescents: a meta-analysis

OBJECTIVE

To evaluate the effect of surgical intervention on catch-up growth as determined by a decreased testicular volume discrepancy in children and adolescents with varicocele.

METHODS

A systematic search was performed using MEDLINE and the PubMed database and cross-referenced as of October 28, 2011 using the terms "varicocele," "children," "adolescent," "surgery," and "testicular volume." All relevant studies were of the testicular volume discrepancy variance before and after surgical repair. The outcomes included the number of patients with initial testicular atrophy and those with catch-up growth after surgical repair. The database search, quality evaluation, and data extraction were independently performed by 2 reviewers.

RESULTS

Of 75 studies, 14 were included for analysis and involved 1475 patients. The combined analysis showed that the testicular volume discrepancy was significantly reduced after surgery in the ≥10% group (P < .00001) and ≥20% group (P < .00001), respectively. No difference was found between the 2 groups (P = .70). Taken together, the number of patient with testicular volume disproportion in all pediatric and adolescent varicocele patients significantly decreased after surgery (P < .00001). The average proportion of catch-up growth was 76.4% (range 52.6%-93.8%).

CONCLUSION

The meta-analysis suggested clear advantages of surgical intervention on reducing testicular hypotrophy when the discrepancy is ≥10% in children and adolescents with varicocele. Additional prospective and controlled studies are warranted to elucidate the treatment of children and adolescents with varicocele.

Recurrence of varicocele after high retroperitoneal repair: implications of intraoperative venography

PURPOSE

We determined whether intraoperative venography results in a decreased recurrence rate after varicocele repair in adolescence.

MATERIALS AND METHODS

We evaluated 177 male adolescents 14 to 19 years old who underwent varicocele repair via the high retroperitoneal approach with artery sparing and intraoperative venography.

RESULTS

Overall the recurrence rate was 2.8% (5 of 177 cases) in the venography group and 11% in historical controls without venography. We identified left-to-right cross communicating vessels in 3 patients with recurrence. Intraoperatively venography revealed nonligated vessels in 21 patients (12%), resulting in revision and repair during the same procedure.

CONCLUSIONS

Intraoperative venography seems to decrease the rate of recurrence. Left-to-right cross communicating vessels may be present in some adolescents with recurrence after varicocelectomy.

The influence of surgical approach and intraoperative venography on successful varicocelectomy in adolescents

PURPOSE

We evaluated the importance of intraoperative venography and surgical approach on varicocele recurrence after surgical varicocelectomy in male adolescents.

MATERIALS AND METHODS

The analysis was done using local data and composite data from the literature. We reviewed the records of patients undergoing varicocele ligation between 1986 and 1995 at our institution. Data were stratified by surgical approach and performance of venography, and compared by cross table analysis. Data were then compiled from the literature from series that included cases stratified according to surgical approach and/or performance of venography. The impact of these parameters on recurrence rates was assessed by computing success rates and cross table analysis.

RESULTS

At our institution 33 boys underwent ligation via a suprainguinal (27) or inguinal (8) approach. Intraoperative post-ligation venography was performed in 16 cases and omitted in 19. Neither surgical approach nor performance of venography influenced the recurrence rate in these patients (not statistically significant). Similarly, venography did not affect the recurrence rate after stratification by surgical approach (not significant). The overall success rate was 97% (34 of 35 cases). These data were added to those of 3 published studies, totaling 252 varicoceles with comparable groupings. Mean success rate after a suprainguinal and inguinal approach was 95.6 (93.2 to 97.4) and 88.3% (82.7 to 100%), respectively. Recurrence tended to be less common after a suprainguinal than an inguinal approach (p = 0.06). Post-ligation venography did not statistically affect the success rate after stratification according to surgical approach but it was associated with a higher success rate when performed with the inguinal approach.

CONCLUSIONS

Irrespective of the performance of venography, the suprainguinal surgical approach yields higher success rates than the inguinal approach to varicoceles in adolescents. Post-ligation intraoperative venography fails to affect significantly the success of varicocele ligation but it may be useful during an inguinal approach.

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.

Ligation of the testicular artery and vein in adolescent varicocele

Proper surgical management of adolescent varicocele is controversial. Recent evidence suggests that the Palomo approach gives the best results. We report on the outcomes of 43 consecutive adolescent boys who underwent operative correction of varicocele by a single surgeon from 1979 to 1992. An inguinal approach with ligation of the vascular pedicle above the vas deferens (modified Palomo) was used in each case. From 1979 to 1983 an attempt was made to preserve the testicular artery but it was successful in only 6 of 12 cases. After 1983 no further attempt was made to preserve the artery and, therefore, 37 patients underwent total ligation of the vascular pedicle above the entry of the vas deferens into the spermatic cord. Most of the varicoceles were grade II. Significant discrepancy in testicular volume (10% difference) constituted the main indication for operation. The ipsilateral (left) testis was smaller in 30 of 37 patients (81%). Of those testes with size discrepancy 90% showed significant volume increase following surgery. Many left testes assumed the same volume as the normal right testis. The only surgical failure (recurrence) of the 43 cases occurred in 1 of the 6 in which artery preservation was successful. There were no surgical failures in the group of 37 boys. Mean followup is 3.7 years. Total ligation of the testicular vascular pedicle seems to afford catch-up growth for smaller ipsilateral testes with low risk for recurrence of the varicocele.