Results and complications of laparoscopic surgery for pediatric varicocele

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.

Analysis of internal spermatic vein embolization through catheter versus laparoscopic high ligation in treatment of left varicocele

OBJECTIVE

Varicocele is a common disease in young and middle-aged men. This study aims to compare the efficacy of internal spermatic vein embolization of left varicocele versus laparoscopic high ligation.

METHODS

From January 2017 to September 2018, a total of 69 varicocele patients were admitted and given the opportunity to choose the treatment option. Among these, 26 patients were treated with sclerosing agent injection, while 43 patients underwent laparoscopic surgery. They were followed up for 12 months after surgery, and the technical success rate, recurrence rate, complication rate, cost, operative time, and hospitalization time with regard to these two methods were analyzed.

RESULTS

All patients completed the medical procedures. There was no recurrence in patients in the sclerotherapy group during the follow-up period; however, the complication rate was 19.2%. Furthermore, the operative time, hospitalization time, and cost of treatment were 31.1 ± 11.1 min, 1.2 ± 0.49 days, and 9613.11 ± 895.97 Yuan, respectively. In the laparoscopic group, 9 patients underwent laparoscopic bilateral high ligation, while 34 patients received treatment on the left side alone. The recurrence rate of left varicocele was 4.7% and the complication rate was 44.2%. Furthermore, the operative time, hospitalization time, and treatment cost were 50.4 ± 14.48 min, 4.0 ± 2.02 days, and 10,948.29 ± 2547.00 Yuan, respectively. Moreover, there were statistically significant differences (P < 0.05) in operative time, hospitalization time, and treatment cost. Patients in the sclerotherapy group had an advantage with respect to the overall complication rate when compared with patients from the laparoscopic group (X² = 4.448, P < 0.05), and there was a statistically significant difference in hydrocele (X² = 4.555, P < 0.05). However, there was no significant difference in the recurrence rate between these two groups (X² = 1.245, P > 0.05).

CONCLUSION

Patients who underwent sclerotherapy showed a higher technical success rate, a lower recurrence rate, fewer complications, and shorter hospitalization time compared to those treated with laparoscopic ligation. Transcatheter sclerosing agent injection may be a preferable treatment option for patients with unilateral varicocele.

Treatment of Varicocele in Children and Adolescents: A Systematic Review and Meta-analysis from the European Association of Urology/European Society for Paediatric Urology Guidelines Panel

CONTEXT

The benefits and harms of intervention (surgical or radiological) versus observation in children and adolescents with varicocele are controversial.

OBJECTIVE

To systematically evaluate the evidence regarding the short- and long-term outcomes of varicocele treatment in children and adolescents.

EVIDENCE ACQUISITION

A systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. A priori protocol was registered to PROSPERO (CRD42018084871), and a literature search was performed for all relevant publications published from January 1980 until June 2017. Randomized controlled trials (RCTs), nonrandomized comparative studies (NRSs), and single-arm case series including a minimum of 50 participants were eligible for inclusion.

EVIDENCE SYNTHESIS

Of 1550 articles identified, 98 articles including 16 130 patients (7-21 yr old) were eligible for inclusion (12 RCTs, 47 NRSs, and 39 case series). Varicocele treatment improved testicular volume (mean difference 1.52ml, 95% confidence interval [CI] 0.73-2.31) and increased total sperm concentration (mean difference 25.54, 95% CI 12.84-38.25) when compared with observation. Open surgery and laparoscopy may have similar treatment success. A significant decrease in hydrocele formation was observed in lymphatic sparing versus non-lymphatic sparing surgery (p=0.02). Our findings are limited by the heterogeneity of the published data, and a lack of long-term outcomes demonstrating sperm parameters and paternity rates.

CONCLUSIONS

Moderate evidence exists on the benefits of varicocele treatment in children and adolescents in terms of testicular volume and sperm concentration. Current evidence does not demonstrate superiority of any of the surgical/interventional techniques regarding treatment success. Long-term outcomes including paternity and fertility still remain unknown.

PATIENT SUMMARY

In this paper, we review benefits and harms of varicocele treatment in children and adolescents. We found moderate evidence that varicocele treatment results in improvement of testicular volume and sperm concentration. Lymphatic sparing surgery decreases hydrocele formation. Paternity and fertility outcomes are not clear.

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

BACKGROUND

Controversy still exists about the indications and the gold standard approach for varicocele treatment in pediatric population.

OBJECTIVE

The authors report their 23 years of experience in laparoscopic varicocele repair in the pediatric population.

STUDY DESIGN

We retrospectively evaluated the data of 345 consecutive patients who underwent laparoscopic left varicocelectomy from January 1993 to December 2015. Average patient age was 12.5 years (range 8-17). Seven out of 345 patients (2%) had a recurrent varicocele, and five out of 345 patients (1.4%) had a varicocele on a single testis. In 335/345 patients (97.1%) we performed a Palomo procedure, and in 10/345 patients (2.9%) an artery-sparing Palomo procedure. After 2010, in 105/345 patients (30.4%) we performed a lymphatic sparing procedure using isosulfan blue injection preoperatively.

RESULTS

All procedures were completed in laparoscopy (Figure), without conversions or intraoperative complications. The average operative time was 17 min (range 14-45) for the Palomo procedure and 26 min (range 18-50) for artery-sparing Palomo. In 45/345 patients (13%) we performed additional procedures. We recorded 4/345 (1.3%) recurrences/persistences in patients undergoing Palomo, while we recorded 1/10 (10%) recurrence/persistence after artery-sparing Palomo. On 230 Palomo procedures performed in the pre-isosulfan blue era, we recorded 25 cases of hydrocele (10.8%), 13 of these were treated with transcrotal puncture and 12 required surgical operation. The last 105 patients undergoing isosulfan blue injection had no postoperative hydrocele. We also reported 10 other complications (I grade Clavien-Dindo) such as umbilical granuloma or instrumental problems.

DISCUSSION

Analyzing the international literature of the last 25 years, most papers focused on the minimally invasive treatment of pediatric varicocele. There are several reasons to perform laparoscopic repair of pediatric varicocele. First of all, it is technically easy to perform, the average operative time is very short, and it has excellent outcome in regard to varicocele persistence/recurrence. In addition it has a very low complication rate, and in particular adopting the intradartoic/intratesticular isosulfan blue injection before surgery we recorded no postoperative hydrocele.

CONCLUSION

On the basis of our 23 years of experience with varicocele repair, we clearly believe that laparoscopic Palomo lymphatic sparing varicocelectomy should be considered the standard of care for the treatment of pediatric patients with varicocele. Laparoscopic varicocelectomy is technically easy and quick to perform, painless, and scarless, with a recurrence rate of about 1%. The use of a preoperative injection of isosulfan blue completely eliminates postoperative hydrocele formation.

Antegrade sclerotherapy in adolescent varicocele patients

INTRODUCTION

In the 1970s, Tauber described the antegrade sclerotherapy technique to treat varicoceles, and reported a 10% recurrence rate. The present study aimed to evaluate paediatric success rates and the effect of modifications to the surgical technique.

METHODS

A prospective study was performed of all adolescent patients undergoing antegrade sclerotherapy surgery. Each patient had an idiopathic varicocele with spontaneous venous reflux on Doppler examination, and underwent cannulation of a pampiniform plexus vein via a scrotal incision under general anaesthetic. Aethoxysklerol^® 3% (2 ml/kg) maximum 3 ml was injected into the pampiniform plexus vein under fluoroscopic monitoring. Success was assessed by clinical examination and Doppler ultrasound 3, 6 and 9 months after surgery. Data were presented as median (interquartile range). Patients were split into three groups: Group A - liquid sclerotherapy with Y connector; Group B - liquid sclerotherapy direct to cannula; and Group C - foam sclerotherapy direct to cannula. Fisher's exact test was used to compare the success rates in each group.

RESULTS

A total of 91 patients underwent antegrade sclerotherapy. The median age was 14.8 years (range 13.7-15.5). Eleven persistent varicoceles occurred and were diagnosed by Doppler ultrasound. The success rate of surgery was 58% in Group A, 90% in Group B and 96% in Group C. Success was significantly higher in Group B and Group C compared with Group A. No testicular atrophy occurred; two wound infections, two haematomas and one hydrocele were recorded (Table).

CONCLUSION

Introduction of antegrade sclerotherapy in the adolescent population resulted in a safe and cost-effective method for the management of adolescent varicocele. Several modifications to the technique have been introduced to achieve a high success rate (96%) with minimal complications.

Varicocele percutaneous embolization outcomes in a pediatric group: 7-year retrospective study

PURPOSE

Percutaneous embolization and surgical repair are the current treatment options for varicocele, but determining method superiority remains controversial. In this retrospective study, we evaluate the technical success, complication and recurrence rates following percutaneous embolization in a pediatric group, which were compared to reported outcomes for surgical repairs.

METHODS

Thirty children treated for percutaneous varicocele embolization were recruited. The side and grade of varicocele, symptoms, testicular asymmetry, mean recurrence time, total radiation dose and complications were evaluated. Recurrence and follow-up complications due to embolization were also reviewed.

RESULTS

The venography showed retrograde filling of the internal spermatic vein with the identification of aberrantly fed vessels in 23 % of patients. None of the patients suffered from procedure complications except one who had venous injury which was treated with a sclerosing agent. The technical success rate was 93 % (28 patients) with a recurrence rate of 13 % (4 patients). Interestingly, the mean radiation dose used was 862.5 µGy m(2), 3 times lower than abdominal CT.

CONCLUSION

Considering the intravascular nature of embolization, which aims to avoid testicular artery and spermatic cord damage (difficult to avoid with the surgical method), and consequently a lower complication rate, along with the same success rate and recurrence rate, our study supports that embolization is a superior method to surgical interventions.

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.

Technical standardization of laparoscopic lymphatic sparing varicocelectomy in children using isosulfan blue

PURPOSE

The lymphatic preservation to prevent hydrocele formation after laparoscopic varicocelectomy is essential. Lymphatic sparing procedures using scrotal injection give a rate of mapping failures of 20%-30%. The aim of the present study is to standardize the technique of injection to perform a lymphatic sparing procedure in case of laparoscopic varicocelectomy.

METHODS

We retrospectively evaluated 50 patients who underwent laparoscopic varicocelectomy from July 2010 to July 2013. Patients were divided into two groups: G1 (25 patients) those who underwent a classical isosulfan blue scrotal intra-dartos injection and G2 (25 patients) those who underwent the new standardized isosulfan blue scrotal intra-dartos/intra-testicular injection.

RESULTS

In G1 lymphatic vessels were identified as blue coloured in 19/25 of cases (76%), in G2 in 25/25 of cases (100%). The results were analyzed using test χ(2) with Yates' correction and there was a statistically significant difference (χ(2)=0.05,1) between G2 and G1. Postoperative hydrocele was noted in 2/6 patients of G1 in whom the lymphatic vessels were not identified.

CONCLUSIONS

Laparoscopic lymphatic sparing varicocelectomy is an effective procedure to adopt in children with varicocele. The intra-dartos/intra-testicular injection of isosulfan blue is significantly better than the previously described intra-dartos injection, permitting to identify lymphatic vessels in 100% of cases in our series. No allergy to isosulfan blue was reported in both groups.

Blue patent lymphography prevents hydrocele after laparoscopic varicocelectomy: 10 years of experience

PURPOSE

Laparoscopic varicocelectomy according to the Palomo technique is the most common procedure adopted in children with testicular varicocele. This procedure involves the ligation of the internal spermatic cord and is associated with a 3%-5% incidence of recurrence and up to 30% incidence of hydroceles. We sought to determine the impact of lymphatic preservation on hydrocele formation and the success of varicocelectomy.

PATIENTS AND METHODS

We retrospectively evaluated 396 patients with a mean age of 13.2 years who underwent laparoscopic varicocelectomy. Patients were divided into two groups: those who underwent a lymphatic-sparing (LS) procedure using isosulfan blue scrotal intra-dartoic injection and those who underwent a non-LS (NLS) technique. The incidences of recurrence/persistence and postoperative hydrocele formation requiring surgery or aspiration were analyzed statistically using the chi-squared test.

RESULTS

Of 396 patients, 244 received a laparoscopic LS procedure, and 152 received an NLS operation. The LS patients in whom the lymphatic vessels were not identified (26/244 [10.6%]) were considered NLS repairs. The follow-up was at least 12 months. LS surgery (218 patients) was associated with a decreased incidence of postoperative hydrocele (0/218 [0%] versus 18/178 [10.1%]; chi-squared test=25.84, difference statistically significant). There was no significant difference in incidence of persistent or recurrent varicocele requiring reoperation following the initial procedure (5/218 [2.2%] versus 5/178 [2.8%]; chi-squared test=0.41, difference statistically not significant).

CONCLUSIONS

Laparoscopic LS varicocelectomy using isosulfan blue is preferable to laparoscopic Palomo repair that does not preserve the lymphatics. It has a significantly lower incidence of postoperative hydroceles and still maintains a low incidence of persistence/recurrence.

Intraabdominal laparoscopy-assisted "open" vessel ligation of testicular vessels: a potential treatment for varicocele

AIM

We tested our laparoscopy-assisted "open" ligation (LOL) technique on testicular vessels.

METHODS

We ligated the left testicular artery and vein (TAV) in 8-week-old male Wister rats using LOL (LOL group; n=10) or laparotomy (open group; n=10). In LOL, a 0-degree laparoscope was introduced through a 5-mm epigastric trocar. A 3-mm grasper was used to expose the left TAV. A lapa-her-closure (LHC) needle loaded with 3-0 SurgiPro was directly inserted into the left lower quadrant where the left TAV should be and advanced under the vessels, and the suture material was released leaving one end outside. The LHC was then withdrawn a little and advanced again over the vessels to grasp the end of the suture material just released to bring it outside. This was proximally repeated. The two ends of both sutures were conventionally tied outside, and the knot was passed through the insertion site and tightened around the vessels. In the open group, the left TAV were ligated using two 3-0 SurgiPro ties. In both groups, the right side was left intact. All rats were sacrificed 2 weeks postoperatively, and both testes were examined with hematoxylin and eosin.

RESULTS

Treatment time was 5-7 minutes for LOL and 7-8 minutes for the open group. Postoperative recovery was uneventful. No adhesions were present between the ligated vessels and bowel in any rat. Histopathology of all left testes showed coagulative necrosis of germinal cells and seminiferous tubules; all right testes were normal.

CONCLUSION

LOL appears to be as effective as open ligation and may find application for treating varicocele.

Management options of varicoceles

Varicocele is one of the most common causes of male infertility. Treatment options for varicoceles includes open varicocelectomy performed at various anatomical levels. Laparoscopic varicocelectomy has been established to be a safe and effective treatment for varicoceles. Robotic surgery has been introduced recently as an alternative surgical option for varicocelectomy. Microsurgical varicocelectomy has gained increasing popularity among experts in male reproductive medicine as the treatment of choice for varicocele because of its superior surgical outcomes. There is a growing volume of literature in the recent years on minimal invasive varicocele treatment with percutaneous retrograde and anterograde venous embolization/sclerotherapy. In this review, we will discuss the advantages and limitations associated with each treatment modality for varicoceles. Employment of these advanced techniques of varicocelectomy can provide a safe and effective approach aiming to eliminate varicocele, preserve testicular function and, in a substantial number of men, increase semen quality and the likelihood of pregnancy.

Percutaneous retrograde endovascular occlusion for pediatric varicocele

BACKGROUND/PURPOSE

The aim of this study was to assess whether percutaneous retrograde endovascular occlusion (PREVO) is effective and safe for the treatment of varicocele in pediatric patients.

METHODS

We retrospectively studied 71 children who underwent PREVO for left-sided varicocele. The primary outcome was the proportion of varicocele-free patients 6 months after PREVO as assessed by ultrasonography.

RESULTS

Seventy-one boys with left-sided grade III varicocele underwent PREVO at a mean age of 13.2 years. PREVO was performed under local anesthesia in all boys but 2, who required general anesthesia. The procedure was technically feasible in 68 (96%) patients. In the remaining 3 patients, the internal spermatic vein could not be catheterized. Minor short-term complications occurred in 6 patients and resolved fully. No major complications or deaths were recorded. The proportion of varicocele-free patients 6 months after PREVO was 93% (66/71) overall and 97% (66/68) in the patients whose PREVO procedure was feasible. No clinical recurrence was observed during the mean follow-up of 17.5 months.

CONCLUSIONS

Percutaneous retrograde endovascular occlusion is an effective minimally invasive approach for varicocele treatment in pediatric patients. It can be safely performed on an outpatient basis under local anesthesia.

Laparoscopic vs open varicocelectomy in children and adolescents: review of the recent literature and meta-analysis

PURPOSE

Laparoscopic varicocelectomy has gained popularity in recent years. The aim of this study was to identify clinical evidence about the reliability of this technique in the recent literature.

METHODS

We performed a Medline search for articles published during the last 10 years, using the key words "varicocele," "treatment," and "adolescent." As limits, we used last 10 years, adolescent, clinical trials, randomized controlled trials, meta-analysis, and multicenter retrospective and prospective studies. The results were investigated in recurrence and hydrocele formation.

RESULTS

We pooled 37 studies, but 26 of these were excluded because they were neither relevant nor concerned an adolescent population. Meta-analysis showed that there was no statistical difference between laparoscopic surgery and open surgery in recurrence rate and postoperative hydrocele rate. In the laparoscopic group, the incidence of recurrence was higher in the patients undergoing artery ligation compared to patients undergoing artery and venous ligation. Furthermore, a lower rate of postoperative hydrocele was recorded in patients undergoing dye injections before laparoscopic ligation.

CONCLUSIONS

Meta-analysis and literature analysis showed that the results after laparoscopic varicocelectomy are comparable to other surgical procedures. The laparoscopic approach has the advantage to treat simultaneously bilateral varicocele.

Lymphatic sparing laparoscopic Palomo varicocelectomy for varicoceles in children: intermediate results

OBJECTIVES

Varicocele is a relatively rare disorder in children that can lead to testicular atrophy and infertility. The ideal surgical treatment for varicoceles is still a matter of controversy because of the frequency of postoperative complications. Here, we report our series of children who underwent lymphatic sparing laparoscopic Palomo varicocelectomy.

PATIENTS AND METHODS

A total of 46 boys, 9 to 14 years old, underwent laparoscopic repair for varicoceles between January 2002 and December 2007. All of them had a left-sided varicocele. The varicocele was diagnosed by physical examination and Doppler ultrasonography. The laparoscopic procedure included obligatory dissection and preservation of the lymphatic vessels, followed by double ligation of the spermatic vessels. Follow-up for these children included physical examination and Doppler ultrasonography.

RESULTS

Lymphatic sparing laparoscopic Palomo varicocelectomy was feasible in all 46 (100%) of the children. Mean operative time was 34.2 minutes (range, 25-42 minutes). There were no intraoperative complications. One patient recurred because of incomplete ligation of spermatic vein. Mean follow-up was 20 months (range, 7-32 months). Hydrocele formation, testicular atrophy, and testicular hypertrophy were not observed postoperatively. However, 2 preoperative hypotrophic testes were noted with 10.4% and 12.5% decreases in size.

CONCLUSIONS

Our study reveals that lymphatic sparing laparoscopic Palomo varicocelectomy in children is safe, effective, and the reliable treatment of pediatric varicocele. However, long-term follow-up is required to best characterize ultimate outcome.

Laparoscopic Palomo varicocele surgery: lessons learned after 10 years' follow up of 156 consecutive pediatric patients

OBJECTIVES

To evaluate our experience using laparoscopic Palomo varicocele ligation in a population under 18years, and confirm the factors involved in postoperative hydrocele formation.

PATIENTS AND METHODS

Between 1997 and 2007, 156 boys diagnosed as having varicocele were evaluated retrospectively. Outcome variables recorded for analysis were age at presentation, symptoms, varicocele grade (Dubin-Amelar classification), testicular atrophy, length of hospital stay, perioperative complications, recurrence and hydrocele formation after surgery. Mean follow up was 5.6 years (6 months- 9 years).

RESULTS

Age at diagnosis ranged between 9 and 18 years. Mean age at operation was 14.1+/-1.8 years. There were 153 left-side varicoceles (98%) and three cases were bilateral. All patients had grade II or III varicocele (38%/62%) and testicular atrophy was noted in 43.8%; 8.1% mentioned testicular pain at diagnosis. All boys underwent Palomo laparoscopic ligation of the spermatic vessels. Mean operative time was 38 min (25-82 min). The last 51 surgeries were performed on a two-trocar basis with Ligasure vascular sealing device and operative time decreased significantly to 22 min (16-32 min) (P<0.05). Median hospital stay was 31+/-8 h. Conversion rate was 1.28%. Twenty-one patients developed hydrocele (13.5%); 11 of these underwent Winkelman-Lord's hydrocelectomy at least 1 year after Palomo (9% of total). Of the remaining 10, two resolved spontaneously and eight were stable at mean 4-year follow up.

CONCLUSIONS

Laparoscopic Palomo varicocele surgery for pediatric patients is a safe and effective procedure. Recurrence and complication rates are similar to those reported with open surgery.

Results and complications of adolescent varicocele repair with intraoperative sodium morrhuate sclerotherapy

PURPOSE

Adolescent varicocele has been shown to affect spermatogenesis and correlate with decreased ipsilateral testicular volume, prompting treatment in a select population. We report our experience with 3 varicocele ligation procedures in concordance with sclerotherapy in adolescent patients.

MATERIALS AND METHODS

A total of 120 males underwent varicocele surgery at our institutions during an 8-year period. Sodium morrhuate sclerotherapy was used in 91 patients and 73 adolescent males fulfilled the 6-month followup criteria. The 73 males who were 9 to 17 years old underwent a total of 75 (bilateral in 2) procedures for varicocele treatment. Of the patients 23 underwent subinguinal microscopic varicocelectomy (group 1), 9 underwent loupe assisted subinguinal varicocelectomy (group 2) and 41 underwent loupe assisted inguinal varicocelectomy (group 3). All patients received intraoperative sclerotherapy using sodium morrhuate injection. Outcome measures included recurrence, complications and catch-up growth at a minimum of 6 months of followup.

RESULTS

The varicocele recurrence rate was 2.7% in patients receiving combined surgical ligation and sclerotherapy ablation. Group 1 had 2 recurrent varicoceles and no hydrocele formation, group 2 had no varicocele recurrence and no hydrocele formation, and group 3 had no varicocele recurrence and 2 postoperative hydroceles. Catch-up growth in the ipsilateral testis was seen in 85% of patients. No atrophy or testicular loss was noted.

CONCLUSIONS

This preliminary experience with combined surgical ligation and sclerotherapy ablation in the adolescent population resulted in low varicocele recurrence with minimal morbidity. Outcomes of loupe assisted varicocelectomy appear to be improved compared to those in previous studies, alluding to an advantage in the addition of sclerotherapy.

Viable testis after retroperitoneal mass cord ligation in internal ring of inguinal canal in 15 kidney recipients: five years of experience

INTRODUCTION

Sometimes in spermatic cord handling procedures like varicocelectomy, hernioraphy, and vasectomy, there is concern about perfusion of the testis. Herein we have presented our experience with retroperitoneal mass ligation of the cord in kidney recipients. Between 2001 and 2006, we performed mass ligation of the spermatic cord, including vas deferens and all spermatic vessels, in 15 kidney recipients (older than 55 years) who gave informed consent. During retroperitoneal preparation of the Iliac fossa for allografting, we performed this maneuver next to the internal ring of the inguinal canal. After performing a J incision in the right iliac fossa, separating fascia, and pushing the peritoneum medially, we isolated the spermatic cord at the internal ring of the inguinal canal for transfixation and placing the allografted kidney in retroperitoneal position with anastomoses of the iliac vessels. Posttransplantation the scrotum of patients was followed up by color Doppler ultrasound and physical examination.

RESULT

Normal circulation was detected in the testis postoperation using color Doppler ultrasound evaluation. Six patients returned with hydrocoeles between 4 and 8 months after transplantation and 3 of them underwent hydrocoelectomy.

CONCLUSION

Mass ligation of the spermatic cord (preinternal ring of inguinal canal) did not disturb the circulation to the testis severely nor did it induce ischemic problems (atrophy). This study suggested an unknown connection between vessels of the cord and other vessels that supply blood to the testis. This study questions the safety of cryo-biopsy of a testis mass by high clamping of the cord and also suggests that vasectomy may be safe in patients with a history of a standard Palomo varicocoelectomy.

Effects of laparoscopic division of spermatic vessels on histological changes of testes: long-term observation in the model of prepubertal rat

Laparoscopic Fowler-Stephens and Palomo procedures are now commonly performed in children with high positioned intra-abdominal cryptorchidism and varicocele, respectively. During the procedures, the spermatic vessels are ligated and therefore the question of risk related to testicular atrophy is often raised. The long-term follow-up of the histology after the procedures is rare. In this study, we simulated a laparoscopic spermatic vessels clipping and division (SVCD) in a prepubertal rat model, and examined the histological alterations of the testes with regard to spermatogenic arrest between prepuberty and middle age. Thirty-day-old Wistar rats divided randomly into three groups underwent laparoscopic sham operation, unilateral SVCD and unilateral SVCD with additional contralateral orchiectomy, respectively. Histological investigations observed on semithin and paraffin sections were performed at seven different postoperative intervals between day 9 and day 540. We defined partial, most and complete spermatogenic arrest of the seminiferous tubules to correspond with mild, severe spermatogenic arrest and atrophy, respectively. Laparoscopic SVCD induced testicular spermatogenic arrest in a total of 85% of the operated testes with different severity; 27% of operated testes with mild or severe spermatogenic arrest were seen between puberty and middle age (day 45-540 postoperative), and their size was only slightly reduced. Of the operated testes, 51% showed atrophic signs with a striking decrease in size, and their contralateral testes revealed in all cases mild or severe spermatogenic arrest started as early as day 45 postoperatively. Parallel to the spermatogenic arrest, Leydig cell hyperplasia developed frequently in impaired testes, especially in those without contralateral testes, finally reaching a typical adenoma size. Laparoscopic SVCD in prepubertal rats could disturb spermatogenesis with differing severity in most cases. This impairment could persist from peripuberty to middle age, and even involve the contralateral testes, in the case of operated testes and show complete spermatogenic arrest. This study showed that laparoscopic SVCD may have high risk in compromising the operated testis.

Lymphatic-sparing laparoscopic varicocelectomy versus microscopic varicocelectomy: is there a difference?

OBJECTIVES

The ideal operation for the adolescent varicoceles has been debated for many years as new techniques or advances in existing technology develop. It is well acknowledged that the Palomo procedure has a negligible recurrence rate but a very high postoperative hydrocele rate compared with a microscopic varicocelectomy (MV). We sought to determine whether lymphatic-sparing laparoscopic varicocelectomy (LSLV) could provide similar negligible recurrence rates as the Palomo approach with the negligible postoperative hydrocele rate seen with MV.

METHODS

We performed a retrospective chart review of patients who underwent either an MV (n = 31) or LSLV (n = 28). In the MV group, the artery and the lymphatics were spared, whereas in the LSLV group, the artery and veins were taken en masse. Statistical analysis included paired Student t-test and Chi-square test for continuous and categorical variables, respectively.

RESULTS

Preoperative testis volumes were not different nor were the postoperative testis volumes between groups. Mean operating time was significantly longer in the MV than the LSLV group (140 minutes versus 51 minutes, P <0.01). With a mean time since surgery of 2 years, we observed only one patient with a recurrent varicocele (MV group); only one patient developed a hydrocele requiring hydrocelectomy (LSLV group).

CONCLUSIONS

Our early data indicate that LSLV and MV are comparable in preventing varicocele recurrence and formation of hydroceles. The primary difference between the procedures is the surgical time, with the LSLV being much faster to perform.

LigaSure vessel sealing system in laparoscopic Palomo varicocele ligation in children and adolescents

PURPOSE

We review our experience with laparoscopic Palomo varicocele ligation using the LigaSure device in children and adolescents.

MATERIALS AND METHODS

Between June 2003 and December 2004, 25 varicoceles were treated by laparoscopic Palomo varicocele ligation using LigaSure vascular sealing. Patient ages ranged from 10 to 19 years (mean, 14.5 years). Indications for surgery included grade II-III varicocele or ipsilateral testicular hypotrophy. One patient was affected by recurrent contralateral inguinal hernia and 2 presented with an ipsilateral patent processus vaginalis. We placed a 5-mm umbilical port for access, and kept pneumoperitoneum below 15 mm Hg. Under laparoscopic guidance, two additional ports of 3 and 5 mm were inserted in the lower right and left quadrants, respectively. Once the vessels were isolated, the vascular sealant was applied 3-4 times to ensure coagulation of the spermatic vessels; the vessels were then divided with laparoscopic 5-mm scissors. Inguinal hernia and patent processus vaginalis were treated according to Schier's technique. All procedures were performed in our day surgery facility.

RESULTS

Mean operative time was 18 minutes, which is significantly less than the time required in a similar group of 12 patients who underwent laparoscopic clip ligation. There were no perioperative complications. Eleven of 16 patients recovered testicular size. Two patients had postoperative hydrocele: the first was treated successfully with scrotal aspiration, while the other patient required scrotal hydrocelectomy.

CONCLUSION

Laparoscopic Palomo varicocele sealing can be performed safely and rapidly and is highly successful in correcting varicoceles in young males. We also found it to be the ideal technique to correct the associated inguinal hernia or patent processus vaginalis.

Laparoscopic varicocele ligation in children and adolescents using isosulphan blue: a prospective randomized trial

OBJECTIVES

To evaluate, in a randomized prospective trial in children and adolescents, the feasibility of isosulphan blue-based lymphatic vessel preservation during laparoscopic varicocelectomy and its impact on the complication rate, as the operative management of varicoceles remains controversial.

PATIENTS AND METHODS

In all, 50 consecutive patients were randomly assigned to two laparoscopic varicocelectomy groups. The indications for surgery included scrotal pain and a difference in testicular size, as well as severe cosmetic impairment. All the patients had a laparoscopic varicocelectomy using three ports. Patients in group A had standard laparoscopy, while those in group B had additional isosulphan blue administered. After surgery, the patients were assessed at 3, 6 and 12 months for varicocele recurrence, hydrocele formation, atrophy, pain or other complications.

RESULTS

There were no intraoperative complications or conversions to open surgery. There were no adverse reactions, scrotal haematomas or atrophy. At 3 months after surgery, the incidence of hydrocele in group A was 20% whereas in group B no hydroceles were detected (P = 0.025); at 6 months the 20% still had hydroceles. One patient in each group had varicocele recurrence associated with persistent pain. In two patients in group B, blue pigmentation of the left hemiscrotum persisted at the 3-month follow-up but resolved by 6 months.

CONCLUSIONS

Laparoscopic repair of varicoceles using isosulphan blue helps to identify and preserve the lymphatic drainage. It prevents secondary hydrocele formation, the most common complication, with no supplementary risk to the patient. Also, testicular oedema causing impaired spermatogenesis can be avoided.

[Complications of laparoscopic urological procedures]

Laparoscopic urology has evolved considerably during last decade as well as number and spectrum of surgical related complications. Experiences reported by laparoscopic trained groups allow preventing, promptly recognizing, and safe and efficient management of the laparoscopic related complications. We present our complications in all patients undergoing urological laparoscopic procedures from November 1992 to June 2005. A literature search was conduced to evaluate complications of every laparoscopic procedure.

The role of Doppler ultrasonography in determining the proper surgical approach to the management of varicocele in children and adolescents

In a study from Italy, colour-Doppler ultrasonography was a reliable diagnostic tool in the preoperative assessment of patients with varicocele. The authors also found that it helped to distinguish those who could be treated laparoscopically from those who should be treated by microsurgical subinguinal ligature.

OBJECTIVE

To investigate whether colour Doppler ultrasonography (CDUS) is a reliable diagnostic tool for selecting patients with varicocele to undergo either laparoscopy or open microsurgical subinguinal ligation.

PATIENTS AND METHODS

In a 3-year period, 42 boys affected by left varicocele were evaluated before surgery by inguinal and scrotal CDUS. Using this method it was possible to distinguish Coolsaet type-1 varicocele (due to isolated renal-internal spermatic vein reflux) and Coolsaet type-3 varicocele (due to associated renal-internal spermatic reflux and iliac-deferential reflux). Boys with Coolsaet type-1 varicocele were treated by a laparoscopic transperitoneal Palomo procedure, whereas those with Coolsaet type-3 varicoceles were treated by lymphatic-sparing microsurgical subinguinal ligation.

RESULTS

The varicocele was Coolsaet type-3 in six patients (14%), who had microsurgical open surgery, and the remaining 36 (86%) had Coolsaet type-1 and had laparoscopic surgery. At the follow-up there was no venous scrotal reflux. In two patients in the laparoscopic group a hydrocele developed after surgery, which resolved spontaneously.

CONCLUSIONS

This study showed that CDUS was a reliable diagnostic tool for assessing boys with varicocele. It clearly distinguished Coolsaet-type 1 varicoceles that can be treated laparoscopically, from Coolsaet type-3 varicoceles that should be treated with microsurgical subinguinal ligature.

Retroperitoneoscopic varicocelectomy in children and adolescents

BACKGROUND/PURPOSE

In the pediatric population the failure rate of sclerotherapy for the treatment of varicocele has been reported to be up to 35%. Therefore, the aim of our study was to evaluate the efficacy of retroperitoneoscopic varicocelectomy (RV) in children and adolescents.

METHODS

A total of 97 patients were operated on for left-sided varicocele using the retroperitoneoscopic approach between January 1999 and July 2003. Median age was 12.3 years (range, 6-16 years). A 10-mm subcostal retroperitoneoscopic port was used. The operation was performed through an operative laparoscope according to Palomo's technique, with the mass division of spermatic vessels after bipolar coagulation below the renal vein. Elective conversion to laparoscopic transperitoneal varicocelectomy was performed in cases of difficulties in identifying the vessels. The postoperative follow-up included clinical and ultrasound assessment (range, 6-48 months).

RESULTS

A total of 17 (17.6%) patients needed elective conversion to laparoscopic transperitoneal varicocelectomy. In RV, the mean operative time was 28 minutes (range, 15-55 minutes), the mean hospital stay was 2 days, persistence rate was 11.2%, and hydrocele occurrence was 6.2%.

CONCLUSIONS

Our results indicate that the RV is an acceptable technique to achieve the high division of the spermatic vessels. The advantage of this anatomic approach is its very low invasiveness.

Laparoscopic varicocele ligation: are there advantages compared with the microscopic subinguinal approach?

OBJECTIVES

To compare the operative time, outcome, complications, and patient costs between laparoscopic varicocele ligation (LVL) and subinguinal microscopic varicocelectomy (SMV) in two patient cohorts. Varicocele therapy is a controversial issue, with no single approach adopted as the best therapeutic option. LVL has been considered more expensive and of no proven benefit compared with SMV.

METHODS

We compared two groups of patients who underwent surgical correction of varicocele at our institutions during a 6-year period. Group 1 included postpubertal adolescents who underwent LVL and group 2 included adults seen at an infertility practice who underwent SMV. The outcome measures selected included operative time, direct hospital costs to the patient, and negative outcomes.

RESULTS

We identified a total of 72 patients, 36 (mean age 13.8 years) in group 1 and 36 (mean age 34.1 years) in group 2. Group 1 had no persistent or recurrent varicoceles compared with 4 patients in group 2. Three men in group 2 required emergency room evaluation and no patient did so in group 1. No hydroceles developed in group 2, but three developed in group 1.

CONCLUSIONS

LVL resulted in shorter operative times and fewer negative outcomes compared with SMV. This translated into lower direct patient costs for LVL. For those who have mastered laparoscopic techniques, LVL should be considered a safe, cost-effective option in the correction of varicoceles.

Laparoscopic varicocelectomy with lymphatic preservation using methylene blue dye

A novel technique is described herein to perform a laparoscopic varicocelectomy using the high-ligation modified Palomo technique. The variation in this case is the preservation of lymphatic drainage by intraoperative identification of the lymphatics using intratesticular injection of methylene blue dye.

Current indications for laparoscopy and retroperitoneoscopy in pediatric urology

Laparoscopy has raised great interest in the past few years in the field of pediatric urology. It has evolved from a simple diagnostic maneuver to complex operative procedures. The aim of this study was to review urologic laparoscopy literature and provide a critical review of this field to establish current indications for videosurgery in pediatric urology. In general, from an anatomic point of view, retroperitoneoscopy seems to be more suitable than the transperitoneal laparoscopic approach for reaching the upper urinary tract. It also is less invasive and complies with the criteria for open renal surgery. With respect to current indications for videosurgery in pediatric urology, the authors have identified several well-established clinical procedures, although no large series have been published for any of the procedures, except for the treatment of varicocele, nonpalpable testis, and nephrectomy. In conclusion, the data reviewed suggest that videosurgery is a safe and feasible technique in pediatric urology if performed by expert surgeons, and that it certainly will develop further in the next few years.

The influence of left renal vein entrapment on outcome after surgical varicocele repair: a color Doppler sonographic demonstration

OBJECTIVE

To evaluate the impact of left renal vein entrapment on outcome after surgical varicocele repair using color Doppler sonography.

METHODS

Eighty-four men had varicoceles on color Doppler sonography (2 right sided, 74 left sided, and 8 bilateral), which were diagnosed on the basis of a venous diameter of 3 mm or greater and venous retrograde flow in the pampiniform plexus of veins during the Valsalva maneuver or when changing from a supine to an upright position. Diagnosis of the left renal vein entrapment was based on the following criteria: antero-posterior diameter of greater than 1 cm and peak velocity of less than 15 cm/s for the left renal vein at the mid portion and anteroposterior diameter of less than 0.2 cm and peak velocity of greater than 110 cm/s (or, alternatively, a diameter ratio and peak velocity ratio of >5) for the left renal vein between the aorta and superior mesenteric artery. All patients underwent surgical varicocele repair. In postoperative follow-up, we compared the presence of left renal vein entrapment with the frequency of varicocele recurrence.

RESULTS

Sixteen (19%) of 84 patients had left renal vein entrapment with a left-sided varicocele. Postoperatively (mean follow-up +/- SD, 19.3 +/- 11.7 months), 27 (32.2%) of 84 had varicocele recurrence, including all 16 patients with left renal vein entrapment and 11 (20.1%) of 68 patients without left renal vein entrapment. The varicocele recurrence rate was significantly greater in patients with left renal vein entrapment (P < .001, Fisher exact test).

CONCLUSIONS

The presence of left renal vein entrapment resulted in a significantly higher varicocele recurrence rate. Patients with varicoceles should routinely be evaluated for the presence of left renal vein entrapment before surgical repair.

Current concepts in minimal access surgery for children

Since the introduction of minimal access surgery to general surgeons in the 1980s, pediatric surgeons have been employing this innovative technology to perform surgery on children. Video technology and miniaturized instruments have brought the laboratory to the operating room; in many cases several small incisions are the only access necessary to perform complicated procedures that would otherwise require a large wound. Additional benefits of minimal access surgery may include reduced postoperative analgesic requirements, shortened length of stay, and faster resumption of normal activities. Increased operative costs offset some of these gains. The pediatric surgical community has embraced minimal access techniques for some operations; others remain controversial.

New surgical techniques in pediatric urology

More sophisticated endoscopic instruments, combined with a better understanding of bladder and urethral pathology, have significantly improved the therapeutic approaches for both posterior urethral valves and ureteroceles. New generation lithotripters have allowed for a safe and efficient method of treating urinary calculi in children, which was once thought too injurious a process with first-generation machines. The rapidly advancing field of laparoscopy, aided by the development of more optically refined and diminutive instruments, has allowed for its application in a wide variety of surgical interventions in pediatric urology. The tubularized incised plate urethroplasty has challenged more traditional approaches to hypospadias repair and is now considered by many pediatric urologists to be the best approach for midshaft and distal hypospadias. The one-stage approach to exstrophy repair may hold the answer to improved continence without a formal bladder neck reconstruction. Finally, the field of tissue engineering leads the way to new advances in autologous biological substitutes in the surgically-challenged patient where there is a shortage of local tissues at the surgeon's disposal.