Nerve injury after laparoscopic varicocelectomy

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.

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.

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.

Surgical management of adolescent varicocele: Systematic review of the world literature

Historically, idiopathic varicocele is the most commonly diagnosed pre-pubertal andrological condition. The clinical presentation of varicocele may vary from dull and dragging unilateral or bilateral testicular pain to visible varicose veins lying over the hemiscrotum. Over the last decade, significant strides were made in managing symptomatic varicoceles, particularly minimal invasive procedures and surgeries. We sought to review the published literature in a systematic manner to gain an overview and streamline the presentations and main treatment modalities.

Infertility in rats subjected to genitofemoral nerve section is not associated with testicular damage

This work was aimed at assessing the relationship between testicular ascent and infertility induced by genitofemoral nerve (GFN) section in rats. Eighteen male rats were assigned to three experimental groups as follows: (i) Group SGFN was subjected to surgical section of genitofemoral nerve; (ii) Group Sham; (iii) Control group. The GFN was cut at puberty (28D), and the contralateral testis removed at 90D, with fertility tests at 120D. At 150D, maturity index, epithelial area and histopathological index of seminiferous tubules of all rats were determined and statistically compared between superior and inferior testicle poles, and between groups. There were no differences in testicular parameters, sperm morphology or sperm concentrations (P > 0.05). Section of NGF interfered with fertility (58.3 ± 15.4 in SGFN versus 83.3 ± 10.5 in Sham) and litter size (6.2 ± 1.1 in SGFN versus 10.7 ± 1.4 in Sham). Cremaster of SGFN group showed early neuropathy. The GFN section induced partial testicular ascent and diminished fertility without damage on testicular morphology or spermatic parameters, because, cremaster could affect the contractibility and ejaculation mechanisms in which it participates. The study of the damage on cremaster induced by an injury on GFN could have an overview of the mechanisms inherent in the testicular ascent induced by this iatrogenic alteration and their potential risks on fertility.

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 treatment of varicocele with microcoil embolization: comparison of treatment outcome with laparoscopic varicocelectomy

Successful treatment of a testicular varicocele, which can result in scrotal pain and swelling as well as male subfertility, can be accomplished via operative ligation of the varicocele or interventional treatment with coil embolization of the testicular vein. This study compared the treatment outcome of percutaneous embolization treatment versus laparoscopic varicocelectomy in patients with symptomatic varicoceles. Patients with varicoceles undergoing either laparoscopic varicocelectomy or percutaneous coil embolization of the testicular vein during a recent 5-year period were analyzed. Treatment outcome and hospital costs of these two minimally invasive treatment modalities were compared. Forty-one patients underwent percutaneous coil embolization of the testicular vein, which were compared with a cohort of 43 patients who underwent laparoscopic varicocelectomy. Technical success in interventional and laparoscopic treatment was 95% and 100%, respectively. The mean operative time or procedural time was 63 +/- 13 minutes and 52 +/- 25 minutes for interventional and laparoscopic cohorts (not significant), respectively. Embolization treatment resulted in two recurrent varicoceles (4.8%) compared to one patient following laparoscopic repair (2.3%, not significant). Embolization treatment was associated with a lower complication rate than laparoscopic repair (9.7% vs 16.3%, p = .03). Regarding cost analysis, no significant difference in hospital cost was noted between the interventional or laparoscopic treatment strategies. Both laparoscopic varicocelectomy and coil embolization are effective treatment modalities for varicoceles. With lower treatment complication rates in the interventional treatment group, coil embolization of the testicular vein offers treatment advantage compared with laparoscopic repair in patients with varicoceles.

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.

Treatment of varicocele with reference to age: a retrospective comparison of three minimally invasive procedures

BACKGROUND

This study investigated whether the therapeutic efficacy and morbidity of three minimally invasive techniques for varicocele correction--laparoscopic varicocelectomy (LV), antegrade sclerotherapy (AS), and retrograde embolization (RE)--differed between children and adults.

METHODS

During a 10-year period, 356 procedures for varicocele correction, including 122 cases of LV, 108 cases of AS, and 126 cases of RE, were performed for 314 patients at our institution. Of these patients, 223 were 19 years of age or younger (group 1), and 133 were older than 19 years (group 2). Diagnosis and postoperative results were established clinically and with the use of Doppler ultrasonography. The failure rates and complications for each procedure were retrospectively evaluated and compared between the two age groups.

RESULTS

The median follow-up period was 69 months (range, 6-122 months). For 25 patients (19.8%), RE was not feasible for technical reasons. In both groups, LV had a lower failure rate than AS or RE, but the difference between LV and AS was not significant in group 1 (7.7(% vs 11.9%; p > 0.5). Also in group 1, AS was associated with fewer complications than LV 1 (4.5% vs 15.4%; p < 0.05). In group 2, LV was significantly more effective in correcting varicoceles than the other two techniques (p < 0.01). In this group, the complication rates for all three procedures did not differ significantly (p > 0.05).

CONCLUSIONS

In our experience, LV was more effective than AS or RE in correcting varicoceles. For children and adolescents, AS may be more indicated because of the slightly lower complication rate and similar recurrence rates, as compared with LV, for this age group. The higher incidence of postoperative hydrocele formation after LV warrants more refined techniques such as the lymphatic-sparing approach.

[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.

Laparoscopic surgery versus antegrade scrotal sclerotherapy: Retrospective comparison of two different approaches for varicocele treatment

OBJECTIVE

Both laparoscopic surgery and antegrade sclerotherapy are effective treatment options in the management of varicoceles. However, very limited data comparing these two approaches are available in the literature. We present our experience regarding outcome and complications with each treatment modality.

PATIENTS AND METHODS

During a 10-year period, 122 cases of laparoscopic varicocelectomy (LV) and 108 cases of antegrade sclerotherapy (AS) were performed in our institution. Diagnosis and postoperative results were established clinically and using Doppler ultrasonography. Data regarding failure rate, complications, operative time and length of hospital stay of each procedure were retrospectively evaluated.

RESULTS

Median follow-up was 59 months (5-130). Failure rates for LV and AS were 4.9% and 15.7%, respectively (p < 0.01). Complications occurred in 13.1% after LV, including 13 cases (10.7%) of hydrocele formation, and 4.6% after AS. Hydroceles following LV were significantly more frequent in patients with compared to patients without previous inguinal surgery (27.8% vs. 8.5%; p < 0.05). There was no significant difference between LV and AS regarding operative time (36 vs. 34 min, p > 0.05) and hospital stay (2.2 vs. 2.1 days, p > 0.5).

CONCLUSIONS

In our experience, LV was more effective than AS in correcting varicoceles. Complications other than hydroceles were higher after AS. The higher incidence of postoperative hydrocele formation following LV warrants strategies such as the lymphatic sparing approach, especially in patients with previous inguinal surgery.