Laparoscopic Varicocelectomy Steps

[Chadwick Bosse]

Despiteextensive information being available on varicoceles and many studies on different surgical solutions, the ideal method of varicocele ligation is still a matter of controversy. The ideal technique would have low recurrence and complication rates [4].

Different approaches have been applied for the treatment of varicocele, including open surgery, sclerotherapy, and, recently, laparoscopy [5,6,7]. The Palomo technique was associated with a relatively high incidence of postoperative discomfort [8] and for this reason the modified Palomo procedure was often preferred [9].

Ivanissevich described a procedure where the testicular vein is tied at the inguinal ring and the testicular artery is spared [8]. In 1991 Aaberge et al. introduced laparoscopic varicocelectomy as the new and less invasive treatment for varicocele [10].

In recent years laparoscopic varicocele ligation (LV) had been popularized and had gained growing acceptance. The built-in magnification of the laparoscope facilitates identification of the spermatic veins and artery, potentially reducing the risk of recurrence of the varicocele and of ischemic damage to the testis. Magnification also allows the surgeon to preserve lymphatics and the genital branches of the genitofemoral nerve that runs along the spermatic vessels, which may reduce lymphocele formation and postoperative pain [11].

Laparoscopic management of varicoceles in adults may reflect the excellent visibility of the posterior abdominal wall achieved using the laparoscope, which allows a thorough search of sites known to be responsible for recurrent varicoceles, viz., renal, vas associated, pelvic, and retropubic cross-over veins [11].

The conventional technique of laparoscopic varix ligation is to ligate the vessels with clips and then transect them in between the clips [12,13,14]. Sasagawa reported that they successfully transected the internal spermatic vessels purely using a harmonic scalpel, which comes only in diameters of 5 and 10 mm [15].

Preoperative semen analysis should be carried out in all patients aged 18 years and above. Pre-anesthetic checkup was done. After the patients were considered fit for surgery, they were informed in their native language about the nature of the disease process, the procedure, the possible complications of the procedure, the possibility of conversion of laparoscopic surgery to open in cases of difficulty and about the hematoma, wound infections, pneumoscrotum, hydrocele, prolonged pain, and recurrence.

Operation theater setup is done as shown in Fig. 1. The procedure is performed under general anesthesia. A prophylactic intravenous antibiotic (third generation cephalosporins IV) is given at induction prior to the incision. The patient is placed in a supine position.

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Lymphatic sparing laparoscopic Palomo varicocelectomy is a safe and reliable technique for varicocele treatment in adolescents and children. The purpose of this study was to compare the outcomes of lymphatic sparing laparoscopic varicocelectomy with and without testicular artery preservation. The prospective random allocation of selected patients was done at Al-Azhar University Hospital, Pediatric Surgery Department from February 2010 till January 2015. All patients underwent lymphatic sparing laparoscopic varicocelectomy and they were divided into two equal groups, group A underwent laparoscopic Palomo without testicular artery sparing and group B underwent the procedure with testicular artery sparing. The main outcome included operative time, postoperative hydrocele, and persistence of varicocele, together with catch-up testicular growth or testicular atrophy.

Lymphatic sparing laparoscopic Palomo varicocelectomy was superior to that with testicular artery preservation as regard varicocele persistence and operative time and hence is preferable for the management of primary pediatric varicocele.

Patients with varicocele complaining of scrotal discomfort or pain may suffer from progressive damage of the testicular tissue, resulting in hypotrophy [4]. Varicocelectomy has numerous approaches as microsurgical sub-inguinal (Goldstein), inguinal (Ivanissevich), abdominal (Palomo), and laparoscopic and sclerotherapy (antegrade and retrograde) [5]. The incidence of hydrocele formation after varicocelectomy is variable and attributed to lymphatic obstruction. Lymphatic sparing varicocelectomy was associated with a decreased incidence of postoperative hydrocele. The hydrocele formation occurred significantly less frequently in the lymphatic sparing in comparison to the non-sparing surgery (1.9% vs. 17.9%) [6].

The purpose of the study was to clarify the comparison between the outcomes of lymphatic sparing laparoscopic varicocelectomy with or without testicular artery preservation as regards the operative time, persistence of varicocele, development of post-operative hydrocele, and catch-up of testicular growth or testicular atrophy.

Symptomatic patients with primary left-sided refluxing varicocele grade 1, 2, or 3 with testicular pain (discomfort or scrotal heaviness), or testicular asymmetry defined as 20% or greater volume differential between both testicles.

Sample size calculation was done by MedCalc version 12.3.0.0 program, statistical calculator based on 95% confidence interval, and power of the study 80% with α error 5%. These values were calculated using sample size producing a minimal sample size for each group 80 cases.

The Statistical Package for Social Sciences program (SPSS) version 20 software tabulated and statistically analyzed collected data. Qualitative data was done by inferential analyses using chi-square test for the independent groups. The significant level was detected at p value p value is a statistical measure for the probability that observed results in the study chancily occurred.

Varicocele is the most common cause of secondary infertility in men causing a decrease in semen parameters and testicular function [10]. It was accompanied by a loss of testicular mass that is increased with age [11]. Varicocele is still without a gold standard treatment [12].

Rizkala et al. found that the recurrence of varicocele after testicular artery preservation was 19% versus 1-3% where the artery was not preserved without any reported testicular atrophy with testicular artery ligation [15].

For intra-operative detection of the testicular lymphatics, there are three different modes of injection: the sub-dartoic, the intra-parenchymal, and the intravaginal. The sub-dartoic injection is done between the dartos and parietal tunica vaginalis space. This is a feasible, rapid and safe method, while its preferred lymphatic pathway is the scrotal one which drains to the inguinal nodes and partially to the testicular system. The intra-parenchymal injection is obtained by a fine needle just within the testis body. This is the most specific and faster approach due to the related regional lymphatic drainage. Intravaginal injection is done in the narrow space between the two layers of tunica vaginalis that is the least performed and the most difficult approach [11].

Testicular atrophy is a rare occurrence and paternity has not been a problem after adolescent varicocelectomy using mass ligation [19]. In a multicenteric Italian research conducted on 161 pediatric and adolescent patients, only 2.2 % recurrence had been detected with the laparoscopic Palomo technique against 3.5% with the modified laparoscopic Palomo with testicular artery preservation without any testicular atrophy in both groups [20].

Mathias et al. found that there was nil significant difference between resection of the testicular artery or its preservation concerning recurrence of varicocele (3.2% vs. 5.5%) or postoperative incidence of hydrocele (9.7% vs. 11.4%) in lymphatic sparing varicocelectomy [22].

Poddoubnyi et al. concluded that testicular artery ligation was preferred as no significant difference was observed in testicular blood flow between artery preservation and artery non-preservation with similar results on semen quality and postoperative paternity rate [23].

Esposito C et al. believed that the standard treatment for varicocele in pediatrics is the lymphatic sparing laparoscopic Palomo varicocelectomy using preoperative intra-dartoic isosulfan blue injection as it is technically easy and fast with no more than 1% recurrence rate [24].

In this study, lymphatic sparing laparoscopic varicocelectomy was feasible in all patients with no postoperative hydrocele in both groups. Testicular artery ligation in group A and testicular artery preservation in group B were done with a significant difference in varicocele persistence that was present in 1.25%, 10% in group A and group B respectively. These results are similar to that of Schwentner [14], Rizkala [15], Feber [17], and Esposito [24] in consideration to high varicocele persistence with artery preservation more than with artery ligation.

The strength of the present study is that the two groups of patients were well balanced as regard preoperative clinical presentation and demographic data. The same surgical team performed all procedures with the same surgical principles. Finally, all patients had objective long-term follow-up by U/S for the detection of complications and precise assessment of the testicular catch-up with every visit.

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