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ORIGINAL ARTICLE Table of Contents   
Year : 2011  |  Volume : 8  |  Issue : 1  |  Page : 40-43
Varicocoelectomy in adolescents: Laparoscopic versus open high ligation technique


1 Department of Pediatric Surgery, Centro Hospitalar do Porto, Porto;Life & Health Sciences Institute (ICVS), Braga, Portugal
2 Department of Pediatric Surgery, Centro Hospitalar do Porto, Porto, Portugal
3 Pediatric Urology Unit, Centro Hospitalar do Porto, Porto, Portugal

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Date of Web Publication6-Apr-2011
 

   Abstract 

Background: Treatment of varicocoele is aimed at eliminating the retrograde reflux of venous blood through the internal spermatic veins. The purpose of this investigation was to compare laparoscopic varicocoelectomy (LV) with open high ligation technique in the adolescent population. Materials and Methods: We retrospectively evaluated 33 adolescents who underwent varicocoelectomy at our paediatric hospital, between May 2004 and September 2008. Patients were divided into two groups depending on the technique: those who had an LV and those submitted to an open varicocoelectomy (OV). We analysed side, age of surgery, follow-up period and the incidence of recurrence/persistence, hydrocoele formation and wound complication. Results: There were 24 patients in the LV group and 9 in the OV group. All varicocoeles were in the left side. Mean age was 12 years in both groups. Mean follow-up time was 32 months for the LV group and 38 months for the OV group (P = 0.49). There was no significant difference in the incidence of hydrocoele in both the groups (25% versus 22%, P = 0.626). There was no recurrence/persistence on the LV group, while in the OV group there were three cases (P = 0.015). Conclusion: LV seems more efficient than open high ligation technique in the treatment of adolescents' varicocoeles. Larger series are necessary to draw more reliable conclusions.

Keywords: Hydrocoele, varicocoele laparoscopic varicocoelectomy

How to cite this article:
Moreira-Pinto J, Osório A, Carvalho F, de Castro JR, de Sousa J, Enes C, Reis A, Cidade-Rodrigues J. Varicocoelectomy in adolescents: Laparoscopic versus open high ligation technique. Afr J Paediatr Surg 2011;8:40-3

How to cite this URL:
Moreira-Pinto J, Osório A, Carvalho F, de Castro JR, de Sousa J, Enes C, Reis A, Cidade-Rodrigues J. Varicocoelectomy in adolescents: Laparoscopic versus open high ligation technique. Afr J Paediatr Surg [serial online] 2011 [cited 2014 Sep 18];8:40-3. Available from: http://www.afrjpaedsurg.org/text.asp?2011/8/1/40/78667

   Introduction Top


The incidence of varicocoele in young men is 15%. There are various treatments available for varicocoele. The common goal of all treatments is to eliminate the retrograde reflux of venous blood through the internal spermatic veins. [1] Success has been reported with high ligation using an open retroperitoneal approach through a suprainguinal incision, also known as Palomo procedure. [2] Other forms of treatment include ligation using Ivanissevich inguinal approach, [3] antegrade sclerotherapy, [4] retrograde embolisation, and microsurgical retroperitoneoscopic and laparoscopic procedures. [5],[6] Laparoscopy is substituting the open retroperitoneal approach in the high ligation of the spermatic vessels for the treatment of varicocoele. [7] The aim of this investigation was to compare laparoscopic varicocoelectomy (LV) with open high ligation technique in the adolescent population.


   Materials and Methods Top


We retrospectively reviewed the charts of all patients who had undergone varicocoelectomy between May 2004 and September 2008 at our paediatric hospital. There were 45 surgeries performed. Exclusion criteria were history of ipsilateral orchidopexy or inguinal hernia repair, varicocoelectomy using techniques other than the laparoscopic or open high ligation, and less than 6 months follow up. Thirty-three patients were included in our study. All the patients had unilateral left varicocoele. Diagnosis was made by physical examination. Doppler ultrasound was performed only when there were doubts about the diagnosis. The indication for repair was varicocoele associated with a small testis, symptomatic varicocoele or physically or psychologically causing discomfort. [8]

The 33 boys in our study were submitted to either LV or suprainguinal/open varicocoelectomy (OV) depending on surgeon's preference for either technique. Each surgeon used always the same technique independent of the patient. The results of these procedures were compared in terms of incidence of hydrocoele formation, recurrence/persistence of the varicocoele, testicular atrophy and wound complications such as infection, paraesthesia and inaesthetic scar.

At our hospital, both LV and OV are performed under general anaesthesia and as day surgery cases. In the LV, a 5-mm port is placed at the cephalad edge of the umbilicus. This is where a 30º scope is placed. Two further 5-mm working ports are inserted, under laparoscopic guidance, in the right iliac fossa at the midclavicular line and in the left iliac fossa [Figure 1]. The posterior peritoneum is incised lateral or anterior to the spermatic cord as higher as possible. We do a mass ligation using an ultrasound sealing device. Lately, we manage to do the varicocoelectomy using only the first two ports. One can gently grasp and incise the peritoneum just using the ultrasound sealing device and then dissect the spermatic vessels using the same technique.
Figure 1: Trocar placement for laparoscopic varicocelectomy

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In the OV, a 5-cm suprainguinal incision is made just medial to the anterior iliac crest. The peritoneum is mobilised medial. The spermatic vessels are identified and the vessels are doubly ligated and divided. The spermatic artery is not preserved, as described by Palomo. [2]

Patients are seen 1 and 6 months after surgery. Imaging studies and other follow-up visits are determined by the attending surgeon. In order to get updated reliable data for this study, a third clinical evaluation was undertaken at the time of collecting the data by a paediatric surgeon who had not participated in any of the surgeries. This surgeon was responsible to collect and work the data.

Comparisons between groups were made by means of the independent Student's t test, for ordered discrete or continuous variables, and the Fisher's exact test for categoric variables. P < 0.05 was considered statistically significant. All analyses were performed with SPSS software (SPSS 15.0).


   Results Top


All the 33 patients included in our study had unilateral left varicocoelectomy. Twenty-four patients had an LV and 9 had an OV. The mean age at surgery was 12.67 ± 1.689 years (minimum = 7, maximum = 18). The mean follow up was 33.27 ± 17.463 months. The two groups were compared [Table 1]. The groups did not significantly differ with regard to age at surgery or follow-up period. No testicular atrophy was reported in either group. We did not find any wound complication. The incidence of hydrocoele formation was similar between the two groups (25% for LV versus 22% for OV, P = 0.626). There was no recurrence/persistence on the LV group while in the OV group there were three cases with recurrence (P = 0.015).
Table 1: Results of LV versus open high ligation varicocoelectomy (OV)

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   Discussion Top


When deciding on the surgical approach to varicocoele repair in an adolescent, it is important to consider the advantages and disadvantages of the various surgical approaches. The perfect technique in terms of low recurrence rate and low hydrocoele formation is not yet decided. [9]

LV has been shown to be at least equally as effective as OV. [10] Laparoscopy has been shown to have same intraoperative safety, shorter hospitalisation, less postoperative complication compared to open surgery, and a significant improvement in seminal analysis (same as open surgery). [10],[11],[12] Although having the lowest failure rate, LV has the highest hydrocoele formation rate. [13] Since its first description in 1988, the laparoscopic Palomo technique has gained popularity and has been considered the preferred method for paediatric and adolescent patients. [7]

Although the study presented is retrospective, we can be sure that some kind randomisation was achieved as each surgeon performed only one type of surgery independent of the patient presented. Moreover, the evaluation by a surgeon not participating in any of the surgeries makes the collected data more reliable. This surgeon worked as a "third party" making an impartial evaluation.

Our data suggest that LV is more effective in treating varicocoele. The high recurrence/persistence rate reported in the OV group (33%) might be justifiable by the number of patients submitted to OV excluded from our study. The majority of patients submitted to OV had only one visit in the first month post surgery and were recommended to return only if they noticed any signs of recurrence or hydrocoele formation. As they did not come to the "third party" consultation, 6 out of 15 patients submitted to OV were excluded from our study because of short follow-up period. Another explanation is that in some patients submitted to OV, small venous collaterals might be missed. The dilatation of small collateral veins following Palomo procedure was described previously by Feber and Kass. [9] That was in fact what we verified when re-operating one of these patients by laparoscopic approach. Unfortunately, not all recurrences were operated at our hospital. So, we cannot be sure what their causes were. Although this high recurrence/persistence rate in the OV group might be overestimated, having no recurrence/persistence cases in the LV group makes us suspect that this is the best method to cure varicocoele in adolescence.

Incidence of hydrocoele formation was similar in both the groups and consistent with that reported by most authors. [14],[15],[16] Theoretically, the ideal surgical option is that which excludes venous drainage possibilities of the testicle but prevents lymphatic accumulation. In the last few years, some groups have attempted to improve the secondary hydrocoele formation rate using methods to identify and spare lymphatics. [17],[18],[19],[20],[21]

Schwentner et al. tried injecting isosulphan blue between dartos and tunica vaginalis in a randomised trial of 50 patients. They reported a hydrocoele rate of 0% and a persistence rate of 4%, which resolved spontaneously at 6 months. [17] Other studies support dye injection and none reports postoperative hydrocoele formation. The major problem is that 8% of patients may have a blue-stained scrotum for up to 6 months following surgery. [18],1[9],[20],[21]

Kocvara et al. described a laparoscopic Palomo technique with lymphatic preservation. They reported a hydrocoele rate of 2.9% in the lymphatics preserved group compared to 17.9% in the conventional group. However, there was a 6.7% persistence rate in the lymphatics sparing varicocoelectomy group and an 8.9% persistence rate for the non-lymphatics sparing varicocoelectomy one. [22] More recently, Glassberg et al. compared the conventional Palomo laparoscopic technique with a lymphatic sparing one. Lymphatic sparing laparoscopic varicocoelectomy was associated with decreased incidence of postoperative hydrocoele requiring surgery (3.4% versus 11.4%) and no significant difference in incidence of persistence/recurrence rate (2.9 and 4.5%, respectively). [23]


   Conclusions Top


LV seems more efficient than open high ligation technique in the treatment of adolescents' varicocoeles. Recent data suggest that preserving lymphatic drainage can diminish hydrocoele formation rate. An attempt to preserve the maximum number of small lymphatics should be made. Larger series are necessary to draw more reliable conclusions.

 
   References Top

1.Turek PJ. Male infertility. In: Tanagho JW, Mcaninch S, editors. Smith's General Urology. 17 th ed. New York: McGraw-Hill; 2008. p. 684-716.  Back to cited text no. 1
    
2.Palomo A. Radical cure of varicocele by a new technique: Preliminary report. J Urol 1949;61:604-7.  Back to cited text no. 2
    
3.Ivanissevich O. Left varicocele due to reflux: Experience with 4470 operative cases in forty-two years. J Int Coll Surg 1960;34:742-55.  Back to cited text no. 3
    
4.May M, Johannsen M, Beutner S, Helke C, Braun KP, Lein M, et al. Laparoscopic surgery versus antegrade scrotal sclerotherapy: Retrospective comparison of two different approaches for varicocele treatment. Eur Urol 2006;49:384-7.  Back to cited text no. 4
    
5.Messina M, Zagordo L, Garzi A, Cerigioni E, Di Maggio G, Roggi A, et al. Treatment of varicocele in pediatric age with retroperitoneoscopic "one trochar" technique. Long term follow-up. Minerva Urol Nefrol 2006;58:81-6.  Back to cited text no. 5
    
6.Watanabe M, Nagai A, Kusumi N, Tsuboi H, Nasu Y, Kumon H. Minimal invasiveness and effectivity of subinguinal microscopic varicocelectomy: A comparative study with retroperitoneal high and laparoscopic approaches. Int J Urol 2005;12:892-8.  Back to cited text no. 6
    
7.Méndez-Gallart R, Bautista-Casasnovas A, Estevez-Martinez E, Varela-Cives R. Laparoscopic palomo surgery: Lessons learned after 10 years follow up of 156 consecutive pediatric patients. J Pediatr Urol 2009;5:126-31.  Back to cited text no. 7
    
8.Tekgül S, Riedmiller H, Gerharz E, Hoebeke P, Kocvara R, Nijman R, et al. Varicocele in children and adolescents. Guidelines on Pediatric Urology. Arnhem, The Netherlands: European Association of Urology, European Society for Paediatric Urology; 2008. p. 25-6.  Back to cited text no. 8
    
9.Feber KM, Kass EJ. Varicocelectomy in adolescent boys: Long-term experience with the palomo procedure. J Urol 2008;180:1657-9.  Back to cited text no. 9
    
10.Simforoosh N, Ziaee SA, Behjati S, Beygi FM, Arianpoor A, Abdi H. Laparoscopic management of varicocele using bipolar cautery versus open high ligation technique: A randomized, clinical trial. J Laparoendosc Adv Surg Tech A 2007;17:743-7.  Back to cited text no. 10
    
11.Abdulmaaboud MR, Shokeir AA, Farage Y, Abd El-Rahman A, El-Rakhawy MM, Mutabagani H. Treatment of varicocele: A comparative study of conventional open surgery, percutaneous retrograde sclerotherapy, and laparoscopy. Urology 1998;52:294-300.  Back to cited text no. 11
    
12.Mandressi A, Buizza C, Antonelli D, Chisena S. Is laparoscopy a worthy method to treat varicocele? Comparison between 160 cases of two-port laparoscopic and 120 cases of open inguinal spermatic vein ligation. J Endourol 1996;10:435-41.  Back to cited text no. 12
    
13.Beutner S, May M, Hoschke B, Helke C, Lein M, Rolgas J, et al. Treatment of varicocele with reference to age: A retrospective comparison of three minimally invasive procedures. Surg Endosc 2007;21:61-5.  Back to cited text no. 13
    
14.Misseri R, Gershbein AB, Horowitz M, Glassberg KI. The adolescent varicocele. II: The incidence of hydrocele and delayed recurrent varicocele after varicocelectomy in a long-term follow-up. BJU Int 2001;87:494-8.  Back to cited text no. 14
    
15.Hassan JM, Adams MC, Pope JC, Demarco RT, Brock JW. Hydrocele formation following laparoscopic varicocelectomy. J Urol 2005;175:1076-9.  Back to cited text no. 15
    
16.Esposito C, Valla JS, Najmaldin A, Shier F, Mattioli G, Savanelli A, et al. Incidence and management of hydrocele following varicocele surgery in children. J Urol 2004;171:1271-3.  Back to cited text no. 16
    
17.Schwentner C, Radmayr C, Lunacek A, Gozzi C, Pinaggera GM, Neururer R, et al. Laparoscopic varicocele ligation in children and adolescents using isosulphan blue: A prospective randomized trial. BJU Int 2006;98:861-5.  Back to cited text no. 17
    
18.Riccabona M, Oswald J, Koen M, Lusuardi L, Radimayr C, Bartsch G. Optimizing the treatment of boys with varicocele: Sequential comparison of 4 techniques. J Urol 2003;169:666-8.  Back to cited text no. 18
    
19.Oswald J, Korner I, Riccabona M. The use of isosulphan blue to identify lymphatic vessels in high retroperitoneal ligation of adolescent varicocele-avoiding postoperative hydrocele. BJU Int 2001;87:502-4.  Back to cited text no. 19
    
20.D'Alessio A, Piro E, Beretta F, Brugnoni M, Marinoni F, Abati L. Lymphatic preservation using methylene blue dye during varicocele surgery: A single-center retrospective study. J Pediatr Urol 2008;4:138-40.  Back to cited text no. 20
    
21.Chiarenza SF, D'Agostino S, Scarpa M, Fabbro M, Costa L, Musi L. Lymphography prior to laparoscopic palomo varicoclectomy to prevent postoperative hydrocele. J Laparoendosc Adv Surg Tech A 2006;16:394-6.  Back to cited text no. 21
    
22.Kocvara R, Dvoracek J, Sedlacek J, Dite Z, Novak K. Lymphatic sparing laparoscopic varicocelectomy: A microsurgical repair. J Urol 2005;173:1751-4.  Back to cited text no. 22
    
23.Glassberg KI, Poon SA, Glertson CK, DeCastro GJ, Misseri R. Laparoscopic lymphatic sparing varicocelectomy in adolescents. J Urol 2008;180:326-30.  Back to cited text no. 23
    

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Correspondence Address:
João Moreira-Pinto
Centro Hospitalar do Porto, Rua da Boavista, no 827, 4050 - 111 Porto
Portugal
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DOI: 10.4103/0189-6725.78667

PMID: 21478585

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1 Varicocoelectomy in adolescents
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African Journal of Paediatric Surgery. 2011; 8(3): 327-328
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