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Dye-assisted lymphatic-sparing laparoscopic varicocelectomy in children
Journal of Pediatric Urology (2013) 9, 33e37
Dye-assisted lymphatic-sparing laparoscopic varicocelectomy in children John-Paul Capolicchio*, Mohamed El-Sherbiny, Alex Brzezinski, Waleed Eassa, Roman Jednak Division of Urology, Montreal Children’s Hospital, McGill University Health Center, 2300 Rue Tupper Room C5.27, Montre´al, QC, Canada H3H 1P3 Received 13 May 2011; accepted 5 November 2011 Available online 1 December 2011
KEYWORDS Varicocelectomy; Lymphatic sparing; Dye; Laparoscopy; Children
Abstract Introduction: The ideal method for varicocelectomy in children remains controversial. We present our experience with dye-assisted lymphatic-sparing laparoscopic varicocelectomy (LSLV) in children, which overcomes the limitations of previously described techniques. Materials and methods: Twenty-five consecutive LSLVs were performed on children with a mean age of 15 years over a 4-year period. Varicocele grade was 3 in 21 cases and grade 2 in 4. Indications for intervention were hypotrophy in 12, pain in 11 cases and family preference in 2. A scrotal injection of lymphatic dye was utilized to spare at least one lymphatic and the remaining spermatic vessels were divided. Results: Lymphatic sparing was accomplished in all cases. Operative time varied from 30 to 140 min (mean 85 26). No perioperative complications were noted. On average follow-up of 13 months a residual varicocele was noted in 2 cases, with no hydrocele and resolution of pain. Mean testicular volume difference diminished from 33% pre to 18% postoperatively. Conclusion: This multi-surgeon experience demonstrates that dye-assisted LSLV is easily accomplished with promising results. It appears that preservation of a single spermatic lymphatic vessel is sufficient, although in some cases a second dye injection is required to visualize the lymphatics. ª 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction Varicocelectomy in children is still without a gold standard treatment. Though the microscopic technique appears to
be effective in adults, there is a reported risk of testicular loss due to arterial injury in even the most experienced hands [1]. This risk is potentially higher in the hands of less experienced surgeons and if the vessels are smaller as in
* Corresponding author. Tel.: þ1 (514) 412 4316; fax: þ1 (514) 412 4384. E-mail address: [email protected] (J.-P. Capolicchio). 1477-5131/$36 ª 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2011.11.004
34
J.-P. Capolicchio et al.
children [2]. The Palomo technique of retroperitoneal mass ligation of the spermatic vessels offers a low recurrence rate but with the risk of postoperative hydrocele averaging 10% short term and up to 30% with extended follow-up [3e5]. Lymphatic sparing theoretically should reduce this risk and is an appealing alternative with sparse supportive literature to date. Initial reports of lymphatic-sparing laparoscopic Palomo have shown excellent results with decreased incidence of secondary hydrocele down to 2e3%, albeit without the aid of lymphatic dyes [6,7]. The only cohorts to report zero hydrocele rates have been those who have used lymphatic dyes to aid in identification of the lymphatics [8,9]. We present our initial experience with dye-assisted lymphatic-sparing laparoscopic varicocelectomy (LSLV) in children, the first North American experience reported in the literature. We contribute novel insights regarding the number of lymphatic vessels which need to be preserved, a comparison of the different lymphatic dyes available and the need for second injection in some cases.
Materials and methods Between May 2006 and May 2010, 25 consecutive left LSLVs were performed by three surgeons with extensive trainee involvement. One surgeon (JPC) served as a mentor for others in their initial cases. Clinical, operative and postoperative data were collected from a retrospective chart review. Children had a mean age of 15.5 1.6 years (range 12e18) and all had primary varicocele on the left side. Clinical grading was done according to Dubin and Amelar [10], and grade III varicocele was detected in 21 (84%) children while 4 had grade II. Indications for intervention were testicular volume asymmetry of greater than 20% in 12 (48%), pain in 11 (44%) and family preference in 2. An associated hydrocele was present in 1 patient and was repaired concomitantly, but prior to the laparoscopy. All patients had general anesthesia, placed in supine position with slight Trendelenburg. A left scrotal, subdartos injection of 2 ml of 1% isosulfan blue (Tyco Healthcare, Pointe-Claire, Canada) or patent blue sodium (Therapex E-Z-EM, Montreal, Canada) dye was done using a 21-gauge needle (Fig. 1). The first 11 cases were done with isosulfan blue and then we switched to patent blue due to cost considerations. A transperitoneal approach was used via a 5-mm umbilical incision. Pneumoperitoneum was established followed by placement of two 5-mm ports at both lower abdominal quadrants. Having inserted the three ports, it is important to note that the insufflation pressure was reduced to 10e12 mmHg, since we found that elevated intraabdominal pressure can hinder visualization of the lymphatics. Exposure of the posterior peritoneum overlying the spermatic vessels was easily achieved, sometimes aided with exaggerated Trendelenburg and contralateral table rotation to mobilize the bowel out of the field. A small posterior peritoneotomy was done over the spermatic vessels. Stained lymphatics are easily seen running alongside the spermatic artery and vein (Fig. 2a), and on a properly color balanced monitor they appear
Figure 1 Ipsilateral subdartos scrotal injection of dye alongside the spermatic cord.
cyan/green color as opposed to the dark blue of the veins. If the stained lymphatics were not immediately seen after posterior peritoneotomy, anesthetic relaxation of the abdominal wall was verified, and if adequate a second injection of lymphatic dye was given. In general, the time from injection to peritoneotomy was circa 10 min. At least one lymphatic was spared (Fig. 2b) and the rest of the spermatic vessels were mass ligated and divided (Fig. 2c and d). Residents were encouraged to perform intra-corporeal knot tying for the mass ligation with 30 silk suture. Follow-up was routinely requested 1, 6 and 12 months postoperatively with an ultrasound at 6e12 months.
Results Dye-assisted LSLV was accomplished successfully in all 25 patients with no intraoperative or postoperative complications. No open conversion was needed. All patients were discharged on the same day. One injection was satisfactory to establish satisfactory lymphangiography in 21 (84%) patients while 4 (16%) patients needed two injections. We spared three lymphatic channels in 1 (4%) patient, two channels in 4 (16%), and then our intent changed to sparing only one lymphatic vessel in the remaining 20 (80%). Lymphatics on the ipsilateral side were identified in all patients, though in 1 patient with difficulty until the insufflation pressure was reduced. In this patient the intraabdominal pressure had crept up due to inadequate anesthetic relaxation of the abdominal wall. Mean operative time was 85 26 min (range 30e140). One patient underwent ipsilateral hydrocelectomy in the same setting for primary hydrocele. Mean follow-up period was 13.3 months (range 6e47). There were no cases of hydrocele noted. Residual varicocele was noted in 2 (8%) patients, one mild and the other initially mild but which
Dye-assisted lymphatic-sparing laparoscopic varicocelectomy
35
Figure 2 a. Lymphatics stained cyano-green are easily identified running alongside the spermatic artery and veins. b. At least one lymphatic is spared. c. Mass ligation and division of the remaining spermatic vessels. d. Solitary spared lymphatic seen after division of the spermatic vessels.
progressively worsened. Preoperative pain resolved in all 11 cases, though one had mild postoperative discomfort which he stated was different to that experienced preoperative. Catch-up growth could be quantified in only 9 of 12 hypotrophy cases who complied with both pre and postoperative ultrasound, with a mean follow-up of 17 months (range 7e37 months). Of these 9 cases, the mean testicular volume difference decreased from 33 12% preoperatively to 18 9% postoperatively (p < 0.03).
Discussion The prevalence of varicocele in the pediatric population varies with age, from less than 1% in boys aged 2e10 years to 7.8% in those 11e14-years old. In the 15e19-year-old age group, the prevalence is similar to that in adults at 14.1% [2]. The currently utilized techniques for varicocele repair include the standard inguinal approach, the microscopic subinguinal approach, laparoscopic techniques, high retroperitoneal Palomo procedure and radiological interventional sclerotherapy, each with advantages and disadvantages and no agreement on a gold standard in the pediatric age group. In particular, children have smaller vasculature than adults, making identification of the spermatic artery more difficult, thus choosing the ideal approach should consider this peculiarity. The difference between children and adults is further emphasized by the fact that recurrence rates after varicocelectomy are higher in children [11,12]. Ivanissevich first described the inguinal approach to varicocele correction [13]. Subsequent studies confirmed
the high incidence of recurrence up to 16% and secondary hydrocele of 14% despite the usage of optical magnification and intraoperative venography, whereas the Palomo technique improved on the recurrence rate [5,14]. Further improving on outcomes, Goldstein and colleagues described a subinguinal approach to varicocele repair with the use of the intraoperative microscope providing greater magnification [11,15]. High success rates reaching up to 98% with 1% secondary hydrocele have been confirmed by other centers as well [16,17]. Interestingly, both of these centers reported the need to use a Doppler probe to help in identifying the testicular artery, despite the use of 25 operative magnification, stating that ‘the artery was not easily visualized’ [17]. This is not surprising when one considers that the adult testicular artery varies from 0.3 to 1.0 mm in diameter and is even smaller in children, thus posing a greater risk of accidental ligation [1,12]. The risk of inadvertent artery ligation was reported to be 1% [1] in a large adult series under a very experienced microsurgeon, and is likely higher in the hands of less experienced surgeons operating on children with smaller vessels. Underscoring this concern, we cannot identify any reports of testicular atrophy with the Palomo procedure but were able to identify at least three reports of testicular atrophy with the microsurgical approach [1,4,18]. This distinct difference in the risk of testicular atrophy between the Palomo and microsurgical varicocelectomy has also been noted by others [2,19]. With the evolution of laparoscopy, minimally invasive varicocelectomy became possible via two or three 3e5-mm ports. Since then the laparoscopic Palomo technique has
36 gained popularity due to the ease of surgery, safety and high success rates of 98%, similar to that of the microsurgical technique. Yet, many were still reporting secondary hydrocele rates of 14% [20] and some as high as 30% with more extensive follow-up [21]. This stimulated advocates of laparoscopic Palomo to consider lymphatic sparing, decreasing the incidence of secondary hydrocele down to 3% [6,7]. Despite these encouraging reports, separation of the thin, colorless lymphatic vessels with the optical magnification provided by the laparoscope was subjective and uncertain in our hands. Even the authors describing the laparoscopic lymphatic-sparing technique mention the early need for the aid of a vascular surgeon in identifying the lymphatic vessels [7]. This difficulty is also evident from their statement: ‘If a small vessel is ambiguous, we err on the side of ligation’. Oswald in 2001 was the first to recommend the use of subdartos scrotal injection of isosulfan blue dye in order to reliably and objectively identify and spare the spermatic lymphatic vessels [22], and in a comparative study this was found to be superior to the standard Palomo procedure [23]. This encouraging experience with the open Palomo was then applied to the laparoscopic Palomo in a prospective randomized trial which again demonstrated a zero rate of secondary hydrocele with the dye-assisted approach [8]. Since then two other European centers have reported similar zero rates of secondary hydrocele with dyeassisted laparoscopic Palomo varicocelectomy [9,24]. Our results are thus the fourth series in the literature to confirm the benefit of a dye-assisted approach. The open Palomo with lymphatic sparing has not been compared to the laparoscopic equivalent, so that comparisons of intraoperative and postoperative outcomes are lacking. Apart from reducing the rate of secondary surgery, it is important to note that lymphatic sparing may also be of benefit in avoiding the deleterious effect of testicular edema on testicular function [25]. Lymphatic staining agents such as isosulfan blue and patent blue sodium have been increasingly used to facilitate lymphatic mapping and identification of sentinel nodes for staging in breast cancer and melanoma. We switched from isosulfan blue to patent blue because of the lower cost and lower side-effect profile. The main concern with isosulfan blue is anaphylaxis, which although quite rare is reported as severe in up to 0.1% of cases in the adult oncology literature [26]. It is unknown whether the site of injection or age of the patient influence the magnitude of this risk. Blue dyes can also falsely affect pulse oximetry readings, shown to be factitious by blood gas analysis [27], and in addition all blue lymphatic dyes should be avoided in patients with glucose-6-phosphate dehydrogenase deficiency. Milder local allergic reactions can occur in up to 3% of cases and bluish discoloration of the scrotal skin has been reported and found to disappear by the 6th month [8]. In our series, we did not record any complications either systemic or related to the site of injection. Of interest, methylene blue has recently been suggested to be equally effective for lymphatic mapping in breast cancer [27]. We attempted its use in 3 cases and were uniformly disappointed with the results. The lymphatic vessels could not be distinguished from the blue spermatic veins, as opposed to the easily seen cyano-green lymphatics when using isosulfan blue or patent blue.
J.-P. Capolicchio et al. Technically we found it very easy to detect the stained retroperitoneal lymphatics and spare them. Initially we were sparing all visualized lymphatics but then we intentionally spared only one, since we noted that an additional lymphatic channel usually courses along the vas deferens. This is the first series to address the question of how many lymphatic vessels need to be spared, since all other series report sparing from two to four visualized channels [8,9,24]. The technique of subdartos scrotal injection of dye is also straightforward, akin to performing a cord block. It is important to note that we injected alongside the spermatic cord and not peri-testicularly. Though technically not a concern, it is important to be aware of the deleterious effects of intra-testicular injection [28]. The main technical point we found was that injection into the subcutaneous space rather than subdartos is what led to non-visualization of the lymphatics in 4 patients, necessitating a second deeper injection. Subcutaneous or intra-dermal injection is immediately noted by the formation of a bleb, whereas subdartos injection does not raise the skin and does not discolor the skin. Finally, in 1 case we initially had difficulty in seeing the stained lymphatics until we noticed that the patient was not well relaxed under anesthesia and the insufflation pressures were elevated. With a reduction in intra-abdominal pressure and application of gentle pressure to the spermatic vessels with a forceps, the stained lymphatics immediately became obvious. We surmise that awareness of these technical nuances may explain our 100% lymphatic detection rate compared to the range of 63e96% in other series [8,9,24]. The limitation of our study is the modest sample size, yet similar to many of the comparative cohorts described in the literature. The size of the cohort does provide the advantage of seeing the results that can be attained even in the early part of the learning curve. The strength of our study is the multi-surgeon nature of the experience, an indicator of reproducibility in other surgeons’ hands, as opposed to many of the single-surgeon experiences reported [7].
Conclusions This early multi-surgeon experience with significant trainee involvement demonstrates that dye-assisted LSLV is easily accomplished with excellent surgical outcome. The use of isosulfan or patent blue dyes provides an objective method to easily and accurately identify lymphatics, though in our hands we found that methylene blue provides no benefit. Sparing one lymphatic appears to be sufficient to avoid secondary hydrocele, but sometimes a second injection is needed. The initial outcomes appear promising, yet a larger cohort is required to accurately assess the efficacy.
Conflict of Interest None.
Funding None.
Dye-assisted lymphatic-sparing laparoscopic varicocelectomy
References [1] Chan PT, Wright EJ, Goldstein M. Incidence and postoperative outcomes of accidental ligation of the testicular artery during microsurgical varicocelectomy. J Urol 2005;173:482e4. [2] Feber KM, Kass EJ. Surgery for the adolescent varicocele. Dialogues Pediatr Urol 2008;30:10e1. [3] Barroso Jr U, Andrade DM, Novaes H, Netto JM, Andrade J. Surgical treatment of varicocele in children with open and laparoscopic Palomo technique: a systematic review of the literature. J Urol 2009;181:2724e8. [4] Diamond DA, Xuewu J, Cilento Jr BG, Bauer SB, Peters CA, Borer JG, et al. Varicocele surgery: a decade’s experience at a children’s hospital. BJU Int 2009;104:246e9. [5] Misseri R, Gershbein AB, Horowitz M, Glassberg KI. The adolescent varicocele. II: the incidence of hydrocele and delayed recurrent varicocele after varicocelectomy in a longterm follow-up. BJU Int 2001;87:494e8. [6] Kocvara R, Dvoracek J, Sedlacek J, Dite Z, Novak K. Lymphatic sparing laparoscopic varicocelectomy: a microsurgical repair. J Urol 2005;173:1751e4. [7] Glassberg KI, Poon SA, Gjertson CK, DeCastro GJ, Misseri R. Laparoscopic lymphatic sparing varicocelectomy in adolescents. J Urol 2008;180:326e30. discussion 30-1. [8] Schwentner C, Radmayr C, Lunacek A, Gozzi C, Pinggera GM, Neururer R, et al. Laparoscopic varicocele ligation in children and adolescents using isosulphan blue: a prospective randomized trial. BJU Int 2006;98:861e5. [9] Golebiewski A, Krolak M, Komasara L, Czauderna P. Dyeassisted lymph vessels sparing laparoscopic varicocelectomy. J Laparoendosc Adv Surg Tech A 2007;17:360e3. [10] Dubin L, Amelar RD. Varicocele size and results of varicocelectomy in selected subfertile men with varicocele. Fertil Steril 1970;21:606e9. [11] Schiff J, Kelly C, Goldstein M, Schlegel P, Poppas D. Managing varicoceles in children: results with microsurgical varicocelectomy. BJU Int 2005;95:399e402. [12] Goldstein M. Adolescent varicocele. J Urol 1995;153:484e5. [13] Ivanissevich O. Left varicocele due to reflux; experience with 4,470 operative cases in forty-two years. J Int Coll Surg 1960; 34:742e55. [14] Kass EJ, Marcol B. Results of varicocele surgery in adolescents: a comparison of techniques. J Urol 1992;148:694e6. [15] Goldstein M, Gilbert BR, Dicker AP, Dwosh J, Gnecco C. Microsurgical inguinal varicocelectomy with delivery of the testis: an artery and lymphatic sparing technique. J Urol 1992;148:1808e11.
37 [16] Yaman O, Soygur T, Zumrutbas AE, Resorlu B. Results of microsurgical subinguinal varicocelectomy in children and adolescents. Urology 2006;68:410e2. [17] Minevich E, Wacksman J, Lewis AG, Sheldon CA. Inguinal microsurgical varicocelectomy in the adolescent: technique and preliminary results. J Urol 1998;159:1022e4. [18] Zampieri N, Cervellione RM. Varicocele in adolescents: a 6year longitudinal and followup observational study. J Urol 2008;180:1653e6. discussion 6. [19] Diamond D. Adolescent versus adult varicoceles e how do evaluation and management differ? J Urol 2009;181: 2418e9. [20] Mendez-Gallart R, Bautista-Casasnovas A, Estevez-Martinez E, Varela-Cives R. Laparoscopic Palomo varicocele surgery: lessons learned after 10 years’ follow up of 156 consecutive pediatric patients. J Pediatr Urol; 2008. [21] Hassan JM, Adams MC, Pope JCt, Demarco RT, Brock 3rd JW. Hydrocele formation following laparoscopic varicocelectomy. J Urol 2006;175:1076e9. [22] Oswald J, Korner I, Riccabona M. The use of isosulphan blue to identify lymphatic vessels in high retroperitoneal ligation of adolescent varicocele e avoiding postoperative hydrocele. BJU Int 2001;87:502e4. [23] Riccabona M, Oswald J, Koen M, Lusuardi L, Radmayr C, Bartsch G. Optimizing the operative treatment of boys with varicocele: sequential comparison of 4 techniques. J Urol 2003;169:666e8. [24] Chiarenza SF, D’Agostino S, Scarpa M, Fabbro M, Costa L, Musi L. Lymphography prior to laparoscopic Palomo varicocelectomy to prevent postoperative hydrocele. J Laparoendosc Adv Surg Tech A 2006;16:394e6. [25] Kocvara R, Dolezal J, Hampl R, Povysil C, Dvoracek J, Hill M, et al. Division of lymphatic vessels at varicocelectomy leads to testicular oedema and decline in testicular function according to the LH-RH analogue stimulation test. Eur Urol 2003;43: 430e5. [26] Kaufman G, Guth AA, Pachter HL, Roses DF. A cautionary tale: anaphylaxis to isosulfan blue dye after 12 years and 3339 cases of lymphatic mapping. Am Surg 2008;74:152e5. [27] Zakaria S, Hoskin TL, Degnim AC. Safety and technical success of methylene blue dye for lymphatic mapping in breast cancer. Am J Surg 2008;196:228e33. [28] Makari JH, Atalla MA, Belman AB, Rushton HG, Kumar S, Pohl HG. Safety and efficacy of intratesticular injection of vital dyes for lymphatic preservation during varicocelectomy. J Urol 2007;178:1026e30. discussion 30.
Dye-assisted lymphatic-sparing laparoscopic varicocelectomy in children John-Paul Capolicchio*, Mohamed El-Sherbiny, Alex Brzezinski, Waleed Eassa, Roman Jednak Division of Urology, Montreal Children’s Hospital, McGill University Health Center, 2300 Rue Tupper Room C5.27, Montre´al, QC, Canada H3H 1P3 Received 13 May 2011; accepted 5 November 2011 Available online 1 December 2011
KEYWORDS Varicocelectomy; Lymphatic sparing; Dye; Laparoscopy; Children
Abstract Introduction: The ideal method for varicocelectomy in children remains controversial. We present our experience with dye-assisted lymphatic-sparing laparoscopic varicocelectomy (LSLV) in children, which overcomes the limitations of previously described techniques. Materials and methods: Twenty-five consecutive LSLVs were performed on children with a mean age of 15 years over a 4-year period. Varicocele grade was 3 in 21 cases and grade 2 in 4. Indications for intervention were hypotrophy in 12, pain in 11 cases and family preference in 2. A scrotal injection of lymphatic dye was utilized to spare at least one lymphatic and the remaining spermatic vessels were divided. Results: Lymphatic sparing was accomplished in all cases. Operative time varied from 30 to 140 min (mean 85 26). No perioperative complications were noted. On average follow-up of 13 months a residual varicocele was noted in 2 cases, with no hydrocele and resolution of pain. Mean testicular volume difference diminished from 33% pre to 18% postoperatively. Conclusion: This multi-surgeon experience demonstrates that dye-assisted LSLV is easily accomplished with promising results. It appears that preservation of a single spermatic lymphatic vessel is sufficient, although in some cases a second dye injection is required to visualize the lymphatics. ª 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction Varicocelectomy in children is still without a gold standard treatment. Though the microscopic technique appears to
be effective in adults, there is a reported risk of testicular loss due to arterial injury in even the most experienced hands [1]. This risk is potentially higher in the hands of less experienced surgeons and if the vessels are smaller as in
* Corresponding author. Tel.: þ1 (514) 412 4316; fax: þ1 (514) 412 4384. E-mail address: [email protected] (J.-P. Capolicchio). 1477-5131/$36 ª 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2011.11.004
34
J.-P. Capolicchio et al.
children [2]. The Palomo technique of retroperitoneal mass ligation of the spermatic vessels offers a low recurrence rate but with the risk of postoperative hydrocele averaging 10% short term and up to 30% with extended follow-up [3e5]. Lymphatic sparing theoretically should reduce this risk and is an appealing alternative with sparse supportive literature to date. Initial reports of lymphatic-sparing laparoscopic Palomo have shown excellent results with decreased incidence of secondary hydrocele down to 2e3%, albeit without the aid of lymphatic dyes [6,7]. The only cohorts to report zero hydrocele rates have been those who have used lymphatic dyes to aid in identification of the lymphatics [8,9]. We present our initial experience with dye-assisted lymphatic-sparing laparoscopic varicocelectomy (LSLV) in children, the first North American experience reported in the literature. We contribute novel insights regarding the number of lymphatic vessels which need to be preserved, a comparison of the different lymphatic dyes available and the need for second injection in some cases.
Materials and methods Between May 2006 and May 2010, 25 consecutive left LSLVs were performed by three surgeons with extensive trainee involvement. One surgeon (JPC) served as a mentor for others in their initial cases. Clinical, operative and postoperative data were collected from a retrospective chart review. Children had a mean age of 15.5 1.6 years (range 12e18) and all had primary varicocele on the left side. Clinical grading was done according to Dubin and Amelar [10], and grade III varicocele was detected in 21 (84%) children while 4 had grade II. Indications for intervention were testicular volume asymmetry of greater than 20% in 12 (48%), pain in 11 (44%) and family preference in 2. An associated hydrocele was present in 1 patient and was repaired concomitantly, but prior to the laparoscopy. All patients had general anesthesia, placed in supine position with slight Trendelenburg. A left scrotal, subdartos injection of 2 ml of 1% isosulfan blue (Tyco Healthcare, Pointe-Claire, Canada) or patent blue sodium (Therapex E-Z-EM, Montreal, Canada) dye was done using a 21-gauge needle (Fig. 1). The first 11 cases were done with isosulfan blue and then we switched to patent blue due to cost considerations. A transperitoneal approach was used via a 5-mm umbilical incision. Pneumoperitoneum was established followed by placement of two 5-mm ports at both lower abdominal quadrants. Having inserted the three ports, it is important to note that the insufflation pressure was reduced to 10e12 mmHg, since we found that elevated intraabdominal pressure can hinder visualization of the lymphatics. Exposure of the posterior peritoneum overlying the spermatic vessels was easily achieved, sometimes aided with exaggerated Trendelenburg and contralateral table rotation to mobilize the bowel out of the field. A small posterior peritoneotomy was done over the spermatic vessels. Stained lymphatics are easily seen running alongside the spermatic artery and vein (Fig. 2a), and on a properly color balanced monitor they appear
Figure 1 Ipsilateral subdartos scrotal injection of dye alongside the spermatic cord.
cyan/green color as opposed to the dark blue of the veins. If the stained lymphatics were not immediately seen after posterior peritoneotomy, anesthetic relaxation of the abdominal wall was verified, and if adequate a second injection of lymphatic dye was given. In general, the time from injection to peritoneotomy was circa 10 min. At least one lymphatic was spared (Fig. 2b) and the rest of the spermatic vessels were mass ligated and divided (Fig. 2c and d). Residents were encouraged to perform intra-corporeal knot tying for the mass ligation with 30 silk suture. Follow-up was routinely requested 1, 6 and 12 months postoperatively with an ultrasound at 6e12 months.
Results Dye-assisted LSLV was accomplished successfully in all 25 patients with no intraoperative or postoperative complications. No open conversion was needed. All patients were discharged on the same day. One injection was satisfactory to establish satisfactory lymphangiography in 21 (84%) patients while 4 (16%) patients needed two injections. We spared three lymphatic channels in 1 (4%) patient, two channels in 4 (16%), and then our intent changed to sparing only one lymphatic vessel in the remaining 20 (80%). Lymphatics on the ipsilateral side were identified in all patients, though in 1 patient with difficulty until the insufflation pressure was reduced. In this patient the intraabdominal pressure had crept up due to inadequate anesthetic relaxation of the abdominal wall. Mean operative time was 85 26 min (range 30e140). One patient underwent ipsilateral hydrocelectomy in the same setting for primary hydrocele. Mean follow-up period was 13.3 months (range 6e47). There were no cases of hydrocele noted. Residual varicocele was noted in 2 (8%) patients, one mild and the other initially mild but which
Dye-assisted lymphatic-sparing laparoscopic varicocelectomy
35
Figure 2 a. Lymphatics stained cyano-green are easily identified running alongside the spermatic artery and veins. b. At least one lymphatic is spared. c. Mass ligation and division of the remaining spermatic vessels. d. Solitary spared lymphatic seen after division of the spermatic vessels.
progressively worsened. Preoperative pain resolved in all 11 cases, though one had mild postoperative discomfort which he stated was different to that experienced preoperative. Catch-up growth could be quantified in only 9 of 12 hypotrophy cases who complied with both pre and postoperative ultrasound, with a mean follow-up of 17 months (range 7e37 months). Of these 9 cases, the mean testicular volume difference decreased from 33 12% preoperatively to 18 9% postoperatively (p < 0.03).
Discussion The prevalence of varicocele in the pediatric population varies with age, from less than 1% in boys aged 2e10 years to 7.8% in those 11e14-years old. In the 15e19-year-old age group, the prevalence is similar to that in adults at 14.1% [2]. The currently utilized techniques for varicocele repair include the standard inguinal approach, the microscopic subinguinal approach, laparoscopic techniques, high retroperitoneal Palomo procedure and radiological interventional sclerotherapy, each with advantages and disadvantages and no agreement on a gold standard in the pediatric age group. In particular, children have smaller vasculature than adults, making identification of the spermatic artery more difficult, thus choosing the ideal approach should consider this peculiarity. The difference between children and adults is further emphasized by the fact that recurrence rates after varicocelectomy are higher in children [11,12]. Ivanissevich first described the inguinal approach to varicocele correction [13]. Subsequent studies confirmed
the high incidence of recurrence up to 16% and secondary hydrocele of 14% despite the usage of optical magnification and intraoperative venography, whereas the Palomo technique improved on the recurrence rate [5,14]. Further improving on outcomes, Goldstein and colleagues described a subinguinal approach to varicocele repair with the use of the intraoperative microscope providing greater magnification [11,15]. High success rates reaching up to 98% with 1% secondary hydrocele have been confirmed by other centers as well [16,17]. Interestingly, both of these centers reported the need to use a Doppler probe to help in identifying the testicular artery, despite the use of 25 operative magnification, stating that ‘the artery was not easily visualized’ [17]. This is not surprising when one considers that the adult testicular artery varies from 0.3 to 1.0 mm in diameter and is even smaller in children, thus posing a greater risk of accidental ligation [1,12]. The risk of inadvertent artery ligation was reported to be 1% [1] in a large adult series under a very experienced microsurgeon, and is likely higher in the hands of less experienced surgeons operating on children with smaller vessels. Underscoring this concern, we cannot identify any reports of testicular atrophy with the Palomo procedure but were able to identify at least three reports of testicular atrophy with the microsurgical approach [1,4,18]. This distinct difference in the risk of testicular atrophy between the Palomo and microsurgical varicocelectomy has also been noted by others [2,19]. With the evolution of laparoscopy, minimally invasive varicocelectomy became possible via two or three 3e5-mm ports. Since then the laparoscopic Palomo technique has
36 gained popularity due to the ease of surgery, safety and high success rates of 98%, similar to that of the microsurgical technique. Yet, many were still reporting secondary hydrocele rates of 14% [20] and some as high as 30% with more extensive follow-up [21]. This stimulated advocates of laparoscopic Palomo to consider lymphatic sparing, decreasing the incidence of secondary hydrocele down to 3% [6,7]. Despite these encouraging reports, separation of the thin, colorless lymphatic vessels with the optical magnification provided by the laparoscope was subjective and uncertain in our hands. Even the authors describing the laparoscopic lymphatic-sparing technique mention the early need for the aid of a vascular surgeon in identifying the lymphatic vessels [7]. This difficulty is also evident from their statement: ‘If a small vessel is ambiguous, we err on the side of ligation’. Oswald in 2001 was the first to recommend the use of subdartos scrotal injection of isosulfan blue dye in order to reliably and objectively identify and spare the spermatic lymphatic vessels [22], and in a comparative study this was found to be superior to the standard Palomo procedure [23]. This encouraging experience with the open Palomo was then applied to the laparoscopic Palomo in a prospective randomized trial which again demonstrated a zero rate of secondary hydrocele with the dye-assisted approach [8]. Since then two other European centers have reported similar zero rates of secondary hydrocele with dyeassisted laparoscopic Palomo varicocelectomy [9,24]. Our results are thus the fourth series in the literature to confirm the benefit of a dye-assisted approach. The open Palomo with lymphatic sparing has not been compared to the laparoscopic equivalent, so that comparisons of intraoperative and postoperative outcomes are lacking. Apart from reducing the rate of secondary surgery, it is important to note that lymphatic sparing may also be of benefit in avoiding the deleterious effect of testicular edema on testicular function [25]. Lymphatic staining agents such as isosulfan blue and patent blue sodium have been increasingly used to facilitate lymphatic mapping and identification of sentinel nodes for staging in breast cancer and melanoma. We switched from isosulfan blue to patent blue because of the lower cost and lower side-effect profile. The main concern with isosulfan blue is anaphylaxis, which although quite rare is reported as severe in up to 0.1% of cases in the adult oncology literature [26]. It is unknown whether the site of injection or age of the patient influence the magnitude of this risk. Blue dyes can also falsely affect pulse oximetry readings, shown to be factitious by blood gas analysis [27], and in addition all blue lymphatic dyes should be avoided in patients with glucose-6-phosphate dehydrogenase deficiency. Milder local allergic reactions can occur in up to 3% of cases and bluish discoloration of the scrotal skin has been reported and found to disappear by the 6th month [8]. In our series, we did not record any complications either systemic or related to the site of injection. Of interest, methylene blue has recently been suggested to be equally effective for lymphatic mapping in breast cancer [27]. We attempted its use in 3 cases and were uniformly disappointed with the results. The lymphatic vessels could not be distinguished from the blue spermatic veins, as opposed to the easily seen cyano-green lymphatics when using isosulfan blue or patent blue.
J.-P. Capolicchio et al. Technically we found it very easy to detect the stained retroperitoneal lymphatics and spare them. Initially we were sparing all visualized lymphatics but then we intentionally spared only one, since we noted that an additional lymphatic channel usually courses along the vas deferens. This is the first series to address the question of how many lymphatic vessels need to be spared, since all other series report sparing from two to four visualized channels [8,9,24]. The technique of subdartos scrotal injection of dye is also straightforward, akin to performing a cord block. It is important to note that we injected alongside the spermatic cord and not peri-testicularly. Though technically not a concern, it is important to be aware of the deleterious effects of intra-testicular injection [28]. The main technical point we found was that injection into the subcutaneous space rather than subdartos is what led to non-visualization of the lymphatics in 4 patients, necessitating a second deeper injection. Subcutaneous or intra-dermal injection is immediately noted by the formation of a bleb, whereas subdartos injection does not raise the skin and does not discolor the skin. Finally, in 1 case we initially had difficulty in seeing the stained lymphatics until we noticed that the patient was not well relaxed under anesthesia and the insufflation pressures were elevated. With a reduction in intra-abdominal pressure and application of gentle pressure to the spermatic vessels with a forceps, the stained lymphatics immediately became obvious. We surmise that awareness of these technical nuances may explain our 100% lymphatic detection rate compared to the range of 63e96% in other series [8,9,24]. The limitation of our study is the modest sample size, yet similar to many of the comparative cohorts described in the literature. The size of the cohort does provide the advantage of seeing the results that can be attained even in the early part of the learning curve. The strength of our study is the multi-surgeon nature of the experience, an indicator of reproducibility in other surgeons’ hands, as opposed to many of the single-surgeon experiences reported [7].
Conclusions This early multi-surgeon experience with significant trainee involvement demonstrates that dye-assisted LSLV is easily accomplished with excellent surgical outcome. The use of isosulfan or patent blue dyes provides an objective method to easily and accurately identify lymphatics, though in our hands we found that methylene blue provides no benefit. Sparing one lymphatic appears to be sufficient to avoid secondary hydrocele, but sometimes a second injection is needed. The initial outcomes appear promising, yet a larger cohort is required to accurately assess the efficacy.
Conflict of Interest None.
Funding None.
Dye-assisted lymphatic-sparing laparoscopic varicocelectomy
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