Optimizing the Operative Treatment of Boys with Varicocele: Sequential Comparison of 4 Techniques

0022-5347/03/1692-0666/0 THE JOURNAL OF UROLOGY® Copyright © 2003 by AMERICAN UROLOGICAL ASSOCIATION

Vol. 169, 666 – 668, February 2003 Printed in U.S.A.

DOI: 10.1097/01.ju.0000047086.34953.82

OPTIMIZING THE OPERATIVE TREATMENT OF BOYS WITH VARICOCELE: SEQUENTIAL COMPARISON OF 4 TECHNIQUES MARCUS RICCABONA,* JOSEF OSWALD, MARK KOEN, LUKAS LUSUARDI, CHRISTIAN RADMAYR AND GEORG BARTSCH From the Department of Pediatric Urology, Krankenhaus Barmherzige Schwestern, Linz and Department of Urology, University of Innsbruck, Innsbruck, Austria

ABSTRACT

Purpose: We compared 4 techniques of varicocele ligation in boys and young adolescents to determine the optimal operative treatment that avoids varicocele recurrence and postoperative hydrocele formation. Materials and Methods: In 10 years a total of 128 varicocelectomies were performed sequentially in 121 boys and young adolescents with a mean age of 12 years using the laparoscopic, inguinal testicular artery sparing, standard Palomo (high mass retroperitoneal ligation) and modified Palomo approaches. The modified Palomo approach involved suprainguinal and retroperitoneal ligation of the veins and artery, and microsurgical sparing of the blue stained lymphatic pathway of the testis. Patients were followed a mean of 52 months. Results: In the 19 boys in the laparoscopy group varicocele persisted in 10% and hydrocele developed in 5%. In the 21 patients who underwent inguinal surgery with artery preservation recurrent varicoceles were identified in 14% and no hydroceles were observed. In the 32 patients who underwent the standard Palomo procedure there was no palpable varicocele persistence or recurrence, while hydroceles developed in 12%. Of the 56 patients in the modified Palomo group varicocele recurred in 1 (2%) and there were no hydroceles. No testicular atrophy developed in any patient. Conclusions: Comparison of all 4 groups revealed significant differences in varicocele recurrence (p ⫽ 0.038) and hydrocele formation (p ⫽ 0.023). Pairwise group comparison showed that the modified Palomo technique resulted in a significant decrease in the incidence of postoperative hydrocele formation compared with the standard Palomo method (p ⫽ 0.015). This procedure can be recommended as the optimal surgical technique for varicocele treatment in males of this young age. KEY WORDS: testis, varicocele, lymphatic system, hydrocele

There is evidence that a varicocele first develops in childhood or early adolescence. It can affect ipsilateral testicular growth, and testicular function progressively and in duration dependent fashion. The reported incidence of varicoceles in males of this age is about 10% to 15%.1 Varicocele is the most common reversible cause of male factor infertility. Currently there are no parameters that reliably predict which boys or adolescents with varicocele may become infertile in adulthood. The younger the patient is at varicocele repair, the more likely the testis is to recover from varicocele induced injury.2 Various surgical and radiographic treatment techniques have been advocated in adults but fewer reports have been published on surgical procedures and outcomes in boys and young adolescents. The most popular treatment for varicocele in childhood has been high retroperitoneal mass ligation of the vasa spermatica interna, resulting in a low incidence of varicocele recurrence but a high postoperative hydrocele rate. There is not yet a commonly accepted and preferred technique for varicocele repair in males of this young age. We report our experience with 4 operative techniques for varicocele repair performed sequentially in a nonrandomized manner with an emphasis on the recurrence and complication rates.

MATERIALS AND METHODS

In the 10 years between January 1992 and December 2001 a total of 128 consecutive varicocele repair operations were performed in 121 boys with a mean age of 12 years (range 4 to 15). A primary left unilateral procedure was performed in 120 children and 1 underwent a primary bilateral procedure. A unilateral procedure was done more than once in 6 boys for recurrent varicocele. The diagnosis of varicocele was made because of an incidental finding, self-diagnosis or symptoms such as scrotal sensation or testicular pain. Varicoceles were classified by physical examination with the patient supine, standing at rest and during the Valsalva maneuver according to the guidelines of the WHO (WHO score).3 Testicular volume was determined before and after the operation using a 7.5 MHz. ultrasound probe and/or orchidometer. Average testicular volume difference was determined by subtracting left from right testicular volume. The diameter of the veins of the plexus pampiniformis and reflux was measured by Doppler ultrasound. The indications for surgery included palpable varicocele grade II in 38 boys and grade III in 90 according to the WHO score as well as ipsilateral growth failure with a proved testicular volume loss of more than 10% compared with the contralateral right testis in 112 (93%). Surgery was not done for subclinical or grade I varicoceles. We used 4 operative techniques sequentially in a nonrandomized manner. In group 1 varicocele ligation was performed laparoscopically with the intent of preserving the

Accepted for publication September 13, 2002. * Requests for reprints: Department of Paediatric Urology, Krankenhaus Barmherzige Schwestern, Seilersta¨tte 4, A-4010 Linz, Austria. 666

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testicular artery. In group 2 an inguinal approach was used, as previously described. All venous vessels within the spermatic cord were ligated at the level of the external inguinal ring without delivery of the testis with the spermatic artery spared. The spermatic artery was identified by visible pulsation and lymphatic channels using a 2.5⫻ loupe for optical magnification. In group 3 the standard Palomo procedure was performed using a suprainguinal retroperitoneal approach. The whole spermatic cord was ligated with 5-zero polyglactin 910 just above the separation from the vas deferens. In group 4, 2 ml. 1% isosulfan blue (the isomer of patent blue) were injected under the tunica dartos close to the parietal wall of the tunica vaginalis at the ipsilateral side of the scrotum 15 to 20 minutes before the operation. The internal spermatic vessels were delivered retroperitoneally via a standard muscle splitting Palomo incision. All veins and the artery were ligated with the blue stained and easily identified lymph glands were spared using microsurgical instruments and a loupe or microscope (see figure). This new technique has been described previously.4 No intraoperative venograms were performed. All patients underwent physical examination and ultrasound every 3 months for 1 year. Varicocele recurrence was defined as a clearly visible or palpable varicocele identified at the 3 or 6-month followup. Postoperative hydrocele formation more than 3 to 6 months in duration warranted a secondary operation. The incidence of varicocele recurrence and postoperative hydrocele development was compared among the 4 techniques using the chi-square and Fisher’s exact tests performed in hierarchical fashion. Differences in the 4 groups were tested at the 5% significance level. Pairwise comparisons of the modified Palomo group with the other groups were made using the Bonferroni correction at the 1.67% significance level. RESULTS

The table lists the results. In the 19 boys in the laparoscopic surgery group varicocele ligation was done intraperitoneally. Preservation of the artery was successful in 11 cases, dubious in 3 and not possible in 4. Varicocele persisted or recurred in 2 of the 19 boys (11%). There were 2 cases of postoperative temporary reactive hydrocele formation, which subsequently completely resolved, and 1 of persistent hydrocele. Testis volume increased in 16 of the 19 patients (84%). In group 2 a previously described inguinal approach was used in 21 boys. Venous ligation sparing the spermatic artery was performed in 20 boys, while in 1 the artery could not be identified. Palpable varicocele persisted in 3 patients (14%).

Delivery of vasa spermatica interna with vessel loop enabled clear identification of blue stained lymph glands.

Results of 4 techniques of varicocele ligation Method Laparoscopic Inguinal artery sparing Palomo: Standard Modified Totals

No. No. Recurrence No. Hydrocele Procedures (%) (%) 19 21

2 (11) 3 (14)

1 (5) 0

32 56

0 1 (2)

4 (13) 0

128

6 (5)

5 (4)

No hydrocele was detected postoperatively. There was a significant volume increase in 16 testes (76%). In 32 patients the standard Palomo procedure was performed. In this group no palpable varicocele persistence or recurrence was noted. However, hydroceles formed in 4 boys (13%). The postoperative increase in ipsilateral testis volume was similar to that after the artery sparing and laparoscopic techniques. Testis volume increased in 28 patients (88%). Of the 56 boys in whom the lymphatic vessels were stained preoperatively it was possible to identify and spare the blue vessels in 46 (82%). Of the remaining 10 patients (18%) the spermatic veins stained blue in 4 (7%) and lymphatic vessel staining was unsuccessful in 6 (11%). In this group there was 1 case of persistent varicocele and no hydrocele formed postoperatively. Catch-up growth of the ipsilateral testis was documented in 52 of the 56 patients (93%). Statistical analysis for the overall comparison of the 4 groups showed significant differences in varicocele recurrence (p ⫽ 0.038) and hydrocele (p ⫽ 0.023). Pairwise group comparison revealed a significant decrease in the incidence of postoperative hydrocele after the modified Palomo procedure compared with the standard Palomo procedure (p ⫽ 0.015). DISCUSSION

Postoperative varicocele persistence or recurrence and hydrocele formation are the most commonly reported and most significant complications of prophylactic varicocele surgery. The incidence of postoperative hydrocele formation is 3% to 33%.5 The highest incidence of persistent varicocele occurs when efforts are made to spare the testicular artery. Kass and Marcol reported a rate of 3.6% to 37.5%.6 They noted no persistent varicoceles in their series of patients when the whole spermatic pedicle was ligated, as initially proposed by Palomo. Ligation of the whole spermatic cord does not lead to the loss of testicular volume or atrophy as long as the patient has not previously undergone inguinal surgery.7 The cause of postoperative hydrocele formation after varicocelectomy is disruption of the lymphatic drainage of the tunica vaginalis.8, 9 The reported incidence of hydrocele formation after the standard Palomo operation is 3% to 25%.8 The most appropriate operative treatment for varicocele in boys and young adolescents in terms of minimizing these complications is still under discussion. Compared with the other methods laparoscopy was more time-consuming, more expensive, carried a higher intraoperative risk and was technically more involved. For these reasons and for cosmesis since 4 small port incisions are needed, laparoscopic varicocele ligation has been abandoned at our clinic. Meticulous ligation of the pampiniform plexus via inguinal access at the level of the external inguinal ring and preservation of the artery and lymphatic vessels were associated with the highest recurrence rate of 14% in our hands. No varicocele recurrence was observed after the classic Palomo operation and similar results have been reported previously. However, this method led to a rather high 13% rate of persistent hydrocele postoperatively. Goldstein et al reported that microsurgical dissection permits reliable identification of the testicular artery and preservation of the lymph glands.10

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Postoperatively hydrocele is a potential problem with any technique used for varicocele ligation but the risk may be greatest with the standard Palomo procedure because no attempt is made to preserve the lymph glands. Preoperative staining with intrascrotal injection of isosulfan blue allows the clear identification and preservation of lymph glands and their differentiation from venous channels. Blebea and Choudry used isosulfan blue injection to treat postoperative lymphatic complications.11 Within 15 to 20 minutes spermatic lymphatic vessels absorb vital dye and become visible. As a result, the postoperative development of hydrocele, which is the most common complication of standard Palomo repair, was prevented. Our results with this modified Palomo technique have been significantly better than with any other surgical procedure. CONCLUSIONS

From this comparison of 4 consecutively used operative techniques it is evident that simple ligation of the spermatic veins carries the risk of persistent or recurrent varicocele, while disruption of the lymphatic vessels of the testis and tunica vaginalis is associated with the risk of postoperative hydrocele. Using vital dyes enables the clear identification and preservation of lymphatic pathways. This modified Palomo procedure involving suprainguinal and retroperitoneal ligation of the veins and artery, and microsurgical sparing of the blue stained lymphatic pathway of the testis seems to be an optimal method for varicocele treatment in boys and young adolescents, minimizing varicocele recurrence and avoiding postoperative hydrocele formation.

Dr. Hanno Ulmer, Institute of Biostatistics, University of Innsbruck, Austria performed the statistical analysis. REFERENCES

1. Kass, E. J., Freitas, J. E. and Bour, J. B.: Adolescent varicocele: objective indications for treatment. J Urol, 142: 579, 1989 2. Kass, E. J. and Belman, A. B.: Reversal of testicular growth failure by varicocele ligation. J Urol, 137: 475, 1987 3. Comparison among different methods for the diagnosis of varicocele. World Health Organization. Fertil Steril, 43: 575, 1985 4. Oswald, J., Korner, I. and Riccabona, M.: The use of isosulphan blue to identify lymphatic vessels in high retroperitoneal ligation of adolescent varicocele—avoiding postoperative hydrocele. BJU Int, 87: 502, 2001 5. Miller, J., Pfeiffer, D., Schumacher, S., Tauber, R., Muller, S. C. and Weidner, W.: Varicocele testis in childhood and adolescence. Urologe A, 41: 68, 2002 6. Kass, E. J. and Marcol, B.: Results of varicocele surgery in adolescents: a comparison of techniques. J Urol, 148: 694, 1992 7. Parrott, T. S. and Hewatt, L.: Ligation of the testicular artery and vein in the adolescent varicocele. J Urol, 152: 791, 1994 8. Szabo, R. and Kessler, R.: Hydrocele following internal spermatic vein ligation: a retrospective study and review of the literature. J Urol, 132: 924, 1984 9. Rinker, J. R. and Allen, L.: A lymphatic defect in hydrocele. Amer Surg, 17: 681, 1951 10. Goldstein, M., Gilbert, B. R., Dicker, A. P., Dwosh, J. and Gnecco, C.: Microsurgical inguinal varicocelectomy with delivery of the testis: an artery and lymphatic sparing technique. J Urol, 148: 1808, 1992 11. Blebea, J. and Choudry, R.: Thigh isosulfan blue injection in the treatment of postoperative lymphatic complications. J Vasc Surg, 30: 350, 1999