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Lymphatic sparing laparoscopic Palomo varicocelectomy for varicoceles in children: intermediate results
Journal of Pediatric Surgery (2009) 44, 1509–1513
www.elsevier.com/locate/jpedsurg
Lymphatic sparing laparoscopic Palomo varicocelectomy for varicoceles in children: intermediate results☆ Qiangsong Tong a,b,⁎,1 , Liduan Zheng b,1 , Shaotao Tang a , Zhiyong Du a , Zehua Wu a , Hong Mei a , Qinglan Ruan a a
Department of Pediatric Surgery, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Hubei 430022, China b Department of Pathology, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Hubei 430022, China Received 26 July 2008; revised 7 October 2008; accepted 8 October 2008
Key words: Varicocele; Laparoscopy; Palomo varicocelectomy; Children
Abstract Objectives: Varicocele is a relatively rare disorder in children that can lead to testicular atrophy and infertility. The ideal surgical treatment for varicoceles is still a matter of controversy because of the frequency of postoperative complications. Here, we report our series of children who underwent lymphatic sparing laparoscopic Palomo varicocelectomy. Patients and Methods: A total of 46 boys, 9 to 14 years old, underwent laparoscopic repair for varicoceles between January 2002 and December 2007. All of them had a left-sided varicocele. The varicocele was diagnosed by physical examination and Doppler ultrasonography. The laparoscopic procedure included obligatory dissection and preservation of the lymphatic vessels, followed by double ligation of the spermatic vessels. Follow-up for these children included physical examination and Doppler ultrasonography. Results: Lymphatic sparing laparoscopic Palomo varicocelectomy was feasible in all 46 (100%) of the children. Mean operative time was 34.2 minutes (range, 25-42 minutes). There were no intraoperative complications. One patient recurred because of incomplete ligation of spermatic vein. Mean follow-up was 20 months (range, 7-32 months). Hydrocele formation, testicular atrophy, and testicular hypertrophy were not observed postoperatively. However, 2 preoperative hypotrophic testes were noted with 10.4% and 12.5% decreases in size. Conclusions: Our study reveals that lymphatic sparing laparoscopic Palomo varicocelectomy in children is safe, effective, and the reliable treatment of pediatric varicocele. However, long-term follow-up is required to best characterize ultimate outcome. © 2009 Elsevier Inc. All rights reserved.
☆
This study was supported by the National Natural Science Foundation of China (30200284, 30600278, 30772359), Program for New Century Excellent Talents in University (NCET-06-0641), and Scientific Research Foundation for the Returned Overseas Chinese Scholars (2008-889). ⁎ Corresponding author. Tel.: +86 27 63776478. E-mail address: [email protected] (Q. Tong). 1 Q. Tong and L. Zheng contributed equally to this work. 0022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2008.10.049
Varicocele is a relatively rare disorder in children, with an average reported incidence of approximately 5% [1]. Although uncommon before puberty, the incidence of varicocele in postpubertal children is similar to that of adulthood [2]. Varicoceles can lead to testicular atrophy
1510
Q. Tong et al.
and infertility; therefore, surgical treatment is frequently required [3]. Multiple methods exist for the treatment of varicoceles, including percutaneous sclerotherapy and open and laparoscopic surgical ligation of the spermatic vessels [3]. Classically, varicocelectomy may be performed either as a high retroperitoneal ligation of the spermatic vein as described by Palomo [4] or as a low superficial inguinal ligation as described by Ivanissevich [5]. With recent advances in minimal access surgery, there have been many reports lauding the safety and efficacy of laparoscopy for the surgical correction of varicocele [6,7]. Whichever treatment is chosen, postoperative complications are fairly common, such as recurrence, persistence, hydrocele, and testicular atrophy [8,9]. Thus, the ideal method of spermatic vein ligation for treating varicoceles is still a matter of controversy. Recurrence is the most common complication after varicocelectomy. Persistent or unidentified collateral veins at the time of ligation are considered to be the main cause of recurrence after varicocele repair [10]. Katten et al [11] reported that preservation of the testicular artery was associated with a higher recurrence rate for varicocele repairs, and this could be related to incomplete ligation of venous tributaries adjacent to the preserved testicular artery. Thus, the Palomo varicocelectomy is a popular approach, which involves ligation of the internal spermatic veins together with the testicular artery [4]. This method has resulted in a significant decrease in the operative failure rate compared with the artery-sparing procedures, with no increase in the incidence of testicular atrophy [12,13]. However, postoperatively, hydroceles are a potential problem with the standard Palomo procedure because no attempt is made to preserve the lymphatic vessels [14]. Therefore, lymphatic sparing procedures have been reconsidered during varicocelectomy. The lymphatic sparing laparoscopic Palomo procedure is one of the surgical options that has recently gained popularity. It is performed using Palomo's general concept of mass ligation of all the enlarged testicular vessels above the inguinal ring with lymphatic preservation [15]. Therefore, it shares similar features with the open Palomo technique. However, the addition of laparoscopy and its magnification allow careful assessment of the whole pelvic
Table 1
Indications for surgery
Indication Pain or scrotal discomfort (varicocele stage) First Second Third Testicular hypotrophy (varicocele stage) First Second Third
No. of patients 4 13 19 2 8 7
region and make it possible to identify all enlarged spermatic vessels and their collaterals along with enlarged vas vessels that should be divided to reduce the risk of recurrence [1618]. In addition, the laparoscopic lymphatic sparing procedure can reduce the occurrence of postoperative hydrocele with better identification of the lymphatic vessels. In the current study, we report on a series of children who underwent lymphatic sparing laparoscopic Palomo varicocelectomy for the treatments of varicoceles and their shortterm outcomes.
1. Patients and methods 1.1. Patients With the institutional review board approval, 46 boys with left varicoceles underwent lymphatic sparing laparoscopic Palomo varicocelectomy between January 2002 and December 2007. Their ages ranged between 9 and 14 years (mean, 12.6). Diagnosis and postoperative results were established clinically and using Doppler ultrasonography. Thirty-six patients presented with scrotal discomfort or pain. Varicocele was graded according to Dubin and Amelar [19]: grade I, vein dilatation palpable during Valsalva maneuver in upright position; grade II, palpable in upright position without Valsalva maneuver; and grade III, palpable and visible dilated veins through scrotal skin in upright position without Valsalva maneuver. There were grade I varicoceles in 6 patients (13.0%), grade II in 21 patients (45.7%), and grade III in 19 patients (41.3%). An ultrasound scan of the testicles was performed along with a color Doppler of the enlarged pampiniform veins to confirm the diagnosis, assess the size and structure of the testes, and define the severity of the venous reflux. Testicular volume was measured ultrasonographically in milliliters using the formula: 0.52 × length × width × height [20]. Testicular atrophy was defined as the presence of either a floppy testicle or a testicle with a volume noticeably smaller than contralateral (N20% volume difference) [21] or smaller than expected according to Prader's puberty stage [22]. In addition, an ultrasound of the abdomen was performed to rule out the presence of any intraabdominal mass, particularly a left renal tumor. Patients underwent surgical treatment if they presented with high-grade varicocele (grade III) or varicocele associated with symptoms and testicular hypotrophy of the left testicle (Table 1).
1.2. Surgical procedure The technique used three 5-mm laparoscopic ports under general anesthesia. Briefly, the patient emptied his bladder before surgery to reduce the risk of bladder injury upon initial trocar placement. The patient was placed in
Lymphatic sparing laparoscopic Palomo varicocelectomy in children approximately 15° of Trendelenburg position at initiation of the procedure. After preparing the operating field and scrotum with antiseptic solutions, 2 mL of 1% solution of isosulphan blue was injected under the tunica dartos near to the parietal wall of tunica vaginalis, light massage of the testicle was carried out for better definition of the lymphatic vessels according to the method of Oswald et al [23]. A 5-mm subumbilical trocar was inserted by open Hasson technique, and the abdominal cavity was insufflated by carbon dioxide to a maximum of 12 mm Hg. The other two 5-mm ports were placed in the right and left lower quadrants under laparoscopic vision. After identification of the testicular vessels and vas deferens, the peritoneum overlying the internal spermatic vessels was incised longitudinally about 2 to 3 cm superior to the internal ring over a distance of about 3 cm. Blunt dissection was used to isolate the spermatic vessels. During this step, care was taken to avoid any injury to the surrounding fat, thereby averting any possible injury to any potential overlaying lymphatic vessels. Contrast-stained lymphatic vessels were isolated from the vascular pedicle and all the enlarged spermatic and vas vessels then were ligated with 2 silk ligatures spaced 1 to 1.5 cm apart with further bipolar coagulation between them. At the end of procedure, the fascia at the 5-mm ports and the skin were reapproximated with silk sutures.
1.3. Follow-up All patients were followed for any postoperative complication via clinical symptom, testicular size, and the presence of any postoperative hydrocele. Treatment outcome was assessed by both physical examination and Doppler ultrasonography for all patients at approximately 6, 12, and 24 months postoperatively. Treatment success was defined as clinical disappearance of the varicocele or as indicated by color-coded Doppler ultrasonography (no retrograde blood flow exceeding 15 cm/s in the internal spermatic vein during a maximal Valsalva maneuver) [24]. Table 2
Summary of intraoperative and postoperative data
Characteristics
Laparoscopic Palomo varicocelectomy
No. of cases Age (y) Operative time (min) Length of stay (d) Complication (%) Recurrence Bleeding requiring revision Wound complication Damage of genitofemoral nerve Testicular atrophy Epididymorchitis Incisional hernia Hydrocele
46 12.6 (range, 9-14) 34.2 ± 5.4 (range, 25-42) 2.1 ± 0.5 (range, 2-4) 1 (2.12) 0 1 (2.12) 0 0 0 0 0
Table 3
1511 Postoperative follow-up results
Characteristic Varicocele Unchanged Disappeared Improved Scrotal discomfort or pain Unchanged Disappeared Improved
No. of cases
%
1 25 20
2.2 54.3 43.5
2 31 3
5.6 86.1 8.3
This outcome definition was applied to all patients regardless of indication for treatment.
2. Results The lymphatic sparing laparoscopic Palomo varicocelectomy procedure was feasible in all of the 46 children, without conversion to open varicocelectomy in any case. The mean operative duration was 34.2 minutes (range, 2542 minutes) (Table 2). Intraoperative blood loss was negligible. There were no intraabdominal visceral or vascular complications, and no postoperative analgesia was required. Immediate postoperative recovery was uneventful in all patients. All patients were ambulatory 4 to 6 hours after the surgical intervention. They complained of a slight pain in the incisional area, which was alleviated with nonnarcotic analgesics. One patient had a wound infection and recovered after administration of antibiotics (Table 2). Mean length of hospitalization was 2.1 ± 0.5 days (range, 2-4 days). Mean follow-up was 20 months (range, 7-32 months). The clinical and ultrasound Doppler examinations at 6, 12, and 24 months after the operation revealed that there was 1 case of recurrence (2.2%), which was presumably because of an error during skeletization of the artery where 1 vein adherent to the spermatic artery was left unligated (Table 2). The recurrence was treated by a reoperative laparoscopic procedure to ligate the missed spermatic vein. No hydrocele formation was observed in any of our patients (Table 2). The varicoceles disappeared in 25 cases (54.3%) and diminished significantly in 20 cases (43.5%) (Table 3). Ultrasound Doppler examination revealed the termination of pathological blood flow in the pampiniform plexus, and collapse of the veins of left testis in ortho- and clinostasis and during a Valsalva test. Of the 36 patients who presented with scrotal discomfort or pain, 31 (86.1%) achieved complete resolution of their symptoms (Table 3). In all cases, testicular size was noted before and after treatment (Table 4). No testicular atrophy was observed at follow-up. Only 2 preoperative hypotrophic testes were noted with loss of volume of 10.4% and 12.5% (15.4 and 15.6 mL, respectively), with regard to the controlateral testis (17.2 and 17.8 mL, respectively).
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Q. Tong et al.
Table 4
Evolution of testicular volume before and after treatment
Characteristic
No. of patients
Preoperative testis volume (mL) Left
Right
Left
Right
Nonhypotrophy Hypotrophy
29 17
15.2 ± 4.8 12.1 ± 3.2 a
15.4 ± 5.2 15.6 ± 4.7
17.3 ± 5.3 16.2 ± 3.8 b
17.1 ± 4.5 17.3 ± 5.1
a b
Postoperative testis volume (mL)
P b .05 for comparison between preoperative left and right testis volume within the hypotrophy group. P b .05 for comparison between preoperative and postoperative left testis volume within the hypotrophy group.
Normal expected growth of the gonad was noted in 43 (93.5%) of 46 patients.
3. Discussion The choice of operation for repair of the varicocele depends on many factors, such as overall success rate, complication rate, patient preference, and physician comfort with the various procedures. Recently, the outcomes of open inguinal, laparoscopic, and subinguinal microscopic varicocelectomy were compared, and their corresponding varicocele recurrence rates were 11% to 13%, 17% to 18%, and 2% to 2.6%, respectively, suggesting that subinguinal microsurgical varicocelectomy offered the best outcome [25,26]. In our series, the lymphatic sparing laparoscopic Palomo varicocelectomy was feasible in all cases with a comparable recurrence rate to the subinguinal approach. The varicoceles disappeared or diminished in 97.8% of the cases, suggesting good to excellent results of this procedure. Our results were similar to others in the literature regarding laparoscopic varicocelectomy in children, which yielded 88 good or excellent results of 90 patients, that is, 97.6% [27]. In our series, the mean length of hospital stay was 2.1 ± 0.5 days. Most of our patients were sent home 1 day after the procedure. However, 1 patient's course was complicated by a wound infection, which required 2 additional days in hospital. We believe that the longer hospital stay in our series was mainly because of prolonged duration of preoperative examination and postoperative recovery for general anesthesia, which is traditionally performed on an outpatient basis in the United States. Because the varicocelectomy is an outpatient surgical procedure in some centers, the prolonged hospitalization may be an important factor in the choice of alternative approaches to the laparoscopic procedure in regions where laparoscopy cannot be performed as an outpatient procedure. Although laparoscopic varicocelectomy may be more time consuming, more expensive, and technically more involved compared with the other methods, it offers some potential advantages, such as simpler preservation of the internal spermatic artery and microsurgical quality of visualization [16-18]. Laparoscopy provided increased visibility of the testicular veins and collaterals up to the internal inguinal ring [18]. In our experience, the optical magnification of the laparoscope and
the anatomic view through the peritoneum allow for precise identification of the collaterals, which are the main cause of recurrence. In our series, 1 case of recurrence was caused by a missed collateral. As our skill level improved, no further recurrences were encountered in our patients. Although the feasibility and effectiveness of laparoscopic Palomo procedure have been reported, hydroceles are frequent postoperative complication of the procedure [28]. In a series of 41 cases after laparoscopic Palomo varicocelectomy, 14 patients (34%) developed various degrees of postoperative hydrocele because of lymphatic obstruction, suggesting the necessity of lymphatic sparing procedures [28]. Under laparoscopic observation, the lymphatic vessels can be distinguished as colorless tubular structures that are usually accompanied by a small serpentine venule [29]. Despite the fact that preservation of lymphatic vessels during a laparoscopic varicocelectomy requires laparoscopic experience and skills, improved visualization of the lymphatic vessels during laparoscopy helps prevent incorrect preservation. One approach to augment visualization of the lymphatic vessels was described by Oswald et al, who injected isosulphan blue into the parietal fold of the tunica vaginalis during the open Palomo procedure and reported no postoperative hydroceles in their initial series of 56 patients [23]. This technique can be readily combined with the laparoscopic approach, as demonstrated by several groups [6,15]. In our study, we used isosulphan blue injection into the tunica vaginalis to stain the lymphatic vessels of the testes for their preservation during ligation of the artery and vein. Our duration of operation and frequency of complications compared well with published data [6]. Postoperative follow-up revealed no hydrocele formation, testicular atrophy, or testicular hypertrophy in our series. We believe that the dye-staining method is safe and efficient for the preservation of lymphatic vessels in laparoscopic varicocelectomy and advocate for its routine use during this procedure. Some authors have indicated that varicocele repair in adolescents with moderate and severe varicoceles can potentially reverse testicular growth arrest and may result in catch-up growth within 12 months of surgery [30]. In our series, despite spermatic artery ligation, the expected growth of gonad was seen in most (93.5%) of the patients without any cases of testicular hypertrophy. Only 2 preoperative hypotrophic testes were noted with loss of volume because of decreased arterial testicular flow as
Lymphatic sparing laparoscopic Palomo varicocelectomy in children revealed by ultrasonography. Together, our short-term results suggest that preservation of lymphatic vessels in laparoscopic Palomo varicocelectomy is effective in the treatment of varicocele in children with few postoperative complications and a minimal number of postoperative hydroceles. However, long-term follow-up is needed to observe the potential late effects of this procedure on hormonal status.
4. Conclusion The lymphatic sparing laparoscopic Palomo procedure is feasible for the treatment of varicoceles in children. Our high efficacy, low recurrence rate, and low complication rate justify the use of this procedure by skilled laparoscopic surgeons for the treatment of pediatric varicoceles. Although the early results of our series are encouraging, a larger series of patients with longer follow-up may be needed before the procedure may be considered the treatment of choice.
Acknowledgment We appreciate Dr. Evan P. Nadler (Division of Pediatric Surgery, New York University School of Medicine) for his efforts in editing this manuscript.
References [1] Akbay E, Cayan S, Doruk E, et al. The prevalence of varicocele and varicocele-related testicular atrophy in Turkish children and adolescents. BJU Int 2000;86:490-3. [2] Stavropoulos NE, Mihailidis I, Hastazeris K, et al. Varicocele in schoolboys. Arch Androl 2002;48:187-92. [3] Paduch DA, Skoog SJ. Current management of adolescent varicocele. Rev Urol 2001;3:120-33. [4] Palomo A. Radical cure of varicocele by a new technique: preliminary report. J Urol 1949;161:604-9. [5] Ivanissevich O. Left varicocele due to reflux; experience with 4,470 operative cases in forty-two years. J Int Coll Surg 1960;34:742-55. [6] Podkamenev VV, Stalmakhovich VN, Urkov PS, et al. Laparoscopic surgery for pediatric varicoceles: randomized controlled trial. J Pediatr Surg 2002;37:727-9. [7] Itoh K, Suzuki Y, Yazawa H, et al. Results and complications of laparoscopic Palomo varicocelecctomy. Arch Androl 2003;49:107-10. [8] Amelar RD. Early and late complications of inguinal varicocelectomy. J Urol 2003;170:366-9. [9] Soulie M, Seguin P, Richeux L, et al. Urological complications of laparoscopic surgery: experience with 350 procedures at a single center. J Urol 2003;165:1960-3.
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[10] Esposito C, Monguzzi G, Gonzalez-Sabin MA, et al. Results and complications of laparoscopic surgery for pediatric varicocele. J Pediatr Surg 2001;36:767-9. [11] Katten S. Incidence and pattern of varicocele recurrence after laparoscopic ligation of the internal spermatic vein with preservation of the testicular artery. Scand J Urol Nephrol 1998;32:335-40. [12] Stern R, Kistler W, Scharli AF. The Palomo procedure in the treatment of boys with varicocele: a retrospective study of testicular growth and fertility. Pediatr Surg Int 1998;14:74-8. [13] Kass EJ, Marcol B. Results of varicocele surgery in adolescents: a comparison of techniques. J Urol 1992;14:694-6. [14] Lund L, Tang YC, Roebuck D, et al. Testicular catch-up growth after varicocele correction in adolescents. Pediatr Surg Int 1999;15: 234-7. [15] Tan HL, Tecson B, Ee MZ, et al. Lymphatic sparing, laparoscopic varicocelectomy: a new surgical technique. Pediatr Surg Int 2004;20: 797-8. [16] Iselin CE, Almagbaly U, Borst F, et al. Safety and efficiency of laparoscopic varicocelectomy in one hundred consecutive cases. Urol Int 1997;58:213-7. [17] Ulker V, Garibyan H, Kurth KH. Comparison of inguinal and laparoscopic approaches in the treatment of varicocele. Int Urol Nephrol 1997;29:71-7. [18] Poddoubnyi IV, Dronov AF, Kovarskii SL, et al. Laparoscopic ligation of testicular veins for varicocele in children. A report of 180 cases. Surg Endosc 2000;14:1107-9. [19] Dubin L, Amelar RD. Etiologic factors in 1294 consecutive cases of male infertility. Fertil Steril 1971;22:469-74. [20] Cimador M, Di Pace M, Castagnetti M, et al. Comprehensive laparoscopic approach to pediatric varicocele based on preoperative color Doppler ultrasound assessment. Surg Endosc 2008;22:701-5. [21] Cohen RC. Laparoscopic varicocelectomy with preservation of the testicular artery in adolescent. J Pediatr Surg 2001;36:394-6. [22] Prader A. Testicular size: assessment and clinical importance. Triangle 1966;7:240-3. [23] 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. [24] Beutner S, May M, Hoschke B, et al. Treatment of varicocele with reference to age: a retrospective comparison of three minimally invasive procedures. Surg Endosc 2007;21:61-5. [25] Al-Kandari AM, Shabaan H, Ibrahim HM, et al. Comparison of outcomes of different varicocelectomy techniques: open inguinal, laparoscopic, and subinguinal microscopic varicocelectomy: a randomized clinical trial. Urology 2007;69:417-20. [26] Al-Said S, Al-Naimi A, Al-Ansari A, et al. Varicocelectomy for male infertility: a comparative study of open, laparoscopic and microsurgical approaches. J Urol 2008;180:266-70. [27] Varlet F, Becmeur F. Laparoscopic treatment of varicoceles in children. Multicentric prospective study of 90 cases. Eur J Pediatr Surg 2001;11: 399-403. [28] Pini Prato A, MacKinlay GA. Is the laparoscopic Palomo procedure for pediatric varicocele safe and effective? Nine years of unicentric experience. Surg Endosc 2006;20:660-4. [29] Kocvara R, Dvoracek J, Sedlacek J, et al. Lymphatic sparing laparoscopic varicocelectomy: a microsurgical repair. J Urol 2005; 173:1751-4. [30] Paduch DA, Niedzielski J. Repair versus observation in adolescent varicocele: a prospective study. J Urol 1997;158:1128-32.
www.elsevier.com/locate/jpedsurg
Lymphatic sparing laparoscopic Palomo varicocelectomy for varicoceles in children: intermediate results☆ Qiangsong Tong a,b,⁎,1 , Liduan Zheng b,1 , Shaotao Tang a , Zhiyong Du a , Zehua Wu a , Hong Mei a , Qinglan Ruan a a
Department of Pediatric Surgery, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Hubei 430022, China b Department of Pathology, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Hubei 430022, China Received 26 July 2008; revised 7 October 2008; accepted 8 October 2008
Key words: Varicocele; Laparoscopy; Palomo varicocelectomy; Children
Abstract Objectives: Varicocele is a relatively rare disorder in children that can lead to testicular atrophy and infertility. The ideal surgical treatment for varicoceles is still a matter of controversy because of the frequency of postoperative complications. Here, we report our series of children who underwent lymphatic sparing laparoscopic Palomo varicocelectomy. Patients and Methods: A total of 46 boys, 9 to 14 years old, underwent laparoscopic repair for varicoceles between January 2002 and December 2007. All of them had a left-sided varicocele. The varicocele was diagnosed by physical examination and Doppler ultrasonography. The laparoscopic procedure included obligatory dissection and preservation of the lymphatic vessels, followed by double ligation of the spermatic vessels. Follow-up for these children included physical examination and Doppler ultrasonography. Results: Lymphatic sparing laparoscopic Palomo varicocelectomy was feasible in all 46 (100%) of the children. Mean operative time was 34.2 minutes (range, 25-42 minutes). There were no intraoperative complications. One patient recurred because of incomplete ligation of spermatic vein. Mean follow-up was 20 months (range, 7-32 months). Hydrocele formation, testicular atrophy, and testicular hypertrophy were not observed postoperatively. However, 2 preoperative hypotrophic testes were noted with 10.4% and 12.5% decreases in size. Conclusions: Our study reveals that lymphatic sparing laparoscopic Palomo varicocelectomy in children is safe, effective, and the reliable treatment of pediatric varicocele. However, long-term follow-up is required to best characterize ultimate outcome. © 2009 Elsevier Inc. All rights reserved.
☆
This study was supported by the National Natural Science Foundation of China (30200284, 30600278, 30772359), Program for New Century Excellent Talents in University (NCET-06-0641), and Scientific Research Foundation for the Returned Overseas Chinese Scholars (2008-889). ⁎ Corresponding author. Tel.: +86 27 63776478. E-mail address: [email protected] (Q. Tong). 1 Q. Tong and L. Zheng contributed equally to this work. 0022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2008.10.049
Varicocele is a relatively rare disorder in children, with an average reported incidence of approximately 5% [1]. Although uncommon before puberty, the incidence of varicocele in postpubertal children is similar to that of adulthood [2]. Varicoceles can lead to testicular atrophy
1510
Q. Tong et al.
and infertility; therefore, surgical treatment is frequently required [3]. Multiple methods exist for the treatment of varicoceles, including percutaneous sclerotherapy and open and laparoscopic surgical ligation of the spermatic vessels [3]. Classically, varicocelectomy may be performed either as a high retroperitoneal ligation of the spermatic vein as described by Palomo [4] or as a low superficial inguinal ligation as described by Ivanissevich [5]. With recent advances in minimal access surgery, there have been many reports lauding the safety and efficacy of laparoscopy for the surgical correction of varicocele [6,7]. Whichever treatment is chosen, postoperative complications are fairly common, such as recurrence, persistence, hydrocele, and testicular atrophy [8,9]. Thus, the ideal method of spermatic vein ligation for treating varicoceles is still a matter of controversy. Recurrence is the most common complication after varicocelectomy. Persistent or unidentified collateral veins at the time of ligation are considered to be the main cause of recurrence after varicocele repair [10]. Katten et al [11] reported that preservation of the testicular artery was associated with a higher recurrence rate for varicocele repairs, and this could be related to incomplete ligation of venous tributaries adjacent to the preserved testicular artery. Thus, the Palomo varicocelectomy is a popular approach, which involves ligation of the internal spermatic veins together with the testicular artery [4]. This method has resulted in a significant decrease in the operative failure rate compared with the artery-sparing procedures, with no increase in the incidence of testicular atrophy [12,13]. However, postoperatively, hydroceles are a potential problem with the standard Palomo procedure because no attempt is made to preserve the lymphatic vessels [14]. Therefore, lymphatic sparing procedures have been reconsidered during varicocelectomy. The lymphatic sparing laparoscopic Palomo procedure is one of the surgical options that has recently gained popularity. It is performed using Palomo's general concept of mass ligation of all the enlarged testicular vessels above the inguinal ring with lymphatic preservation [15]. Therefore, it shares similar features with the open Palomo technique. However, the addition of laparoscopy and its magnification allow careful assessment of the whole pelvic
Table 1
Indications for surgery
Indication Pain or scrotal discomfort (varicocele stage) First Second Third Testicular hypotrophy (varicocele stage) First Second Third
No. of patients 4 13 19 2 8 7
region and make it possible to identify all enlarged spermatic vessels and their collaterals along with enlarged vas vessels that should be divided to reduce the risk of recurrence [1618]. In addition, the laparoscopic lymphatic sparing procedure can reduce the occurrence of postoperative hydrocele with better identification of the lymphatic vessels. In the current study, we report on a series of children who underwent lymphatic sparing laparoscopic Palomo varicocelectomy for the treatments of varicoceles and their shortterm outcomes.
1. Patients and methods 1.1. Patients With the institutional review board approval, 46 boys with left varicoceles underwent lymphatic sparing laparoscopic Palomo varicocelectomy between January 2002 and December 2007. Their ages ranged between 9 and 14 years (mean, 12.6). Diagnosis and postoperative results were established clinically and using Doppler ultrasonography. Thirty-six patients presented with scrotal discomfort or pain. Varicocele was graded according to Dubin and Amelar [19]: grade I, vein dilatation palpable during Valsalva maneuver in upright position; grade II, palpable in upright position without Valsalva maneuver; and grade III, palpable and visible dilated veins through scrotal skin in upright position without Valsalva maneuver. There were grade I varicoceles in 6 patients (13.0%), grade II in 21 patients (45.7%), and grade III in 19 patients (41.3%). An ultrasound scan of the testicles was performed along with a color Doppler of the enlarged pampiniform veins to confirm the diagnosis, assess the size and structure of the testes, and define the severity of the venous reflux. Testicular volume was measured ultrasonographically in milliliters using the formula: 0.52 × length × width × height [20]. Testicular atrophy was defined as the presence of either a floppy testicle or a testicle with a volume noticeably smaller than contralateral (N20% volume difference) [21] or smaller than expected according to Prader's puberty stage [22]. In addition, an ultrasound of the abdomen was performed to rule out the presence of any intraabdominal mass, particularly a left renal tumor. Patients underwent surgical treatment if they presented with high-grade varicocele (grade III) or varicocele associated with symptoms and testicular hypotrophy of the left testicle (Table 1).
1.2. Surgical procedure The technique used three 5-mm laparoscopic ports under general anesthesia. Briefly, the patient emptied his bladder before surgery to reduce the risk of bladder injury upon initial trocar placement. The patient was placed in
Lymphatic sparing laparoscopic Palomo varicocelectomy in children approximately 15° of Trendelenburg position at initiation of the procedure. After preparing the operating field and scrotum with antiseptic solutions, 2 mL of 1% solution of isosulphan blue was injected under the tunica dartos near to the parietal wall of tunica vaginalis, light massage of the testicle was carried out for better definition of the lymphatic vessels according to the method of Oswald et al [23]. A 5-mm subumbilical trocar was inserted by open Hasson technique, and the abdominal cavity was insufflated by carbon dioxide to a maximum of 12 mm Hg. The other two 5-mm ports were placed in the right and left lower quadrants under laparoscopic vision. After identification of the testicular vessels and vas deferens, the peritoneum overlying the internal spermatic vessels was incised longitudinally about 2 to 3 cm superior to the internal ring over a distance of about 3 cm. Blunt dissection was used to isolate the spermatic vessels. During this step, care was taken to avoid any injury to the surrounding fat, thereby averting any possible injury to any potential overlaying lymphatic vessels. Contrast-stained lymphatic vessels were isolated from the vascular pedicle and all the enlarged spermatic and vas vessels then were ligated with 2 silk ligatures spaced 1 to 1.5 cm apart with further bipolar coagulation between them. At the end of procedure, the fascia at the 5-mm ports and the skin were reapproximated with silk sutures.
1.3. Follow-up All patients were followed for any postoperative complication via clinical symptom, testicular size, and the presence of any postoperative hydrocele. Treatment outcome was assessed by both physical examination and Doppler ultrasonography for all patients at approximately 6, 12, and 24 months postoperatively. Treatment success was defined as clinical disappearance of the varicocele or as indicated by color-coded Doppler ultrasonography (no retrograde blood flow exceeding 15 cm/s in the internal spermatic vein during a maximal Valsalva maneuver) [24]. Table 2
Summary of intraoperative and postoperative data
Characteristics
Laparoscopic Palomo varicocelectomy
No. of cases Age (y) Operative time (min) Length of stay (d) Complication (%) Recurrence Bleeding requiring revision Wound complication Damage of genitofemoral nerve Testicular atrophy Epididymorchitis Incisional hernia Hydrocele
46 12.6 (range, 9-14) 34.2 ± 5.4 (range, 25-42) 2.1 ± 0.5 (range, 2-4) 1 (2.12) 0 1 (2.12) 0 0 0 0 0
Table 3
1511 Postoperative follow-up results
Characteristic Varicocele Unchanged Disappeared Improved Scrotal discomfort or pain Unchanged Disappeared Improved
No. of cases
%
1 25 20
2.2 54.3 43.5
2 31 3
5.6 86.1 8.3
This outcome definition was applied to all patients regardless of indication for treatment.
2. Results The lymphatic sparing laparoscopic Palomo varicocelectomy procedure was feasible in all of the 46 children, without conversion to open varicocelectomy in any case. The mean operative duration was 34.2 minutes (range, 2542 minutes) (Table 2). Intraoperative blood loss was negligible. There were no intraabdominal visceral or vascular complications, and no postoperative analgesia was required. Immediate postoperative recovery was uneventful in all patients. All patients were ambulatory 4 to 6 hours after the surgical intervention. They complained of a slight pain in the incisional area, which was alleviated with nonnarcotic analgesics. One patient had a wound infection and recovered after administration of antibiotics (Table 2). Mean length of hospitalization was 2.1 ± 0.5 days (range, 2-4 days). Mean follow-up was 20 months (range, 7-32 months). The clinical and ultrasound Doppler examinations at 6, 12, and 24 months after the operation revealed that there was 1 case of recurrence (2.2%), which was presumably because of an error during skeletization of the artery where 1 vein adherent to the spermatic artery was left unligated (Table 2). The recurrence was treated by a reoperative laparoscopic procedure to ligate the missed spermatic vein. No hydrocele formation was observed in any of our patients (Table 2). The varicoceles disappeared in 25 cases (54.3%) and diminished significantly in 20 cases (43.5%) (Table 3). Ultrasound Doppler examination revealed the termination of pathological blood flow in the pampiniform plexus, and collapse of the veins of left testis in ortho- and clinostasis and during a Valsalva test. Of the 36 patients who presented with scrotal discomfort or pain, 31 (86.1%) achieved complete resolution of their symptoms (Table 3). In all cases, testicular size was noted before and after treatment (Table 4). No testicular atrophy was observed at follow-up. Only 2 preoperative hypotrophic testes were noted with loss of volume of 10.4% and 12.5% (15.4 and 15.6 mL, respectively), with regard to the controlateral testis (17.2 and 17.8 mL, respectively).
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Table 4
Evolution of testicular volume before and after treatment
Characteristic
No. of patients
Preoperative testis volume (mL) Left
Right
Left
Right
Nonhypotrophy Hypotrophy
29 17
15.2 ± 4.8 12.1 ± 3.2 a
15.4 ± 5.2 15.6 ± 4.7
17.3 ± 5.3 16.2 ± 3.8 b
17.1 ± 4.5 17.3 ± 5.1
a b
Postoperative testis volume (mL)
P b .05 for comparison between preoperative left and right testis volume within the hypotrophy group. P b .05 for comparison between preoperative and postoperative left testis volume within the hypotrophy group.
Normal expected growth of the gonad was noted in 43 (93.5%) of 46 patients.
3. Discussion The choice of operation for repair of the varicocele depends on many factors, such as overall success rate, complication rate, patient preference, and physician comfort with the various procedures. Recently, the outcomes of open inguinal, laparoscopic, and subinguinal microscopic varicocelectomy were compared, and their corresponding varicocele recurrence rates were 11% to 13%, 17% to 18%, and 2% to 2.6%, respectively, suggesting that subinguinal microsurgical varicocelectomy offered the best outcome [25,26]. In our series, the lymphatic sparing laparoscopic Palomo varicocelectomy was feasible in all cases with a comparable recurrence rate to the subinguinal approach. The varicoceles disappeared or diminished in 97.8% of the cases, suggesting good to excellent results of this procedure. Our results were similar to others in the literature regarding laparoscopic varicocelectomy in children, which yielded 88 good or excellent results of 90 patients, that is, 97.6% [27]. In our series, the mean length of hospital stay was 2.1 ± 0.5 days. Most of our patients were sent home 1 day after the procedure. However, 1 patient's course was complicated by a wound infection, which required 2 additional days in hospital. We believe that the longer hospital stay in our series was mainly because of prolonged duration of preoperative examination and postoperative recovery for general anesthesia, which is traditionally performed on an outpatient basis in the United States. Because the varicocelectomy is an outpatient surgical procedure in some centers, the prolonged hospitalization may be an important factor in the choice of alternative approaches to the laparoscopic procedure in regions where laparoscopy cannot be performed as an outpatient procedure. Although laparoscopic varicocelectomy may be more time consuming, more expensive, and technically more involved compared with the other methods, it offers some potential advantages, such as simpler preservation of the internal spermatic artery and microsurgical quality of visualization [16-18]. Laparoscopy provided increased visibility of the testicular veins and collaterals up to the internal inguinal ring [18]. In our experience, the optical magnification of the laparoscope and
the anatomic view through the peritoneum allow for precise identification of the collaterals, which are the main cause of recurrence. In our series, 1 case of recurrence was caused by a missed collateral. As our skill level improved, no further recurrences were encountered in our patients. Although the feasibility and effectiveness of laparoscopic Palomo procedure have been reported, hydroceles are frequent postoperative complication of the procedure [28]. In a series of 41 cases after laparoscopic Palomo varicocelectomy, 14 patients (34%) developed various degrees of postoperative hydrocele because of lymphatic obstruction, suggesting the necessity of lymphatic sparing procedures [28]. Under laparoscopic observation, the lymphatic vessels can be distinguished as colorless tubular structures that are usually accompanied by a small serpentine venule [29]. Despite the fact that preservation of lymphatic vessels during a laparoscopic varicocelectomy requires laparoscopic experience and skills, improved visualization of the lymphatic vessels during laparoscopy helps prevent incorrect preservation. One approach to augment visualization of the lymphatic vessels was described by Oswald et al, who injected isosulphan blue into the parietal fold of the tunica vaginalis during the open Palomo procedure and reported no postoperative hydroceles in their initial series of 56 patients [23]. This technique can be readily combined with the laparoscopic approach, as demonstrated by several groups [6,15]. In our study, we used isosulphan blue injection into the tunica vaginalis to stain the lymphatic vessels of the testes for their preservation during ligation of the artery and vein. Our duration of operation and frequency of complications compared well with published data [6]. Postoperative follow-up revealed no hydrocele formation, testicular atrophy, or testicular hypertrophy in our series. We believe that the dye-staining method is safe and efficient for the preservation of lymphatic vessels in laparoscopic varicocelectomy and advocate for its routine use during this procedure. Some authors have indicated that varicocele repair in adolescents with moderate and severe varicoceles can potentially reverse testicular growth arrest and may result in catch-up growth within 12 months of surgery [30]. In our series, despite spermatic artery ligation, the expected growth of gonad was seen in most (93.5%) of the patients without any cases of testicular hypertrophy. Only 2 preoperative hypotrophic testes were noted with loss of volume because of decreased arterial testicular flow as
Lymphatic sparing laparoscopic Palomo varicocelectomy in children revealed by ultrasonography. Together, our short-term results suggest that preservation of lymphatic vessels in laparoscopic Palomo varicocelectomy is effective in the treatment of varicocele in children with few postoperative complications and a minimal number of postoperative hydroceles. However, long-term follow-up is needed to observe the potential late effects of this procedure on hormonal status.
4. Conclusion The lymphatic sparing laparoscopic Palomo procedure is feasible for the treatment of varicoceles in children. Our high efficacy, low recurrence rate, and low complication rate justify the use of this procedure by skilled laparoscopic surgeons for the treatment of pediatric varicoceles. Although the early results of our series are encouraging, a larger series of patients with longer follow-up may be needed before the procedure may be considered the treatment of choice.
Acknowledgment We appreciate Dr. Evan P. Nadler (Division of Pediatric Surgery, New York University School of Medicine) for his efforts in editing this manuscript.
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