Laparoendoscopic Single-Site Varicocele Repair in Adolescents—Initial Experience at a Single Institution

Introduction

V aricoceles are considered to be a leading cause of male factor infertility, and their presence in adolescents raises primarily fertility concerns. ¹ Most varicoceles in adolescents are detected incidentally during routine physical examination, although sometimes they can produce pain. ² It is unclear which varicoceles should be repaired in children, but reported indications for varicocele repair include decreased testis volume or varicocele related pain. ² Surgical ligation of the spermatic vein is the fundamental principle used to correct the varicocele. ³

Several surgical procedures have been used to ligate the spermatic vein during varicocele repair, including open retroperitoneal (Palomo), open inguinal (Ivanissevitch), microscopic, and laparoscopic. ^{4 –6} In the pediatric urology literature, open retroperitoneal or laparoscopic repair has been suggested to be procedures of choice for adolescent varicocele repair because of their low complication and recurrence rates and because most pediatric urologists are familiar with this approach. ^3,7

Because laparoscopic varicocele repair has been recommended as one method of effective and safe varicocele repair in adolescents, ^{8 –10} laparoendoscopic single-site (LESS) varicocele repair has been explored as a modification that exposes the patient to only one port placement. ¹¹ Although case reports have indicated that LESS is feasible for adolescent varicocele repair, this report represents the first series regarding the utility of this approach. ¹¹

Patients and Methods

This study was a retrospective review of 11 consecutive boys aged 18 years or younger who were treated with LESS varicocelectomy between 2009 and 2010 at our institution. This study was approved by our Institutional Review Board. Indications for varicocele surgery included a 20% or greater decrease in testis volume on ultrasonography or scrotal pain secondary to the varicocele. ¹² In all cases, the diagnosis of varicocele was confirmed by ultrasonography. Variables examined included operative time, patient body mass index (BMI), patient age, varicocele grade and laterality, blood loss, complications, and cost. Operative time was defined as time from skin incision to closure. End point of the LESS procedure was resolution of the varicocele. We did not use catch-up testis growth as an end point, because follow-up time was not sufficient. Intraoperative problems and complications were evaluated. Postoperative complications, including testis atrophy, umbilical hernia, and hydrocele, were determined.

Results

In all, there were 11 unilateral, grade 3, left LESS varicocelectomies in patients with a mean age of 15 years (Table 1). Mean time from diagnosis of varicocele to varicocele repair was 2.3 years, with a range of 3 months to 4 years. Nine patients had surgery because of decreased testis volume of 20% or greater on ultrasonography. Two boys had the procedure because of chronic varicocele-related pain that was interfering with quality of life. Testis size was symmetric in these two patients. Mean postoperative follow-up was 6.8 months (range 4–14 mos).

BMI ranged from 6.4 to 22.5 with a mean BMI of 19.2. Although most of our patients tended to be thin, this was not because of selection bias, because all patients who had varicocele repair during the study time period underwent LESS. There were no conversions to open or traditional laparoscopy, and no additional ports or access sites were needed to complete the operation in any patient. Estimated blood loss was minimal and was recorded at less than 30 mL for all cases. Mean operative time was 66.9 minutes with a range of 48 to 91 minutes. Longer operative times were recorded during the initial four procedures. We believe the longer operative time we experienced during the first cases was because of our learning curve. Longer operative times were not related to patient BMI. Our operative time decreased as we gained more experience with LESS varicocelectomy.

There were no complications during any LESS procedure, and all boys were discharged home on the same day of surgery, after a brief period of observation in the recovery room. One patient returned to the emergency room 7 hours after discharge complaining of severe umbilical pain. This patient's physical examination and abdominal ultrasonography had negative results; he was treated with acetaminophen and codeine and was discharged home without admission to the hospital.

During the postoperative follow-up period, there were no instances of umbilical hernias, hypertrophic umbilical scarring, wound infection, or hematoma. All varicoceles resolved, and there has been no varicocele recurrence or no testis atrophy; one small left hydrocele was not repaired. In all cases, the surgical scar is well hidden, even in very thin patients with a shallow umbilicus.

Discussion

This report demonstrates that LESS varicocele repair is a safe and effective option for adolescent varicocele repair, confirming previous case reports. ¹¹ LESS was effective for repairing the varicocele without any significant intraopertive or postoperative complications. Because laparoscopic varicocele repair has been suggested to be an effective procedure for children with varicoceles, the LESS modification of the laparoscopic approach should be investigated further, because it only exposes the patient to one port placement. ^3,10

In adolescents, the open retroperitoneal and laparoscopic approaches for varicocele repair both have a low recurrence rate of 1% to 5% and few associated complications. Because of the reported success with these approaches, some authors have suggested them to be the procedures of choice for adolescent varicocele repair. ^5,10,13 One drawback to this approach is that when mass cord ligation is performed, cephalad to the vas deferens, hydrocele formation can be up to 35%. ⁷ The significance of these hydroceles, however, is uncertain, because less than 5% will need repair. ⁷ In LESS varicocele repair, the ease, efficacy, and complication rates should be similar to these proven techniques if LESS is to be should be considered a viable alternative for adolescent varicocele repair.

The technique we used for LESS varicocelectomy is similar to that previously described, and cord ligation is similar to standard laparoscopic varicocele repair. ¹¹ We performed mass ligation above the level of the vas deferens and made no effort to identify the testicular artery or lymphatics. There were no instances of testis atrophy during the follow-up period, and there was only one small hydrocele that did not necessitate repair. It is possible that the hydrocele could have been avoided if a lymphatic-sparing technique had been performed, but this technique has never been reported using LESS.

It has been reported that a lymphatic-sparing laparoscopic varicocele repair reduces the postoperative hydrocele rate to 3.4%, without increasing the incidence of persistent or recurrent varicocele necessitating reoperation. ¹⁰ Other reports of lymphatic-sparing varicocele repair have indicated similarly low hydrocele formation in 5% and recurrent varicoceles in 2.5% of patients. ¹⁴ It is, however, uncertain if these hydroceles are clinically significant and warrant surgery. At this time, we are unaware of any reports of LESS lymphatic-sparing varicocele repair, but given the low incidence of postoperative hydrocele formation with this approach, it seems to represent an area for future investigation.

A testis artery-sparing technique has been described for standard laparoscopic varicocele repair, but this method has been reported to result in varicocele recurrence rates as high has 38%. ¹⁵ There may also be little benefit to artery-sparing laparoscopic or LESS varicocele repair, because a case of testis atrophy has never been reported when using a mass cord ligation above the level of the vas deferens. ² Because there appears to be little benefit associated with the artery-sparing technique and its risk for recurrence is high, it utility appears limited.

Subinguinal microscopic varicocele repair is popular in adults, but is less commonly performed in adolescents. ³ Reports have suggested that even in the most experienced hands, microscopic varicocele repair can carry a 1% to 5% risk of testis atrophy, if the testis artery is inadvertently ligated. ¹¹ It is likely that this rate of testis atrophy would vary, upward or downward, based on surgeon experience and case volume. It has been suggested, however, that even this small risk of atrophy is not acceptable in children, who do not undergo repair because of infertility. ⁶

The inguinal approach has been reported to be an inadequate procedure for adolescent varicocele repair. ³ This approach consists of individual ligation of veins in the inguinal canal, with or without magnification. This approach has reported recurrence rates of up to 28%, and the risk for hydrocele formation can be as high as 16%. ^{2 –4} Because of these considerations, some authors suggest the inguinal approach for varicocele repair should be abandoned in children in favor of the retroperitoneal open or laparoscopic approach. ³

Our procedure-based cost analysis was limited, because we did not directly compare LESS with an alternative form of varicocele repair during the same time/cost period. Compared with standard open repair, however, our data at least suggest that LESS is a more expensive procedure because of the bendable instruments, the port, and longer operative time. Excluding time utilization in the operating and recovery rooms, we estimated that the additional costs that are specific to LESS varicocelectomy amounted to $3908 per patient.

A benefit of any LESS procedure is the postoperative scar. In all cases, LESS varicocele repair resulted in virtually “scarless surgery,” even in patients who were very thin and had a shallow umbilicus. In these patients, it is important to place the semicircular incision on the inner margin of the umbilicus and not directly on the anterior abdominal wall. We believe that careful placement of the curvilinear incision adds to the cosmetic benefit of LESS, because the incision follows the natural contour of the body and the umbilicus provides natural camouflage. Although the 2.0 to 2.5 cm incision is physically larger than individual incisions used for standard laparoscopic varicocele repair, we believe the LESS incision provides a better cosmetic result, because in standard laparoscopic varicocele repair, two or three smaller (3- or 5-mm) horizontal incisions are placed in more noticeable abdominal locations. These incisions are therefore smaller than a LESS incision, but may be more noticeable, because they are not hidden by the umbilicus. Future studies are needed to examine scar satisfaction in patients and parents after LESS and other forms of varicocele repair.

Conclusion

This series demonstrates that LESS varicocele repair appears to offer the same benefits of traditional laparoscopy but less risk, because it only exposes the patient to one port. LESS repair can be challenging, however, because of instrument clashing. Cosmetically, LESS results in a well-hidden umbilical scar, even in very thin patients, which may represent an additional advantage of LESS. Further studies are needed to determine the feasibility of lymphatic-sparing LESS varicocele repair and to compare LESS with alternative forms of varicocele repair to determine comparative risks, benefits, and patient satisfaction.