Electrocoagulation Versus Clips in Laparoscopic Varicocelectomy in Boys

Introduction

Varicocele occurs in about 15% of adolescents. ¹ It is hardly even noticed in children under 10 years old. Since varicocele coexists in 35–40% with subfertility in men, the surgical treatment in those cases seems to be useful.^1,2 For many years, the necessity of surgical treatment of varicocele in pubescence has been discussed in the medical environment. Four methods of treatment are mainly used: open surgery (Palomo operation, microsurgical operation, laparoscopic varicocelectomy, percutaneus embolization, and retrograde embolization. Until quite lately, surgical treatment of varicocele was very seldom done. From the second half of the 1990s, in the time of laparoscopy evolution, the number of varicocele operations has increased considerably. Laparoscopic varicocelectomy is a minimally invasive method. In this operation, the spermatic vein and artery can be cut by electrocoagulation or clips. The most common postoperative complications involve persistent varicocele and hydrocele. To avoid the above mentioned complications it is important to choose the right and optimal method of treatment. The aim of this work was to assess the outcome of laparoscopic varicoelectomy by using electrocoagulation versus clips, with special attention to complications and the age of operated patients.

Materials and Methods

In the Pediatric Surgery and Urology Department of the Medical University of Wroclaw (Wroclaw, Poland), 139 boys with varicocele were operated on by using laparoscopy in the years 1995–2007. The age of the adolescents ranged from 9 to 18 years (average, 13.3). For the follow-up examination, 68 (49%) boys applied. The indications for operative procedure were as follows: grade III varicocele according to the Dubin-Amelaar scale or grade II with a coexisting decrease of testis volume or pain. The laparoscopic operation was performed by using two or three trocars, and, exceptionally, four trocars (2 cases). After the insertion of optic and additional trocars, the peritoneum was incised and the spermatic vessels were prepared. In the first method of treatment, the spermatic vessels were cut by electrocoagulation (Monopolar diatermy). In the second method, the testicular vessels were closed by applying 5-mm titanic clips and transected between clips. In 38 of 68 boys (55.8%), electrocoagulation was used. In the next 29 of 68 cases (42.3%), clips were used. Exceptionally, in 1 of 68 cases (1.5%), both methods of diatermy and clips were performed. The spermatic artery was saved in 5 cases, which were operated on by using diatermy and in 3 by using clips. Results of the treatment in the controlled group were analyzed. The follow-up after the operation lasted from 0.5 to 7 years (average, 2.7). In all cases, ultrasonography of the scrotum and physical examination were performed. All patients were asked to give a subjective opinion of cosmetic effect after the operation in a 3-grade scale (3: very good effect; 2: acceptable effect; 1: bad effect).

Results

Among 68 patients from the follow-up group, the persistent varicocele with grade II and III (Dubin-Amelaar classification) were recognized in 5 boys (7.3%). The above mentioned children were qualified to the reoperation. In the group of boys, who were operated by using diatermy, persistent varicocele was noticed in 10.5% (4), while in those who were operated on by using clips the persistent varicocele was recognized only in 3.4% (1). Varicocele with grade I, not demanding a second operation, was recognized in 9 boys (14.7%) (4 by clips, 5 by coagulation). Nine of 10 children had varicocele grade III and 1 of 10 grade II before the surgery. In the rest of the group of 53 patients (77.9%), the varicocele were not found.

The most often found complication was hydrocele. It was recognized in 13.8% (4) of boys operated on by using clips and in 23.7% (9) boys operated on by using diatermy. The above-mentioned patients were qualified to the hydrocele operation. In 24 children (35.8%), a small amount of fluid was visible only in ultrasonography.

Among other complications there were occasionaly found a cyst of epididymis (3 patients), long-lasting pain of the, testicles (2 patients), testicle edema (1 patient), and microcalcification of the testicles visible only in ultrasonography (2 children) (Table 1). Satisfied cosmetic effect was achieved in 61 of 68 patients (self opinion), which makes about 90% of the patients. The most common reason of disappointment was hydrocele (3 patients), persistent varicocele (2 patients), or scars after the surgery (2 patients) (Table 2).

Discussion

Varicocele occurs in about 15% of boys and healthy men and in about 40% of men with infertility. ¹ In histopatologic examination, damage of the testicles is found in 20% of adults and 46% boys with varicocele. ³ The surgical treatment of varicocele in adults is unquestionable. Settlement of indications, age, and methods of treatment of this disease in children and adolescents in pubescence is a controversial theme.^1,2 The amount of varicocelectomy increased radically in the second half of the 1990s during laparoscopy's period of introduction. In the past, these operations in adolescents were performed very rarely.

In the literature, there is an opinion that 20% of boys with varicocele can have problems with fertility in the future. ¹ Among varicocele pathologies mentioned are venous blood retention, hypoxia, reflux of blood from kidneys and andrenal gland, which causes increase of the progesteron, catecholamine, PGE level, and an increase of testis temperature. It is connected with a decrease of growth and testicle cohesion. It is hard to estimate the level of degenerative changes in the testicles because of the physiologic changes of an increase of the left and right testicle. Kolon's studies, based on the group of boys with varicocele, indicated a change of testicle volume within the limit of standard in 85% of boys. His researches lasted 2 years and were based on ultrasound imaging. In his opinion, the decrease of testicle size of more than 15%, in comparison to the healthy testicle, measured during one ultrasonography is not sufficient as an indication to the operation. It is recommended to compare the testical volume after 2 or even 3 years in the next few ultrasonography examinations. ⁴ Diamond has also analyzed patients by using the same method. Estimating from a group of 41 boys with varicocele, he has not found any essential change of volume of involved testicle in 12 months of observation. ⁵

The most common complication of the varicocele operation is hydrocele. It is connected with breaking reflux of lymph from the vaginal coat of the testis. There is no single optimal method to decrease the percentage of persistent varicocele and hydrocele, and scientists still researched for it. Should only the spermatic vein be ligated or both spermatic vessels? Should a lymph-vessels–saving operation be chosen or not? Should spermatic vessels be ligated by diatermy or clips?

Sautter indicated 24% of hydrocele on a group of 34 boys with varicocele, who have been laparoscopically operated on by using ligation of spermatic vein with clips. ⁶ Other researchers published results of 22% of hydrocele after laparoscopic ligation of both spermatic vessels when using clips and 12% after classic operation (Palomo). ⁷ Cobellis indicated 6.2% hydrocele in the group of 97 patients who had ligated both spermatic vessels, using diatermy. ⁸ In our study, we have stated a total of 13.8% (4 patients) of hydrocele after ligation of spermatic vessels when using clips and 23.7% (9 patients) using diatermy. During varicocelectomy, using diatermy, the spermatic vessels are coagulated and very often, in addition to this, comes the coagulation of lymph vessels, which are located next to the spermatic vein and artery. The lymph vessels are colorless, thin, and hard to identify. We believe that clips decrease the risk of thermal effect to lymph vessels and, in consequence, the chance for unpleasent complication of hydrocele.

In order to decrease the percentage of complications of hydrocele, Oswald and Than have proposed the injection of dye, methylene blue, which is used to color and save the lymphatic vessels during the operation.^9,10 Glassberg, in his study, based on a large group of 191 boys, has indicated only 3.4% hydrocele after a lymphatic-saving operation and 11.4% hydrocele without a lymphatic-saving operation. ¹¹ Glassberg has not observed an essential difference in persistent varicocele, in comparison of both methods. ¹¹ However, Kocvara has indicated an increased (to 6%) persistent varicocele after a lymphatic-saving operation. ¹²

The trend of decreasing percentage of hydrocele after varicoceletomy in adults, in comparison with adolescence, can be observed in the literature. Matsuda described 7.3% of hydrocele, ¹³ and Sami Al-Said 5.5%, ¹⁴ after laparoscopic ligation of both vessels in adults. We have observed a decrease of hydrocele in boys who had been operated on after turning 13 to 9.5% and after turning 14 to 6.6%. Unfortunately, the group of boys over 14 years is too small (15 boys) to draw essential conclusions. Studies should be performed on a wider group of patients. There is a lack of publications that consider the various age of patients. The studies are done either on adults or adolescence.

A spermatic-artery–saving operation, in Pintus's opinion, increases the percentage of persistent varicocele to 16% (in the Palomo operation). ¹⁵ Much more improvement is observed after ligation of both spermatic vessels than after ligation of only the spermatic vein. ¹⁶ Additionaly, the researchers emphasize that ligation of both vessels are technically easier to perform. ¹⁷ After ligation of both vessels, other researchers have not observed any persistence of varicocele. After ligation of only the spermatic vein, there was observed 11.5% of persistent varicocele. Much more complications of persistent varicocele (14.2%) after an artery-sparing operation have been observed by Ralph and Timoney and 17% by Sautter.^6,18 In our research, persistent varicocele have been indicated in 7.3% of boys. Both spermatic vessels have been ligated in most of the patients (89%). The group of boys who have been operated on by the artery-sparing method is too small to draw conclusions (8 patients). Much less of a percentage of persistent varicocele was indicated in patients who have been operated by using clips (3.4%). After using diatermy, persistence of varicocele has grown to 10.5%. Similar results were observed by Cobellis. In his research, based on a group of 97 boys after varicocelectomy using diatermy with ligation of both vessels, 11% of persistent varicocele was observed. ¹⁹

Influence of a harmful act of varicocele on testicle and, in consequence, danger of infertility was proved repeatedly. Despite this, it is hard to ascertain equal indications to the varicocelectomy in adolescence. Because of a high percentage of persistent varicocele and hydrocele after the operation in boys, that qualification to this operation should be at least very careful. Equal and carried out in many centers, studies are necessary in order to assertain indications to operate varicocele in boys and, also, to assertain the optimal methods of treatment.

Conclusions

Varicocelectomy using clips seems to give less complications than using diatermy and should be the first choice, of treatment.