Outcome of Lymphatic- and Artery-Sparing Surgery for Pediatric Varicocoele

Introduction

While experience with laparoscopic procedures and innovative techniques have been increasing, so has the technical specifications of the equipment used. This is resulting in increased clarity in visualization by laparoscopy and also allowing magnification to levels approaching the definition achieved with microsurgery. The increased visibility now afforded to the surgeon by this improved resolution allows microanatomy to be appreciated at laparoscopy, thus allowing for fine dissection and sparing of lymphatic channels. In this article, we report on our experience with these improved technologies in the context of a lymphatic- and artery-sparing modified Palomo procedure for treatment of the pediatric varicocoele. The aim of this study was to determine the outcome of lymphatic and spermatic artery-sparing exclusive laparoscopic spermatic vein ligation for pediatric varicocele (i.e., a modified Palomo's procedure), in particular, investigating the rate of varicocele persistence, hydrocele development, and additional postoperative complications.

Materials and Methods

All boys undergoing laparoscopic varicocele surgery between June 2004 and February 2009 were included. They all had clinically diagnosed unilateral left-sided varicoceles. All of the operations were undertaken by a single lead consultant pediatric surgeon, using a standard technique. The demographic details, operative findings, complications, and length of stay were recorded on a Microsoft Excel spreadsheet. At scheduled follow-up, any clinical evidence of recurrence, persistence of varices, or development of a hydrocoele was sought and recorded. Any other arising complications were also noted.

A transperitoneal approach was used. A transumbilical incision, utilizing the Hasson technique, allowed the introduction of a 5-mm camera port. The camera used was an autoclavable Karl Storz 3-CCD-TRICAM, with an integrated Parfocal Zoom Lens (f = 14–28 mm, 2x; Tuttlingen, Germany). Two further 5-mm ports were inserted under direct vision, one in the midline supra pubically and the other low down in the right iliac fossa. The spermatic vessels were identified approximately 5 cm proximal to the internal ring, and the retroperitoneum was entered by peritoneal division over the vessels. The view of the retroperitoneal structures allowed identification and separation of the spermatic vein or veins from the contiguous artery and lymphatics. The spermatic vein was thus primarily isolated and secured with ligaclips and subsequently divided. Other veins, particularly those accompanying the vas deferens and tributaries of the inferior epigastric, were ligated, if enlarged and tortuous.

Results

A total of 19 boys underwent laparoscopic varicocoele surgery between June 2004 and February 2009. All varicocoeles were grade 2 or worse and ages of patients ranged from 11.9 to 16.4 years (mean, 14.6; standard deviation, 1.27). The lymphatic-sparing modification of the Palomo technique was utilized in all cases. Patients were admitted on the day of surgery, and 15 were discharged the same day, with the remaining 4 discharged after an overnight stay.

At surgery, 11 patients were found to have a single, large spermatic vein, whereas the rest (8) had multiple veins. Three patients had veins other than the spermatic ligated during the procedure—2 had veins of the vas deferens ligated, and 1 had a tributary of the main spermatic vein ligated. The only intraoperative complication was a serosal injury to the gut, which was sutured immediately, and the patient was discharged the same day. One further patient was readmitted with abdominal pain postoperatively. He required opioid analgesia in hospital, but the pain was self-limiting, with no definite cause found.

At follow-up (mean, 2.56 years; range, 0.9–4.7), only 1 hydrocele had occurred (5%), which settled spontaneously and did not require intervention. Persistent varices were documented in 4 boys (21%); however, these had all, bar 1 case, reduced in size following the operation and were asymptomatic. The single symptomatic case was reoperated on at 6 months following initial intervention and required a low ligation of spermatic vein performed via a groin approach. No patients suffered any clinically detectable reduction in testicular size.

Discussion

A varicocele is an abnormal dilation and tortuosity of the pampiniform plexus of veins, which drains the testicle. The dilation of these vessels to greater than 2 mm in diameter (normal, 0.5–1.5) is defined as a varicocele. These can be classified into those palpable on straining, those palpable without straining, and those that are visible, grades 1–3, respectively. ¹ A varicocele is a very common abnormality occurring in 15% of the male population and is associated with decreased fertility. Surgical correction of the varicolcele has been shown to improve abnormal semen parameters in 46% of subfertile men, ² and hence, early treatment is recommended. As yet, there is no definitive agreement on the most appropriate procedure to correct adolescent varicoceles.

Mass ligation of the testicular vascular pedicle with excision of a segment of the vessels was described by Palomo in 1949. In recent years, this has been converted to a laparoscopic procedure. There have been multiple reports of medium to high postoperative hydrocoele rates (12–31%),^3–7 though the discrepancy between these rates and others is marked (5–7%).^8–10 In studies comparing laparoscopic lymphatic-sparing procedures, compared to laparoscopic mass ligation, the postoperative hydrocoele rate is significantly lower with lymphatic sparing (1.9 and 17.9%, respectively). ¹¹ In our study, only 1 patient developed a hydrocele (5%), and this would be consistent with these findings. It has been noted that when these hydrocoeles are aspirated, they have high protein content, and it is postulated that this is likely to be due to interruption of lymphatic drainage. ⁸ In addition to this, division of the lymphatic vessels may also lead to testicular edema, causing an insulating effect, leading to a decline in testicular function. ¹²

Though there has been noticeable discrepancy between the rates of hydrocele, ⁷ it still remains the most common complication of this procedure, and various methods to try and reduce its occurrence have been suggested. These include the use of dye^5,13 or microsurgery ¹⁴ to try and preserve the lymphatics. Although microscopic varicocelectomy has low rates of postoperative hydrocele and reoccurrence, it is technically very challenging and associated with a longer operating time, compared to laparoscopic lymphatic-sparing varicocelectomy. ¹⁵ The use of dye to highlight the lymphatics has produced a 0% hydrocele rate; however, there are additional risks, as the spermatic vessels may be damaged on dye injection, and a significant number (8%) sustained staining to the scrotum for up to 6 months postoperatively. ¹⁶ In recent years, with improvement in laparoscopic equipment and better magnification, the lymphatics can be identified as colorless tubular structures and preserved without the need for staining.

Despite the incidence of hydrocoele, the Palomo technique is still preferred by the majority of surgeons, due to its lower reoccurrence rates. ⁸ However, preservation of the testicular artery has been advocated for some time, as it should eliminate the risk of testicular atrophy postoperatively. ⁹ This may be particularly important in those patients who had had previous inguinal surgery, where there may already be damage to the collateral supply to the testis or in patients who may later request vasectomy or develop complications requiring further surgery, such as hydrocoele, who would be at greatly increased risk of testicular atrophy. In addition to reducing the risk of testicular atrophy, those who undergo an artery-sparing procedure have been shown to have better postoperative semen parameters than those who undergo a mass-ligation procedure. ¹⁷

The technologic advances of laparoscopy are enabling more precise anatomy to be observed and hence more precise dissections to be carried out. The importance of identification and preservation of the small lymphatic vessels in varicocelectomy, is not only in preventing postoperative hydrocoeles, but also in improving testicular function. Our series of cases shows promising results in this area (1 hydrocele). The reoccurrence rate with the artery-sparing technique may be perceived to be too high (21%). This may be as a consequence of selectively sparing the artery, lymphatic vessels, and, possibly, smaller venous tributaries, which would otherwise be ligated in the mass-ligation technique. In our series, all patients, except 1, experienced a resolution of their symptoms, which was the principal reason for operation. We believe this may have been due to decompression of the larger varices, but incomplete ligation of the smaller tributaries, as discussed previously. The effect of persistent varices on the fertility status of these patients is currently unknown, and they may require revision surgery in the future if subfertile.

Undoubtedly, the debate as to whether an artery- and lymphatic-sparing technique is preferable will not be resolved by this study, but it does give a promising early outcome regarding the incidence of hydrocoeles. However, concerns over the high persistent rates remain and require further study.

Conclusions

For the moment, it would be reasonable to accept that the artery-sparing procedure has its place in certain individuals who have had previous inguinal surgery or may require surgery in the future. We would hope that this report may prompt a new study comparing the outcomes of the method described with the traditional en-masse ligation over multiple centers, but with a standardized data-collecting system to try and form a powerful argument for the ideal treatment.