Varicocele Surgery: 10 Years of Experience in Two Pediatric Surgical Centers

Introduction

The earliest accounts of varicocele stretch back to the times of antiquity. In the 1st century AD, Celsus, a famous Roman encyclopedist, credits the Greeks with the first description of a varicocele in De Medicina. ¹ The debate of whether men should be treated for these “bags of worms” on their scrotum dates back to a similar time and has been the focus of copious studies. There is good evidence at present to suggest that varicocele is associated with loss of testicular volume and subfertility in men.^2–5 This is thought to be mediated by a combination of factors, including a rise in scrotal and testicular temperature as a result of venous reflux,^6,7 oxidative stress,^8,9 and Leydig cell dysfunction.^5,10

The adverse associations with varicocele have fueled the drive to perfect the optimal surgical technique for the management of this condition. Current surgical approaches include the classic Palomo (retroperitoneal mass ligation), ¹¹ the Ivanissevich (inguinal), ¹² the ISA (internal spermatic artery sparing), laparoscopic varicocelectomy, and also fairly recently microsurgical techniques. Introduced in the early 1990s by Winfield and Donovan, the use of laparoscopic varicocele surgery has been increasingly adopted in units across the world for its precision and minimally invasive nature.^13,14 However, this novel technique does not appear to exempt patients from the documented side effects of open varicocele surgery, most notably hydrocele, recurrence, and failure to resolve symptoms. At present, there are conflicting data regarding which surgical approach causes the fewest number of complications and has the best outcome about fertility. For example, some reports suggest a higher rate of hydrocele with the laparoscopic approach as opposed to open surgery,^15–18 whereas others find no statistically significant difference in hydrocele formation between the two approaches.^19,20

Although there is a plethora of published articles on pediatric varicoceles in the last decade, studies reflecting surgical outcomes in the United Kingdom are limited to a small study of 19 cases. ²¹ In this study, we report on 10 years' experience of varicocele surgery in two pediatric surgical units and compare the outcomes of open versus laparoscopic techniques. We believe this is the largest series from the United Kingdom on pediatric varicocele surgery.

Subjects and Methods

A retrospective review of patient records was performed in two pediatric surgical centers over a 10-year period from May 1999 to April 2009. All patients in this study were younger than 16 years at the time of surgery. All operations were performed by eight pediatric surgical consultants. The techniques used were either artery-sparing selective venous ligation or mass ligation of testicular artery and veins using laparoscopic or open approach. For open surgery, the inguinal approach was used, and vessels were ligated using sutures. Laparoscopic surgery was performed through the transperitoneal approach, and endoscopic clips were used to ligate the vessels. The technique used was entirely dependent on the choice of the operating surgeon.

All patients were routinely reviewed 6–8 weeks after surgery. Further follow-up appointment was based on the progress of the patient and choice of the operating surgeon. The median hospital follow-up period for all children in this study was 8 months (range, 8 weeks–3 years). As the Pediatric Surgical Units cover specific geographical areas, it was expected that if these children developed any complication, they should have been treated in the same hospital. However, to confirm that none of the complications was missed, the general practitioners (family physicians) and parents of all patients were contacted over the telephone during data collection. If these telephone consults are considered as follow-ups, the median follow-up period becomes 6 years.

The primary outcome measure of this study was recurrence of varicocele, and the secondary outcome was development of postoperative hydrocele. Binary logistic regression analysis using age, laparoscopy, and artery-sparing ligation as independent variables was used to predict outcome. SPSS Statistics version 18 (SPSS Inc., Chicago, IL) was used for data analysis. This study was approved by the local research and development teams from both hospitals.

Results

Thirty-seven children had surgery for varicocele during the study period. The median age of operation was 14 years (range, 11–16 years). All the boys had left-sided Dubin and Amelar Grade 2 varicocele except one, who had Grade 3 varicocele. ²²

Most common presenting complaint was palpable lump. Three children had a smaller unilateral testis at presentation (Table 1).

Sixty-eight percent of procedures were laparoscopic, and 70% were artery-sparing (Table 2).

Six (16%) children had recurrence of variococeles, 4 (16%) had laparoscopic surgery (3 artery-sparing), and 2 (17%) had open surgery (both artery-sparing). On logistic regression analysis, increasing age significantly decreased the chances of recurrence (P=.021). Recurrence rates after laparoscopic and open surgery were similar. Artery-sparing ligation was independently associated with higher recurrence, but the association was not statistically significant (Table 3). Recurrence was small and asymptomatic in 2 children, and further surgery was not required. In the remaining 4 children, 2 were successfully treated with open mass ligation, 1 child was operated on by an adult urologist in a different hospital, and one family decided not to have reoperation.

Six (16%) children had postoperative hydrocele; 5 had laparoscopic surgery (3 artery-sparing). Chances of hydrocele were higher in laparoscopic surgery and artery-sparing ligation and lower in older children, but none of the associations was statistically significant (Table 3). All 6 children had a small asymptomatic hydrocele, and none of them had surgery.

There was no recorded testicular atrophy after surgery and there was no catch-up growth of testicles in the 3 patients with preoperatively reduced testicular size.

Discussion

The term varicocele was originally coined by British surgeon T.B. Curling in 1843 to describe the pathologic dilation of veins of the spermatic cord. ¹ Varicoceles arise from a reversal of blood flow within the internal spermatic and cremasteric vein. ²³ There are several theories to explain how varicoceles develop. The three main ones are the anatomical difference between the venous drainage of the right and left testes, the absence of competent valves in the venous system, and possible compression of the renal vein between the aorta and the superior mesenteric vein, which leads to increased hydrostatic pressure from within the testicular vein. ²⁴

Conclusions from epidemiologic studies suggest that approximately 15% of all men in the general population have a clinical varicocele. ⁷ Varicoceles commonly arise during puberty as demonstrated by a study done in Denmark by Oster ²⁵ that showed no evidence of varicoceles in schoolchildren between the age of 6 to 9 years old but increasing numbers of varicoceles in the 10–14-year-old group. At 19 years of age, the incidence is thought to be about 19% of the general population. ²⁶ The incidence of varicoceles is much higher in the population of men with secondary infertility and accounts for 20–40% of cases. Therefore, it is thought that varicoceles have an effect on fertility.

According to guidelines on pediatric urology produced by the European Society for Pediatric Urology in 2010, indications for surgical intervention include varicocele associated with a small testis, additional testicular condition affecting fertility, bilateral palpable varicocele, pathological sperm quality (in older adolescents), varicocele associated with supernormal responses to luteinizing hormone releasing hormone stimulation test, and symptomatic varicoceles. ²⁷

Different techniques have been described in managing varicoceles. They can broadly be divided into embolization and surgical intervention, which can be further divided into open versus laparoscopic techniques. ²⁸ Embolization of varicoceles can be performed in either an anterograde or retrograde manner. In anterograde embolization, the embolizing material is infused through a vein that is part of the pampiniform plexus within the scrotum. ²⁹ In retrograde embolization, the femoral vein is cannulated. Embolization is dependent on the availability of a skilled interventional radiologist, and 35% of children undergoing embolization will eventually require surgical intervention. ³⁰

The several surgical approaches that have been described for open surgery include the subinguinal, inguinal, and retroperitoneal. ²⁸ Open procedures can also be aided with the microscope. In laparoscopic surgery, the varicocelectomy can be performed by the intraperitoneal, preperitoneal, or lumbotomy approach. ³¹ When varicocelectomy is performed using either the open or the laparoscopic approach, surgeons may opt to adopt the mass ligation technique or the artery- and/or lymphatic-sparing technique.

A recent review of adult literature suggests microsurgical techniques have the lowest recurrence and hydrocele development with the highest postoperative fertility. ³² Complications of varicocele surgery were highest in laparoscopic techniques, and in current adult practice microsurgical techniques are gold standard. ³² Although there are studies demonstrating no major difference in testicular vascular anatomy in adults and adolescents, microsurgical techniques are still not popular in pediatric practice, which is evident from the paucity of literature.^33,34 We assume this is due to the lack of microsurgical training among pediatric surgeons, as most of the pediatric surgical procedures do not involve the operating microscope. To train all pediatric surgeons to perform microsurgery for this low-volume procedure may be a challenge. However, the results of microsurgery for varicocele in children are yet to be investigated.

Comparing artery-sparing versus mass ligation, there is a higher failure rate in the group undergoing the artery-sparing technique. ²¹ A recent meta-analysis on pediatric varicocelectomy confirms that ligation of both artery and veins during laparoscopic varicocelectomy significantly reduces the recurrence rate. ³⁵ This was similar to our study.

There are conflicting data on post-varicocelectomy hydrocele in adolescents. A recent review of 400 patients from the American adolescent varicocele register revealed the lowest rates of hydrocele after laparoscopic lymphatic-sparing ligation. ³⁶ Artery-sparing ligation was also found to be associated with fewer hydroceles. ²¹ However, the rates of hydrocele are lowest after microsurgical techniques in adults. ³² In our study, it was found that laparoscopy and artery-sparing ligation were associated with higher rates of hydrocele. However, there were no additional measures taken to spare the lymphatics in any of our cases. Studies have shown that dye-assisted lymphatic-sparing techniques have lower hydrocele rates.^37–39

Although none of our patients required surgery for hydrocele, it has been reported that repeated aspirations of hydrocele fluid are not curative and that Jaboulay hydrocelectomy is often necessary. ³⁶ It was also found that the mean time to detect palpable varicocele was 2 years after operation. ³⁶ None of the children in our study required surgery for hydrocele as none of them was symptomatic and cosmetically unacceptable.

Although there have been studies showing in patients with small testicular volume preoperatively that there is catch-up growth in testicular volume post-varicocelectomy, ⁴⁰ we were unable to obtain evidence of catch-up growth in our study of the 3 patients who had small testicular volume preoperatively.

The clinical significance of a higher recurrence rate following varicocelectomy in younger children in our study is uncertain. We hypothesize that surgery on prepubertal gonadal vessels is more challenging than that on adolescents. Younger children could also develop better collateral circulation after ligation. Delaying surgery in young children may improve rates of recurrence; however, the effects on fertility due to the delay in surgery remain unknown.

This study has the limitations of a retrospective study and being uncontrolled. Selection bias to the surgical approach could not be eliminated. Our study can be criticized for smaller sample size, because of which most of our observations were not statistically significant. We decided not to collect data beyond the last 10 years to improve sample size because of the significant evolution of surgical techniques in the last 10 years and the nonavailability of laparoscopic instruments prior to our study period. These two centers were selected because of the identical practice among the surgeons. Because of significant variability in managing varicocele in different centers, recruiting more centers would have resulted in a diverse group with significant selection bias. However, this study is still the largest series from the United Kingdom on pediatric varicocele surgery.

In our study, the best surgical outcome in terms of recurrence and hydrocele was obtained after open mass ligation of both testicular artery and vein. However, the results were not as good as the microsurgical techniques in adults. However, because of the abundance of conflicting data regarding outcome of different surgical techniques of varicocelectomy in the pediatric population, additional studies in larger populations are still warranted to aid in improved patient selection for surgical intervention and also in choice of surgical technique used.