Lymphatic Sparing Varicocelectomy Research Articles

Long lasting effect on testes following methylene blue injection in laparoscopic lymphatic sparing varicocelectomy

Injection of methylene blue to testis has been shown to have adverse effect in animal studies but it is still being used frequently as lymphatic mapping agent during lymphatic sparing varicocelectomy in adolescent varicoceles. We aim to report postoperative ultrasound changes after subaortic injection of methylene blue in human testes. A retrospective observational study of consecutive patients under 18 years old undergoing laparoscopic varicocelectomy from August 2017 to August 2021 was performed. Demographics such as age, symptoms, pre-operative testicular volume was collected. Primary outcome was change on testicular ultrasound at 3, 6, 12 months after the operation. Secondary outcome was testicular volume difference between affected and unaffected testes, and growth rate of affected testis at 1 year after the operation. Fifty-eight patients were included, with median age of 15 years old (IQR 11-18 years). Thirty-one patients had non-lymphatic sparing varicocelectomy (Group A) and 27 patients had lymphatic sparing varicocelectomy (Group B). There was no statistical difference between the mean testicular volume difference between the two groups, but hydrocele rate was significantly higher in Group A (16% vs 0%, p=0.03). In group B, 6 patients (22.2%, p=0.005) developed testicular change detectable by ultrasound. No statistical difference could be demonstrated for median testicular size difference (between affected and unaffected testes) at 1 year between group with and without ultrasound change (-23% vs 0%, p=0.36). Median follow up time was 20.4 months (IQR 5-32 months). Varicocele treatments improve testicular volume and increase total sperm concentration and lymphatic sparing surgery significantly decreased post-operative hydrocele rates [2]. Different agents have been used to delineate lymphatic vessels and one commonly used agent is methylene blue [10,15-16]. However it has been shown in other animal studies that intraparenchymal injection of methylene blue to rat testis result in degenerative changes [18]. Our study is the first to describe post-operative changes of human testes on imaging after lymphatic sparing varicocelectomy with subdartoic injection of methylene blue. Six patients (22.2%) demonstrated new onset testicular changes on post-operative ultrasound. Although no statistically significant testicular volume reduction was seen in the group with change on imaging, these observations may serve as a surrogate marker for testicular injury or reduced testicular function. It will be desirable for future studies if we can investigate it further with hormonal markers or semen analysis after puberty has been reached. Lymphatic sparing procedure reduced post-operative hydrocele in adolescent varicocele, however long-lasting effect on testis is evident with subdartoic injection of methylene blue. This agent must be used with caution and long term follow up of these patients are needed.

Comparison of the result of Doppler sonography before and after laparoscopic artery and lymphatic sparing varicocelectomy with microsurgical subinguinal varicocelectomy.

Background:Based on the importance of varicocele, the aim of this is to compare the comparison between doppler sonography before and after laparoscopic lymphatic sparing varicocelectomy and microsurgical subinguinal varicocelectomy.Patients and Methods:Patients with primary varicocele who were referred to Ahwaz Imam Khomeini Hospital after informed consent were included. Primary information included varicocele severity, pain intensity, latency, Doppler sonography (Resistive index (RI), venous return, venous diameter before and after Valsalva) were obtained, and then patients were entered into one of the two groups of surgery. The admission duration, return to work duration, the pain and analgesic consumption, and the length of anxiety were recorded in patients. Patients were examined 3 months later, and the severity of varicocele in the examination, pain score, latency, Doppler sonography indices, sperm indices in both groups were registered. In the end, the information is entered into Statistical Package for the Social Sciences (SPSS) statistical software and evaluated.Results:We observed that the severity of varicocele (P = 0.34), pain (P = 0.45), latralite (P = 0.56), RI (P = 0.65), intravenous diameter (P = 0.75) did not show statistically significant difference between the two groups, also in evaluating these indices after surgery, there were significant differences between the two groups in pain (P = 0.04) and time for return to work (P = 0.036).Conclusions:The methods used in varicocelectomy did not have any effect on the outcome of the treatment. Accordingly, using any of these methods can improve the post-surgical state of the patients and promote the fertility performance and reduction of complications due to surgery in patients.

SC92 - Microsurgical pre-peritoneal lymphatic sparing varicocelectomy in adolescents: Results on a large series of patients

SC92 - Microsurgical pre-peritoneal lymphatic sparing varicocelectomy in adolescents: Results on a large series of patients

Two decades of experience with laparoscopic varicocele repair in children: Standardizing the technique

Controversy still exists about the indications and the gold standard approach for varicocele treatment in pediatric population. The authors report their 23 years of experience in laparoscopic varicocele repair in the pediatric population. We retrospectively evaluated the data of 345 consecutive patients who underwent laparoscopic left varicocelectomy from January 1993 to December 2015. Average patient age was 12.5 years (range 8-17). Seven out of 345 patients (2%) had a recurrent varicocele, and five out of 345 patients (1.4%) had a varicocele on a single testis. In 335/345 patients (97.1%) we performed a Palomo procedure, and in 10/345 patients (2.9%) an artery-sparing Palomo procedure. After 2010, in 105/345 patients (30.4%) we performed a lymphatic sparing procedure using isosulfan blue injection preoperatively. All procedures were completed in laparoscopy (Figure), without conversions or intraoperative complications. The average operative time was 17min (range 14-45) for the Palomo procedure and 26min (range 18-50) for artery-sparing Palomo. In 45/345 patients (13%) we performed additional procedures. We recorded 4/345 (1.3%) recurrences/persistences in patients undergoing Palomo, while we recorded 1/10 (10%) recurrence/persistence after artery-sparing Palomo. On 230 Palomo procedures performed in the pre-isosulfan blue era, we recorded 25 cases of hydrocele (10.8%), 13 of these were treated with transcrotal puncture and 12 required surgical operation. The last 105 patients undergoing isosulfan blue injection had no postoperative hydrocele. We also reported 10 other complications (I grade Clavien-Dindo) such as umbilical granuloma or instrumental problems. Analyzing the international literature of the last 25 years, most papers focused on the minimally invasive treatment of pediatric varicocele. There are several reasons to perform laparoscopic repair of pediatric varicocele. First of all, it is technically easy to perform, the average operative time is very short, and it has excellent outcome in regard to varicocele persistence/recurrence. In addition it has a very low complication rate, and in particular adopting the intradartoic/intratesticular isosulfan blue injection before surgery we recorded no postoperative hydrocele. On the basis of our 23 years of experience with varicocele repair, we clearly believe that laparoscopic Palomo lymphatic sparing varicocelectomy should be considered the standard of care for the treatment of pediatric patients with varicocele. Laparoscopic varicocelectomy is technically easy and quick to perform, painless, and scarless, with a recurrence rate of about 1%. The use of a preoperative injection of isosulfan blue completely eliminates postoperative hydrocele formation.

Technical standardization of laparoscopic lymphatic sparing varicocelectomy in children using isosulfan blue

PurposeThe lymphatic preservation to prevent hydrocele formation after laparoscopic varicocelectomy is essential. Lymphatic sparing procedures using scrotal injection give a rate of mapping failures of 20%–30%. The aim of the present study is to standardize the technique of injection to perform a lymphatic sparing procedure in case of laparoscopic varicocelectomy. MethodsWe retrospectively evaluated 50 patients who underwent laparoscopic varicocelectomy from July 2010 to July 2013. Patients were divided into two groups: G1 (25 patients) those who underwent a classical isosulfan blue scrotal intra-dartos injection and G2 (25 patients) those who underwent the new standardized isosulfan blue scrotal intra-dartos/intra-testicular injection. ResultsIn G1 lymphatic vessels were identified as blue coloured in 19/25 of cases (76%), in G2 in 25/25 of cases (100%). The results were analyzed using test χ2 with Yates' correction and there was a statistically significant difference (χ2=0.05,1) between G2 and G1. Postoperative hydrocele was noted in 2/6 patients of G1 in whom the lymphatic vessels were not identified. ConclusionsLaparoscopic lymphatic sparing varicocelectomy is an effective procedure to adopt in children with varicocele. The intra-dartos/intra-testicular injection of isosulfan blue is significantly better than the previously described intra-dartos injection, permitting to identify lymphatic vessels in 100% of cases in our series. No allergy to isosulfan blue was reported in both groups.

Laparoendoscopic single-site artery and lymphatic sparing varicocelectomy (LESS-V) versus subinguinal microscopic varicocelectomy for infertile men

Laparoendoscopic single-site (LESS) has gained increasing attention due to the potential to maximize the benefits of laparoscopic surgery. This study aimed to compare laparoendoscopic single-site artery and lymphatic sparing varicocelectomy (LESS-V) with subinguinal microscopic varicocelectomy (SMV) in terms of intraoperative parameters and postoperative outcomes in infertile men with palpable varicocele.

Observations on Hydroceles Following Adolescent Varicocelectomy

There is wide variation in the reported incidence of hydrocele after varicocelectomy (0% to 29%). We determined the incidence of hydroceles and hydrocelectomy following adolescent varicocelectomy, the time it took for them to manifest, and the results of aspiration and surgical correction. Our adolescent varicocele registry was reviewed to identify patients with a post-varicocelectomy hydrocele. We evaluated physical examination and ultrasound findings, postoperative interval to development and treatment results. A total of 400 patients with at least 6 months of postoperative followup underwent 521 varicocelectomies (16 redo, 1 right, 104 bilateral) from 1987 to 2010. Mean followup was 32 months (range 6 to 182). Hydrocele was detected in 80 of 521 (15.4%) at a mean of 2 years after surgery. The incidence of hydrocele was higher in open vs laparoscopic (p <0.001), bilateral vs unilateral (p = 0.013), nonlymphatic sparing vs lymphatic sparing (p = 0.043) and Palomo vs laparoscopic nonlymphatic sparing (p = 0.001) procedures. Eight patients underwent aspiration for a large postoperative hydrocele. In all 8 patients fluid returned to pre-aspiration status. There were 29 patients (5.6%) who underwent Jaboulay bottleneck hydrocelectomy and none had recurrence. Hydroceles are a common sequela of varicocelectomy, with the fewest hydroceles occurring after laparoscopic lymphatic sparing varicocelectomy. Patients should be followed for at least 2 years after varicocelectomy to examine for the presence of hydroceles. Although there have been reports on the use of aspiration for post-varicocelectomy hydrocele, we have not had success in those with a single aspiration. Jaboulay bottleneck hydrocelectomy had a 100% success rate in this select group.

Lymphatic Sparing Versus Lymphatic Non-Sparing Laparoscopic Varicocelectomy in Children and Adolescents: A Systematic Review and Meta-Analysis

The aim of this study was to explore the true efficacy and potential advantages of lymphatic sparing laparoscopic varicocelectomy (LSV) over lymphatic non-sparing laparoscopic varicocelectomy (LNSV) in children and adolescents. A search was made for studies published up until 31 August 2010 using the terms "lymphatic sparing varicocelectomy", "laparoscopy", "adolescent" and "children" in the Medline, Embase, Ovid, Web of Science, and Cochrane databases. Randomized controlled trials (RCTs) and observational clinical studies (OCSs) comparing LSV and LNSV were included. A systematic review and meta-analysis was performed using odds ratios (ORs) for dichotomous variables. Out of 127 studies, 2 RCTs and 4 OCSs were eligible for inclusion, comprising 489 cases of LSV and 307 cases of LNSV. The hydrocele rates after LSV were significantly lower than after LNSV (OR = 0.19; 95% confidence interval [CI] = 0.10 to 0.36; p < 0.00001). However, no significant difference was observed between LSV and LNSV with regard to recurrence (OR = 0.65; 95% CI = 0.32-1.33; p = 0.24) or catch-up growth (OR = 2.14; 95% CI =0.97-4.72; p = 0.06). LSV is valuable in reducing the incidence of postoperative hydrocele, with similar recurrence and catch-up growth rates as LNSV. A series of RCTs are warranted to explore the efficacy of LSV in the management of varicocele in children and adolescents.

C131 Surgical treatment of varicocele in children with open suprainguinal microscopic lymphatic sparing varicocelectomy

C131 Surgical treatment of varicocele in children with open suprainguinal microscopic lymphatic sparing varicocelectomy

Adolescent varicocelectomy: Postoperative catch-up growth is not secondary to lymphatic ligation

Purpose The major indication for adolescent varicocelectomy is testicular asymmetry with the left testicle smaller than the right. Catch-up growth following surgery is one of the parameters used to assess efficacy of surgery. However, it is not clear whether this represents true tissue growth or increased interstitial fluid secondary to lymphatic obstruction. The purpose of this study was to compare catch-up growth in patients who underwent varicocelectomy with and without lymphatic preservation. Materials and methods We retrospectively analyzed the outcomes of 136 boys (mean age 15.1 years) who had 10% or greater preoperative testicular asymmetry and underwent varicocelectomy between 1997 and 2006. Surgery was either a laparoscopic nonlymphatic sparing or laparoscopic lymphatic sparing varicocelectomy. All patients had pre- and postoperative ultrasound volume measurements at least 6 months following surgery. The groups were compared for incidence of postoperative catch-up growth, achieving less than 10% testicular asymmetry. Results After a mean follow up of 24.7 months, catch-up growth was achieved in 62.8% of patients. There was no significant difference between the groups in regard to catch-up growth (51.7% vs 66.3%, P = 0.193). Conclusions Since no significant difference was found between the laparoscopic nonlymphatic sparing and laparoscopic lymphatic sparing varicocelectomies, we conclude that lymphatic obstruction is not the cause of catch-up growth.

Laparoscopic Lymphatic Sparing Varicocelectomy in Adolescents

Laparoscopic varicocelectomy is similar to an open Palomo repair. Both procedures involve en masse ligation of the internal spermatic cord, and both are associated with a 1% to 3% incidence of recurrence and up to a 30% incidence of hydroceles. We sought to determine the impact of lymphatic preservation on hydrocele formation and the success of varicocelectomy. We retrospectively evaluated 191 patients with a mean age of 15.2 years who underwent laparoscopic varicocelectomy and at least 6 months of followup. Patients were divided into 2 groups-those who had undergone a lymphatic sparing procedure and those who had undergone a nonlymphatic sparing technique. The incidence of recurrence/persistence, postoperative hydrocele formation and postoperative hydrocele requiring surgery or aspiration was analyzed. A total of 174 laparoscopic lymphatic sparing procedures (132 patients, 42 bilateral) and 88 nonlymphatic sparing repairs (59 patients, 29 bilateral) were performed, with a mean followup of 26.1 months. Lymphatic sparing surgery was associated with a decreased incidence of postoperative hydrocele (3.4% vs 11.4%, p = 0.025). There was no significant difference in incidence of persistent or recurrent varicocele requiring reoperation following lymphatic sparing (5 sides, 2.9%) vs nonlymphatic sparing (4 sides, 4.5%) varicocelectomy (p = 0.736). Laparoscopic lymphatic sparing varicocelectomy is preferable to an open or laparoscopic Palomo repair that does not preserve the lymphatics. It has a significantly lower incidence of postoperative hydroceles, especially those requiring surgical intervention, and still maintains a low incidence of persistence/recurrence. The procedure is especially advantageous for bilateral varicocelectomy.