Lymphatic Sparing Research Articles

Laparoscopic varicocelectomy: Does intraoperative lymphography with vital dye influence the outcome?

Vital dyes lymphography during laparoscopic varicocelectomy (LV) has been suggested to allow for lymphatic mapping thereby allowing for lymphatic sparing (LS) and subsequent reduction of hydrocele formation. Intratesticular injection of the dye seems to achieve the best lymphatic visualization, however, the potential toxicity of some agents, is a cause of concern for the risk of testicular pathological changes. We report our experience with LV, to test the hypothesis that Intraoperative lymphography with methylene blue (BL), is safe and reduces the rate of post-operative hydrocelectomy. Secondary aim was to evaluate the effect of intratesticular injection of the dye. Retrospective review of all consecutive patients undergoing LV<18 years of age, between 2018 and 2022, and with at least 12-month follow-up. We compared hydrocele rate after LS-LV vs. non-LS-LV and between patients undergoing LS with vs. without BL and according to injection site. Post-operative ultrasounds were reviewed to rule out testicular anomalies in patients undergoing BL. Reoperations for varicocele were also noted. 116 patients undergoing LV at a median (range) age of 14 (10-17) years were included. Post-operative hydrocelectomy rate was significantly more common (p=0.033) in patients undergoing non-LS (3/38, 8%) vs. LS (0/78) LV. No hydrocelectomy was performed in patients undergoing LS-LV with (0/47) or without (0/31) BL. Vital dye injection site was intra-testicular in 21/47 (45%) cases. Avascular intra-testicular lesions were identified in 4 (19%) patients and persisted after a median (range) follow-up time of 21 (14-28) months. Two varicoceles were reoperated for recurrence, one in each group. Vital dyes lymphography improves lymphatics visualization during LV. Although, in present study, overall hydrocele rate was not significantly different in patients undergoing LS vs. non-LS procedures, hydrocelectomy was required only after non-LS procedures. In keeping with other 2 recent studies, avascular intratesticular lesions were observed in one fifth of cases undergoing Intratesticular dye injection. These lesions did not change during follow-up, but their clinical significance remains to clarify. Limitations of study include the retrospective design and the small number of patients undergoing intratesticular dye injection, but still this is one of the largest series with long-term follow-up of intratesticular lesions after BL. LS-LV significantly reduced the risk of hydrocelectomy, irrespective to the use of BL. Intratesticular methylene blue injection was associated with persistent testicular lesions on follow-up ultrasounds in 19% of cases. More studies are necessary to prove the safety of dye injections into the testis.

Usefulness of indocyanine green in the laparoscopic Palomo technique: a comparative study.

To find out whether the use of indocyanine green for lymphatic sparing in the laparoscopic Palomo technique reduces the incidence of postoperative hydrocele. A comparative cohort study of varicocele patients treated with the laparoscopic Palomo technique from 2008 to 2023 was carried out. Patients were divided into two groups according to whether fluorescence lymphography (intratesticular indocyanine green) had been performed or not. Epidemiological, surgical, and clinical data, as well as complications, were recorded. A hypothesis test was conducted using the SPSS software. 30 patients undergoing varicocele surgery through the laparoscopic Palomo technique were included. They were divided into two groups -lymphatic sparing (n=13) vs. spermatic vessel ligation without sparing (n=17). Mean age at surgery was 14 years. 5 cases of postoperative hydrocele were identified in the no lymphatic sparing group. 1 of them required surgery for hydrocele treatment. No hydrocele cases were noted in the lymphography group. The difference was statistically significant (p=0.032). There were no statistically significant differences in terms of operating times or mean hospital stay. No recurrences, postoperative testicular atrophies, or indocyanine-green-related complications were recorded. Mean follow-up was 11.4 months. The use of indocyanine green for lymphatic sparing in the treatment of varicocele through the laparoscopic Palomo technique significantly reduces the incidence of postoperative hydrocele.

Indocyanine green (ICG)-GUIDED lymphatic sparing laparoscopic varicocelectomy in children and adolescents. Is intratesticular injection of the dye safe? A mid-term follow-up study

Laparoscopic Palomo varicocelectomy using indocyanine green (ICG) fluorescent lymphography (FL) is standardized technique to perform lymphatic sparing and avoid post-operative hydrocele. No data regarding the safety of intratesticular injection of ICG are currently available. The study aimed to assess the safety and efficacy of this procedure at mid-term follow-up. Seventy-two patients (median age 14.5 years) undergoing laparoscopic Palomo varicocelectomy using ICG-FL from January 2019 to July 2022, were enrolled. Operative indication was high-grade varicocele in all patients, associated symptoms in 30/72 (41.7%) and left testicular hypotrophy in 42/72 (58.3%). Follow-up included clinical examination at 1, 6, 12 months and scrotal Doppler ultrasonography (US) at 12 months postoperatively to assess varicocele persistence, hydrocele, and injections-related complications. Lymphatic sparing was achieved using ICG-FL in all cases. No intra-operative complications or adverse reactions secondary to ICG occurred. The median follow-up was 22.8 months (range 11-49). Self-limited scrotal hematoma at the injection site occurred in 1/72 (1.4%). Intratesticular hypoechoic millimetric area was detected at the injection site in3/72 (4.2%) on US. This finding disappeared after 1-year observation in 2/3 cases (66.7%) (Figure). Persistent grade II varicocele was observed in 4/72 (5.5%), not requiring re-intervention. No hydrocele occurred and 14/22 (63.6%) with pre-operative hypotrophy showed catch-up growth. ICG-FL was clinically safe, with no allergy or systemic adverse reactions to the dye reported in this series. No injury directly related to the injection of the dye was clinically observed, except for self-limiting scrotal hematoma in one patient. A millimetric hypoechoic and avascular area in the body of the left testicle at the injection site was found on scrotal US at 1-year follow-up in 3 patients of our series. This finding does not seem to be clinically relevant as patients were asymptomatic and serum tumor markerswere normal in all cases. Furthermore, the hypoechoic area with calcifications resolved 1 year later in 2/3 patients. The absence of evolution of this finding seems to exclude the heteroplastic nature. We hypothesized that this finding may be linked to elevated volume and/or pressure of intratesticular injection. Future prospective study with larger series and longer follow-up is needed to assess long-term testicular outcomes. Laparoscopic Palomo varicocelectomy using ICG-FL reported excellent outcomes with low incidence ofvaricocele persistence and no post-operativehydrocele. These preliminary data also confirmed safety of intratesticular injection of ICG at mid-term follow-up, without specific risks for both testis and patient.

A systematic review and meta-analysis on the efficacy of internal spermatic artery ligation during laparoscopic varicocelectomy in children and adolescents: Is it safe?

Challenges in identifying small testicular arteries and lack of microscopic experience have led to a rising trend in the use of laparoscopic technique for pediatric and adolescent varicocele. The controversy over artery ligation (AL) and artery preservation (AP) during laparoscopic varicocelectomy (LV) is still debatable. This study investigates the effectiveness of AL and AP during LV in pediatric and adolescent varicocele cases. The systematic searches based on PRISMA guideline were conducted in PubMed, Scopus, ScienceDirect, Web of Science and ProQuest databases with pre-defined keywords. Both quantitative and qualitative analyses were performed to assess catch-up growth, persistence, recurrence, hydrocele, operative time, post-operative testicular volume, and sperm analysis. A total of 1512 patients from 9 eligible studies were included. There were no significant differences in catch up growth (OR 0.89; 95%CI 0.53, 1.51; p = 0.68) or hydrocele incidence (OR 0.59; 95%CI 0.28, 1.24; p = 0.16). The recurrence rate and persistence rate in AP group is significantly higher compared to AL group (OR 2.95; 95%CI 1.53, 5.68; p = 0.001 and OR 5.13; 95% CI 2.04, 12.88; p = 0.0005, respectively). The mean operative time during laparoscopic varicocelectomy is significantly longer when arteries are preserved as opposed to when they are ligated (OR 5.33; 95%CI 2.05, 8.60; p = 0.001). AL and AP both improved testicular volume and post-operative sperm analysis. AL showed higher efficacy and comparable safety to AP. We recommend using AL with lymphatic sparing to minimize hydrocele complications.

Prospective Randomized Controlled Trial Comparing Laparoscopic Palomo Surgery versus Scrotal Antegrade Sclerotherapy in Adolescent Varicocele.

Varicocele is a common condition in adolescence and the most common correctable cause of infertility. This study aimed to analyze and compare the outcomes of scrotal antegrade sclerotherapy (SAS) and laparoscopic Palomo surgery (LPS) in a tertiary referral centre. Patients with left grade 3 varicocele indicated for surgery were prospectively enrolled and randomly allocated to the SAS and LPS groups, with their respective contralateral normal testes taken as controls. The primary outcome measures were clinical varicocele recurrence, testicular catch-up growth, and post-operative hydrocele. All patients were evaluated clinically and using Doppler ultrasound by radiologists. From 2015 to 2020, 113 patients completed the study and were statistically analyzed (SAS, n = 57; LPS, n = 56). All patients had significantly smaller testes pre-operatively that the testicular volume differences with control testes were -23% in SAS and -19% in LPS. At 12-month follow-up, there were no statistical significant difference in clinical recurrences between the 2 groups (SAS = 5.3% vs LPS = 5.4%, P>.05, non-inferiority test). Testicular catch-up growths were observed in both groups, the mean testicular volume difference between the treatment and control testes reduced from -23% to -8.1% in SAS (P<.001) and -19% to -9.3% in LPS (P<.001) at 12-month follow-up. There was no post-operative hydrocele in SAS compared to 7 in LPS (0% vs 13%, P = .006). Both SAS and LPS are safe and effective procedures for treatment of adolescent varicocele with significant positive effect on testicular catch-up growth. SAS is not inferior to LPS in terms of clinical recurrence rate and with significantly less post-operative hydrocele.

Elective nodal irradiation mitigates local and systemic immunity generated by combination radiation and immunotherapy in head and neck tumors

In the setting of conventional radiation therapy, even when combined with immunotherapy, head and neck cancer often recurs locally and regionally. Elective nodal irradiation (ENI) is commonly employed to decrease regional recurrence. Given our developing understanding that immune cells are radio-sensitive, and that T cell priming occurs in the draining lymph nodes (DLNs), we hypothesize that radiation therapy directed at the primary tumor only will increase the effectiveness of immunotherapies. We find that ENI increases local, distant, and metastatic tumor growth. Multi-compartmental analysis of the primary/distant tumor, the DLNs, and the blood shows that ENI decreases the immune response systemically. Additionally, we find that ENI decreases antigen-specific T cells and epitope spreading. Treating the primary tumor with radiation and immunotherapy, however, fails to reduce regional recurrence, but this is reversed by either concurrent sentinel lymph node resection or irradiation. Our data support using lymphatic sparing radiation therapy for head and neck cancer.

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.

Abstract IA-014: Strategies to enhance the immunogenicity of radiation therapy

Abstract Radiation is an ideal partner to enhance cancer immunogenicity. In response to DNA damage, cytosolic DNA released from the nucleus and mitochondria activates sensors like cGAS/STING, leading to release of IFNβ, that recruits and activates BAFT3+ dendritic cells, for cross-presentation and cross-priming of CD8+ T cells (Deng L et al, Immunity 2014; Vanpouille-Box C et al, Nature Communications 2017; Yamazaki T et al, Nat Immunol. 2020 Aug 3). Radiation also increases the trafficking of activated CD8+ T cells by releasing CXCL16, a chemokine that binds to CXCR6 (Matsumura et al., J Immunol, 2008). Recent evidence has demonstrated how as part of DNA damage response to radiation, genes mutated in cancer are expressed, availing neoantigens to the patient’s immune system (Formenti S et al,Nature Medicine, 2018). By recruiting both the innate and adaptive immune response in combination with immune checkpoint blockade (ICB) radiation can convert the irradiated tumor into an in situ vaccine. While ongoing translational and clinical research is testing radiation immunogenicity with current immunotherapy, the focus of this presentation is on how to best apply the immunogenic effects in combination with standard systemic cancer therapies. Most standard cancer therapies also have relevant effects on the immune system (for example see Ameratunga M et al, Clin Cancer Res 2019): deciphering the immunological effects that accompany the cytocidal effects of available cancer therapies can guide their optimal integration. With regards to RT, the relevance to an immune response of selecting specific treatment fields, lymphatic sparing, specific radiation dose and fractionation as well as optimal sequencing iare rapidly emerging. For instance, in the setting of metastatic disease, cancer heterogeneity (De Mattos-Arruda L, et al. Cell, 2019) requires radiation targeting of all detectable metastatic deposits. A multi-institutional Canadian trial on oligometastatic cancer patients (with up to 5 metastases) has demonstrated a promising improvement in time-to-progression and survival after stereotactic body radiotherapy (SBRT) to each metastasis (Palma DA et al, Lancet, 2019). In addition to targeting heterogeneity, maximal reduction of tumor burden by multi-site SBRT can enable an immunological equilibrium and potentially prolong survival. Conversely, preclinical evidence discourages the inclusion of draining nodal stations in the field of radiotherapy (Marciscano A et al, Clin Cancer Res; 2018). Finally, data about the optimal timing of integration of SBRT with systemic therapy will be presented, by describing the example of oligometastatic ER+ breast cancer. The preclinical results of different sequencing of focal radiation with with CDK4/6 inhibitors and endocrine therapy in a murine model of ER+ breast cancer will be presented (Petroni G. et al, Clinical Cancer Research, in press), as well as the emerging evidence for the type of selective remodeling of TME that radiotherapy induces when given before this systemic therapy combination. Citation Format: Silvia C. Formenti. Strategies to enhance the immunogenicity of radiation therapy [abstract]. In: Proceedings of the AACR Virtual Special Conference on Radiation Science and Medicine; 2021 Mar 2-3. Philadelphia (PA): AACR; Clin Cancer Res 2021;27(8_Suppl):Abstract nr IA-014.

Lymphatic sparing laparoscopic varicocelectomy with or without testicular artery preservation: is there a difference?

BackgroundLymphatic sparing laparoscopic Palomo varicocelectomy is a safe and reliable technique for varicocele treatment in adolescents and children. The purpose of this study was to compare the outcomes of lymphatic sparing laparoscopic varicocelectomy with and without testicular artery preservation. The prospective random allocation of selected patients was done at Al-Azhar University Hospital, Pediatric Surgery Department from February 2010 till January 2015. All patients underwent lymphatic sparing laparoscopic varicocelectomy and they were divided into two equal groups, group A underwent laparoscopic Palomo without testicular artery sparing and group B underwent the procedure with testicular artery sparing. The main outcome included operative time, postoperative hydrocele, and persistence of varicocele, together with catch-up testicular growth or testicular atrophy.ResultsOne hundred and sixty male patients presented with left-sided primary varicocele that was diagnosed clinically and affirmed by color Doppler ultrasonography. The mean age was 14.25 ± 1.6 years (ranged 13-16 years). There was one case of persistent varicocele in group A, compared to 8 cases in group B with a statistically significant difference (p = 0.016). A significant difference had been found in the operative time (p = 0.001) between both groups. No hydrocele or testicular atrophy had been detected in both groups. No significant inter-group differences were seen in aspects of age, varicocele grade, and catch-up testicular growth. The mean follow-up period was 42 months (24-60 months).ConclusionLymphatic sparing laparoscopic Palomo varicocelectomy was superior to that with testicular artery preservation as regard varicocele persistence and operative time and hence is preferable for the management of primary pediatric varicocele.

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

Indocyanine Green Fluorescence Lymphography: A New Technique to Perform Lymphatic Sparing Laparoscopic Palomo Varicocelectomy in Children.

Laparoscopic Palomo varicocelectomy is one the most common approaches adopted to treat pediatric varicocele, but postoperative hydrocele still remains a potential problem with this procedure. This study aimed to evaluate the outcome of a new technique of lymphography using indocyanine green (ICG)-enhanced fluorescence to perform lymphatic sparing laparoscopic Palomo varicocelectomy. The records of 25 patients who underwent laparoscopic left varicocelectomy in our unit from March 2017 to March 2018 were retrospectively evaluated. The average patients' age was 13.7 years (range 12-16). All patients had a high degree varicocele associated with left testicular hypotrophy and symptoms. All procedures were performed in laparoscopy using three trocars. After trocars' positioning, 2 mL of ICG solution was directly injected into the left testicle. Using ICG fluorescence, the lymphatic vessels were clearly identified and spared, and then the entire spermatic bundle was clipped and divided according to Palomo's principle. The average operative time was 18 minutes (range 10-25). No conversions to open surgery and no allergy or other adverse reactions induced by ICG were reported. At a maximum follow-up of 18 months, no recurrence of varicocele or postoperative hydrocele was recorded. Our preliminary experience showed that ICG fluorescence lymphography is a safe and effective option to perform lymphatic sparing laparoscopic Palomo varicocelectomy in children and adolescents with high degree varicocele. The intratesticular injection of ICG and use of fluorescence vision allowed identification of lymphatic vessels in 100% of cases. No allergy to ICG or postoperative hydrocele was reported in our experience.

Surgical approaches for varicocele in pediatric patient.

Varicocele represents one of the most common surgically correctible urologic anomalies in adolescent males. The best procedure for the treatment of adolescent varicocele has not been established, but with recent advances in minimal access surgery, there have been many reports praising the safety and efficacy of laparoscopy and retroperitoneoscopy for the surgical correction of varicocele in adolescent. The aim of this review is to compare the results of Palomo's technique, with retroperitoneoscopic and transperitoneoscopic approaches in adolescent, analyzing recurrence, testicular growth and complications. A literature search on PubMed and Cochrane Database was conducted with regard to management of varicocele in adolescent population. Twenty two English language studies that compared outcome of different minimally invasive treatments or outcome of minimally invasive and traditional surgical treatments for adolescent diagnosed with varicocele were included. Intraoperative complications of minimally invasive approaches occur in early cases, but in pediatric urology these procedures would become more efficient with experience and these approaches continue to increase in number. Postoperative hydrocele is the most postoperative compliance of Palom technique, and reports have shown a wide range of variability for his incidence, depending on the technique used for surgical treatment. Literature showed an increase of testicular volume for real growth of testis after surgery, and an intratesticular improvement in sperm quality after minimally invasive approach. In laparoscopic approach reports have showed very low recurrence because allows better vision of collateral veins, and a lymphatic sparing technique permit to identify lymphatic vessels in 100% of cases. The literature has shown that laparoscopic varicocelectomy is the surgical approach most commonly reported in adolescent patients, and that its use is increasing for better training for surgeons and the ability to avoid operational hydrocele that is a main complication after technical Palomo's technique.

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.

Real-time Intraoperative Fluorescent Lymphography: A New Technique for Lymphatic Sparing Surgery.

Many surgical procedures can produce persistent lymphorrhea, lymphoceles, and lymphedema after lymph node and lymph vessel damage. Appropriate visualization of the lymphatic system is challenging. Indocyanine green (ICG) is a well-known nontoxic dye for lymphatic flow evaluation. ICG fluorescence-guided lymphography has emerged as a promising technique for intraoperative lymphatic mapping. Our goal was to develop a high spatial resolution, real-time intraoperative imaging technique to avoid or recognize early deep lymphatic vessel damage. We intraoperatively performed ICG fluorescence-guided lymphography during a kidney transplant. ICG was injected in the subcutaneous tissue of the patient's groin in the Scarpa's triangle. A dedicated laparoscopic high-definition camera system was used. Soon after ICG injection, the lymphatic vessels were identified in the abdominal retroperitoneal compartment as fluorescent linear structures running side by side to the iliac vessels. Surgical dissection was therefore performed, avoiding iatrogenic damage to major lymphatic structures. Another ICG injection at the end of the procedure confirmed that the lymphatic vessels were intact without lymph spread. Intraoperative lymphatic mapping with an ICG fluorescence-sensitive camera system is a safe and feasible procedure. ICG real-time fluorescence lymphography can be used to avoid or recognize early deep lymphatic vessel damage and reduce postoperative complications related to the lymphatic system.

73. Lymphatic duct Sparing Partial Mastectomy (LSPM) – The concept and the practice

73. Lymphatic duct Sparing Partial Mastectomy (LSPM) – The concept and the practice

Comparative study between dye assisted microsurgical Subinguinal Varicocelectomy versus Subinguinal Conventional Technique for treatment of primary varicocele

Background Division of lymphatic vessels during varicocelectomy could lead to secondary hydrocele formation and decrease of testicular function due to testicular edema. It was suggested that the use of methylene blue dye combined with optical magnification could reduce the incidence of postvaricocelectomy complications. Aim of the work To evaluate efficacy and safety of the dye assisted subingunial varicocelectomy with optical magnification in the treatment of primary varicocele. Patients and methods Sixty five patients having 80 primary varicoceles were randomly divided into two groups according to treatment procedure. The indications of surgery included patients with primary varicocele with infertility or varicocele with life style limiting pain. Thirty three patients (having 40 varicoceles) underwent subinguinal varicocelectomy with the aid of optical magnification after injection of dye (group I), and 32 patients (having 40 varicoceles) treated by subinguinal varicocelectomy with neither injection of dye nor magnification (group II). After surgery, the patients were assessed at 2 weeks, 3 months and 6 months for hydrocele formation, size of the testes using ultrasound, varicocele recurrence, pain or other complications. Results There were no reported complications with arterial injury in group I, while four procedures (10%) in group II were complicated by minor injury of the internal spermatic artery with P value = 0.045*. One procedure was complicated by hydrocele in group I (2.5%) in contrast to 7 procedures in group II (17.5%) with P value = 0.006*. Also, one procedure in group I and 7 procedures in group II were complicated by varicocele recurrence. This difference was statistically significant, P value = 0.006*. Conclusion Dye assisted lymphatic sparing subinguinal microsurgical varicocelectomy is simple, feasible, and could minimize varicocelectomy related complications.

Microscopic Retroperitoneal Varicocelectomy With Artery and Lymphatic Sparing: An Alternative Treatment for Varicocele in Infertile Men

To compare the therapeutic effect of arterial and lymphatic sparing microscopic retroperitoneal varicocelectomy (MRV) with that of microscopic subinguinal varicocelectomy (MSV) for treatment of varicocele in infertile men. We conducted a prospective and controlled study to evaluate the therapeutic efficacy of MRV and MSV for treatment of varicocele in infertile men. A total of 80 patients were randomly chosen to undergo MRV (n = 40) or MSV (n = 40) treatment. All patients were followed up at 3, 6, and 12 months after surgery. Semen parameters, pregnancy, recurrence, and complications were examined. Mean operation time in the MRV group was significantly shorter than that in MSV group (38.92 ± 5.67 min vs 91.35 ± 15.08 min), and the number of observed spermatic veins in MRV group was significantly less than that in MSV group (3.59 ± 0.76 vs 18.22 ± 2.83). Sperm count and motility were significantly improved at 12 months follow-up in both groups compared with preoperative values, and the sperm count in the MRV group at 3 months was significantly higher than that in MSV group. Moreover, the incidence of scrotal edema was higher in the MSV group, although natural pregnancy rate was not significantly different between 2 groups at 1-year follow-up (42.1% vs 44.7%). MRV with artery and lymphatic sparing is a simple and effective technique for treatment of varicocele in infertile men.

Surgery of male infertility: an update

Surgery for male infertility includes three main areas: varicocele surgery, recanalization of seminal tract, sperm retrieval.Varicocele treatment in infertily is still controversial. Recent scientific evidence appears to demonstrate that in selected cases varicocele treatment is beneficial in improving semen parameters and pregnancy rate. The key for the success of treatment seems to be a correct indication. It is our opinion that varicocele should be treated in presence of abnormal semen parameters, when clinically significant, and in adolescents with atrophy of the affected testis. So far, no specific technique, either surgical, microsurgical or sclerotherapic, can be considered the gold standard. Good results in our hands have been obtained with the microsurgical lymphatic sparing high ligation of internal spermatic vein.Innovations in surgery for seminal tract obstructions include the new tubular invagination techniques for epididimovasostomy, which showed excellent results with a simplified and time-saving microsurgical approach. In distal obstructions, a new transperineal ultrasound-guided approach has been proposed for the diagnostic work-up and treatment. Advantages of this technique and of the TURED must be balanced with those of immediate sperm retrieval for ART.In sperm retrieval, microTESE represents the most important surgical evolution in non-obstructive azoospermia. We have recently proposed a new stepwise approach starting with a minimal equatorial incision for conventional testicular biopsy which is extended to perform microTESE only when no sperm is retrieved. In this way microTESE is offered only to patients who really need it. Another field of innovation is sperm retrieval for ICSI in patients with Klinefelter Syndrome.

Percutaneous embolization: a viable treatment option for varicocele.

There are several options in the treatment of varicocele. Surgical repair either by open or microsurgical approach, laparoscopy, or through percutaneous embolization of the internal spermatic vein have been used to treat varicocele [1]. Regardless of the chosen technique, the ultimate goal relies on the occlusion of the dilated veins that drain the testis. Percutaneous embolization offers a rapid recovery and can be successfully accomplished in approximately 90% of attempts. However, the technique demands interventional radiologic expertise and has potential serious complications, including vascular perforation, coil migration, and thrombosis of pampiniform plexus [2]. Prasivoravong et al. [3] report results from a case series of men undergoing varicocele embolization. They evaluated men with grade III unilateral varicocele and identified improvements in sperm morphology. Percutaneous embolization can be a valuable treatment option for recurrences after surgery since patients may not want to undergo another operation and surgeons may not feel comfortable with artery and lymphatic sparing technique. Percutaneous approach can offer a viable treatment approach for men complaining of scrotal pain (orchialgia) from varicocele because inflammation and scarring from operation may contribute to additional pain. Further studies are necessary to determine the benefit of percutaneous embolization in men with bilateral and lower grades of varicocele. Additional comparative studies comparing the different treatment options for varicocele can help determine the best treatment option for men that present with varicocele-associated infertility.