Laparoscopic versus open high ligation of the testicular veins for the treatment of varicocele.

The purpose of this study is to determine the relative advantages of laparoscopic varicocelectomy compared to the conventional open high ligation of Palomo. We studied 193 patients who presented with varicocele. While 65 patients were treated by open high ligation of the testicular veins, 128 patients had laparoscopic varicocelectomy. In addition to varicocele ligation, 14 patients (11%) had laparoscopy-assisted right orchidopexy, and 5 patients (4%) had laparoscopic repair of concomitant right inguinal hernia. The mean hospital stay was 3.5 days and 1.3 days, respectively, and the recurrence rates were 10.8% and 3.9%, respectively. Return to normal activity was significantly earlier in Group II (mean 4.5 days) compared to Group I (mean 8.9 days). There was no incidence of testicular atrophy in any case in the study, regardless of whether the testicular artery was ligated or preserved during surgery. We conclude that laparoscopic varicocelectomy is safe, effective and minimally invasive. In addition to its better cosmetic results and advantage in case of bilateral disease, it allows excellent exposure and control of the affected vessels. Furthermore, the shorter hospital stay and the earlier return to normal activities are very important advantages in recommending this technique as an efficient alternative to the open surgical method.

INTRODUCTION

Whereas varicocele before puberty is rare, the prevalence of this disease in adolescence is equivalent to that in the general male population: 12.4 to 16.2%, with an average of 15%.[1,2] In addition, the incidence of varicocele in male patients investigated for infertility is approximately 40%.[3,4] Varicocele can negatively and progressively affect the testicular growth, histology and function resulting in progressive decline in fertility.[5] Fifty percent to 60% of men who have had their varicocele treated show improvement in semen quality.[3] In the last few years, varicocelectomy has been performed successfully via laparoscopy.[6-12]

The present study compares the laparoscopic and conventional open methods for high ligation of varicocele.

PATIENTS AND METHODS

The study included 193 patients divided into two groups according to their referrals. Sixty-five consecutive patients who were referred to the urology department (Group I) had open varicocelectomy by Palomo's technique.[14] One hundred and twenty-eight patients (Group II), referred to the general and pediatric surgery departments, had laparoscopic varicocelectomy. All the operations were performed in Mafraq Hospital between November 1995 and November 1998. The ages of the patients in Group I ranged between 8 and 42 years, with an average of 24.4 years. Those in Group II were between 8 and 39 years, with an average of 21.3 years. The majority of school age patients were asymptomatic, and the disease was discovered during routine medical check-up. While testicular pain and/or swelling were the main complaint among patients between 15 and 25 years of age, subfertility was the major presentation among those above 25 years of age. The diagnosis of varicocele was established mainly by clinical examination with the patient in upright position. The disease was graded according to the criteria published by Lion et al.[13] In the majority of cases, the disease was of grade II or III. Nine patients in Group I (13.8%) and 21 patients in Group II (16.4%) had recurrent disease. Sixty-two patients in Group I (95.4%) and 109 patients in Group II (85.2%) had left-sided disease. Bilateral varicocele was present in 3 patients in Group I (4.6%) and in 19 patients in Group II (14.8%) (. Doppler ultrasound scan was done in all cases to confirm the diagnosis and to evaluate the testicular size pre- and postoperatively. For patients with subfertility, seminal analysis was done at least twice preoperatively, and then checked every 6 months for 18 to 24 months postoperatively. The examination included sperm count, the percentage of sperm motility each hour for four hours, and the presence of abnormal forms. Results of semen analysis were evaluated according to the criteria of the World Health Organization laboratory manual.[14]

SURGICAL TECHNIQUE

All patients in Group I had high ligation of the dilated testicular veins by the technique described by Palomo in 1969.[15]

Laparoscopic varicocelectomy was performed with the patient in the supine or Trendelenburg position (20-30 degrees head down). A urinary catheter was routinely inserted after the induction of anesthesia to evacuate the bladder. A Veress needle for the creation of pneumoperitoneum was introduced into the abdomen through a supra-umbilical transverse skin incision. Carbon dioxide insufflation was maintained through the Veress needle at a rate of 1-2 liters per minute, and the intra-abdominal pressure was kept between 11-14 mm Hg, depending on the patient's age. After the withdrawal of the Veress needle, a 5-mm trocar was inserted through the umbilical incision, connected to the carbon dioxide insufflator, and a 0 or 30 degree laparoscope was introduced into the peritoneal cavity. In all cases, the abdominal and pelvic viscera were examined in addition to the spermatic vessels and internal inguinal rings on both sides. For unilateral varicoceles, the working ports consisted of two 5-mm trocars introduced via a stab in the ipsilateral iliac fossa and in the contralateral iliac fossa in the midclavicular lines. The operator was standing on the contralateral side of the operating table using the working ports, while the assistant surgeon was standing on the ipsilateral side and controlling the laparoscope. After identifying the spermatic vessels, the overlying peritoneum was caught with a blunt grasper in the ipsilateral port. Using a blunt endo-scissors in the contralateral port, a T-shaped incision was made parallel to and lateral to the spermatic vessels. The vascular bundle was then carefully grasped and dissected approximately 3-5 cm from the parietal peritoneum and underlying structures using a blunt endo-scissors or a diathermy hook. The testicular artery was not always searched for; this was relatively more difficult in the pediatric age group. The testicular veins were clipped approximately 3-5 cm above the internal inguinal ring and then divided between the clips. At the conclusion of the procedure, the abdominal cavity was desufflated, and the trocars were removed under vision. The operative time was calculated from the induction of anesthesia until skin closure.

RESULTS

In Group II, other procedures were concomitantly performed, including right orchidopexy in 14 patients (11%), repair of right inguinal hernia on 5 patients (4%) and removal of a chronically inflamed appendix in one child (0.8%). In Group I, the average operative time was 38.5 minutes for unilateral cases and 69.5 minutes for bilateral cases. For laparoscopic varicocelectomy, the overall average of the operative time for the unilateral cases was 58.3 minutes and 74.2 minutes for bilateral cases. The average operative time for the first 20 operations was 69.8 minutes for unilateral operations and 92.5 minutes for bilateral cases. With increasing familiarity with the technique, the timings were gradually reduced in the remaining cases to 42.3 and 71.8 minutes, respectively (. While no collateral veins were reported at operation in Group I, retropubic collateral channels were identified in 8 patients (6.3%), and lateral collaterals were found in 22 patients (17%) during laparoscopic varicocelectomy. All the collateral veins were interrupted laparoscopically using either clipping or diathermy coagulation, according to their sizes. The testicular artery was detected in 49 patients (75.4%) in Group I and in 120 patients (93.8%) in Group II.

There were no intra-abdominal visceral or vascular injuries associated with laparoscopic varicocelectomy. Three patients (2.3%) had pneumoscrotum, which has spontaneously resolved within 24-48 hours. The postoperative hospital stay for patients in Group I was 2-8 days, with a mean of 3.5 days. In Group II, the postoperative hospital stay was shorter, 1 to 3 days, with a mean of 1.3 days.

One patient in each group developed wound infection that responded to systemic antibiotics. Almost all wound complications in Group II occurred at the site of the umbilical port. Scrotal edema occurred in 11 patients in Group I (17%) compared to only 3 patients in Group II (2.3%). Postoperative wound pain was subjectively evaluated among patients above the age of 12 years, and its intensity was estimated on the basis of the number of narcotic injections administered during the first 24 hours after surgery. While all patients in Group I required one or more narcotic injections, 87% of those in Group II did not require any narcotic injection (. Five children (3.9%) in Group II had mild postoperative shoulder pain, which was gradually resolved in 24 hours. Return to school or normal activities was markedly faster after laparoscopic varicocelectomy. Patients who had open surgery returned to their normal activities after 7-14 days, with a mean of 8.9 days compared to 3-7 days for those who had laparoscopic varicocelectomy, with a mean of 4.5 days.

All patients were regularly followed up for 18 to 36 months postoperatively. Ipsilateral hydrocele developed in three patients in each group (4.6% and 2.3% respectively). Seven patients in Group I (10.8%) and five patients in Group II (3.9%) had recurrence of the disease within 6 to 18 months postoperatively. No testicular atrophy was reported in any case in the study, regardless of whether the testicular artery was clipped or not. This was based on the postoperative seminal parameters and the measurement of testicular size.

Seminal analysis was done for 21 patients in Group I and 45 patients in Group II. According to the results of the preoperative semen analyses, the postoperative seminal parameters were classified into: “improved,” “no change,” or “worse” categories. Improvement of seminal parameters after varicocele ligation was observed in 43% of cases in Group I and in 51% of cases in Group II (.

DISCUSSION

Varicocele has generally been attributed to the absence or incompetence of valves in the internal spermatic veins.[16] However, with the help of spermatic venography, bypassing collateral channels have been found in about 20% of patients with varicocele despite competent venous valves.[17,18] In the present study, 23% of patients in Group II had collateral channels detected at operation.

The sole indication for surgery in the present study was the presence of varicocele, even when asymptomatic. This was based on the concept that early correction of varicocele will alter not only the progressive decline in fertility but will also prevent future infertility in younger male patients.[4,19,20] The relatively higher rate of reversal of the seminal parameters (51% vs 43%) and the fewer incidences of recurrent varicocele (3.9% vs 10.8%) after laparoscopic varicocelectomy can be attributed to better visualization and access provided by the laparoscopic approach.

The mean operative time of laparoscopic varicocelectomy reported in the present series was similar to that reported by Donovan and Winfield[10] and Tan et al.[21] However, it was markedly shorter than that reported by Fuse et al.[22] Technical failures and problems with the laparoscopic instruments constituted the major causes of prolonged operative time for laparoscopic varicocelectomy. Furthermore, adhesions of the bowel to the parietal peritoneum of the groin were found in 19 out of 21 patients with recurrent varicocele after open surgical varicocelectomy. Neither obesity nor the presence of bilateral or recurrent disease was a problem for performing varicocelectomy via laparoscopy.

Although laparoscopic varicocelectomy has been performed by many surgeons on a day-surgery basis,[21,23,24] the mean hospital stay after laparoscopic varicocelectomy in our study was relatively longer than was anticipated. This difference was partially attributed to some cultural and social factors. Almost all our patients prefer to remain in the hospital and do not wish to resume activities until complete pain relief. In addition, the local health system covers the majority of the costs. Additional factors that contributed to prolonged hospital stay were postoperative wound complications and the performance of additional operative procedures, particularly inguinal hernia repair. The hospital stay after laparoscopic varicocelectomy was not affected by whether the disease was unilateral or bilateral. Similar to other studies,[25,26] we did not find any significant difference between testicular artery ligation and preservation during varicocelectomy.

CONCLUSIONS

Laparoscopic varicocelectomy is a minimally invasive procedure that is easy to perform with simple instruments. Not only can the bilateral varicocele be easily dealt with through the same ports, but other procedures, such as hernia repair and orchidopexy, can also be simultaneously performed. It is the best approach when recurrent disease and obesity are problems. The clear visualization and magnification it provides facilitate control of the affected vessels and enable detection of abnormal collateral channels, one of the major reasons for postoperative recurrence. Compared to the open technique, laparoscopic varicocelectomy has minimal postoperative morbidity, shorter convalescence and a faster return to normal activities. Therefore, we recommend that the laparoscopic technique for varicocele ligation replace the conventional open method.

Table 1.

Symptoms and grades of varicocele.

	Group I Open Varicocelectomy (65)	Group II Lap Varicocelectomy (128)
Symptoms:
8-14 years old:	13	41
Testicular pain	3 (23%)	6 (14.6%)
15-25 years old:	29	56
Testicular pain/swelling	22 (76%)	40 (71.4%)
Infertility	10 (34.5)	16 (28.6%)
>25 years old:	23	31
Testicular pain/swelling	18 (78.3%)	24 (77.4%)
Infertility	21 (91.3%)	29 (93.5%)
Grades:
I	5 (7.7%)	12 (9.4%)
II	24 (36.9%)	37 (28.9%)
III	36 (55.4%)	79 (61.7%)

Table 2.

Comparative operative time in both groups.

	Group I Open Varicocelectomy (65)	Group II Lap Varicocelectomy (128)
Unilateral Disease		First 20 patients
Range	24-48 min.	79-119 min.
Average	38.5 min.	69.8 min
		Following 118 patients:
		Range: 48-69 min.
		Average: 42.3 min.
		Overall average:
		58.3 min.
Bilateral Disease		First 20 patients:
Range	42-86 min.	82-119 min.
Average	69.5 min.	92.5 min.
		Following 118 patients:
		Range: 7-92 min.
		Average: 71.8 min
		Overall average: 74.2
min

Table 3.

Postoperative complications.

	Group I Open Varicocelectomy (65)	Group II Lap Varicocelectomy (128)
Postoperative pain
( > 12 years old)	(56 patients)	(94 patients)
• No narcotic inject.
• 1 injection	46 (82%)	82 (87%)
• 2 injections	10 (18%)	11 (11.7%)
• > 2 injections	-	1 (1.1%)
Wound erythema	6 (9.2%)	3 (2.3%)
Wound infection	1 (1.5%)	1 (0.8%)
Hydrocele	3 (4.6%)	3 (2.3%)
Recurrent varicocele	7 (10.8%)	5 (3.9%)

Table 4.

Postoperative seminal analysis in both groups.

	Group I Open Varicocelectomy (65)	Group II Lap Varicocelectomy (128)
Test done	21	45
Improved	9 (43%)	23 (51%)
No change	7 (33%)	14 (31%)
Worse	5 (24%)	8 (18%)