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Indian Pediatr 2019;56: 653-658 |
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Laparoscopic Versus Open High Ligation
for Adolescent Varicocele: A 6-year Single Center Study
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Miro Jukic 1,
Mate Todoric2,
Jakov Todoric1,
Tomislav Susnjar1
and Zenon Pogorelic1,2
From Department of 1Pediatric Surgery,
University Hospital of Split, Spinciceva; and 2University of
Split, School of Medicine, Soltanska; Split, Croatia.
Correspondence to: Miro Jukic, MD, Department of
Pediatric Surgery, University Hospital of Split,
Spinciceva 1, 21 000 Split, Croatia.
Email:
[email protected]
Received: October 30, 2018;
Initial review: April 15, 2019;
Accepted: June 21, 2019.
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Objective: The aim of this study
was to compare the outcomes of high ligation in adolescents with
varicocele between open and laparoscopic surgical approaches. Design:
Retrospective study. Setting: The study was conducted from
January 2012 to January 2018, with median follow-up of 36 months, in the
division of pediatric surgery at tertiary-care hospital. Patients:
Data of 537 adolescents who underwent varicocelectomy were classified
into two groups, depending on surgical approach. Intervention:
Open or laparoscopic varicocelectomy. Main outcome measures:
Indications for surgery, complications, duration of surgery, hospital
stay, and recurrences rate. Results: The median age of the
patients was 15 years. The median (IQR) duration of surgery was 12
(11,15.3) min in laparoscopic and 25 (10,30) min in open group (P<0.001).
The most common complication was hydrocele (n=29), which was more
common in open group (6.8% vs 1.4%; P=0.01). A total of 16
recurrences were recorded, all in open group (P=0.049). In both
groups, sperm concentration (P<0.001), morphology (P<0.001)
and motility (laparoscopy, P=0.001; P=0.02; open
varicocelectomy, P=0.001; P=0.04) improved six months
after surgery in patients with varicocele stage I and II. In stage III
there was an improvement in sperm concentration (P=0.002; P=0.001)
and morphology (P=0.03; P=0.06), while sperm motility (P=0.15;
P=0.2) did not significantly recover in either of the groups.
Conclusions: Laparoscopic and open varicocelectomy are equally
effective and result in significant improvement of testicular volume,
disappearance of pain, and sperm parameters in adolescents. Based on our
findings laparoscopic varicocelectomy is associated with shorter
operating time, shorter hospitalization, faster recovery, and fewer
complications and recurrences.
Key words: Complications, Outcome,
Spermiogram, Surgery, Varicocelectomy.
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A varicocele is defined as dilated and tortuous
veins within the pampiniform plexus of scrotal veins and they are the
most common cause of male infertility [1]. The causes of varicocele are
multifactorial, but the end result is a pathological dilation of the
veins draining the testicles, leading to increased temperature in the
seminiferous tubules [2]. Varicocele causes a progressive time-dependent
decline in semen quality [3]. Although uncommon below 10 years,
incidence increases rapidly in the age group 10 to 18 years [4].
Overall, varicocele occurs in 10% to 15% of children and adolescents and
in 40% of the males with infertility [1-5]. Approximately 90% of
varicoceles are left-sided and about 10% of varicoceles are bilateral.
Isolated right-sided varicoceles are extremely rare, and usually are
related with retroperitoneal masses that may compress spermatic veins
[1, 3-5].
There are several surgical techniques to treat
varicoceles, including open inguinal, subinguinal microscopic and
laparoscopic ligation of spermatic veins [5,6]. Each technique has its
own advantages and disadvantages, and conflicting results have been
achieved in different studies [1,2,5-9], but to date there has been no
consensus as to which technique should be considered the gold standard
for treatment of varicocele in children and adolescents. The aim of this
study was to evaluate the demographic and clinical characteristics and
indications for surgery in the children and adolescents undergoing
varicocelectomy, and to evaluate postoperative outcomes and effects on
testicular volume improvement and semen parameters during a 6-year
period between open and laparoscopic high ligation of varicocele.
Methods
The case records of 556 pediatric patients who
underwent varicocelectomy between 1 January, 2012 and 1 January, 2018 at
the Clinical department of pediatric surgery, University Hospital of
Split, Croatia, were retro-spectively reviewed. Of these, 19 patients
were excluded from the analysis because they met one or more exclusion
criteria. Informed consent was obtained from the parents or legal
guardians of all the patients for the surgeries. Ethics Committee of the
University Hospital of Split approved this study. All patients with
symptomatic varicocele younger than 18 years of age who were operated
because of varicocele were enrolled in the study. The exclusion criteria
were: patients operated in other institutions and followed-up at our
outpatient clinic, patients with recurrent varicocele who underwent
varicocelectomy before January 2012, and patients with incomplete data
or follow-up shorter than 6 months. Based on approach used for
varicocelectomy, the patients were divided into two groups viz.
laparoscopic and open varicocelectomy.
Dilation of the pampiniform plexus vessels greater
than 2 mm on ultrasound was considered as varicocele. In all the
patients, physical examination, levels of serum LH/FSH, ultrasound of
the testicles, and urinary tract were performed. For patients older than
16 years of age, semen analysis was carried out before treatment.
Varicocele was graded according to Dubin and Ambler’s classification
[10]. Indications for varicocelectomy were testicular atrophy (volume
discrepancy >20%), persistent pain or testicular discomfort, abnormal
semen parameters and elevated serum levels of LH/FSH. The choice of
operating procedure was based on the operating surgeon’s preference.
The primary outcome measures were the treatment
outcomes, the frequency of intraoperative or post-operative
complications, the rate of recurrence, and the sperm quality and count
analysis in 6 months and 1 year postoperatively. The secondary outcome
variables were indications for surgical treatment, duration of surgery,
hospital stay and the rate of reoperations. The intraoperative
complications included access-related complications, such as organ
lesions, thermal damage of intra-abdominal organs, and bleeding.
Postoperative complications included bleeding into the abdominal wall,
wound infection, pain, recurrence and formation of hydrocele.
Open surgical approach: Open high ligation was
done through 3-4 cm incision using muscle splitting abdominal approach.
Testicular vessels were approached extra-peritoneally. Vessels were
double ligated with absorbable sutures (Vycril
Plus 2/0 - polyglactin 910, Ethicon,
Cincinnati, Ohio, USA) and resected. Wound was closed in layers with
same absorbable sutures and skin was closed with non-absorbable sutures
(Premilene 3/0, Braun
Surgical S.A., Rubi, Spain).
Laparoscopic surgical approach: A Veress needle
was introduced below the umbilicus and CO 2
insufflated at pressure of 8-12 mmHg depending on the
patient’s age and body weight. The first trocar was introduced through
the same incision. After exploration of the abdominal cavity, two
additional 5 mm trocars were introduced in the right and left
midclavicular line, 1-2 cm below the horizontal line to the umbilicus,
along the lateral border of each abdominal rectus muscle. After
identification of spermatic vessels and identification of vas deferens
the peritoneum was opened by using laparoscopic scissors in the lateral
aspect from a point 1 cm superior to the internal inguinal ring along
the testicular vessels to expose them. After mobilization of spermatic
vessels, accompanying lymphatic was preserved from the spermatic veins.
Non-absorbable polymeric ligating clips (Click’aV Ligating Clips ML;
Grena Ltd Think Medical, Brentford-London, UK) were used for ligation of
spermatic vessels. Spermatic vessels were resected by using laparoscopic
scissors. The trocars were subsequently removed. Skin incisions were
closed by non-absorbable skin sutures. Data on all complications and/or
recurrences were recorded. Hematoma was treated by haemostatic suture,
wound infections were all treated conservatively and for patients with
consecutive hydrocele a Jabouley-Winckelmann procedure was performed.
All recurrences of varicocele were reoperated by subinguinal approach.
The patients were followed up at our outpatient
clinic at the first and fourth week after surgery for detection of any
complications. Skin sutures were removed during the first week visit.
Follow-up program consisted of physical examination and ultrasound 6
months after surgery to assess testicular size, the presence of late
complications, and persistence or recurrence of the varicocele. Semen
analysis was performed 6 months and 1 year after surgery for patients
older than 16 years of age. Improvement was defined based on primary
indication for surgery: reduction of the testicular volume difference
below 20%; complete recovery of the spermiogram or recovery in at least
in two out of three tested categories (total sperm count, normal sperm
morphology, sperm motility); improvement in hormone status to normal
baseline values and reduction of the pain one month after surgery.
Statistical analysis: The data were analyzed by
using SPSS 24.0 (IBM Corp, Armonk, NY) software. Differences in median
values of quantitative variables between the groups of patients were
tested with Mann–Whitney U test. The chi-square test was used for the
statistical analysis of the categorical data. The difference between
pre- and post-operative seminal data was analyzed by using a paired
Wilcoxon signed-rank test. All values of P<0.05 were considered
to indicate statistical significance.
Results
A total of 537 adolescents, with median age of 15
(IQR 15, 17) years were included in the study. Of that number, 142
(26.5%) were operated laparoscopically and 395 (73.5%) by open approach.
Of the total number of patients, left-sided varicocele was found in 533
patients (99.26%), with majority having grade III varicocele (268,
49.9%). Median (IQR) diameters of veins were 3.3 (3.1, 4.8) mm for all
patients, with no difference between the groups. With that noted, median
diameters of veins in varicocele grades I, II, and III were 2.9, 3.2,
and 4.0 mm, in laparoscopic group and 2.8, 3.1, and 4.0 in open group,
respectively. The hospital stay, operation time, complication rate, and
recurrences were all significantly higher for open varicocelectomy group
as compared those operated laparoscopically (Table I).
TABLE I Baseline Characteristics and Treatment Outcomes of Adolescents with Varicocele (N=437)
Characteristic
|
Laparoscopic |
Open
|
|
varicocelectomy |
varicocelectomy
|
|
(n=142) |
(n=395) |
Lateralization |
Left
|
141 (99.3) |
392 (99.2) |
Bilateral |
1 (0.7) |
3 (0.8) |
Grade |
Grade I |
9 (6.3) |
33 (8.4) |
Grade II |
65 (45.8) |
162 (41) |
Grade III |
68 (47.9) |
200 (50.6) |
Vein diameter (mm)* |
3.4 (3.1-4.8) |
3.2 (2.9-4.8) |
Treatment outcomes
|
Hospital stay (d)* |
1 (1, 1) |
1.3(1, 1) |
Operation time (min)$* |
12 (11, 15.25) |
25 (10, 30) |
Complications# |
3 (2.1) |
32 (81) |
Consecutive hydrocele#
|
2 (1.4) |
27 (6.8) |
Wound hematoma
|
1 (0.7) |
1 (0.3) |
Wound infection |
0 (0) |
4 (1) |
Recurrence# |
0 (0) |
16 (4.1) |
Follow-up (mo)$* |
43(16, 46) |
32 (24, 56) |
Indication for surgery |
Testicular atrophy |
80 (45.2) |
207 (47.9) |
Pathological spermiogram |
41 (23.2) |
87 (20.2) |
Hormonal status disorder |
11 (6.2) |
45 (10.4) |
Subjective discomfort/pain |
45 (25.4) |
93 (21.5) |
All values in n (%) except *median (IQR); $P<0.001;
#P=0.01.
Note: Some patients had more than one indication for surgical
treatment. |
The most frequent recorded indication for surgical
intervention was difference in testicular volume >20% (287, 65.7%) (Table
I). Total of 448 patients (108 in Group I and 340 in Group II) had
one indication for surgical intervention, whilst in 89 patients (34 in
Group I and 55 in Group II) two or more indications for varicocelectomy
were recorded. A total of 35 complications were recorded; 32 in open
group and 3 in laparoscopic group (P=0.01). The most common
complication was consecutive hydrocele (n=29), followed by wound
infection (n=4) and wound hematoma (n=2). From total of 29
hydroceles, 27 were recorded in open group, and only 2 in laparoscopic
group (P=0.014). A total of 16 recurrences were recorded, all in
open varicocelectomy group (P=0.049) (Table I).
Most of the children showed improvement in their
indication for surgery after varicocelectomy. There were no significant
differences between the groups in improvement of tested parameters
regarding surgical technique (Table II).
TABLE II Improvement in Various Outcome Parameters After Varicocele Treatment
|
Laparoscopic
|
Open
|
|
varicocelectomy |
varicocelectomy
|
Parameter |
n (%) |
n (%) |
Spermiogram |
34/41 (83.0) |
71/87 (81.6) |
Pain |
41/45 (91.1) |
84/93 (90.4) |
Testicular atrophy |
71/80 (88.8) |
183/207 (88.4)
|
Elevated LH/FSH |
6/11 (54.6) |
25/45 (55.5) |
All P>0.05 for comparison between laparoscopic and open
surgery; LH: Lutenizing hormone, FSH: Follice stimulating
hormone. |
For laparoscopic varicocelectomy sperm concentration
(P<0.001), morphology (P<0.001), and motility (P=0.001;
P=0.02) improved 6 months after surgery in patients with
varicocele grades of I and II, respectively. However, in grade III
varicocele, only sperm concentration (P=0.002) and morphology (P=0.03)
improved whereas motility (P=0.1) did not change significantly.
For open varicocelectomy sperm concentration (P<0.001),
morphology (P<0.001), and motility (P=0.001; P=0.04)
improved 6 months after surgery in patients with varicocele grades of I
and II, respectively. However, in grade III varicocele, only sperm
concentration (P=0.001) improved, while morphology (P=0.06)
and motility (P=0.2) did not change significantly. There was no
statistically significant difference in tested parameters in two
compared techniques and solely the technique does not affect the final
outcome of the spermiogram (Table III).
TABLE III Treatment Outcomes Due to Changes in Spermiogram Before Treatment and 1 Year After the Surgery
|
Laparoscopic varicocelectomy |
Open varicocelectomy |
|
Before surgery |
12 mo after surgery |
P value |
Before surgery |
12 mo after surgery |
P value |
Total sperm count |
19.05 (16.9, 24.1) |
41.9 (33.8, 45.1) |
0.0001 |
22.6 (17.4, 26.2) |
40.1 (31.8, 44.1) |
0.0001 |
(milions/mL) |
|
|
|
|
|
|
Normal sperm
|
35.8 (34.3, 39.9) |
64.2 (59.8, 69.9) |
0.001 |
35.2 (29.8, 39.5) |
61.9 (48.5, 68.1) |
0.002 |
morphology (%) |
|
|
|
|
|
|
Sperm motility (%) |
31.4 (26.5, 35.4) |
47.6 (38.4, 52) |
0.02 |
32.1(30, 38.3) |
44.8(37.9, 51) |
0.03 |
All values in median (IQR); P>0.05 for comparison between
laparoscopic and open varicocelectomy for all three outcomes. |
Discussion
In this study indications for varicocelectomy,
duration of surgery, complication and recurrence rates as well as the
improvement after surgery between laparoscopic and open varicocelectomy
were retrospectively observed. In majority of the patients from both
groups significant improvement in sperm parameters, testicular volume,
and disappearance of pain was recorded, so we can conclude that both
techniques are equally effective in treatment of varicocele in
adolescents. On the other hand, laparoscopic varicocelectomy showed
benefits in significantly shorter operating time, shorter
hospitalization and faster recovery and has fewer complications and
recurrences rates.
Retrospective character and lack of randomization in
selected operative technique are the main limitations of this study,
although we have implemented multiple plausibility checks and cross
validations in our data collection tool. Further prospective and
randomized studies are needed to confirm results of this study.
The most important issue regarding varicocele in
adolescents is to define true indications for varicocelectomy in that
age group and to filter the patients who really need and would benefit
from surgical treatment [5]. Although there are ethical issues regarding
adolescent sperm analysis, clinicians agree that a spermiogram may be
done in adolescents over the age of 16, because many studies have shown
improvement of sperm quality after varicocelectomy [5,10]. In general,
in adolescent population, varicocelectomy is indicated in cases of
pathological spermiogram, testicular atrophy, elevated FSH/LH and
varicocele associated with persistent pain and discomfort. After
establishing proper indications for surgical treatment the question
remains what technique is superior for the pediatric patients as well as
cost/benefit aspect. The laparoscopic approach for varicocelectomy has
gained popularity, especially in pediatric patients, because of its
minimally invasive nature, safeness and simplicity [11]. The question
remains what is the optimal age for varicocelectomy in adolescents. The
median of age at the time of surgery in our study is in accord with the
data published in the literature, where an average age range is from 15
to 18 years [12,13]. Our data regarding hospital stay after surgery
correlates with various studies where it ranges from 24 to 66 hours for
laparoscopic approach and 26-72 hours in open approach [8-9,14].
In our study, median of operation time for
laparoscopic varicocelectomy was significantly shorter compared to open
technique which is not in accordance with most of the published studies
[6,9,10], although there is another study reporting shorter operative
time in laparoscopic approach [7]. Higher level of skill and training in
laparoscopy of our surgeons can be the cause for shorter operation time
of laparoscopic varicocelectomy in our study. The most significant
complications after varicocelectomy are recurrence of varicocele and the
formation of hydrocele. In our study, no recurrence of varicocele was
observed in laparoscopic group, while in the group operated by open
approach the rate of recurrence was 4.1% as similar to other published
studies [8,14,15]. In our study, the incidence of consecutive hydrocele
in the laparoscopic group was significantly less than in the open group.
In literature an incidence of hydrocele formation after varicocelectomy
is equal or even higher in laparoscopic approach [1,4]. Our results in
favor of laparoscopic approach could be explained by expertise of the
surgeon in laparoscopy as well as careful sparing of lymph vessels
[16-18]. It has been shown that sparing the lymph drainage is associated
with lower incidence of postoperative hydrocele which requires surgical
intervention [16].
Many studies show that both laparoscopic and open
varicocelectomies are equally efficient, although laparoscopic approach
could show advantages in terms of shorter hospital stay, reduced
operation time and faster postoperative recovery with benefit from
greater likelihood of consent to treatment due to better cosmetic
results [8,19,20]. Also better cosmesis and easier treatment by
laparoscopy is in bilateral varicocele where operation can be done
through the same ports, or to perform other procedures simultaneously,
such as inguinal hernia surgery and orhidopexy [8,20]. Spermiogram
findings after varicocelectomies in a long-term follow-up show an
increase in total sperm count, but not the sperm motility [21]. Most of
the published data correlates with our findings which showed no
statistically significant difference between supra-inguinal,
sub-inguinal or inguinal varicocelectomy regarding total count and
motility of sperm in spermiogram and that all operation techniques led
to statistically significant improvement in spermiogram [15,17,22].
Based on our findings laparoscopic and open
varicocelectomy are both equally efficient in treatment of varicocele in
adolescents. Laparoscopic varicocelectomy has significantly lower rate
of postoperative complications and recurrences as well as shorter
operative time in comparison with open approach. Faster recovery and
shorter hospital stay are also noted after laparoscopic approach.
Contributors: MJ: Conceptualized and designed the
study, analyzed data, wrote the paper; MT: Collected the data, helped in
analysis and drafted the manuscript; JT: Hellped collecting the data and
drafted the manuscript; TS: Performed literature review, drafted and
revised manuscript; ZP: Supervised and revised manuscript critically for
important intellectual content and also performed statistical analysis
of the data and wrote results section.
Funding: None; Competing Interest: None
stated.
What Is Already Known?
• Laparoscopic and open varicocelectomy are
equally effective and result in significant improvement of
testicular volume, disappearance of pain, and sperm parameters
in adolescents.
What This Study Adds?
• Laparoscopic varicocelectomy is associated
with significantly shorter operating time, shorter
hospitalization, and has fewer complications and recurrences
rates.
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