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Esposito C, Leva E, Castagnetti M, Cerulo M, Cardarelli M, Del Conte F, Esposito G, Chiodi A, Chiarenza M, Di Mento C, Escolino M. Robotic-assisted versus conventional laparoscopic ICG-fluorescence lymphatic-sparing palomo varicocelectomy: a comparative retrospective study of techniques and outcomes. World J Urol 2024; 42:215. [PMID: 38581596 PMCID: PMC10998803 DOI: 10.1007/s00345-024-04909-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 02/26/2024] [Indexed: 04/08/2024] Open
Abstract
PURPOSE This study aimed to compare techniques and outcomes of robotic-assisted varicocelectomy (RAV) and laparoscopic varicocelectomy (LV). METHODS The medical records of 40 patients, who received RAV and LV over a 2-year period, were retrospectively analyzed. Palomo lymphatic-sparing varicocelectomy using ICG fluorescence was adopted in all cases. Three 5-mm trocars were placed in LV, whereas four ports, three 8-mm and one 5-mm, were placed in RAV. The spermatic vessels were ligated using clips in LV and ligatures in RAV. The two groups were compared regarding patient baseline and operative outcomes. RESULTS All patients, with median age of 14 years (range 11-17), had left grade 3 varicocele according to Dubin-Amelar. All were symptomatic and 33/40 (82.5%) presented left testicular hypotrophy. All procedures were completed without conversion. The average operative time was significantly shorter in LV [20 min (range 11-30)] than in RAV [34.5 min (range 30-46)] (p = 0.001). No significant differences regarding analgesic requirement and hospitalization were observed (p = 0.55). At long-term follow-up (30 months), no complications occurred in both groups. The cosmetic outcome was significantly better in LV than RAV at 6-month and 12-month evaluations (p = 0.001). The total cost was significantly lower in LV (1.587,07 €) compared to RAV (5.650,31 €) (p = 0.001). CONCLUSION RAV can be safely and effectively performed in pediatric patients, with the same excellent outcomes as conventional laparoscopic procedure. Laparoscopy has the advantages of faster surgery, smaller instruments, better cosmesis and lower cost than robotics. To date, laparoscopy remains preferable to robotics to treat pediatric varicocele.
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Affiliation(s)
- Ciro Esposito
- Pediatric Surgery Unit, Federico II University Hospital, Via Pansini 5, 80131, Naples, Italy
| | - Ernesto Leva
- Pediatric Surgery Unit, Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Mariapina Cerulo
- Pediatric Surgery Unit, Federico II University Hospital, Via Pansini 5, 80131, Naples, Italy
| | - Mery Cardarelli
- Pediatric Surgery Unit, Ospedale Maggiore Policlinico, Milan, Italy
| | - Fulvia Del Conte
- Pediatric Surgery Unit, Federico II University Hospital, Via Pansini 5, 80131, Naples, Italy
| | | | - Annalisa Chiodi
- Pediatric Surgery Unit, Federico II University Hospital, Via Pansini 5, 80131, Naples, Italy
| | | | - Claudia Di Mento
- Pediatric Surgery Unit, Federico II University Hospital, Via Pansini 5, 80131, Naples, Italy
| | - Maria Escolino
- Pediatric Surgery Unit, Federico II University Hospital, Via Pansini 5, 80131, Naples, Italy.
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Esposito C, Borgogni R, Chiodi A, Cerulo M, Autorino G, Esposito G, Coppola V, Del Conte F, Di Mento C, Escolino M. 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. J Pediatr Urol 2024; 20:282.e1-282.e6. [PMID: 38061982 DOI: 10.1016/j.jpurol.2023.11.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 10/11/2023] [Accepted: 11/18/2023] [Indexed: 04/22/2024]
Abstract
BACKGROUND 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. OBJECTIVE The study aimed to assess the safety and efficacy of this procedure at mid-term follow-up. STUDY DESIGN 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. RESULTS 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 in 3/72 (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. DISCUSSION 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 markers were 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. CONCLUSION Laparoscopic Palomo varicocelectomy using ICG-FL reported excellent outcomes with low incidence of varicocele persistence and no post-operative hydrocele. These preliminary data also confirmed safety of intratesticular injection of ICG at mid-term follow-up, without specific risks for both testis and patient.
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Affiliation(s)
- Ciro Esposito
- Division of Pediatric Surgery, Federico II University Hospital, Naples, Italy.
| | - Rachele Borgogni
- Division of Pediatric Surgery, Federico II University Hospital, Naples, Italy
| | - Annalisa Chiodi
- Division of Pediatric Surgery, Federico II University Hospital, Naples, Italy
| | - Mariapina Cerulo
- Division of Pediatric Surgery, Federico II University Hospital, Naples, Italy
| | - Giuseppe Autorino
- Division of Pediatric Surgery, Federico II University Hospital, Naples, Italy
| | | | - Vincenzo Coppola
- Division of Pediatric Surgery, Federico II University Hospital, Naples, Italy
| | - Fulvia Del Conte
- Division of Pediatric Surgery, Federico II University Hospital, Naples, Italy
| | - Claudia Di Mento
- Division of Pediatric Surgery, Federico II University Hospital, Naples, Italy
| | - Maria Escolino
- Division of Pediatric Surgery, Federico II University Hospital, Naples, Italy
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Tandon S, Bennett D, Mark Nataraja R, Pacilli M. Outcome following the surgical management of varicocele in children and adolescents: a systematic review and meta-analysis. Ther Adv Urol 2023; 15:17562872231206239. [PMID: 37868369 PMCID: PMC10590051 DOI: 10.1177/17562872231206239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 09/19/2023] [Indexed: 10/24/2023] Open
Abstract
Background The ideal surgical approach for the management of varicocele in children and adolescents remains controversial. Several techniques are available including artery- or lymphatic-sparing with optical magnification (via open inguinal or sub-inguinal approach), laparoscopic, antegrade and retrograde embolization/sclerotherapy. Objectives We aimed to appraise the clinical outcomes of these techniques in children and adolescents. Data Sources and Methods A systematic review was conducted (1997-2023). Meta-analysis or proportional meta-analysis for non-comparative studies (Freeman-Tukey transformation) using the random effects model was conducted. Results are expressed as overall proportion % and 95% confidence interval (CI). Results We identified 1910 studies; 632 duplicates were removed, 1278 were screened, 203 were reviewed and 56 were included, with 12 reporting on 2 different techniques (total of 68 data sets). Optical magnification via inguinal approach (498 cases): recurrence 2.5% (0.6-5.6), hydrocele 1.6% (0.47-3.4), testicular atrophy 1% (0.3-2.0), complications 1.1% (0.2-2.6); optical magnification via sub-inguinal approach (592 cases): recurrence 2.1% (0.7-4.4), hydrocele 1.26% (0.5-2.3), testicular atrophy 0.5% (0.1-1.3), complications 4% (1.0-8.8). Laparoscopic with mass-ligation/division (1943 cases): recurrence 2.9% (1.5-4.6), hydrocele 11.4% (8.3-14.9); complications 1.5% (0.6-2.9); laparoscopic with lymphatic-sparing (974 cases): recurrence 2.4% (1.5-3.5), hydrocele 1.2% (0.45-3.36), complications 1.2% (0.05-3.9); laparoscopic with artery-sparing (228 cases): recurrence 6.6% (2.3-12.9), hydrocele 6.5% (2.6-12.0). Antegrade embolization/sclerotherapy (403 cases): recurrence 7.6% (5.2-10.4), hydrocele 0.8% (0.17-1.9), technical failure 0.6% (0.1-1.6), complications 4.0% (2.3-6.1); retrograde embolization/sclerotherapy (509 cases): recurrence 6.9% (4.6-9.5), hydrocele 0.8% (0.05-2.5), technical failure 10.2% (4.6-17.6), and complications 4.8% (1.0-11.2). Conclusion The recurrence rate varies between 2.1% and 7.6% and is higher with the embolization/sclerotherapy techniques. Post-operative hydrocele rate varies between 0.8% and 11.4% and is higher with the laparoscopic mass-ligation/division technique. Testicular atrophy has not been reported with the laparoscopic and embolization/sclerotherapy techniques. The retrograde embolization technique is associated with 10% technical failure (inability to complete the procedure). The laparoscopic lymphatic-sparing technique is characterized by the lowest recurrence rate, incidence of hydrocele and other complications, and no reports of testicular atrophy.
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Affiliation(s)
- Sarthak Tandon
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Australia
| | - Daniel Bennett
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Australia
| | - Ramesh Mark Nataraja
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Australia
- Department of Paediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Department of Surgery, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Maurizio Pacilli
- Department of Paediatric Surgery, Level 5, Monash Children's Hospital, 246 Clayton Road, Clayton, VIC 3168, Australia
- Department of Paediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Department of Surgery, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
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Cho C, Chiu PK, Chu RW. Preliminary experience with indocyanine green lymphography during microsurgical subinguinal varicocelectomy. SURGICAL PRACTICE 2021. [DOI: 10.1111/1744-1633.12529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Chak‐Lam Cho
- S.H. Ho Urology Centre, Department of Surgery The Chinese University of Hong Kong Hong Kong
- Department of Surgery Union Hospital Hong Kong
| | - Peter Ka‐Fung Chiu
- S.H. Ho Urology Centre, Department of Surgery The Chinese University of Hong Kong Hong Kong
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Soares-Aquino C, Vasconcelos-Castro S, Campos JM, Soares-Oliveira M. 15-Year varicocelectomy outcomes in pediatric age: Beware of genitofemoral nerve injury. J Pediatr Urol 2021; 17:537.e1-537.e5. [PMID: 34099399 DOI: 10.1016/j.jpurol.2021.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 04/18/2021] [Accepted: 05/09/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Varicocele affects 15% of adolescents. The main postoperative complications are recurrence and hydrocele; nerve injury is rarely reported. OBJECTIVE The aims of this study are: to assess the complications after laparoscopic varicocelectomy, namely nerve injury; and to assess if nerve injury is more frequent using "hot" or "cold" ligation. STUDY DESIGN Retrospective study of varicocele cases submitted to laparoscopic correction in our department from April 2006 to March 2020. Parameters analyzed were: age, clinical findings, surgical indication, operative technique, and outcomes. Comparison was done between the "cold" versus "hot" vessel section technique. RESULTS 110 patients, with median age 14-years-old, were included. Most cases were on the left side and grade 3. Fifty patients (45%) presented complications: 21% recurrence; 18% hydrocele; and 3% genitofemoral nerve injury. Nerve injury was independent of the technique used. DISCUSSION Genitofemoral nerve injury is a complication with unknown cause and all cases are related to laparoscopic technique. It was suggested that "hot" methods of ligation of the vessels can lead to higher incidence of the lesion, but that was not corroborated in our analysis. Possible explanations for its occurrence are: a wide peritoneal window opening created with electrocautery near the internal inguinal ring; and additional dissection required to isolate the testicular veins from the artery. Prospective studies are needed to clarify the real incidence of genitofemoral nerve injury and its causes. CONCLUSIONS Laparoscopic varicocelectomy seems to be safe and effective, although complications remain frequent regardless of the technique used. Genitofemoral nerve injury is a complication rarely described that may require rehabilitation, and so awareness for this problem is of paramount importance.
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Affiliation(s)
- Carolina Soares-Aquino
- Department of Pediatric Surgery, Centro Hospitalar Universitário São João, Alameda Professor Hernâni Monteiro, Porto, 4200-319, Portugal.
| | - Sofia Vasconcelos-Castro
- Department of Pediatric Surgery, Centro Hospitalar Universitário São João, Alameda Professor Hernâni Monteiro, Porto, 4200-319, Portugal
| | - José Miguel Campos
- Department of Pediatric Surgery, Centro Hospitalar Universitário São João, Alameda Professor Hernâni Monteiro, Porto, 4200-319, Portugal
| | - Miguel Soares-Oliveira
- Department of Pediatric Surgery, Centro Hospitalar Universitário São João, Alameda Professor Hernâni Monteiro, Porto, 4200-319, Portugal; Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, Porto, 4200-319, Portugal
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Abstract
Varicocele is defined as an abnormal dilation and tortuosity of the internal spermatic veins found within the pampiniform plexus. It is a common finding in adolescents and adult men alike, however its diagnosis in the adolescent population poses different dilemmas in regard to indications for treatment than in adults. Failed Paternity is a clear-cut indication for repair in adult men attempting to father children. In adolescents, the physicians, family and patients must consider potential for future fertility problems which may or may not actually become of concern. Assessing the degree of negative effect of the varicocele on an adolescent's testicular health can also be difficult as teenagers typically are not asked to provide semen for analysis and thus surrogate markers for testicular health such as testicular size differentials must be used. Treatment options for the adolescent varicocele are similar to options in adult populations. While risks and benefits of various techniques can be considered, the gold standard for varicocele repair in adolescents has not been clearly defined. We aim to discuss diagnosis of varicocele, considerations for initiating treatment of varicocele in the adolescent, and techniques for management.
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Affiliation(s)
- Sabine Zundel
- Pediatric Surgery, Children's Hospital Lucerne, 6000 Lucerne 16, Switzerland.
| | - Philipp Szavay
- Pediatric Surgery, Children's Hospital Lucerne, 6000 Lucerne 16, Switzerland
| | - Irina Stanasel
- Pediatric Urology, Children's Health UT Southwestern Medical Center, Dallas, TX, United States
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Esposito C, Turrà F, Del Conte F, Izzo S, Gargiulo F, Farina A, Severino G, Cerulo M, Escolino M. Indocyanine Green Fluorescence Lymphography: A New Technique to Perform Lymphatic Sparing Laparoscopic Palomo Varicocelectomy in Children. J Laparoendosc Adv Surg Tech A 2019; 29:564-567. [DOI: 10.1089/lap.2018.0624] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ciro Esposito
- Pediatric Surgery Unit, “Federico II” University of Naples, Naples, Italy
| | - Francesco Turrà
- Pediatric Surgery Unit, “Federico II” University of Naples, Naples, Italy
| | - Fulvia Del Conte
- Pediatric Surgery Unit, “Federico II” University of Naples, Naples, Italy
| | - Serena Izzo
- Pediatric Surgery Unit, “Federico II” University of Naples, Naples, Italy
| | - Francesca Gargiulo
- Pediatric Surgery Unit, “Federico II” University of Naples, Naples, Italy
| | - Alessandra Farina
- Pediatric Surgery Unit, “Federico II” University of Naples, Naples, Italy
| | - Giovanni Severino
- Pediatric Surgery Unit, “Federico II” University of Naples, Naples, Italy
| | - Mariapina Cerulo
- Pediatric Surgery Unit, “Federico II” University of Naples, Naples, Italy
| | - Maria Escolino
- Pediatric Surgery Unit, “Federico II” University of Naples, Naples, Italy
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Silay MS, Hoen L, Quadackaers J, Undre S, Bogaert G, Dogan HS, Kocvara R, Nijman RJM, Radmayr C, Tekgul S, Stein R. Treatment of Varicocele in Children and Adolescents: A Systematic Review and Meta-analysis from the European Association of Urology/European Society for Paediatric Urology Guidelines Panel. Eur Urol 2018; 75:448-461. [PMID: 30316583 DOI: 10.1016/j.eururo.2018.09.042] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 09/24/2018] [Indexed: 11/30/2022]
Abstract
CONTEXT The benefits and harms of intervention (surgical or radiological) versus observation in children and adolescents with varicocele are controversial. OBJECTIVE To systematically evaluate the evidence regarding the short- and long-term outcomes of varicocele treatment in children and adolescents. EVIDENCE ACQUISITION A systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. A priori protocol was registered to PROSPERO (CRD42018084871), and a literature search was performed for all relevant publications published from January 1980 until June 2017. Randomized controlled trials (RCTs), nonrandomized comparative studies (NRSs), and single-arm case series including a minimum of 50 participants were eligible for inclusion. EVIDENCE SYNTHESIS Of 1550 articles identified, 98 articles including 16 130 patients (7-21 yr old) were eligible for inclusion (12 RCTs, 47 NRSs, and 39 case series). Varicocele treatment improved testicular volume (mean difference 1.52ml, 95% confidence interval [CI] 0.73-2.31) and increased total sperm concentration (mean difference 25.54, 95% CI 12.84-38.25) when compared with observation. Open surgery and laparoscopy may have similar treatment success. A significant decrease in hydrocele formation was observed in lymphatic sparing versus non-lymphatic sparing surgery (p=0.02). Our findings are limited by the heterogeneity of the published data, and a lack of long-term outcomes demonstrating sperm parameters and paternity rates. CONCLUSIONS Moderate evidence exists on the benefits of varicocele treatment in children and adolescents in terms of testicular volume and sperm concentration. Current evidence does not demonstrate superiority of any of the surgical/interventional techniques regarding treatment success. Long-term outcomes including paternity and fertility still remain unknown. PATIENT SUMMARY In this paper, we review benefits and harms of varicocele treatment in children and adolescents. We found moderate evidence that varicocele treatment results in improvement of testicular volume and sperm concentration. Lymphatic sparing surgery decreases hydrocele formation. Paternity and fertility outcomes are not clear.
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Affiliation(s)
- Mesrur Selcuk Silay
- Division of Pediatric Urology, Department of Urology, Istanbul Medeniyet University, Istanbul, Turkey.
| | - Lisette Hoen
- Department of Urology, Erasmus MC, Rotterdam, The Netherlands
| | - Josine Quadackaers
- Department of Urology and Pediatric Urology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Shabnam Undre
- Department of Pediatric and Adult Urology, East and North Herts NHS Trust, Stevenage, UK
| | - Guy Bogaert
- Department of Urology, University of Leuven, Leuven, Belgium
| | - Hasan Serkan Dogan
- Division of Pediatric Urology, Department of Urology, Hacettepe University, Ankara, Turkey
| | - Radim Kocvara
- Department of Urology, General Teaching Hospital and Charles University 1st Faculty of Medicine in Praha, Prague, Czech Republic
| | - Rien J M Nijman
- Department of Urology and Pediatric Urology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Christian Radmayr
- Department of Urology, Medical University of Innsbruck, Innsbruck, Austria
| | - Serdar Tekgul
- Division of Pediatric Urology, Department of Urology, Hacettepe University, Ankara, Turkey
| | - Raimund Stein
- Department of Pediatric, Adolescent and Reconstructive Urology, University of Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Marte A. The history of varicocele: from antiquity to the modern ERA. Int Braz J Urol 2018; 44:563-576. [PMID: 29570260 PMCID: PMC5996787 DOI: 10.1590/s1677-5538.ibju.2017.0386] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 01/22/2018] [Indexed: 11/22/2022] Open
Abstract
Men have most likely been affected by varicocele since the assumption of the upright position. In De Medicina, written during the first century AD, Celsus credits the Greeks with the first description of a varicocele, and he recorded his own acute observation: “The veins are swollen and twisted over the testicle, which becomes smaller”. Celsus himself is credited with the distinction between varicocele (dilation of surface veins) and “cirsocele” (dilation of deep veins). There has been a long history of treatment attempts and failures, some of which are remarkably strange, that have sometimes cul- minated in tragedy, as in the case of French professor Jacques-Mathieu Delpech (1772-1832). Although some questions regarding the etiopathology and treatment of varico- cele remain unanswered, a succession of more or less conservative attempts involving all medical cultures has been performed throughout history. The report by W.S. Tulloch in 1952 brought varicocele into the era of modern evidence-based medicine, and varicocele surgery finally progressed beyond the aim of merely relieving scrotal pain and swelling. From 1970 to 2000, varicocelectomies gained worldwide attention for the treatment of male infertility. Several innovative procedures to correct varicoceles began to appear in the world's literature as interventional radiology, microsurgery, laparoscopy, and robotics, while comprehensive review articles were also published on the subject of varicocelectomies. Microsurgery is nowadays used worldwide and it can be considered to be the gold standard for correcting infertility linked to varicocele.
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Affiliation(s)
- Antonio Marte
- Unità di Chirurgia Pediatrica, Università della Campania - Luigi Vanvitelli, Napoli, Italia
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Zundel S, Szavay P, Hacker HW, Shavit S. Adolescent varicocele: Efficacy of indication-to-treat protocol and proposal of a grading system for postoperative hydroceles. J Pediatr Urol 2018; 14:152.e1-152.e6. [PMID: 29477693 DOI: 10.1016/j.jpurol.2017.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 12/09/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Varicocele is a common urologic anomaly in adolescent males; however, evidence-based treatment guidelines do not exist. Hydroceles are known to be a common complication after surgical therapy, with a wide variation in the reported incidence between 1 and 40%. AIM This study aimed to introduce a standardized indication-to-treat protocol and prove its efficacy by analyzing the outcome of patients. Secondly, it aimed to better define postoperative hydroceles because the wide variation of reported incidence is attributed to a lack of definition. METHODS Our standardized treatment protocol included an initial assessment with clinical grading of varicoceles, ultrasound evaluation of testicular volume, and calculation of the atrophy index. Indications for surgical treatment were testicular volume asymmetry >20%, discomfort and pain, or bilateral varicocele. The Palomo procedure (laparoscopically since 2005) was the standard procedure. Postoperative hydroceles were graded according to clinical findings and symptoms: Grade I, sonographic chance finding without clinical correlate; Grade II, palpable but clinically insignificant; Grade III, symptomatic. All patients treated according to the defined protocol were prospectively monitored between January 2001 and December 2015. RESULTS A total of 129 patients with left varicocele were referred to our institution; 70 fulfilled the indication criteria for surgical treatment. Twenty-eight of these patients were treated for volume asymmetry, 26 of these showed catch-up growth. Forty-two patients were treated for discomfort and pain; the symptoms subsided in all of them. Postoperative hydroceles were detected in 36 patients (51%). In 29 patients this was a sonographic chance finding (Grade I). Three patients showed a palpable but clinically insignificant postoperative hydrocele (Grade II) and four patients (5.7%) showed symptomatic hydrocele (Grade III) where treatment was recommended. DISCUSSION The treatment protocol allowed judicious indication for surgery and postoperative outcomes similar to previous reports. The high rate of catch-up growth in operated cases represents a proxy for successful treatment in cases where more precise parameters, like semen quality or paternity rate, were not yet detectable. The introduced grading system for postoperative hydroceles provs to be a valid and appropriate instrument, and promises to be a standardized method for comparing outcomes in future studies. CONCLUSION The indication-to-treat protocol proved to be easily applicable, highly efficient, and have outcomes comparable to international literature. The necessity for a standardized grading of postoperative hydroceles was underscored in the data.
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Affiliation(s)
- S Zundel
- Department of Pediatric Surgery, Children's Hospital, Lucerne, Switzerland.
| | - P Szavay
- Department of Pediatric Surgery, Children's Hospital, Lucerne, Switzerland
| | - H-W Hacker
- Department of Pediatric Surgery, Children's Hospital, Lucerne, Switzerland
| | - S Shavit
- Department of Pediatric Surgery, Children's Hospital, Lucerne, Switzerland
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Esposito C, Escolino M, Castagnetti M, Cerulo M, Settimi A, Cortese G, Turrà F, Iannazzone M, Izzo S, Servillo G. Two decades of experience with laparoscopic varicocele repair in children: Standardizing the technique. J Pediatr Urol 2018; 14:10.e1-10.e7. [PMID: 28807743 DOI: 10.1016/j.jpurol.2017.06.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 06/28/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Controversy still exists about the indications and the gold standard approach for varicocele treatment in pediatric population. OBJECTIVE The authors report their 23 years of experience in laparoscopic varicocele repair in the pediatric population. STUDY DESIGN 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. RESULTS All procedures were completed in laparoscopy (Figure), without conversions or intraoperative complications. The average operative time was 17 min (range 14-45) for the Palomo procedure and 26 min (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. DISCUSSION 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. CONCLUSION 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.
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Affiliation(s)
- Ciro Esposito
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy.
| | - Maria Escolino
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
| | | | - Mariapina Cerulo
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
| | - Alessandro Settimi
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
| | - Giuseppe Cortese
- Department of Anesthesiology, Federico II University of Naples, Naples, Italy
| | - Francesco Turrà
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
| | - Marta Iannazzone
- Department of Anesthesiology, Federico II University of Naples, Naples, Italy
| | - Serena Izzo
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
| | - Giuseppe Servillo
- Department of Anesthesiology, Federico II University of Naples, Naples, Italy
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Parrilli A, Roberti A, Escolino M, Esposito C. Surgical approaches for varicocele in pediatric patient. Transl Pediatr 2016; 5:227-232. [PMID: 27867844 PMCID: PMC5107384 DOI: 10.21037/tp.2016.09.11] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Alejandra Parrilli
- Department of Pediatric Surgery, University of Caracas, Caracas, Venezuela
| | - Agnese Roberti
- Department of Translational Medical Sciences, Pediatric Surgery, Federico II University of Naples, Via Pansini 5, 80131 Naples, Italy
| | - Maria Escolino
- Department of Translational Medical Sciences, Pediatric Surgery, Federico II University of Naples, Via Pansini 5, 80131 Naples, Italy
| | - Ciro Esposito
- Department of Translational Medical Sciences, Pediatric Surgery, Federico II University of Naples, Via Pansini 5, 80131 Naples, Italy
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Yu W, Rao T, Ruan Y, Yuan R, Cheng F. Laparoscopic Varicocelectomy in Adolescents: Artery Ligation and Artery Preservation. Urology 2016; 89:150-4. [DOI: 10.1016/j.urology.2015.11.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 11/06/2015] [Accepted: 11/27/2015] [Indexed: 11/17/2022]
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