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

Summary
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 8e17). 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 14e45) for the
Palomo procedure and 26 min (range 18e50) for arterysparing
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.