Indications

Although clear indications exist for consideration for a varicocelectomy in adults, as outlined by the American Urologic Association (AUA) guidelines, which are mainly based on fertility testing, there is very little guidance for the pediatric patient aside from noting that varicocelectomy may be offered due to testicular size discrepancy [17]. However, these recommendations are nonspecific and are at variance with common clinical practice; when patients present with testicular asymmetry associated with a varicocele, 32% of practitioners intervene immediately despite data indicating that 85% of adolescent males presenting with greater than a 15% testicular size discrepancy will become normal after 2 years of observation [5, 6].

There are noteworthy differences between the pediatric and adult population; most adolescents present asymptomatically (the “bag of worms” finding on routine exam) and without a fertility question, whereas in the adult population fertility evaluations disclose varicoceles in up to 35% of men found to be subfertile [18]. In addition, whereas assessing semen analysis is common in the adult population, only 13.1% of practitioners routinely obtain a semen analysis on adolescents with varicoceles. Furthermore, 48% of practitioners report discomfort discussing this issue with their adolescent patients and parents [19]. These differences highlight the difficulty in managing and knowing when to operate on a pediatric patient.

A closer examination of the question of surgical timing comes from a recent review by Kolon, who advocates for repair of the adolescent varicocele once the child is Tanner stage V and the total testicular volume is low, semen parameters are low, androgen laboratory results are abnormal, or the patient is symptomatic (rare) [2]. However, only 10% of pediatric urologists send semen for analysis at <17 years [5]. Although Kolon’s review puts more weight on persistent abnormal semen analysis focusing on total motility counts (TMC) below 20 million and waiting until the patient reaches at least Tanner V maturity, others have used the testicular volume percent difference (TV_diff) as cut‐off [2]. Diamond et al. found a correlation between a percent volume difference measured via ultrasound of >10% and lower TMC. However, at the 10% cut‐off there would be a considerable number of patients with normal semen parameters. Hence some authors advocate for 20% TV_diff as there was an inverse relationship between TV_diff and TMC [3]. It is worth noting that Christman et al. followed 73 adolescent patients serially for a median of 2.7 years and was not able to reproduce the same finding [20]. They conclude that during adolescence there is too much variability to accurately assess future semen parameters; however, they do note that if the total testicular volume is low there is a significant correlation with low TMC.

Another parameter explored for indication for varicocelectomy is venous backflow. Van Batavia et al. reported that 50 of 53 adolescents with TV_diff of >15% and peak retrograde flow greater than 38 cm/s failed to demonstrate catch‐up growth after mean follow‐up of 15.5 months [21]. These patients may be at risk for future fertility problems. Last, although rare in the adolescent population, pain is a consideration for varicocelectomy.

Anatomy

Each variation of varicocelectomy takes into account the complex vasculature of the testis. Varicoceles develop when the pampiniform plexus experiences increased venous backflow and dilates due to elevated pressures. While the right internal spermatic vein drains directly into the inferior vena cava, the left internal spermatic vein connects to the left renal vein where backflow is higher. Hence, the majority of varicoceles are left sided. Consideration of a retroperitoneal mass or other pathology is indicated when there is a right‐sided varicocele, and although pathology is rare we recommend retroperitoneal imaging when present [22]. Although the pampiniform plexus, eventually becoming the internal spermatic vein, is the main drainage of the testicle, the testicle and epididymis are also drained by the posterior spermatic plexus which flows into the external iliac vein and the cremasteric vein which drains into the pudendal vein. These collaterals allow for venous return following varicocelectomy.

The arterial blood supply to the testis is also complex, with blood coming from three arteries: (i) testicular artery from aorta; (ii) deferential artery from either the superior or inferior vesical artery off the internal iliac; and (iii) cremasteric artery from inferior epigastric artery. Thus, if the testicular artery is sacrificed, as in the Palomo repair, the testicle still receives adequate blood flow. Last, the primary lymphatics channels follow the testicular artery and hence can be confidently spared via a laparoscopic approach.

Surgical procedure

The patient is brought into the operating suite after emptying his bladder. Following induction of general anesthesia, the patient remains in the supine position with his arms tucked. We prefer that both the surgeon and the assistant stand on the contralateral side from the varicocele. If desired, the patient may have a jell roll placed on the ipsilateral side of the varicocele to help keep the bowel away from the operative field (Figure 119.1; see Video 119.1). The required instruments are listed in Box 119.1.

Although this procedure has been reported using a single‐site 20 mm port method, a three‐port approach remains the most common [23, 24]. We place 5 mm trocars in the umbilicus, the right lateral rectus margin approximately 2 cm below the umbilicus and another port just superior to McBurney’s point. This positioning and trocar placement can be mirrored for an isolated right‐sided varicocele. For a bilateral varicocele repair, trocars are placed in the umbilicus, right and left lateral rectus margins approximately 2 cm below the umbilicus. An alternative trochar placement strategy is an umbilical port, one placed at the right lateral rectus margin about 2 cm from the umbilicus, and one placed midline approximately 8 cm below the umbilicus. In this case the camera is transferred from the umbilical trocar to the right lateral trocar when transitioning from operating on the left varicocele to the right side.

Starting at the umbilical site, we evert the umbilicus and make a 5 mm vertical incision using electrocautery down through to the fascia (Figure 119.2). We use a 5 mm VeraStep Veress needle to insufflate with CO₂ at a rate of 3 l/min to a pressure of 10–15 mmHg, depending on the patient’s body habitus. Once adequate pneumoperitoneum is achieved, the needle is exchanged for the 5 mm trocar in the nonslip sheath. A 30° lens is placed through the umbilical trocar and the other two 5 mm trocars are placed under direct vision with careful attention to avoid bowel and the inferior epigastric vessels (Figure 119.3). After inspection of all entry points and adjacent structures to ensure no damage, we look for closed internal rings bilaterally. Slight Trendelenburg position helps to allow the bowel to fall away from the cord. After identifying the spermatic cord and the vas deferens, a Maryland grasper is placed through the superior trocar and scissors in the inferior trocar and an incision is made in the posterior peritoneum over the spermatic cord vessels approximately 5 cm superior to the internal ring (Figure 119.4). Once the cord is isolated for a distance, two 5 mm clips are placed superiorly and two clips inferiorly and the gondal veins is divided (Figure 119.5). In cases where the bundle is wider than the length of a clip, the clips are applied and the cord is partially transected and then another series of clips are applied to complete occlusion of the cord both proximally and distally and the cord severed. After inspecting for hemostasis the clips are then tucked under the peritoneum to avoid contact with the bowel (Figure 119.6

Related posts:

1: Perioperative Considerations Radiation Safety During Diagnosis and Treatment Cryotherapy of the Prostate Bipolar Vaporization of the Prostate Laparoscopic Applications to Renal Calculus Disease Pelvic Lymphadenectomy

Stay updated, free articles. Join our Telegram channel

Join