Abstract:: The ideal method for varicocelectomy in children remains controversial. We present our experience with dye-assisted lymphatic-sparing laparoscopic varicocelectomy (LSLV) in children, which overcomes the limitations of previously described techniques. Materials and methods : Five consecutive LSLVs were performed over a period of three years on children with a mean age of twelve years. The varicocele grade was three in one case and grade 2 in four cases, respectively. A left subdartos injection of 2 ml of Indi… Show more
“…The procedure is facilitated by the magnifying effect of the laparoscopic lens, which allows for excellent visualization of the structures of the vascular bundle. To achieve better visualization of the lymphatics, recent findings have shown that intra-dartos/intra-testicular injection of isosulfan blue is significantly better than the previously described intra-dartos injection, thereby allowing identification of lymphatic vessels in 100% of the cases in our series [43][44][45][46].…”
At present, treatment of varicocele is still controversial in adolescents for at least three reasons. Firstly, the long-term outcome of treatment is not known in the absence of spermiogram support and in terms of long-term follow-up. Secondly, it is still uncertain which is the best type of operation for children/adolescents. Thirdly, the principle that if a technique is designed for adults, it can also be safely performed in adolescents cannot be applied. A recent systematic literature review and meta-analysis demonstrated that open and laparoscopic techniques appear to yield better results with a microsurgical approach compared with laparoscopy. However, laparoscopic techniques that preserve the lymphatic vessels appear to have a clear advantage by preventing postoperative hydrocele. At present, the evaluation and choice of treatment for adolescent varicocele patients are based not on objective fertility criteria (paternity) but on indirect evidence that testicular function or spermatogenesis and thus ultimately also fertility may be compromised. In the absence of sufficient data regarding the treatment of varicocele at a pediatric age, the choice of the technique appears to depend largely on the experience and preferences of the surgeon rather than on a shared option.
“…The procedure is facilitated by the magnifying effect of the laparoscopic lens, which allows for excellent visualization of the structures of the vascular bundle. To achieve better visualization of the lymphatics, recent findings have shown that intra-dartos/intra-testicular injection of isosulfan blue is significantly better than the previously described intra-dartos injection, thereby allowing identification of lymphatic vessels in 100% of the cases in our series [43][44][45][46].…”
At present, treatment of varicocele is still controversial in adolescents for at least three reasons. Firstly, the long-term outcome of treatment is not known in the absence of spermiogram support and in terms of long-term follow-up. Secondly, it is still uncertain which is the best type of operation for children/adolescents. Thirdly, the principle that if a technique is designed for adults, it can also be safely performed in adolescents cannot be applied. A recent systematic literature review and meta-analysis demonstrated that open and laparoscopic techniques appear to yield better results with a microsurgical approach compared with laparoscopy. However, laparoscopic techniques that preserve the lymphatic vessels appear to have a clear advantage by preventing postoperative hydrocele. At present, the evaluation and choice of treatment for adolescent varicocele patients are based not on objective fertility criteria (paternity) but on indirect evidence that testicular function or spermatogenesis and thus ultimately also fertility may be compromised. In the absence of sufficient data regarding the treatment of varicocele at a pediatric age, the choice of the technique appears to depend largely on the experience and preferences of the surgeon rather than on a shared option.
“…Methylene blue was avoided because this dye may cause local tissue reactions. Ishibashi et al (23) used Indigo carmine because there has been extensive experience with this dye in cases of lymphatic mapping and sentinel node identification in cases of breast cancer. If 1-2 lymphatic channels were preserved during a varicocelectomy, there were no postoperative hydroceles.…”
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.
“…Ishibashi et al . 82 used Indigo carmine because there has been extensive experience with this dye in cases of lymphatic mapping and sentinel node identification in cases of breast cancer. If 1–2 lymphatic channels were preserved during a varicocelectomy, there were no postoperative hydroceles.…”
Varicoceles had been recognized in clinical practice for over a century. Originally, these procedures were utilized for the management of pain but, since 1952, the repairs had been mostly for the treatment of male infertility. However, the diagnosis and treatment of varicoceles were controversial, because the pathophysiology was not clear, the entry criteria of the studies varied among centers, and there were few randomized clinical trials. Nevertheless, clinicians continued developing techniques for the correction of varicoceles, basic scientists continued investigations on the pathophysiology of varicoceles, and new outcome data from prospective randomized trials have appeared in the world's literature. Therefore, this special edition of the Asian Journal of Andrology was proposed to report much of the new information related to varicoceles and, as a specific part of this project, the present article was developed as a comprehensive review of the evolution and refinements of the corrective procedures.
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