Laparoscopic staple interruption versus laparoscopic varicocelectomy for the treatment of varicocele value and effect: A comparative study

Laparoscopic staple interruption versus laparoscopic varicocelectomy for the treatment of varicocele value and effect: A comparative study

Ghada Morshed, MD,MRCS; Hany Habashy, MD Department of Surgery, El-Fayoum University Hospital,  Fayoum, Egypt.

Abstract

Background: Varicocele is an abnormal  dilation of the pampiniform plexus that constitutes the primary drainage of the testis. It is found approximately in 15% of male adolescents with a left sided predominance. Laparoscopic varicocelectomy has been proposed as an alternative surgical procedure for the repair of varicocele with reported benefits of better convalescence, minimal invasiveness and less analgesic requirement postoperatively

Patients and methods: The study was done in ElFayoum UniversityHospitalfromNovember

2011 till November 2012 and it included twenty cases with varicocele. The patients were divided into two groups: The first group (10 patients) was subjected to laparoscopic staple interruption for treatment of varicocele  with cutting  the gonadal  vein or veins in between the clips, the second group (10 patients) was subjected to laparoscopic staple interruption  for treatment of varicocele without cutting inbetween the clips.

Results: All the procedures in the two groups were completed satisfactorily, with no intraoperative complications. No significant difference was found in the operative time between the two groups (25.5±3.12minutes  and 26.2±4.23 minutes for group I and II respectively) (p=0.889). Most  patients in the two groups had moderate pain, with no significant difference between  the two groups  (p=0.801).  The hospital  stay was not significantly  different  among the patients of the two study groups (1.7±0.82  days in group  I and 1.5±0.68  days in group II) (p=0.870).  There were no post operative complications,  only one patient in the 2nd group experienced recurrence symptoms of varicocele.

Conclusion:  In conclusion,  laparoscopic  staple  interruption  for treatment  of  varicocele without  cutting  inbetween   the  clips  is  more  superior  to  traditional  laparoscopic   staple interruption with cutting the gonadal vein or veins inbetween the clips for treatment of varicocele regarding the lower risk to cut the vas deference or spermatic artery. The spermatic count was the same as well as the spermatic motility and abnormal forms.

Key words:  Varicocele, laparoscopic varicocelectomy, semen analysis, Palomo's operation.

Introduction:

Varicoceles have been associated with progressive deterioration oftesticular function and testicular hypotrophy.!,2 Varicocele repair can  halt  or  even  reverse  this  progression.3

Over recent decades, varicocelectomy has developed with numerous approaches: microsurgical  subinguinal  (Goldstein), inguinal (Ivanissevich), and abdominal (Palomo,  non  artery  sparing).   Advantages of   laparoscopic   varicocelectomy    include:

increased   magnification,   facilitating   more accurate  identification   of  vessels,  such  as spermatic collateral veins, (i.e. veins running along side the  spermatic  cord  and together entering  the  internal  ring,  a possible  cause of recurrence  if left alone), lymphatics  (the ligation   of  which   can   lead  to   hydrocele formation) and the internal spermatic artery.4,5

Moreover,  laparoscopic  varicocelectomy   is safe even after prior inguinal surgery. The characteristic   supra-inguinal   access  allows

for   high  ligation   of  fewer   vems  vs.  the subinguinal approach.

Aim of the study:

To compare the outcome including operative time, semen analysis, and complications  between laparoscopic staple interruption for treatment  of varicocele  with cutting  the  gonadal vein or veins inbetween the clips and  only  application  of  the clips without  cutting  inbetween  the clips

Patients and  methods:

The  present  study  involved  20  patients with symptomatic varicocele. These patients presented to Fayoum University Hospital outpatient clinic. They were subjected to clinical examination, pre-operative routine investigations,  and  pre-operative  scrotal duplex. Clinical assessment included age, marital status, and history of having children, special habits of medical importance, complaint, urologic symptoms and local examination findings.

Preoperative assessment included:

1-  Routine  investigations   including  semen analysis.

2- Duplex study to determine the presence of reflux and the size of the spermatic veins. These  patients  were  randomly  allocated into two groups depending on the procedure

to be done:

Group A:    10 patients included post pubertal adolescents to be subjected to laparoscopic staple interruption for treatment of varicocele with cutting the gonadal vein or veins inbetween the clips. Four of them had bilateral varicoceles.

Group B: 10 patients included postpubertal adolescents to be subjected to laparoscopic staple interruption for treatment of varicocele without cutting inbetween the clips. Three of them had bilateral varicoceles.

1-  Group A  (laparoscopic staple interruption for treatment of varicocele with cutting the gonadal vein or veins inbetween the clips)

All patients were subjected to general anesthesia  with  endo-tracheal  intubation. They   were   placed   in   the   Trendlenburg

pos1t10n. Trans-peritoneal  approach  was carried out which consisted of induction of pneumo-peritoneum by insufflation of C02 through  an open technique through  a supra­ umbilical   mini-incision.   As   the   pressure intra-abdominally reached 14mmHg, a safety

10-mm trocar sheath unit was introduced through the same incision. Pressure was then established   at   12-14mmHg.   Through  that port, a 0-degree scope was inserted and the abdominal  cavity  inspected.   Two  working ports were further  introduced  at a level just caudal  to  the  umbilicus  and  lateral  to  the rectus muscle of both right and left lower quadrants. One of them was of 5-mm caliber and  the  other  was  of  10-mm  caliber.  This array of trocars was used in either left or bilateral cases.

T-shaped  peritoneal   incision   was  made to provide ample exposure for access to the spermatic   vascular   bundle   just   cephalad to  the  internal  inguinal  ring.  Freeing  the entire spermatic vascular bundle from the surroundings was done. The spermatic artery was identified and isolated in an attempt for its preservation. The internal spermatic vein was  individually  clipped  and divided  using the 10-mm hemoclip applier.

2-  Group B  (laparoscopic staple interruption for treatment of varicocele without cutting inbetween the clips)

The same previous steps but the internal spermatic   vein   was   individually    clipped but not divided using the 10-mm hemoclip applier.

Post-operative Work-up:

All patients of both groups were given parentral antibiotics (cefotaxime 1gm) i.v. 12 hours after the operation, and allowed oral liquid diet 12 hours after the operation. All patients were discharged 24 hours to return after one week to remove the stitches.

Clinical assessment of the patients as regards testicular  pain, size of the testis and size ofvaricocele was done after 1 month.

Color coded duplex was done to all patients to  assess  the  presence  or absence of  reflux and size of spermatic veins after 1 month.

Statistical analysis:

Differences between means and the effects of treatments were detrmined by one-way ANOVA using Tukey's test,  P<0.05 was considered statistically significant.

Results:

The study included twenty cases with varicocele.  They ranged in age from 19 to 42 years (mean =25.5 years). Table(1&2).

The  study  included  twenty   cases  with

varicocele. They ranged in age from 19 to 42 years (mean =25.5 years). Table(1&2).

The patients were divided into two groups according  to the  operative  procedure  done. The first group (10 patients) was subjected to laparoscopic staple interruption for treatment of varicocele  with cutting  the  gonadal  vein or veins inbetween the clips Figure(l).  The second group (10 patients) was subjected to laparoscopic staple interruption for  treatment of varicocele without cutting inbetween the clips Figure(2).

Figure (1 a,b,c,d&e): Laparoscopic staple interruption for treatment of varicocele with cutting the gonadal vein or veins inbetween the clips.

Figure (2 a,b,c,d):  Laparoscopic staple interruption for treatment of varicocele without cutting inbetween the clips.

Table (1): Clinical data in group I with u/s side.

Table (2): Clinical  data in group II with u/s side.

Table (3): Comparison between the two groups regarding clinical features.

Table (4): Resu/Js ofpre and postoperative u/s examination.

Table (5): A comparison between the two groups of patients preoperatively as regards their resu/Js of Duplex findings.

Table (6): Results of pre and postoperative semen analysis.

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= 0                            =

Table (7): A comparison  between the two groups of patients preoperatively as regards their results of semen analysis.

Table (8): Comparison between group I and II pre and postoperatively regarding semen analysis findings.

Table (9): Comparison between the two groups regarding operative time, postoperative pain and hospital stay

All  the  procedures   in  the  two  groups were completed satisfactorily, with no intraoperative complications. No significant difference was found in the operative time between the two groups (25.5±3.12  minutes and 26.2±4.23 minutes for group I and II respectively) (p=0.889) Table(9).

Most patients in the two groups had moderate pain. According to the visual scale, the  mean  of  group  I was  5.7±2.22  and  of group  II  was  6.3±3.05  with  no  significant

difference between the two groups (p=0.801) Table(9).

The patients in the two groups were not different regarding the frequency and dosage of  postoperative  analgesics.     The  hospital stay  was  not  significantly  different  among the patients of the two study groups (1.7±0.82 days in group I and 1.5±0.68 days in group II) (p=0.870) Table(9).

At follow-up,  none of the patients in the two  groups  had  developed  a  postoperative

hydrocele.   Only   one  patient   in   the   2nd group experienced recurrent symptoms of varicocele.

Discussion:

A varicocele  is  an  abnormal  dilation  of the pampiniform plexus that constitutes the primary  drainage  of  the  testis.  It is  found approximately  in 15%  of male  adolescents. The majority  of which  is due to retrograde flow of blood in the internal spermatic vein.6

Several  treatment   options  are  available and include spermatic vein sclerotherapy or embolisation  and  open  surgical  ligation  of the varix through  a retroperitoneal,  inguinal or a subinguinal approach. Laparoscopic varicocelectomy  has been proposed as an alternative  surgical procedure  for the  repair of varicocele with reported benefits of better convalescence,   minimal   invasiveness   and less analgesic  requirement  post-operatively. It was reported as one of the most commonly performed  laparoscopic  procedures  m surgery.7

The major advantage of the laparoscopic approach is that it provides a direct and magnified view of the structures allowing precise  identification  and  dissection.  It likewise  allows  a bilateral  laparoscopic ligation to be done through the same incisions, instead  of  the two  incisions  required  in an open surgical approach. However the main disadvantages  of laparoscopy  are the higher cost and the need for multiple port placements, which make it quite inappropriate in treating a unilateral varicocele.8

Varicoceles are most frequently diagnosed when  a patient  is 15-25  years  of  age,  and rarely develop after the age of 40.9

Our study included twenty cases with varicocele.  They ranged in age from 19 to 42 years (mean =25.5 years). The patients were divided into two groups according to the operative procedure done. The first group (10 patients) was subjected to laparoscopic staple interruption for   treatment of varicocele with cutting the gonadal  vein or veins  inbetween the clips. The second group (10 patients) was subjected to laparoscopic   staple interruption for  treatment  of  varicocele  without  cutting

inbetween the clips. The patients were randomly distributed between the two groups.

Comparing  the mean age of both groups,

it was found that there was no significant difference   between  them   (24.7  years  and

26.3 years for group I and II respectively) (p=0.689),  denoting  good  matching  of patients.

The  mean   duration   of   the   disease   in group  I was 15.6  months  and  16.4  months in group II with no statistically significant difference (p=0.847). In an experimental studylO it was found that there was significant increase in apoptosis at the end of the first month in the varicocele cases and that this apoptosis continued with time. Because the histopathologic    injury,   which   is   parallel to apoptosis, increased, they believe that treatment  in the early phase of varicocele  is important for prevention of probable injury.

Varicoceles are implicated in 70% to 80%

of men with secondary infertility.ll It was found in our study that infertility represented the most common presentation in our patients (40%) (30% in group I and 50% in group II), followed  by pain (35%) and swelling  which represented (25%).

It was noticed  that the  mean age  of the infertility cases (28.38 years) was larger than that ofthe pain cases (25.71 years) and that of the swelling cases (24.4 years).

Physical   examination   in  a  warm  room is the  mainstay  of diagnosis  of  varicocele, but this is affected by a low sensibility and specificity, especially in cases of low grade varicocele.  The sensitivity  and specificity  of varicocele detection approaches 100% with color Doppler ultrasound.l2 Color Doppler ultrasound will certainly become the gold standard inthe investigation ofvaricocele.l3,14

In this work, color Doppler study revealed additional  nine  cases  with  bilateral  disease that were not detected clinically.

Primary varicocele, by far is more common

on the left side in approximately 90% of cases, it is bilateral in 8 to 9 % and is right sided in 1 to 2%.15 Abnormality  apparently  has a high bilateral prevalence (80.7%).  This may suggest that we should consider varicocele as a bilateral disease. This result coincided with

our study.

In  a study  it  was  found  that  varicocele repair in adults with a clinical left varicocele increased left testicular volume and improved semen  profiles.l6  In contrary,  in our  study, no changes have been detected regarding testicular volume following varicocelectomy.

Varicocele  is a  very  common  pathology in  infertile  men,  but  it  is  unclear  whether only  one common  pathway  or whether multiple mechanisms negatively affect spermatogenesis.  Therefore,  varicocele  may be associated with a variety of spermatogenic conditions, ranging from completely normal seminal parameters to moderate oligo spermia or azoospermia. Different researchers have focused  upon the effect of varicocele  in the function  and number  of human sperm  cells and  sperm  characteristics.l 7,18,19  Varicocele causes damage to sperm DNA and changes sperm motility.20

Comparing the preoperative semen parameters of patients in both groups, there were no statistically significant difference regarding the mean spermatic count (29.3 x106/ml and 22.8 x106/ml in group I and II respectively) (p=O.l36), the mean spermatic motility  after  one  hour  (39.7%  and  46.9% in group  I and II respectively)  (p=  0.263), the   mean    spermatic    motility   after   two hours (28.9% and 30.5% in group I and II respectively) (p= 0.708), the mean spermatic motility after three hours (19.3% and 23.3% in group I and II respectively) (p= 0.359) and the mean ofthe abnormal forms (42.5% and

43.6%  in  group  I  and  II respectively)  (p=

0.879).

Comparing the postoperative semen parameters  of patients in both groups, there was significant increase in the mean spermatic count in group I (from 29.3 x 106/ml to 39.5 x 106/ml) (p= 0.063) and (from 22.8 x 106/ ml to 32.6 x 106/ml) (p=0.033) in group II p<0.05, thus the improvement in spermatic count shows  significant  difference  between the two groups.

In a study it was found thatthe improvement in spermatic motility after one hour was from

28.42%±23.22% to 39.92%±22.06% in their

patients post-varicocelectomy. 21

In our study, it was observed that the spermatic motility improved in both groups postoperatively  after  1st, 2nd and 3rd hours; although, the improvement was statistically insignificant.

In  our  study, it  was  observed  that  there

was no significant improvement regarding abnormal forms in group I (p= 0.631),  or in group II (p=0.928).

In this work the procedures in the two groups were completed satisfactorily, with no intra-operative complications.  No significant difference was found in the operative time between the first and second groups (25.5 minutes and 26.2 minutes for group I and II respectively) (p=0.889).

Most of patients in the two groups had moderate  postoperative  pain.  According  to the visual scale, the mean of group I was 5.7 and of group II was 6.3 with no significant difference between the two groups (p=0.801).

The  patients  in the  two  groups  showed no difference regarding the frequency and dosage of postoperative analgesics.

The hospital stay was not significantly different among the patients of the two study groups (1.7 days in group I and 1.5 days in group II) (p=0.870).

The most frequent complication of varicocelectomy was hydrocele formation, occurring in as many as 30% of the patients. The etiology is likely that of lymphatic obstruction, evidenced by the high average protein content of post varicocelectomy hydroceles  compared  to  that  of  edematous fluid   produced   by   venous   obstruction.22

However, none of our patients developed a postoperative hydrocele.

In our study in all cases, identification  of

the testicular artery was done successfully. In a study  aiming to  determine if laparoscopic varicocelectomy  with preservation of the testicular  artery  is a satisfactory  alternative to standard open surgical techniques in adolescents it was found that the laparoscopic technique with preservation of the testicular artery is an acceptable alternative to open surgical treatment of varicoceles. Further, it eliminates the risk of testicular  atrophy and it is the technique  of choice  when previous

inguinal surgery has been performed.23

Conclusion:

Laparoscopic staple interruption for treatment of varicocele without cutting inbetween the clips is more superior to traditional   laparoscopic   staple  interruption for   treatment   of   varicocele   with   cutting the   gonadal  vein  or  veins  inbetween   the clips  especially  regarding the  lower  risk to cut  the  vas  deference  or  spermatic  artery, and spermatic count with the same results regarding spermatic motility   and abnormal forms.

A limitation of the present study was the absence of a control group of observation or no treatment to add to the debate on the real value of varicocelectomy  in treating male infertility.

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