Laparoscopic Varicocelectomy

in the Adolescent Male

Israel Franco, MD

Address
Pediatric Urology Associates, PC, 19 Bradhurst Avenue,
Hawthorne, NY 10532, USA.
E-mail:Ifranco@Pedsurology.com
Current Urology Reports 2004, 5:132136
Current Science Inc. ISSN 1527-2737
Copyright 2004 by Current Science Inc.

Laparoscopic varicocelectomy was introduced in the early

1990s as an alternative to the Palomo varicocelectomy.
Since its introduction, the procedure has gained favor
within the pediatric urology community. Laparoscopic varicocelectomy has been performed using the intraperitoneal,
preperitoneal, and lumbotomy approaches with almost the
same results as those obtained with the Palomo procedure.
The complication rates are relatively low for this procedure
except for the hydrocele rate, which has been similar to
that encountered with the open Palomo approach. In this
article, the results obtained with this procedure and the
technique are explored. As more pediatric urologists
become adept with laparoscopic techniques, we will continue to see an increase in the number of cases performed
using this technique.

Introduction
Varicoceles typically are first identified when children are
between the ages of 10 and 15 years of age, with an occasional 7- or 8-year-old having scrotal swelling. These
patients normally are identified at the time of school physical examinations by a primary care physician. It is possible
that many smaller varicoceles are missed and diagnosed
until adulthood. We routinely identify enlarged and
numerous vessels in the cord of young boys at the time of
hernia repair or orchiopexy. Are these prepubertal patients
manifesting a subclinical varicocele that later will be clinically evident? There is no consensus on how to mange the
prepubescent varicocele. Richter et al. [1] sent a survey to
300 infertility specialists and pediatric urologists. The
results were mixed, with approximately half of the group
treating the varicocele and the other observing the patients.
There has not been a study describing what happens to
prepubescent boys with varicoceles later in adulthood. In
these cases in which prominent veins are identified, it is
always difficult to decide what to do with these vessels. The
varicocele once identified will persist throughout the boys

life; when and if it poses a problem with fertility in every

man is an issue that remains to be resolved. The dilation
possibly caused by reflux of the internal spermatic vein and
pampiniform plexus of the testis may lead to progressive
testicular insult and, in some cases but not always, results
in infertility. The feeling that the gonadotoxic effects of the
varicocele are variable, but most likely progressive, may
explain the varied infertility rates in male patients. The
incidence of varicoceles has been reported to be approximately 15% of the male population, making it a very prevalent disease. This very high prevalence rate has led to
some difficulties in deciding which patients should be
treated. When the adult male patient presents for evaluation of infertility, a semen analysis is used to direct the
treatment of the patient. Adolescent patients rarely present
with infertility issues; therefore, other criteria have been
devised, which guide in the selection of the patients in
need of surgical intervention. Testicular asymmetry, pain,
or abnormal semen analysis are considered absolute indications for correction of the varicocele in the adolescent
patient. Infertility generally is not one of the reasons used
in this age group. However, there are exceptions to everything. While working in an inner city hospital, I did have
the experience of having a 14-year-old male present for an
infertility work-up. When asked how he knew that he had a
problem, he proudly confessed that he had been trying to
impregnate his girlfriend for some time.
Over the years, the management of the varicocele has
evolved from the standard Ivanissevich inguinal approach
described in 1918 to the Palomo repair with its retroperitoneal approach and mass ligation of the gonadal vessels to
the various combinations of other procedures. The more
recent introduction of the subinguinal approach and its
microscopic variation has become the standard in the
adult population. Several reports are available documenting the success rates in adolescent patients [2,3,4]. The
results vary widely, with Lemack et al. [2] reporting no
recurrences (short follow-up period, average 7 months)
and Greenfield et al. [3] reporting a 14% recurrence rate,
with the second operation yielding a perfect result. This
disparity in results is an indicator of the difficulty encountered in isolating the artery in the young adolescent male;
it is much more difficult to isolate than in an older, fully
developed adolescent. Identification of the artery and separation of the artery from the veins that typically envelope
the artery is difficult in the young patient. It will be inter-

Laparoscopic Varicocelectomy in the Adolescent Male Franco

esting to note what the true success rate for the subinguinal
microscopic approach is as more reports come out in the
coming years. Sclerotherapy has become a popular option
in Europe, but has gained few advocates in the United
States [57]. The failure rate can be as high as 20% in some
series. Mazzoni et al. [7] reported the best results in adolescents, which were a failure rate of 4% and no hydroceles.
The high failure rate associated with this technique does
not make up for the cost savings that the Europeans commonly tout in there reports because they rarely include the
cost of the retreatments in their calculations.
In the adolescent patient, the benchmark procedure
has become the Palomo approach, which has a nominal
recurrence rate. In 1992, Kass and Marcol [8] reported on
102 patients who underwent varicocelectomy using different approaches. The recurrence rate with the Ivanisevic
approach was 16%, 11% with the retroperitoneal arterysparing approach, and 0% with the Palomo mass ligation
approach. Dolan et al. [9] experienced very similar results
in their series of patients for whom attempts at preservation of the artery led to failures; the same authors have not
reported any failures in the mass ligation group. The Palomo mass ligation recurrence results mimic those of the
microscopic varicocelectomy in adult patients. An attempt
at preservation of testicular arteries with the retroperitoneal approach has led to poor results, which is evidenced
by the results noted by multiple authors [1013]. After
recurrences, the main complication encountered with varicocelectomy has been hydroceles. The hydrocele rate
appears to be the same with laparoscopic varicocelectomy
as with open varicocelectomy, but is higher than that seen
with the microscopic varicocelectomy and sclerotherapy.
Misseri et al. [14] have reported that hydrocele may show
up as late as 3 years after surgery. Given these results, it
would behoove anyone who reviews the literature to be
wary of reports that document negligible recurrence or
hydrocele rates when they report follow-ups of less than 3
years. In 2003, Riccabona et al. [12] reported on their experience with selective preservation of lymphatics during an
open Palomo repair. They saw no hydroceles and reported
a 2% recurrence rate. In a similar fashion, Misseri and
Glassberg [15] reported on their experience with laparoscopic varicocelectomy with selective preservation of the
artery and preservation of the lymphatics. They claim that
lymphatics channels can be identified laparoscopically and
preserved at the time of the procedure. Their claims of
lower hydroceles rates need to be tempered by the same
fire that gave us the statement that hydroceles can occur as
late as 3 years after surgery.
The Palomo varicocelectomy calls for a mass ligation of
the artery and vein complex. Initially, this led to concerns
that interruption of the arterial flow could lead to vascular
compromise. However, there have been numerous reports
of this technique with no testicular atrophy. Some authors
have not encountered any cases of testicular atrophy with
mass ligations of the vessels. In the past, an attempt to sep-

133

arate the artery and perform a venogram was made to identify other venous channels that could lead to recurrences
[1618]. The recurrence rate with this technique was 3.6%.
Any surgeon who has performed a subinguinal microscopic varicocelectomy on a young adolescent knows how
hard it is to isolate the artery from the group of veins that
invest it. Many surgeons have performed an unwitting
mass ligation of the vessels and fortunately did not experience atrophy of the testis. Even during the period in which
Palomo varicocelectomies were being performed with testicular artery preservation and concomitant intraoperative
venography to look for collaterals, it is very likely that
many arteries were tied off unwittingly by surgeons who
thought they had preserved these vessels. A recent study by
Sergey et al. [19] that examined testicular blood flow in
the testis of adolescent boys who underwent varicocelectomy using an artery-sparing technique or an en mass
approach revealed some interesting results. There was no
difference in the resistive index in either group if the varicocele was corrected. The authors found that the resistive
index was elevated on the side of the varicocele before surgery and in cases in which there was a failure. The resistive
index is a measure of the flow within the vessels and that
the resistive index remained stable in both procedures is
evidence that there is no significant hemodynamic alterations after ligation. The resistive index was elevated the
most in patients who experienced pain before and after
surgery, indicating that pain may be a hemodynamic effect.
In a study by Barqawi et al. [20] in which 44 laparoscopic varicocelectomies were preformed in adolescent
boys, it was found that mass ligation of the vessels in 13
boys who had undergone previous groin surgery did not
result in atrophy of the testis. These findings need to be
corroborated by other studies before it can be advocated as
a standard measure. Most surgeons, when faced with an
adolescent who has undergone a previous groin procedure,
would opt for an artery-sparing surgical procedure or
venous embolization.
One of the earliest procedures in which urologists cut
their teeth while learning laparoscopy in its nascent phase
was the varicocelectomy. Laparoscopic varicocelectomy
lends itself very well to the management of the adolescent
varicocele because the procedure is a standard Palomo
operation through an intraperitoneal approach. There have
been modifications of the bulk ligation laparoscopic varicocelectomy throughout the years. These include attempts
to preserve the artery and some also have attempted to preserve the lymphatics that run with the gonadal vessels.
Numerous studies have been published throughout the
years indicating that laparoscopic varicocelectomy is just as
effective as the open retroperitoneal Palomo approach. In
our own study comparing laparoscopic varicocelectomy to
open varicocelectomy, we found no difference between the
two techniques. The recurrence rate and the hydrocele rate
were 0% and 6% to 7% in both respectively. Initially, it was
thought that laparoscopic varicocelectomy was likely to

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Pediatric Urology

have lower hydrocele rates than those reported with the

Palomo approach, but as time progressed, the incidence of
hydroceles appears to be the same.

Procedure
Laparoscopic varicocelectomy is one of the simplest laparoscopic procedures that urologists perform. It generally
is used as the stepping-stone procedure to teach residents
and new laparoscopists. The intraperitoneal approach is
quite simple and straightforward. Gaining access to the
abdomen is done in one of several ways: by using a modified Hassan technique or using the Veress needle to create a
pneumoperitoneum and then entering with a trocar. Several options are available when gaining entry and some are
safer than others, or at least give that impression. The standard trocars that cut through the abdominal wall are
slowly being replaced by trocars that displace muscle. The
advantage of these trocars is that the manufactures claim
that there is a decreased need to close the trocar site with
sutures; they also tend to cause less bleeding on insertion.
Another form of trocar is the radially dilating trocar. This
trocar includes the Veress needle within the radially dilating sheath, which reduces the need for a second puncture,
thereby making trocar placement inherently safer. The
radial dilation of the tract is not supposed to necessitate
closure of the wound. It has been my personal preference
to close all of the 5-mm trocar sites and, in many instances,
3-mm trocar sites with a suture. The benchmark that I use
when I close these sites is not visual inspection of the
abdominal wall, but listening for air leaking from the site.
If there is no air leakage, it is unlikely that anything will
come through the trocar site. This strategy has worked well
over the past 10 years when performing laparoscopy in
children of all ages. No trocar site herniations have
occurred and, in patients who have had second laparoscopic procedures, there have been no adhesions to the
abdominal wall. The more recent introduction of the optical dilating trocars obviates the blind puncture and should
be able to reduce trocar-related bowel injuries. This technique requires a fair amount of experience before one is
able to confidently recognize landmarks. Once a surgeon
becomes familiar with the techniques, it is a very useful
adjunct, especially in obese patients. In the older, more
muscular boys, the Veress needle is used to insufflate and
we enter the abdomen with a radially expanding dilator or
an Optiview trocar (Ethicon Cincinnati, OH). Once inside
the abdomen, the internal inguinal rings are inspected to
look for hernias. Adhesions from the left colon to the left
ring are taken down if necessary. This is encountered in a
moderate number of patients and these generally will need
to be taken down to allow for high access to the gonadal
vessels. An incision then is made superior and lateral to the
gonadal vessels as cephalad as possible without mobilizing
the colon. Once the peritoneum is opened, the bundle of
vessels is swept off of the abdominal wall and a right angle

clamp is used to clean the space to provide room for placement of clips. For patients in whom the gonadal vessels are
to be preserved, the peritoneum is mobilized off the vessels
and the artery is identified using a laparoscopic Doppler
probe. Some surgeons have attempted to preserve lymphatics during this phase (Glassberg, personal communication). It is difficult to sometimes tell the difference
between a lymphatic and a small venule; in this case, it is
safer to take the vessels to prevent a recurrence.
Trocar placement can vary from surgeon to surgeon. In
general, a triangular placement of the trocars facilitates the
mechanics of the operation and leads to lessened operator
fatigue. In addition to the trocar at the umbilicus, another
trocar is placed at the level of the umbilicus in the midclavicular line and a third is placed midway between the umbilicus and the pubis. Care needs to be taken when placing
this trocar so that the bladder is not injured. The vessels
can be ligated with various means. The simplest method is
to ligate the veins with a silk suture. This is the cheapest
way of doing it and also allows the novice laparoscopists to
practice their knot-tying skills. There are various clip appliers on the market, from disposable ones to nondisposable
ones. The disposable clip appliers have been known to
have poor holding characteristics and have failed to release
properly on some occasions. Some 5-mm clips are Sshaped, have especially poor holding characteristics, and
are prone to slipping off the vessels. The better metal clips
will compress from the end first, locking the tissue and preventing it from slipping away from the clip. The problem
with 5-mm clips is that in many instances, the mass of vessels is quite large and the bundle needs to be split in two.
This occasionally leads to the need for two disposable clip
appliers to be used. In the authors experience, the cheapest, safest, and most reliable way of ligating all vessels is
with the use of the nondisposable locking clip applier by
Weck (Pilling Weck Canada L.P., Markham, Ontario).
Some surgeons are using the Ligasure (Boulder, CO) device
to fulgurate the vessels. If the pediatric laparoscopic surgeons feel comfortable fulgurating the pulmonary and
splenic vessels with this device, these small spermatic vessels should prove to be no match for this device.

Extraperitoneal approach
The extraperitoneal approach came about as a result of an
attempt to do inguinal hernia repairs in adults without
using a transperitoneal route. The advocates of this technique claim that the risk of bowel injury over-rides the
extra time that it takes to do the procedure. An infraumbilical incision is made and the dissection is carried down to
the posterior sheath. At this time, a balloon dilator is
inserted into the preperitoneal space and the space is
expanded. The additional working trocars are inserted and
the vessels are isolated. Once the vessels are isolated,
whether the artery is taken or lymphatics are spared is a
matter of personal preference. The approach is not without
its complications. There are problems with large preperito-

Laparoscopic Varicocelectomy in the Adolescent Male Franco

neal hematomas, subcutaneous emphysema, injuries to

the superficial epigastric vessels, and an inability to
develop the space. The working space is limited and suction in the space collapses the working area very rapidly.
Recurrence rates and hydrocele rates are the same as with
the intraperitoneal approach.

Lumboscopic approach
A rarely described approach to the gonadal vessels involves
a retroperitoneal approach much like that for a nephrectomy. The problems commonly encountered with this
approach in the cases described by Esposito et al. [21] is
that the peritoneum was commonly entered during the
procedure and the working space was confined. To increase
the size of the working space would just put the patient at
risk for further tears in the peritoneum or retroperitoneal
bleeding. Access was gained in a manner similar to that
used for a retroperitoneal nephrectomy, with an incision
being made just below the 12th rib and the space developed digitally first and then with the lens once the trocar
was in place. The vessels then were found in a manner
identical to that used in an open Palomo approach, sweeping the peritoneum medially and identifying the vessels on
the edge of the ureter. Ligation of the vessels then was
done per the surgeons preference.

Conclusions
The etiology and management of the adolescent varicocele
leave plenty of room for discussion. The ideal means to correct the problem in the adolescent has not been defined. Conceptually, the operation should have a nominal recurrence
and hydrocele rate, with no risk of testicular atrophy and
100% catch-up testicular growth. We have yet to find or perfect the operation we have at hand to satisfy all of these criteria. It appears that laparoscopic varicocelectomy is capable of
producing satisfactory results in every category, except with
regard to hydroceles. Continued modifications of the laparoscopic varicocelectomy, with attempts to preserve the lymphatics, may result in this being the ideal operation. The
magnification inherent with laparoscopy and the rapidity of
the operation give it an edge over the other procedures that
are being performed. As the present generation of urologists
continue to improve their laparoscopic skills, there will be
and increase in the number of surgeons feeling comfortable
with performing this operation.

References and Recommended Reading

Papers of particular interest, published recently, have been
highlighted as:

Of importance
Of major importance
1.

Richter F, Stock JA, LaSalle M, et al.: Management of prepubertal varicoceles: results of a questionnaire study among pediatric urologists and urologists with infertility training.
Urology 2001, 58:98102.

2.

135

Lemack G, Uzzo R, Schlegel P, Goldstein M: Microsurgical

repair of the adolescent varicocele. J Urol 1998, 160:179181.
3. Greenfield S, Seville P, Wan J: Experience with varicoceles in
children and young adults. J Urol 2002, 168:16841688.
This study contrasts the previous study results showing that when
urologists are new to a particular procedure, there is a learning curve
that is present, which is clearly shown to be present in this report.
Both studies have low hydrocele rates.
4. Silveri M, Adorisio O, Pane A, et al.: Subinguinal microsurgical
ligation: its effectiveness in pediatric and adolescent varicocele. Scand J Urol Nephrol 2003, 37:5354.
5. Kuenkel MR, Korth K: Rationale for antegrade sclerotherapy
in varicoceles. Eur Urol 1995, 27:1317.
6. Sautter T, Sulser T, Suter S, et al.: Treatment of varicocele: a
prospective randomized comparison of laparoscopy versus
antegrade sclerotherapy. Eur Urol 2002, 41:398400.
7. Mazzoni G, Spagnoli A, Lucchetti MC, et al.: Adolescent varicocele: tauber antegrade sclerotherapy versus Palomo repair.
J Urol 2001, 166:14621464.
8. Kass EJ, Marcol B: Results of varicocele surgery in adolescents:
a comparison of techniques. J Urol 1992, 148:694696.
9. Dolan D, Samadi A, Palmer L, Franco I: A randomized comparison of laparoscopic vs. open varicocelectomy in the pediatric population. Presented at 20th World Congress of Endourology
and SWL. Genoa, Italy: September 2002. J Endourol 2002,
16(suppl 1):A79.
10. Podkamenev VV, Stalmakhovich VN, Urkov PS, et al.: Laparoscopic surgery for pediatric varicoceles: randomized controlled trial. J Pediatr Surg 2002, 37:727729.
11. Abdulmaaboud MR, Shokeir AA, Farage Y, et al.: Treatment of
varicocele: a comparative study of conventional open surgery, percutaneous retrograde sclerotherapy, and laparoscopy. Urology 1998, 52:294300.
12. Riccabona M, Oswald J, Koen M, et al.: Optimizing the operative treatment of boys with varicocele: sequential comparison
of 4 techniques. J Urol 2003, 169:666668.
13. Koyle M, Furness P, Barqawi A: Laparoscopic Palomo varicocele ligation in children and adolescents. Ped Endosurg Innov
Techn 2003, 6:1519.
14. Misseri R, Gershbein AB, Horowitz M, Glassberg KI: The adolescent varicocele. II: the incidence of hydrocele and delayed
recurrent varicocele after varicocelectomy in a long-term
follow-up. BJU Int 2001, 87:494498.
This paper confirms that studies with follow-up periods of less than
3 years can lead to misinformation, especially when it comes to
reporting hydrocele rates.
15. Misseri R, Glassberg K: Laparoscopic varicocelectomy: Is there
an Advantage? Presented at 20th World Congress of Endourology
and SWL. Genoa, Italy: September 2002. J Endourol
2002, 16(suppl 1):A78.
16. Levitt S, Gill B, Katlowitz N, et al.: Routine intraoperative
post-ligation venography in the pediatric varicocele. J Urol
1987, 137:716718.
17. Palmer LS, Cohen S, Reda EF, et al.: Intraoperative spermatic
venography reconsidered. J Urol 1995, 154:225227.
18. Gill B, Kogan SJ, Maldonado J, et al.: Significance of intraoperative venographic patterns on the postoperative recurrence
and surgical incision placement of pediatric varicoceles.
J Urol 1990, 144:502505.
19. Sergey K, Oleg K, Yihiel B, et al.: Laparoscopic Palomo procedure: the impact of internal spermatic artery ligation on testicular blood flow. Ped Endosurg Innov Tech 2003, 7:297301.
This paper is useful in helping us understand the flow dynamics of
varicoceles. This study may explain the cause of painful varicoceles.

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20. Barqawi A, Furness P III, Koyle M: Laparoscopic Palomo varicocelectomy in the adolescent is safe after previous ipsilateral
inguinal surgery. BJU Int 2002, 89:269272.
This paper helps allay fears that many surgeons have regarding the
Palomo mass ligation varicocelectomy with regard to the patient who
had prior inguinal surgery. It is not a definitive study and by no
means is it 100% safe to say that testicular atrophy could never happen in a patient who had groin surgery. The numbers in the study are
too small to have any type of real statistical significance because the
likelyhood of a vascular accident during inguinal surgery is in single
digits, thereby necessitating hundreds if not thousands of patients
who underwent inguinal surgery to have varicocele repairs to be able
to make a definitive statement.

21.

Esposito C, Monguzzi G, Gonzalez-Sabin M, et al.: Laparoscopic treatment of pediatric varicocele: a multicenter study
of the Italian society of video surgery in infancy. J Urol
2000, 163:19441946.

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