Varicocele (VC) is the dilatation, tortuosity and elongation of the vasculature of the seminiferous plexus due to obstruction of reflux or valve failure and stagnation of blood flow in the seminiferous veins. It is rarely seen in prepubertal children, but the incidence rises from about 10 years of age to about 4.1%-16.2%. The main clinical manifestations are scrotal swelling and discomfort, pain and male infertility in adulthood. Early diagnosis and timely treatment can effectively reverse testicular dysgenesis, improve semen quality and reduce the incidence of infertility in adulthood.
Spermatic vein high ligation is one of the effective methods for the treatment of varicocele, and traditional laparoscopic surgery is usually performed with three or four holes.
Data and Methods
Clinical data
There were 16 patients, aged 8-15 years, average 10.6 years, 14 cases on the left side and 2 cases on both sides, with medical history of 3-14 months, average 7.5 months. On physical examination, the scrotum was enlarged, and strands, clusters or worm-like twisted and dilated trabecular spermatic plexus could be palpated in the scrotum, 5 cases in degree II and 11 cases in degree III. Preoperative scrotal ultrasound showed that the left or bilateral spermatic veins were significantly dilated, with an internal diameter of 2.1-3.2 mm, averaging 2.4 mm, and there was blood reflux signal in all cases, excluding secondary varicocele. The child reported a sensation of swelling and discomfort in the scrotum, which gradually worsened, and the symptoms were relieved after lying down at rest and worsened when walking upright or exercising.
Surgical approach
Under general anesthesia, the patient was placed in a lying position with the buttocks elevated and the head low and feet elevated at 20-30°, and the operated side elevated at 15-30°. The organs and bilateral internal spermatic veins were observed, and intestinal injury and subabdominal bleeding were excluded. A 5-mm longitudinal incision was made in the middle of the umbilicus and pubic symphysis line under laparoscopic guidance, and a 5-mm Trocar was inserted to establish the operating channel, and the intestinal canal was retracted to reveal the operative field.
Replace the operating scissors and cut the lateral peritoneum along the surface of the spermatic vessels at a distance of 3-5 cm from the opening of the internal ring in the shape of a “T” for about 2 cm, free the spermatic vessels and see the pulsating spermatic artery, free the internal spermatic vein for 2-3 cm and double block it with two Hemolok, pay attention to protect the spermatic artery accompanying the internal spermatic vein when separating it, observe the wound without bleeding under the laparoscope, the lateral peritoneum can be left untreated, and probe for any missed spermatic veins. The procedure was completed after exploring the spermatic vein without missing. The intra-abdominal CO2 gas was evacuated, the operating forceps and laparoscope were withdrawn sequentially, and the incision was glued with tissue glue.
Follow-up
The postoperative follow-up ranged from 6 to 24 months and included incisional healing, disappearance of varicose veins, recurrence and complications such as testicular atrophy.
Results
The operation was successful in all 16 children, and the operation time was 25-40 min, with an average of 28 min; there was no intraoperative bleeding, no vas deferens injury, no retroperitoneal hematoma, etc. The postoperative incision pain and abdominal pain were mild, and the children could move around 1 day after the operation; there was no fever, incision infection, no subcutaneous and scrotal emphysema, and no scrotal hematoma. The varicose veins were significantly reduced at the time of discharge, among which 13 cases had disappeared, 2 cases had reduced symptoms, 1 case had numbness in the left upper limb, which was significantly reduced after 1 day of observation, and all of them were followed up from 6 to 24 months after surgery, with an average of 12 months. There was no recurrence during the follow-up period, and the scrotal masses were all significantly reduced or disappeared, and no complications such as epididymitis and testicular atrophy occurred.
Discussion
Pediatric varicocele is not uncommon clinically, but usually occurs on the left side, accounting for about 80% to 98%, and less than 20% on both sides, and rarely occurs on the right side alone. The prevalence of varicocele is rare in prepubertal children and increases from about 10 years of age, with the prevalence of varicocele in adolescents ranging from 4.1% to 16.2% according to foreign literature [4]. The prevalence of varicocele in adolescents has been reported to be 8.5%-19.8% in the domestic literature. The prevalence is 1% in adolescents younger than 10 years of age and 11% in adolescents between 11 and 19 years of age.
Varicocele can be divided into two types: primary and secondary. In patients with varicocele, blood flow is reduced due to compression of arteries by tortuous veins in the scrotum, poor venous return, stagnation of blood, reflux of harmful metabolic substances in the adrenal glands and renal veins, combined with increased local temperature, accumulation of CO2 in testicular tissues, long-term local hypoxia, and increased concentrations of catecholamines, cortisol, and prostaglandins in the blood can affect the spermatogenic capacity of the testes.
Wu Rongde et al. found that varicocele already damages testicular tissue during childhood and prepubertal period, and the spermatogenic and supporting cells of the testis already show obvious pathological changes, which will become more obvious as the child grows older and the degree of the disease increases, and will eventually affect the right testis, and the earlier the treatment, the better the prognosis.
The European Pediatric Urology Guidelines 2011 recommend the following indications for surgery for adolescent varicocele:
(i) a reduction in testicular volume associated with varicocele;
(ii) alteration of the local environment of the testis that affects fertility;
(iii) Bilateral significant varicocele;
④Abnormal semen quality (late adolescence);
⑤ Varicocele with an abnormal response to luteinizing hormone-releasing hormone stimulation test;
(6) Severe varicocele symptoms. Traditional treatment methods are open surgery, mainly trans-inguinal route and retroperitoneal route, which are gradually abandoned clinically due to the high trauma of traditional open surgery and high recurrence rate, up to 7-35% with an average of 14.97%.
Laparoscopic high spermatic vein ligation with less trauma and faster recovery has been widely used in the clinic. The surgical methods include Ivan issevich procedure with preservation of the spermatic artery and Palomo procedure with high spermatic vascular ligation. Laparoscopic high spermatic vein ligation has been used in the clinic since 1990, and most of them are operated by three- or four-port method. We adopted the Ivanissevich procedure with preservation of the spermatic artery, and all of them used two 5-mm puncture holes, one hole for laparoscopy and one hole for operation, and all of them completed the operation successfully. 16 children in our group had no bleeding during the operation, no complications such as damage to the spermatic artery, vas deferens and abdominal organs, and no postoperative complications such as scrotal hematoma, epididymitis and testicular atrophy.
Our experience is that the advantages of the two-hole method laparoscopic surgery are.
(1) the surgery is less traumatic, the incision is aesthetically pleasing and does not damage the muscles and blood vessels, and this advantage is more obvious for bilateral lesions. Two of the laparoscopic cases in this group were bilateral, and only two holes were needed to complete the surgery, whereas open surgery required two incisions, which resulted in larger postoperative scars and affected the aesthetics.
After entering the abdominal cavity, the spermatic vein is clearly visible, and the laparoscope has a magnifying effect, so the artery, vein and vas deferens can be clearly distinguished. Hemolok double ligation, no need to cut the blood vessels, minimal bleeding, and even more superior if it is bilateral.
(3) Short operation time, reduced intraoperative and postoperative complications, fast postoperative recovery, and laparoscopic surgery should be chosen for those who have failed open surgery and those who have undergone inguinal surgery.
Two-hole laparoscopy is easier to operate than single-hole laparoscopy, does not require special single-hole laparoscopic operating instruments, is inexpensive, easy to learn, and more suitable for the current Chinese situation; it is less traumatic, less scarring, and more beautiful than three-hole and four-hole laparoscopy.
We advocate laparoscopic surgery for pediatric varicocele based on more skilled laparoscopic techniques, which will be safer and more effective. In conclusion, the two-hole method laparoscopic varicocele high ligation is less traumatic, more effective, faster recovery, safe and feasible, easy for clinicians to master, and worthy of clinical promotion in pediatric surgery.