Laparoscopic varicocele ligation in children and adolescents using isosulphan blue: a prospective randomized trial

Abstract

OBJECTIVES To evaluate, in a randomized prospective trial in children and adolescents, the feasibility of isosulphan blue‐based lymphatic vessel preservation during laparoscopic varicocelectomy and its impact on the complication rate, as the operative management of varicoceles remains controversial. PATIENTS AND METHODS In all, 50 consecutive patients were randomly assigned to two laparoscopic varicocelectomy groups. The indications for surgery included scrotal pain and a difference in testicular size, as well as severe cosmetic impairment. All the patients had a laparoscopic varicocelectomy using three ports. Patients in group A had standard laparoscopy, while those in group B had additional isosulphan blue administered. After surgery, the patients were assessed at 3, 6 and 12 months for varicocele recurrence, hydrocele formation, atrophy, pain or other complications. RESULTS There were no intraoperative complications or conversions to open surgery. There were no adverse reactions, scrotal haematomas or atrophy. At 3 months after surgery, the incidence of hydrocele in group A was 20% whereas in group B no hydroceles were detected (P = 0.025); at 6 months the 20% still had hydroceles. One patient in each group had varicocele recurrence associated with persistent pain. In two patients in group B, blue pigmentation of the left hemiscrotum persisted at the 3‐month follow‐up but resolved by 6 months. CONCLUSIONS Laparoscopic repair of varicoceles using isosulphan blue helps to identify and preserve the lymphatic drainage. It prevents secondary hydrocele formation, the most common complication, with no supplementary risk to the patient. Also, testicular oedema causing impaired spermatogenesis can be avoided.

Indigo Carmine Dye-Assisted Lymphatic-Sparing Laparoscopic Palomo Varicocelectomy In Children

“…They considered laparoscopic Palomo procedure with lymphatic sparing to be the most effective for varicocele treatment in children and adolescents. Furthermore, Schwentner et al (10) in a prospective randomized trial demonstrated no secondary hydrocele with the dye-assisted approach. Since then many studies have reported nearly zero rates of secondary hydrocele with dye-assisted LSLV (11,12).…”

“…As a lymphatic staining agent the use of isosulfan blue is considered to be best (7,(10)(11)(12), because its use is well established in clinical practice and it is cheap. Tan et al (13) described the technique of in vivo methylene blue mapping of testicular lymphatic vessels during laparoscopic varicocelectomy.…”

Varicocele surgery: a decade’s experience at a children’s hospital

“…In addition to the well established Ivanissevich (inguinal) and Palomo (high retroperitoneal with mass ligation) techniques, the subinguinal and laparoscopic approaches have gained greater acceptance [1,2,6,7]. Modifications of all of these procedures have also been described, including microsurgery technique ( × 10 magnification using the operating microscope), testicular artery and lymphatic sparing, and lymphatic opacification [7,8]. Because our centre has many experienced paediatric urologists who use the spectrum of techniques described for spermatic vein ligation, we sought to evaluate the strengths and weaknesses of each surgical approach.…”

“…The median (range) age at surgery was 15 (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21) years. Patients were stratified based on the surgical technique…”

“…In all, 92 patients undergoing surgical spermatic vein ligation at Children's Hospital Boston between 1996 and 2006, and with > 1 year of followup, were evaluated. The median (range) age at surgery was 15 (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21) years. Before and after surgery, the varicocele grade (according to Dubin and Amelar [3]), testicular volume and testicular consistency were determined by the attending urologist.…”