Laparoscopic vs Sclerotherapy for Varicoceles: Who Prevails?

Abstract

Surgical management of adolescent varicoceles has seen great enthusiasm for innovation over the past few decades. For those patients who meet clear criteria for intervention, several treatment options exist. The initial technique of high retroperitoneal en bloc ligation of spermatic vessels, described over 70 years ago by Alejandro Palomo, 1 has evolved to now include modifications such as testicular artery-sparing and/or lymphatic-sparing technique. 2 Alternatively, the subinguinal microscopic varicocelectomy (with both arterial-and lymphatic-sparing techniques, as well as ligation of gubernacular vessels to prevent recurrence) or endovascular therapy via interventional radiology is available. 2 At our institution, all 3 treatment options are offered to patients and their families.In this issue of The Journal, Chung et al (page 600) report their outcomes in a much-needed randomized controlled trial assessing surgical techniques for adolescent varicoceles. 3 The authors present us with an appropriately powered, unbiased, and well-executed study. While the scrotal antegrade sclerotherapy (SAS) approach has been previously discussed by Tauber and Johnsen, 4 and Mazzoni et al, 5 this is the first report supporting the technique against laparoscopic Palomo surgery. As of the latest survey of pediatric urologists, the laparoscopic approach is the most well known and widely performed. 6 The authors discuss several important findings: 1. Sclerotherapy via a scrotal, antegrade approach has a recurrence rate of 5.3%, which is equivalent to the laparoscopic Palomo surgery recurrence rate of 5.3%. The SAS recurrence rate is lower than the 10%-16% reported relapse rate in studies from radiologic literature. 2 2. The liquid agent of air-foamed sodium tetradecyl sulphate plus Lipiodol (ethiodized oil) is a safe sclerotherapy agent, without any report of allergic reaction, venous rupture, extravasation, or epididymo-orchitis in the treated cohort. 3. Catch-up growth of the ipsilateral testicle was shown in both surgical approaches at an equivalent rate at 12 months postoperatively.