Minilaparoscopic varicocelectomy with preservation of testicular artery and lymphatic vessels by using intracorporeal knot-tying technique: five-year experience.

Abstract

In this study we present our experience using minilaparoscopic intracorporeal knot tying to ligate internal spermatic veins (ISV) while sparing the spermatic artery and lymphatics.
Minilaparoscopic varicocelectomies were performed in 87 patients between January 2004 and January 2009. All varicoceles were detected clinically according to the World Health Organization (WHO) classification and confirmed by scrotal color Doppler ultrasonography. The surgical indications were scrotal symptoms in 71, infertility in 16, and both conditions in 2. Three 3.5 mm minilaparoscopic ports were used for the operation. The ISVs were dissected and then ligated with intracorporeal knot-tying. The testicular artery and lymphatic vessels were carefully preserved to minimize procedure-related complications.
Unilateral laparoscopic varicocelectomy was performed in 21 (24.2%) patients and bilateral in 66 (75.8%). Mean operative time was 71.1 ± 29.2 and 46.8 ± 12.6 min for bilateral and unilateral varicocelectomies, respectively. All patients were discharged within 24 h after surgery. Neither immediate major nor late procedure-related complications were noted. Of the 71 patients with scrotal symptoms, the symptoms completely subsided in 55 (77.5%) and partially subsided in 10 (14.1%). Only one (1.2%) recurrent varicocele was detected within a mean follow-up of 21 months (range = 3-42). Neither hydrocele formation nor testicular atrophy was found during the follow-up period.
Our 5-year experience revealed that minilaparoscopic varicocelectomy with sparing of artery and lymphatic vessels could safely and effectively ligate all spermatic veins and preserve spermatic arteries and lymphatic channels without leading to a high varicocele persistence or recurrence.

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Minilaparoscopic Varicocelectomy with Preservation of Testicular Artery and Lymphatic Vessels by Using
Intracorporeal Knot-tying Technique: Five-year Experience
Article Sub-Title
ArticleTitle
Article CopyRightSociété Internationale de Chirurgie
(This will be the copyright line in the final PDF)
Journal NameWorld Journal of Surgery
Corresponding AuthorFamily Name Tsai
Particle
Given Name Yao-Chou
Suffix
DivisionDepartment of Urology
Organization Buddhist Tzu Chi General Hospital
AddressTaipei Branch, 289 Jianguo Road, Xindian city, Taipei, Taiwan
Division
Organization Medical College of Tzu Chi University
AddressHualien, Taiwan
Email tsai0523@ms29.url.com.tw
AuthorFamily NameChung
Particle
Given NameShiu-Dong
Suffix
DivisionDepartment of Urology
OrganizationFar Eastern Memorial Hospital
AddressTaipei, Taiwan
Email
AuthorFamily NameWu
Particle
Given NameChia-Chang
Suffix
DivisionDepartment of Urology
OrganizationTaipei Medical University, Shuang Ho Hospital
AddressTaipei, Taiwan
Email
AuthorFamily NameLin
Particle
Given Name Victor Chia-Hsiang
Suffix
Division Department of Urology, Institute of Biotechnology and Chemical Engineering
OrganizationE-Da Hospital, and I-Shou University
AddressKaoshiung, Taiwan
Email

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AuthorFamily NameHo
Particle
Given Name Chen-Hsun
Suffix
Division Department of Urology
Organization Buddhist Tzu Chi General Hospital
AddressTaipei Branch, 289 Jianguo Road, Xindian city, Taipei, Taiwan
Email
AuthorFamily NameYang
Particle
Given Name Stephen Shei Dei
Suffix
DivisionDepartment of Urology
OrganizationBuddhist Tzu Chi General Hospital
Address Taipei Branch, 289 Jianguo Road, Xindian city, Taipei, Taiwan
Email
Schedule
Received
Revised
Accepted
AbstractBackground:
In this study we present our experience using minilaparoscopic intracorporeal knot tying to ligate internal
spermatic veins (ISV) while sparing the spermatic artery and lymphatics.
Methods:
Minilaparoscopic varicocelectomies were performed in 87 patients between January 2004 and January 2009.
All varicoceles were detected clinically according to the World Health Organization (WHO) classification
and confirmed by scrotal color Doppler ultrasonography. The surgical indications were scrotal symptoms in
71, infertility in 16, and both conditions in 2. Three 3-mm minilaparoscopic ports were used for the operation.
The ISVs were dissected and then ligated with intracorporeal knot-tying. The testicular artery and lymphatic
vessels were carefully preserved to minimize procedure-related complications.
Results:
Unilateral laparoscopic varicocelectomy was performed in 21 (24.2%) patients and bilateral in 66 (75.8%).
Mean operative time was 71.1 ± 29.2 and 46.8 ± 12.6 min for bilateral and unilateral varicocelectomies,
respectively. All patients were discharged within 24 h after surgery. Neither immediate major nor late
procedure-related complications were noted. Of the 71 patients with scrotal symptoms, the symptoms
completely subsided in 55 (77.5%) and partially subsided in 10 (14.1%). Only one (1.2%) recurrent varicocele
was detected within a mean follow-up of 21 months (range = 3–42). Neither hydrocele formation nor testicular
atrophy was found during the follow-up period.
Conclusion:
Our 5-year experience revealed that minilaparoscopic varicocelectomy with sparing of artery and lymphatic
vessels could safely and effectively ligate all spermatic veins and preserve spermatic arteries and lymphatic
channels without leading to a high varicocele persistence or recurrence.
Footnote Information
S.-D. Chung and C.-C. Wu contributed equally to this work.

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Medical College of Tzu Chi University, Hualien, Taiwan
12
3 Minilaparoscopic Varicocelectomy with Preservation of Testicular
4 Artery and Lymphatic Vessels by Using Intracorporeal
5 Knot-tying Technique: Five-year Experience
6
Shiu-Dong Chung•Chia-Chang Wu•
Victor Chia-Hsiang Lin•Chen-Hsun Ho•
Stephen Shei Dei Yang•Yao-Chou Tsai
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8
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? Socie ´te ´ Internationale de Chirurgie 2011
11
Abstract
Background
using minilaparoscopic intracorporeal knot tying to ligate
internal spermatic veins (ISV) while sparing the spermatic
artery and lymphatics.
Methods
Minilaparoscopic varicocelectomies were per-
formed in 87 patients between January 2004 and January
2009. All varicoceles were detected clinically according to
the World Health Organization (WHO) classification and
confirmed by scrotal color Doppler ultrasonography. The
surgical indications were scrotal symptoms in 71, infertility
in 16, and both conditions in 2. Three 3-mm minilaparo-
scopic ports were used for the operation. The ISVs were
dissected and then ligated with intracorporeal knot-tying.
12
In this study we present our experience
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The testicular artery and lymphatic vessels were carefully
preserved to minimize procedure-related complications.
Results
Unilateral laparoscopic varicocelectomy was
performed in 21 (24.2%) patients and bilateral in 66
(75.8%). Mean operative time was 71.1 ± 29.2 and
46.8 ± 12.6 min for bilateral and unilateral varicocelec-
tomies, respectively. All patients were discharged within
24 h after surgery. Neither immediate major nor late pro-
cedure-related complications were noted. Of the 71 patients
with scrotal symptoms, the symptoms completely subsided
in 55 (77.5%) and partially subsided in 10 (14.1%). Only
one (1.2%) recurrent varicocele was detected within a
mean follow-up of 21 months (range = 3–42). Neither
hydrocele formation nor testicular atrophy was found
during the follow-up period.
Conclusion
Our 5-year experience revealed that minila-
paroscopic varicocelectomy with sparing of artery and
lymphatic vessels could safely and effectively ligate all
spermatic veins and preserve spermatic arteries and
lymphatic channels without leading to a high varicocele
persistence or recurrence.
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Introduction
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Varicocele is considered one of the important causes of
male infertility and prepubertal testicular atrophy [1, 2].
The reported incidence of varicocele in the general popu-
lation and infertile populations is about 15 and 35%,
respectively [3, 4]. There are several well-established sur-
gical approaches for varicocele repair, including retrograde
or antegrade sclerotherapy and open and laparoscopic
surgical ligation of the internal spermatic veins (ISVs).
Laparoscopic varicocelectomy has been used widely in
managing varicoceles in pediatric and adolescent patients.
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A1 S.-D. Chung and C.-C. Wu contributed equally to this work.
A2
A3
A4
S.-D. Chung
Department of Urology, Far Eastern Memorial Hospital,
Taipei, Taiwan
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A6
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C.-C. Wu
Department of Urology, Taipei Medical University,
Shuang Ho Hospital, Taipei, Taiwan
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V. C.-H. Lin
Department of Urology, Institute of Biotechnology and
Chemical Engineering, E-Da Hospital, and I-Shou University,
Kaoshiung, Taiwan
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A13
A14
A15
C.-H. Ho ? S. S. D. Yang ? Y.-C. Tsai (&)
Department of Urology, Buddhist Tzu Chi General Hospital,
Taipei Branch, 289 Jianguo Road, Xindian city, Taipei, Taiwan
e-mail: tsai0523@ms29.url.com.tw
A16
A17
Y.-C. Tsai
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port under the umbilicus and the other two placed at the
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Previous studies have proved it to be a rapid, safe,
effective, and minimally invasive alternative for varicocele
correction [5–8]. Conventional laparoscopic varicocelec-
tomy was criticized for its high cost and relatively large
trocar wounds (5, 5, and 5 mm or 5, 10, and 5 mm trocars)
[9]. With the introduction of minilaparoscopic instruments,
reduced perioperative morbidity and better cosmetic results
were announced [10].
In 2004, our preliminary results of mini-laparoscopic
varicocelectomy combined with sparing of the artery and
lymphatic vessels was confirmed to be a safe and effective
procedure in treating varicoceles with minimal invasive-
ness [8]. However,highincidencesofpersistentorrecurrent
varicocele have been considered a drawback of testicular
artery-sparing varicocelectomy except open microsurgical
varicocelectomy. Hence, we designed a prospective trial of
minilaparoscopic varicocelectomy using an intracorporeal
knot-tying technique for ISV ligation along with testicular
artery and lymphatic vessel sparing.
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Materials and methods
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Between January 2004 and January 2009, 87 males with
scrotal symptoms and/or infertility underwent minilaparo-
scopic varicocelectomies via three 3.5 mm trocar ports.
The mean age was 27.9 ± 11.0 years. The surgical indi-
cations were scrotal symptoms in 71 patients (81.6%),
infertility in 16 (18.4%), and both conditions in 2 (2.3%).
We performed bilateral varicocelectomy for patients with
bilateral varicoceles and for those who were infertile
[11–13]. The definition of infertility was failure to establish
pregnancy under unprotected intercourse for more than
1 year. At least two semen analyses were performed for
infertile patients before surgery.
All varicoceles were detected clinically by physical
examination according to the guidelines of WHO [14].
A grade I varicocele is defined as a palpable impulse of
dilated veins with Valsalva’s maneuver but without venous
tortuosity; grade II is palpable tortuosity through the skin
with an impulse on Valsalva’s maneuver, and grade III is
palpable tortuosity without abdominal straining during
examination. Scrotal color Doppler ultrasonography was
also performed for varicocele confirmation. A dilated ISV
with a diameter[3 mm and a reverse of venous blood flow
under Valsalva’s maneuver was considered as varicocele.
The patient received endotracheal general anesthesia
and was placed in the Trendelenburg position to displace
the bowel cephalad. The pneumoperitoneum was estab-
lished by a Veress needle with an insufflating pressure
between 10 and 12 mmHg. Three 3.5 mm trocars were
placed in an isosceles triangle formation, with a camera
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lateral border of each rectus abdominis muscle. The 3 mm
laparoscopic instruments were used for the operation.
The spermatic cord at the internal ring was identified
and then the parietal peritoneum overlying the spermatic
cord was incised by scissors. The engorged ISVs were then
identified, dissected, ligated, and divided. The venous
ligation was performed by a freehand intracorporeal knot-
tying technique with 3-0 silk ligature. The lymphatic ves-
sels and testicular artery were meticulously identified and
preserved (Fig. 1). The small para-arterial veins that
sandwich the spermatic arteries were meticulously sepa-
rated and ligated (Fig. 2). In order to test the adequacy of
the ligation of refluxing veins, we applied manual com-
pression on the scrotum to observe whether the proximal
venous dilatation still existed. No electrocautery was used
during the whole operation to avoid thermal injury to the
spermatic cord and adjacent tissues. At the end of the
operation the carbon dioxide was expelled and the two
3.5-mm working ports were removed under direct vision.
The three small incisions were sealed with Steri-StripTM
instead of conventional skin sutures or staples.
All patients were discharged on the day of the operation
or the next day. Patients were followed up at 1 week and 3,
6, and 12 months postoperatively. Scrotal color Doppler
ultrasonography was performed for all patients and semen
analysis was done for infertility patients. Recurrent vari-
cocele was determined by physical examination if one had
clinically relevant varicocele during follow-up.
Values are presented as the mean ± SD. For continuous
variables, the treatments were compared using t-tests.
A P value\0.05 was considered statistically significant.
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Fig. 1 The lymphatic vessels (arrowhead) and testicular artery
(arrow) were meticulously identified and dissected
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Results
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Of all 87 patients, varicoceles were left-sided in 20
(23.0%), right-sided in 1 (1.1%), and bilateral in 66
(75.9%). A total of 153 varicocelectomies were performed.
Mean operative time was 71.1 ± 29.2 and 46.8 ±
12.6 min for bilateral and unilateral varicocelectomies,
respectively. Mean number of ligated ISVs was 2.8 ± 1.2
for left side and 2.6 ± 1.3 for right side (range = 1–5).
The testicular artery was identified and preserved in all
patients. In 120 of 153 (78%) varicoceles, small para-
arterial veins were identified and meticulously divided.
Aberrant collateral veins that were far from main trunk of
internal spermatic vessels were noted in 8 (5.2%) patients
and were also ligated and divided. One incidental right
indirect inguinal hernia was identified and the internal
inguinal ring was repaired with the hernia sac ligated and
transected. All the procedures were completed laparo-
scopically and no perioperative complications were
documented.
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The mean follow-up period was 12.7 ± 8.1 months.
Four patients complained of mild postoperative wound
pain which was relieved by oral analgesics and subsided
within one week. Of the 71 patients with scrotal symptoms,
the symptoms completely subsided in 55 (77.5%) and
partially improved in 10 (14.1%). The treatment success
rate in patients with scrotal symptoms was 91.5%. Six of
71 (8.4%) had no improvement at all. There was only one
varicocele recurrence which was confirmed by color
Doppler ultrasound. The patient had left varicocele recur-
rence (0.6%) after bilateral varicocelectomy for refractory
scrotal symptoms and underwent open subinguinal venous
ligation one year after laparoscopic surgery. Seven (41%)
of 17 adolescents had testicular asymmetry before the
operation, with the left testicle smaller than the right;
catch-up growth was achieved in 3/7 (42%) cases. Post-
operative epididymitis, hydrocele formation, and testicular
atrophy were not found during the follow-up period.
Comparing the seminal parameters before and after treat-
ment, with a 6-month interval in infertile patients,
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Fig. 2 The small periarterial venae comitans (arrow) that sandwich the spermatic artery (arrowhead) were meticulously separated
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87 patients had collateral veins that were all separated and
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significant increases in sperm concentration, motility, and
normal forms were observed (Table 1).
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Discussion
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The ideal technique for treating varicoceles should be
ligation of all spermatic veins with preservation of sper-
matic arteries and lymphatics [15]. Open microsurgical
varicocele repair is regarded as the gold standard of treat-
ment to achieve this goal. However, microsurgical vari-
cocelectomy should be performed by a highly skilled and
experienced surgeon because of the high number of inter-
nal spermatic vein channels and greater risk for arterial
injury due to the small artery diameter at the level of the
external inguinal ring. This level of skill and experience is
not easily available among general urologists. The tech-
nique used in this study had success (0.6% recurrence rate)
comparable to that of open microsurgical varicocelectomy
and a minimal complication rate. Thus, with the higher
magnification of the laparoscope and meticulous dissection
using delicate 3-mm laparoscopic instruments, the success
of microscopic varicocelectomy could also be achieved
with the current technique.
Highrates ofpersistent
(3.6–37.5%) have been considered a drawback of laparo-
scopic testicular artery-sparing varicocelectomy [16].
However, there have been several series reporting a low
recurrent rate (0.6–3%) with the loupe-assisted microsur-
gical technique, even though the testicular artery and
lymphatic vessels were preserved [17, 18]. In this study,
the endoscope provided a clear and magnified surgical
view that was as good as that of the loupe in microsurgery.
Therefore, the possibility of missing ISVs for division
could be minimized, and even the small periarterial venae
comitans that were too tiny to be grasped by conventional
5-mm laparoscopic instruments could be easily dissected
and divided by 3-mm laparoscopic instruments (Fig. 2).
Nyirady et al. [6] even advocated the importance of
dividing the collateral veins, which were believed to be a
major cause of varicocele recurrence. In our series, 8 of our
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or recurrentvaricocele
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divided with care to avoid varicocele recurrence. The low
recurrent rate (0.6%) of our study confirmed that minila-
paroscopic technique was as effective as the microsurgical
open technique in delicate ISV ligation. However, a pro-
spective trial is needed to confirm our speculation.
Compared with traditional open varicocelectomy, there
are several advantages of laparoscopic varicocelectomy
that have been well discussed and accepted [8]. First,
smaller minilaparoscopic incisions lead to less postopera-
tive pain and quicker convalescence. Second, patients who
have bilateral varicoceles would prefer concomitant varix
ligation using three laparoscopic working ports without
creating further wounds. Third, an aberrant course (bifur-
cation) of ISVs, which could possibly be missed by a
conventional high ligation technique, can definitely be
found and treated. Fourth, bowel adhesions over the course
of ISV, which might be related to the patient’s lower
abdominal discomfort, could be released during the
operation.
With the remarkable advances in laparoscopic instru-
ments nowadays, smaller working ports, e.g., 2 or 3 mm,
and instruments have been introduced for laparoscopic
surgeries. Matsuda et al. [10] observed that in their vari-
cocele patients who were grouped and treated with 10-mm
and 5-mm ports, the 5-mm-port group had less postopera-
tive wound pain and shorter convalescence than the 10-mm
port group. Chueh et al. [19] further reported their expe-
riences using minilaparoscopic instruments for varix liga-
tion and found that smaller trocar wounds yielded better
cosmetic results, less wound pain, and faster convales-
cence. Our study using minilaparoscopic instruments con-
firmed the advantage of minimally invasive surgery. All 87
patients of our study group were satisfied with the slight
wound pain and excellent cosmetic results.
The traditional mass high ligation of ISV carried a
greater risk of persistent postoperative hydrocele (5–25%)
compared to a lymphatic vessel-sparing procedure (0–3%)
[20–22]. Though most hydroceles resolved spontaneously,
postoperative testicular edema induced by lymphatic
channel division might lead to decreased testicular function
[22]. Besides, the increased hydrocele pressure might lead
to malfunction of spermatogenesis and testicular hypoxia,
which should be avoided in infertile men and adolescents
[23]. In our series none of our patients developed testicular
atrophy or hydrocele after the operation. Thus, we firmly
believe that by means of meticulous dissection and pres-
ervation of both the testicular artery and the lymphatic
vessels, varicocelectomy-related complications could be
minimized.
A high rate of bilateral varicoceles (73%) has been
documented in infertile men [24]. Scherr et al. [11] and
Pasqualotto et al. [12] advocated that bilateral varicoce-
lectomies should be performed for patients with left grade
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Table 1 Preoperative and postoperative seminal parameters in 16
infertile patients
Semen parametersPreoperative Postoperative P
Sperm concentration (million/
ml)
39.3 ± 26.9 52.6 ± 23.80.016
Motility (%) 53.0 ± 18.3 63.6 ± 12.80.010
Normal morphology (%)72.8 ± 8.378.0 ± 8.50.009
Values are mean ± standard deviation (SD)
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could also be expected.
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II-III and right grade 0 (subclinical) varicoceles because an
unrepaired right subclinical varicocele would have a
detrimental effect on bilateral testis function. Therefore, we
performed bilateral varicocelectomies in infertile men and
in those who had left grade II-III and right subclinical
varicoceles. During the follow-up period, we observed a
significant improvement in seminal parameters in infertile
patients. The results strengthened our belief that even an
asymptomatic right subclinical varicocele should be
repaired. However, a prospective study is needed to clarify
the role of a bilateral varicocelectomy in an infertile man
who has only a left varicocele.
Varicocele ligation had been confirmed to be an effec-
tive treatment for scrotal pain [25–27]. Although the liga-
tion methods varied, the reported resolution (complete and
partial) rate of pain is around 90% in the published liter-
ature [25–27]. This is quite comparable to the results
achieved by our technique. Possible reasons why varico-
cele ligation failed to relieve the pain in some are the
preoperative varicocele grade, pain characteristics, dura-
tion of pain and testicular pathologies other than varico-
cele. However, the relationships between cases and
associated risk factors could not be identified in the current
study. Therefore, a large-scale prospective randomized
study is needed to identify the factors that caused varico-
cele ligation not to relieve pain.
One of the biggest drawbacks of laparoscopic varico-
celectomy is the increased cost that is derived from the
laparoscopic consumables like disposable trocars, vessel-
sealing devices, and/or endoclips. In the current described
procedure, the cost of laparoscopic surgery was decreased
by using reusable trocars/instruments and an intracorporeal
knot ligation technique. The additional advantages of
intracorporeal knot ligation are that it is energy- and
thermal-free. Hence, the risk of spermatic artery, lymphatic
channel, and visceral organ thermal injury is avoided. The
main drawbacks of the intracorporeal knot-tying technique
are that it is more demanding and takes longer to perform
than other vessel ligation methods.
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Conclusions
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Our results revealed that minilaparoscopic intracorporeal
knot-tying varicocelectomy could safely and effectively
ligate all spermatic veins and preserve spermatic arteries
and lymphatic channels without leading to high varicocele
persistence or recurrence. With careful dissection and
preservation of the internal spermatic artery and lymphatic
vessels under the laparoscope, varicocele-related compli-
cations could be minimized. Good cosmetic results,
improved scrotal symptoms, and improved semen qualities
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References
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1. Kass EJ, Reitelman C (1995) Adolescent varicocele. Urol Clin
Am 22:151–159
2. Kass EJ, Freitas JE, Bour JB (1989) Adolescent varicocele:
objective indications for treatment. J Urol 142:579–582
3. Jarow JP, Coburn M, Sigman M (1996) Incidence of varicoceles
in men with primary and secondary infertility. Urology 47:73–76
4. Meacham RB, Townsend RR, Rademacher E et al (1994) The
incidence of varicoceles in the general population when evaluated
by physical exam, gray scale sonography and color Doppler
sonography. J Urol 151:1535–1538
5. Pintus C, Rodriguez Matas MJ, Manzoni C et al (2001) Varico-
cele in pediatric patients: comparative assessment of different
therapeutic approaches. Urology 57:154–157
6. Nyirady P, Kiss A, Pirot L et al (2002) Evaluation of 100 lapa-
roscopic varicocele operations with preservation of testicular
artery and ligation of collateral vein in children and adolescents.
Eur Urol 42:594–597
7. Koyle MA, Oottamasathien S, Barqawi A et al (2004) Laparo-
scopic Palomo varicocele ligation in children and adolescents:
results of 103 cases. J Urol 172:1749–1752
8. Wu CC, Yang SS, Wang CC et al (2004) Mini-laparoscopic
varicocelectomy using the knot-tying technique: a preliminary
report. JTUA 15:153–158
9. Riccabona M, Oswald J, Koen M et al (2003) Optimizing the
operative treatment of boys with varicocele: sequential compar-
ison of 4 techniques. J Urol 169:666–668
10. Matsuda T, Ogura K, Uchida J et al (1995) Smaller ports result in
shorter convalescence after laparoscopic varicocelectomy [see
comment]. J Urol 153:1175–1177
11. Scherr D, Goldstein M (1999) Comparison of bilateral versus
unilateral varicocelectomy in men with palpable bilateral varic-
oceles. J Urol 162:85–88
12. Pasqualotto FF, Lucon AM, de Goes PM et al (2005) Is it
worthwhile to operate on subclinical right varicocele in patients
with grade II-III varicocele in the left testicle? J Assist Reprod
Genet 22:227–231
13. Libman J, Larvi K, Lo K et al (2006) Beneficial effect of
microsurgical varicocelectomy is superior for men with bilateral
versus unilateral repair. J Urol 176:2602–2605
14. World Health Organization (1987) Comparison among different
methods for the diagnosis of varicocele. Fertil Steril 47:833
15. Cayan S, Shavakhabov S, Kadioglu A (2008) Treatment of pal-
pable varicocele in infertile men: a meta-analysis to define the
best technique. J Androl 30:33–40
16. Kass EJ, Marcol B (1992) Results of varicocele surgery in ado-
lescents: a comparison of techniques. J Urol 148:694–696
17. Goldstein M, Gilbert BR, Dicker AP et al (1992) Microsurgical
inguinal varicocelectomy with delivery of the testis: an artery and
lymphatic sparing technique. J Urol 148:1808–1811
18. Hsieh ML, Chang PL, Huang ST et al (2003) Loupe-assisted high
inguinal varicocelectomy for sub-fertile men with varicoceles.
Chang Gung Med J 26:479–484
19. Chueh S, Liao C, Wang S et al (2005) Clipless needlescopic
bilateral varix ligation. J Androl 26(1):93–97
20. Hassan JM, Adams MC, Pope JC et al (2006) Hydrocele for-
mation following laparoscopic varicocelectomy. J Urol 175:
1076–1079
21. Szabo R, Kessler R (1984) Hydrocele following internal sper-
matic vein ligation: a retrospective study and review of the lit-
erature. J Urol 132:924–925
22. Kocvara R, Dolezal J, Hampl R et al (2003) Division of lym-
phatic vessels at varicocelectomy leads to testicular oedema and
World J Surg
123
Journal : Large 268
Dispatch :
22-4-2011
Pages :
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384
385
386
387
388
389
390
391
decline in testicular function according to the LH-RH analogue
stimulation test. Euro Urol 43:430–435
23. Bayne A, Paduch D, Skoog SJ (2008) Pressure, fluid and ana-
tomical characteristics of abdominoscrotal hydroceles in infants.
J Urol 180:1720–1723
24. Cayan S, Erdemir F, Ozbey I et al (2002) Can varicocelectomy
significantly change the way couples use assisted reproductive
technologies? J Urol 167:1749–1752
392
393
394
395
396
397
398
399
400
25. Park HJ, Lee SS, Park NC (2011) Predictors of pain resolution
after varicocelectomy for painful varicocele. Asian J Androl. doi:
10.1038/aja.2010.87
26. Maghraby HA (2002) Laparoscopic varicocelectomy for painful
varicoceles: merits and outcomes. J Endourol 16:107–110
27. Al-Buheissi SZ, Patel HR, Wazait HD et al (2007) Predictors of
success in surgical ligation of painful varicocele. Urol Int
79:33–36
World J Surg
123
Journal : Large 268
Dispatch :
22-4-2011
Pages :
6
Article No. :
1115
h
4
LE
h
4
TYPESET
MS Code :
WJS-10-12-1519
h
CP
h
DISK
Author Proof