LAPAROSCOPIC TREATMENT OF PEDIATRIC VARICOCELE: A MULTICENTER STUDY OF THE ITALIAN SOCIETY OF VIDEO SURGERY IN INFANCY CIRO ESPOSITO, GIAN LUCA MONGUZZI, MIGUEL ANTONIO GONZALEZ-SABIN, RENATO RUBINO, LEONARDO MONTINARO, ALFONSO PAPPARELLA AND GIUSEPPE AMICI From the Division of Pediatric Surgery, “Federico II” University of Naples and Second University of Naples, Naples, “Magna Graecia” University of Catanzaro and Pugliese Hospital, Catanzaro, Buzzi Hospital, Milan and University of Bari, Bari, Italy, and William Soler Hospital, La Habana, Cuba ABSTRACT Purpose: We report preliminary results of a multicenter study of the Italian Society of Video Surgery in Infancy on the laparoscopic treatment of pediatric varicocele. Materials and Methods: A total of 161 children 6 to 16 years old (median age 12.5) underwent laparoscopic treatment of varicocele at 6 pediatric surgery divisions. Varicocele was on the left side in 159 cases (98.7%) and bilateral in 2 (1.3%). Two boys had recurrent left varicocele. All children were treated with laparoscopy, including ligation of the spermatic veins only in 28 (17.3%), and ligation of the testicular veins and artery in 133 (82.7%). In 10 boys (6.2%) an additional procedure was done simultaneously, including closure of an apparently patent peri- toneal vaginal duct on the right side in 7 and resection of epiploic adhesions between the intestinal loops and abdominal wall from previous appendectomy in the remaining 3. Results: Average operative time was 30 minutes and hospitalization was about 24 hours. At followup there were 13 minor complications (8%), including left hydrocele in 9 children who underwent the Palomo technique, minor scrotal emphysema in 2 and umbilical granuloma in 2. In our series varicocele recurred in 1 boy (3.5%) who underwent ligation of the spermatic veins only and in 3 (2.2%) treated with the Palomo technique. Conclusions: Our preliminary experience shows that the results of the laparoscopic approach are comparable to those of the open approach. However, the important advantages of laparoscopy over the open approach are its minimal invasiveness and precision of intervention. Moreover, laparoscopy allows treatment of other intra-abdominal pathological conditions using the same anesthesia, as in 10 patients in our series. We believe that ligating the testicular veins and artery is preferable to ligating the testicular veins only, even if the incidence of hydrocele is not negligible after the Palomo procedure. KEY WORDS: testis; varicocele; infertility, male; laparoscopy Varicocele is considered the most identifiable cause of male infertility. 1 The incidence of varicocele in the prepubertal age ranges from 10% to 15% in various series and the importance of early treatment in childhood for preventing testicular damage is widely accepted. 2 Treatment options include sper- matic vein sclerotherapy or embolization, classical surgical treatment via the scrotal, high retroperitoneal or inguinal approach, microsurgical bypass and more recently laparos- copy. 3–7 We report preliminary results of the multicenter study of the Italian Society of Video Surgery in Infancy of the laparoscopic treatment of varicocele in children. PATIENTS AND METHODS In a 3-year period from January 1995 to December 1997, 195 children 6 to 16 years old (median age 12.5) underwent laparoscopic treatment of varicocele at 6 pediatric surgery divisions. In this study we present only 161 of the 195 cases because 34 reports were not correct or complete. Varicocele was on the left side in 159 cases (98.7%) and bilateral in 2 (1.3%). Two boys had recurrent left varicocele after previous open surgery. Table 1 shows the results of preoperative examinations. In the 2 cases of recurrent varicocele venography showed reflux through the deferential veins and recurrence via the spermatic internal veins in 1 each. Varicoceles were graded according to the Horner classification as first degree—palpable but not well visible in 21 cases (13%), second degree—palpable and clearly visible in 83 (51.5%), and third degree—large in 57 (35.5%). Third degree varicocele was always an indication for surgery. In cases of first and second degree varicocele pain or scrotal discomfort, or testicular asymmetry with hypotrophy of the side affected was also an indication (table 2). All 57 boys with third degree varicocele were symptomatic and 42 of the 57 (73.6%) had testicular hypotrophy. All children were treated via laparoscopy. After the induction of general anesthesia the patient was place in the Trendelenburg position. In 141 cases (87.6%) we used 3 trocars in triangu- Accepted for publication December 10, 1999. Editor’s Note: This article is the fifth of 5 published in this issue for which category 1 CME credits can be earned. In- structions for obtaining credits are given with the questions on pages 1956 and 1957. TABLE 1. Preoperative diagnostic evaluations No. Pts. (%) Supine + standing scrotal examination 161 (100) Testicular vol. determination 161 (100) Scrotal + color Doppler ultrasound 75 (46.5) Preop. venography 16 (9.9) 0022-5347/00/1636-1944/0 THE JOURNAL OF UROLOGY ® Vol. 163, 1944 –1946, June 2000 Copyright © 2000 by AMERICAN UROLOGICAL ASSOCIATION,INC. ® Printed in U.S.A. 1944