Stesura Seveso Archivio Italiano di Urologia e Andrologia 2023; 95(3):11627 1 SYSTEMATIC REVIEW tion and infertility. Discomfort due to varicocele, testicular size asymmetry exceeding 20% or testicular atrophy, bilat- eral varicocele, and high-grade varicocele are indications of varicocelectomy in adolescents (5, 6). Previous studies have shown that testicular hypotrophy can improve in 40- 100% of cases after varicocelectomy, significantly enhanc- ing parameters such as sperm concentration, total and pro- gressive motility, and morphology (7, 8). Microsurgical varicocelectomy is still rarely used in the pediatric population due to several factors (9). Lack of experience with microscopic techniques, smaller testicu- lar arteries, and lower blood pressure from systemic arter- ies in pediatric patients are difficulties that make arterial identification more difficult in the subinguinal or inguinal approach. Consequently, there has been a growing adop- tion of laparoscopic techniques by pediatric urologists over the past decade. This is primarily attributed to the numerous advantages these techniques offer, including faster operating and recovery times as well as visualiza- tion capabilities comparable to microsurgery (10, 11). Laparoscopic varicocelectomy (LV) using Palomo's method, which involves the simultaneous ligation of the internal spermatic vein (ISV) and internal spermatic artery (ISA), has demonstrated a favorable success rate without any significant increase in the risk of testicular atrophy (12). However, there is debate among pediatric urologists regarding the importance of artery preservation during varicocelectomy. The controversy surrounding the need for artery preservation (AP) during LV has also been report- ed in several studies. Some studies suggest that the AP procedure is more appropriate as it prevents iatrogenic testicular trauma and reduces the incidence of postopera- tive hydrocele, while others report that artery ligation (AL) has a low recurrence and hydrocele rate but may disrupt testicular growth and future fertility. Conversely, the AP procedure has been associated with higher rates of per- sistence and recurrence compared to AL during LV (3, 4, 13). Currently, there is a lack of well-established evidence- based medicine (EBM) studies comparing AL and AP dur- ing LV. In order to determine the impact of arterial liga- tion following LV, this systematic review and meta-analy- sis aims to assess the efficacy and safety of laparoscopic varicocelectomy, comparing procedures with or without artery preservation in pediatric and adolescent population. Introduction: Challenges in identifying small testicular arteries and lack of microscopic experience have led to a rising trend in the use of laparoscopic technique for pediatric and adolescent varicocele. The contro- versy over artery ligation (AL) and artery preservation (AP) during laparoscopic varicocelectomy (LV) is still debatable. This study investigates the effectiveness of AL and AP during LV in pediatric and adolescent varicocele cases. Methods: The systematic searches based on PRISMA guideline were conducted in PubMed, Scopus, ScienceDirect, Web of Science and ProQuest databases with pre-defined keywords. Both quantitative and qualitative analyses were performed to assess catch-up growth, persistence, recurrence, hydrocele, oper- ative time, post-operative testicular volume, and sperm analysis. Results: A total of 1512 patients from 9 eligible studies were included. There were no significant differences in catch up growth (OR 0.89; 95%CI 0.53, 1.51; p = 0.68) or hydrocele inci- dence (OR 0.59; 95%CI 0.28, 1.24; p = 0.16). The recurrence rate and persistence rate in AP group is significantly higher compared to AL group (OR 2.95; 95%CI 1.53, 5.68; p = 0.001 and OR 5.13; 95% CI 2.04, 12.88; p = 0.0005, respectively). The mean operative time during laparoscopic varicocelectomy is significantly longer when arteries are preserved as opposed to when they are ligated (OR 5.33; 95%CI 2.05, 8.60; p = 0.001). AL and AP both improved testicular volume and post-operative sperm analysis. Conclusions: AL showed higher efficacy and comparable safety to AP. We recommend using AL with lymphatic sparing to mini- mize hydrocele complications. KEY WORDS: Adolescent; Pediatric andrology; Varicocele; Undescended; Testes; Laparoscopic; Ligation; Testicular artery. Submitted 31 July 2023; Accepted 3 August 2023 INTRODUCTION Varicocele is a medical condition characterized by the enlargement of the pampiniform plexus veins within the spermatic cord and is known to be a leading cause of male infertility (1, 2). The incidence in boys until puberty ranges from 2% to 11% and increases up to 16% in post- pubertal adolescents (3, 4). Inadequate management of varicocele in adolescents can lead to impairment of testic- ular growth, which can result in spermatogenesis dysfunc- A systematic review and meta-analysis on the efficacy of internal spermatic artery ligation during laparoscopic varicocelectomy in children and adolescents: Is it safe? Ahmad Nurfakhri Syarief, Ilham Akbar Rahman, Agung Ravi Saputra Sangadji, Tarmono Djojodimedjo, Fikri Rizaldi Department of Urology, Faculty of Medicine, Universitas Airlangga and Dr. Soetomo General-Academic Hospital, Surabaya, East Java, Indonesia. DOI: 10.4081/aiua.2023.11627 Summary Archivio Italiano di Urologia e Andrologia 2023; 95(3):11627 A. Nurfakhri Syarief, I. Akbar Rahman, A. Ravi Saputra Sangadji, T. Djojodimedjo, F. Rizaldi 2 MATERIALS AND METHODS This study followed a predetermined protocol according to the guidelines outlined by the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) (14) Initial searches were conducted to ensure that the specific char- acteristics outlined in the PICO (Population, Intervention, Comparison, Outcome) framework had not been previously investigated, thereby avoiding duplication of existing meta- analyses. The literature searches were conducted using sev- eral databases, including PubMed, Scopus, ScienceDirect, Web of Science, and ProQuest. The selected keywords used for the search were described as “varicocele”, “varicocelecto- my”, “laparoscopic varicocelectomy”, “laparoscopic Palomo”, “ligated artery”, “artery ligation”, “spared artery”, “artery sparing”, “preserved artery”, and “artery preservation”. The study's protocol was registered with PROSPERO (CRD42023445437). Criteria for inclusion and exclusion To be considered for inclusion, eligible articles need to meet specific criteria. These criteria included comparative stud- ies, written in English, having at least two comparison groups, and reporting data on catch-up growth, persistence, recurrence, hydrocele, and operation time in laparoscopic varicocelectomy with or without artery preservation. During the selection process, studies that fell under the fol- lowing categories were excluded: animal experimental stud- ies, publication types other than original research, unpub- lished articles, and abstract-only findings. Data extraction Two separate researchers col- lected the data using a prede- fined extraction template. In cases of discrepancies or dis- agreements during data extraction, a third investigator would be involved to discuss and make the final decision. The extracted information encompassed various aspects, including study details (such as authors, publication date, study design, sample size, inclusion and exclusion crite- ria, and follow-up duration), subject characteristics at base- line (such as age, intervention types, and study location), also qualitative and quantita- tive outcomes (such as catch- up growth, persistence, recur- rence, hydrocele, operation time, testicular volume, and sperm analysis). Quality assessment The assessment of potential research bias in non-ran- domized studies was conducted using the Newcastle- Ottawa Scale (NOS), which evaluates parameters related to selection, comparability, and exposure. The results obtained from the NOS assessment are categorized into three groups. A score ranging from 0 to 3 implicates a low-quality study, a score from 4 to 6 implicates a medi- um-quality study, and a score from 7 to 9 implicates a high-quality study. For randomized controlled trial (RCT) studies, the assessment of potential research bias was con- ducted using the Cochrane RoB tools V2, which evaluates four domains, such as randomization process, deviations from intended intervention, missing outcome data, meas- urement, and selection of reported outcome (15). Statistical analysis The measured endpoints included catch-up growth, per- sistence, recurrence, hydrocele incidence, and mean operative time. For the dichotomous variable analysis, Odds Ratio (OR) with a 95% Confidence Interval (CI) was used, and a p-value below 0.05 was considered statisti- cally significant. The continuous variable was assessed using Mean Difference (MD). Heterogeneity between stud- ies was evaluated using I2, where an I2 value above 50% indicated high heterogeneity and a random-effects model was applied for pooled analysis. If I2 was less than 50%, a fixed-effects model was used. The statistical analysis Figure 1. identification of studies. Archivio Italiano di Urologia e Andrologia 2023; 95(3):11627 3 Safety of artery ligation in pediatric laparoscopic varicocelectomy was conducted using RevMan 5.4 for Windows software, and the results were presented through Forest plots and descriptive narratives. RESULTS Systematic search results An initial 393 articles were found according to the used keywords. Complete eligibility assessment resulted in nine matched articles for further qualitative and quantitative analysis (Figure 1). Seven included studies were retrospec- tive cohorts in design, while the other two were RCTs. Baseline characteristics of the included studies This research included a total of 1512 patients with a mean age of 13.7 years, ranging from 6 to 20 years old. These participants comprised various articles published between 1999 and 2020. This study represented a total of 1409 patients with unilat- eral left-side varicocele and 103 patients with bilateral varic- ocele. Most of the participants presented with varicocele grade II-III. The detailed characteristics and outcomes data of the included studies are shown in Table 1 and Table 2. Risk of bias assessment Regarding the selection aspect, all included studies demon- strated a robust selection process, ensuring the populations were fairly representative of young men with varicocele. Moreover, the comparative and exposure aspects were well addressed, with adequate follow-up duration and relatively low dropout rates. Based on the final assessment, three studies achieved a NOS score of eight, while the other four studies received a NOS score of seven, indicating a low risk of bias (Table 3). However, the RCT studies assessed using the Cochrane RoB tool V2 (Figure 2) raised some concerns due to insufficient clarity regarding the randomization process described in the article. Table 1. Characteristics data of included studies. Study Design Age (years) Intervention Sample Varicocele type Degree Outcome Follow up size of varicocele (month) Lund, 1999 (17) Observational 12.9 (8-15) Laparoscopy varicocelectomy AP 13 6 (left), NR Recurrency, catch up growth 6-48 AL 7 7 (bilateral) NR F. Varlet, 2000 (16) Observational 12.15 (7-16) Laparoscopy varicocelectomy AP 28 84 (left), NR Persistency, testicular hypotrophy/ 11.1 (2-36) AL 59 3 (bilateral) NR atrophy, catch up growth Ciro Esposito, 2001 (6) Observational 11.5 (6-17) Laparoscopy varicocelectomy AP 30 209 (left), I: 26, II :98, 7 Hydrocele, Recurrency 26 (12-72) AL 181 2 (bilateral) III: 8 Nicola Zampieri, RCT 14.3 (12-16) Laparoscopy varicocelectomy AP 59 59 (left) II: 82, III: 40 Recurrency/persistency, Hydrocele, 18 2007 (20) AL 63 63 (left) Operative time, Sperm quality parameters A.M. Fast, 2013 (13) Observational 15.5 (9.3-20.6) Laparoscopy varicocelectomy AP 41 28 (left), 13 (bilateral) NR Recurrency, catch up growth 30.5 or lymph node sparing AL 312 241 (left), 71 (bilateral) NR 33.3 laparoscopy varicocelectomy K.S. Kim, 2013 (19) Observational 13.2 ± 2.1 Laparoscopy varicocelectomy AP 50 50 (left) II: 10, III: 40 Recurrency/persistency, Catch up growth, 21 ± 12.3 AL 42 42 (left) II: 9, III: 33 Operative time Weimin Yu, 2015 (4) Observational 17.3 ± 2.4 Laparoscopy varicocelectomy AP 57 122 (left) II: 36, III: 21 Recurrency, Hydrocele, Catch up growth, 17.1 ± 7.4 AL 65 II: 41, III: 24 Sperm quality parameters 17.8 ± 7.0 Ciro Esposito, 2017 (8) Observational 12.5 (8-17) Laparoscopy varicocelectomy AP 10 345 (left) III: 10 Recurrency, operative time, testis volume, 28.8 ± 8.3 or lymph node sparing AL 335 II: 66, III: 269 hydrocele laparoscopy varicocelectomy Abdelaziz Yehya, RCT 14.25 ± 1.6 Lymph node sparing AP 80 160 (left) II: 28, III: 52 Persistency, Catch up growth, operative time, 42 2020 (18) laparoscopy varicocelectomy AL 80 II: 32, III: 48 testicular volume NR: Not Reported; AP: Artery Preservation; AL: Artery Ligation. Figure 2. Risk of bias assessment. Archivio Italiano di Urologia e Andrologia 2023; 95(3):11627 A. Nurfakhri Syarief, I. Akbar Rahman, A. Ravi Saputra Sangadji, T. Djojodimedjo, F. Rizaldi 4 Meta-analysis result on catch-up growth Based on a meta-analysis of the six papers included (4, 13, 16-19), there is no statistically significant difference in the amount of catch-up growth between AL and AP during laparoscopic varicocelectomy (OR 0.89; 95%CI 0.53, 1.51; p = 0.68) (Figure 3). The fixed-effects model was used due to low heterogeneity between studies (p = 0.81; I2 = 0%). Of the six studies, Fast et al. and Yehya et al. represented higher statistical weight compared to other studies due to a larger sample size (13, 18). Meta-analysis result on persistence rate Four studies were analyzed in this meta-analysis (16, 18- 20), the persistence rate revealed a significant difference in which the AP group provided the higher persistence compared to the AL group (OR 5.13; 95%CI 2.04, 12.88; p = 0.0005) (Figure 4). Because of the low heterogeneity observed between studies, the fixed-effects model was employed (p = 0.88; I2 = 0%). Table 3. Risk of bias assessmment using Newcastle Ottawa Scale. Authors Selection Comparatibility Exposure Total Score Lund, 1999 *** ** *** 8 Varlet et al. 2000 *** ** *** 8 Esposito et al. 2001 *** ** *** 8 Kim et al. 2013 *** ** ** 7 Fast et. al 2013 *** ** ** 7 Weimin Yu et al. 2015 *** ** ** 7 Esposito et al. 2018 *** ** ** 7 Table 2. Outcomes data of included studies. Study Intervention Recurrence Persistence Hydrocele Catch-up growth Post-op Operative time Post-op Sperm Analysis Volume testis 12 24 Final Hypotrophy/ (minutes) Sperm count Motility Morphology Pre op Post op months months visit Testicular Atrophy (miillion/ml) (%) (%) Lund, 1999 AP 2/20 NR 3/20 NR NR 18/20 NR NR NR NR NR NR NR AL 2/7 NR 0/7 NR NR 5/7 NR NR NR NR NR NR NR F. Varlet, 2000 AP NR 9/28 11 NR NR 3/12 1/12 NR NR NR NR NR NR AL NR 5/60 NR NR 11/30 3/30 NR NR NR NR NR NR Ciro Esposito, 2001 AP 2/30 NR 0/30 NR NR NR 0/30 30 (20-70) NR NR NR NR NR AL 3/181 NR 14/181 NR NR NR 0/181 NR NR NR NR NR Nicola Zampieri, 2007 AP 5/59 1/59 1/59 NR NR NR NR 35-60 73.81 45.73 45.13 NR NR (0.2-250) (0-75) (9-89) AL 0/63 0/63 8/63 NR NR NR NR 20-40 58.85 39.04 38 NR NR (3.5-182) (11-68) (6-85) A. M. Fast, 2013 AP 5/41 NR NR 12/33 22/33 27/33 0/41 NR NR NR NR NR NR AL 17/312 NR NR 81/236 147/236 194/236 0/312 NR NR NR NR NR NR K.S. Kim, 2013 AP 8/50 3/50 0/50 14/15 NR NR 0/50 83.1 ± 31.8 NR NR NR NR NR AL 1/42 1/42 2/42 9/10 NR NR 0/42 72.5 ± 33.4 NR NR NR NR NR Weimin Yu, 2015 AP 3/57 NR 4/57 14/23 18/23 NR NR 41.3 ± 8.8 62.5 ± 39.2 52.2 ± 16.6 11.5 ± 1.5 NR NR AL 2/65 NR 4/65 10/24 19/24 NR NR 39.5 ± 7.1 60.4 ± 38.2 49.1 ± 19.9 10.7 ± 1.5 NR NR Ciro Esposito, 2017 AP 1/10 NR 2/10 NR NR NR 0/10 26 (18-50) NR NR NR 12.4 ± 4.9 NR 29.3 ± 10.3 AL 4/335 NR 23/335 NR NR NR 0/335 17 (14-45) NR NR NR 12.0 ± 5.2 15.4 ± 4.8 17.6 ± 5.3 Abdelaziz Yehya, 2020 AP NR 8/80 0/80 NR 68/80 NR 0/80 40 ± 2.6 NR NR NR 12.2 ± 3.1 16.3 ± 4 AL NR 1/80 0/80 NR 71/80 NR 0/80 35 ± 2.8 NR NR NR 14.1 ± 4.6 17.1 ± 5.1 NR: Not Reported; AP: Artery Preservation; AL: Artery Ligation. Figure 3. Meta-analysis result on catch-up growth. Archivio Italiano di Urologia e Andrologia 2023; 95(3):11627 5 Safety of artery ligation in pediatric laparoscopic varicocelectomy Meta-analysis result on recurrence rate Seven studies were analyzed for this outcome (8, 13, 17- 21). On pooling analysis of the data, the recurrence rate in AP group is higher compared to AL group (OR 2.95; 95%CI 1.53, 5.68; p = 0.001) (Figure 5). Most of the stud- ies demonstrated a higher recurrence rate in artery preser- vation group, except for one study (17). The fixed-effects model was applied because there was minimal heterogene- ity observed between studies (p = 0.25; I2 = 23%). Meta-analysis result on hydrocele incidence The analysis of six included studies reveals that there is no significant statistical difference in hydrocele incidence between AL and AP during laparoscopic varicocelectomy (OR 0.59; 95%CI 0.28, 1.24; p = 0.16) (Figure 6) (4, 8, 17, 19-21). The choice of the fixed-effects model was based on the minimal heterogeneity observed among the studies (p = 0.08; I2 = 50%). Varlet et al. reported 11 patients with postoperative hydrocele, but the number of patients in each group was unknown (16). Meta-analysis result on mean operative time According to a meta-analysis of the four papers included (8, 18-20), the mean operative time during laparoscopic varicocelectomy is significantly longer when arteries are preserved as opposed to when they are ligated (OR 5.33; 95%CI 2.05, 8.60; p = 0.001) (Figure 7). The mean oper- ative time was expressed in minutes. Due to significant heterogeneity observed between studies, the random- effects model was employed (p = 0.02; I2 = 69%). Esposito Figure 4. Meta-analysis result on persistence rate. Figure 5. Meta-analysis result on recurrence rate. Figure 6. Meta-analysis result on hydrocele incidence. Archivio Italiano di Urologia e Andrologia 2023; 95(3):11627 A. Nurfakhri Syarief, I. Akbar Rahman, A. Ravi Saputra Sangadji, T. Djojodimedjo, F. Rizaldi 6 et al. reported an average operating time of 30 minutes. However, it was unclear for each group (6). Qualitative synthesis of testicular volume In this study, two separate studies reported the change in testicular volume before and after surgery (8, 18). There was an increase in testicular volume observed in both AL and AP groups during laparoscopic varicocelectomy. However, the significance of the difference could not be analyzed due to the absence of one data point in the post- surgery testicular volume in the study conducted by Esposito et al. (8). Qualitative synthesis of postoperative sperm analysis Two included studies provided information regarding post-surgery sperm analysis in the AL and AP groups (4, 20). The results reported that AL and AP laparoscopic varicocelectomy both resulted in normal sperm parame- ters following the surgery, with slightly higher values observed in the AP group. However, due to the lack of studies reporting sperm analysis after the surgery, it was not possible to analyze and provide the quantitative data comprehensively. However, the initial result of this qual- itative analysis may provide an idea that there is no dif- ference in postoperative sperm outcome between AP and AL during laparoscopic varicocelectomy. DISCUSSIONS This is the first systematic review and meta-analysis that compares the efficacy and safety of AL and AP during LV in pediatric and adolescent population. In our research, we have prioritized catch-up growth as the main focus due to its significant potential for enhancing testicular function and positively influencing fertility outcomes in individuals with varicocele. Both AL and AP groups demonstrated an increase of 63 to 86% testicular catch- up growth within 12 to 24 months after surgery (22-25). Weimin Yu et al. in their study, reported that a lower rate of catch-up growth was observed in the AL group during the first year of follow-up. They suggested that the remodeling of neovascularization in testicular drainage after the AL procedure, which is important for maintain- ing normal testicular metabolism, may require a relative- ly longer time (4). The findings of similar outcome in catch-up growth between AL and AP procedures in this study may be due to the fact that both techniques demon- strated identical effects on testicular blood flow (26). As observed in a recent meta-analysis, surgical correction of varicocele may result in superior catch-up growth of the affected testis. It can be inferred that the acceleration of growth in the affected testes is attributed to the removal of the detrimental effects of varicocele on testicular devel- opment (19). One of the concerns in this study was the incidence of postoperative hypotrophic testes. From the analysis of nine included studies, only study conducted by Varlet et al. reported the incident (4, 8, 13, 16-21). Contrast with Yehya et al., whose study reported a significant increase in testicular volume even though the ISA were ligated dur- ing LV (18). Ligation above the level of the internal inguinal ring is considered safe because there are collat- eral arteries below the internal ring that play a role in pro- viding an adequate blood supply to the testicle, prevent- ing a significant decrease in oxygen and nutrient delivery (27, 28). Those collateral arteries become more favorable for maintaining blood supply to the testicles as a result of reduced blood flow from the main artery after ligation (8). Previous surgery on the inguinal area like hernia repair, may result in significant injury to the collateral tes- ticular arteries, such as the cremasteric and differentialis arteries. These injuries may provide an impact on post- operative hypotrophy events in case AL procedure is per- formed (16). Although no studies have specifically observed the role of collateral arteries in testicular volume growth in the ligation artery group, an increase in volume suggests the occurrence of vascular adaptations. However, it is important to note that an increase in tes- ticular volume after arterial ligation is not always accom- panied by an increase in testicular function or sperm quality. Spermatogenesis may still be impaired due to loss of primary blood supply (20). Sperm analysis after varicocelectomy in adolescents is not routinely examined because of the barriers of parental consent, even though it is an important parameter after varicocelectomy (29). This is maybe the reason that only two of our nine included studies reported the sperm analysis parameters post-operation (4, 20) According to the findings of Zampieri et al., the AP group demonstrat- ed superior semen quality compared to the AL group, even though there is no statistically significant difference between the two groups. In terms of mean sperm con- centration outcome, the AP group demonstrated a higher value compared to the AL group (73.81 x 106 and 58.85 x 106, respectively). Furthermore, the AP group exhibit- ed higher sperm motility (45.73%) compared to the AL Figure 7. Meta-analysis result on mean operative time. Archivio Italiano di Urologia e Andrologia 2023; 95(3):11627 7 Safety of artery ligation in pediatric laparoscopic varicocelectomy group (39.04%), with a greater proportion of normal morphology sperm cells (45.13% vs. 38%). They believe that AP is necessary since preserving the normal blood supply of the arteries seems more appropriate to prevent testicular damage and dysfunction (20). Therefore, it is important to consider further studies with long-term fol- low-up to assess the parameters of sperm function and quality in the postoperative evaluation of the AL group before determining whether the AL method adversely affects testicular function and spermatogenesis. Our study reveals a notable contrast in the recurrence and persistence rates between AP and AL groups. Specifically, the group that underwent arterial preservation showed a higher recurrence and persistence rate. This finding aligns with Kattan et al.'s findings, which reported that AP exhibited a higher recurrence rate compared to AL. This was mainly due to the presence of blood flow in non- functional collateral veins as a result of venous pressure increases following ISV ligation or failing to ligate the small veins along the anterior wall of ISA due to fear of injuring the artery. Mass ligation of the gonadal vessels allows for complete obliteration, thus preventing missed collateral veins (30). Another possible reason for persis- tency could be the existence of collateral veins that origi- nate from the internal spermatic vein below the occlusion site and directly drain into the internal iliac vein or the inferior cava (31). However, there have been several stud- ies reporting a low recurrent rate (0.6-3%), even though the testicular artery and lymphatic vessels are preserved. A study by Chung et al. declares that the possibility of missing small periarterial veins can be minimized. They can be easily divided and dissected using 3 mm mini laparoscopic instruments (32). However, future research needs to be done on a larger scale to prove this statement. Our investigation showed no significant difference in the incidence of hydroceles between artery preservation and ligation, in contrast to the findings of a study by Zampieri et al., which found a correlation between AL and the development of hydroceles. They suggest that the com- plete ligation of spermatic and lymphatic vessels can cause blood stasis within the scrotum (20). The risk of develop- ing hydrocele may be increased if lymphatic preservation is not performed. However, there was no association between artery preservation or ligation and hydrocele inci- dence, as reported in a study by Weimin Yu et al. (4). Liang et al.'s meta-analysis indicated that selecting a lymphatic preservation method is advisable to decrease the occur- rence of hydroceles. This is because the standard Palomo procedure does not involve the preservation of lymphatic glands, leading to the accumulation of lymphatic fluid in the scrotum, which contributes to a higher risk of hydro- cele formation (33). Mathias et al. found that there was no significant difference between arterial sparring and liga- tion regarding the incidence of postoperative hydrocele in lymphatic sparing varicocelectomy. Yehya et al. also con- firmed this by reporting no incidence of hydrocele in both the AP and AL groups during lymphatic sparring LV (18). While we found that the AP group significantly had a longer mean operative time than the AL group, Weimin Yu et al. found no statistically significant difference between the two groups (4). The operating time may vary depend- ing on the surgeon's experience (24). This is probably the reason that this outcome in this study possessed a higher heterogeneity compared to another outcome. This metic- ulous process involves carefully locating and preserving the arterial blood supply while removing or ligating the dilated veins causing the varicocele. The surgeon must exercise caution and take the necessary time to ensure the arteries are properly identified and spared from damage. Consequently, this longer time requirement is attributed to the surgeon's focus on accuracy and the intricate nature of preserving the arterial blood flow during the procedure (34). Together with practical experience, it appears that there is a learning curve that enables surgeons to perform this technique more efficiently, resulting in shorter opera- tive times as their expertise grows (24). One of several limitations of this meta-analysis is the lack of RCT studies in contrast with more observational stud- ies. RCTs are considered the gold standard for establish- ing causal relationships due to their rigorous design and randomization process. On the other hand, observational studies rely on naturally occurring data and a lack of ran- dom assignment of participants, making them more sus- ceptible to confounding factors and biases. Moreover, the long-term assessment regarding catch-up growth and tes- ticular function following varicocelectomy in this age group could be feasibly obtained by performing prospec- tive cohort studies and retrospective analyses. Several variations such as interventions in LV procedures where some were accompanied by lymphatic sparring and sub- sequently testicular development which were assessed by different standards became another limitation in this study. Therefore, outcome measures such as hydrocele and catch-up growth can be biased. We expect that future research will include longterm follow-up and a uniform examination of sperm parameters while adhering to strict ethical approval protocols. CONCLUSIONS This study highlights the superior efficacy of the AL tech- nique, which maintains similar safety to the AP tech- nique. We recommend adopting the AL technique with lymphatic sparing routinely to enhance efficacy and min- imize hydrocele complications. Additionally, the evalua- tion of sperm parameters is essential to fully establish the efficacy profile of laparoscopic varicocelectomy in the pediatric and adolescent population. REFERENCES 1. Vanlangenhove P, Everaert K, Van Maele G, Defreyne L. Tolerance of glue embolization under local anesthesia in varicoceles: a comparative study of two different cyanoacrylates. Eur J Radiol. 2014; 83:559-63. 2. Elbardisi H, Agarwal A, Majzoub A, Al Said S, Alnawasra H, Khalafalla K, Al Rumaihi K, Al Ansari A, et al. Does the number of veins ligated during microsurgical subinguinal varicocelectomy impact improvement in pain post-surgery? Transl Androl Urol. 2017; 6:264-270. 3. Park S, Kim KS, Lee C, et al. Impact of internal spermatic artery preservation during laparoscopic varicocelectomy on recurrence and the catch-up growth rate in adolescents. J Pediatr Urol. 2014; 10:435-40. Archivio Italiano di Urologia e Andrologia 2023; 95(3):11627 A. Nurfakhri Syarief, I. Akbar Rahman, A. Ravi Saputra Sangadji, T. Djojodimedjo, F. Rizaldi 8 4. Yu W, Rao T, Ruan Y, et al. Laparoscopic Varicocelectomy in Adolescents: Artery Ligation and Artery Preservation. Urology. 2015; 89:150-4. 5. Chrouser K, Vandersteen D, Crocker J, Reinberg Y. Nerve injury after laparoscopic varicocelectomy. J Urol. 2004; 172:691-3. 6. Esposito C, Monguzzi G, Gonzalez-Sabin MA, et al. Results and complications of laparoscopic surgery for pediatric varicocele. Int J Ped Surg. 2001; 36:767-9. 7. Youssef T, Abdalla E. Single incision transumbilical laparoscopic varicocelectomy versus the conventional laparoscopic technique: A randomized clinical study. Int J Surg. 2015; 18:178-83. 8. Esposito C, Escolino M, Castagnetti M, et al. Two decades of expe- rience with laparoscopic varicocele repair in children: Standardizing the technique. J Pediatr Urol. 2017; 14:10.e1-10.e7. 9. Parrilli A, Roberti A, Escolino M, Esposito C. Surgical approaches for varicocele in pediatric patient. Transl Pediatr. 2016; 5:227-32. 10. Hassan JM, Adams MC, Pope JC, et al. Hydrocele Formation Following Laparoscopic Varicocelectomy. J Urol. 2006; 175:1076-9. 11. Méndez-Gallart R, García-Palacios M, Rodríguez-Barca P, et al. 15 years' experience in the single-port laparoscopic treatment of pediatric varicocele with Ligasure® technology. Cir Pediatr. 2023; 36:33-9. 12. Tong Q, Zheng L, Tang S, et al. Lymphatic sparing laparoscopic Palomo varicocelectomy for varicoceles in children: intermediate results. J Pediatr Surg [Internet]. 2009; 44:1509-13. 13. Fast AM, Deibert CM, Van Batavia JP, et al. Adolescent varico- celectomy: does artery sparing influence recurrence rate and/or catch-up growth? Androl 2013; 2:159-64. 14. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 29; 372:n71-n71. 15. Sterne JAC, Savovic J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019; 366:l4898. 16. Varlet F, Becmeur F, Thieme G, et al. Laparoscopic Treatment of Varicoceles in Children Multicentric Prospective Study of 90 Cases. Eur J Pediatr Surg. 2001; 11:399-403. 17. Lund L, Tang YC, Roebuck D, et al. Testicular catch-up growth after varicocele correction in adolescents. Pediatr Surg Int. 1999; 15:234-7. 18. Yehya A, Abdalrazek M, Gamaan I, et al. Lymphatic sparing laparoscopic varicocelectomy with or without testicular artery preservation: is there a difference? Ann Pediatr Surg 2020; 16:16 19. Kim KS, Lee C, Song SH, et al. Impact of internal spermatic artery preservation during laparoscopic varicocelectomy on recur- rence and the catch-up growth rate in adolescents. J Pediatr Urol 2013; 10:435-40. 20. Zampieri N, Zuin V, Corroppolo M, et al. Varicocele and Adolescents: Semen Quality After 2 Different Laparoscopic Procedures. J Androl. 2007; 28:727-33. 21. Esposito C, Monguzzi GL, Gonzalez-Sabin MA, et al. Laparoscopic treatment of pediatric varicocele: a multicenter study of the italian soci- ety of video surgery in infancy. J Urol. 2000; 163:1944-6. 22. Poon SA, Kozakowski KA, DeCastro GJ, et al. Adolescent varic- ocelectomy: Postoperative catch-up growth is not secondary to lym- phatic ligation. J Pediatr Urol 2009; 5:37-41. 23. Yaman O, Soygur T, Zumrutbas AE, Resorlu B. Results of micro- surgical subinguinal varicocelectomy in children and adolescents. Urol. 2006; 68:410-2. 24. Koyle MA, Oottamasathien S, Barqawi A, et al. Laparoscopic palomo varicocele ligation in children and adolescents: Results of 103 cases. J Urol. 2004; 172:1749-52. 25. Riccabona M, Oswald J, Koen M, et al. Optimizing the operative treatment of boys with varicocele: sequential comparison of 4 tech- niques. J Urol. 2003; 169:666-8. 26. Poddoubnyi I V, Dronov AF, Kovarskyi SL, et al. Laparoscopic ligation of testicular veins for varicocele in children: A report of 180 cases. Surg Endosc. 2000; 14:1107-9. 27. Islam S, Islam M, Sarkar S, Paran S. Outcome of laparoscopic varicocelectomy with mass ligation technique for symptomatic varic- ocele. Arch Surg Clin Res. 2019; 3:065-9. 28. Mirilas P, Mentessidou A. Microsurgical subinguinal varicocelec- tomy in children, adolescents, and adults: Surgical anatomy and anatomically justified technique. J Androl. 2012; 33:338-49. 29. Fine RG, Gitlin J, Reda EF, Palmer LS. Barriers to use of semen analysis in the adolescent with a varicocele: Survey of patient, parental, and practitioner attitudes. J Pediatr Urol. 2016; 12:41.e1- 41.e6. 30. Kattan S. The Impact of Internal Spermatic Artery Ligation dur- ing Laparoscopic Varicocelectomy on Recurrence Rate and Short Post Operative Outcome. Scand J Urol Nephrol. 2001; 35:218-21. 31. Fallara G, Tang S, Pang KH, et al. Treatment of Persistent or Recurrent Varicoceles: A Systematic Review.Eur Urol Focus; 2023; 9:531-40. 32. Chung SD, Wu CC, Lin VCH, et al. Minilaparoscopic varicoc- electomy with preservation of testicular artery and lymphatic vessels by using intracorporeal knot-tying technique: Five-year experience. World J Surg. 2011; 35:1785-90. 33. Liang Z, Guo J, Zhang H, et al. Lymphatic sparing versus lym- phatic non-sparing laparoscopic varicocelectomy in children and adolescents: A systematic review and meta-analysis. Vol. 21, European J Pediatr Surg. 2011; 21:147-53. 34. Islam SR, Paul D, Sarkar SA, et al. Laparoscopic Varicocelectomy by Artery Preserving and Mass Ligation Technique- A Comparative Study. J Biomed Eng Med Imaging. 2022; 11:87-95. Correspondence Ahmad Nurfakhri Syarief afkurologi@gmail.com Ilham Akbar Rahman ilhamakbaarr@gmail.com Agung Ravi Saputra Sangadji agung.ravi.saputra-2022@fk.unair.ac.id Tarmono Djojodimedjo tar_urology@yahoo.com Fikri Rizaldi, MD (Corresponding Author) fikririz@gmail.com Department of Urology, Faculty of Medicine, Universitas Airlangga and Universitas Airlangga Teaching Hospital, Surabaya, East Java, Indonesia Conflict of interest: The authors declare no potential conflict of interest.