LAPAROSCOPIC UROLOGY Laparoscopic Varicocelectomy with Single Incision in Children Qimin Chen, Liang Zhong, Shaofeng Wu, Yang Sun, Guanqun Ju, Jie Sun* Purpose: Single-port laparoscopic varicocelectomy has recently been introduced. As an instrument with three ports was too large for use in children, a modified technique using a single incision with two trocars was attempted in our department. This study was designed to compare the new method with the traditional laparoscopic method involving three ports. Materials and Methods: Twelve boys with a total of 14 varicoceles were admitted for laparoscopic varicoce- lectomy through a single incision with two trocars. Thirty-two patients with 33 varicoceles were treated using traditional three-port laparoscopy, and were reviewed as controls. Data were collected to compare the two groups. Results: All procedures were completed successfully in both groups. There were no significant differences in terms of patients’ age, operative time, blood loss, analgesic requirement, hospital stay, and complications. Conclusion: The technique of laparoscopic varicocelectomy through a single incision with two trocars is safe, effective, and cosmetically acceptable. Keywords: laparoscopy; adolescent; vascular surgical procedures; methods; postoperative complications; treat- ment outcome; urologic surgical procedures. INTRODUCTION Adolescent varicocele is a common condition that is often encountered by pediatric urologists. The prevalence of the disease in the pediatric population is about 10% to 15%.(1) Although many factors are involved in the genesis of a varicocele, primary reno- spermatic reflux is the most common cause of the dis- ease. As this can create both testicular and sperm dam- age leading to testicular atrophy and oligozoospermia, many pediatric urologists are recommending varicoce- lectomy in children.(2) Several surgical techniques for treatment have been de- scribed, and controversy still surrounds the advantages and disadvantages of the different options.(3) With de- creased postoperative pain, improved cosmetic appear- ance, and reduced hospital stay and convalescence, lap- aroscopic varicocele surgery is an accepted procedure in China. Recently, single-port laparoscopic surgery via the umbilicus to repair varicoceles has been reported.(4) The concealed scar of this “scarless” technique has led to wider use. However, a special port with three inserts was too large for use in children. A modified single in- cision with two trocars is used by our department. Com- pared to other means of surgical access, the wound is more suited to the shape of the umbilicus. MATERIALS AND METHODS Patients From March 2011 to February 2012, 12 boys aged 9 to 18 years (mean age 13.6 years) were admitted to our hospital for the treatment of varicocele. Twelve patients had varicoceles on the left side only, while two patients had bilateral varicoceles. Four had grade II varicoceles and the other 10 had grade III varicoceles. This study was conducted in accordance with the declaration of Helsinki. This study was conducted with approval from the Ethics Committee of Shanghai Jiao Tong Univer- sity. Written informed consent was obtained from all participants’ guardians. All the clinical diagnoses were verified by a Doppler study and a retroperitoneal loca- tion was excluded. Laparoscopic Procedure The patient was placed in the supine position. An in- fraumbilical incision of about 10 mm was made. After dissection with mosquito clamps and varicocele hooks, the peritoneum was opened under direct vision. Two 5 mm trocars were inserted into the abdominal cavity through the single incision (Figure). After carbon di- Department of Urology, Shanghai Children’s Medical Center Affiliated to Shanghai Jiao Tong University School of Medi- cine, Shanghai 200127, China. *Correspondence: Department of Urology, Shanghai Children’s Medical Center Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China. Tel: +86 021 38625709. Fax: +86 021 58393915. E-mail: jiesundoc@126.com. Received January 2015 & Accepted November 2015 Vol 12 No 06 November-December 2015 2400 Laparoscopic Varicocelectomy with Single Incision-Chen et al. oxide insufflation, a 5 mm laparoscope was used for visualization, and a straight working instrument was inserted. The patient was maintained in the Trendelen- burg position and rotated slightly to the contralateral side of the operated vessels. The spermatic vessels were identified in the retroperitoneum. The peritoneum was then opened alongside the spermatic vessels as high as possible above the internal inguinal ring. The vessels were dissected free and divided with a harmonic scal- pel. No attempt was made to spare the testicular artery or adjacent lymphatics. All patients were discharged on the 2nd postoperative day and returned to the hospital for scheduled follow-up. A group of 32 patients with 33 varicoceles was treated using traditional three-port laparoscopy between 2009 and 2010, and was served as control group. Statistical Analysis Data on age, operative time, blood loss, analgesic re- quirement, hospital stay, and complications were col- lected. The unpaired t-test with mean and standard de- viations (SD) was used for comparisons. A value of P < .05 was considered to be significant. RESULTS The average operating time was 25.0 minutes, and there was no significant blood loss during any operations. No postoperative complications were observed after 1 year of follow-up; complications were defined as wound infection, dehiscence, hydrocele, testicular atrophy, or recurrence. Each incision was hidden well within the umbilicus. After the wound healed, the cosmetic result was excellent. All procedures were completed success- fully using either the modified single incision with two trocars or the three-port technique. There were no sig- nificant differences between the two groups in terms of patients’ age, operative time, blood loss, analgesic re- quirement, hospital stay, or complications (Table). DISCUSSION About 30% of patients with a varicocele are subfer- tile.(5) However, repair of adult varicocele in infertile men does not always result in fertility. Many urologists therefore advocate performing varicocelectomy in chil- dren.(6) In our hospital, significant varicocele is rou- tinely treated to preserve future fertility. Several types of procedures are currently used to treat varicocele, including interventional radiologic vein embolization, inguinal microscopic testicular artery-sparing varicoce- lectomy, spermaticoepigastric venous anastomosis, and Palomo varicocele ligation.(3,7-12) Evolving laparoscopic techniques are mostly based on the Palomo procedure. Several reports have described laparoscopic extraperi- toneal treatment for varicocele.(1,13,14) The principal dis- advantages with this method are insufficiency of ret- roperitoneal space and difficulty in orientation, which are more significant in children. The transperitoneal approach was chosen, as we previously noted the ease of access and minimal invasiveness with this technique. A single incision with two trocars was used 2 years previously by the authors of this study. Many surgeons have reported the use of a single port while performing laparoscopic varicocelectomy. In this process, a special- ly manufactured port with three inserts was necessary. (15-17) Although the device was innovative, it is not suita- ble for use in children. The high cost of instruments for laparoendoscopic single-site surgery has also hindered update of traditional endoscopic ports in pediatric spe- cialty hospitals in China. Two 5 mm trocars could be inserted into the peritone- um through a single small infraumbilical incision with minimal or no gas leakage. Pneumoperitoneum was in- duced with carbon dioxide to a pressure of 13 mmHg. Both the laparoscope and working instruments used in the operation were straight. The spermatic vessels could be identified at the internal ring of the inguinal canal where the vas deferens joins the spermatic cord. The spermatic vessels were divided as high as possi- ble. When feasible, vessels were coagulated with a har- monic scalpel without using hemoclips. Although some spermatic veins have been reported to merge, this an- Table. Clinical data analysis of varicocele with different laparoscopic treatments.* Variables Single Incision with Two Trocars (12 patients, n = 14) Traditional Three Ports (32 patients, n = 33) P Value Age (years) 13.6 ± 2.6 15.3 ± 3.7 .126 Operative time (minutes) 25.0 ± 5.7 28.9 ± 10.2 .187 Blood loss (mL) 0 0 > .05 Analgesic requirement 0 1 .82 Hospital stay (days) 2.1 ± 0.6 3.1 ± 1.2 .26 Complications 0 1 hydrocele .82 * Data are presented as mean ± SD. Laparoscopic Urology 2401 atomical variant was not observed in our study.(18) All vessels were therefore carefully isolated. We have no experience with the artery-sparing technique, but most surgeons believe that there is a higher risk of varicocele recurrence with techniques that preserve lymphatic or arterial supply.(19,20) Therefore, surgeons who perform lymphatic or arterial preservation need to employ strat- egies to ensure venous collaterals are ligated.(21) The high division of both the testicular artery and vein re- sulted in a satisfactory outcome with no incidence of testicular atrophy in any of the patients we treated. With conventional laparoscopic equipment, the bilater- al spermatic vessels can be inspected simultaneously. In our study, two patients underwent bilateral varicocelec- tomy. Based on our experience, the two trocar insertion sites were placed in a line perpendicular to the midline of the body (Figure), and the position of the laparo- scope was closer to the dilated vessels, making it more convenient to observe and operate. Follow-up was performed for an entire year. As shown in the Table, there were no significant differences when compared to the three-port technique, including opera- tive time, blood loss, and hospital stay. The cosmetic appearance was not scientifically evaluated. The sur- geon’s subjective assessment was that single-port inci- sions were cosmetically superior. CONCLUSIONS Laparoscopic varicocelectomy through a single incision with two trocars involves only a small modification in technology. The learning curve was very short for a senior laparoscopic urologist, after the main challenge of performing without triangulation was overcome. ACKNOWLEDGMENTS We are grateful to the National Natural Science Foun- dation of China and Science and Technology Commis- sion of Shanghai Municipality for the financial support (Grant No. 81270689 & 12ZR1419200). CONFLICT OF INTEREST None declared. REFERENCES 1. Cobellis G, Mastroianni L, Cruccetti A, Amici G, Martino A. Retroperitoneoscopic varicocelectomy in children and adolescents. 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