Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy.
Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy.
J Pediatr Urol. 2018 Feb;14(1):10.e1-10.e7. doi: 10.1016/j.jpurol.2017.06.017. Epub 2017 Jul 26.
Controversy still exists about the indications and the gold standard approach for varicocele treatment in pediatric population.
The authors report their 23 years of experience in laparoscopic varicocele repair in the pediatric population.
We retrospectively evaluated the data of 345 consecutive patients who underwent laparoscopic left varicocelectomy from January 1993 to December 2015. Average patient age was 12.5 years (range 8-17). Seven out of 345 patients (2%) had a recurrent varicocele, and five out of 345 patients (1.4%) had a varicocele on a single testis. In 335/345 patients (97.1%) we performed a Palomo procedure, and in 10/345 patients (2.9%) an artery-sparing Palomo procedure. After 2010, in 105/345 patients (30.4%) we performed a lymphatic sparing procedure using isosulfan blue injection preoperatively.
All procedures were completed in laparoscopy (Figure), without conversions or intraoperative complications. The average operative time was 17 min (range 14-45) for the Palomo procedure and 26 min (range 18-50) for artery-sparing Palomo. In 45/345 patients (13%) we performed additional procedures. We recorded 4/345 (1.3%) recurrences/persistences in patients undergoing Palomo, while we recorded 1/10 (10%) recurrence/persistence after artery-sparing Palomo. On 230 Palomo procedures performed in the pre-isosulfan blue era, we recorded 25 cases of hydrocele (10.8%), 13 of these were treated with transcrotal puncture and 12 required surgical operation. The last 105 patients undergoing isosulfan blue injection had no postoperative hydrocele. We also reported 10 other complications (I grade Clavien-Dindo) such as umbilical granuloma or instrumental problems.
Analyzing the international literature of the last 25 years, most papers focused on the minimally invasive treatment of pediatric varicocele. There are several reasons to perform laparoscopic repair of pediatric varicocele. First of all, it is technically easy to perform, the average operative time is very short, and it has excellent outcome in regard to varicocele persistence/recurrence. In addition it has a very low complication rate, and in particular adopting the intradartoic/intratesticular isosulfan blue injection before surgery we recorded no postoperative hydrocele.
On the basis of our 23 years of experience with varicocele repair, we clearly believe that laparoscopic Palomo lymphatic sparing varicocelectomy should be considered the standard of care for the treatment of pediatric patients with varicocele. Laparoscopic varicocelectomy is technically easy and quick to perform, painless, and scarless, with a recurrence rate of about 1%. The use of a preoperative injection of isosulfan blue completely eliminates postoperative hydrocele formation.
小儿精索静脉曲张的治疗适应证和金标准仍存在争议。
作者报告了他们在小儿人群中进行腹腔镜精索静脉曲张修复的 23 年经验。
我们回顾性评估了 1993 年 1 月至 2015 年 12 月期间 345 例连续接受腹腔镜左侧精索静脉曲张切除术的患者数据。平均患者年龄为 12.5 岁（8-17 岁）。345 例患者中有 7 例（2%）出现精索静脉曲张复发，345 例中有 5 例（1.4%）单侧睾丸精索静脉曲张。335/345 例（97.1%）患者行 Palomo 手术，10/345 例（2.9%）行保留动脉的 Palomo 手术。2010 年后，105/345 例（30.4%）患者在术前使用异硫蓝注射行淋巴管保留术。
所有手术均在腹腔镜下完成（图），无中转或术中并发症。Palomo 手术的平均手术时间为 17 分钟（14-45 分钟），保留动脉的 Palomo 手术为 26 分钟（18-50 分钟）。45/345 例（13%）患者行附加手术。Palomo 组中有 4/345（1.3%）例患者出现复发/持续存在，而保留动脉的 Palomo 组中有 1/10（10%）例患者出现复发/持续存在。在异硫蓝注射前的 230 例 Palomo 手术中，我们记录了 25 例（10.8%）鞘膜积液，其中 13 例经经阴囊穿刺治疗，12 例需要手术治疗。最后 105 例接受异硫蓝注射的患者术后均无鞘膜积液。我们还报告了 10 例其他并发症（Clavien-Dindo I 级），如脐部肉芽肿或器械问题。
分析过去 25 年的国际文献，大多数论文都集中在小儿精索静脉曲张的微创治疗上。有几个原因可以进行小儿精索静脉曲张的腹腔镜修复。首先，它的技术操作简单，平均手术时间非常短，在精索静脉曲张持续/复发方面有很好的效果。此外，它的并发症发生率很低，特别是在术前采用经皮/睾丸内注射异硫蓝，我们记录到术后无鞘膜积液形成。
基于我们 23 年的精索静脉曲张修复经验，我们清楚地认为，腹腔镜 Palomo 淋巴管保留精索静脉曲张切除术应被视为治疗小儿精索静脉曲张的标准方法。腹腔镜精索静脉曲张切除术技术操作简单、快速、无痛、无疤痕，复发率约为 1%。术前注射异硫蓝可完全消除术后鞘膜积液形成。
