|Year : 2016 | Volume
| Issue : 3 | Page : 87-93
Comparative study between dye assisted microsurgical Subinguinal Varicocelectomy versus Subinguinal Conventional Technique for treatment of primary varicocele
Wafik I Aborahma1, Mohamed M Elwageh2, Ahmed H Elbarbary2, Mohamed A Elhenedy2
1 Ministery of Health, Faculty of Medicine, Tanta University, Tanta, Gharbia, Egypt
2 Department of Vascular Surgery, Faculty of Medicine, Tanta University, Tanta, Gharbia, Egypt
|Date of Submission||09-Feb-2016|
|Date of Acceptance||29-Mar-2016|
|Date of Web Publication||19-Jan-2017|
Mohamed M Elwageh
Department of Vascular Surgery, Faculty of Medicine, Tanta University, Tanta, Gharbia
Background Division of lymphatic vessels during varicocelectomy could lead to secondary hydrocele formation and decrease of testicular function due to testicular edema. It was suggested that the use of methylene blue dye combined with optical magnification could reduce the incidence of postvaricocelectomy complications.
Aim of the work To evaluate efficacy and safety of the dye assisted subingunial varicocelectomy with optical magnification in the treatment of primary varicocele.
Patients and methods Sixty five patients having 80 primary varicoceles were randomly divided into two groups according to treatment procedure. The indications of surgery included patients with primary varicocele with infertility or varicocele with life style limiting pain. Thirty three patients (having 40 varicoceles) underwent subinguinal varicocelectomy with the aid of optical magnification after injection of dye (group I), and 32 patients (having 40 varicoceles) treated by subinguinal varicocelectomy with neither injection of dye nor magnification (group II). After surgery, the patients were assessed at 2 weeks, 3 months and 6 months for hydrocele formation, size of the testes using ultrasound, varicocele recurrence, pain or other complications.
Results There were no reported complications with arterial injury in group I, while four procedures (10%) in group II were complicated by minor injury of the internal spermatic artery with P value = 0.045*. One procedure was complicated by hydrocele in group I (2.5%) in contrast to 7 procedures in group II (17.5%) with P value = 0.006*. Also, one procedure in group I and 7 procedures in group II were complicated by varicocele recurrence. This difference was statistically significant, P value = 0.006*.
Conclusion Dye assisted lymphatic sparing subinguinal microsurgical varicocelectomy is simple, feasible, and could minimize varicocelectomy related complications.
Keywords: Varicocelectomy, dye assisted, microsurgery, lymphatic sparing, varicocele
|How to cite this article:|
Aborahma WI, Elwageh MM, Elbarbary AH, Elhenedy MA. Comparative study between dye assisted microsurgical Subinguinal Varicocelectomy versus Subinguinal Conventional Technique for treatment of primary varicocele. Tanta Med J 2016;44:87-93
|How to cite this URL:|
Aborahma WI, Elwageh MM, Elbarbary AH, Elhenedy MA. Comparative study between dye assisted microsurgical Subinguinal Varicocelectomy versus Subinguinal Conventional Technique for treatment of primary varicocele. Tanta Med J [serial online] 2016 [cited 2018 Jan 20];44:87-93. Available from: http://www.tdj.eg.net/text.asp?2016/44/3/87/198479
| Introduction|| |
Varicocele is an abnormal tortuosity and dilatation of testicular veins within the spermatic cord that first develops in childhood or early adolescence. The prevalence of varicocele in adolescent boys is estimated to be 11-15% . A clinical varicocele is observed in 10-20% of the general population, in 35-40% of patients with primary infertility and in up to 80% of patients with secondary infertility . Varicocelectomy is indicated in the case of infertility, when the testicular volume is decreased in adolescents, and when associated with persistent pain .
Palomo’s technique, first described in 1949, involves en- mass transection of the testicular vessels in the retroperitoneum above the internal ring . There are many approaches to transect the internal spermatic veins such as transinguinal ligation, subinguinal ligation, and laparoscopic suprainguinal ligation. Each technique has its own advantages and disadvantages ,. Up to date there has been no consensus on which technique should be considered to be the gold standard treatment of varicocele .
The incidence of hydrocele formation after varicocelectomy varies from  to 33%. Lymphatic obstruction is more likely than venous obstruction to be the cause. Varicocele recurrence rate after Palomo’s procedure has been reported to range from 0-16% . Partial or complete division of lymphatic vessels during varicocelectomy not only leads to hydrocele formation but also results in decline in testicular function as indicated by the luteinizing hormone-releasing hormone analogue stimulation test .
There are different approaches to preserve lymphatic drainage of the testes and scrotum, for example, microscopic varicocelectomy, laparoscopic varicocelectomy, lymphatic hydrodissection, and a dye assisted technique using methylene blue or isosulfan blue, to enable identification and preservation of lymphatic vessels during varicocelectomy . The aim of this study was to evaluate the dye assisted lymphatic sparing subinguinal varicocelectomy technique with the aid of optical magnification as regards feasibility, safety and results.
| Patients and methods|| |
Study design: This prospective randomized study was conducted on 65 patients having 80 primary varicoceles admitted to vascular surgery unit, department of general surg ery, Tanta University Hospitals in the period from January 2014 to June 2015. Patients were divided randomly according to treatment procedure between two groups: Group I; 33 patients having 40 primary varicoceles treated by sub-inguinal varicocelectomy with the aid of optical magnification (3 × magnification) after injection of 2 ml of methylene blue dye in the inter-tunical space and group II; 32 patients having 40 primary varicoceles treated by subinguinal varicocelectomy with neither injection of a dye nor aid of magnification.
Inclusion criteria: Patients with grade 2 or grade 3 varicocele presenting with either infertility in whom semen analysis showed at least one abnormal parameter (sperm motility less than 50%, sperm count less than 20 million /ml, velocity less than 35m/sec, abnormal forms more than 40%) or with life style limiting pain, were included in this study.
Exclusion criteria: Patients with varicocele associated with hydrocele or inguinal hernia, known allergy to methylene blue dye, secondary and recurrent varicocele, varicocele complicated by thrombophlebitis and varicocele with infertility due to other causes (demonstrated by andrologists).
Before participation in the study a written informed consent was taken from each patient according to the ethical committee arrangement measures of the faculty.
All patients were subjected to full history taking with special emphasis on pain and infertility together with full clinical examination. Varicocele was diagnosed primarily by physical examination in erect position. Ultrasound scan (U/S) of the testicles was performed along with color Doppler of the enlarged pampiniform veins to confirm the diagnosis, asses the size of the testis, and define the severity of venous reflux. The varicocele was graded from 1 to 3 according to severity (Dubin and Amelar classification): grade 1, vein dilatation palpable during Valsalva maneuver in the upright position; grade 2, palpable in the upright position without Valsalva maneuver; and grade 3, palpable and visible dilated veins through scrotal skin in the upright position without Valsalva maneuver . Testicular volume was measured by U/S. Testicular atrophy was defined as the presence of either a floppy testicle or a testicle with a volume noticeably smaller than the other testicle (>20% volume difference). Catch up growth was defined as resolution of asymmetry of less than 20% on postoperative ultrasound . Routine laboratory investigations and semen analysis were done for all patients.
Operative procedure: Under spinal or general anesthesia, a 3 cm transverse incision was done below the external inguinal ring. The subcutaneous tissue was then dissected until the spermatic cord was identified. The spermatic cord was delivered into the wound using gentle traction with a Babcock forceps. In procedures done for patients of group I, mapping of testicular lymphatics was achieved by injection of 2 ml of methylene blue dye with a 30 G needle into the space between the tunica vaginalis and tunica albuginea. The external spermatic veins and gubernacular vein passing on the under surface of the cord were then dissected under loupe magnification (3 × magnification) and tied with 3-0 polyglactan (vicryl) ties. The fascial layers of the cord were then opened. The vas deferens and its vessels were identified and preserved in their fascial compartment posteriorly. The testicular artery was then identified and preserved. All the internal spermatic veins were ligated with 3-0 or 4-0 vicryl. The internal spermatic artery and numerous blue stained lymphatic vessels only were left behind. Then closure of the layers of the cord using 3-0 vicryl was done ([Figure 1],[Figure 2],[Figure 3],[Figure 4]).
|Figure 3: Ectatic vein nearby a blue stained lymphatic vessels easily identified.|
Click here to view
In procedures of group II, the same steps of operation in group I but with neither injection of dye nor use of optical magnification ([Figure 5],[Figure 6],[Figure 7]). All operations were performed by the same surgical team after taking written consent from all patients.
|Figure 7: Testicular veins were dissected and tied with 3-0 or 4-0 vicryl.|
Click here to view
Patients were discharged the following day to allow assessment of any immediate postoperative complications.
Follow up was achieved by phone calls and office visits at all scheduled intervals. Clinical follow-up early after 2 weeks for any postoperative complications as hydrocele, testicular edema, scrotal ecchymosis and hematocele, testicular volume changes, wound infection as well as pain relief was carried out. Late follow-up at 3 and 6 months postoperatively was done by clinical examination and Doppler U/S to reveal degree of reflux, testicular volume changes and hydrocele if present. Semen analysis was done for detection of any changes in semen parameters.
Statistical presentation and analysis of the present study was conducted, using the mean, standard deviation and chi-square test by Statistical Package for Social Sciences (SPSS) version 16. P values ≤ 0.05 were considered significant.
| Results|| |
Total number of our patients in both groups was 65 patients for whom 80 varicocelectomy procedures were done. Group I included 33 patients, 26 of them (79%) had unilateral primary varicocele and 7 (21%) had bilateral varicocele (with total number of 40 varicoceles). Group II; control group included 32 patients, 24 of them (75%) had unilateral varicocele and 8 (25%) had bilateral varicocele (with total number of 40 varicoceles). The mean age of patients in group I was 26.4 years and that for group II was 24.34 years.
There was no significant statistical difference in indications of surgery between both groups of our patients as demonstrated in [Table 1]. Three patients (9.09%) in group I presented with life style limiting scrotal pain and 30 patients (90.91%) presented with infertility. In group II, 4 patients (12.5%) presented with scrotal pain and 28(87.5%) presented with infertility, as evident in [Table 1].
Fifteen varicoceles (37.5%) in group I were grade 2 and 25 (62.5%) were grade 3 while in group II there were 18 varicoceles (45%) grade 2 and 22 varicoceles (55%) grade 3 as revealed in [Table 2].
Intraoperative assessment: In group I staining of lymphatic vessels was successful in all patients. Draining lymphatic vessels were clearly identified by their bluish appearance and could be easily preserved. There was no allergy or hypersensitivity to methylene blue in all patients. There was no arterial injury in operations in group I, while in group II there were 4 operations (10%) complicated by arterial injury in the form of puncture of the internal spermatic artery which could be controlled by compression. The difference between the two groups was statistically significant with P value 0.005*. The operative time in group I ranged from 50 -75 minutes (57.50 ± 12.25 minutes), while in group II it ranged from 35 - 60 minutes (52 ± 6.78 minutes). The difference was statistically significant with P value 0.045* as shown in [Table 3].
Postoperative assessment: Scrotal pain subsided postoperatively in all patients except in one case in group II. Postoperative scrotal edema developed in 3 operations (7.5%) in group I and 7 operations (17.5%) in group II resolved within 2-4 weeks. The difference was not statistically significant with P value of 0.23. Two operations (5%) in group I and 4 operations (10%) in group II were complicated by scrotal ecchymosis resolved after 1-2 weeks, the difference was not statistically significant with p value of 0.125. However there was a significant difference between both groups as regards hydrocele formation and varicocele recurrence. Hydrocele developed in one operation (2.5%) in group I while it developed in 7 operations (17.5%) in group II with p value of 0.006*. Similarly varicocele recurred in one operation (2.5%) in group I and in 7 operations (17.5%) in group II with P value of 0.006*, [Table 4].
The mean of preoperative and postoperative semen analysis parameters showed significant improvement in all parameters in both groups. Improvement was more evident in group I than in group II, but the difference was not statistically significant as shown in [Table 5].
In group I the mean sperm count ± SD before operation was 23.75 million/ml ± 2.09 and 6 months postoperative it was 37.35 ± 2.24% with p value 0.004*. In group II the mean sperm count ± SD before operations was 24.34 million/ml ± 2.14 and 6 months post-operative it was 35.82 million/ml ± 2.45 with p value 0.005*. In group I the mean abnormal forms ± SD preoperatively was 51.75% ± 6.65 and 6 months postoperative it was 27.45% ± 4.01 with p value 0.003*, while in group II the mean abnormal forms ± SD before operations was 49.95% ± 6.65 and 6 months postoperative it was 38.8% ± 6.05 with p value 0.004*. The mean sperm motility ± SD before operations was 24.90m/sec ± 1.83 in group I while it was 38.35m/sec ± 2.13, 6 months postoperative with p value 0.004*. In group II the mean sperm motility ± SD before operations was 25.12m/sec ± 1.9 and 6 months after operation it was 37.57m/sec ± 2.02% with P value 0.005*.
There was an increase in the post-operative testicular size in comparison with the pre-operative size in both groups as measured by U/S. This increase was higher in group II than in group I and the difference statistically was significant as illustrated in [Table 6]. In group I, the mean pre-operative testicular size ± SD was 15.59 cm3 ± 0.439, after 2 weeks it increased to 17.49 cm3 ± 0.438 and after 3 months it was 16.5 cm3 ± 0.338. In group II, the mean preoperative testicular size ± SD was 16.12 cm3 ± 0.524, after 2 weeks it increased to 21.04 cm3 ± 0.648 and after 3 months it was 20.04 cm3 ± 0.548.
| Discussion|| |
The currently utilized techniques for varicocele repair include the inguinal approach, the microscopic sub-inguinal approach, laparoscopic techniques, high retro-peritoneal Palomo´s procedure, and radiological interventional sclerotherapy, each with advantages and disadvantages and there is no agreement on the gold standard treatment. This is confirmed by a high rate of recurrence or complications that afflict the choices .
Vander Brink et al. suggested that it is not proven to discriminate microscopically between isolated lymphatic vessels and very small veins in spite of the use of optical magnification .
The present study was conducted to evaluate the aid of optical magnification and dye injection in lymphatic sparing sub-inguinal varicocelectomy as preservation of lymphatics could prevent post- operative hydrocele and improve the semen parameters.
In this study, the mean operative time in group I was longer than in group II (57.5min ± 15.25) and (52.12min ± 6.78) per side respectively. This statistically significant difference (P = 0.045*), may be attributed to the time consumed by dye injection and time passed waiting for staining of the lymphatics which ranged from 2 to 7 min after injection. This was in accordance with Abd Ellatif et al. . As they found that the mean operative time ± SD in group 1 was longer than in group 2 (42.1min ± 9.87) and (37.5min ± 6.4) respectively but the difference was not statistically significant (P = 0.23). On the contrary Schwentner et al.  injected 1% isosulphan blue intertunically 15 minutes before operations and noticed that the operative time of dye assisted microsurgical varicocelectomy was significantly shorter (p = 0.001*). Also Zini et al.  found that after technical modification of microsurgical varicocelectomy by injection of dye few minutes before beginning the operation, the operative time could be reduced.
In this study there were no allergic reactions to methylene blue and no wound infection. These results are similar to those recorded by Ghanem et al.  and Lemack et al. 
Clinical considerations of preservation of testicular artery during sub-inguinal varicocelectomy revealed improved semen parameters, testicular size, fertility and spontaneous pregnancy after treatment . In this study, there was no case of arterial injury during the operation in group I, but in group II there were 4 cases (10%) of arterial injury in the form of puncture of the internal spermatic artery which could be controlled by compression and the difference was statistically significant (P = 0.005*). This difference may be attributed to the use of magnifying surgical loupe and dye injection in group I. These data are in accordance with results reported by Ghazy et al.  as they recorded 2 cases (8%) with arterial injury in group A(no magnification and no use of dye) but in group B(where there were optical magnification and use of dye) there were no cases of arterial injury with P = 0.001*.
Lymphatic obstruction is more likely than venous obstruction to be the cause of hydrocele formation . Moreover, it was found that impaired lymphatic drainage also impairs testicular function and that post-operative catch up growth is due to interstitial edema . Oswald et al.  first described the use of dye in varicocele surgery. They use isosulfan blue dye through scrotal injection in 28 boys before high retroperitoneal ligation of varicocele. There was no postoperative hydrocele in their study. In our study, there was one procedure in group I (2.5%), and 7 procedures (17.5%) in group II were complicated by post-operative hydrocele and the difference was statistically significant (P value = 0.006*). Similarly Schwentner et al.  compared the occurrence of post-operative hydrocele in 50 adolescents assigned randomly to undergo laparoscopic Palomo varicocelectomy with or without isosulfan blue at 3 months after surgery, the incidence of hydrocele formation was 0 and 20% respectively. These data coincide with those obtained from this study.
We reported in this series that the post-operative testicular size change measured by U/S was higher in group II than in group I and the difference was statistically significant at 2 weeks and 3 months follow-up. This may signify the role of lymphatic sparing with the aid of dye and loupe magnification in preventing post-varicocelectomy testicular catch-up growth as much of this growth is caused by interstitial testicular edema due to lymphatic damage as reported by Kocvara et al.  These results are in accordance with Lavin et al.  who found minimal change in testicular size (from 9.2% to 4.7%) following lymphatic sparing embolization of varicocele.
Kocvara et al.  demonstrated a decrease in testicular function in patients with testicular edema and they stressed the importance of lymphatic drainage preservation to ensure a better andrological outcome. In the present study, a comparison between the pre-operative and post-operative semen parameters in both groups showed significant improvement in all parameters. In group I, the P- value of sperm count was 0.005*, sperm motility was0.006* and abnormal forms was 0.005*. In group II, P- value of sperm count was 0.004*, sperm motility was 0.006*, and of abnormal forms was 0.004*. However there was no significant difference in the degree of improvement between both groups.
The incidence of varicocele recurrence after varicocelectomy varies from 0.6-35%24, . In this study we reported only one procedure (2.5%) of recurrence in group I but there were 7 procedures (17.5%) with recurrence in group II. This low rate of recurrence in patients of group I could be attributed to using optical magnification during spermatic vein ligation, which helps to deal with even very small veins. This is in accordance with studies done by Richter et al.26 and Amelar .
| Conclusion|| |
The present study showed that dye assisted lymphatic sparing sub-inguinal microsurgical varicocelectomy can be performed easily, is feasible, and can deal with all spermatic veins. With careful dissection and preservation of the testicular artery and lymphatic vessels, varicocelectomy related complications could be minimized.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]