Laparoscopic Treatment of Varicoceles in Children

Dear Sirs,

I read the recent article on laparoscopic treatment of varicoceles in children with immense interest. The well-designed multicenter prospective study showed that varicoceles greatly diminished or completely disappeared in 91.6 % of children submitted to mass ligation and division (or equivalent procedures) of the internal spermatic veins and artery. In comparison, only 67.9 % of children in the artery-preserving group enjoyed the same degree of success. Furthermore, the 30 artery ligations produced no testicular atrophy. The authors rightly concluded that total laparoscopic ligation of the testicular vascular bundle above the vas deferens is highly effective and free from the risk of testicular atrophy. However, even though clear evidence exists as to the superiority of mass ligation over the artery-sparing technique in terms of efficacy ([2]), skepticism about its safety still prevails to date. Notably, in another article published in almost the same month, an author expressed a diametrically opposite view, stating repeatedly that he remained unconvinced of the long-term safety of the mass ligation technique ([1]). In fact, this emphatic remark arose in response to an earlier correspondence from me ([3]). I endorsed the role of the mass ligation technique as a safe and effective treatment for pediatric varicoceles, stating that our success rates with this technique were consistently higher than that of the artery-sparing technique (100 % vs. 54.5 % in 1995, and 100 % vs. 79 % in 2002), without incurring any testicular atrophy thoughout the study period - as Varlet and colleagues experienced virtually concurrently ([3]). Apparently, all my efforts were in vain.

As a matter of fact, the skeptic respondent remained unconvinced despite the provision of more evidence beyond the mere absence of testicular atrophy. For instance, I have documented, by intraoperative Doppler ultrasonography of the testis just before and after clamping of the testicular artery, that the testicular parenchymal circulation remained unchanged upon laparoscopic interruption of the testicular artery blood flow. Nonetheless, the respondent dismissed this study as being qualitative at best. In anticipation of the possible argument that atrophy of the testis represents a severe degree of ischemic insult, I tried to look at the subtler changes in spermatogenesis. I secured, albeit with some difficulties, repeated semen samples from five of our early patients undergoing total ligation of the internal spermatic vascular bundle at 12 to 15 years of age. All the samples showed normal mobility of the sperm (> 50 % at 1 hr after collection) with sperm counts ranging from 61 - 180 × 10⁶/mL and averaging 92 × 10⁶/mL (n: 20 - 250 × 10⁶/mL). Again, the responding author discounted the strong evidence on the grounds that the number of patients was too few and that sperm count does not necessarily correlate with fertility. Last, he was, explicitly, not convinced by the single example of a patient who impregnated his wife after testicular artery ligation.

To settle once and for all the perennial debate on whether it is safe to ligate the testicular artery, I would urge the multicenter study group to follow their large cohort of patients and provide in due course the hard evidence (and ultimate outcome), i.e. paternity in the mass ligation and the artery-sparing groups. Clearly, the study will take many years - only then can we be perfectly sure that recalcitrant skeptics can be convinced and the use of an otherwise highly effective technique vindicated.

References

• 1 Cohen R. Laparoscopic varicocelectomy with preservation of testicular artery in adolescents.  J Pediatr Surg. 2002;  37 142-143
• 2 Ng W T, Wong M K, Book K S. Laparoscopic varicocelectomy in pediatric patients.  Urol. 1995;  46 121-122
• 3 Ng W T. Laparoscopic varicocelectomy with preservation of testicular artery in adolescents.  J Pediatr Surg. 2002;  37 142-143