Endoscopic varicocelectomy by extraperitoneal route: A novel technique

International Journal of Surgery 7 (2009) 377–381

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Endoscopic varicocelectomy by extraperitoneal route: A novel technique Brij B. Agarwal a, b, *, Kumar Manish a, b a b

Dr. Agarwal’s Surgery & Yoga, F-81, Street #4, Virender Nagar, New Delhi - 110058, India Department of Surgery, Sir Ganga Ram Hospital, New Delhi - 110060, India

a r t i c l e i n f o

a b s t r a c t

Article history: Received 3 May 2009 Received in revised form 10 June 2009 Accepted 11 June 2009 Available online 21 June 2009

Background: Varicocelectomy for male infertility has been performed laparoscopically by transabdominal preperitoneal (TAPP) approach. Laparoscopic varicocelectomy (LV) has a potential risk of intraperitoneal injuries. LV fails to tackle the possible collateral veins in inguinal canal below the deep inguinal ring. Despite the inherent benefits of retro or extraperitoneal approach for urological procedures, the extraperitoneal varicocelectomy has not been widely practiced. Energy sources have been suspected in potential trauma to vas. Totally extraperitoneal (TEP) approach is a well established procedure for inguinal region. We utilized TEP approach to perform varicocelectomy without using energy source.

Keywords: Infertility Varicocele Endoscopic Extraperitoneal Energy source

Method: Between January 2000 and March 2005 16 males having bilateral varicocele, subnormal semen parameters and inability to father a child with reproductively healthy female partner were operated. Varicocelectomy was done by TEP route. Results: 16 males having different grades of varicocele, mean sperm counts of 29.25 million/ml and mean sperm motility of 26% were operated. There was no technical difficulty, visceral injury, conversion, bleeding or need to use energy source. There was no recurrence or reduction in testicular size. Postoperative hydroceles (11 out of 32 varicoceles) resolved within 3 months without any intervention. Mean sperm counts and motility improved to 68.25 million/ml and 63.18% respectively. Pregnancy was reported by 11 couples during a follow up of 2 years. Conclusion: Endoscopic varicocelectomy by extraperitoneal route is a safe procedure. Ó 2009 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction Minimally invasive surgery has been applied to wide variety of urological procedures.1 Laparoscopic varicocelectomy (LV) is more effective than antegrade sclerotherapy (AS) or retrograde embolization (RE).2 LV reverses the insult to spermatogenesis3 making it the commonest surgical procedure for male infertility.4 Transabdominal preperitoneal approach (TAPP) is universally used2 despite an emphasis on extraperitoneal access5 in urological procedures. TAPP carries the risk of serious injuries3 to small bowel,6 sigmoid colon,7 nerves8 and vessels.6 Sometimes it requires mobilization of sigmoid colon8 or adhesiolysis of bowel loops overlying the testicular vessels.7 Use of energy sources in TAPP is associated with bowel burns and neuropraxia.6 Such serious complications3 have led to abandonment of LV at some centers.9 Superiority of totally extraperitoneal (TEP) approach over TAPP is

* Corresponding author. Tel.: þ91 9810124256. E-mail addresses: [email protected], [email protected] (B.B. Agarwal), [email protected] (K. Manish). URL: http://www.endosurgeon.org

well accepted by hernia surgeons dealing with inguinal region.10 Use of energy sources in hernia surgery is also a cause of concern in context of male infertility.11 With this insight from the literature we performed extraperitoneal varicocelectomy without using any energy source.12 2. Materials and methods This prospective study was conducted by a surgeon from January 2000 – March 2005, following ‘good clinical practice’ and ethics guidelines. All patients were referred from the Gynaecologists after diagnosis of bilateral varicocele in infertile male partners of gynaecologically healthy females. All the couples included were unable to conceive after at least 3 years of consummated marriage. Diagnosis of varicocele was made on clinical palpation. It was documented by a Doppler examination to measure the testicular size and severity of venous reflux. Varicocele was graded according to guidelines of WHO.13 Only male partners having normal hormone levels, normal testicular size and subnormal semen parameters were included. All patients were briefed about the possibility of recurrence, failure to sire and complications like

1743-9191/$ – see front matter Ó 2009 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijsu.2009.06.006

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hydrocele. Informed consent was obtained after explanation of these in presence of female partner unless the male preferred otherwise. Routine hematology, biochemistry, abdominal ultrasound and pre-anesthesia evaluation were done. They were asked to pass urine just before being taken to the operation table. All the patients were operated under general anesthesia (GA). Standard laparoscopy instruments and capnosufflation were used as in TEP repair of inguinal hernias. Optical access was achieved via an infraumbilical incision going through the anterior rectus sheath. The rectus muscle of either side was retracted laterally to expose the posterior rectus sheath. A 10 mm. Hassan’s Trocar was introduced in the space between the muscle and the posterior rectus sheath. Capnosufflation of 10–12 mm Hg was then instituted. The extraperitoneal/pre-vesical space was dissected under vision with the help of the telescope. This was done with the sweeping and darting movements of the telescope aided by the inflow of the gas. Working space around both the deep inguinal rings was created following these movements. Two working ports of 5 mm each were then introduced lateral to the rectii on either side at a convenient distance from the umbilicus. This was usually midway from pubis to umbilicus. After identification of the peritoneal reflection, the posterior peritoneum was gently swept cranially away from the spermatic pedicle. The spermatic pedicle was identified by a tug on ipsilateral testicle and followed cranially from the deep inguinal ring. The vas was visualized at the deep ring. Its deviation medially and away from the vasa spermatica interna (VSI)7 was confirmed (Figs. 1 and 2). VSI was lifted with an atraumatic grasper close to deep ring and pulled out of inguinal canal as far as possible aided by cephalad push to the testicle. Pulling the VSI out of inguinal canal exposed the parallel inguinal collaterals, external spermatic vein or vein from vein to vas (Fig. 3) and vein from inferior epigastric vein (Fig. 4). Veins seen entering VSI at this point were divided between clips. VSI was then released to slide back into scrotum. Venous tributaries of inferior epigastric vein seen entering from medial side of deep ring were similarly divided. The VSI proximal to the point of medial deviation of vas was dissected for at least 2’’ more by sweeping the posterior peritoneum away from it. Inclusion of all structures of VSI and the collaterals in the dissected part was confirmed by craniocaudal tug on the ipsilateral testicle. The ipsilateral testicle could be seen pulled up into the inguinal canal (Fig. 5). The dissected VSI

Fig. 1. Circle in the picture outlines the deep ring with cord structures in relation to inferior epigastric vessels (IEV), iliac vessels, peritoneal reflection.

Fig. 2. Showing the peritoneal reflection, cord structures including medial deviation of vas (marked by arrow), iliac vessels and inferior epigastric vessels.

was then divided between haemostat clips or ligatures of 3-0 vicryl (Figs. 6 and 7). The ligatures included the entire mass of VIS including the artery as recommended by Koyle et al.7 Hemostasis was ensured. No energy sources were used though they were available as standby.14 Same procedure was repeated on the other side to accomplish bilateral varicocelectomy.15 Endoscopic varicocelectomy by extraperitoneal route (EVE) was now completed with de-sufflation and closure of ports as in TEP repair of hernia. Patients were allowed drinks on complete recovery from GA. They were discharged once they walked to pass urine and could tie their waist belt. They were instructed to resume normal activities of daily living. They were followed up for local care of port sites till one week as usual. EVE specific follow up included: - Evaluation for hydrocele at 6 weeks and 3 months - Scrotal ultrasound for testicular size, any hydrocele and venous reflux at 6 months. Semen analysis at 12 months. - They were advised to inform of conception as and when it happened.

Fig. 3. Showing Collateral vessels, from vein to vas (1), a parallel collateral from inguinal canal (2) & from the inferior epigastric vein (3).

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Fig. 6. Showing adequacy of space, length of vasa spermatica interna pulled in operating field being clipped.

3. Results Fig. 4. Collateral vein from inferior epigastric vein.

EVE was performed for 32 varicoceles in 16 patients with the mean age of 28 years (range 20–33 years). A total of 9, 17 and 6 varicoceles were of grade I, II and III respectively. Preoperative sperm counts were 10–60 million/ml (mean 29.25 million/ml). Preoperative sperm motility was 1–80% (mean 26%). The mean operative time was 65 min (range 50–140 min). There was no conversion; need to use energy sources, technical difficulty, intraoperative bleeding or visceral injury. Hydrocele was observed at 6 weeks in 11 of 32 varicoceles operated. All of them resolved by 3 months without any intervention. At 12 months, the sperm counts were 49–92 million/ml (mean 68.25 million/ml). Sperm motility was 47–84% (mean 63.18%). Improvement in sperm counts as well as sperm motility was statistically significant (Student’s t-test). Pregnancy was reported in 11 patients (68.75%) during a follow up of 2 years. Scrotal ultrasound and doppler at 6 months revealed no decrease in size of testis, development of hydrocele or recurrence of venous reflux. There was no clinical recurrence during a mean follow up of 47 months (36–96 months).

Fig. 5. (a &b) Testis is pulled up into the inguinal canal while pulling out the spermatic cord into the operating area.

Fig. 7. Showing the multiple tortuous collateral veins in the spermatic cord.

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4. Discussion Varicocelectomy is the most common4 surgical procedure for properly diagnosed infertile male.3 It remains the procedure of choice despite a contrary Cochrane Meta-analysis.16 AS and RE are associated with technical difficulties2, inconsistent17 and poor results.2 They may be associated with complications like acute abdominal pain, vagal crisis, funiculitis,17 vessel wall perforation,18 scrotal hematoma, epididymorchitis, testicular atrophy and radiation exposure.2 Laparoscopic varicocelectomy first reported by Hagood et al.19 based upon Palomo’s principle has proven to be effective.20 Various surgical principles like internal spermatic artery (ISA) sparing, lymphatic sparing and plication of spermatic fascia over the enlarged vessels have been explored.20 In a large series Koyle et al.7 have recommended mass occlusion of VSI as efficacious and safe procedure with good results. Ligation of ISA is no more a concern4 and is considered desirable.21 So far laparoscopic varicocelectomy has been practiced by TAPP approach. TAPP approach violates the sanctity of closed peritoneal cavity. It is also associated with potential injury to bowel, vessels and nerves apart from port site hernias.6,7 A Cochrane Meta-analysis22 comparing TAPP with TEP has shown association of TAPP with higher rates of port site hernias apart from visceral injuries that are unique to TAPP. This allowed us to perform this study without having a TAPP control group. Need to apply minimally invasive surgery in urology,1 emphasis on extraperitoneal approach,5 and need to innovate6 are cherished goals. Need for an extraperitoneal endoscopic approach has been felt for long. Abdel-Meguid and Hirsch23 reported a retero-peritoneal approach. But it required a flank position, specialized instruments and a 20 mm long primary incision besides two 10 mm additional ports. It could be used only for unilateral varicocele and failed to access subinguinal collateral veins. Our technique of EVE relies on a gold standard endoscopic approach for a ‘standard of care’ inguinal region procedure.24 Kadyrov et al.25 have reported the superiority of TEP approach in comparison to TAPP. Their supra-pubic approach is technically challenging and requires special optical trocars for entry. It also had limitation of working space and needed energized dissection for maintaining a clear vision. Our extraperitoneal approach is from the infraumbilical access to the rectus sheath and provides a large working area being created in an absolutely avascular plane. Use of energized dissection in varicocelectomy is associated with serious concerns including ureteric injury as reported by Valla et al.26,27 Valla JS,26 a proponent of avoiding peritoneal entry in varicocelectomy and an advocate of retroperitoneoscopy has reported several limitations with his approach i.e. limitation of working space, higher conversion rates and potentially hostile retroperitoneal fat. According to him bilateral varicoceles, obesity and retroperitoneal fibrosis are contraindications for retroperitoneoscopy. Our technique of EVE is truly extraperitoneal as we enter anterior to the peritoneum. This Ante-peritoneal space is not functionally divided as in the case of retroperitoneum where to cross from one side to the other is not possible. Ante-peritoneal space is a contiguous zone hence provides easy access to bilateral varicoceles from a single infraumbilical entry. Apart from TAPP approach, use of energy sources is a concern in dealing with male infertility.11 While energy related bowel, vascular and neural injuries6 are avoided in TEP approach the risk of collateral damage to vas remains.11 Our experience of TEP hernia repair and avoiding use of energy sources12 facilitated EVE as described. TEP approach in EVE obviated any need to deal with sigmoid colon or bowel adhesions to approach the cord structures.7 Totality of VSI once separated from Vas was also easy to confirm by TEP route as in classical Palomo’s operation. Knowledge of open surgery and application of its principles6 ensured replication of

Fig. 8. Showing various collaterals [A – Vas deferens, B – Vein from vein to vas, C – Parallel veins pulled out from inguinal canal, D – Vein from inferior epigastric vein].

Palomo’s procedure endoscopically. EVE also made is possible to pull out the VSI out of inguinal canal and ligate the external spermatic veins perforating the posterior wall of inguinal canal. These perforators29 were better seen due to endomagnification in EVE. Other venous collaterals like confluence of external spermatic vein to inferior epigastric vein,30 parallel venules in inguinal canal,21 dilated cremastric vein draining into inferior epigastric vein,31 anomalous internal spermatic veins and pelvic collaterals32 can be efficaciously dealt with by our technique (Fig. 8). Results of TEP approach compare favorably with those reported in literature for both laparoscopic as well as gold standard open surgical approaches.33 Our study lacks a large sample size and randomized control. But the advantages of TEP approach are obvious.10 Being able to answer a valid question with the help of available theoretical and technical tools is a basic cannon of scientific pursuit.28 EVE based upon accumulated knowledge of varicocele related anatomy, experience of extraperitoneal inguinal region surgeries and use of available surgical tools answers the quest for an extraperitoneal approach for varicocelectomy. Even for unilateral cases it seems better due to accessibility of potential collaterals from high retroperitoneal region to subinguinal region. Hydrocele, a common sequel of varicocelectomy can manifest after even three years.34 In the present study all the hydroceles resolved in the initial three months of the follow up. This study showed that technique of EVE, avoidance of energy sources and proper selection of patients gives good results in male infertility. This is borne out by the fact that EVE combines the benefits of high retroperitoneal and subinguinal approach with endomagnification35 performed by minimally invasive techniques. EVE is surgeon friendly and technically nonchallenging because most of us are now well versed with TEP, hernia surgeries. Even our urologist colleagues are utilizing the similar approach for endoscopic radical prostatectomy. The entry to Ante-peritoneum, dissection, space creation and insufflation of extraperitoneal space is identical to our procedure. EVE also proved to be patient friendly due to early resumption of activities of daily living. Avoidance of energized dissection protects the patient from collateral damage as well as the operating room personnel, the atmosphere and the climate from pollution36 5. Conclusion Varicocelectomy can be safely performed endoscopically by an extraperitoneal approach. It should be evaluated on a larger scale in all indications for varicocelectomy.

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Conflicts of interest None declared. Funding None declared. Ethical approval Cleared by the Research & Ethics Committee, Agarwal Nursing Home, Janakpuri, New Delhi 110058, India. Dated 8th May 1999. Acknowledgement We are grateful to Ms. Pooja Pant and Mr. Nayan Agarwal for their valuable help in documentation and preparation of manuscript. References 1. Sweeney DD, Smaldone MC, Docimo SG. Minimally invasive surgery for urologic disease in children. Nat Clin Pract Urol 2007;4:26–38. 2. Beutner S, May M, Hoschke B, Helke C, Lein M, Roigas J, et al. Treatment of varicocele with reference to age: a retrospective comparison of three minimally invasive procedures. Surg Endosc 2007;21:61–5. 3. The Practice Committee of the American Society for Reproductive Medicine. Report on varicocele and infertility. Fertil Steril 2006;86:93–5. 4. Chan PTK, Wright EJ, Goldstein M. Incidence and postoperative outcomes of accidental ligation of the testicular artery during microsurgical varicocelectomy. J Urol 2005;173:482–4. 5. Peters CA. Laparoscopy in pediatric urology. Curr Opin Urol 2004;14:67–73. 6. Vallancien G, Cathelineau X, Baumert H, Doublet JD, Guillonneau B. Complications of transperitoneal laparoscopic surgery in urology: review of 1,311 procedures at a single center. J Urol 2002;168:23–6. 7. Koyle MA, Oottamasathien S, Barqawi A, Rajimwale A, Furness PD. Laparoscopic Palomo varicocele ligation in children and adolescents: results of 103 cases. J Urol 2004;172:1749–52. 8. Poddoubnyi IV, Dronov AF, Kovarsky SL, Korznikova IN, Darenkov IA, Zalikhim DV. Laparoscopic ligation of testicular veins for varicocele in children. A report of 180 cases. Surg Endosc 2000;14:1107–9. 9. Riccabona M, Oswald J, Koen M, Lusuardi L, Radmayr C, Bartsch G. Optimizing the operative treatment of boys with varicocele: sequential comparison of 4 techniques. J Urol 2003;69:666–8. 10. Kuhry E, van Veen RN, Langeveld HR, Steyerberg EW, Jeekel J, Bonjer HJ. Open or endoscopic total extraperitoneal inguinal hernia repair? A systematic review. Surg Endosc 2007;21:161–6. 11. Piotr W, Ermanno ET. Is there an increased risk of the vas deferens occlusion after mesh inguinal hernioplasty and what can we do about it? Ann Surg 2007;245:154–5. 12. Agarwal BB, Gupta MK, Agarwal S, Mahajan KC. Anatomical footprint for safe laparoscopic cholecystectomy without using any energy source – a modified technique. Surg Endosc 2007;21(12):2154–8. 13. World Health Organization. Comparison among different methods for the diagnosis of varicocele. Fertil Steril 1985;43(4):575–82. 14. Agarwal BB. Are energy sources required in laparoscopic cholecystectomy? Or they should be stand by. Surg Endosc 2007;21(6):1042. 15. Gat Y, Bachar GN, Zukerman Z, Belenky A, Gornish M. Varicocele: a bilateral disease. Fertil Steril 2004;81:424–9.

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