Usefulness of indocyanine green in the laparoscopic Palomo technique: a comparative study. / Utilidad del verde de indocianina en el procedimiento de Palomo laparoscópico: estudio comparativo.

OBJECTIVE: To find out whether the use of indocyanine green for lymphatic sparing in the laparoscopic Palomo technique reduces the incidence of postoperative hydrocele. MATERIALS AND METHODS: A comparative cohort study of varicocele patients treated with the laparoscopic Palomo technique from 2008 to 2023 was carried out. Patients were divided into two groups according to whether fluorescence lymphography (intratesticular indocyanine green) had been performed or not. Epidemiological, surgical, and clinical data, as well as complications, were recorded. A hypothesis test was conducted using the SPSS software. RESULTS: 30 patients undergoing varicocele surgery through the laparoscopic Palomo technique were included. They were divided into two groups -lymphatic sparing (n= 13) vs. spermatic vessel ligation without sparing (n= 17). Mean age at surgery was 14 years. 5 cases of postoperative hydrocele were identified in the no lymphatic sparing group. 1 of them required surgery for hydrocele treatment. No hydrocele cases were noted in the lymphography group. The difference was statistically significant (p= 0.032). There were no statistically significant differences in terms of operating times or mean hospital stay. No recurrences, postoperative testicular atrophies, or indocyanine-green-related complications were recorded. Mean follow-up was 11.4 months. CONCLUSIONS: The use of indocyanine green for lymphatic sparing in the treatment of varicocele through the laparoscopic Palomo technique significantly reduces the incidence of postoperative hydrocele.

OBJETIVOS: Comprobar si el uso del verde de indocianina para la preservación linfática en la técnica de Palomo laparoscópico reduce la incidencia de hidrocele postoperatorio. MATERIAL Y METODOS: Se realizó un estudio comparativo de cohortes históricas incluyendo los pacientes tratados de varicocele mediante Palomo laparoscópico entre 2008 y 2023. Se dividieron en 2 grupos en función de la realización de linfografía con fluorescencia (verde de indocianina intratesticular). Se recogieron datos epidemiológicos, quirúrgicos, clínicos y complicaciones. Se realizó un análisis de contraste de hipótesis utilizando el programa SPSS. RESULTADOS: Se incluyeron 30 pacientes intervenidos de varicocele mediante la técnica de Palomo laparoscópico divididos en 2 grupos: en 13 se realizó preservación linfática y en 17 ligadura de vasos espermáticos sin preservación. La edad media en el momento de la cirugía fue de 14 años. Se identificaron 5 casos de hidrocele postoperatorio en el grupo sin preservación linfática. Uno requirió intervención quirúrgica para el tratamiento del hidrocele. No se identificó ningún caso de hidrocele en el grupo de la linfografía. La diferencia resultó estadísticamente significativa, p= 0,032. No hubo diferencias estadísticamente significativas en el tiempo quirúrgico ni en la estancia media. No se objetivaron recidivas, atrofias testiculares postquirúrgicas ni complicaciones asociadas al uso del verde de indocianina. El tiempo medio de seguimiento fue 11,4 meses. CONCLUSIONES: El uso del verde de indocianina para la preservación linfática en el tratamiento del varicocele mediante Palomo laparoscópico reduce significativamente la incidencia de hidrocele postoperatorio.

Indocyanine Green Fluorescence Lymphography: A New Technique to Perform Lymphatic Sparing Laparoscopic Palomo Varicocelectomy in Children.

BACKGROUND: Laparoscopic Palomo varicocelectomy is one the most common approaches adopted to treat pediatric varicocele, but postoperative hydrocele still remains a potential problem with this procedure. This study aimed to evaluate the outcome of a new technique of lymphography using indocyanine green (ICG)-enhanced fluorescence to perform lymphatic sparing laparoscopic Palomo varicocelectomy. PATIENTS AND METHODS: The records of 25 patients who underwent laparoscopic left varicocelectomy in our unit from March 2017 to March 2018 were retrospectively evaluated. The average patients' age was 13.7 years (range 12-16). All patients had a high degree varicocele associated with left testicular hypotrophy and symptoms. All procedures were performed in laparoscopy using three trocars. After trocars' positioning, 2 mL of ICG solution was directly injected into the left testicle. Using ICG fluorescence, the lymphatic vessels were clearly identified and spared, and then the entire spermatic bundle was clipped and divided according to Palomo's principle. RESULTS: The average operative time was 18 minutes (range 10-25). No conversions to open surgery and no allergy or other adverse reactions induced by ICG were reported. At a maximum follow-up of 18 months, no recurrence of varicocele or postoperative hydrocele was recorded. CONCLUSIONS: Our preliminary experience showed that ICG fluorescence lymphography is a safe and effective option to perform lymphatic sparing laparoscopic Palomo varicocelectomy in children and adolescents with high degree varicocele. The intratesticular injection of ICG and use of fluorescence vision allowed identification of lymphatic vessels in 100% of cases. No allergy to ICG or postoperative hydrocele was reported in our experience.

Two decades of experience with laparoscopic varicocele repair in children: Standardizing the technique.

BACKGROUND: Controversy still exists about the indications and the gold standard approach for varicocele treatment in pediatric population. OBJECTIVE: The authors report their 23 years of experience in laparoscopic varicocele repair in the pediatric population. STUDY DESIGN: 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. RESULTS: 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. DISCUSSION: 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. CONCLUSION: 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.

[Comparative characteristic of methods for operative treatment of patients suffering varicocele].

Efficacy and security of treatment of varicocele constitute a complex issues in urology, necessitating the additional investigations conduction. The results of surgical treatment of 280 patients, suffering left-sided varicocele and operated using three different methods--retroperitoneal varicocelectomy, laparoscopic varicocelectomy and subinguinal microsurgical varicocelectomy (SMV)--were analyzed. The advantages and faults of these methods were estimated, basing on the recurrence rate, complications by hidrocele occurrence and changes in the patients quality of life. SMV was determined as most effective and secure method of varicocele correction. The data obtained may be useful for choice of tactics for the disease treatment.

Technical standardization of laparoscopic lymphatic sparing varicocelectomy in children using isosulfan blue.

PURPOSE: The lymphatic preservation to prevent hydrocele formation after laparoscopic varicocelectomy is essential. Lymphatic sparing procedures using scrotal injection give a rate of mapping failures of 20%-30%. The aim of the present study is to standardize the technique of injection to perform a lymphatic sparing procedure in case of laparoscopic varicocelectomy. METHODS: We retrospectively evaluated 50 patients who underwent laparoscopic varicocelectomy from July 2010 to July 2013. Patients were divided into two groups: G1 (25 patients) those who underwent a classical isosulfan blue scrotal intra-dartos injection and G2 (25 patients) those who underwent the new standardized isosulfan blue scrotal intra-dartos/intra-testicular injection. RESULTS: In G1 lymphatic vessels were identified as blue coloured in 19/25 of cases (76%), in G2 in 25/25 of cases (100%). The results were analyzed using test χ(2) with Yates' correction and there was a statistically significant difference (χ(2)=0.05,1) between G2 and G1. Postoperative hydrocele was noted in 2/6 patients of G1 in whom the lymphatic vessels were not identified. CONCLUSIONS: Laparoscopic lymphatic sparing varicocelectomy is an effective procedure to adopt in children with varicocele. The intra-dartos/intra-testicular injection of isosulfan blue is significantly better than the previously described intra-dartos injection, permitting to identify lymphatic vessels in 100% of cases in our series. No allergy to isosulfan blue was reported in both groups.

Long term outcomes of lymphatic sparing laparoscopic varicocelectomy.

OBJECTIVE: To assess the long-term occurrence of hydroceles and varicocele recurrence in patients receiving lymphatic sparing laparoscopic varicocelectomy (LSLV) compared to those receiving plain laparoscopic varicocelectomy (PLV), and also to assess the growth of testicular volume postoperatively. METHODS: We employed a standard three-trocar configuration. The spermatic vessels were identified in the retroperitoneum above the internal inguinal ring. Lymphatics were dissected free from the spermatic artery and veins based on laparoscopic appearance. The spermatic artery and veins were divided between plastic locking clips. We performed a retrospective chart review of all pediatric patients who underwent laparoscopic varicocelectomy between June 2003 and January 2009. RESULTS: Of a total of 97 patients, 67 underwent LSLV with mean follow-up of 45.8 ± 20.7 months and 30 underwent PLV with mean follow-up of 40.8 ± 25.3 months (p = 15). There was a 4.5% hydrocele rate in the LSLV group compared to 43.3% in the PLV group. Of the patients who underwent a PLV and subsequently developed a hydrocele, 31% (n = 4) required a hydrocelectomy, vs none of those who developed a hydrocele after LSLV. Varicocele rate was 6% in the LSLV group vs 3.3% in the PLV group. However, when the artery was not preserved, the probability of recurrence in the LSLV group was 1.3%. Time to hydrocele formation was 16 months in the LSLV group vs 37 months in the PLV group. There was catch-up testicular growth in both groups. CONCLUSIONS: There appears to be increased risk of need for a hydrocelectomy after a PLV as compared to LSLV. Performing a lymphatic sparing, non-artery preserving, laparoscopic varicocelectomy has success and complication rates comparable with those of subinguinal microsurgical varicocelectomy. There appears to be excellent catch-up testicular growth with either laparoscopic varicocelectomy technique.

Dye assisted lymphatic sparing subinguinal varicocelectomy. A prospective randomized study.

BACKGROUND: Division of lymphatic vessels during varicocelectomy could lead to hydrocele formation and decrease in testicular function due to testicular edema. We determined if the use of methylene blue combined with optical magnification reduces the incidence of post-varicocelectomy hydrocele. METHODS: Consecutive patients treated for varicocele at our institution were evaluated for inclusion. Participants were randomly allocated to receive either subinguinal varicocelectomy after 2 ml intratunical space injection of methylene blue and group 2 in whom no mapping technique was adopted during subinguinal varicocelectomy. After surgery, the patients were assessed at 2 weeks, 6 and 12 months for hydrocele, testicular edema, varicocele recurrence, atrophy, pain or other complications with mean follow-up was 15 ± 7 months. RESULTS: Eighty patients with varicocele were randomized and completed the study. There were no intra complications in either group. In group (1) no patient had a hydrocele after surgery. By contrast, in group (2) there were four cases of secondary hydrocele (10%; P = 0.041)); no testicular hypertrophy was observed following lymphatic sparing surgery; One patient in each group had varicocele recurrence. Pregnancy was reported in 30 patients (37.5%) during the follow-up period, 17 of them (42.5%) were group (1) difference was not significantly different among both groups. CONCLUSIONS: Subinguinal varicocelectomy using combination of optical magnification and lymphatic staining (methylene blue) offers simple and quick preservation of the draining lymphatic vessels and avoids secondary hydrocele formation. ClinicalTrials.gov ID: NCT01259258.

[Differential indications in hydrocele operations - a contribution to prophylaxis for recurrent hydrocele]. / Differenzialindikationen bei Hydrozelenoperationen - ein Beitrag zur Prophylaxe einer Rezidivhydrozele.

BACKGROUND: In the operative treatment of idiopathic hydroceles the available techniques are frequently not selected as indicated according to the different expansions of hydroceles but rather the accustomed procedures are used. MATERIAL AND METHODS: In a retrospective analysis the methods and complications of hydrocele operations were evaluated. RESULTS: From 1988 to 2008 195  hydroceles in 191  patients were operated upon: 22 (11.3 %) by eversion (according to Jaboulay), 27 (13.8 %) by resection (according to von Bergmann) and 146 (74.9 %) by a combination of resection and eversion (according to Kocher) of the tunica vaginalis communis. In 14 (7.2 %) patients the operation was indicated by a recurrent hydrocele, either after an eversion alone (n = 7) or after an insufficient resection (n = 7) of the tunica vaginalis communis. As complications of the operation an abscess occurred in 4 (21 %) cases, a haematoma in 5 (2.6 %) cases and a combination of both had to be reoperated in 2 (1.0 %) cases. CONCLUSIONS: In order to prevent recurrent hydroceles the available methods for the operative treatment of idiopathic hydrocele should be selected according to the different expansions of the hydroceles and as such consequently executed.

Initial experience with percutaneous selective embolization: A truly minimally invasive treatment of the adolescent varicocele with no risk of hydrocele development.

OBJECTIVE: Postoperative hydrocele development is a frustrating complication of varicocele surgical repair. To avoid this complication, we began to offer percutaneous embolization as a treatment option. We present our initial experience with this technique. METHODS: A retrospective review of all patients who underwent percutaneous embolization and sclerotherapy of a varicocele at our institution was performed. RESULTS: There were 27 patients with a mean age of 16 years (range 13-19 years). Indications included pain (48%), varicocele size (30%) and persistent testicular asymmetry (22%). Four patients had experienced failure of a previous surgical repair. Follow-up data were available for 21 patients (mean 9 months). The varicocele resolved in 19 patients (91%) with no evidence of hydrocele formation in any of the boys. There was resolution of pain in all patients for whom this was the indication for the procedure. In the two failures, access to the lower spermatic vein was not possible owing to the number and tortuosity of the vessels. CONCLUSIONS: Percutaneous embolization and sclerotherapy represent a truly minimally invasive treatment with low morbidity, minimal pain and rapid recovery. In our early experience, since lymphatic channels are completely avoided, there appears to be no risk of hydrocele formation.

Lymphatic sparing microscopic retroperitoneal varicocelectomy: a preliminary experience.

PURPOSE: One of the most common approaches to varicocele in adolescents is the Palomo technique. We report the experience of a single surgeon using a modification in which an operating microscope was brought into the field so that lymphatics were identified and preserved. By sparing lymphatics we attempted to reduce the hydrocele rate to levels achieved with microscopic inguinal and subinguinal surgery. MATERIALS AND METHODS: A total of 20 boys with grade III varicocele underwent retroperitoneal gonadal vessel ligation with microscope assisted sparing of lymphatics between November 2004 and June 2007. Mean patient age was 15 years and mean followup was 11.2 months (range 1 to 29). RESULTS: Microscopic retroperitoneal varicocelectomy was performed in all patients with sparing of lymphatics under high power microscope. Clinical examination was performed at 1 week, 3, 6 and 12 months, and then annually to assess for recurrence and hydrocele. All boys who were followed had no hydrocele or recurrence. CONCLUSIONS: The microscope has had a large role in inguinal and subinguinal approaches. However, this technique takes up to 2 hours and testicular atrophy has been reported. There were no complications and operative time was shorter. Our technique, which uses magnification in the retroperitoneum, has not been described previously. It combines the simplicity of the original Palomo technique with a short period of microscopic dissection for identification and sparing of the lymphatics. This modification results in high success rates and fewer postoperative hydroceles.

'Preemptive hydrocelectomy' in subinguinal varicocelectomy.

BACKGROUND/AIMS: The hydrocele rate is very low after microsurgical subinguinal varicocelectomy, but microsurgical expertise is not always available in pediatric centers. We describe a modified technique to reduce the hydrocele rate after subinguinal varicocelectomy performed without an operating microscope. METHODS: A retrospective review was performed of 142 non-microsurgical subinguinal varicocelectomies performed at a single pediatric center. In 96 patients, varicocelectomy was combined with the excision and eversion of the tunica vaginalis ('pre-emptive hydrocelectomy') while in the remaining 46 cases the vaginalis was left untouched. RESULTS: Pre-emptive hydrocelectomy allowed a significant reduction in the hydrocele rate in comparison to cases in whom the vaginalis was left untouched, hydrocele rate 4.3 vs. 13% (p = 0.04). In patients undergoing preemptive hydrocelectomy, hydrocele occurred in 3 of 54 (5.5%) cases in whom the vaginalis was only excised and only 1 of 42 (2.4%) in whom it was also everted. No testicular complications were observed. CONCLUSIONS: In centers performing subinguinal varicocelectomy without the aid of an operating microscope, pre-emptive hydrocelectomy with eversion of the vaginalis might be offered as an adjunctive treatment with limited associated morbidity that might be able to reduce the incidence of postoperative hydrocele.

Lymphatic preservation using methylene blue dye during varicocele surgery: a single-center retrospective study.

OBJECTIVE: Hydrocele and testicular edema caused by division of lymphatic vessels during varicocelectomy could lead to decrease in testicular function. In-vivo methylene blue mapping of testicular lymphatic vessels should prevent damage to the lymphatic system. MATERIALS AND METHODS: We retrospectively compared outcomes for 46 patients who received an intraparenchymal injection of 0.25 ml of vital dye (isosulphan blue) before a laparoscopic or an inguinal/subinguinal spermatic vein ligation with 93 controls in whom no mapping technique was adopted. RESULTS: Methylene blue mapping of testicular lymphatics reduced the incidence of postvaricocelectomy hydrocele from 6.4% (6/93) to 2.1% (1/46); the incidence of hydrocele was 0% in all cases of successful lymphatic mapping. CONCLUSION: Mapping of testicular lymphatic drainage with intraparenchymal vital dye is an easy, safe, rapid and cost-free technique. We stress the importance of sparing the lymphatic system to ensure the best andrological outcome.

Impact of seven rounds of mass administration of diethylcarbamazine and ivermectin on prevalence of chronic lymphatic filariasis in south India.

OBJECTIVE: To evaluate the impact of seven rounds of mass administration of diethylcarbamazine (DEC) and ivermectin on the prevalence of chronic lymphatic filariasis and to compare it with that observed in a placebo arm in a community-level trial. METHODS: Cross-sectional clinical surveys were carried out before and after seven rounds of mass drug administration (MDA). About 54-75% of the target population were treated at each round of MDA. RESULTS: After seven rounds, the hydrocele prevalence had declined from the pre-intervention level of 20.5-5.1% (P < 0.05) in the DEC arm, from 23.9% to 10.4% (P < 0.05) in the ivermectin arm and from 20.4% to 10.9% (P < 0.05) in the placebo arm, equivalent to reductions of 75.3%, 56.6% and 46.6%, respectively. The lymphoedema/elephantiasis prevalence declined only marginally and without statistical significance from 3.7% to 3.2%, 4.6% to 3.9% and 2.9% to 2.3% in the DEC, ivermectin and placebo arm. After the seventh MDA, none of the sampled people in the 0-20 age group was found with hydrocele and there was a statistically significant decline in hydrocele prevalence in all other age groups in the communities treated with DEC, the drug known to have macrofilaricidal effect. The impact was relatively less in ivermectin arm. CONCLUSION: Repeated DEC administration has the potential to prevent incidence of new hydrocele cases and may resolve the manifestation at least in a proportion of affected people. Apart from reducing the microfilaraemia prevalence and transmission of infection, MDA also results in significant public health benefits by reducing the burden of hydrocele in treated communities.

Community's knowledge and perceptions about filarial elephantiasis and hydrocele in coastal Orissa, India.

This study assesses people's knowledge and perceptions on transmission, prevention and eradication of elephantiasis and hydrocele, common manifestations of chronic lymphatic filariasis (LF). The assessment was done during mass drug administration (MDA) of the programme to eliminate LF in the State of Orissa, India. A household survey with pre-tested interview questionnaire was conducted in four LF endemic districts of Orissa state, India, where the MDA has been taken place. The sampling units (clusters of households) of the household survey are taken based on (1) urban/rural and (2) type of or absence of health facility. A total of 1,448 respondents were selected randomly. Majority of the respondents heard about elephantiasis and hydrocele. About one third of them know that mosquito bite is the cause of elephantiasis but very few people know about hydrocele. Around 50% of the respondent believed that elephantiasis could be cured completely, while almost 60% said that it could be totally removed from the community. But for hydrocele, more than 80% of respondents showed a positive approach for cure and nearly about 70% said that hydrocele could totally be eradicated from community. Various causes and methods of cure and prevention were suggested. Around 55% of respondents suggested that elephantiasis can be eradicated by taking medicine, but only 40% felt that hydrocele can be cured by taking medicine. Basic knowledge on LF is poor and relatively low proportion of people knows that LF can be eliminated by taking medicine. As there are plans to undertake further rounds of MDA in Orissa, people's knowledge has to be strengthened and perception and attitudes have to be addressed to achieve positive behavioural change, which eventually lead to higher compliance of MDA.

Lymphatic vessel hydrodissection during varicocelectomy.

We report a new technique of preserving the lymphatics during varicocelectomy using saline infusion that we have termed "lymphatic hydrodissection."

Dye-assisted lymph vessels sparing laparoscopic varicocelectomy.

OBJECTIVE: Hydrocele, the main complication of laparoscopic varicocelectomy, is thought to result from a disruption of gonadal lymphatics. The aim of this study was to evaluate the effectiveness of patent blue V dyeing to identify and preserve lymphatic vessels and to assess whether the lymphatic sparing technique avoids postoperative hydrocele in adolescent boys undergoing a laparoscopic procedure. MATERIALS AND METHODS: Fifty-two (52) boys affected by varicocele Grade III (range, 12-16 years) underwent a left-sided laparoscopic varicocelectomy. Twenty-six (26) boys were randomly assigned to a lymphatic nonsparing (LNS) group, and the others to a lymphatic sparing (LS) group. Before surgery in the LS group, 2 mL of patent blue V was injected under the tunica dartos on the left side. RESULTS: All varicocelectomies were performed laparoscopically. Lymphatic vessels were identified in 23 (88.5%) boys of the LS group. In the remaining three (11.5%), the lymphatics could not be identified clearly. No adverse local or generalized reactions were noted. At a mean follow-up of 14 months, no recurrent varicocele or testicular volume reduction were detected. Hydrocele developed in 4 LNS patients and 1 was operated on. No patient from the LS group developed a hydrocele. CONCLUSIONS: Staining gonadal lymph vessels with patent blue V is an effective and simple method of visualization of the lymphatic drainage from the testis. Blue-stained lymph vessels could be readily distinguished and preserved during a laparoscopic varicocelectomy, which results in a decrease of hydrocele development. To validate an efficacy of vital staining of lymphatic vessels in avoiding hydrocele formation, a larger series and longer follow-up are necessary.

Laparoscopic varicocele ligation in children and adolescents using isosulphan blue: a prospective randomized trial.

OBJECTIVES: To evaluate, in a randomized prospective trial in children and adolescents, the feasibility of isosulphan blue-based lymphatic vessel preservation during laparoscopic varicocelectomy and its impact on the complication rate, as the operative management of varicoceles remains controversial. PATIENTS AND METHODS: In all, 50 consecutive patients were randomly assigned to two laparoscopic varicocelectomy groups. The indications for surgery included scrotal pain and a difference in testicular size, as well as severe cosmetic impairment. All the patients had a laparoscopic varicocelectomy using three ports. Patients in group A had standard laparoscopy, while those in group B had additional isosulphan blue administered. After surgery, the patients were assessed at 3, 6 and 12 months for varicocele recurrence, hydrocele formation, atrophy, pain or other complications. RESULTS: There were no intraoperative complications or conversions to open surgery. There were no adverse reactions, scrotal haematomas or atrophy. At 3 months after surgery, the incidence of hydrocele in group A was 20% whereas in group B no hydroceles were detected (P = 0.025); at 6 months the 20% still had hydroceles. One patient in each group had varicocele recurrence associated with persistent pain. In two patients in group B, blue pigmentation of the left hemiscrotum persisted at the 3-month follow-up but resolved by 6 months. CONCLUSIONS: Laparoscopic repair of varicoceles using isosulphan blue helps to identify and preserve the lymphatic drainage. It prevents secondary hydrocele formation, the most common complication, with no supplementary risk to the patient. Also, testicular oedema causing impaired spermatogenesis can be avoided.

Lymphography prior to laparoscopic Palomo varicocelectomy to prevent postoperative hydrocele.

BACKGROUND: We report our experience with preoperative lymphography to identify and perioperatively preserve the ligature of the lymphatic vessels to reduce the incidence of postoperative testicular hydrocele in patients undergoing laparoscopic Palomo varicocelectomy for adolescent varicocele. MATERIALS AND METHODS: Twenty-seven consecutive patients with varicocele had preoperative lymphography. The mean age was 13.5 years (range, 8-18 years) and the mean grade of varicocele was III. We performed lymphography with intrascrotal isosulfan blue. The laparoscopic Palomo procedure was successfully carried out in all patients. RESULTS: In 17 patients (63%) we were able to identify and conserve the lymphatic vessels by lymphography. Mean follow-up was 9.5 months (range, 6-24 months). None of the 27 patients had a recurrence. None of the 17 patients with positive lymphography had a testicular hydrocele. One of the 10 remaining patients developed a sizable hydrocele. CONCLUSION: Preoperative lymphography prior to laparoscopic Palomo varicocelectomy is a simple and feasible method for preventing testicular hydrocele. However, the method should be standardized to identify the exact site, the correct level of injection of blue dye, and to determine the optimal time to perform lymphography prior to the procedure.