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Is It Necessary to Identify and Ligate Distal Collateral Veins During Varicocelectomy to Decrease Varicocele Recurrence?

Saturday, October 20, 2012
Grand Ballroom A/B (Hilton Riverside)
Angela M. Fast, B.S., Jason P. Van Batavia, M.D., Shannon N. Nees, BS and Kenneth I. Glassberg, MD, FAAP, Division of Pediatric Urology, Department of Urology, Columbia University College of Physicians and Surgeons, Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY

Purpose:   Numerous authors have suggested that distal collateral veins, such as the external spermatic, cremasteric, gubernacular, deferential and scrotal accessory veins, should be identified and ligated to decrease the recurrence rate following varicocelectomy. Recently, some centers have even advocated obtaining Doppler ultrasound to identify collaterals prior to surgery and adjusting the surgical approach based on these findings. In the Palomo and laparoscopic varicocelectomy approaches, exposure is proximal to the internal ring and these aforementioned collaterals are not accessible in the operative field and thus not identified or ligated. We sought to determine our varicocelectomy results when these collateral veins were not taken into account at the initial surgery and report our observations for those requiring redo varicocelectomy.

Methods:   We retrospectively reviewed our adolescent varicocele database to identify patients who had undergone varicocelectomy and were <21 years of age at the time of surgery. Only patients who had undergone a Palomo or laparoscopic approach were included to ensure that no surgical manipulation occurred to the collaterals in the inguinal canal or scrotum. Recurrence was defined as a persistent or recurrent grade 2 or 3 varicocele with a retrograde flow velocity of ³10 cm/sec.

Results:   Between 1997 and 2012, 513 varicocelectomies (81 Palomo, 432 laparoscopic) were performed in 419 patients (mean age: 15.4 years, range 9.2-21.0; mean follow-up: 34.3 months, median: 29.8 months). Overall, 323 of 418 patients (77.3%) had a unilateral left varicocelectomy and 95 of 419 patients (22.6%) had a bilateral repair. There were 25 recurrences (4.9%), all on the left, that required redo varicocelectomy. Six patients (24%) did not develop a recurrence until two or more years following surgery. Of the 25, 21 patients underwent redo varicocelectomy, 2 are scheduled for redo varicocelectomy and 2 went to an outside physician for their redo varicocelectomy. Of the redo varicocelectomies, all patients were noted to have dilated veins in the spermatic vessels proximal to their junction with the vas deferens with continuation of these veins into the spermatic cord. In one redo, a dilated deferential vein was ligated. There were no recurrences in the 21 redo varicocelectomies performed.

Conclusion: Given that this series had an essentially 100% success rate when redo surgeries were included without ligating distal collateral veins in all but one case, it appears that the significance of collaterals below the internal ring as an etiology to recurrence and necessity of Doppler ultrasound to identify collaterals pre-varicocelectomy for planning surgical approach is debatable. Given the high success in both initial and redo varicocelectomies in this series, distal collateral veins may play a much smaller role in varicocele formation and recurrence than previously thought.