Mikrocerrahi varikosel ameliyatı bilimsel çalışmalar türkçe-ingilizce

THE SYSTEMATİC USE OF İNTRAOPERATİVE VASCULAR DOPPLER ULTRASOUND DURİNG MİCROSURGİCAL SUBİNGUİNAL VARİCOCELECTOMY İMPROVES PRECİSE İDENTİFİCATİON AND PRESERVATİON OF TESTİCULAR BLOOD SUPPLY

OBJECTİVE
To evaluate the impact of systematic use of intraoperative Doppler ultrasound during microsurgical subinguinal varicocele repair.
DESİGN
Prospective clinical study.
SETTİNG
Andrology laboratory and male infertility section of the urology department of a tertiary care hospital.
PATİENT(S)
Two hundred and thirteen men with clinical varicocele.
INTERVENTİON(S)
Subinguinal microsurgical varicocele ligation using an intraoperative vascular Doppler flow detector.
MAİN OUTCOME MEASURE(S)
Number of veins ligated, lymphatic spared, arteries identified or accidentally ligated.
RESULT(S)
A statistically significant greater number of arteries were identified and preserved when intraoperative vascular Doppler was used. In addition, the average number of internal spermatic veins ligated was statistically significantly greater in the same group. Accidental artery ligation occurred in two cases (1.1%) in which the Doppler was not applied. There was no statistically significant difference in number of lymphatics spared between groups.

Our findings showed that concomitant use of intraoperative vascular Doppler during microsurgical varicocelectomy allows more arterial branches to be preserved, and more internal spermatic veins are likely to be ligated. This device should be considered an attractive tool to improve surgical outcomes and safety.
Key Words:Varicocelemale factor infertilitymicrosurgeryDoppler ultrasoundvaricocelectomy
Current data support that varicocele repair does indeed have a beneficial effect on improving seminal parameters as well as assisting infertile couples to achieve pregnancy spontaneously (12). A variety of open surgical techniques have been used to repair this condition, including retroperitoneal, inguinal, and subinguinal approaches (2). None of these has been proven superior to the others in its ability to improve fertility; however, they have different recurrence rates and potential complications.
The classic inguinal approach is associated with a longer time to postoperative return to work due to opening the external oblique fascia (3). The subinguinal approach has the same principals as the inguinal approach but is performed through an incision below the external inguinal ring, obviating the need to open the aponeurosis of the external oblique and thus causing less pain and resulting in a shorter recovery period (45). On the other hand, the spermatic cord at the subinguinal level has a greater number of internal spermatic veins, which means there is an increased likelihood of encountering multiple spermatic arteries compared with the inguinal approach (5).
Attempts at decreasing the complication and recurrence rates after this procedure have led to microsurgical techniques that allow better preservation of the testicular artery and lymphatics vessels, resulting in a lower incidence of hydrocele (46). Also, ligation of the testicular artery can result in damage to the seminiferous tubules even without testicular atrophy (78), so a dissection technique that enables the preservation of spermatic artery and all branches is preferred.
Previous studies have reported that multiple spermatic arteries can be identified in approximately 40% of the spermatic cords during microsurgical varicocelectomy at the subinguinal level (59). The identification of the main spermatic artery can be confirmed by visualization of clear pulsatile movement and/or evidence of antegrade, pulsatile blood flow after gentle lifting and partial occlusion of the vessel. However, the identification of tiny secondary arteries is not always obvious, and intraoperative Doppler ultrasound has been used for this purpose (1011).
To our knowledge, the impact of systematic use of intraoperative Doppler ultrasound during microsurgical subinguinal varicocele repair has not been described in the literature. Thus, our study evaluated whether subinguinal microsurgical varicocele ligation can be improved with the use of intraoperative Doppler ultrasound for a more precise identification and preservation of spermatic arteries. We hypothesized that this device could increase the number of arterial branches identified.
MATERİALS AND METHODS
The University of São Paulo's institutional review board approved this study. Between August 2004 and July 2008, a total of 213 consecutive patients underwent 377 subinguinal varicocelectomies and were prospectively evaluated in this study. One hundred and twenty-three of the 213 (57.7%) patients underwent the gold standard technique: microsurgical subinguinal varicocelectomy. The remaining 90 (42.3%) patients underwent exactly the same technique with the addition of a sterile intraoperative probe attached to a 9.3 Mhz vascular Doppler flow detector (Vascular Technology Inc., Nashua, NH).
All patients were referred to our institution for evaluation of male factor infertility and had clinically palpable varicocele. During the scrotal examination performed with the patient in the standing position, varicocele was clinically classified as grade 1 (palpable with the Valsalva maneuver), grade 2 (palpable without the Valsalva maneuver), or grade 3 (visible through the scrotal skin). Patients who had undergone previous varicocele repair through the inguinal approach, any scrotal surgery, or any hernia repair were excluded from this study.
Surgical Techniques
All procedures were performed by three male factor infertility specialists who were familiar with the technique (M.C., R.P., and J.H.). All procedures were performed under regional or general anesthesia. After antibiotics had been administered, a 1.5 to 2 cm subinguinal incision was made 1 cm below the external inguinal ring. The Camper fascia and Scarpa fascia were incised, exposing the spermatic cord, which was then surrounded by a Penrose drain.
In the group without Doppler, microsurgical varicocele repair was performed using the artery and lymphatic sparing technique, as previously described elsewhere (12). Briefly, the spermatic cord was mobilized out of the incision to permit identification of the external spermatic veins that penetrated the floor of the inguinal canal. These identified external spermatic veins were ligated with 4-0 silk ties and divided. After that, dissection was performed under a Zeiss operating microscope (Carl Zeiss, Thornwood, NY) at 8 to 15 power magnification. The cremasteric fibers were divided in a longitudinal fashion, and the internal spermatic cord and pampiniform plexus were then dissected out. Small bleeders were controlled with a microsurgical bipolar cautery. A meticulous dissection of the spermatic cord was used to ensure proper identification of the testicular arterial blood supply. A papaverine solution was used to help identify visual arterial pulsation. The internal spermatic veins were then ligated and divided after all arteries in the cord had been identified and preserved. All the lymphatics identified were carefully preserved.
In the group with intraoperative Doppler, the same technique was applied, but all spermatic vessels were systematically scanned with the vascular Doppler before ligation, regardless of their visual appearance or absence of pulsation. The spermatic cord was then returned to the normal position.
The Scarpa fascia was closed with an interrupted absorbable suture, and the skin was closed with a running subcuticular 5-0 absorbable monofilament suture.
Intraoperative Evaluation
During the procedures, the number of internal spermatic veins, spermatic arteries, and lymphatics found within the spermatic cord was recorded. Any inadvertent damage, failure to recognize the artery, or accidental artery ligation was documented by a pulsatile twitching of the ligated vessel, and the operative time were recorded.
We compared the categorical variables between the subinguinal microsurgical technique using ultrasound Doppler with the same technique without the Doppler using the chi-square test and Fisher's exact test. Student's t-test was used for the normally distributed continuous variables. All analyses were performed with MINITAB (version 14.2; SixSigma, Austin, TX) and SPSS (version 14.0; SPSS Institute Inc., Cary, NC). P<.05 was considered statistically significant.
RESULTS
The preoperative characteristics are described in Table 1. There were no statistically significant differences in patient age or varicocele grade between the two groups. We performed 164 bilateral procedures and 49 on the left side only. There was a higher incidence of bilateral procedures in the group where Doppler was used.

Table 1Preoperative data of men submitted to microsurgical subinguinal varicocele repair with and without vascular Doppler.

With Doppler (n = 123)

Without Doppler (n = 90)

P value

Agea

30.2 ± 7.7

29.3 ± 7.7

0.56

Varicocele Gradeb

 Grade 1

19 (15.5%)

13 (14.4%)

 Grade 2

53 (43.0%)

40 (44.5%)

0.50

 Grade 3

51 (41.5%)

37 (41.1%)

Varicocele Sideb

 Left

21 (17.1%)

28 (31.1%)

0.03

 Bilateral

102 (82.9%)

62 (68.9%)

 

aValues are mean and SD. Compared using Student's unpaired t-test.
bData presented as number (percentage) of patients. Compared using Chi-square test. P<0.05 was considered statistically significant.
As shown in Table 2, a statistically significantly greater number of arteries were identified and preserved when intraoperative vascular Doppler was used. Data concerning surgery using the vascular device and without it show that a solitary artery is identified in 45.5% and 69.5% of cords, respectively; two arteries are identified in 43.5% and 28.5%, respectively; and three or more arteries are identified in 11% and 2%, respectively. The average number of internal spermatic veins ligated was statistically significantly higher in the vascular device group. Accidental artery ligation documented by a pulsatile twitching of the ligated vessel stump under magnification occurred in two cases in which the Doppler was not applied. There was no statistically significant difference in the number of lymphatics spared between the groups. There was no statistically significant difference in operating time for bilateral or unilateral repair between the groups (see Table 2).


Table 2Intraoperative evaluation of internal spermatic veins ligated, number of lymphatic spared, arteries preserved and injured in 377 spermatic cord dissections during microsurgical subinguinal varicocele repair with and without vascular Doppler.

Variable

With Doppler (No. spermatic cords = 225)

Without Doppler (No. spermatic cords = 152)

Pvalue

Number of veins ligateda

8.0 (3.1)

7.3 (2.8)

0.02

Number of arteries preserveda

1.6 (0.6)

1.3 (0.5)

<0.01

Number of arteries injuredb

0

2 (1.1%)

0.06

Number of lymphatics spareda

2.2 (1.2)

2.0 (1.5)

0.21

Operative time unilateral repair (min)a

52.8 ± 17.8

53.0 ± 36.7

0.98

Operative time bilateral repair (min)a

101.0 ± 16.2

101.9 ± 16.3

0.37

aValues are mean and SD. Compared using Student's unpaired t-test.
bData presented as number (percentage) of patients. Compared using Chi-square test. P<0.05 was considered statistically significant.
Discussion
The augmented probability of encountering multiple spermatic arterial branches in the subinguinal region contributes to the technical difficulty of this approach (5). The number of spermatic arteries identified in the spermatic cord seems depend on the level of the dissection. Jarow et al. (13) found numerous arterial branches in 81% of the spermatic cords upon histologic analysis, which is higher than in clinical observation studies (5). Therefore, it is possible that inadvertent unrecognized ligation of a small (secondary) internal spermatic artery occurs more frequently than reported. Although there is no unanimity about the necessity to preserve all testicular arterial branches (1415), inadvertent ligations might be responsible for suboptimal spermatogenic recovery or failure to improve fertility in some cases (16).
Our study presented an incidence of unintentional artery ligation of two out of 152 cases (1.1%) without the Doppler, which is similar to the major reported study in the literature (17). Although preservation of cremasteric and/or secondary internal spermatic arteries is likely to contribute to a low incidence of adverse outcomes, the spontaneous pregnancy rate appears to be statistically significantly lower than in arterial intact cases. Therefore, there is growing support for artery-sparing techniques, and every effort should be made to avoid accidental arterial ligation during varicocelectomy. Although the results did not reach statistical significance because of the limited number of patients, we found no arterial ligation in the group of Doppler cases.
Chan et al. (17) discussed several reasons why accidental ligations may occur. First, the size of the arteries may be so small that the pulsation is difficult to identify. Second, aggressive manipulation of the vessels during dissection can lead to spasm, making it difficult to identify arterial pulsation. Third, the arteries tend to be in close proximity to or buried under complex branches of veins. In all these situations, the use of vascular Doppler may help to preserve the arterial branches.
Grober et al. (9) reported that the number of arteries preserved during varicocelectomy does not correlate with improvement in semen parameters. These negative findings do not mean that preservation of only a single testicular artery will necessarily be sufficient to maintain or even optimize testicular function. Instead, the investigators suggested that these results may simply reflect the variable intraoperative arterial anatomy of the spermatic cord (9).
Current data indicate that preoperative parameters are not predictive of the number of testicular arteries identified at the time of surgery (9). As a result, the application of technological advances in varicocelectomy, including optical magnification, microsurgery skills, and vascular Doppler, should be offered to patients to achieve maximal preservation of the arterial blood supply to the testes.
Recent studies have shown that the total number of veins ligated has a statistically significant positive correlation with improvements in total sperm motility and sperm concentration (1819). These results suggest that ligating a larger number of veins should lead to a greater decrease in the reflux, which in turn would lead to diminished insult to spermatogenesis. Surprisingly, in our study we found more spermatic veins ligated when using the Doppler ultrasound. The possible explanation would be that there is a higher confidence during dissection of a dense complex of adherent veins surrounding the artery in 95% of cases during the subinguinal approach (5). Thus, the practice of avoiding dissection of individual vessels in this situation because the arterial pulsation is less prominent may lead to a lower number of veins ligated when Doppler is not helping the perfect identification the bloody flow, even with visual absence of pulsation.
Although we performed a prospective study, the nonrandomized design is a drawback of this series. It was not possible to randomize the cases because equipment importation issues meant we did not have the vascular probes available in every surgery. Our findings suggest that concomitant use of intraoperative vascular Doppler during subinguinal varicocelectomy allows more arterial branches to be identified and therefore preserved. Also, more internal spermatic veins are likely to be ligated.
Microsurgical technique remains the gold-standard procedure for the varicocele repair, but the concomitant use of intraoperative Doppler should be considered as a tool to improve surgical outcome and safety. Additional research is needed to clarify whether the use of Doppler during varicocelectomy is likely to improve testicular function and seminal parameters.

References

1.Agarwal, A., Deepinder, F., Cocuzza, M., Agarwal, R., Short, R.A., Sabanegh, E. et al. Efficacy of varicocelectomy in improving semen parameters: new meta-analytical approach. Urology. 2007; 70:532–538

2.Marmar, J.L., Agarwal, A., Prabakaran, S., Agarwal, R., Short, R.A., Benoff, S. et al. Reassessing the value of varicocelectomy as a treatment for male subfertility with a new meta-analysis. Fertil Steril.2007; 88: 639–648

3.Ivanissevich, O. Left varicocele due to reflux; experience with 4,470 operative cases in forty-two years. J Int Coll Surg. 1960; 34: 742–755

4.Marmar, J.L., DeBenedictis, T.J., and Praiss, D. The management of varicoceles by microdissection of the spermatic cord at the external inguinal ring. Fertil Steril. 1985; 43: 583–588

5.Hopps, C.V., Lemer, M.L., Schlegel, P.N., and Goldstein, M. Intraoperative varicocele anatomy: a microscopic study of the inguinal versus subinguinal approach. J Urol. 2003; 170: 2366–2370

6.Goldstein, M., Gilbert, B.R., Dicker, A.P., Dwosh, J., and Gnecco, C. Microsurgical inguinal varicocelectomy with delivery of the testis: an artery and lymphatic sparing technique. J Urol. 1992;148: 1808–1811

7.Silber, S.J. Microsurgical aspects of varicocele. Fertil Steril. 1979; 31: 230–232

8.Steinberger, E. and Tjioe, D.Y. Spermatogenesis in rat testes after experimental ischemia. Fertil Steril. 1969; 20: 639–649

9.Grober, E.D., O'Brien, J., Jarvi, K.A., and Zini, A. Preservation of testicular arteries during subinguinal microsurgical varicocelectomy: clinical considerations. J Androl. 2004; 25: 740–743

10.Minevich, E., Wacksman, J., Lewis, A.G., and Sheldon, C.A. Inguinal microsurgical varicocelectomy in the adolescent: technique and preliminary results. J Urol. 1998; 159: 1022–1024

11.Wosnitzer, M. and Roth, J.A. Optical magnification and Doppler ultrasound probe for varicocelectomy. Urology. 1983; 22: 24–26

12.Marmar, J.L. and Kim, Y. Subinguinal microsurgical varicocelectomy: a technical critique and statistical analysis of semen and pregnancy data. J Urol. 1994; 152: 1127–1132

13.Jarow, J.P., Ogle, A., Kaspar, J., and Hopkins, M. Testicular artery ramification within the inguinal canal. J Urol. 1992; 147: 1290–1292

14.Matsuda, T., Horii, Y., and Yoshida, O. Should the testicular artery be preserved at varicocelectomy?. J Urol. 1993; 149: 1357–1360

15.Student, V., Zatura, F., Scheinar, J., Vrtal, R., and Vrana, J. Testicle hemodynamics in patients after laparoscopic varicocelectomy evaluated using color Doppler sonography. Eur Urol. 1998; 33: 91–93

16.Penn, I., Mackie, G., Halgrimson, C.G., and Starzl, T.E. Testicular complications following renal transplantation. Ann Surg. 1972; 176: 697–699

17.Chan, P.T., Wright, E.J., and Goldstein, M. Incidence and postoperative outcomes of accidental ligation of the testicular artery during microsurgical varicocelectomy. J Urol. 2005; 173: 482–484

18.Belani, J.S., Yan, Y., and Naughton, C.K. Does varicocele grade predict vein number and size at microsurgical subinguinal repair?. Urology. 2004; 64: 137–139

19.Pasqualotto, F.F., Lucon, A.M., de Goes, P.M., Sobreiro, B.P., Hallak, J., Pasqualotto, E.B. et al.Relationship between the number of veins ligated in a varicocelectomy with testicular volume, hormonal levels and semen parameters outcome. J Assist Reprod Genet. 2005; 22: 245–249

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