Journal of Pediatric Surgery 49 (2014) 583–585
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Trans-scrotal varicocelectomy in adolescents: Clinical and surgical outcomes Nicola Zampieri a,⁎, Gianfranco Zampieri a, Lucio Antonello b, Francesco Saverio Camoglio c a b c
Casa di Cura “San Francesco” Hospital, Department of Surgery, via monte Ortigara 21/b, 37100, Verona, Italy Department of Anesthesiology; Policlinico "G.B.Rossi", piazzale Scuro n. 1-Verona, Italy Department of Surgical Sciences, Pediatric Surgical Unit, Policlinico "G.B.Rossi", piazzale Scuron. 1-Verona University of Verona, Verona, Italy
a r t i c l e
i n f o
Article history: Received 3 June 2013 Received in revised form 26 July 2013 Accepted 30 July 2013 Key words: Varicocele Adolescents Scrotal Local anesthesia
a b s t r a c t Background: The gold standard to treat varicocele in adolescents is still under discussion. The aim of this study is to evaluate the role of trans-scrotal varicocelectomy and show the results obtained by using local anesthesia in combination with preoperative sedation. Materials and Methods: Between January 2010 and January 2012, this surgical and anesthesiology procedure was proposed to study patients. Inclusion and exclusion criteria were created. Patients received trans-scrotal varicocelectomy with lymphatic and artery sparing technique under local anesthesia with mild sedation anesthesia. Patients were followed for 6 months after surgery, and complications were recorded. Results: Eighteen patients were treated with this technique. Three patients required additional sedation with propofol. None had recurrence of varicocele, and one patient showed post-operative hydrocele. All patients were discharged within 24 h following surgery. Three patients used ibuprofen and paracetamol for two days after surgery. Conclusions: Local anesthesia in the pediatric age group could be used for varicocelectomy with mild sedation anesthesia. © 2014 Elsevier Inc. All rights reserved.
The gold standard to treat varicocele in adolescents is yet to be determined. At present all the techniques suggested require surgery under general anesthesia. Local anesthesia is mainly used in percutaneous techniques with either retrograde or anterograde scleroembolization. Although this method is less invasive, it appears to have higher failure rates (Level of evidence: 2; Grade of recommendation: B.) as reported in the guidelines by the American Academy of Pediatrics (www.aap.org). Exclusively surgical techniques are all performed under general anesthesia while spinal anesthesia is mainly used in adults or patients aged N18 years receiving inguinal/subinguinal techniques [1–4]. Local anesthesia has never been used in adolescents because patients usually offer poor collaboration and all of the most commonly used procedures to treat varicocele in pediatric patients (i.e. suprainguinal, laparoscopic and retroperineoscopic techniques) require general anesthesia. The purpose of this study is to present an alternative surgical technique performed under local anesthesia with pre-operative sedation.
⁎ Corresponding author. Pediatric Surgical Unit, Policlinico “G. B. Rossi”, Piazzale L.A. Scuro, 37134-Verona-Italy. Tel.: +39 45 8124916; fax: ++39 45 8124662. E-mail address: [email protected] (N. Zampieri). 0022-3468/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2013.07.023
1. Materials and methods Between January 2010 and January 2012 adolescent patients with varicocele were treated following a new surgical and anesthesia approach. After oral and written consent was obtained from their parents, varicocelectomy was performed on a group of patients aged 13 to 16 years using this surgical and anesthesiological procedure (usually performed by the same authors in adult patients). Inclusion and exclusion criteria for this study were as follows: patients with grade III left varicocele and testicular hypotrophy N 20% (left side), no other previous surgery, no scrotal trauma. Patients who did not complete follow-up were excluded from the study. In compliance with the study protocol, all patients were observed every six months after surgery. 1.1. Procedure (Fig. 1) An anesthesiologist induced local anesthesia with Naropin 0.75% (10 cc) and lidocaine 2% (5 cc) around the spermatic cord and the ilioinguinal nerve, around the outer external spermatic fascia and in the cremasteric muscle 15 min before surgery. Pre-operative sedation was obtained using midazolam (before entering the Operating Room) and propofol (at the time of skin incision) with standard dose per
584
N. Zampieri et al. / Journal of Pediatric Surgery 49 (2014) 583–585
weight. The surgical procedure had a trans-scrotal approach: after scrotal incision all fasciae were opened. Without testicular delivery all spermatic veins were isolated and ligated. Lymphatic and artery sparing procedures were then performed for each patient under optical magnification. At the end of the procedure, the skin was sutured with absorbable stitches and topical surgical glow (seal) without a dressing. None of the patients received antibiotics after treatment. The Authors analyzed efficacy and relapse rates as well as post-operative hydrocele rates. Complications were classified following the Clavien Classification of Surgical Complications [5]. Statistical analysis was performed using the chi-square and Fischer exact tests. P value less than .05 was considered significant for the correlation between the variables. 2. Results During the study period 18 patients were treated with this technique. Age range was between 13 and 16 years. At present, all patients are followed at the Authors’ Institution and have completed follow-up (at least 2 controls). All patients had grade III varicocele, 3 had scrotal ptosis managed using a jockstrap for 1 month after surgery. None of the patients developed testicular atrophy or showed recurrence of varicocele, while a moderate hydrocele occurred in 1 patient (5%). For this last patient a “wait and see” observation approach was used. Surgically it was more difficult to treat patients with scrotal ptosis. They had very thin scrotal veins with a consequent increased risk of bleeding. There were no surgical complications during surgery or during follow-up. Operation time was 22 ± 08 min; 3 patients (18.75%) needed additional sedation with an increased dosage of propofol but none required intubation. Post-operative analgesic treatment was managed with ibuprofen and paracetamol in all patients until discharged from hospital. Three
patients used analgesics at home for 2 more days, while the remaining patients did not report any use of analgesics for more than 1 day after discharge (pb0.05). Patients treated with this procedure did not report lumbar pain (common referred pain from the testicle) or inguinal/scrotal pain. All patients were discharged within 24 h and started drinking liquids two hours after surgery. 3. Discussion The technique with local–regional anesthesia to treat varicocele was suggested by many authors but all cases received spinal anesthesia [1,2]. Although it is well known that spinal anesthesia involves many complications such as headache, lumbar pain and urinary retention, it is the most common choice for the surgical treatment of varicocele in adult patients. In a recent paper Kadihasanoglu et al. described the results obtained in a randomized study regarding the use of local vs. spinal anesthesia in the treatment of varicocele. They concluded that local anesthesia is efficient, safe and it can be used for this type of surgical procedures [1]. Their study reported the use of both techniques in patients aged N 18 years focusing also on the comparison of reported pain following one or the other technique. The results showed that the group receiving local anesthesia had more peri-operative pain than the spinal anesthesia group, although symptoms in the two groups 24 h after surgery was not statistically different. Despite the high number of studies carried out on the treatment of varicocele in the pediatric age group it is clear that at present a surgical or anesthesiological gold standard is yet to be determined. Many authors agree on the fact that the veins should be ligated and then excised. Also, testicular delivery should be avoided in order to reduce post-operative pain [6–11]. As reported by Park et al., Kim et al. and Mirilas et al., testicular delivery in adolescents without gubernacular vein enlargement is not
Fig. 1. Surgical procedure: under local anesthesia (A), we performed a trans-scrotal incision (B); through the incision we performed standard veins ligature with lymphatic and artery sparing technique (C), then the skin is closed with absorbable suture (D).
N. Zampieri et al. / Journal of Pediatric Surgery 49 (2014) 583–585
necessary. This is why testicular delivery was not performed during the study procedure. [7] As for anesthesia, it is important to remember that local anesthesia has fewer complications than spinal anesthesia but it should always be performed by expert clinicians who know the anatomical landmarks for drug administration [12–14]. The anesthesiological procedure suggested in this study requires administration of midazolam before the patients enters the Operating Room, then local anesthesia is induced 15 min before the first incision and propofol administered at the moment of the first incision. If performed correctly this procedure allows effective collaboration of the patients despite their young age avoiding the use of general anesthesia. Also, early post-operative recovery and short hospital stay improve the administrative management of the Unit. The testicular innervation is complex therefore, this technique can be successful only if all the efferent nerves (ilioinguinal, iliohypogastric, and genitofemoral nerves) are blocked. For this reason, especially during the pre-operative phase, the collaboration of patients is of paramount importance to carry out the anesthesiological procedure accurately. Possible criticisms of the study are the following: 1) although all patients received follow-up at one year after surgery, a longer follow-up period could be necessary to exclude possible long-term complications such as recurrence; 2) the study population is still too small especially to assess tolerability of the procedure in the pediatric age; 3) effective collaboration with the anesthesiologist is essential; this clinician needs to be highly skilled and well rounded on performing local anesthesia and managing pediatric patients; 4) only three surgeons used this technique so a comparison with other clinical experiences would be advisable to obtain more consistent results. From a surgical point of view it is important to remember that at the level of the scrotum the pampiniform plexus consists of many well-adhered thin veins with an increased risk of bleeding when highly dilated. When operating at the level of the scrotum surgeons should pay close attention also to the arterial vascularisation of the area and to the vas deferens, located more posteriorly than the pampiniform plexus. To prevent post-operative testicular pain, which is usually perceived as a lumbar pain, surgeons should avoid compression and prolonged manipulation of the testicle since local anesthesia eliminates pain but patients can still feel an uncomfortable sensation of pressure.
585
This study shows that local anesthesia with mild sedation anesthesia can be used in the pediatric age group (especially adolescents) although surgical accuracy remains imperative for the overall favorable outcome of the procedure. The authors also believe that it is necessary to carry out further studies in order to compare the many different surgical procedures and anesthesia methods available.
References [1] Kadihasanoglu M, Karaguzel E, Kacar CK, et al. Local or spinal anesthesia in subinguinal varicocelectomy: a prospective randomized study. Urology 2012;80:9–14. [2] Park K, Cho SY, Kim SW. The surgical difficulty of microsurgical subinguinal varicocelectomy is similar regardless of age. J Urol 2011;186:2397–401. [3] Mirilas P, Mentessidou A. Microsurgical subinguinal varicocelectomy in children, adolescents and adults: surgical anatomy and anatomically justified technique. J Androl 2012;33:338–49. [4] Nordin P, Hernell H, Unosson M, et al. Type of anesthesia and patient acceptance in groin hernia repair: a multicentre randomized trial. Hernia 2004;8:220–5. [5] Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205–13. [6] Al-Kandari AM, Shabaan H, Ibrahim HM, et al. Comparison of outcomes of different varicocelectomy techniques: open inguinal, laparoscopic, and subinguinal microscopic varicocelectomy: a randomized clinical trial. Urology 2007;69:417–20. [7] Kim OS, Chung HS, Park K. Modified microsurgical subinguinal varicocelectomy without testicular delivery. Andrologia 2011;43:405–8. [8] Zampieri N, Mantovani A, Ottolenghi A, et al. Testicular catch-up growth after varicocelectomy: does surgical technique make a difference? Urology 2009;73:289–92. [9] Cimador M, Pensabene M, Sergio M, et al. Focus on pediatric and adolescent varicocele: a single institution experience. Int J Androl 2012;35:700–5. [10] Grober ED, O’Brien J, Jarvi KA, et al. Preservation of testicular arteries during subinguinal microsurgical varicocelectomy: clinical consideration. J Androl 2004;25:740–3. [11] Goldstein M, Gilbert BR, Dicker AP, et al. Microsurgical inguinal varicocelectomy with delivery of the testis: an artery and lymphatic sparing technique. J Urol 1992;148:1808–11. [12] Akcaboy EY, Akcaboy ZN, Gogus N. Ambulatory inguinal herniorraphy: paravertebral block versus spinal anesthesia. Minerva Anestesiol 2009;75:684–91. [13] Freedman JM, Li DK, Drasner K, et al. Transient neurologic symptoms after spinal anesthesia: an epidemiologic study of 1,863 patients. Anesthesiology 1998;89:633–41. [14] Hampl KF, Heinamann-Wiedner S, Luginbuehl, et al. Transient neurologic symptoms after spinal anesthesia: a lower incidence with prilocaine and bupivacaine than with lidocaine. Anesthesiology 1998;88:629–33.
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Trans-scrotal varicocelectomy in adolescents: Clinical and surgical outcomes Nicola Zampieri a,⁎, Gianfranco Zampieri a, Lucio Antonello b, Francesco Saverio Camoglio c a b c
Casa di Cura “San Francesco” Hospital, Department of Surgery, via monte Ortigara 21/b, 37100, Verona, Italy Department of Anesthesiology; Policlinico "G.B.Rossi", piazzale Scuro n. 1-Verona, Italy Department of Surgical Sciences, Pediatric Surgical Unit, Policlinico "G.B.Rossi", piazzale Scuron. 1-Verona University of Verona, Verona, Italy
a r t i c l e
i n f o
Article history: Received 3 June 2013 Received in revised form 26 July 2013 Accepted 30 July 2013 Key words: Varicocele Adolescents Scrotal Local anesthesia
a b s t r a c t Background: The gold standard to treat varicocele in adolescents is still under discussion. The aim of this study is to evaluate the role of trans-scrotal varicocelectomy and show the results obtained by using local anesthesia in combination with preoperative sedation. Materials and Methods: Between January 2010 and January 2012, this surgical and anesthesiology procedure was proposed to study patients. Inclusion and exclusion criteria were created. Patients received trans-scrotal varicocelectomy with lymphatic and artery sparing technique under local anesthesia with mild sedation anesthesia. Patients were followed for 6 months after surgery, and complications were recorded. Results: Eighteen patients were treated with this technique. Three patients required additional sedation with propofol. None had recurrence of varicocele, and one patient showed post-operative hydrocele. All patients were discharged within 24 h following surgery. Three patients used ibuprofen and paracetamol for two days after surgery. Conclusions: Local anesthesia in the pediatric age group could be used for varicocelectomy with mild sedation anesthesia. © 2014 Elsevier Inc. All rights reserved.
The gold standard to treat varicocele in adolescents is yet to be determined. At present all the techniques suggested require surgery under general anesthesia. Local anesthesia is mainly used in percutaneous techniques with either retrograde or anterograde scleroembolization. Although this method is less invasive, it appears to have higher failure rates (Level of evidence: 2; Grade of recommendation: B.) as reported in the guidelines by the American Academy of Pediatrics (www.aap.org). Exclusively surgical techniques are all performed under general anesthesia while spinal anesthesia is mainly used in adults or patients aged N18 years receiving inguinal/subinguinal techniques [1–4]. Local anesthesia has never been used in adolescents because patients usually offer poor collaboration and all of the most commonly used procedures to treat varicocele in pediatric patients (i.e. suprainguinal, laparoscopic and retroperineoscopic techniques) require general anesthesia. The purpose of this study is to present an alternative surgical technique performed under local anesthesia with pre-operative sedation.
⁎ Corresponding author. Pediatric Surgical Unit, Policlinico “G. B. Rossi”, Piazzale L.A. Scuro, 37134-Verona-Italy. Tel.: +39 45 8124916; fax: ++39 45 8124662. E-mail address: [email protected] (N. Zampieri). 0022-3468/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2013.07.023
1. Materials and methods Between January 2010 and January 2012 adolescent patients with varicocele were treated following a new surgical and anesthesia approach. After oral and written consent was obtained from their parents, varicocelectomy was performed on a group of patients aged 13 to 16 years using this surgical and anesthesiological procedure (usually performed by the same authors in adult patients). Inclusion and exclusion criteria for this study were as follows: patients with grade III left varicocele and testicular hypotrophy N 20% (left side), no other previous surgery, no scrotal trauma. Patients who did not complete follow-up were excluded from the study. In compliance with the study protocol, all patients were observed every six months after surgery. 1.1. Procedure (Fig. 1) An anesthesiologist induced local anesthesia with Naropin 0.75% (10 cc) and lidocaine 2% (5 cc) around the spermatic cord and the ilioinguinal nerve, around the outer external spermatic fascia and in the cremasteric muscle 15 min before surgery. Pre-operative sedation was obtained using midazolam (before entering the Operating Room) and propofol (at the time of skin incision) with standard dose per
584
N. Zampieri et al. / Journal of Pediatric Surgery 49 (2014) 583–585
weight. The surgical procedure had a trans-scrotal approach: after scrotal incision all fasciae were opened. Without testicular delivery all spermatic veins were isolated and ligated. Lymphatic and artery sparing procedures were then performed for each patient under optical magnification. At the end of the procedure, the skin was sutured with absorbable stitches and topical surgical glow (seal) without a dressing. None of the patients received antibiotics after treatment. The Authors analyzed efficacy and relapse rates as well as post-operative hydrocele rates. Complications were classified following the Clavien Classification of Surgical Complications [5]. Statistical analysis was performed using the chi-square and Fischer exact tests. P value less than .05 was considered significant for the correlation between the variables. 2. Results During the study period 18 patients were treated with this technique. Age range was between 13 and 16 years. At present, all patients are followed at the Authors’ Institution and have completed follow-up (at least 2 controls). All patients had grade III varicocele, 3 had scrotal ptosis managed using a jockstrap for 1 month after surgery. None of the patients developed testicular atrophy or showed recurrence of varicocele, while a moderate hydrocele occurred in 1 patient (5%). For this last patient a “wait and see” observation approach was used. Surgically it was more difficult to treat patients with scrotal ptosis. They had very thin scrotal veins with a consequent increased risk of bleeding. There were no surgical complications during surgery or during follow-up. Operation time was 22 ± 08 min; 3 patients (18.75%) needed additional sedation with an increased dosage of propofol but none required intubation. Post-operative analgesic treatment was managed with ibuprofen and paracetamol in all patients until discharged from hospital. Three
patients used analgesics at home for 2 more days, while the remaining patients did not report any use of analgesics for more than 1 day after discharge (pb0.05). Patients treated with this procedure did not report lumbar pain (common referred pain from the testicle) or inguinal/scrotal pain. All patients were discharged within 24 h and started drinking liquids two hours after surgery. 3. Discussion The technique with local–regional anesthesia to treat varicocele was suggested by many authors but all cases received spinal anesthesia [1,2]. Although it is well known that spinal anesthesia involves many complications such as headache, lumbar pain and urinary retention, it is the most common choice for the surgical treatment of varicocele in adult patients. In a recent paper Kadihasanoglu et al. described the results obtained in a randomized study regarding the use of local vs. spinal anesthesia in the treatment of varicocele. They concluded that local anesthesia is efficient, safe and it can be used for this type of surgical procedures [1]. Their study reported the use of both techniques in patients aged N 18 years focusing also on the comparison of reported pain following one or the other technique. The results showed that the group receiving local anesthesia had more peri-operative pain than the spinal anesthesia group, although symptoms in the two groups 24 h after surgery was not statistically different. Despite the high number of studies carried out on the treatment of varicocele in the pediatric age group it is clear that at present a surgical or anesthesiological gold standard is yet to be determined. Many authors agree on the fact that the veins should be ligated and then excised. Also, testicular delivery should be avoided in order to reduce post-operative pain [6–11]. As reported by Park et al., Kim et al. and Mirilas et al., testicular delivery in adolescents without gubernacular vein enlargement is not
Fig. 1. Surgical procedure: under local anesthesia (A), we performed a trans-scrotal incision (B); through the incision we performed standard veins ligature with lymphatic and artery sparing technique (C), then the skin is closed with absorbable suture (D).
N. Zampieri et al. / Journal of Pediatric Surgery 49 (2014) 583–585
necessary. This is why testicular delivery was not performed during the study procedure. [7] As for anesthesia, it is important to remember that local anesthesia has fewer complications than spinal anesthesia but it should always be performed by expert clinicians who know the anatomical landmarks for drug administration [12–14]. The anesthesiological procedure suggested in this study requires administration of midazolam before the patients enters the Operating Room, then local anesthesia is induced 15 min before the first incision and propofol administered at the moment of the first incision. If performed correctly this procedure allows effective collaboration of the patients despite their young age avoiding the use of general anesthesia. Also, early post-operative recovery and short hospital stay improve the administrative management of the Unit. The testicular innervation is complex therefore, this technique can be successful only if all the efferent nerves (ilioinguinal, iliohypogastric, and genitofemoral nerves) are blocked. For this reason, especially during the pre-operative phase, the collaboration of patients is of paramount importance to carry out the anesthesiological procedure accurately. Possible criticisms of the study are the following: 1) although all patients received follow-up at one year after surgery, a longer follow-up period could be necessary to exclude possible long-term complications such as recurrence; 2) the study population is still too small especially to assess tolerability of the procedure in the pediatric age; 3) effective collaboration with the anesthesiologist is essential; this clinician needs to be highly skilled and well rounded on performing local anesthesia and managing pediatric patients; 4) only three surgeons used this technique so a comparison with other clinical experiences would be advisable to obtain more consistent results. From a surgical point of view it is important to remember that at the level of the scrotum the pampiniform plexus consists of many well-adhered thin veins with an increased risk of bleeding when highly dilated. When operating at the level of the scrotum surgeons should pay close attention also to the arterial vascularisation of the area and to the vas deferens, located more posteriorly than the pampiniform plexus. To prevent post-operative testicular pain, which is usually perceived as a lumbar pain, surgeons should avoid compression and prolonged manipulation of the testicle since local anesthesia eliminates pain but patients can still feel an uncomfortable sensation of pressure.
585
This study shows that local anesthesia with mild sedation anesthesia can be used in the pediatric age group (especially adolescents) although surgical accuracy remains imperative for the overall favorable outcome of the procedure. The authors also believe that it is necessary to carry out further studies in order to compare the many different surgical procedures and anesthesia methods available.
References [1] Kadihasanoglu M, Karaguzel E, Kacar CK, et al. Local or spinal anesthesia in subinguinal varicocelectomy: a prospective randomized study. Urology 2012;80:9–14. [2] Park K, Cho SY, Kim SW. The surgical difficulty of microsurgical subinguinal varicocelectomy is similar regardless of age. J Urol 2011;186:2397–401. [3] Mirilas P, Mentessidou A. Microsurgical subinguinal varicocelectomy in children, adolescents and adults: surgical anatomy and anatomically justified technique. J Androl 2012;33:338–49. [4] Nordin P, Hernell H, Unosson M, et al. Type of anesthesia and patient acceptance in groin hernia repair: a multicentre randomized trial. Hernia 2004;8:220–5. [5] Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205–13. [6] Al-Kandari AM, Shabaan H, Ibrahim HM, et al. Comparison of outcomes of different varicocelectomy techniques: open inguinal, laparoscopic, and subinguinal microscopic varicocelectomy: a randomized clinical trial. Urology 2007;69:417–20. [7] Kim OS, Chung HS, Park K. Modified microsurgical subinguinal varicocelectomy without testicular delivery. Andrologia 2011;43:405–8. [8] Zampieri N, Mantovani A, Ottolenghi A, et al. Testicular catch-up growth after varicocelectomy: does surgical technique make a difference? Urology 2009;73:289–92. [9] Cimador M, Pensabene M, Sergio M, et al. Focus on pediatric and adolescent varicocele: a single institution experience. Int J Androl 2012;35:700–5. [10] Grober ED, O’Brien J, Jarvi KA, et al. Preservation of testicular arteries during subinguinal microsurgical varicocelectomy: clinical consideration. J Androl 2004;25:740–3. [11] Goldstein M, Gilbert BR, Dicker AP, et al. Microsurgical inguinal varicocelectomy with delivery of the testis: an artery and lymphatic sparing technique. J Urol 1992;148:1808–11. [12] Akcaboy EY, Akcaboy ZN, Gogus N. Ambulatory inguinal herniorraphy: paravertebral block versus spinal anesthesia. Minerva Anestesiol 2009;75:684–91. [13] Freedman JM, Li DK, Drasner K, et al. Transient neurologic symptoms after spinal anesthesia: an epidemiologic study of 1,863 patients. Anesthesiology 1998;89:633–41. [14] Hampl KF, Heinamann-Wiedner S, Luginbuehl, et al. Transient neurologic symptoms after spinal anesthesia: a lower incidence with prilocaine and bupivacaine than with lidocaine. Anesthesiology 1998;88:629–33.
