Clinical and therapeutic aspects of laparoscopic varicocelectomy: a cross-sectional study in Douala, Cameroon

¹Department of Surgery and Specialties, Faculty of Medicine and Biomedical Sciences, Yaoundé, Yaoundé, Cameroon, ²Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon

^&Corresponding author
Nwaha Makon Axel Stephane, Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon

Introduction    

Varicocele is an abnormal and tortuosity of the pampiniform venous plexus and the internal spermatic veins that drains the testicle. It is a well-recognized cause of decrease testicular function affecting approximately 15-20% of all males globally [1]. It can result in testicular pain and discomfort, atrophy and has an adverse effect on spermatogenesis and infertility [2]. The cause of testicular injury in patients with varicocele is presumed to be linked to increase scrotal pressure, but the pathogenesis remains poorly understood and could be multifactorial [3]. Several urologists have proven recently that varicocele consists of the most frequent treatable etiology of male infertility worldwide and is found in approximately 40% of males presenting for infertility problems [4]. Clinically grading system defines varicocele as grade 0 (subclinical): non-palpable and visualized only by Doppler ultrasound; grade 1: palpable with valsava maneuver; grade 2: palpable but not visible; grade 3: visible. In the absence of surgical indication, observation remains the management option of adolescents with varicocele. The main indications for surgical treatment of varicocele include; bilateral testicular atrophy, pain and abnormal semen analysis. There are different surgical approaches used in the treatment of varicocele including; inguinal, sub inguinal, retroperitoneal or laparoscopic [5]. Generally, despite evolution of several treatment methods of varicocele, laparoscopy remains one of the most frequently used methods of treatment for bilateral varicocele. In Europe, interventional radiology including microembolisation is more frequently used for treatment of varicocele [6]. The exploitation of laparoscopy in the management of varicocele in resource limited settings like ours is not sufficiently exploited. It is based on this background that we report our experience on laparoscopic varicocelectomy. This includes 71 patients treated for varicocele using laparoscopic approach in two urological units in Douala over a period of 6 years.

Methods     

Study design and participants: we retrospectively reviewed records of 71 patients who had laparoscopic varicocelectomy over the period of 6 years (January 2015 to May 2021) at the urological surgical unit at the Laquantinie hospital. We included all patients who underwent laparoscopic varicocelectomy indicated for symptomatic varicocele. Varicocele was diagnosed using clinical examination of patients, Valsava maneuver and Doppler ultrasound of the testis was done for all patients. Semen analysis was done for patients who complained of infertility. Symptomatic varicocele was defined as patients with varicocele presenting with scrotal pain, testicular atrophy and altered seminal analysis.

Surgical technique: laparoscopic varicocelectomy was realized under general anesthesia and endotracheal intubation in supine position. All the patients were placed in a urinary catheter to avoid bladder lesion. Pneumoperitoneum was achieved using a veress needle. Insufflation using CO₂ was realized by direct puncture at the supra-umbilical region in all our patients (Figure 1). We used 3 working port since all our patients benefited from bilateral varicocelectomy. A 10 mm working port was placed at the supra-umbilical region for the introduction of the camera. Two working ports of 5 mm were placed at each iliac fossa for the dissecting forceps (Figure 2). The internal inguinal ring was identified, and the posterior peritoneum was incised 3 cm above the trajectory of the spermatic vessels (Figure 3). Dilated veins were then identified, dissected secured and clipped while carefully preserving the internal spermatic artery (Figure 4, Figure 5).

Statistical analysis: data on demographics, clinical symptoms, ultrasound findings, operative findings and post-surgical outcomes were recorded for each patient. Data collection was achieved using structured questionnaires by consulting patient records, post-surgical reports and by carefully viewing videos of the different operative procedures. Data were analyzed using EPI info 7.0. parametric variables were reported as means and standard deviations and percentages and counts were used to report categorical variables.

Ethical clearance: study was approved by institutional ethics committee.

Results     

A total of 71 files of patients were collected.

Socio-demographic characteristics: the mean age was 34.34 ± 9.40 years old (range, 16 - 62 years) (Figure 6). Married people were most affected by this pathology, with a frequency of 56.34% compared to singles. Civil servants are the most affected by this pathology at a frequency of 40.85% followed by students in 18.30% of cases.

Clinical features: varicocele was mainly diagnosed in a context of scrotal pain for 33 patients (46.48%) and infertility for 32 patients (45.07%) (Table 1). Other symptoms reported by patients included scrotal discomfort (n = 36.62%), scrotal deformation among 24 (33.8%) and heaviness of scrotum for 18 (25.35%) patients (Table 2). Twelve patients (16.9%) had a history of hypertension and 35 (49.29%) had a past surgical history among which, 8 (22.85%) had previously had a varicocelectomy and 22 (62.85%) had a visceral surgical procedure in the past (Table 3). Our 71 patients had a total of 142 varicocelectomy procedures: 56 (78.87%) cases were unilateral with one case of isolated right varicocele, 15 (21.12%) cases were bilateral and 7(9.86%) patients had recurrent varicocele (Table 4). 41 (57.14%) patients had grade 2 varicocele and only 5 (7.04%) patients had grade 3 varicocele. Scrotal pain was the most reported indication for surgery in our study in 35(49.03%) patients (Table 5).

Operative results: transperitoneal varicocelectomy was performed in all patients, with preservation of spermatic artery in 81.7% of the cases. In all 71 patients, dilated veins were simply clipped without sectioning of spermatic veins. Intraoperative findings included adhesions in 11 (15.49%) patients. Four intraoperative complications were encountered. Vascular injury was encountered in 4(5.63%), and 2 (2.82%) cases were converted to open surgery (Table 6). The vascular injuries were all due to spermatic arterial rupture, and this was the only intraoperative complication encountered. Conversion to open surgery was done in two of these cases, while the other two cases were managed by electrocoagulation of the spermatic artery. These vascular lesions were among patients operated using conservation of spermatic artery technic. The mean duration of hospital stay was 1.51 ± 1.31 days (range, 1 - 7 days). Most patients were discharged on the first day post-surgery.

Outcomes: post-operative evolution was simple in 62 (87.32%) patients. However, we notice surgical site infection in 2 (2.82%) patients despite administration of antibiotic prophylaxis, 5 (7.04%) patients had post-operative pains, 1 (1.41%) patient had hydrocele post-surgery and 1 (1.41%) patient had subcutaneous emphysema at the penis and scrotum (Table 7). The delay period for patients to return to their normal activity was 4.39 ± 4.34 days (range, 2 - 28 days).

Discussion     

A total of 71 patients were included in our study. Our results were lower than those of Yasir SI of Morocco, Abdem SA et al. in Egypt, who had 30 and 18 patients respectively in their studies [7,8]. This could be related to the fact that contrary to Cameroon, laparoscopy is not the only modality in use in treatment of varicocele in these different countries. The mean age of our patients was 34.34 ± 9.40 years. The median age range was 30 and 40 years. This could be explained by the fact that this age group is sexually active and, for desire to procreate, these patients will consult more frequently. Felix Seiler et al. in Germany and Hisham et al. in Emirate found a lower average age of 30.2 and 21.3 respectively [9]. This could be explained by the absence of a system of varicocele screening during medical visits at our different academic institutions. Civil servants (40.85%) and students (18.30%) represented the majority of our participants. Our results are similar to that of Yevi D et al. in Benin, who found civil servants as the most represented profession [8]. This is due to the fact that our study was conducted in an urban setting. 49.29% of patients operated had a past history of surgery among which 62.85% had laparotomy, a reason which could explain the high rate of intraoperative adhesions. Our results are far higher than of Kbaier et al. in Tunisia, who had no past surgical history in their study population [10]. Varicocele was mainly diagnosed in a context of one or more clinical signs of varicocele in 52% of patients and infertility for 32 (45.07%) patients. Yasir S in Morocco reported a lower infertility rate of 23% [11]. Contrary, Kachrilas et al. in England did not report any notion of infertility in their study population. This could be explained by the fact that Caucasian have the attitude of seeking medical consultation earlier compared to our study population who most often auto medicate and consults only when they have a symptomatic health problem and are not habitual to systematic health checks [12]. Among our 71 patients, 77.46% had left varicocele. These results were slightly lower than those of Hisham et al. of the Emirate and Yasir of Morocco and Kachrilas of England who reported left varicocele in 87.93%, 87%, 85.4% respectively among their study participants [9,11,12]. Grade 2 varicocele was the most reported in our study (57.14%), results similar to that reported by Argawal et al. in India with 53.14% of grade 2 varicocele. Contrary, Hassan in the USA had grade 3 varicocele most reported among their participants with a prevalence of 75% [13,14]. Scrotal pain was the most reported indication for surgery in our study (49.03%). This was contrary to the results of Kbaier et al. in Tunisia, who reported infertility as the first indication for surgery among 54.83% of patients [10]. Adhesions were the principal intraoperative findings in 15.49% of our patients. Similarly, Shazly et al. reported 17.8% of intraoperative adhesions among participants. This could be explained by the fact that 30.98% of patients in our study had a past history of visceral surgery [15].

Surgical technic: all our patients were operated using the trans-peritoneal approach and 81.70% of patients had their spermatic artery preserved. This result is lower than that of Kumar et al. and Farag et al. who realized preservation of the spermatic vessels in all their patients [7,16]. This great difference is linked to the fact that our surgical procedures were realized by specialists undergoing Masters training on laparoscopy, who avoid vascular manipulations due to their limited laparoscopic experience. Intra-operative surgical complications occurred in 4 patients (5.63%), essentially vascular lesion, among which two were converted to open surgery and the others were managed using electrocoagulation. This complication rates are higher than those of Shazly et al. and Hassan et al. who did not have any intra-operative complications in their different series [14,15]. This could be explained by the fact that in our study, the surgical procedures were realized by specialized undergoing a masters training in laparoscopy who lack great experience in manipulating laparoscopic equipment. The post-operative complication rate was 12.68%. Several studies have proven the advantage of laparoscopic surgery with respect to reduction of post-operative complications [12,13,17]. Post-surgical evolution was simple in 67 (87.32%) patients, 5(7.04%) patients had post-operative pains. Our results were higher than that of Yasir in Morocco, who did not report any post-operative pain. This difference was linked to the fact that post-operative pains occurred in patients who did not receive analgesics post-surgery [11]. Surgical site infections were reported in 2(2.82%) patients in our series. This result is slightly higher than of Hisham et al. and Akin et al. who had 1case of surgical site infection. This low percentage of surgical site infection could be explained by the fact that all the patients of these different series received preoperative antibiotic prophylaxis [9,17]. Post-operative hydrocele was reported in a single patient (1.41%) and occurred 1 month post-surgery. Johnson in the USA and Abdel et al. reported higher rates of post-operative hydrocele of 17.6% and 10% respectively [5,18]. This difference could be due to the fact that many of our patients did not perform post-operative control testicular ultrasound.

Conversion: during our study, 2(2.82%) patients had conversion to open surgery. This conversion rate is higher than that reported by Abdel et al., Akin et al. and Kachrilas et al. who did not have any case of surgical conversion in their different series [12,17,19]. This difference is probably linked to the fact that the surgeons in our series were less experience with vascular dissections. The mean hospital stay for our patients was 1.51 days, similar to results reported by Shazly et al. in Egypt [15]. However, we noticed a prolonged hospital stay of some patients and this was essentially among patients who had post-operative complications and the patients who had surgical conversion to laparotomy. The mean duration of patients to return to their normal activities was 4.39 days. Yasir et al. reported a shorter mean duration of 2.5 days to return to normal activities among their patients [20]. Our result was due to the fact that many of our patients were scared to their normal activities, given that this surgical approach was new to them.

Conclusion     

Laparoscopy is a new technic for varicocele treatment and requires rigorous surgeons training and practice. It is a safe alternative surgical approach for treatment of symptomatic varicocele, and it's becoming feasible in our resource limited settings. It offers the advantage of high rate of symptom regression, less invasive, less post-operative pain, low rate of postoperative hydrocele and reduces time to return to normal activities post-surgery. It is also best indicated in patients with bilateral hydrocele. However, the high-cost due to the limited number of competent surgeons capable of performing this procedure in our setting can´t be neglected.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Conception and design of study: Nwaha Makon, Mbouche Landry. Acquisition of data: Thomas Hassler, Fouda Jean Cedrick. Analysis and interpretation of data: Essola Basile. Drafting the manuscript: Agbor Tanyi Orock. All the authors have read and agreed to the final manuscript.

Tables and figures     

Table 1: clinical signs and symptoms presented during consultation

Table 2: circumstance of diagnosis

Table 3: distribution of patients past surgical history

Table 4: topographic distribution of varicocele

Table 5: indications of varicocelectomy

Table 6: intra-operative complications

Table 7: distribution of post-operative outcomes

Figure 1: patient installation in dorsal decubitus position with pneumoperitoneum realized following direct puncture at the supra-umbilical region

Figure 2: introduction of working ports, 10 mm port at the supra-umbilical region and 5mm ports at the right and left iliac fossa

Figure 3: identification of the internal inguinal ring and the trajectory of the spermatic vessels and vas deferens

Figure 4: dissection and isolation of the varicose spermatic veins from the spermatic cord.

Figure 5: double ligation of varicocele using clips

Figure 6: age distribution of study participants

References