Surgical Practice

(2005)

9

, 56–57 Letter to the Editor

Blackwell Science, LtdOxford, UKASHSurgical Practice1744-16252005 Blackwell Publishing Asia Pty LtdMay 2005925657Letter to the editorLetter to the EditorLetter to the Editor

Letter to the Editor

Varicocele: Current controversies in treatment

To the Editor,

The recent article titled ‘Varicocele: Current controver-sies in pathophysiology and treatment’ is another well-presented, masterly review of the condition, which forso many years has generated much controversy anddiscussion, amongst urologists and paediatric sur-geons alike.

1

Unfortunately, throughout this otherwiseexhaustive review, no mention was made of the manyissues that are still hotly debated concerning the sur-gical treatment – the most intriguing aspect from theperspective of your readership. It was just stated thatthe microsurgical subinguinal or low inguinal openapproach is the method of choice as it has the highest(99.5%) success rate and lowest morbidity. Appar-ently, the categorical conclusion was based on thefigures presented in Table 2 of the original article,which was adopted from a text on fertility/infertilitypublished in 1995. In the same comparison table, thefailure rate for laparoscopic varicocelectomy wasdepicted as ?5–15%. Coincidentally, in the same year,I reviewed in a urology journal the success rates oflaparoscopic varicocelectomy citing results from sixseries then available.

2

Four series reported 100% suc-cess, whilst the success rates of the remainder were97.1% and 99%. Of note also is the fact that urologicalpublications in the ensuring years have, again, amplyattested to the high success rate (95–100%) of thelaparoscopic approach.

3–5

The disparity of results in the literature can beexplained by many factors, such as variation in thecriteria used to define ‘success’ and difference in out-come parameter(s) analysed: semen characteristics,testicular volume, painful symptoms, grading of vari-cosity, recurrence or fertility/pregnancy (cannot be99.5%!).

To add to the controversy, there are two additionalfactors affecting the success rate, namely, the targetage group under study and the technical details, forinstance, whether the internal spermatic artery is addi-tionally ligated or not. It was the latter issue that hasbeen the focus of lingering dispute, particularly in themanagement of adolescent varicoceles.

In young adolescents it would be more difficult toisolate and preserve the diminutive lymphatics andinternal spermatic artery entwined in small, fre-

quently adherent venous collaterals, all of whichhave to be interrupted if recurrence is to be pre-vented.

2

No wonder then that the reported successrate in most series consisting mainly of paediatricpatients and utilising the artery-sparing technique fellfar short of the aforementioned 95–100% successrate for adults.

2,6,7

We advocated, therefore, the sim-pler technique – mass ligation and division of theinternal spermatic vascular pedicle – for young ado-lescents.

2

Our preliminary results did show improve-ment to 100% success, which is maintained for the84 varicocelectomies amassed to date.

8

Inevitably,the idea of achieving good results at the expense ofthe arterial supply has raised concerns about itssafety and added fuel to the fire for continuing con-troversy.

9,10

Sceptics are adamant that ligating theinternal spermatic artery is unsafe and should beavoided at all costs.

6

We thus feel gratified by theobservation that a growing body of evidence hasrecently emerged supporting our claim to the con-trary.

7,10–13

In particular, well-conducted comparativestudies have reaffirmed our earlier findings that massligation produced better results without testicularatrophy.

7,11

Nonetheless, skepticism still exists asthere are no randomised studies comparing theultimate outcome end-point – fatherhood, when theboys grow up.

On the other hand, the issue of morbidity appearsjust as controversial. Comparative studies of openmethods versus laparoscopy were scanty and non-randomised; their results in terms of differences inpostoperative morbidity outcomes were conflict-ing.

14–16

Seemingly, the only tangible benefit to theopen approach rests on its avoidance of generalanaesthesia, which, however, is still needed foringuinal varicocelectomy in paediatric patients.

Controversies notwithstanding, for any givenpatient, it behooves the attending surgeon to choosethe optimal operation based on individual patientcharacteristics, disease condition, and his expertise –urology or laparoscopy.

Wai-Tat NG

Department of Surgery, Yan Chai Hospital, 7-11 YanChai Street, Tsuen Wan, New Territories, Hong Kong SAR.

Letter to the Editor 57

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