the adolescent varicocele is a common condition that often presents to the pediatric or general urologist .
in addition , it is postulated that the adult varicocele is a persistence of the adolescent finding , rather than a new occurrence .
correction of this condition has led to increases in measurable outcomes of fertility including sperm motility and viability , as well as total sperm count .
current practice substitutes testicular size and consistency for semen analysis in the pediatric age group , using ipsilateral testicular atrophy , changes in testicular consistency or persistent orchalgia as indications for varicocele treatment .
herein , we describe a modified laparoscopic technique for the treatment of clinically significant varicoceles .
the hospital records of consecutive pediatric patients who presented with clinically significant varicoceles between may 2000 and july 2003 were reviewed .
only those without a history of abdominal or pelvic surgery were eligible for a laparoscopic repair .
two laparoscopic ports were utilized , using the 5-mm innerdyne ( innerdyne , inc . ,
access to the peritoneal cavity was gained by the supraumbilical placement of a veress needle , where the first 5-mm port was subsequently placed .
a second 5-mm port was positioned under direct vision caudal and lateral to the umbilicus on the contralateral side of the varicocele .
after identification of the spermatic cord , the gonadal vessels were isolated from the vas deferens by using a combination of blunt and harmonic scalpel dissection .
fulguration of the spermatic vessels cephalad to the divergence of the vas deferens was then performed with the harmonic scalpel , with subsequent division of the vessels .
the port incisions were closed with a running absorbable subcuticular suture and the wounds were dressed with steri - strips and sterile op - site .
ten clinically significant varicoceles were identified in 9 patients during the study period , all of which were ligated with this technique .
the patients had a mean age of 14 years ( range , 12 to 17 ) .
one patient presented with the primary complaint of scrotal pain , 3 patients presented with ipsilateral testicular atrophy , and 4 patients had both scrotal pain and ipsilateral testicular atrophy .
nine of the treated varicoceles were grade iii and 1 was grade ii ( table 1 ) .
the mean operating room time was 53 minutes ( range , 45 to 65 ) .
all patients were discharged from the ambulatory surgery unit and returned to their regular physical activity within 2 weeks after surgery .
upon clinical re - evaluation 6 weeks post surgery , there was no evidence of varicocele recurrence or hydrocele formation , and all patients were asymptomatic .
all patients who presented with pain had complete resolution of their symptoms ( table 2 ) .
patients with ipsilateral testicular atrophy presented due to a noticeable discrepancy in size of the affected testicle .
these patients were followed with serial examinations by the same physician ( bpk ) for an extended period of time beyond the postoperative period for determination of catch - up growth .
catch - up growth was not measured using an orchidometer , but rather was defined as a significant increase in size of a previously undersized testicle in comparison with the unaffected side .
six of the 7 patients who presented with ipsilateral testicular atrophy demonstrated catch - up growth of the affected testicle with an average total follow - up of 13.5 weeks ( range , 6 to 57 ) .
many studies have demonstrated that varicocelectomy is effective in treating clinically significant varicoceles in the pediatric population .
currently , it is unknown what the effect of treatment will ultimately have on future fertility , as repair of the adult varicocele in infertile men does not always result in fertility .
it would seem that some irreversible damage to testicular function results from the presence of a varicocele during adolescence .
these include radiological spermatic vein sclerotherapy or embolization , the standard surgical techniques of palomo or high retroperitoneal ligation , the inguinal microscopic testicular artery sparing approach , and the evolving laparoscopic approach .
factors such as surgeon preference , recurrence and complication rates , and cost influence the decision of which approach is most appropriate .
recurrence rates are related to the ability to ablate as many venous channels as possible during surgery .
attempts to spare the testicular artery generally increase the recurrence rate by neglecting to ablate the periarterial venous outflow .
the recurrence rates for the standard open techniques of palomo ( 0% to 2.2% ) and microsurgery ( 0.6% to 2.1% ) demonstrate an advantage over radiological intervention ( 5% to 25% ) .
proponents of an artery sparing technique argue that damage to the seminiferous tubules may be occurring with testicular artery ligation despite the lack of testicular atrophy at follow - up .
however , no advantage in rate of testicular atrophy or catch - up growth for an artery sparing technique has been reported .
the formation of a hydrocele is related to ablation of the lymphatic drainage of the tunica vaginalis .
microscopic techniques are required to avoid this undesired outcome and have been reported to limit the rate of hydrocele formation ( 0% to 1% ) compared with standard open techniques ( 3% to 25% ) .
regardless of technique , most patients are able to be treated on an outpatient basis with little recovery time . in our series , no hydrocele formation or varicocele recurrence is reported , and the resolution of scrotal pain occurred in all patients .
the primary concern of the laparoscopic approach to varicocelectomy has been the high associated cost and required expertise .
our study demonstrates that reasonable operative times can be expected , ranging from 50 minutes to 60 minutes .
resident surgeons performed most of the cases with limited laparoscopic experience under the supervision of a single fellowship trained pediatric urologist ( bpk ) . by using a limited number of 5-mm ports ,
the advantage of a 2-port system over a 3-port system is the proposed reduced operative time and expense of placing and closing the additional port site . in our series
, we did not find it necessary to place a third port for additional hands in achieving hemostatic control , but were prepared to do so if needed .
the authors concluded that their 4-port laparoscopic system , compared with other methods , was more time consuming , more expensive , carried a higher intraoperative risk , and was technically more involved .
podkamenev et al reported a series of 654 patients randomly assigned to laparoscopic and open surgical arms . both operations utilized the palomo technique , with preservation of the lymphatics and ligation of the testicular artery and veins above the inguinal canal .
in contrast to the previous report , the authors concluded that their laparoscopic approach was similar in regards to recurrence rates and superior in regards to hydrocele formation , scrotal edema , operating time , and convalescence .
esposito et al published their initial experience with the laparoscopic treatment of pediatric varicoceles in a series of 161 patients .
they used a combination of techniques including a 2- or 3-port approach with ligation of both the testicular artery and vein by the palomo technique or ligation of the veins only by using the ivanissevitch procedure .
these authors also concluded that the recurrence and complication rates of the laparoscopic approach are comparable to if not better than those of the open or radiological approach .
our 2-port laparoscopic varicocelectomy is comparable to traditional open surgical approaches in recurrence and complication rates .
this laparoscopic repair is demonstrated to be an acceptable alternative and may be superior to open techniques in operating time , convalescence , and cosmesis . the procedure is easily mastered and does not require microsurgical skills .
 background and objectives : the surgical indications and proper management of varicoceles in the pediatric population continue to be controversial . historically , open surgical approaches have had recurrence rates between 2% to 6% and a low rate of complications . 
 we present a modified laparoscopic technique for the treatment of clinically significant varicoceles.methods:consecutive pediatric patients presenting with clinically significant varicoceles between may 2000 and july 2003 were considered for laparoscopic varicocelectomy . 
 a 5-mm 2-port laparoscopic varicocelectomy was performed , with supraumbilical and contralateral lower quadrant placement of the trocars . 
 the harmonic scalpel was used to fulgurate the spermatic vessels in a nonartery sparing technique.results:ten clinically significant varicoceles were identified in 9 patients , all of which were ligated with this technique . 
 one patient was treated for bilateral varicoceles . 
 average operating room time was 53 minutes ( range , 45 to 65 ) . 
 all patients were discharged from the ambulatory surgery unit and returned to their regular physical activity within 2 weeks after surgery . upon clinical reevaluation 6 weeks post surgery 
 , there was no evidence of varicocele recurrence or hydrocele formation , and all patients were asymptomatic.conclusions:our 2-port laparoscopic varicocelectomy is comparable to traditional open surgical approaches in recurrence and complication rates 
 . this laparoscopic repair may be superior to open techniques in operating time , convalescence , and cosmesis . 
 the procedure is easily mastered and does not require microsurgical skills . 
INTRODUCTION
METHODS
RESULTS
DISCUSSION
CONCLUSIONS