ISSN 2312-6760 2015 University of Babylon

Original Research Article Prophylaxis of Hydrocele after Varicocelectomy

*Hussein Oudah Al-Jasmawy Adel Ibraheem Muhi Ali Abdulhaleem Kadhim Hilla Teaching General Hospital, Hilla, IRAQ

E-mail: [email protected]*

Accepted 15 July,2015 Abstract Hydrocele comes on the top of complications after surgical repair of varicocele.To evaluate the efficacy of selective vein ligation procedure by the aid of loupe optical magnification with creation of a window in tunica .vaginalis to prevent the formation of hydrocele after varicocelectomy Two hundred patients with varicocele treated were analyzed. A study is applied on two patient groups, of each one hundred patient. Group 1: Conventional procedures for varicocele, without use of optical magnification including: Paloma, inguinal mass ligation and subinguinal selective ligation, and a group 2; underwent subinguinal selective varicocelectomy with the aid of optical magnifications and completed by creation of a window in tunica vaginalis. .Hydrocele, as a complication following varicocelectomy, is reduced from 15% in group 1 to 3% in group 2 By theaid of optical magnification with creation a window in tunica vaginalis,a significant decrease in incidence of post varicocelectomy hydrocele in group 2 was found. So this procedure seems effective and we recommend its .addition to the standard procedures of varicocelectomy

.Key words : hydrocele; varicocelectomy; optical magnification; window in tunica vaginalis

الخلصة القيله المائية هي اكثر المضاعفات التي تحدث بعد العلج الجراحي لدوالي الخصية.في هذه الدراسة تم تقييم فعالية طريقة عقد الوريد النتقائي للدوالي بمساعدة التكبير البصري مع فتح شباك في الغللة المهبلية للخصية لتجنب حدوث القيلة المائية بعد عملية دوالي الخصية.تمت دراسة حالة 200 مريض وتم تقسيمهم الى مجموعتين المجموعة الولى 100 مريض اجريت لهم العملية بالطرق التقليدية وهي بالوما والعقد الكتلي والعقد المغبني النتقائي بينما تم اجراء العمليات للمجموعة الثانية باضافة التحوير المذكور.وجد من تحليل النتائج حدوث قلة كبيرة في نسبة حدوث القيلة المائية في المجموعة الثانية. لذلك تبدو هذه الطريقة مفيدة وننصح باضافة هذا التحوير عند اجراء العمليات التقليدية لدوالي الخصية. ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ

1 Following different surgical repair procedures on spermatic venous plexus dilatation, hydrocele comes on the top of

2 Al-Jasmawy et al. MJB-2015 complications. The incidence of this surrounding tissues. The veins are ligated complication varies from 3% to 33% and divided separately then a creation of a (average about 7%) [6]. Lymphatic window in tunica vaginalis in a round or obstruction during surgery claimed to be elliptical shape 2 cm byknife incision and the cause of post varicocelectomy resection of a tunica with diathermy of its hydrocele, due to iatrogenic injury of .edges spermatid cord lymphatic vessels [7]. To All 200 patients included in this study were avoid this complication, preservation of responsive to contact and follow upafter 6 lymphatics is advised with no place for months and 12 months to evaluate and total spermatic cord ligation in any surgical .analyze surgical results repair of varicocele. If acute swelling of the scrotum occurred after surgery we usually Results believe that this is edema, but in this case it The patient characteristics are listed in could be a true hydrocele [8]. Identification Table 1, no intergroupdifferences were and preserving lymphatic, observed in terms of age,presentation and hydrodissections, [9] preemptive laterality. Mean age was 26.50 in group 1 hydrocelectomy in and 25.40 in group 2. Infertility was in 85 subinguinalvaricocelectomy, [10] using patients(85%) in group 1 and in 12 patients methylene blue as technique to preserve (12%) in group 2. Left sided varicocele was lymphatics [11], and usingmicroscope, [12] .the common presentation in the twogroups are different attempts to decrease incidence In group 1: conventional surgical approach of hydrocele formation after these surgical was done in 100 patients,hydroceleas a .procedures complication occurred in a Paloma (20%), The aim of this study is to assist the value mass ligation (20%) and selective of using optical magnifications of 3X (30 subinguinal vein ligation (14%) and times power lens) for optimal identification theoverall incidence was15 cases (15%), of spermatic veins, arteries, vas and .((Table 2 lymphatics, and creating a window in In group 2: Surgery was done by selective tunica vaginalis to avoid postoperative subinguinal vein ligation with the aid of .formation of hydrocele optical magnification with creation of a Patients and Methods window in tunica vaginalis. In this group In Babylon, a 200 patients presented postoperative hydrocele occurred in only 3 toPrivate Hospitals and Hilla Teaching .(patients (3% General Hospital from a period between* 2005-2014*.The patients ages were Discussion between 16-55 years and presented with The different therapeutic methods in scrotal swelling associated with infertility treating varicocele associated with high and/or pain. Diagnosis of varicocele rate of complications and recurrence, so confirmed by clinical and sonography none regarded as the best [10]. Studies study. Seminal analysis done to all patients, found that the protein concentration of the and indications for surgical treatments hydrocele fluid of post varicocel-ectomy established. We divided the patients into 2 fluid was consistent with lymphatic .groups obstruction,[6]this may explain the believe For group 1:(100) patients; the standard that lymphatic obstruction rather than operative procedures including Paloma, venous obstruction is the cause of this inguinal mass ligation,selective complication, so lymphatic vessels subinguinalligation was performed (table preservation regarded as important factor 2 ), for group 2: (100) patients; we used a .to prevent this sequel modification to prevent hydrocele To compare our modification with other formation by the aids of loupe optical surgical procedures, firstly the high magnification, of 3X, to identify veins from retroperitoneal ligation as per the Paloma’s Al-Jasmawy et al. MJB-2015 technic [13] is prone to a higher recurrence procedures to avoid hydrocele formation. rate if high ligations were above the 4th The other advantage of this approach is its lumber vertebra. The anatomical reason is low-cost, easy applicability and with no that the communications between the .need of microscope or laparoscope medial vascular trunk and ureteric vessels were demonstrated, as well as anastomoses Conclusions between the two medial trunks across the Subinguinal approach in doing repair of .[midline in more than 50% of cases [14 varicocele by the aid of optical Secondly, in mass ligation there is increase magnification with a creation of a window in the chances of damage to the testicular in tunica vaginalis significantly avoid artery (which may reduce the chances of postoperative formation of hydrocele and improvement), while lymphatic vessels we recommend the addition of this injury mostly the cause of post-operative modification to the standards operative .[hydrocele [15 .procedures of varicocelectomy Lastly, in laparoscopic ligation of varicocele like high retroperitoneal ligation:1- there is association of high recurrence rates of up to 45%; in addition .Table 1 : Patients Characteristics to the high possibility of trauma to testicular artery [16]. 2- not as in using Patients details (Group 1 (100 Group 2 (100) G ل ر microscope, in laparoscopy there is little degree of magnification , so lymphatics (Mean age (years 26.50 2 may be ligated with veins , leadingPresentation to the with Infertility (85%) 85 (88% same sequel[17]. 3-the procedure is also 85 8 associated with the possible compli-cationsPresentation with pain (15%) 15 (12% of transperitoneal laparoscopy such as (Left: 90 (90% (Left: 87 (87% .injury to the bowel vessels andSide ileus involved with varicocele (Right: 6 (6% (Right: 8(8% Most surgeons now perform inguinal and (Bilateral: 4 (4% (Bilateral: 5(5% subinguinal procedures employing loupes or microscope for optical magnifications.By magnifications they can minimize trauma to lymphatic and testicular artery obtaining decrease the .[recurrence of varicocele [16 The advantage of magnifications using Table2:Postoperative optics and the clear field which give us, we complications according to the can decrease atrophy of the testis which type of surgical procedure. may follow testicular artery trauma. [18] In addition to that by the aid of magnification No. of No. of operated we can do the repair if testicular artery postoperative cases Surgical procedure [injured. [19 hydrocele. In the present study optical magnification Group 1: help us in ligating spermatic veins 2 10 Paloma selectively, avoid testicular artery injury by 20% [15%] 1 5 mass ligation identifying it and to preserve lymphatic 12 85 selective subinguinal vessels. Hydrocele formation decreased Group2: significantly to 3 cases (3%) comparing Selective subinguinal with with 15 patients (15%) in group 1 in which 3% [3%] 3 100 window + optical magnification we used the traditional methods without magnification or creation of a window. There is no difference from the reported Al-Jasmawy et al. 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