BACKGROUND: This study aimed to assess whether deferential reflux in pediatric
and adolescent varicocele can be successfully treated laparoscopically.
MATERIALS AND METHODS: Since 2001 at our institution, 148 boys were evaluated for
a left varicocele. Preoperatively,all the patients underwent ultrasound scan
assessment of testicular volume and color-Doppler US (CDUS)to rule out reflux
into the internal spermatic vein (ISV), deferential vein, or cremasteric vein.
Boys with ISV reflux were treated by laparoscopic transperitoneal Palomo; boys
with isolated deferential reflux or associated to ISV reflux were
laparoscopically managed adding to the former procedure, coagulation or clipping 
of refluxing deferential veins.
RESULTS: Reflux in both the ISV and the deferential vein was observed in 21
(14.1%) out 148 boys with varicocele.Only one case (0.6%) of varicocele was
caused by an isolated deferential reflux. No reflux in the cremasteric vein was
observed. After a median follow up period of 2 years (range, 6 months-5 years),
none of our patients with deferential reflux experienced varicocele recurrence
either clinically or according to CDUS scanning.No testicular atrophy was
observed.
CONCLUSION: Our diagnostic approach is a rigorous standard for identifying all
the venous systems concurring with the varicocele. Our proposed technique with
laparoscopic interruption or coagulation of deferential veins when proved by CDUS
to be refluxing may allow successful treatment for most varicoceles. This method 
allows reduction in recurrence of varicocele due to a missed deferential reflux

CASTAGNETTI, M

CATALANO, P

CIMADOR, Marcello

DE GRAZIA, Enrico

DI PACE, Maria Rita

SERGIO, Maria

Archivio istituzionale della ricerca - Università di Palermo

JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUESVolume , Number , 2009© Mary Ann Liebert, Inc.DOI: 10.1089/lap.2008.0239Laparoscopic Surgery of Deferential Reflux in Pediatric and Adolescent VaricoceleMarcello Cimador, MD, Maria R. Di Pace, MD, Maria Sergio, MD, Pieralba Catalano, MD,Marco Castagnetti, MD, and Enrico De Grazia, MDAbstractBackground: This study aimed to assess whether deferential reflux in pediatric and adolescent varicocele canbe successfully treated laparoscopically.Materials and Methods: Since 2001 at our institution, 148 boys were evaluated for a left varicocele. Preopera-tively, all the patients underwent ultrasound scan assessment of testicular volume and color-Doppler US (CDUS)to rule out reflux into the internal spermatic vein (ISV), deferential vein, or cremasteric vein. Boys with ISV re-flux were treated by laparoscopic transperitoneal Palomo; boys with isolated deferential reflux or associated toISV reflux were laparoscopically managed adding to the former procedure, coagulation or clipping of reflux-ing deferential veins.Results: Reflux in both the ISV and the deferential vein was observed in 21 (14.1%) out 148 boys with varico-cele. Only one case (0.6%) of varicocele was caused by an isolated deferential reflux. No reflux in the cremas-teric vein was observed. After a median follow up period of 2 years (range, 6 months–5 years), none of our pa-tients with deferential reflux experienced varicocele recurrence either clinically or according to CDUS scanning.No testicular atrophy was observed.Conclusion: Our diagnostic approach is a rigorous standard for identifying all the venous systems concurringwith the varicocele. Our proposed technique with laparoscopic interruption or coagulation of deferential veinswhen proved by CDUS to be refluxing may allow successful treatment for most varicoceles. This method al-lows reduction in recurrence of varicocele due to a missed deferential reflux.1IntroductionTHE IDEAL METHOD for varicocele treatment is still contro-versial. Actually, varicocele repair may be accomplishedby open surgery, laparoscopy, or interventional radiology.1–2Besides, treatment may be performed at different levels, in-cluding retroperitoneal, inguinal, and subinguinal. All thesemethods, however, have been reported to be associated withsome risk of varicocele persistence/recurrence due to col-lateral refluxing veins not interrupted at surgery.Indeed, in some 75% of cases, the varicocele is caused bya reflux in a single internal spermatic vein (ISV)3 and can betreated successfully by any approach. In the remaining cases,instead, multiple refluxing venous systems may be present.Starting from the venographic studies by Coolsaet,3 whoclassified varicocele in three different types, and the additionalstudies by Franco et al., who questioned the existence of a cre-masteric reflux,4 we have developed a preoperative color-Doppler ultrasound (CDUS) technique for the preoperative as-sessment of the varicocele pathophysiology.5 This method po-tentially allows for a preoperative noninvasive identificationof the refluxing veins subtending the varicocele, and a differ-entiation of those actually refluxing from those dilated due tooverflow.5–7 Using this tool, we have detected some patientsin whom a reflux in the deferential veins was associated to theISV reflux, and even some rare cases in whom a deferential re-flux was the only cause of the varicocele. Herein we detailedour experience with the CDUS diagnosis and the laparoscopictreatment of cases of pediatric and adolescent varicocele withevidence of deferential reflux.Materials and MethodsFrom January 2001 to April 2008, 148 patients with a me-dian age of 12.4 years (range, 7.1–16 years) were admitted atour institution for the presence of a left varicocele. All varic-Pediatric Surgical Unit, Department of Mother and Child Care, Università di Palermo, Palermo, Italy.oceles were graded by scrotal physical examination accord-ing to Dubin and Amelar8 in the supine and upright posi-tions. Patients underwent surgical treatment if presentingwith a grade 3 varicocele or a grade 2 varicocele, this latterif associated with hypotrophy of the left testicle, pain or scro-tal discomfort. Preoperatively, all the patients underwent ul-trasound scan assessment performed using a linear multi-frequency 7 to 13 MHz transducer connected to an AlokaProsound SSV500, (Tokyo, Japan). For CDUS pulse repeti-tion, the frequency was set at 1.5 kHz. Using ultrasound, tes-ticular volume was calculated in milliliters with the formulaV  0.71 LDW of the testicular ellipsoid.9 Left scrotal, in-guinal and pelvic venous networks were investigated as pre-viously described.5 Patients presenting at surgery with di-lated deferential veins proved by preoperative CDUS to berefluxing were treated by a Palomo procedure, combinedwith coagulation or clipping and division of deferentialvein(s) as follows. A new setup of trocar position wasadopted in these cases (Fig. 1). Optical was placed in rightiliac fossa and two operative accesses were opened on mid-line, at umbilicus and hypogastrium. The retroperitonealwindow, previously opened on spermatic vessels for carry-ing out the Palomo procedure, was widened toward the in-ternal inguinal ring. The deferential vein(s) running as satel-lite(s) of the vas were gently dissected off the deferentialartery, which was spared because it could remain the almostunique blood supply of the testicle. The deferential vein thenwas coagulated with bipolar diathermy, or clamped by clipsand divided (Fig. 2). Sometimes it was easier to approach thedeferential vein in the deep pelvis just beneath the iliac ves-sels. In these cases, a second retroperitoneal window was re-quired. Clinical and CDUS follow-up were performed 1, 3,6, and 12 months postoperatively and then every year. Re-currence or persistence of the varicocele, the presence of ahydrocele, and testicular volume were evaluated. Data arereported as median and range.ResultsAccording to the findings, 112 boys (75.6%) had a grade 3and 36 (24.3%) a grade 2 varicocele. A total of 16 boys witha grade 2 varicocele reported left scrotal discomfort or pain,whereas the remaining boys had testicular asymmetry. In126 cases (85.1%), CDUS showed reflux in the ISV only,whereas a reflux in both the ISV and the deferential vein wasobserved in the remaining 21 cases (14.1%). Only one case(0.6%) of varicocele was caused by an isolated deferential re-flux. No refluxing cremasteric vein was observed.Based on these findings, in 21 boys with associated ISV-deferential reflux and in one boy with isolated deferentialreflux, transperitoneal laparoscopic Palomo procedure wasperformed, adding coagulation or clipping and section of thedeferential vein. In two cases, we approached the deferen-tial vein in the deep pelvis because of a more evident dila-tion of the vein just underneath the left iliac vessels.After a median follow up period of 2 years (range, 6months–5 years), none of our patients with deferential refluxexperienced varicocele recurrence either clinically or ac-cording to CDUS scanning. No case of testicular atrophy wasobserved. In 2 (9%) out 22 patients a mild postoperative hy-drocele was observed at 3 months follow-up. Both hydroce-les resolved spontaneously, within 1 year. In one out two pa-tients approached in the deep pelvis, a temporaryparesthesia and a mild pain of the left thigh was recorded.These symptoms appeared immediately after surgery andspontaneously resolved within two weeks without any dis-ability.DiscussionVaricocele can be approached by different therapeuticstrategies: percutaneous embolization or sclerosis; open sur-gery interruption of the spermatic vein at different levels;microsurgical venous bypass. Nevertheless no single ap-proach can be adopted as the best.10–11 Laparoscopic orretroperitoneoscopic treatment of varicocele has recentlybeen advocated as a simple, safe and effective technique, andit is comparable with other procedures in terms of recurrenceand complication rates.11 However, a review of publishedreports shows that little attention has so far been paid to thedifferent types of venous reflux (renal-internal spermaticand/or iliac-deferential reflux) in selecting the best surgicalprocedure. Starting from our previous studies, in our opin-ion a correct approach for treating varicocele should be onlybased on understanding of the pathophysiology. Otherwise,surgical technique should imply the mandatory interruptionof all venous networks potentially causing reflux.In our experience, preoperative CDUS study, aiming todistinguish different types of varicoceles has been consid-ered the key-point of surgical success rate. The exact knowl-edge of venous refluxes involved in varicocele gave us thechance for a selected treatment in all observed cases. CDUSwas an effective, noninvasive and reliable tool for investi-gating varicocele in all ages.The deferential vein, which is a satellite of the vas defer-ens, is not detectable on CDUS in healthy boys, either at restor under a Valsalva maneuver. It only becomes visible if di-lated and refluxing. To detect such a change easily, the leftexternal iliac artery can serve as a landmark, as the defer-ential vein runs over it and arches downwards. The lattercan be easily identified as an arch over the external iliac ves-sels running from the internal inguinal orifice down thepelvis and joining the vesical vein. CDUS provides a clearCIMADOR ET AL.2FIG. 1. Trocars setup approaching deferential reflux. Opti-cal is inserted in right iliac fossa, whereas two operative portsare on the midline.demonstration of a deferential reflux, which can be treatedby laparoscopic clipping or coagulation of deferentialvein(s).The clinical relevance of deferential reflux, its role onpathogenesis of varicocele and on ultimate adult fertility, isquestionable at present. Perhaps a controlled trial may prop-erly address this issue. For ethical reasons, we do not havea control group of untreated deferential refluxes, but in-volvement of deferential reflux in recurrences of varicocelehas been previously demonstrated by venography.11,13In this scenario, Dudai et al.12 suggested that should besystematically interrupted both the ISV and the inferior epi-gastric vessels. This procedure, however, causes unnecessarydivision of many non-refluxing veins and can address onlya possible cremasteric reflux, whereas CDUS has allowed usto identify the refluxing venous systems preoperatively andhence to select the surgical treatment accordingly. On the ba-sis of CDUS findings, in a previous study, we proposed torestrict open microsurgical subinguinal varicocelectomy tocases with reflux in multiple systems and to treat varicoce-LAPAROSCOPY IN DEFERENTIAL REFLUX 3FIG. 2. Laparoscopic approach to deferential vein. (A–B) Dilated deferential vein easily detectable on laparoscopic view.(C–D) The deferential vein is picked-up far from the vas. (E–H) Division of vein after clipping.les due to a reflux in the ISV only by a laparoscopic Palomoprocedure. Doing so, we did not observe any recurrence in42 treated cases.5 In this study, we tested the possibility ofextending the laparoscopic treatment also to patients withmultiple refluxing venous systems. Indeed, facing a reflux-ing deferential vein, we managed to dissect, coagulate, anddivide this vein laparoscopically near the vas deferens. Ex-treme care must be paid during dissection to avoid injuriesto the surrounding vessels, vas deference, and deferentialartery, which in some cases could become the almost uniqueblood supply to the testicle. To date, however, we have notexperienced any case of testicular atrophy. Interruption ofthe epigastric vessels could be added to the procedure fortreatment of a cremasteric reflux if present. In the current se-ries of 22 cases of deferential reflux, there was no recurrence.Furthermore, for a better approach to deferential reflux wehave changed our trocars setup. Optical trocar has beenmoved from the umbilicus to right iliac fossa and operativetrocars on the midline, in the umbilicus and hypogastrium.This different approach gave us the best view and manipu-lation of the deferential veins running in the deep pelvis. Infew cases, we chose to manage the deferential vein in thedeep pelvis, but a second retroperitoneal window was re-quired. In these cases it is mandatory to restrict the use ofelectric cautery, since it may cause an injury to the gen-itofemoral nerve leading to post-operative sensory deficit, asobserved in one case in our series. The described techniquecan clearly address only varicoceles due to reflux in the ISV,deferential, or cremasteric veins. Cases with other types ofpelvic refluxing veins are missed. Nevertheless, the inci-dence of these rare refluxing vessels is very low,13–14 andtheir actual role in causing a clinically relevant varicocele isquestionable. The proposed procedure also showed a lowrate of hydroceles (9%) for a nonartery-sparing technique ifcompared to other studies.11 However, in this series hydro-celes resolved spontaneously within one year follow-up.ConclusionsIn conclusion, our diagnostic approach is a rigorous stan-dard for identifying all the venous systems concurring withthe varicocele. Our proposed technique with laparoscopic in-terruption or coagulation of deferential veins when provedby CDUS to be refluxing may allow successful treatment formost varicoceles. In experienced hands, it is a safe procedureand no testicular atrophy has been observed in the presentstudy. This method dramatically reduces recurrence of varic-ocele due to a missed deferential reflux.Disclosure StatementNo competing financial interests exist.References1. Skoog SJ, Roberts KP, Goldstein M, Pryor JL The adolescentvaricocele: what’s new with an old problem in young pa-tients? Pediatrics 1996;100:112–122.2. Diamond DA Adolescent varicocele: emerging understand-ing. BJU Int 2003;92:48–51.3. Coolsaet BL. The varicocele syndrome: venography deter-mining the optimal level for surgical management. J Urol1980;124:833–839.4. Franco G, Iori F, de Dominicis C, Dal Forno S, et al. Chal-lenging the role of cremasteric reflux in the pathogenesis ofvaricocele using a new venographic approach. J Urol1999;161:117–121.5. Cimador M, Di Pace MR, Peritore M, et al. The role of color-doppler ultrasound in determining the proper surgical ap-proach to the management of varicocele in children and ado-lescents. BJU Int 2006;97:1291–1297.6. Niedzielski J, Paduch D, Raczynsji P. Assessment of ado-lescent varicocele. Pediatr Surg Int 1997;12:410–413.7. Nagar H, Mabjeesh NJ. Decision making in pediatric varic-ocele surgery: use of color Doppler ultrasound. Pediatr SurgInt 2000;15:75–76.8. Dubin L, Amelar RD Varicocele size and results of varicoc-electomy in selected subfertile men with varicocele. FertilSteril 1970;21:606–609.9. Sakamoto H, Saito K, Oohta M et al., Testicular volume mea-surement: comparison of ultrasonography, orchidometry,and water displacement, Urology 2007;69:152–157.10. Kass EJ. Editorial: adolescent varicocele. J Urol 1995;154:1483.11. Esposito C, Monguzzi GL, Gonzales-Sabin MA et al.Lapa-roscopic treatment of pediatric varicocele: a multicenterstudy of the Italian Society of Videosurgery in infancy. J Urol2000;163:1944–1946.12. Dudai M, Sayfan J, Mesholam J, Sperber Y . Laparoscopicsimultaneous ligation of internal and external spermaticveins for varicocele. J Urol 1995;153:704–705.13. Niedzielski J, Paduch DA Recurrence of varicocele after highretroperitoneal repair: implications of intraoperative venog-raphy. J Urol 2001;165:927–929.14. Campobasso P Blue venography in adolescent varicocelec-tomy: a modified surgical approach. J Pediatr Surg 1997;32:1298–1301.Address reprint requests to:Marcello Cimador, MDDipartimento Universitario Materno-InfantileUniversità di PalermoVia Cardinale Rampolla, 190142 PalermoItalyE-mail: mcimador@unipa.itCIMADOR ET AL.4

Laparoscopic Surgery of Deferential Reflux in Pediatric and Adolescent Varicocele

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Laparoscopic Surgery of Deferential Reflux in Pediatric and Adolescent Varicocele

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