CC BY
8
https://doi.org/10.29013/ESR-20-1.2-41-44
Tandilava Rene, MD., Ph D., Associate Professor, of the Batumi Shota Rustaveli State University, JSC "EVEX Hospitals" M. Iashvili Batumi Maternal
and Child Central Hospital E-mail: dr.rene-geo@mail.ru.
Tandilava Zurab,
student of The Faculty of Medicine, Friedrich-Alexander University Erlangen-Nurnberg, Germany
OUR METHOD OF SURGICAL TREATMENT FOR VARICOCELE IN CHILDREN
Abstract. The operation, named after Ivanissevich, performed in children for varicocele, under intraoperative phlebotesticulography, is highly effective. The venography method permits to prognosticate a postoperative period course, to prevent the disease recurrence occurrence. A surgical method, applied for varicocele correction has an advantages, because it includes the excision of the testis veins in a wide fashion together with anastomoses from the upper third of a lumbar portion to deep inguinal ring, to the testis vein formation region, permitting to omit a reason for the disease recurrence without application of roentgencontrast investigation. The method was used in 145 children for a left - sided varicocele stages II—III. Complications were not observed. In terms of follow - up before 2 years the recurrences were not observed.
Keywords: varicocele, phlebotesticulography, operation named after Ivanissevich, vein of testis.
Introduction technique aggravates the circulatory disorders in the
Varicocele is a common disease that is found in testicle. Endovascular occlusion of the testicular vein
0.7—20% of older boys [5]. The interpretation of its and endoscopic interventions are expensive meth-
origin remains controversial. The lateral varicocele ap- ods that have not solved the problem of varicocele
pears to be an age-related puberty decompensation treatment [6]. However, isolated interventions per-
of a dysembryogenetic anomaly of the hemiazygos formed on the venous vessel, justified in terms of cir-
vein system. It is based on congenital mesenchymal culatory physiology, are not always effective. In the
dystrophy with subsequent development of local dis- children and adolescents, unsatisfactory results reach
complexation of collagen in the vascular walls [3]. 18—34% [7]. The same is proved by own experience
Coupled with circulatory disorders of the testicle, the of surgical treatment of420 patients. The procedure
disease leads to damage to the sperm epithelium and was unsuccessful in 23% of patients [1; 2; 4].
is one of the frequent causes of male infertility [9]. Dissatisfaction with the results of treatment
The process of organ parenchyma atrophy can be prompts the researchers to an in-depth study of the
suspended surgically. Our observations and experi- problem of varicocele, which in the circumstances of
ence support the view that Ivanissevich technique high morbidity and risk of irreversible changes in the
is an optimal method of surgical operation. Palomo genital glands becomes socially important.
There are reports in the literature about the existence of untapped possibilities of known methods of surgical correction of varicocele. There are evidence of the expediency of X-ray control over the course of surgical intervention [8; 10]. With use of phlebotes-ticulography performed at the afferent and efferent testicular vessels stages, the authors have achieved a significant reduction in the number of relapses to 3.6% [8]. This fact served as the basis for the application of our proposed modification of Ivanissevich technique.
Materials and methods
We used the method of phlebotesteculography during surgery using Ivanisevich technique. During the surgery we find and ligate vena spermatica, cut and catheterize the distal end. Through the catheter syringe is injected 15-20 ml 60% solution of vero-grafine within 10-15 seconds. An X-ray image is taken. Analyzing the resulting phlebogram, the condition of plexus pampiniformis is assessed, and the focus is fixed on the peculiarities of peripheral circulation, in cases of contrast of the proximal section of the testicular vein, the localization of collaterals responsible for it is performed. They are found, ligated and cut. The procedure is repeated until all the vessels bypassing the ligated section of the testicular vein are completely bound. When the operation is complete, the catheter is removed and the wound is sutured tightly. This technique is used in 45 children aged 12-15 years with left-sided varicocele 11 to 111 degrees, of which 13 had a relapse. In order to achieve a final result maximum number of phlebo-grams [3] was performed in 4 patients, in 25 patients 1 phlebogram was enough.
Results and discussion
Long-term results of surgeries using Ivanissevich technique performed under the control of intraoperative phlebotesticulography were studied in 43 patients. Varicocele was eliminated in all children. No progression of trophic changes in testicles was registered by ultrasound results during 1.5-3 years of observation.
Phlebotesteculograms made it possible to study X-ray anatomy of testicular vein system, to determine the reasons for unsatisfactory results of Ivanissevich technique.
The analysis of intraoperative phlebotesticulo-grams confirms the opinion that the unsatisfactory results of Ivanissevich technique are connected with the renewal of blood circulation in the testicular vein basin by intra-system anastomoses represented by different caliber, sometimes thread-shaped, veins. They are located along the vascular bundle and may not be detected visually during the operation, but clearly contrast with intraoperative phlebotesticulography. This mechanism of disease recurrence has been confirmed in 13 patients who were previously operated on for left-side varicocele.
The testicular veins own anastomoses are most often located at the junction of the anterior and posterior parts of plexsus pampiniformis at the deep groin ring (20). Collaterals were found in 6 patients in the middle third and 9 in the upper third. The satellite veins accompanied the main trunk in 5 patients. In 3 cases collaterals were not detected, the veins of the scatter type were anastomized between each other at different levels.
After cessation of reno-caval anastomosis, the blood flow from plexus pampiniformis is directed to iliac vessels along the direct path through the cremaster vein (42 patients). In this case, dilation of the enlarged veins in the scrotum occurred quickly, during the first hours or days after surgery.
These anatomical features of the testicular vein pool provided the basis for a more effective method of surgical correction of varicocele, which is aimed at preventing recurrence of the disease without the use of X-ray contrast examination. In order to achieve this goal, we skeletonize the vein in the terminal area at the level of the upper third of the lumbar spine by exposing the test vessels ret-roperitoneally and bandaging it. The ligated vessels are crossed 5 mm distally from the ligature. Similar actions are performed at the deep inguinal ring in
the area of the test vein formation. We tie all the vessels with collaterials detected by the ligatures underneath them and cross them 5 mm proximal to the ligature. The remaining section of the testicular vein crossed between two ligatures is separated from the peritoneum, gently released from the testicular artery and lymphatic collectors, and dissected over the length.
The method was applied in 145 children with left-handed varicocele of 11—111 degree. The surgeries were performed without complications. No relapses were found during 2 years of observation of the operated patients.
Examination of the testicular vein has an advantage in comparison with Ivanissevich technique as it provides for dissection of the main venous vessel in wide range together with visualized anastomoses, mechanical destruction during invisible "natural" collaterals, completely interrupting the blood flow in the pool of the testicular vein. Ivanissevich technique does not include excision, but a simple intersection of the venous vessel in its lower third does not prevent the recurrence of the disease.
Therefore, the efficiency of Ivanissevich technique is increased using intraoperative phlebotes-ticulography at the stages of ligation of afferent and efferent testicular vessels. However, the applied method of surgical correction of varicocele has the advantage, as it involves the dissection of the testicular vein in a wide range together with anastomoses, which eliminates the cause of the disease recurrence without X-ray contrast examination.
Our observations clarify the pathogenesis of varicocele in terms of the pathophysiology of testicular circulation. In case of impaired venous outflow from the testicle, which caused the development of varicose veins of the spermatic cord, ligation of the main
venous vessel is a kind of provocative moment, an additional and deliberately created obstacle to the advancement of blood in the natural way. The calculation is carried out on the intensification of the blood circulation pathways bypassing the blocked zone by the prepared collaterals, first of all, by the creamy vein, capable of "unloading" the partially bulky plexus, recreating the acceptable conditions for hemocirculation, preservation of the hemot-esticular barrier. In response to the ligation of the testicular vein, the peripheral resistance increases sharply, and more arterial blood enters the testicu-lar vein as the peripheral resistance in the testicular vessels has become less than in the testicular vein after the ligation. As a result, the testicle receives full arterial nutrition. Varicosities of the spermatic cord become empty.
Conclusion
When treating varicocele in children, Ivanissevich technique is justified from the point of view of circulatory physiology. Let us note the high efficiency of this technique, performed under the control of intraoperative phlebotesteculography. The efficiency of the surgery is related to the unloading of the pool of the hemiazygos vein. The absolute condition is a thorough ligation and cutting of the main and smallest additional trunks of the testicular vein with obligatory preservation of the lymphatic collectors of the testicle and the seminal cord. Radiological control over the course of the operation allows predicting the course of the postoperative period and preventing the possibility of a relapse. However, the applied method of surgical correction of varicocele has an advantage, as it involves cutting of the testicular vein in a wide range together with anastomoses, which eliminates the cause of the disease recurrence without contrast X-ray monitoring.
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