ADOLESCENT VARICOCELECTOMY AFTER PREVIOUS INGUINAL SURGERY 1721

in 2002 after the laparoscopic Palomo procedure(reference 5 in article), including different varicoce-lectomy types and a larger population. Results sug-gest that previous inguinal surgery is not a riskfactor for testicular atrophy after operative varico-celectomy.

The authors acknowledge that a cohort of 22 pa-tients does not allow them to state with confidencethat the risk of varicocelectomy in this select groupis absolutely negligible. There is limited evidence inthe literature on improved fertility after varicocelec-

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REFERENCES

Surg Int 2008; 24: 583.

urologists should be careful when recommendingvaricocelectomy in patients at increased risk for com-plications. In this patient group when varicocelec-tomy is really needed, antegrade sclerosis (Tauberprocedure) or retrograde sclero-embolization is pref-erable.

R. Maximilian Cervellione

Department of Paediatric UrologyNew Royal Manchester Children’s Hospital

Manchester, United Kingdom

tomy in children and adolescents. Thus, pediatric

Pediatric varicocele repair is a controversial topic,especially in the setting of previous inguinal sur-gery. We hoped to shed some light on this subjectand share our experience with other pediatric urol-ogists confronted with this problem. We have shownthat surgical varicocelectomy is safe after previoushernia repair, with low recurrence and postopera-tive hydrocele rates.

We disagree that a percutaneous approach, eitherby antegrade or retrograde scleroembolization, ispreferable to surgical intervention, as this state-ment is unsubstantiated by the current state ofanalysis. Antegrade sclerotherapy has been de-scribed in several studies for primary varicocele re-pair. However, even in this more favorable scenarioit was not without complications, including scrotalhematoma with compromise of testicular circula-tion, reflux of sclerosing material into the testis andinability to locate suitable veins. In children these

is forced to repeat the incision to search for a secondor third vein suitable for cannulation (reference 1 inZampieri comment). A persistence or recurrencerate of about 8% has been reported in severalstudies.1

Retrograde sclerotherapy is also not without sig-nificant drawbacks, including the need to access thefemoral or basilic vein, inability to advance the cath-eter into the spermatic vein due to anatomical vari-ants and significant x-ray exposure. In 1 study meanprocedure duration was 90 minutes for unilateraland 120 minutes for pediatric cases with a meanx-ray exposure of 3.5 minutes.2 Furthermore, a re-currence/persistence rate of 11% to 16% was notedin this pediatric series. In another study of 51 chil-dren the most common complication was perforationof the internal spermatic vein, which was treatedconservatively.3 A significant subset of patients hadmoderate pampiniform phlebitis due to passage of

vessels are small and fragile, and often the surgeon sclerosing agent into the scrotal portion of varicocele.

1. Mazzoni G: Adolescent varicocele: treatment byantegrade sclerotherapy. J Pediatr Surg 2001; 36:1546.

2. Granata C, Oddone M, Toma P et al: Retrogradepercutaneous sclerotherapy of left idiopathic vari-cocele in children: results and follow-up. Pediatr

3. Pieri S, Minucci S, Morucci M et al: Percutaneoustreatment of varicocele. 13-Year experience withthe transbrachial approach. Radiol Med 2001; 101:

165.