**5. Treatment**

For centuries, treatment of varicocele has been associated with correction of the scrotum swelling and ultimately also the pain.

Varicocele surgery dates back to the first century AD. According to Hotchkiss, Cornelius Celsus (25 BC–ca. 50 AD) performed the first documented ligation and cauterization of a varicocele. In 1541, Ambroise Paré provided the most poetic and effective definition of varicocele. He described a condition of "compact groups of

### *Controversies in the Laparoscopic Treatment of Varicocele in the Pediatric Population DOI: http://dx.doi.org/10.5772/intechopen.106793*

vessels filled with melancholic blood and often growing in men of melancholy temper". "Melancholic" probably refers to slow and "toxic" blood, and one can, therefore, assume that Paré was aware of blood stasis in varicocele veins. Only in the past century has treatment of varicocele entered the age of modern evidence-based medicine, and varicocele surgery has finally progressed beyond merely providing relief of scrotal pain and swelling. The first studies to document an improvement in semen quality and an increase in pregnancy rates following treatment of varicocele were by Barwell in 1885, Bennett in 1889, and Macomber and Sanders in 1929. William Selby Tulloch (1913–1988) was the first surgeon to repair a varicocele for the treatment of infertility. His initial report described an infertile man with bilateral varicoceles and testicular biopsy-proven maturation arrest. This patient was able to attain an increase in sperm concentration and give rise to a natural pregnancy after their varicocele was repaired. Tulloch's report contributed to the worldwide acceptance of the role of varicocele in male infertility [25–28].

Coming to the modern era, the common principle that rules the modern treatment of varicocele in the pediatric population is the closure of refluxing veins and sparing of lymphatic vessels and arteries. Naturally, no specific procedure has been conceived specifically for this particular population. Rather, all treatment options have originated from the practice of adult male infertility. These comprise standard open surgery, microsurgical-assisted techniques, laparoscopy/robot-assisted surgery, and percutaneous embolization.

In 2015, the European Society for Pediatric Urology and the European Association of Urology formulated the following recommendations for management of varicocele in children and adolescents:

The recommended indication criteria for varicocelectomy in children and adolescents are varicocele associated with a small testis:


These recommendations have been reaffirmed in the European Association of Urology document of 2022 [29].

Inguinal exploration has been a standard procedure for many years, with ligation of all venous vessels as described by Bernardi and Ivanissevich [30, 31].

Palomo retroperitoneal ligation of arteries and veins above the internal inguinal ring was proposed in 1949. The technique has a high success rate and a low risk of testicular atrophy. As stated in Palomo's publication, the blood supply of the testis is preserved mainly by the integrity of the cremasteric and deferential arteries [32].

With the advent of laparoscopy, Palomo ligation has become the most common operation feasible in a short time by use of two or three trocars or by single-incision laparoscopic surgery (SILS) [33].

Indeed, at present, the two techniques that have gained worldwide acceptance for use in children/adolescents are laparoscopy and subinguinal microsurgery.

As for venous embolization, according to some authors, venous embolization has the advantage of being a minimally invasive procedure with a faster return to normal activities and a considerably lower cost. The most common technique utilizes a combination of thrombogenic fibered metal coils and a liquid sclerosant to ensure occlusion of both large and small veins. However, other materials such as biological glues and vascular plugs may also be utilized. Coils are the most commonly used embolization agent due to their safety features, easy handling, and low cost. Complications associated with coil insertion such as migration to the heart or pulmonary arteries and infection are rare but potentially serious. Moreover, the use of X-rays can be considered a disadvantage [34, 35].
