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

Over time, other investigators have questioned the need to deliver the testicle as part of a microsurgical inguinal varicocelectomy. For example, Ramasamy and Schlegel in their comparative study in adults demonstrated that there were no varicocele recurrences with either procedure and that delivery of the testis did not provide any beneficial effects on the semen quality or pregnancy rates after varicocelectomy. On the other hand, Spinelli and coauthors reported in a randomized controlled trial, a case series of seventy adolescents suffering from varicocele and reduction of the ipsilateral testicular volume greater than 20%, that lymphatic vessel and arteriole-sparing microsurgical inguinal varicocelectomy with delivery and ligature of all collateral and gubernacular veins of the testis resulted in significantly higher left testicular catch-up growth compared to non-delivery of the testis. Unfortunately, pediatric urologists are less likely than andrologists to use the microscopic approach due to limited experience and concern over post-varicocelectomy ipsilateral testicular atrophy, which is a rare but devastating occurrence [56, 57].

However, a recommendable use of the microsurgical approach should be previous operations for inguinal hernia or cryptorchidism, in which laparoscopic ligation can induce testicular ischemia. Any future vasectomy interventions, with sectioning of the deferential artery, can also lead to testicular atrophy as this is one of the vicariant arteries of testicular vitality [58, 59].

Cayan et al. in 2017 performed a meta-analysis that included 20 studies. The authors considered artery sparing, hydrocele, recurrence, morbidity, and reoperation rates. The results were as follows:

Laparoscopy: Hydrocele 2–15%, Recurrence1–15%, Reoperation 2–4%. Microsurgery: Hydrocele 0–3%, Recurrence 0–3%, Reoperation 0%–0.1%. Radiologic embolization: Hydrocele 0–5%, Recurrence 15–20%, Reoperation 5%–9.9% [60].

#### **Figure 5.**

*Drawing of microsurgical varicocelectomy according to Marmar's technique (right) and Goldstein's technique (left).*

**Figure 6.** *Marmar's technique.*

A recent review by Macey in 2018 found that the most common surgical approaches to varicocelectomy were laparoscopic (38%), subinguinal microsurgical (28%), inguinal (14%), and retroperitoneal (13%). These studies suggest a lack of consensus regarding diagnosis, management, and operative approaches for pediatric and adolescent varicoceles among pediatric urologists. Moreover, this degree of heterogeneity limits the development of standardized guidelines in this population (**Figures 5** and **6**) [61].
