Lymph-Sparing Laparoscopic Palomo Varicocelectomy: Comparison Between Paratesticular Use of Patent Blue and Indocyanine Green in Teenagers

Abstract

Aim/Background:

Lymph-sparing Palomo varicocelectomy has been shown to have low recurrence rates and low hydrocele rates. Patent blue (PB) has traditionally been used to visualize lymph vessels but may lead to permanent staining of the scrotal skin. Recently, intratesticular injection of indocyanine green (ICG) was used to visualize lymph vessels. As intratesticular injection is associated with testicular necrosis, we favor paratesticular injection. No data on the experience with paratesticular injection to visualize lymph vessels have been published to date. With this video, we demonstrate the feasibility and highlight differences between ICG and PB.

Methods:

Using intraoperative video material from two teenage patients, the operative steps of the procedure are demonstrated and the differences between the two types of dye are highlighted. Both patients were operated for grad three varicocele with testicular volume difference exceeding 20%. The injection was performed identically for both dyes. PB was used undiluted; for ICG, the 25 mg powder ampulla was dissolved in 5 mL of water and 2 mL of this solution was injected. Needle size: 24G.

Result and Conclusion:

ICG visualizes lymphatic vessels after paratesticular injection. 15–20 minutes after injection, the spermatic vessels light up as well, at 25 minutes the peritoneal boarders started to fluoresce. This nonselective staining decreased visualization. There was no staining of the scrotal skin after ICG injection. PB allows for a longer selective visualization of lymphatic vessels but intermittently stains the scrotum and poses the risk of permanent tattooing of the skin. Further data are required to evaluate the reliability of visualization and thus its influence on hydrocele occurrence.

No competing financial interests exist.

Runtime of video: 3 mins 23 secs

Consent: Authors have received and archived patient consent for video recording and publication in advance of video recording of procedure.