Varicocele by def i ni tion im plied any ab nor mal di la -

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1 /STRUÈNI RAD UDK DOI: /ACI K Lap aro scopic lig a ture of sper matic veins as a method of... surgical management of varicocele B. M. Kajmakoviæ 1, Z.M. Džamiæ 1,2, S. Dragiæeviæ 1, M. Aæimoviæ 1,2, B. Milojeviæ 1, J. Hadži Djokiæ 3 1 Clinic of Urol ogy, Clin i cal Cen tre of Ser bia, Bel grade 2 Uni ver sity of Bel grade, Fac ulty of Med i cine 3 Ser bian Acad emy of Sci ences and Arts, Bel grade Objective: To present the surgical technique of lap aro scopic li ga tion sper matic vein in the treat - ment of varicocele as well as the re sults of this pro ce dure. Material and meth ods: The study was con ducted at the Clinic of Urol ogy, Clin i cal Cen tre of Ser - bia, dur ing the sev en teen months, from No vem - ber 2012 till March of Dur ing this time, the thirteen patients underwent laparoscopic ligation of sper matic vein. In clud ing fac tors for this type of sur - gi cal treat ment were clin i cally man i fest varicocele and/or bad find ing of se men. Results: Dur ing the sev en teen months, thir teen pa - tients underwent laparoscopic spermatic vein ligature. The youn gest pa tient was 21 years old, while the old - est pa tient was 38 years old. The me dian was years. 6 pa tients had varicocele Gr III, and with 7 pa - tients we ver i fied varicocele Gr II. The du ra tion of sur gery ranged from 15 to 70 min utes, with a me dian of min utes. The amount of gas that was insufflated dur ing sur gery ranged from 14.1 l to 45 l, with a me dian of 23:32 lit ters. Three pa tients un der - went lap aro scopic lig a ture of sper matic vein with pres er va tion of sper matic ar tery. In ter ven tions in which underwent preservation of artery lasted longer (me dian 60 min utes) than it was the case in the group of patients without preservation (the median 28.1 minutes). Conclusion: Lap aro scopic li ga tion of sper matic veins is a safe, min i mally in va sive, rapid and ef fec tive pro - ce dures. The level of post op er a tive com pli ca tions is min i mal learn ing curve fast and pa tient dis com fort is min i mized. The pro ce dure is the fi nan cial cost ef fec - tive, es pe cially com pared with the open sur gi cal pro - ce dure. Key words: varicocele, lap a ros copy, lap aro scopic li ga tion of sper matic veins, Valsalva ma neu ver, Tan ner grad ing, Dopp ler ul tra sound. rezime INTRODUCTION: Varicocele by def i ni tion im plied any ab nor mal di la - tion of sper matic veins within the sper matic cord of pampiniform plexus. Varicocele is of ten en coun tered in nor mal men, and is of ten one of the ma jor risk fac tors for adult male in fer til ity. Al though it im ply as con gen i tal le sions, varicocele is rarely di ag nosed be fore ad o les cence, and the fre quency is di rectly pro por tional to age, type of di ag nos tic method, as well as Tan ner stage. It is set tled that varicocele le - sions were mainly re served for left hemiscrotum. Re cent stud ies in di cate that the varicocele oc curs bi lat er ally in up to 7% to 10% of cases. The in tro duc tion of Dopp ler ultrasonography in the di ag no sis of varicocele per cent age bi lat eral varicocele was raised from 7% to 17% of cases 1,2. Ma jor eti o log i cal fac tor for varicocele are a ge - netic pre dis po si tion, body habitus and/or ve nous ab nor - mal i ties. In Ser bia, there is still ab sence of a pro gram for the early de tec tion of varicocele. Most of varicocele is de - tected ac ci den tally, while in a mi nor ity of cases di ag no sis is es tab lished on the base of med i cal his tory in for ma tion, scrotal dis com fort and edema of left hemiscrotum. Pa - tients re port pain sen sa tions in the scro tum from 2% to 11% of the cases 3. The af fected tes ti cle is softer in most cases. Also it was no ticed the geo graphic pre dis po si tion to the varices of pampiniform plexus. In rare cases, the ex is tence of varicocele was de tected af ter rup ture pampiniform plexus in sport traumatism. At phys i cal ex - am i na tion of the scro tum varicocele is man i fested as a scrotal swell ing with pos i tive pal pa ble find ings of thick - ened sper matic cord, both in peace and dur ing per form - ing V alsalva ma neu ver. Stan dard grad ing im plied three de grees of varicocele: in the first de gree varicocele is pal pa ble only when per - form ing Valsalva ma neu ver, the sec ond level im plied pal pa ble but not vis i ble en - large ment of pampiniform plexus, while the third de gree im plied not only pal pa ble but also clear vis i ble varicocele.

2 50 B.M. Kajmakoviæ et al. ACI Vol. LXI TABLE 1 RESULTS OF VARICOCELE RECONSTRUCTION IN ADULT POPULATION 12 (Campbell-Walsh Urology, 9th ed.) Procedure Recurrence/ persistence Hydrocele Testicular atrophy Open supra inguinal procedure (Paloma) 2%-4% 0%-30% / Laparoscopic procedure without arterial preservation 0%-9% 11%-32% / Laparoscopic procedure with arterial preservation 1%-7% 0%-4% / Microscopic sub inguinal procedure 0%-10% 0%-6% rarely Microscopic inguinal procedures 7%-33% 8%-14% / Sclerotic therapy 6%-35% occasionally rarely Ad di tional di ag nos tic as sis tance is a color Dopp ler ul - tra sound. Dur ing this di ag nos tic mo dal ity, at ten tion is paid to the di am e ter of the sper matic vein, as well as the pres ence of ve nous re flux. In sup port of the ex is tence of varicocele speak facts of the di am e ter of sper matic veins greater than 3 mm, as well as ver i fi ca tion of ve nous re - flux. A com bi na tion of these two pa ram e ters highly speaks in fa vor of man i fest varicocele 4. Color Dopp ler ul - tra sound ver i fied a high flow rate greater than 38 cm/s in con junc tion with the high testicular asym me try, also in di - cates the ex is tence of sig nif i cant varicocele 5,6. Both sides mea sure ment of vol ume and di men sions (per formed with orchidometers) of the tes tis is an op tional di ag nos tic pro - ce dure (Tan ner grad ing). It is an in dis put able fact of causal con nec tion be tween varicocele with testicular growth, dis tur bance of spermatogenesis and in fer til ity. Con nec tion stems from the pro - longed el e va tion of scrotal tem per a ture, which is thought to be the pri mary eti o log i cal sub strate 7. Ad e quate ther a - peu tic mo dal ity for the treat ment of varicocele is con - ducted pri mar ily on the ba sis of the pres ence and as sess the risk fac tors that lead to re duced fer til ity. As a ther a peu tic ap proach, strict mon i tor ing of pa tients is still one of the ma jor mo dal ity, in the most adult varicocele. This mo dal ity is the treat ment of choice for pa tients with mild symp toms and nor mal spermogram8. Main in di ca tions for sur gi cal treat ment of varicocele are as follows: uni lat eral (dextral>20%) or bi lat eral testicular hypotrophy, scrotal pain, ab nor mal spermogram and Tanner stage 5. For rep a ra tion of varicocele in adult one can use a num - ber of sur gi cal pro ce dures from an open to lap aro scopic or microsurgical pro ce dures. The most fre quently used are: in gui nal or subinguinal re con struc tion, lap aro scopic retroperitoneal or trans peritoneal pro ce dures and mo dal i - ties of like as venography ap proach. The most com monly used pro ce dure is the mi cro scopic subinguinal lig a ture of sper matic veins 9. This pro ce dure re quires the proper FIGURE 1. POSITION OF THE PA TIENT ON THE OPERATING AREA equip ment (mi cro scope and mi cro in stru ments). The sec - ond fre quent one is an open sur gi cal high lig a ture of sper matic veins by Paloma with/or with out pres er va tion of sper matic ar tery 10. Last years as a ther a peu tic mo dal ity states also a ro bot-guided lig a ture of sper matic veins 11. The de cision on the type of sur gi cal pro ce dure is left to the urol o gist him self de pend to his pref er ences, ex pe ri - ence, and level of com pli ca tions (Ta ble 1). MA TE RIAL AND METH ODS: The study was con ducted at the Clinic of Urol ogy at Clin i cal Cen tre of Ser bia, dur ing the sev en teen months, from No vem ber 2012 till March of Dur ing this time, thir teen pa tients un der went lap aro scopic sper matic vein lig a ture. In clud ing fac tors for this type of sur gi cal treat ment were clin i cally man i fested varicocele and/or poor find ings of spermogram. For clin i cal ver i fi ca tion of varicocele we used med i cal his tory, pre vi ous his tory of the dis ease, if it was the case of treat ment of in fer til ity, phys i cal pal pa ble ex am i na tion with Valsalva test, and ul - tra sound ex am i na tion of the scro tum, with mor pho log i cal find ings in the tes tes and color Dopp ler sonography of blood flow. To each pa tient was dur ing prehospital di ag - no sis made spermogram. Mon i tor ing of pa tients was car -

3 Br. 3 Lap aro scopic lig a ture of sper matic veins as a method of sur gi cal 51 man age ment of varicocele FIGURE 2 OPERATIONAL FIELD BEFORE SURGERY FIGURE 3. PLACEMENT OF PORTS FIGURE 4. OPERATIVE FIELD AFTER SURGERY ried out up to three months af ter the sur gi cal treat ment and in volved sub jec tive data about scrotal pain and/or en - hance ment of the scro tum, ultrasonography, and a con trol spermogram that was per formed two months af ter the in - ter ven tion. SURGICAL TECHNIQUE: Pa tients are ad mit ted af ter be ing done in am bu la tory con di tions com plete di ag nos tic eval u a tion both in terms of eval u at ing the de gree of varicocele and the con se - quence of the ste ril ity. His tory data ob tained ba sic in for - ma tion about the level of dis com fort (pri mar ily sub jec tive as sess ment of varicocele size and in ten sity of pain or dis - com fort). Also, urol o gist be comes fa mil iar with the ear - lier his tory of in fer til ity re lated to the cou ple and any even tual steps taken to wards the es tab lish ment of preg - nancy un til the mo ment when the pa tient ad dressed for uro log i cal as sis tance. Phys i cal ex am i na tion ob tained a clear in sight into the ap pear ance of the ex ter nal gen i ta lia, pay ing par tic u lar at ten tion to the size of the both tes tes, or at the level of testicular dis crep ancy. Phys i cal ex am i - na tion pro vides in sight into the de gree of pain at tes ti - cles. Also, pal pa ble one ver ify the size of varicocele. Ultrasonography ex am i na tion of the scro tum pro vides in - sight into the width of pampiniform plexus, and the de - gree of ve nous re flux when per form ing Valsalva test, as well as the di am e ter of the sper matic veins. Ul tra sound al lows mor pho log i cal ex am i na tion of the tes ti cles bi lat er - ally, with an as sess ment of dis crep an cies in the di men - sions of the tes ti cles in quan ti ta tive terms. If the cause of hos pi tal ad mis sions for treat ment of var i cose vein is in - fer til ity, or poor spermogram find ings, the pa tient is re - quired to do spermogram pre op er a tively with time of sex - ual ab sti nence for a pe riod of three to five days. The ini - tial find ings will serve for post op er a tive com par i son and eval u a tion of the ther a peu tic ef fect. Pa tients on ad mis - sion need to do an in ter nist ex am i na tion with the per mis - sion to op er a tion in GETA (gen eral endotracheal an es - the sia). Based on the pre hos pi tal di ag nos tics all pa tients are di vided into three groups, as noted in the in tro duc tory part. Pa tients were hos pi tal ized for a to tal of three days. On the first day, the day of ad mis sion, the pa tient un - dergo to anal y sis of CBCS, bio chem i cal anal y sis, anal y - sis of bleed ing time, and the urine. The pa tient is dis - played be fore an es the si ol o gist with all the doc u ments pur pose of pre par ing for sur gery. There is no spe cial re - quire for bowel prep a ra tion be fore in ter ven tion. On the sec ond day the pa tient un der goes sur gi cal treat ment. Af - ter sur gery he was con verted to a gen eral ward care. On the third day the pa tient has been sent home to re cover. Some stud ies de scribe lap aro scopic li ga tion of sper matic veins in the am bu lance con di tions in the form of one-day sur gery 13. On the day of sur gery, the pa tient is ad min is - tered with parenteral an ti bi otic, usu ally a third-gen er a tion cephalosporin, which are then con tin ued in the next five days in the form of oral ad min is tra tion. The set ting of the pa tient im me di ately be fore the in ter - ven tion. The pa tient is placed in su pine po si tion on the op er at ing ta ble in a com pletely hor i zon tal po si tion, ly ing on his back with his legs slightly spread. Both op er a tor and as sis tant are faced to the pa tient against the lap aro scopic col umn and video out put. Both op er a tor and an as sis tant stand ing by the right side of the pa tient. Lap aro scopic col umn is set to the left side of the pa tient op po site the op er a tor and as sis tant. Nurse oc cu - pies a po si tion lat eral to the left of lap aro scopic col umn with in stru ments ta ble set just above the foot of the patient (Figure 1). The instrumentarium (gen eral): Scal pel; Two Alison grips; Surgical forceps; Scis sors; Nee dle holder; Su ture for Re con struc tion list peri to neum, Vicryl 2/0; Su ture for re con struc tion of sub cu ta ne ous tis sue (1/0);

4 52 B.M. Kajmakoviæ et al. ACI Vol. LXI Su ture for the re con struc tion of the skin (3/0). Ports: One 10 mm work ing port (metal port); One 11 mm op ti cal port for the place ment of the cam - era - plas tic port; One 5-mm work ing plas tic port; Re duc tion of 10 mm port; Bi po lar ca ble A60003C, Monopolar ca ble A0357. Lap aro scopic instrumentarium: Monopolar scis sors A64320A (WA608800C sleeve, han dle WA60101C); Bi po lar Mary land dis sec tor WA6430C (sleeve WA60800C, han dle WA60101C); Hem-o-lock me dium size (L); Suc tion; Lap aro scopic nee dle holder, Storz 26173KAF. All lap aro scopic in stru ments are the Storz. De scrip tion of the pro ce dure. The pa tient is placed in su pine po si tion, with left hand placed away of body for an es thetic ma nip u la tion (iv. ac cess and mon i tor ing of vi - tal pa ram e ters). The uri nary cath e ter is not placed be - cause of the short du ra tion of the in ter ven tion be cause the mea sure ment of fluid bal ance is not an important parameter. The op er a tive field is wide clean up and pre pare for the in ter ven tion from the line xyphoid pro cess to the scro - tum. Af ter that, the op er a tive field is widely pre pared in - clud ing left hemiscrotum. This is nec es sary due to eas ier ac cess to the left tes ti cle so as to trac tion eas ily iden ti fied an intracorporal sper matic veins, and in or der to per form mas sage of pampiniform plexus to evac u ate the blood in the same way. Lap aro scopic instrumentarium is pre pare on the right side of the pa tient fixed by us ing clasps in or - der to be within easy reach of the op er a tor in any moment of operation (Figure 2). Via place ment of the Veress nee dle the pneumoperi to - neum is es tab lish. The nee dle is placed 2 cm from the umbilicus, fol lowed by the place ment of the op ti cal 11 mm tro cars. The in ci sion in the skin has to be 50% greater than the di men sion of the trocar. Af ter in ci sion of the skin the dis so ci a tion of the sub cu ta ne ous ad i pose tis - sue is per formed down to the level of the fas cia. Then, with two Allis clamps fas cia is to be com prise and the place ment of Veress nee dle is next step. The Veress nee - dle has two parts that are in de pend ently moved, the in ner part of the nee dle is blunted at the top and is hol low, and the sec ond one is ex ter nal, sharp ened struc ture for per fo - ra tion. Dur ing place ment of Veress nee dle one en coun - ters the two bar ri ers (the first is fas cia and the sec ond is peri to neum). Only af ter the sec ond per fo ra tion it is rea - son able to ex pect that the Veress nee dle is in the right place, in the lu men of the intra-ab dom i nal space. The test is con ducted in the way such as through the nee dle is in - jected 10 ml of phys i o log i cal sa line, which should be easy to en ter, fol lowed by the as pi ra tion dur ing which the fluid must not re turn to the sy ringe of the Veress nee dle. If the liq uid is re turned to the syringe, position of the needle tip is in the space between the fascia and the peritoneum. FIGURE 1. AGE FIGURE 2. DURATION OF SURGERY FIGURE 3. THE AMOUNT OF CO 2 If how ever, dur ing as pi ra tion through Veress nee dle an un clean brown ish con tent ap pears, it is likely that dur ing nee dle place ment there was a bowel per fo ra tion and as pi - ra tion of in tes ti nal con tents. In this case, it is nec es sary to re peat the pro ce dure to es tab lish ing pneumoperitoneum, fol lowed by lap aro scopic in tes ti nal re con struc tion or con - vert the op er a tion 14. This strat egy is also nec es sary dur - ing any other lap aro scopic sur gery when the bowel in jury oc curs while place ment of Veress nee dle. Af ter suc cess -

5 Br. 3 Lap aro scopic lig a ture of sper matic veins as a method of sur gi cal 53 man age ment of varicocele (sur gi cal tech nique) FIGURE 4. GRADE OF VARICOCELE FIGURE 5. PRESERVATION SPERMATIC ARTERY ful place ment of the Veress nee dle es tab lish the ca ble for CO2 insufflation and en able the gas flow. Intracavitary pres sure should be main tained at a level of 14 mm Hg (mer cury) while the gas flow main tained for about 2 li ters per min ute. Insufflation con tin ues un til the amount of gas in the ab dom i nal cav ity even tu ally climbs the value of 5 to 6 li ters. At this point re quired insufflation is es tab - lished for se cure place ment of the trocar. The op ti cal trocar of 11 mm is placed at the point where pre vi ously skin in ci sion was made for place ment of Veress nee dle. The first plas tic work ing port of 5 mm is placed on the two fin ger breadths of su pe rior an te rior iliac spine, un der the vi sion en sur ing that dur ing punc ture no per fo ra tion in jury was done. The other metal work ing port of 10 mm is placed half way be tween the um bi li cus to the an te rior su pe rior iliac spine. A 5 mm work ing port should be re - served for the sur geon s dom i nant hand. Place ment of ports is per formed in ac cor dance with stan dard lap aro - scopic pos tu lates that dic tate safe place ment of ports. Al - though there is pub lished pos i tive ex pe ri ence of two port lap aro scopic pro ce dures, at the Clinic of Urol ogy for the lap aro scopic lig a ture of sper matic veins we use three ports with equal success15 (Fig ure 3). Pri mary ex plo ra tion al lows the op er a tor to ori en tate by iden ti fy ing the in ter nal in gui nal ring and the po si tion of sper matic ves sels. At this point great as sis tance does gen - tle with drawal of the left tes ti cle which move sper matic ves sels to sim plify the iden ti fi ca tion. The pa tient in this point of op er a tion sets to Trendelenburg po si tion. This po si tion al lows eas ier elim i na tion of blood from pampiniform plexus. Af ter iden ti fy ing the ba sic an a tom i cal struc tures one can ap proach to de lib er a tion of in tes tine for easy han dling and ac cess to the sper matic blood structures. Then, the in ci sion of peri to neum can be made just above sper matic ves sels with a length of 30 mm, as far as it is usu ally re quired for easy dis so ci a tion and sub se quent place ment of hem-o-lock clip. If the con di tions re quire peritoneal in ci sion can be lon ger. Then, the dis so ci a tion sper matic can be done. Iden ti fy ing of the par tic u lar ar tery and sper matic vein or veins is next step. Vas cu lar struc - tures are dis so ci ated with a length of 3-5 cm, tak ing care to avoid in jury, as well as strict con trol of hemostasis of nu mer ous nu tri tive blood ves sels. With ad e quate de lib er - a tion of vas cu lar struc tures one can ap proaches to place - ment of hem-o-lock clips li gat ing en-mass both ve nous struc tures and sper matic ar tery. At this level can be li - gated sper matic ar tery with out fear. Be cause of ex ist ing col lat eral ves sels, in this case it will not oc cur the tes ti - cles ischemia. The place ment of the two hem-o-lock clip is done to the sper matic ves sels, af ter what the cut ting can be done. Im me di ately prior to place ment of hem-olock clips it is nec es sary to mas sage pampiniform plexus for blood evac u a tion. This ma neu ver re duces later post - op er a tive pain in hemiscrotum that oc cur as a con se - quence of al tered throm bo sis of var i cose plexus. The sam ple can be sent for histopathological anal y sis, but it is not stan dard prac tice. Af ter li ga tion and re sec tion of vas - cu lar struc tures one can ap proach to ad di tional con trol of hemostasis and re con struc tion of peri to neum with Vicryl 2/0 su tures. Place ment of drain with this in ter ven tion is not necessary. Gas supply was stopped, the abdominal cavity was maximally discharged of gas and the ports was removed. Next step was reconstruction of the port openings by layers (Figure 4). RE SULTS: Dur ing the sev en teen months, as far as this mo dal ity of sur gi cal treat ment ap plied to the Clinic of Urol ogy, Clin i - cal Cen tre of Ser bia, thir teen pa tients un der went lap aro - scopic sper matic vein ligature. The youn gest pa tient was 21 years old, while the old est pa tient was 38 years old. Me dian was years (Fig ure 1). The du ra tion of sur gery ranged from 15 to 70 min utes 19, with a me dian of min utes (Fig ure 2). Quan tity of insufflated gas dur ing sur gery ranged from 14.1 li ters to 45 li ters, with a me dian of 23:32 li ters (Figure 3). All pa tients had ei ther Gr II or Gr III clin i cal varicocele. 6 pa tients had varicocele Gr III, whereas 7 pa tients ver i fied varicocele Gr II (Fig ure 4). Dur ing the sur gi cal pro ce dure there was no intraoperative blood loss. None of the pa tients had a drain placed. Pa tients were hos pi tal ized for three hos pi tal days 20,21. Perioperative and post op er a tive pain is not reg - is tered. In two pa tients, there was ap pear ance of a tran - sient pain in the left hemiscrotum for up to three days. Three pa tients un der went lap aro scopic lig a ture of sper - matic vein with pres er va tion of sper matic ar tery 19,20, while the re main ing ten pa tients un der went lig a ture of with out pres er va tion (Fig ure 5). In ter ven tions with pres -

6 54 B.M. Kajmakoviæ et al. ACI Vol. LXI er va tion of ar tery lasted lon ger (me dian 60 min utes) than was the case in the group of pa tients with out pres er va tion (the me dian 28.1 min utes). Only with one pa tient there was com pli cated re con struc tion of sper matic veins. The main symp tom was scrotal pain and dis com fort. It was a ter tiary op er a tion, af ter pa tient un der went pri mary in ter - ven tion with microsurgical Mar-Mar pro ce dure, fol lowed by sec ond ary high in gui nal lig a ture (Paloma). With this pa tient (28 years) it was a re cur rent varicocele Gr III. The in ter ven tion lasted 30 min utes and did not in clude pre - serv ing sper matic ar tery. The quan tity of CO 2 was 20 li - ters. Post op er a tively, the pa tient did not state the oc cur - rence of pain in the left hemiscrotum. The con trol exam oc curred two months af ter the in ter ven tion, spermogram was valid. DIS CUS SION: Com par ing with the re sults of sim i lar stud ies, our pre - lim i nary ex pe ri ence with this pro ce dure was pretty mod - est 16,17,18,19. Tak ing into con sid er ation the age of pa tients, pub lished ex pe ri ences are quite sim i lar to those to which we have faced 25. The mean age pa tients op er ated on in this man ner are quite sim i lar to those in com par a tive stud ies. The de gree of varicocele, du ra tion of sur gery, quan tity of insufflated gas dur ing sur gery, intraoperative blood loss as well as a num ber of hos pi tal days 20,21 were also sim i lar to com par a tive stud ies. Most of pa tient un der went pro ce dure with out ar te rial pres er va tion, but sim i lar as in other stud ies re sults were suf fi cient, and de gree of scrotal pain was min i mal. CON CLU SION: Lap aro scopic lig a ture of sper matic vein is a safe, min i - mally in va sive, rapid and ef fec tive pro ce dures which is ad e quate sub sti tute for microsurgical pro ce dure which is lim ited with tech ni cal con di tions of per for mance. The pro ce dure re quires a mod est lap aro scopic ex pe ri ence, level of post op er a tive com pli ca tions is min i mal, learn ing curve quick and pa tient dis com fort is min i mized. Led by mod est ex pe ri ence, the in ter ven tion in near fu ture may be re duced to a one-day in ter ven tion sur gery. Last but not least, it is im por tant to point out the eco nomic as pect of the pro ce dure; more cost ef fec tive, es pe cially com pared with open sur gi cal li ga tion of sper matic vein (Paloma tech nique). SUMMARY Cilj rada: Prikazati hiruršku tehniku laparoskopske lig - a ture vene spermatike u leèenju varikocele, kao i dosadašnje rezultate ove pro ce dure. Materijal i metode: Istraživanje je sprovedeno na Klinici za urologiju, Klinièkog centra Srbije, tokom sedamnaest meseci, od novembra meseca godine do marta meseca godine. Tokom ovog vremena trinaest pacijenata je podvrgnuto laparoskopskoj ligaturi spermatiène vene. Ukljuèujuæi faktori za ovaj vid hirurškog tretmana podrazumevali su klinièki manifestnu varikocelu i/ili loš nalaz spermograma. Rezultati i diskusija: Tokom sedamnaest meseci, koliko se ovaj modalitet hirurškog leèenja primenjuje na Klinici za urologiju Klinièkog centra Srbije, trinaest pacijenata je podvrgnuto laparoskopskoj ligaturi spermatiène vene. Najmladji pacijent je imao 21 godinu, dok je najstariji pacijent bio 38 godina star. Medijana je iznosila godina. 6 pacijenata je imalo varikocelu Gr III, dok je kod 7 pacijenata verifikovana varikocela Gr II. Vreme trajanja operacije iznosilo je od 15 do 70 minuta, sa medijanom od minuta. Kolièina insufliranog gasa tokom hirurške intervencije iznosila je od 14.1 litara do 45 litara, sa medijanom od litara. Kod tri pacijenta je uèinjena laparoskopska ligaruta spermatiène vene sa prezervacijom spermatiène arterije. Intervencije kod kojih je uèinjena prezervacija arterije trajale su duže (medijana 60 minuta), nego što je to bio sluèaj u grupi pacijenata bez prezervacije (medijana 28.1 minuta). Zakljuèak: Laparoskopska ligatura spermatiène vene je sigurna, minimalno invazivna, brza i uèinkovita procedura. Nivo postoperativnih komplikacija je minimalan, krivulja uèenja brza a diskomfor pacijenata je sveden na min i mum. Procedura je finansijski isplativija, naroèito poredeæi je sa otvorenom hirurškom procedurom. Kljuène reèi: varikocela, laparoskopija, laparoskopska ligatura spermatiène vene, Valsalva manevar, Tanerovo gradiranje, dopler ultrazvuk. REF ER ENCE: 1. 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