INTRAOPERATIVE VENOGRAPHY FOR PEDIATRIC VARICOCELES 227 REFERENCES

1. Oster, J.: Variwcele in children and adolescents. An invehga- tion of the incidence among Danish school children. Scand. J. Urol. Nephrol., 5: 27, 1971.

2. Steeno, O., Knops, J., Declerck, L., Adimoelja, A and Van de Voorde, H.: Prevention of fertility disorders by detection and treatment of varicocele at school and college age. Andrologia, 8 47, 1976.

3. Risser, W. L. and Lipschultz, L. I.: Frequency of varieoceles in black adolescents. J. Adolesc. Health Care, I: 28,19&L.

4. Coolsaet, B. L. R. A: The variwcele syndrome: venography de- termining the optimal level for surgical management. J. Urol., 124: 833, 1980.

5. Kaes, E. J. and Marc~l, B.: Reeults of varieocele surgery in adolescents: a comparison of techniques. J. Urol., part 2,148: 694,1992.

6. Wosnitzer, M. and h t h , J. h: Optical magnification and Doppler d tmnund probe for varicocel&my. Urology, 22: 24,1983.

7. Gill, B., Kogan, S. J., Maldonado, J., Reds, E. and Levitt, S. B.: Significance of intraoperative venographic patterns on the postoperative recurrence and surgical incision placement of pediatric varicoceles. J. Urol., part 2, lW 502, 1990.

8. Levitt, S. B., Gill, B., Katlowitz., N., Kogan, S. J. and Reda, E.: Routine intraoperative post-ligation venography in the treat- ment of the pediatric v a r i m l e . J. Urol., 131: 716, 1987.

9. KraeR, H., Kriz-Klimek, H. and Hokhneider, A. M.: Experience with surgery for varicocele in childhood. Z. Kinderchir., 34: 272, 1981.

10. Reitelman, C., Burbige, K. h, Sawczuk, I. S. and Henele, T. W.: Diagnosis and surgical correction of the pediatric var imle . J. Urol., part 2, 138: 1038,1987.

11. Parrott, T. S. and Hewatt, L.: Ligation of the testicular artery and vein in adolescent variwcele. J. Urol., part 2, 162 791, 1994.

12. Goldstein, M.: Mini-incision microsurgical inguinal or subingui- nal varicoceledomy with delivery of the testis. Read at annual meeting of society for Pediatric Urology, San Francisco, Cali- fornia, May 14, 1994.

EDITORIAL COMMENT My concern with this clinical study involves 2 areas. 1) The oper-

ation performed is billed as a testicular artery sparing technique, whereas efforts to ensure that the artery was left intact, such as optical magnification and/or the Doppler probe, were only "usually

used" or omitted. Most nonlapammpic varicocele surgeons admit that aceuate visualization of the spermatic artery ie difficult even in the best of circumstances. How can the authors be sure that the spermatic artery was indeed spared? This is important since their technique is specitically contrasted with nonartery sparing tech- niques, such as our own (reference 11 in article) and that of Kase and M m l (reference 5 in article). Furthermore, the authors suggest that their procedure spares the artery yet provides an acceptably low (8.6%) Ltecurrence" rate. It would seem imperative to provide better evidence that the artery was not inadvertently ligated along with the vein. 2) Venography did not statistically improve the "recurrence" rate yet it undoubtedly doubled operative time since most urgeo one perform routine variwcele correction in about an hour. In this era of managed care and close inspection of coetrr does this approach really improve patient care?

T h o r n S. P a m Pediatric Urology Emory University School of Medicine Atlanta. Georgia

REPLY BY AUTHORS This clinical study does not and was not intended to argue the

merits of spermatic artery preservation as opposed to mass ligation of the spermatic vessels for the treatment of variwceles in children. In the early 1980s when intraoperative venography was proposed our prejudice was to make every attempt to preserve the testicular artery and reduce the high reported varicocele recurrence rate in children. The initial report published in this Journal (reference 8 in article) pro@ the use of intraoperative venography for accom- plishing low recurrence rates in children, albeit at the expense of additional operative time. Papaverine, optical magdkat ion and Doppler probes were increasingly ueed as the study progressed to ensure artery preservation. No claim was ever made that the artery was always spared. We agree that the recurrence rate with mass ligation is low and that operative time is significantly reduced. However, the point of thie report is to rehte our initial claim that intraoperative venography is useful for reducing recurrence rates when artery sparing techniques are chosen for variwceledomy. Al- though we currently practice mass ligation for varieocelectomy and, indeed, have experienced the same low recurrence rate and signifi- cantly reduced operative time, we continue to harbor some concern regarding the long-term effects of testicular arbery transeetion on fertility potential. Only long-term studies, not yet available, will determine the wisdom of our current approach.