Indocyanine Green Fluorescence Lymphography for Lymphatic-Sparing Laparoscopic Palomo Varicocelectomy in Children: 5-Year Experience and Technical Considerations

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BACKGROUND: This study reports our 5-year experience in performing lymphography using indocyanine green (ICG)-enhanced fluorescence to perform lymphatic-sparing laparoscopic Palomo varicocelectomy. PATIENTS AND METHODS: The records of 103 patients who underwent laparoscopic left varicocelectomy from March 2018 to April 2023 were retrospectively evaluated. The average patients' age was 13.7 years (range: 12-16). High-degree varicocele was associated with left testicular hypotrophy, and symptoms were present in all patients. At the beginning of our experience, in 41 cases, we injected 2 mL of ICG solution into the testis, then we reduced the amount of ICG solution to 1 mL, having the same results. The lymphatic vessels were clearly identified and spared, then the entire spermatic bundle was clipped and divided according to Palomo's principle. RESULTS: We reported no conversions to open surgery and no adverse reactions induced by ICG. The average operative time was 18 minutes (range: 10-35). We performed clinical evaluations at 1 week, 1 month, 6 months, 1 year, and 2 years after surgery, and Ultrasound (US) was performed at 1 and 2 years postoperatively. In 3 patients, we discovered a small calcification due to the injection of the dye inside the testis; for this reason, we reduced the amount of ICG from 2 to 1 mL with the disappearance of this problem. No recurrence of varicocele or postoperative hydrocele was recorded. CONCLUSIONS: Our 5-year experience showed that the intratesticular injection of ICG and use of fluorescence vision allowed identification of lymphatic. ICG fluorescence lymphography is a safe and effective option to perform lymphatic-sparing laparoscopic Palomo varicocelectomy in children and adolescents with high-degree varicocele. No allergy to ICG or postoperative hydrocele was reported in our experience. It is preferable to inject 1 mL of ICG solution in the testis to avoid the risk of having small calcification in the testis at US controls.

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