Results of Adults Laparoscopic Varicocelectomy in a Limited Setting: A Study in Yaoundé (Cameroon)

Background: Varicocele is an abnormal dilation and tortuosity of the internal spermatic veins within the pampiniform plexus veins draining the testicle. The principle of varicocele treatment is to block the reflux in the internal spermatic vein while preserving the internal spermatic artery, lymphatics and vas deferens. Treatment can be performed through percutaneous venous embolization or surgical correction, either open or laparoscopic approach. The purpose of the study was to review our experience in the management of laparoscopic varicocele repair and to assess the outcomes after operation. Methods: We retrospectively reviewed files of patients who underwent laparoscopic varicocelectomy from January 2010 to December 2009 in three health center of Yaoundé (Cameroon). Clinical and diagnosis features of varicocele, indication for surgery, operative procedure and outcomes, as well as long-term follow-up of were analyzed. Results: A total of 74 file of patients were collected. The average age of patients was 36.93 years old. Among them, 43 (58.11%) had varicocele grade 1, 21 (28.38%) grade 2, and 2 (2.70%) grade 3. rence and hydrocele in 1 case (1.35%), symptoms’ regression in 87% of cases and pregnancy in 65.9% of cases of infertility. Conclusion: Laparoscopic varicocelectomy is feasible and safe in our setting, with good results. We emphasize this approach in even in low setting like our own.


Introduction
Varicocele is an abnormal dilation and tortuosity of the internal spermatic veins within the pampiniform plexus veins draining the testicle. It can result in testicular discomfort, atrophy, infertility, and possibly hypogonadism [1]. Varicocele represents the most common surgically treatable cause of male infertility worldwide and is found in approximately 15% of all adult males and 40% of males presenting for infertility evaluation [2]. The clinical grading system defines varicoceles as grade 0 (subclinical): nonpalpable and visualized only by color doppler ultrasound; grade 1: palpable only with Valsalva maneuver; grade 2: easily palpable but not visible; and grade 3: easily visible. There is abundant evidence that a varicocele may alter testicular growth, spermatogenesis, and fertility potential.
The cause of testicular injury is presumed to be related to increased scrotal temperature, but the pathogenesis remains poorly understood. Observation remains the approach of choice for the majority of adolescents with varicocele until a surgical indication is present. Despite the aforementioned limitations regarding testicular hypotrophy, the main indications for surgical intervention remain significant left (≥20%) or bilateral testicular hypotrophy, pain, or abnormal semen analysis findings [1]. Several approaches exist to correct the varicocele: inguinal or subinguinal, laparoscopic or retroperitoneal, or venographic. The laparoscopic varicocele, introduced by Sanchez-de-Badajoz et al. in 1990 utilises a transperitoneal intra-abdominal approach, which offers several advantages including increased efficiency for bilateral surgery and relatively short operating times [3]. However, this approach is an intra-abdominal procedure and carries a small added risk for complications, e.g. visceral injury from trocar placement [3]. Laparoscopic varicocelectomy in an uncommon procedure in low setting where open approaches are still commonly practice. We present our experience and outcomes of laparoscopic varicocelectomy in three health structures in Yaoundé, Cameroon.

Statistical Analysis
For each patient, we recorded data, on demographics, clinical symptoms, ultra-

Results
A total of 74 file of patients were collected.

Socio-Demographic Characteristics
The mean age was 36.93 ± 9.65 years old (range, 16 -69 years). Students are the most affected by this pathology at a frequency of 12.16% followed by traders in 8.11% of cases. Other occupations were estimated at less than 5% for each.

Operative Results
Dilated veins were simply clipped in 75.68% of cases. In the other cases (24.32%), dilated veins were sectioned after clipping. No intraoperative complications were recorded. The mean operative time was 31.9 ± 8.6 minutes (range, 16 -60 min).
All patients were discharged first day post-operative.

Outcomes
With a mean follow-up period of 27 months (range, 13 -108 months). Five

Discussion
The mean age of our patients was 36.93 ± 9.65. This result is comparable to that of Diao et al. in Senegal, which had an average age of 36.5 years [4]. It is a pathology that is rare before the age of 10 and therefore the incidence increases after this age [5]. On the other hand, in Morocco Benazzouz et al. [6] found a lower average age of 29.71 years. Students and traders were the most affected profession in our study. A study has shown that occupations that require prolonged standing may be risk factors for the occurrence of varicocele [7].
Our study found that infertility and scrotal discomfort were the most frequent complaints. These data do not correspond to those found by Diallo et al. [8] in Conakry. They showed that 80.7% of cases presented with infertility problem.
Scrotal pain and mass followed with 10.9% and 8.4% respectively. Indeed, the prevalence of varicocele in men presenting for infertility is in the range of 25% -35%, and in that subset of men with secondary infertility it is 50% -80% [9].
This could be related to the mentalities and habits of the populations of sub-Saharan Africa who consult only when they have a symptomatic health problem and are very little adept at the systematic health check. Moreover, it is estimated that the prevalence of pain with varicocele is around 2% -10% although, the association between varicocele and pain is not clearly established [10]. The average consultation time in our patients was 28.16 ± 33.58 months.
This confirms the fact that most people in sub-Saharan Africa consult late. Thus, the longer the consultation time, the more the disease is diagnosed at an advanced stage. Out of 74 patients, bilateral and grade 3 varicocele were prevalent.
These results are in total contradiction with the literature which finds the left side as the one that is most affected in 85% to 90% of cases. It is also reported that a right palpable varicocele is normally found in cases of bilateral varicocele [11]. Concerning the severity of varicocele, Diallo et al. [11] in their study revealed the following figures: on the right, grade 0 (50%), grade 1 (27.8%), grade 2 (22.4%); on the left, grade 3 (49.6%), grade 2 (33.61%), grade 0 (1.7%). On the other hand, a systematic review including 1299 men reported 32.1% of patients with varicocele grade 1, 67.9% with grade 2 and 3 [12]. This showed that varicocele is diagnosed at a more or less advanced. The delay in the consultation of patients could be an explanation for this situation in our study.

Surgical Technique
The main operative indication was infertility in 59.5% of cases. The common indications of varicocelectomy are infertility, testicular hypotrophy and pain [13]. This is supported by other studies [10] [14] this fact shows that the couple's infertility could be considered as a common health problem with varicocele as the main correctable cause. Concerning the operative technique, we have not found any particular recommendations in the literature with regard to the diameter of the operator trocars. On the other hand, two trocar operators in iliac fossa and supra pubic or iliac fossa were enough to perform this surgery. Despite the ad-  [17]. Our morbidity was of 5.4%. Recurrence and hydroceles rate in our study were 4% and 1.3% respectively. These findings are comparable to those of the literature who found post-operative recurrence rates varying from 3% to 6% and hydrocele rates ranging from 7% to 43% [18]. We found a symptom regression rate of 87%. This is similar to the 86% of success reported by Peterson et al. [19] however one study by Altunoluk et al. [20] showed that the regression of symptoms was function of the duration of the pain. The longer the symptoms last the pain regress after varicocelectomy. We noticed 29 (65.9%) pregnancies achieved. The spontaneous pregnancy rate after laparoscopic varicocelectomy varies from 13% to 40% [21].
Limitations of our study include its retrospective nature, subject to selection bias and missing data.

Conclusion
Laparoscopic varicocelectomy is feasible, safe and reproducible even in a low setting income like our own. Results are good with high rate of symptoms' regression, high rate of pregnancy recorded, low rate of recurrence and postoperative hydrocele. We emphasize the use of this approach in the surgical management of patients with varicocele.