Vernihora D. Optimization of Diagnostic and Surgical Treatment of Varicocele in Children and adolescent (Clinical Study)

The aim of the dissertation was to improve the results of varicocele diagnosis and treatment by applying NIRS (Near-infrared spectroscopy) research and additional contrast visualization of vascular structures in children with varicocele. The study reflects the results of our own observations of instrumental, laboratory, and clinical research of patients and their surgical treatment. Inclusion criteria for the study were: boys under 18 years of age; verified diagnosis of grade III varicocele in combination with intermittent pain in the ipsilateral testicle or testicular atrophy of more than 20% compared to the contralateral side; the presence of signed informed consent from parents and patients for surgical intervention. Exclusion criteria from the study were: presence of aorto-mesenteric compression; varicocele caused by abdominal masses or tumors; May-Thurner syndrome; isolated grade III varicocele. Patients who reached the age of 16 and expressed the desire, and after obtaining informed consent from the child and parents, underwent a spermogram for diagnosis verification. To verify the diagnosis, the following methods were applied: physical examination of the scrotum with and without Valsalva maneuver in both vertical and horizontal positions, ultrasound examination (US) of the scrotum with Doppler mapping in horizontal and vertical positions with and without Valsalva maneuver, and spermogram for patients over 16 years old (n=41). Scientific novelty: For the first time, NIRS methodology has been applied to determine the hemodynamic state of the testes in diagnosing varicocele in children, where significant differences in rSO2 indicators were found between a healthy testicle (60% - 50%) and a pathological one (41%). For the first time, based on determining the diagnostic value of parameters of near-infrared spectroscopy, predictors of early preclinical testicular damage in varicose veins of the spermatic cord have been identified. ROC analysis results showed that a difference in NIRS indicators greater than 4% may serve as a diagnostic criterion for impaired testicular blood flow due to spermatic cord venous enlargement. A correlation was established between diagnostic criteria for assessing the structural state of the testicle in boys with varicocele at stages of surgical treatment. The Δ rSO2 parameter was identified as a diagnostic criterion for choosing varicocele treatment tactics, confirming its significance in determining testicular hypotrophy and spermogram abnormalities: values greater than 13% may indicate testicular hypotrophy, and values greater than 11% may indicate spermogram abnormalities associated with oxidative stress. Contrast enhancement of lymphatic vessels was first applied during microsurgical subinguinal access by introducing methylene blue under the testicular membrane in children. It was proven that the use of the developed diagnostic-treatment algorithm, based on the results of diagnosing and treating varicocele in children, improved treatment outcomes by reducing complications by 5.8%. Practical significance: It has been established that near-infrared spectroscopy is a safe and informative examination complex for patients with varicocele during observation and surgical treatment stages, allowing for the initiation of surgical treatment before visible changes in testicular size occur. A difference in NIRS indicators greater than 4% indicates impaired testicular blood flow due to spermatic cord venous enlargement. Values greater than 13% may indicate testicular hypotrophy. A differential approach to surgical treatment tactics has been developed and implemented in the work of the urological ward based on hemodynamic changes in testicular parenchyma in children with varicocele. Subinguinal microsurgical varicocelectomy with modified lymphatic structure contrast enhancement has been developed and implemented in the work of the urological ward, reducing the overall complication rate by 5.8%.