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  • one of my friend has a vasionable varicocel and coplaining while he setting to the chair he fell pain he says that after surgery opration you mentioned that 20% of the cases it will next so how long does it takes to recurrent. do sperm count go up after surgery opration. thanks. dr khalil elaj
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  2. 2. NORMAL ANATOMYOF PAMPINIFORM PLEXUS Union of multiple spermatic veins frm back of testis and epididymis. Ascend along cord infront of the ductus deferens below the superficial inguinal ring.They unite to form 3-4 veins--inguinal canal—enter abdo thru deep ring--forms 2 veins which unite—testicular vein-- IVC—acute. Drain from testes,epididymis and vas deferens-drain into spermatic veins Left spermatic vein drains into renal vein and right spermatic into inferior vena cava and then into the rt renal vein.
  4. 4. What is varicocele? Dilatation and tortuosity of the pampiniform plexus and so also of the testicular veins. Seen commonly in men aged 15-30yrs and rarely after 40yrs. Occur in 15-20% of all males and 40% of all infertile males. Normal small vessels of plexus- 0.5-1.5mm. Diameter greater than 2mm- Varicocele.
  5. 5.  Seen commonly on the left side –5 reasons. -longer -enters at right angle to the renal vein -left testicular artery arching over it -a loaded sigmoid colon. - compressed b/w the aorta and SMA.
  6. 6. Aetiology and types 1.IDIOPATHIC/PRIMARY – due to incompetency of valves. 98% occur on the left side. 2.SECONDARY- pelvic or abdominal mass. - L renal cell carcinoma with tumor thrombus in left vein. -Nutcracker syndrome- SMA compressing left vein. Common conditions- RCC, Retroperitoneal fibrosis or adhesions.
  7. 7. CLINICAL FEATURES Swelling Dragging /aching pain in the groin and scrotum “ bag of worms” feeling Scrotum on the affected side hangs down. On lying down,it gets reduced. Bow sign- hold varicocele b/w thumb and fingers,patient is asked to bow-reduced in size.
  8. 8.  Cough impulse present Long standing cases- affected side testis is reduced in size and softer. Fertility problems.
  9. 9. Varicocele and subfertility Altered heat exchange mechanism due to stagnation- hyperthermia-inhibition of spermatogenesis. Increased temperature-increased metabolic activity-depletion of glycogen storage-injury of parenchyma of testis-oligospermia. Hypoxia, Leydig cell dysfunction-low testosterone. Maturation arrest-poor spermatogenesis.
  10. 10. INVESTIGATIONS Venous doppler of the scrotum and groin- -standing/ valsalva’s manouevre. U/S abdomen to look for kidney tumours. Semen analysis
  11. 11. GRADING 1.SMALL - identified only by bearing down i.e, an increase in abdominal pressure. 2.MODERATE - identified by palpation w/o bearing down. 3.LARGE - easily identifed by inspection alone. 4.SEVERELY TORTUOUS.
  12. 12. INDICATIONS FOR SURGERY American Urological Society recommends that varicocele treatment should be offered to the male partner of a couple attempting to conceive when all of the following are present. A varicocele is palpable. The couple has documented infertility. The female has normal fertility or potentially correctable infertility. The male partner has one or more abnormal semen parameters or sperm function test results.
  13. 13.  The indications in adolescents- presence of significant testicular asymmetry (>20%) demonstrated on serial examinations, testicular pain, and abnormal semen analysis results. Very large varicoceles may also be repaired; however, in the absence of atrophy, this indication is relative and controversial .
  14. 14. TREATMENT 3 SURGICAL AND 1 NON SURGICAL PROCEDURE. VARICOCELECTOMY- The most common approaches are inguinal (groin)-easier and safer. retroperitoneal (abdominal) infrainguinal/subinguinal (below the groin), suprainguinal extraperitonial( Palomo’s operation), Scrotal approach- grade 4.
  15. 15.  Done in GA or spinal. 2-3 inch incision. Ligate the offending veins. Avoid strenuous exercise for several days after surgery. Apply scrotal support.
  16. 16. Complications 20% chance of recurrence. 5% chance of hydrocele Damage to testicular artery. Infection. hematoma
  17. 17. 2. MICRODISSECTION Microsurgery (also called microsurgical ligation) smaller incision is made. Cut the skin and fatty tissue. Because muscle is not cut-less pain and faster recovery. The doctor identifies the varicoceles (swollen veins) through an operating microscope. Large varicoceles are cut and stapled closed. Smaller varicoceles are cut and stitched shut. Takes less than an hour and recovery time is short. Higher success rate,fewer complications,smaller scar.
  18. 18. 3.LAPROSCOPY Similar to conventional surgery. Incision made on abdomen. High ligations required. Larger incision or more retraction needed. Complications more- testicular artery injuryy and hydrocele.
  19. 19. IV. Coil Embolization, Radiologic Balloon Occlusion or Radiologic Ablation Non-surgical procedure. Steel coil or silicone balloon catheter is introduced into a vein below the groin through a nick in the skin. Passed under X-ray guidance. Tiny metal coils or other embolizing agents introduced through the catheter.
  20. 20.  No stitches needed. Patient can go back in 24hrs. Lower rates of complications. Disadv- less effective, higher recurrence(5- 11%), danger that the coil could migrate to the heart and cause death .
  21. 21. CONTRAINDICATIONS Subclinical varicocele in an infertile person- controversial. discovery of a varicocele at the time of vasectomy or vasectomy reversal-relative contraindication to immediate repair. A 6-month delayed repair is recommended -to allow the development of collateral vessels to decrease the chance of vascular compromise to the testicle.