Varicocele is an abnormal dilation & tortuosity of the internal spermaticveins within the pampiniform plexus of the spermatic cord.• Represents the most common cause of primary & secondary infertility in the male.• Varicoceles are present in 15% of normal males, 19% to 41% in men with primary infertility,& up to 81% of men with secondary infertility.
• Turbulent venous flow related to the insertion of the gonadal veins; either the left gonadal with a right angle into the left renal vein or the right gonadal directly into the IVC.• Incompetent or absent venous valves in the gonadal veins allow retrograde reflux of blood into the scrotum on standing.• The “nutcracker phenomenon” as the left renal vein may be compressed between the superior mesenteric artery and the aorta.
• The Presence of varicocele has a genetic background which is not necessarily related to the severity of the disease• Varicocele in adolescents is associated with thin tall body habitus• 90% of varicoceles are presented on the left side while the presence of large right side varicocele especially un-decopressible may indicate retroperitoneal or caval pathology such as renal neoplasms.
• Varicocele is associated with a progressive and duration-dependent decline in testicular function.1. Elevated intrascrotal temperature resulting in reductions in testosterone synthesis by Leydig cells, injury to germinal cell membranes, altered protein metabolism, & reduced Sertoli cell function.2. The free reflux of renal and adrenal metabolites from the left renal vein are directly gonadotoxic.3. Impaired venous drainage results in hypoxia, poor clearance of gonadotoxins, and elevated levels of oxidative stress.
• Despite having a congenital background it is not diagnosed before the age of 10 years.• Grade I: Small, detectable only during the Valsalva maneuver.• Grade II: Moderate, can be palpated without Valsalva.• Grade III: Large, visible through the scrotal skin & classically described as feeling like a “bag of worms”, & decompresses in supine position.• Sub-Clinical Varicoceles are those not detected clinically but diagnosed only detected by ultrasonography with or without doppler, radionucleotide scans, thermography & venography.
• Although clinical varicoceles do not require confirmation with ultrasound examination, color Doppler ultrasound may be required when the clinical examination is difficult.• Demonstration of reversal of venous blood flow with the Valsalva maneuver or spermatic vein diameters of 3 mm or greater support the diagnosis of varicocele.• Scrotal ultrasound is not recommended for screening for subclinical varicoceles as repair of these has not been demonstrated to be of clinical benefit.
• Venography of the internal spermatic veins has been used to diagnose and treat varicoceles• Although nearly 100% (Most Sensitive) of clinical varicocele patients will demonstrate reflux on venographic examination, left internal spermatic vein reflux has been reported in up to 70% of patients without a palpable varicocele. (High false positive results & Limited Specificity)• It does have utility in patients with presumed post-varicocelectomy recurrence both for confirmation of the diagnosis and embolization of persistent vessels.
1. Palpable varicocele on physical examination.2. Large varicoceles producing clinical symptoms such as dull hemiscrotal discomfort or sense of heaviness3. The couple has known infertility with the female partner has normal fertility or a potentially treatable cause of infertility.4. The male partner has abnormal semen parameters or abnormal results from sperm function tests.5. Adolescent males with unilateral or bilateral clinical varicoceles & ipsilateral testicular hypotrophy (20% or 3ml volume decrement from the contralateral testis)• Patients with subclinical varicoceles are not candidates for varicocele treatment due to lack of demonstrated efficacy in this population.• The various methods of varicocele treatment all involve ligation or occlusion of dilated gonadal veins.
• The very 1st approach for varicocele repair employed in the early 1900s• Involves mass ligation & Excision of the varicosed veins.• Not preferred practically due to the high incidence of testicular artery injury with subsequent impairment of the testicular blood supply, testicular atrophy & more impaired spermatogenesis & fertility.
Incision at the level of the internal ring near to the Anterior Superior Iliac Spine. Splitting of the External & Internal Oblique Muscles. Exposure of the Internal Spermatic Artery & Vein retroperitoneaelly near the ureter where only one or two large veins are present & the testicular artery is not yet branched & so easy to separate. High recurrence rate 15% due to preservation of the testicular artery & the peri-arterial venae comitatntes which communicates with the larger internal spermatic veins causing recurrence. Recurrence is prevented by intentional artery ligation, However it may cause testicular atrophy & subsequent azoospermia.
It is an essence retroperitoneal approach with similar advantages & disadvantages, including rate of recurrence. The internal spermatic veins are ligated with the laparoscope at the same level as the retroperitoneal approach with preservation of the testicular artery. The magnification provided by the laparoscope allows visualization of the testicular artery. With experience, the lymphatics may be visualized and preserved as well preventing secondary hydrocele formation. Additional possible complications include visceral & vascular injury, air embolism & peritonitis.
Allows access to external spermatic and gubernacular veins which causes recurrences if not ligated. Microsurgical varicocelectomies has resulted in marked decrease in the incidence of Secondary Hydrocele formation (compared to the conventional operations with average 7%) due to easy identification of lymphatics, Plus that identification of testicular artery helps avoiding azoospermia & atrophy
Small Testicular Artery Artery adherent to fasciaPrecious Testicular Artery Difficult Opening & Closure of fasciaBetter Dissection & fascia Better Exposure & Ligation of veinsClosure Easier in performance More Difficult in Performance
Incision• Inguinal: The incision begins at the external ring and extended laterally 2 to 3.5 cm along Langer lines.• Sub-Inguinal: The incision is placed in the skin lines just below the external ring.• Camper’s & Scarpa’s Fascia are divided, Superficial Epigastric Artery or Vein are retracted or ligated.
In the Inguinal Approach• The External Oblique aponeurosis is opened along the length of the wound in the direction of its fibers• Grasping of the spermatic cord & delivery of it through the wound to be surrounded with a penrose drain after sparing of the ilioinguinal nerve & genital branch of the genitofemoral nerve
In the Sub-Inguinal Approach• An index finger is introduced into the wound and along the cord into the scrotum then hooked under the external inguinal ring.• A Richardson retractor is slid along the back of the index finger and retracted over the cord toward the scrotum.• The spermatic cord will be revealed between the index finger and retractor, delievered & then surrounded with a large Penrose drain.
Dissection of the cord• The Internal & External Spermatic fascias are opened & the cord is inspected for pulsations of the testicular artery to be dissected away• The Cord veins are dissected starting with the large veins with taking care of possible adherant testicular artery (50% Possibility)
Dissection of the cord• All veins are then ligated (except the vasal veins to allow venous return) with 4-0 silk ligatures or cauterized if less than 1 mm.• After complete dissection only the testicular artery, cremasteric arteries, cremasteric muscle fibers, nerves, lymphatics and vas deferens with its vessels should remain.
Delievery of the Testis• Delivery of the testis through a small inguinal or subinguinal incision guarantees direct access to all veins close to the testes• Assiciated hydrocele (15%) can alter testicular tempreture regulation, so should be repaired if noticed with delivery of the testis followed by a tube drain for 24 hours.
Special Tools• The Magnification Microscope with 10-25 power magnification.• The Micro-Doppler is very useeful for identifiying the testicular artery.• The Automatic Clip Applier for ligation of the veins especially smaller veins.
• Scarpa and Camper fascia are re-approximated with a single or continuous 3-0 plain catgut suture, and the skin is approximated with a 5-0 monofilament absorbable subcuticular suture.• A scrotal supporter is applied and stuffed with fluff-type dressings.• The patient is discharged on the day of surgery with a prescription for Tylenol with codeine. Light work may be resumed in 2 or 3 days.
• Does not prevent recurrence (4% to 11%) but allows visualization of all collaterals difficult to be seen with the 2D view.• Drawbacks: 1) Take 1-3 hours to perform compared with 25 to 45 minutes required for surgical repair. 2) Femoral vein perforation or thrombosis 3) Anaphylaxis to radiographic medium 4) Recurrence with large varicoceles & with Failure to cannulate small collaterals 5) Migration of the balloon or coil into the renal vein, resulting in loss of a kidney, pulmonary embolization
• The most common complication with incidence 3 -33% (Average 7%).• With the high protein content proved to be due to lymphatic obstruction.• Creates an insulating layer around the testes impairing the efficiency of the counter-current heat exchange mechanism obviating the benefit of varicocelectomy.• The Use of Magnification helps good identification of lymphatics & preventing hydrocele formation.
• The testicular artery forms 2/3 of the blood supply to the testes (with the vasal & cremasteric arteries form the remaining 1/3).• Is 1-1.5 mm in diameter, adherent to a large spermatic vein (40% of men) & Surrounded by a network of tiny veins (20% of men).• Injury or ligation of the testicular artery carries with it the risk of testicular atrophy and/or impaired spermatogenesis. (which is less likely to occur in children due to compensatory neovascularization).• The Use of Magnification & Micro-Doppler helps good identification & Preservation of the testicular artery.
• The incidence of recurrence after varicocele repair varies from 0.6% to 45%• Recurrence is mostly associated with: 1. Pediatric Varicocele 2. Non-Magnified Operations 3. Retro-peritoneal approaches (that misses the parallel inguinal collaterals)
• Mean increases in sperm density of 9.7 million/mL, motility increases of 9.9%, sperm morphology improvement by 3% have been reported with improvement in semen quality in 51% to 78% of infertile men.• About 60% of Azoospermic patients with varicoceles have shown some potential for return of sperms to their semen after varicocele repair (Still requiring ART to obtain conception)
• Spontaneous pregnancy rates after varicocele treatment have been reported to average between 30% and 50% within about 8 months duration.• Recovery of testicular volume in adolescent patients, so called “catch-up growth,” has been reported to occur in up to 80% of boys with grade II or III varicoceles.• Treatment does not produce improvement in cases with underlying genetic abnormalities associated with subfertility.