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Varicocele

SECTION II – PROCEDURES TO IMPROVE SPERM PRODUCTION


VARICOCELE
Introduction
 It is found normally in
o 15% of general population
o 35 - 40% of men with primary infertility
o 70 - 81% of men with secondary infertility
 Therefore, varicocele is the most surgically correctable cause of male infertility.
 15% of the normal male population and in up to 40% of patients with male infertility
 World Health Organization reported that varicoceles were found in 25.4% of men with abnormal
semen parameters compared with 11.7% of men with normal semen.
Natural history
 Varicocele is a/w progressive and duration-dependent decline in testicular function - impaired
semen quality and decreased Leydig cell function. Varicocele repairs have been shown to
improve not only spermatogenesis but also Leydig cell function.
Grading of Varicocele
 I - Palpable only with the Valsalva maneuver
 II - Palpable without the Valsalva maneuver
 III - Visible through the scrotal skin
 On scrotal US – dilated veins > 3.5 mm
Subclinical varicoceles
 Diagnosed only on USG
 Studies have demonstrated that subclinical varicoceles have no impact on fertility and that
repair of subclinical varicoceles does not improve fertility rates.
Four indications for treatment in adult men
 The couple has known infertility
 The female partner has normal fertility or a potentially treatable cause of infertility
 The varicocele is palpable on physical examination, or if it is suspected, the varicocele is
corroborated by ultrasound examination
 The male partner has an abnormal semen analysis
Indication of treatment in adolescent men
 Reduction in ipsilateral testicular size, otherwise observation and /or semen analysis.
Varicocelectomy
 Ligation of all internal spermatic veins to prevent the retrograde flow of blood
 Most commonly performed operation for treatment of male infertility
 Repair of varicocele will halt any further damage to testicular function and, in a large percentage
of men, result in improved spermatogenesis, as well as enhanced Leydig cell function.
 Repair of larger varicoceles results in significantly greater improvement in semen quality than
does repair of smaller varicoceles.
Techniques:
 Scrotal (Not done now a days)
 Retroperitoneal (Palomo)
 Conventional Inguinal
 Laparoscopic
 Radiographic Occlusion
 Microsurgery: (Preferred)
o Inguinal
o Subinguinal

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Varicocele

Incisions

Scrotal
 Now obsolete due to increased risk of testicular artery injury & high failure rate.
 Scrotal operations are to be avoided because damage to arterial supply of testis  testicular
atrophy  further impairment of spermatogenesis and fertility
Retroperitoneal (Palomo)
 Incision at level of internal inguinal ring.
 Retroperitoneal (open or laparoscopic) – high ligation of internal spermatic vein above internal
inguinal ring & preserving the internal spermatic artery
 Steps: Incision at level of internal inguinal ring  splitting of external and internal oblique
muscles  exposure of internal spermatic artery and vein retroperitoneally near ureter.
 Still a commonly employed method especially in children.
 The operation involves working in a deep hole. Because at this level the internal spermatic
vessels cannot be delivered into the wound, they must be dissected and ligated in situ.
 Advantage:
o Isolates internal spermatic veins proximally, near the point of drainage into left renal
vein. At this level, only one or two large veins are present.
o In addition, the testicular artery has not yet branched and is often distinct from internal
spermatic veins.
o Involve ligation of fewest number of veins,
 Disadvantage
o High incidence of recurrence, especially in children and adolescents, when the testicular
artery is intentionally preserved. (~11 - 15%)
o Identification and preservation of 1.0 to 1.5 mm testicular artery is difficult, especially in
children (artery is small)
o Difficulty in identifying and preserving lymphatics - postoperative hydrocele formation ~
7% to 33%
 Failure is usually due to
o Preservation of periarterial plexus of fine veins (venae comitantes) along with artery.
They communicate with larger internal spermatic veins  may dilate  recurrence.
o Less commonly, due to parallel inguinal or retroperitoneal collaterals.
o Dilated cremasteric veins, another cause of recurrence, cannot be identified with a
retroperitoneal approach.
 Recurrence can be markedly reduced by intentional ligation of testicular artery. This assures
ligation of the periarterial fine veins. Effect of artery ligation, in children, on subsequent
spermatogenesis is uncertain. In adults, bilateral artery ligation  occasional azoospermia and
testicular atrophy.

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Varicocele

Laparoscopic
 Essentially a retroperitoneal approach
 Many advantages and disadvantages are similar to open retroperitoneal.
 internal spermatic vessels and vas deferens can be clearly visualized.
 Magnification allows visualization of testicular artery.
 With experience, lymphatics may be visualized and preserved as well.
 Internal spermatic veins are ligated at same level as in Palomo approach.
 Lap varicocelectomy allows preservation of testicular artery and lymphatics
 The incidence of recurrence ~ similar to open
 These recurrences would be due to collaterals joining the internal spermatic vein near its
entrance to the renal vein, or entering the renal vein separately.
 Recurrence rate of 2.9% to 4.5% (up to 17%)
 An artery ligation but lymphatic-sparing laparoscopic technique has markedly reduced the
incidence of postoperative hydrocele formation in children
 Potential complications of laparoscopic varicocelectomy (injury to bowel, vessels or viscera, air
embolism, peritonitis) are significantly more serious than those associated with the open
techniques
 Furthermore, laparoscopic varicocelectomy requires GA
 The microsurgical techniques can be performed using LA/RA and employ an incision of 2.5 to 3
cm for U/L. This is equal to or less than the sum of incisions employed for a laparoscopic
approach.
 Postoperative pain and recovery from laparoscopic technique = Subinguinal varicocelectomy
 Laparoscopic varicocelectomy is less cost-effective than open
 It is a reasonable alternative for the repair of bilateral varicoceles in hands of experienced
surgeons
Conclusion Lap Approach
 Excessively invasive for what should be a minor outpatient procedure.
 Recurrence rate of less than 2%
 Formation of hydrocele in 5% to 8% of patients.

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Varicocele

Microsurgical
 Inguinal & Subinguinal
 Preferred approaches
 Less morbidity a/w subinguinal (infrainguinal) Vs. laparoscopic and inguinal - because of
preservation of muscle layers and inguinal canal.
 However, a greater number of internal spermatic veins and arteries lie below the external ring,
making this procedure technically more challenging
Inguinal (External Oblique Opened) versus Subinguinal (Fascia Intact) Varicocelectomy: Indications
Inguinal Subinguinal
1. Children or prepubertal adolescents 1. Prior inguinal surgery
2. Solitary testis 2. Obesity
3. Tight, low external ring 3. Lax, capacious external ring
4. Short cord, high-lying testis 4. High external ring
5. Less experienced with microsurgical repair 5. Long cord with low-lying testis
6. Very experienced with microsurgical repair

Inguinal (Ivanessivich)
 Inguinal incision above ext. ring with ligation of dilated veins
 If the decision is made to perform an inguinal operation, and thus to open the fascia, the incision
is begun at the external ring and extended laterally 2 to 3.5 cm along Langer lines.
 If an inguinal approach is selected, external oblique aponeurosis is cleaned and opened the
length of the incision to the external inguinal ring in the direction of its fibers. 3-0 absorbable
suture placed at the apex of external oblique incision. Spermatic cord is grasped with a Babcock
clamp and delivered through the wound he ilioinguinal and genital branches of the
genitofemoral nerve are excluded. Cord is then surrounded with a large Penrose drain
 Disadvantage: Testicular Artery to vein adherence in 50%; hydrocele formation
Subinguinal approach
 Preservation of muscles & inguinal canal
 If the operation is to be performed subinguinally, the incision is placed in the skin lines just
below the external ring.
 Before making the incision, the location of the external inguinal ring is determined by
invagination of the scrotal skin
 Size of incision is determined by the size of the testis
 Atrophic testes can be delivered through a 2- to 2.5-cm incision
 Large testes require a 3-cm incision.
 The incision is made within Langer lines to minimize scarring.
 If a subinguinal incision was made, Camper and Scarpa fascia are incised  index finger into the
wound and along the cord into the scrotum  index finger is then hooked under external
inguinal ring, retracting it cephalad  A small Richardson retractor  retracted caudad over the
cord toward the scrotum  spermatic cord will be revealed between the index finger and

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Varicocele

retractor  assistant grasps the cord with a Babcock clamp and delivers it through the wound 
The cord is surrounded with a large Penrose drain.
 Disadvantage = greater number of veins & art. lie below ext. ring. Next - see figure

 Magnification is increased to 10
to 25 power and, after irrigation
with 1% papaverine solution, cord
is inspected for presence of
pulsations revealing location of
testicular artery.
 Micro-Doppler is extremely useful
 Once the testicular artery is
identified, it is dissected free of all
surrounding tissue, tiny veins, and
lymphatics using a fine-tipped
nonlocking micro needle holder
and microforceps.
 Artery is encircled with a vessel
loop for positive identification
and gentle retraction
 In approximately 50% of cases the
testicular artery is adherent to the
undersurface of a large vein

All external spermatic veins are identified and At the completion of dissection, only testicular
doubly ligated with hemoclips and divided arteries, cremasteric arteries, cremaster muscle
fibers, nerves, lymphatics, and vas deferens with
its vessels remain.

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Varicocele

Radiographic Occlusion Techniques


Intraoperative Venography
 Intraoperative venography has been tried to visualize the venous collaterals.
 Reduces the incidence of varicocele recurrence
 But 2D view often does not enable the surgeon to identify location of all collaterals
Percutaneous Embolization – (Radiographic balloon or coil occlusion of internal spermatic veins)
 Performed under LA through a small cut-down incision over femoral vein (or IJV).
 Embolization of spermatic veins – coils/ balloons/ sclerotherapy.
 Overall success rate – 68%.
 Indication
o Recurrent or persistent varicocele, when anatomy causing the varicocele needs to be
radiographically clarified.
 Recurrence
o Recurrence rate after balloon # was originally 11% (more recently = 4%)
o Failure to successfully cannulate small collaterals and external spermatic veins results in
recurrence.
o Placement of a balloon/coil is successful in 75-90% attempts.
o  significant number undergoing radiographic occlusion will ultimately require a surgical
approach.
 Disadv - Takes 1-3 hours to perform (vs. 25-45 minutes for open).
 Serious complications (Rare)
o Migration of the balloon or coil into the renal vein, resulting in loss of a kidney
o pulmonary embolization
o femoral vein perforation or thrombosis
o anaphylactic reaction to radiographic contrast medium
Antegrade scrotal sclerotherapy via cannulation of a scrotal vein (Europe)
 Recurrence rate is similar to balloon or coil
 Long-term follow-up is not available
 Larger the varicocele, the higher the failure and recurrence

Results of Varicocelectomy
 Studies have shown that repair of varicoceles can retard further damage to testicular function .
 Significant improvement in semen analysis in 60% to 80%.
 Improves not only semen motility, density and morphologic features, but also serum FSH and
testosterone levels.
 No difference noted b/w laparoscopic & open approach, but higher c/c in laparoscopic group.
 Reported pregnancy rates after varicocelectomy vary from 20% to 60%. RCT of surgery vs. no
surgery  pregnancy rate @ 1 year = 44% in surgery group vs. 10% in controls.
 Microsurgical varicocelectomy results in return of sperm to ejaculate in upto 60% of
azoospermic men with palpable varicoceles.
 The results of varicocelectomy are also related to the size of the varicocele. Repair of large
varicoceles results in a significantly greater improvement in semen quality than repair of small
varicoceles. Overall pregnancy rates are similar regardless of varicocele size.
 Younger the patient is at the time of varicocele repair, the greater the improvement after repair
and the more likely the testis is to recover from varicocele-induced injury.
 Varicocele recurrence, testicular artery ligation, or postvaricocelectomy hydrocele formation are
often a/w poor postoperative results
 In infertile men with low serum testosterone levels, microsurgical varicocelectomy alone
results in substantial improvement in serum testosterone levels

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Varicocele

Predictors of successful repair


 Sperm concentration > 5 million/ml or density > 50 million per ejaculate.
 Lack of testicular atrophy.
 Sperm motility of 60% or more.
 Serum FSH values less than 300 ng/mL (normal = 50 to 300 ng/mL)

Complications of Varicocelectomy
Technique Artery Hydrocele (%) Failure (%) Potential for
preserved Serious morbidity
Retroperitoneal No 7 15-25 No
Conventional inguinal No 3-30 5-15 No
Laparoscopic Yes 12 3-15 Yes
Radiographic Yes 0 15-25 Yes
Microscopic Yes 0 1.0 No

Cost Effectiveness
 Probability of a live birth after a varicocelectomy was 29.7% versus 25.4% after IVF-ICSI.
 The cost per delivered baby was $26,268 after varicocelectomy compared with $89,091 with IVF-
ICSI.

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