16. varicoceles
TRANSCRIPT
Varicoceles
Xiang Wang, M.D., Ph.D.
Prof. of Urology
Department of Urology
Huashan Hospital
Fudan University
E-mail: [email protected]
Varicocele
dilatation of the pampiniform venous plexus and the internal spermatic vein
well-recognized cause of decreased testicular function
very rare < 9 y.o.
~16% of adolescents
~15-20% of all males
40% of infertile males
scrotal varicoceles are the most common cause of poor sperm production and decreased semen quality
Varicoceles are present in 15% of the normal male population and in up to 40% of patients with male infertility ( Nagler and Martinis, 1997 ). In approximately 70% of patients with secondary infertility, a varicocele is an underlying cause ( Witt and Lipshultz, 1993 ).
The World Health Organization concluded that varicoceles are clearly associated with impairment of testicular function and infertility.
Campbell-Walsh Urology, 9th ed.
Varicocele and infertility
Varicoceles have been associated with impaired semen quality and decreased Leydig cell function, and this impairment has been shown to be progressive in nature.
A varicocele is now recognized as the most surgically correctable cause of male infertility, and a varicocele repair is the most commonly performed surgical procedure in treatment of male infertility.
Campbell-Walsh Urology, 9th ed.
The prevalence of varicocele and
associated testicular hypotrophy by age
Age, years Prevalence, %
of varicocele hypotrophic testis
<11 0 0
11–14 6–8 7.3
15–19 11–19 9.3
History
first recognized as a clinical problem in 16th century
relationship between infertility and varicocele proposed in late 19th century, thereafter, others reported association with arrest of sperm secretion and the subsequent restoration of fertility following repair
enlarged scrotal veins in teenagers referenced as early as 1885
History
1950s report of fertility following varicocele repair in an individual known to be azoospermic surgical correction as clinical approach to certain
kinds of male infertility gained support among American surgeons
Continued research documented recurrent pattern of low sperm count, poor motility, and predominance of abnormal sperm forms (stress pattern of semen) not specific to varicocele
suggests early evidence of testicular damage
Varicocele
80-90% involve the left testicle
anatomic factors (1) angle at which left testicular vein enters left renal vein
(2) lack of effective antireflux valves at juncture of testicular vein and renal vein
(3) increased renal vein pressure due to compression between the superior mesenteric artery and the aorta (ie, nutcracker effect)
35-40% of men with palpable left varicocele may actually have bilateral varicoceles
Recent study by Gat et al ~ 80% of men with a left clinical varicocele had bilateral varicoceles revealed by noninvasive radiologic testing
Varicocele Presentation
Scrotal mass/swelling, symptoms of acute or chronic scrotal discomfort, differing testicular sizes without a palpable variocele, and incidental finding on scrotal US
Grading: Grade 0 - Subclinical varicocele, Dx by US or venography
Grade 1 – palpable with Valsalva maneuver
Grade 2 - Easily detected without Valsalva maneuver
Grade 3 - Detected visually at a distance
Varicocele Presentation
Most asymptomatic
usually unilateral and almost always left-sided unilateral right-sided varicocele should prompt
investigation for retroperitoneal process mass that causes obstruction of the right internal spermatic vein
Thrombosis/occlusion of the inferior vena cava must be ruled out
Situs inversus another etiology of right-sided varicocele
Initial presentation usually occurs during puberty, with incidence in 13-year-old adolescent boys equal to that of adult men
Varicocele
Multiple investigators have directly
correlated the degree of testicular atrophy
with varicocele grade
Steeno et al testis volume reduced by 81%
with grade 3 and by 34% with grade 2
No patients with grade 1 had testicular atrophy
Pathophysiology
Unknown how impairment of sperm structure, function, and production occurs interference with thermoregulation
other theories include the possible effects of pressure, oxygen deprivation, heat injury, and toxins Despite considerable research, no one theory proved
unquestionably
Regardless, indisputably a significant factor in decreasing testicular function and in reducing semen quality in large percentage of men seeking infertility treatment
Histology
Histologic studies seminiferous tubule
sclerosis, small vessel degenerative
changes, and abnormalities of Leydig,
Sertoli, and germ cells
changes have been documented in patients
as young as 12 years
Management
Presence of a varicocele does not necessitate surgical correction
Indications for surgical correction Relief of significant testicular discomfort or pain not
responsive to routine symptomatic treatment
testicular atrophy (volume difference >20% or > 2cc)
possible contribution to unexplained male infertility
varicocele may cause progressive damage to testes, resulting in further atrophy and impairment of seminal parameters
Management
The AUA Male Infertility Best Practice Policy Committee recommends treatment be offered to the male partner when all the following are present: varicocele is palpable
couple has documented infertility
female has normal fertility
one or more abnormal semen parameters or sperm function test results
men who have a palpable varicocele and abnormal semen analyses findings but are not currently attempting to conceive should also be offered varicocele repair
Management
No strict criteria necessitate surgical intervention in adolescents
Each case handled individually discussion among patient, parents, and physician regarding risks
of intervention and potential impact on future fertility
general guidelines used by some pediatric urologist include the presence of one or more of the following: Varicocele associated with decreased ipsilateral testicular size
(20% volume deficit in the involved testis)
Bilateral varicoceles
Symptomatic painful varicocele
Abnormal findings on semen analysis
2010 EAU guideline: adolescent
Varicocele treatment is recommended for adolescents
who have progressive failure of testicular development
documented by serial clinical examination.
Varicocele
Lipshultz and Corriere (1997) suggested that varicoceles were associated with
testicular atrophy that was progressive with age
observed that testicular biopsy specimens taken from prepubertal boys with varicoceles already revealed histologic abnormalities
Kass and Belman (1987) first to demonstrate significant increase in testicular
volume after varicocele repair in adolescents
did not study semen parameters
Surgical Management
ideal technique is to ligate all of the internal and external spermatic veins with preservation of spermatic arteries and lymphatics
internal spermatic artery may be divided with transperitoneal or retroperitoneal approach does not usually cause testicular atrophy due to generous
collateral circulation to testicle
3 most common surgical approaches inguinal
Retroperitoneal
subinguinal
Subinguinal
Incision made over external ring at or near the pubic tubercle obviates the opening of the external oblique aponeurosis
Dilated cremasteric veins ligated
Spermatic cord opened spermatic veins in pampiniform plexus separated and ligated
any dilated veins that accompany the vas deferens also ligated
Microscopic subinguinal approach
Operating microscope used to dissect out and preserve the testicular arteries and lymphatic vessels
Some advocate delivering testicle into wound and ligating external spermatic and gubernacular veins
recurrence rate 0-2%, complication rate 1-5%
Inguinal
Incision made over course of inguinal canal
Ligation of cremasteric, deferential, and
spermatic veins performed with arterial
preservation
Microscope may be used as well
Retroperitoneal
Low abdominal incision above internal ring
High ligation performed of entire spermatic pedicle (Palomo procedure)
testicular artery–sparing procedure performed by opening the spermatic fascia to identify and preserve the artery
Laparoscopic-assisted retroperitoneal approach
Artery may be spared
lengthens the procedure
higher recurrence rate (6-15%)
due to inguinal and retroperitoneal collateral veins, failure to ligate fine periarterial veins when testicular artery preserved
20% incidence of hydroceles at 6 months if lymphatics not preserved
Embolization/Sclerotherapy
Percutaneous Embolization
Least invasive means of varicocele repair
Internal spermatic vein accessed via cannulation of femoral vein balloon and/or coil occlusion of varicocele
failure rate of up to 15%
Antegrade sclerotherapy
success rate is > 90%
hydroceles are not a complication
Conclusions
Most methods of varicocelectomy result in similar short-term results
Open microsurgical inguinal or subinguinal techniques in adults shown to cause fewer recurrences and complications
Given that efficacy all techniques is nearly equivalent, attention must be paid to the morbidity of the individual procedure and expertise of the operating surgeon
Complication Rates Associated with
Different Varicocele Repairs
Technique
Artery
Preserved
Hydrocele (%) Recurrence (%)
Retroperitoneal No 7 11-15
Conventional inguinal No 3-39 9-16
Laparoscopic Yes 5-8 <2
Radiographic Yes 0 4-11
Microscopic inguinal or
subinguinal
Yes 0 <2
Campbell-Walsh Urology, 9th ed.
Chan P. Indian J Urol. 2011;27(1):65-73.
Follow Up
Check patient's semen 3-4 months after
surgery if done for infertility
spermatogenesis requires approximately
72 days
any effects from varicocele repair on semen
parameters are delayed
Considerations
Vasectomy after mass ligation
varicocelectomy likely to result in testicular
atrophy
Further supports artery-sparing technique
Thanks for your attention.