in the name of god hassan jamshidian md imam khomeini hospital
TRANSCRIPT
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In the name of God
Hassan Jamshidian MD
Imam Khomeini Hospital
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Varicocele• Is found in:• 15% of the general population
• 35% of men with primary infertility
• 70-81% of men with the secondary infertility
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Definition
Abn. Tortuosity and dilatation of the testicular veins within
the spermatic cord
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varicocele
• The most correctable cause of male infertility
• Approximately 90% left sided
• 10% bilateral,some reports more
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Why is predominant in Lt. side?
• 1-Difference in the venous drainage
• 2-Absence of the venous valves is more common on the Lt side
• 3- The left renal vein may be compressed between the superior mesenteric artery and the aorta
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Varicocele & Infertility• 1-Temperature• 2-Reflux of the renal and adrenal
metabolites from the renal vein & hypoxia
• Decreased motility in 90% & count in 20%
• Stress pattern
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Varicocele-Grading
• Grade 1
• Grade 2
• Grade 3
• Grade sub clinical
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varicocele• Majoity of men with varicocele are
fertile• Normal gonadotropin and testosterone
level• Some elevated FSH• Abn. GnRH are often present in
adolescent and subfertile men with varicocele
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Whom should be repaired?
• 1-in infertility with any grade• 2-Adolescents with grade 2 or 3 with
ipsilateral testicular growth retardation
• The presence of a varicocele alone is not an indication for varicocele repair,because the majority of men with varicocele are fertile
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Repair of varicocele will halt any further damage to
testicular functionIn large percentage of men ,results in improved spermatogenesis(70%),
as well as enhanced Leydig cell function
Conception rate 40-50%
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Techniques of Varicocelectomy
Technique artery p. Hydc. Failure
-----------------------------------------------------------
Retropr. No 7% 15-20%
Inguinal No 3-30% 5-15%
Laparoscopic Yes 12% 5-15%
Microcopical Yes 0 1%
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Hydrocele
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Hydrocele-Definition
• The accumulation of fluid within the tunica vaginalis
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Hydrocele
•1-Communicating
•2-Simple
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Communicating hydrocele
• -Persistence of the processus vaginalis• Smaller in the morning• Frequently bluish hue in thin scrotal skin• Easy transillumination• Same anatomic defect in hernia• Congenital in origin• All should be explored through an inguinal
incision
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Simple hydrocele
• Caused by:
• 1-After varicocelectomy
• 2-Radiation
• 3-Testicular tumors
• 4-Orchio-epididymites
• 5-Trauma
• 6-Idiopathic(The most common)
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Ultasonography is the best method for diagnosis of the
hydrocele
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DD of Hydrocele• Cord cyst
• Spermatocele
• Tumor of the testis
• Hernia
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Hydrocelectomy
• 1-Excisional Technique
• 2-Plication Technique
• 3- Window operation
• 4-Dartos Pouch Technique• 5-Scleroplasty(Tetracycline derivatives)
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Comlications of hydrocelectomy
• Hematoma (the most common)
• Injury to the epididymis or the vas deferens
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Undescended Testis
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UDT classification
• Cryptorchid
• Ectopic
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Cryptorchid
• Intra-abdominal(retroperitoneal)
• Intracanalicular
• Extracanalicular(suprapubic or infrapubic)the most common
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Ectopic testis
• Misdiracted outside the normal path of descent
• Superficial inguinal (the most common)
• Transverse scrotal
• Femoral
• Perineal
• Prepenile
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UDT incidence• 3% of full term at birth• Unilateral is more common than bilateral• 30% in premature infants• Prevalent among small for age, low birth
weight, twin neonates• 70-77% descend spontaneously by 3 months
of age• By age 1 year ,incidence is 1% ,and remains
constant throughout adulthood
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In order for normal spermatogenesis to occur ,it is necessary for the normal testes to descend into the scrotum, a
specialized, low temp. environment that maintains a
temp. 2 to 3 F lower than core body temp.
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Theories of Descent and Maldescent
• Endocrine factors
• Gubernaculum
• Intra-abdominal pressure
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Consequences of UDT
• 1-Infertility
• 2-Neoplasia
• 3-Hernia
• 4-Testicular torsion
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UDT-neoplasia
• Incidence of test. Tumor in general population is 1 in 100,000,but in UDT is 1 in 2,550(40 times more)
• Orchiopexy does not reduce the cancer rate ,but can help in early diagnosis
• The most common type in UDT is Seminoma• The prevalence of carcinoma in situ is 1.7%
in UDT
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Diagnosis-UDT
• Laparoscopy
• CT
• MRIUltrasonography
• Testicular angiography or venography
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management-UDT
• Orchiopexy before or at 1 year of age
• Hormonal therapy(HCG, GnRH)
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UDT-surgical treatment
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Torsion of the spermatic cord and
testis
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Torsion
• Intravaginal
• Extravaginal
• Gold standard time 6 hours