Editing Varicocele

== Background ==

* '''Definition of a varicocele: abnormal dilation and tortuosity of the gonadal/internal spermatic veins within the pampiniform plexus'''

== Epidemiology ==

* '''Found in ≈15% of the general population, 35% of men with primary infertility''', and 75-81% of men with secondary infertility
** '''Prevalence of clinically diagnosed varicoceles in adolescents (8-16%) similar to prevalence in adults (15%)'''
** Adolescent varicocele may contribute significantly to the risk of subfertility in adulthood

== Pathogenesis ==

* '''The primary factors are believed to be:'''
*# '''Increased venous pressure in the left renal vein'''
*# '''Valvular incompetence of the gonadal vein at its junction with the left renal vein'''
*# '''Collateral venous anastomoses'''
* '''The “nutcracker phenomenon” (compression of the left renal vein between the aorta and superior mesenteric artery) may account for the varicocele in some boys'''
* '''A tall, thin body habitus (low BMI) is associated with varicoceles in adolescents and adults'''
* '''Solitary right varicoceles are rare. Should one be of abrupt onset, renal pathology such as tumour should be considered'''

== Grading ==

* '''Grade 0 (subclinical): non-palpable and visualized only by colour-doppler US'''
* '''Grade 1: palpable only with Valsalva maneuver but not visible on physical exam'''
* '''Grade 2: easily palpable but not visible on physical exam'''
* '''Grade 3: easily visible on physical exam'''

== Associated Pathologic Processes ==

* '''Can impair testicular growth and fertilty with a progressive and duration-dependent decline by interrupting counter-current heat exchange provided by pampinoform plexus, resulting in increased testicular temperature'''
*# '''Testicular growth'''
*#* “Catch-up” growth, defined as normalization of left relative to right testicular size, occurs in 32-83% of patients after varicocele repair
*#* '''Significant discrepancy between left and right testicular size remains the primary indication for varicocele correction'''
*# '''Fertility'''
*#* Reliable standards for semen quality based on Tanner stage or age do not exist
*#* '''Trends toward poorer sperm quality may be limited to a subset of affected males with varicocele'''
*#** '''Varicocle grade and postoperative testicular catch-up growth do not reliably predict ultimate semen quality'''
*# '''Hormonal Function'''
*#* '''LH and FSH levels are not consistently different in the presence or absence of varicocele in adolescents'''

== Diagnosis and Evaluation ==

* The vast majority of varicoceles in children and adolescents are identified incidentally
* '''History and Physical Exam'''
** '''Physical Exam'''
*** '''The patient should be examined in both the supine and standing positions.''' '''The veins should decompress in the supine position; failure to do so, particularly on the right side, warrants evaluation (CT or sonogram) for an abdominal or pelvic mass.'''
** '''Testicular consistency''' should be assessed; the affected testis may be soft.
** '''Measurement of testicular volume''' is important because it may predicate surgical intervention

== Management ==

* '''Observation remains the approach of choice for the majority of adolescents with varicocele until a surgical indication is present'''
* '''Varicocelectomy'''
** '''Indications (4):'''
**# '''Significant (≥20%) size discrepancy'''
**# '''Bilateral testicular hypotrophy'''
**# '''Abnormal semen analysis findings;''' most reliable in boys of Tanner stage 5 and/or at least 18 years of age
**# '''Pain;''' a rare indication
** '''Potential benefits'''
*** '''Halt the progressive duration-dependent decline in semen quality found in men with varicoceles.'''
**** '''Repair of large varicoceles results in a significantly greater improvement in semen quality than repair of small varicoceles'''
***** Microsurgical varicocelectomy results in return of sperm to the ejaculate in up to 50% of azoospermic men with palpable varicoceles
**** A randomized controlled trial of surgery versus no surgery in infertile men with varicoceles revealed a pregnancy rate of 44% at 1 year in the surgery group versus 10% in the control group.
**** See Risk Caculator for Predicting Changes in Semen Parameters in Infertile Men After Varicocele Repair
*** '''Improve Leydig cell function, resulting in increased testosterone levels'''
**** In infertile men with low serum testosterone levels, microsurgical varicocelectomy alone results in substantial improvement in serum testosterone levels
** '''The pampiniform plexus of veins forms from the gonadal/internal spermatic veins.'''
*** '''These veins are ligated during varicocele ligation surgery.'''
** '''Deferential veins follow the vas deferens and empty into the internal iliac/hypogastric veins.'''
*** '''These veins are spared during varicocele ligation surgery.'''
** '''Approaches (5)'''
**# '''Radiographic'''
**# '''Retroperitoneal'''
**# '''Laparoscopic'''
**# '''Conventional inguinal'''
**# '''Microsurgical Inguinal and Subinguinal'''

### '''Radiographic'''
###* Venographic placement of agents (3% sodium tetradecyl sulfate or polidocanol, with or without intravascular coils or balloons)
###* Can be done in either a retrograde or antegrade fashion
###* '''Advantages:'''
###*# '''Identify and classify the venous collateralization as possible routes of outflow and reflux'''
###*# '''Minimally invasive approach''' through a transfemoral venous puncture done under local anesthesia (with or without sedation)
###* '''Disadvantages'''
###*# '''High incidence of varicocele recurrence'''
###*# '''Radiation exposure'''
###*# '''Short follow-up in available literature'''
### '''Retroperitoneal'''
###* '''Involves incision at the level of the internal inguinal ring, splitting of the external and internal oblique muscles, and exposure of the gonadal/internal spermatic artery and vein retroperitoneally near the ureter.'''
###* '''Still a commonly used method for the repair of varicocele, especially in children.'''
###* '''Advantages:'''
###** '''Involves ligation of the fewest number of veins'''
###*** This approach isolates the gonadal/internal spermatic veins proximally, near the point of drainage into the left renal vein. At this level, only 1-2 large veins are present, and in addition the testicular artery has not yet branched and is often distinctly separate from the internal spermatic veins.
###**** Despite the above statment, CW11 Table 25-5 suggests that the artery is not preserved with retroperitoneal approach
###* '''Disadvantages:'''
###** '''High incidence of varicocele recurrence and hydrocele formation'''
### '''Laparoscopic'''
###* '''In essence a retroperitoneal approach'''
###* '''Similar advantages and disadvantages to those of the open retroperitoneal approach'''
###** '''High incidence of hydrocele formation'''
### '''Conventional inguinal'''
###* '''Disadvantages:'''
###** '''High incidence of hydrocele formation'''
###** '''Artery not preserved'''
###* If an inguinal approach is selected, the external oblique aponeurosis is cleaned and opened the length of the incision to the external inguinal ring in the direction of its fibers. A 3-0 absorbable suture placed at the apex of the external oblique incision facilitates later closure. The spermatic cord is grasped with a Babcock clamp and delivered through the wound. '''The ilioinguinal and genital branches of the genitofemoral nerve are carefully excluded from the cord,''' which is then surrounded with a large Penrose drain
### '''Microsurgical Inguinal and Subinguinal'''
###* '''Advantages'''
###*# '''Facilitates artery and lymphatic sparing'''
###*# '''Low rate of varicocele recurrence'''
###*# '''Low risk of hydrocele'''
###* '''Disadvantages:'''
###*# '''May be time-consuming'''
###*# '''Requires microscopic surgical skills'''
###* '''Indications for inguinal vs. subinguinal varicocelectomy (see CW11 Table 25-6)'''
###** '''Subinguinal approach'''
###*** '''Currently the most popular approach'''
###*** '''Preferred in men with a history of any prior inguinal surgery'''
###*** Significantly more difficult than a high inguinal operation and should be used only by surgeons who perform the operation frequently
###*** '''Associated in rare cases with testicular atrophy (necrosis), which has not been reported for suprainguinal procedures'''
###** '''Inguinal approach'''
###*** '''Used when simultaneous ipsilateral hernia repair is performed'''
###* '''An inguinal or subinguinal approach allows access to cremesteric/external spermatic vein and even gubernacular veins'''
###* '''At the completion of the microsurgical varicocelectomy, only the testicular arteries, cremasteric arteries, lymphatics, and vas deferens with its vessels remain (i.e. deferential artery and vein are intact)'''
###** '''As long as at least one set of deferential veins remains intact, venous return will be adequate'''
##* '''Scrotal'''
##** '''Avoided because damage to the arterial supply of the testis frequently results in testicular atrophy and further impairment of spermatogenesis and fertility'''
#* '''Complications'''
#*# '''Failure (varicocele persistence or recurrence''')
#*# '''Hydrocele''' formation after varicocelectomy is caused by lymphatic obstruction
#*# '''Injury or ligation of the testicular artery''' carries with it the risk of testicular atrophy and/or impaired spermatogenesis
#*#* See Table 25-5 for techniques and complications of varicocelectomy
#*#** '''UrologySchool.com Summary of Table'''
#*#*** '''High rates of varicocle recurrence: retroperitoneal and radiographic'''
#*#*** '''High rates of hydrocele: retroperitoneal, laparoscopic, and conventional inguinal'''
#*#*** '''Artery not preserved: retroperitoneal and conventional inguinal'''

== References ==

* Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 25
* Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 146