Editing Varicocele (section)

==== Varicocelectomy ====

===== Indications (4): =====
# '''<span style="color:#ff0000">Significant (≥20%) size discrepancy</span>'''
# '''<span style="color:#ff0000">Bilateral testicular hypotrophy</span>'''
# '''<span style="color:#ff0000">Abnormal semen analysis findings</span>;''' most reliable in boys of Tanner stage 5 and/or at least 18 years of age
# '''<span style="color:#ff0000">Pain</span>;''' 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 Calculator 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

===== Anatomical considerations =====

* '''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) =====
# '''<span style="color:#ff0000">Radiographic</span>'''
# '''<span style="color:#ff0000">Retroperitoneal</span>'''
# '''<span style="color:#ff0000">Laparoscopic</span>'''
# '''<span style="color:#ff0000">Conventional inguinal</span>'''
# '''<span style="color:#ff0000">Microsurgical Inguinal and Subinguinal</span>'''

====== 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 statement, 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'''

===== Adverse Events =====
# '''<span style="color:#ff0000">Failure (varicocele persistence or recurrence</span>''')
# '''<span style="color:#ff0000">Hydrocele</span>''' formation after varicocelectomy is caused by lymphatic obstruction
# '''<span style="color:#ff0000">Injury or ligation of the testicular artery</span>''' carries with it the risk of testicular atrophy and/or impaired spermatogenesis
#* '''UrologySchool.com Summary'''
#** '''High rates of varicocle recurrence: retroperitoneal and radiographic'''
#** '''High rates of hydrocele: retroperitoneal, laparoscopic, and conventional inguinal'''
#** '''Artery not preserved: retroperitoneal and conventional inguinal'''