Varicocele: Difference between revisions
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== Background == | == Background == | ||
* '''Definition of a varicocele: abnormal dilation and tortuosity of the gonadal/internal spermatic veins within the pampiniform plexus''' | * '''<span style="color:#ff0000">Definition of a varicocele: abnormal dilation and tortuosity of the gonadal/internal spermatic veins within the pampiniform plexus</span>''' | ||
== Epidemiology == | == Epidemiology == | ||
* '''Found in ≈15% of the general population, 35% of men with primary infertility''', and 75-81% of men with secondary infertility | * '''<span style="color:#ff0000">Found in ≈15% of the general population</span>, 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%)''' | ** '''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 | ** Adolescent varicocele may contribute significantly to the risk of subfertility in adulthood | ||
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* '''The “nutcracker phenomenon” (compression of the left renal vein between the aorta and superior mesenteric artery) may account for the varicocele in some boys''' | * '''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''' | * '''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''' | * '''<span style="color:#ff0000">Solitary right varicoceles are rare. Should one be of abrupt onset, renal pathology such as tumour should be considered</span>''' | ||
== Grading == | == Grading == | ||
* '''Grade 0 (subclinical): non-palpable and visualized only by colour-doppler US''' | * '''<span style="color:#ff0000">Grade 0 (subclinical): non-palpable and visualized only by colour-doppler US</span>''' | ||
* '''Grade 1: palpable only with Valsalva maneuver but not visible on physical exam''' | * '''<span style="color:#ff0000">Grade 1: palpable only with Valsalva maneuver but not visible on physical exam</span>''' | ||
* '''Grade 2: easily palpable but not visible on physical exam''' | * '''<span style="color:#ff0000">Grade 2: easily palpable but not visible on physical exam</span>''' | ||
* '''Grade 3: easily visible on physical exam''' | * '''<span style="color:#ff0000">Grade 3: easily visible on physical exam</span>''' | ||
== Associated Pathologic Processes == | == Associated Pathologic Processes == | ||
* '''Can impair testicular growth and | * '''Can impair testicular growth and fertility with a progressive and duration-dependent decline by interrupting counter-current heat exchange provided by pampinoform plexus, resulting in increased testicular temperature''' | ||
*# '''Testicular growth''' | *# '''Testicular growth''' | ||
*#* “Catch-up” growth, defined as normalization of left relative to right testicular size, occurs in 32-83% of patients after varicocele repair | *#* “Catch-up” growth, defined as normalization of left relative to right testicular size, occurs in 32-83% of patients after varicocele repair | ||
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* Vast majority of varicoceles in children and adolescents are identified incidentally | * Vast majority of varicoceles in children and adolescents are identified incidentally | ||
* ''' | *85% are left unilateral due to asymmetric gonadal vein anatomy, 15% may be either bilateral (more common) or right unilateral (less common)[https://pubmed.ncbi.nlm.nih.gov/33295257/ §] | ||
** ''' | |||
*** '''Examine the patient in both the supine and standing positions.''' '''The veins should decompress in the supine position | === History and Physical Exam === | ||
*** ''' | * '''<span style="color:#ff0000">Physical Exam''' | ||
*** ''' | ** '''<span style="color:#ff0000">Genitals''' | ||
*''' | ***'''<span style="color:#ff0000">Scrotum''' | ||
**''' | ****'''<span style="color:#ff0000">Examine the patient in both the supine and standing positions, with and without Valsalva.''' '''The veins should decompress in the supine position''' | ||
***''' | *****Failure to do so, particularly on the right side, may be from an abdominal or pelvic mass. | ||
**** '''Testicular''' | |||
*****'''Consistency'''; affected testis may be soft | |||
***** '''Volume;''' may predicate surgical intervention | |||
=== Imaging === | |||
*'''Abdominal/pelvic CT or US''' | |||
**'''Indications''' | |||
***'''<span style="color:#ff0000">Consider for males with a new onset or non-reducible varicocele, especially if varicocele is large[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]''' | |||
***'''Routine imaging based solely on the presence of a right varicocele is unnecessary.[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]''' | |||
== Management == | == Management == | ||
=== Observation === | === Options === | ||
# '''<span style="color:#ff0000">Observation</span>''' | |||
# '''<span style="color:#ff0000">Varicocelectomy</span>''' | |||
==== Observation ==== | |||
* '''Remains the approach of choice for the majority of adolescents with varicocele until a surgical indication is present''' | * '''<span style="color:#ff0000">Remains the approach of choice for the majority of adolescents with varicocele until a surgical indication is present</span>''' | ||
=== Varicocelectomy === | ==== Varicocelectomy ==== | ||
==== Indications (4): ==== | ===== Indications (4): ===== | ||
# '''Significant (≥20%) size discrepancy''' | # '''<span style="color:#ff0000">Significant (≥20%) size discrepancy</span>''' | ||
# '''Bilateral testicular hypotrophy''' | # '''<span style="color:#ff0000">Bilateral testicular hypotrophy</span>''' | ||
# '''Abnormal semen analysis findings;''' most reliable in boys of Tanner stage 5 and/or at least 18 years of age | # '''<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 | ||
# '''Pain;''' a rare indication | # '''<span style="color:#ff0000">Pain</span>;''' a rare indication | ||
==== Potential benefits ==== | ===== Potential benefits ===== | ||
* '''Halt the progressive duration-dependent decline in semen quality found in men with varicoceles.''' | * '''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''' | ** '''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 | *** 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. | ** 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 | ** See Risk Calculator for Predicting Changes in Semen Parameters in Infertile Men After Varicocele Repair | ||
* '''Improve Leydig cell function, resulting in increased testosterone levels''' | * '''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 | ** In infertile men with low serum testosterone levels, microsurgical varicocelectomy alone results in substantial improvement in serum testosterone levels | ||
==== Anatomical considerations ==== | ===== Anatomical considerations ===== | ||
* '''The pampiniform plexus of veins forms from the gonadal/internal spermatic veins.''' | * '''The pampiniform plexus of veins forms from the gonadal/internal spermatic veins.''' | ||
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** '''These veins are spared during varicocele ligation surgery.''' | ** '''These veins are spared during varicocele ligation surgery.''' | ||
==== Approaches (5) ==== | ===== Approaches (5) ===== | ||
# '''Radiographic''' | # '''<span style="color:#ff0000">Radiographic</span>''' | ||
# '''Retroperitoneal''' | # '''<span style="color:#ff0000">Retroperitoneal</span>''' | ||
# '''Laparoscopic''' | # '''<span style="color:#ff0000">Laparoscopic</span>''' | ||
# '''Conventional inguinal''' | # '''<span style="color:#ff0000">Conventional inguinal</span>''' | ||
# '''Microsurgical Inguinal and Subinguinal''' | # '''<span style="color:#ff0000">Microsurgical Inguinal and Subinguinal</span>''' | ||
===== Radiographic ===== | ====== Radiographic ====== | ||
* Venographic placement of agents (3% sodium tetradecyl sulfate or polidocanol, with or without intravascular coils or balloons) | * 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 | * Can be done in either a retrograde or antegrade fashion | ||
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*# '''Short follow-up in available literature''' | *# '''Short follow-up in available literature''' | ||
===== Retroperitoneal ===== | ====== 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.''' | * '''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.''' | * '''Still a commonly used method for the repair of varicocele, especially in children.''' | ||
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** '''Involves ligation of the fewest number of veins''' | ** '''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. | *** 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 | **** Despite the above statement, CW11 Table 25-5 suggests that the artery is not preserved with retroperitoneal approach | ||
* '''Disadvantages:''' | * '''Disadvantages:''' | ||
** '''High incidence of varicocele recurrence and hydrocele formation''' | ** '''High incidence of varicocele recurrence and hydrocele formation''' | ||
===== Laparoscopic ===== | ====== Laparoscopic ====== | ||
* '''In essence a retroperitoneal approach''' | * '''In essence a retroperitoneal approach''' | ||
* '''Similar advantages and disadvantages to those of the open retroperitoneal approach''' | * '''Similar advantages and disadvantages to those of the open retroperitoneal approach''' | ||
** '''High incidence of hydrocele formation''' | ** '''High incidence of hydrocele formation''' | ||
===== Conventional inguinal ===== | ====== Conventional inguinal ====== | ||
* '''Disadvantages:''' | * '''Disadvantages:''' | ||
** '''High incidence of hydrocele formation''' | ** '''High incidence of hydrocele formation''' | ||
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* 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 | * 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 ===== | ====== Microsurgical Inguinal and Subinguinal ====== | ||
* '''Advantages''' | * '''Advantages''' | ||
*# '''Facilitates artery and lymphatic sparing''' | *# '''Facilitates artery and lymphatic sparing''' | ||
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** '''As long as at least one set of deferential veins remains intact, venous return will be adequate''' | ** '''As long as at least one set of deferential veins remains intact, venous return will be adequate''' | ||
===== Scrotal ===== | ====== Scrotal ====== | ||
* '''Avoided because damage to the arterial supply of the testis frequently results in testicular atrophy and further impairment of spermatogenesis and fertility''' | * '''Avoided because damage to the arterial supply of the testis frequently results in testicular atrophy and further impairment of spermatogenesis and fertility''' | ||
==== | ===== Adverse Events ===== | ||
# '''Failure (varicocele persistence or recurrence''') | # '''<span style="color:#ff0000">Failure (varicocele persistence or recurrence</span>''') | ||
# '''Hydrocele''' formation after varicocelectomy is caused by lymphatic obstruction | # '''<span style="color:#ff0000">Hydrocele</span>''' 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 | # '''<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''' | ||
# | |||
== References == | == References == | ||