Varicocele: Difference between revisions
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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 | ||
=== History and Physical Exam === | |||
* '''Physical Exam''' | |||
** '''Examine the patient 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 | |||
=== Imaging === | |||
*'''Abdominal/pelvic CT or US''' | |||
**'''Indicated if veins do not decompress in the supine position, particularly on the right side.''' | |||
== Management == | == Management == | ||
=== Observation === | === Options === | ||
# '''Observation''' | |||
# '''Varicocelectomy''' | |||
==== Observation ==== | |||
* '''Remains the approach of choice for the majority of adolescents with varicocele until a surgical indication is present''' | * '''Remains the approach of choice for the majority of adolescents with varicocele until a surgical indication is present''' | ||
=== Varicocelectomy === | ==== Varicocelectomy ==== | ||
==== Indications (4): ==== | ===== Indications (4): ===== | ||
# '''<span style="color:#ff0000">Significant (≥20%) size discrepancy</span>''' | # '''<span style="color:#ff0000">Significant (≥20%) size discrepancy</span>''' | ||
# '''<span style="color:#ff0000">Bilateral testicular hypotrophy</span>''' | # '''<span style="color:#ff0000">Bilateral testicular hypotrophy</span>''' | ||
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# '''<span style="color:#ff0000">Pain</span>;''' 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''' | ||
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** 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) ===== | ||
# '''<span style="color:#ff0000">Radiographic</span>''' | # '''<span style="color:#ff0000">Radiographic</span>''' | ||
# '''<span style="color:#ff0000">Retroperitoneal</span>''' | # '''<span style="color:#ff0000">Retroperitoneal</span>''' | ||
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# '''<span style="color:#ff0000">Microsurgical Inguinal and Subinguinal</span>''' | # '''<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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** '''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''' | ||
==== Complications ==== | ===== Complications ===== | ||
# '''Failure (varicocele persistence or recurrence''') | # '''Failure (varicocele persistence or recurrence''') | ||
# '''Hydrocele''' formation after varicocelectomy is caused by lymphatic obstruction | # '''Hydrocele''' formation after varicocelectomy is caused by lymphatic obstruction |
Revision as of 11:40, 7 March 2023
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
- Testicular growth
Diagnosis and Evaluation
- Vast majority of varicoceles in children and adolescents are identified incidentally
History and Physical Exam
- Physical Exam
- Examine the patient 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
Imaging
- Abdominal/pelvic CT or US
- Indicated if veins do not decompress in the supine position, particularly on the right side.
Management
Options
- Observation
- Varicocelectomy
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 Calculator for Predicting Changes in Semen Parameters in Infertile Men After Varicocele Repair
- Repair of large varicoceles results in a significantly greater improvement in semen quality than repair of small varicoceles
- 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)
- 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 statement, CW11 Table 25-5 suggests that the artery is not preserved with retroperitoneal approach
- 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.
- Involves ligation of the fewest number of veins
- 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
- Subinguinal approach
- 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
- UrologySchool.com Summary of Table
- See Table 25-5 for techniques and complications of varicocelectomy
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