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
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
“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
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
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
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
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
Avoided because damage to the arterial supply of the testis frequently results in testicular atrophy and further impairment of spermatogenesis and fertility