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Download MBBS Urology Presentations 14 Varicocoele Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Urology 14 Varicocoele PPT-Powerpoint Presentations and lecture notes

This post was last modified on 08 April 2022




VARICOCOELE

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? Union of multiple spermatic

veins from back of testes

and epididymis

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? Ascend along cord infront of

ductus deferens below the

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superficial inguinal ring.they

unite to form 3-4 veins-

inguinal canal- enter

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abdomen through deep ring

-form 2 veins which unite to

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form testicular vein

? Left vein drain into renal

vein and right vein drain into

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IVC
What is varicocoele
? Dilatation and tortuosity of pampiniform plexus and so also of

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testicular veins

? Seen commonly in men aged 15-30 years and rarely after 40 years

? Occur in 15-20% of all males and 40 % of all infertile males

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? Normal small vessels of plexus measures 0.5-1.5 mm, diameter

greater than 2 mm- varicocoele

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? Most common correctable cause of male infertility

? Affects 19 to 41% of men with primary infertility and 45 to 81% of

men with secondary infertility.

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? Etiology and pathophysiology of varicoceles remain incompletely

understood with only a few understudied theories
? Seen commonly on left side

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?Longer
?Enters at right angle to renal vein
?Arching of left testicular artery
?Loaded sigmoid colon
?Compressed between aorta and SMA

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History
? First recognized as a clinical problem in 16th century

? Relationship between infertility and varicocele proposed in late 19th

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century

? thereafter, others reported association with arrest of sperm secretion and the

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subsequent restoration of fertility following repair

? Enlarged scrotal veins in teenagers referenced as early as 1885


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? 1950s report of fertility following varicocele repair in an individual

known to be azoospermic

? surgical correction as clinical approach to certain kinds of male infertility

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gained support among American surgeons



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? Continued research documented recurrent pattern of low sperm

count, poor motility, and predominance of abnormal sperm forms

(stress pattern of semen)

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? not specific to varicocele

? suggests early evidence of testicular damage

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Etiology -three commonly accepted theories

?Differences between left and right testicular venous drainage

anatomy:

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The left internal spermatic vein has about 8-10 mm H2O higher blood

pressure and relatively slower blood flow compared with the right side.

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This is mainly caused by the drainage of the left testicular vein to the

left renal vein with a perpendicular angle, whereas in the right

testicular vein the drainage is to the vena cava at a steeper angle. This

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causes less cranial venous drainage.


?Venous reflux:

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Reflux to the pampiniform plexus is caused by the lack of valves in the

internal spermatic vein and/or the reflux caused by venous collateral

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flow.

?Partial obstruction of testicular

veins:

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This phenomenon, cal ed `the

nutcracker phenomenon,' occurs

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when a specific vein is compressed

by arteries. In proximal type, the left

renal vein is compressed by the aorta

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and the superior mesenteric artery.

In distal type, the left common iliac

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artery compresses the left common

iliac vein.


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Pathophysiology

? Increased blood flow in patients with varicocele compared with healthy

controls in colour Doppler studies.

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? An increase in interstitial fluid -increased number of leukocytes potential y

attributable to this increase.

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? Higher testicular temperature

? Increased venous pressure

? Higher apoptotic index

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? Impairment of the blood-- testis barrier, which leads to the formation of

anti-sperm antibodies.15
TYPES

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? 1.IDIOPATHIC/PRIMARY

- due to incompetency of valves
- 98 % on left side

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? 2. SECONDARY- Pelvic or abdominal mmass

-left renal cell carcinoma with tumor thrombus in left vein
- nutcracker syndrome- SMA compressing left vein

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Clinical features
? Swelling
? Dragging/aching pain in groin and scrotum
? Bag of worms feeling
? Scrotum on affected side hangs down

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? Bow sign- hold varicocoele b/w thumb and fingers- reduced in size
? Cough impulse present
? Long standing cases- affected testes is reduced in size and softer
? Fertility problems

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Varicocoele and subfertility
? Altered heat exchange mechanism due to stagnation- hypothermia-

inhibition of spermatogenesis

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? Increased temperature ? increased metabolic activity- depletion of

glycogen storage- injury to parenchyma of testes-oligospermia

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? Hypoxia, Leydig cell dysfunction- low testosterone

? Maturation arrest- poor spermatogenesis
Investigations
? Venous doppler of scrotum and groin- standing/Valsalva manouevre

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? Doppler Criteria
?dilation of spermatic veins with demonstration of reversal of flow

with color Doppler

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? cutoffs between normal and abnormal veins are 2 to 3 mm in

diameter

?Dilation of veins without demonstrated reversal of flow on color

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Doppler does not represent a varicocele,

? USG Abdomen

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? Semen analysis

? Hormone laboratory testing
? total and free testosterone levels,
? luteinizing and follicle-stimulating hormones,

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?prolactin level,
?estrogen (E2) level.

Although a patient with clinical varicocele may exhibit laboratory results consistent

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with hypergonadotropic hypogonadism, it is important to consider other causes for

infertility based on these results.
Management
? Presence of a varicocele does not necessitate surgical correction

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? Indications for surgical correction

? Relief of significant testicular discomfort or pain not responsive to routine

symptomatic treatment

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? testicular atrophy (volume difference >20% or > 2cc)

? possible contribution to unexplained male infertility

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? varicocele may cause progressive damage to testes, resulting in further

atrophy and impairment of seminal parameters

Management

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? The AUA Male Infertility Best Practice Policy Committee recommends treatment

be offered to the male partner when all the following are present:

? varicocele is palpable

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? couple has documented infertility

? female has normal fertility

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? one or more abnormal semen parameters or sperm function test results

? men who have a palpable varicocele and abnormal semen analyses findings but

are not currently attempting to conceive should also be offered varicocele repair

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Management- ADOLESCENTS
? No strict criteria necessitate surgical intervention in adolescents
? Each case handled individually

? discussion among patient, parents, and physician regarding risks of intervention and

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potential impact on future fertility

? general guidelines used by some pediatric urologist include the presence of one

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or more of the following:

? Varicocele associated with decreased ipsilateral testicular size (20% volume deficit in the

involved testis)

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? Bilateral varicoceles

? Symptomatic painful varicocele

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? Abnormal findings on semen analysis

Varicocele

? Lipshultz and Corriere (1997)

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? suggested that varicoceles were associated with testicular atrophy that was

progressive with age

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? observed that testicular biopsy specimens taken from prepubertal boys with

varicoceles already revealed histologic abnormalities

? Kass and Belman (1987)

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? first to demonstrate significant increase in testicular volume after varicocele

repair in adolescents

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? did not study semen parameters
Management Options
? Treatment options for varicocele can be divided into two major

categories

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? (1) percutaneous occlusion, by intravenous injection of various

materials to occlude the varicoceles

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? (2) surgical ligation or clipping of the varicoceles to prevent venous

reflux.

Embolization/Sclerotherapy

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Percutaneous Embolization

? described over three decades ago

? retrograde occlusion /anterograde technique.

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? Least invasive means of varicocele repair

? Internal spermatic vein accessed via cannulation of femoral vein

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? bal oon and/or coil occlusion of varicocele

? failure rate of up to 15%

Antegrade sclerotherapy

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? success rate is > 90%

? hydroceles are not a complication

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Retrograde Approach
? the right femoral vein is punctured to

insert an angiocatheter to gain access to

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the internal spermatic vein via the

inferior vena cava and the left renal vein.

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On confirming the anatomy and the

presence of reflux in the testicular vein,

it is occluded in a retrograde fashion

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(i.e., against the natural direction of the

internal spermatic venous return).

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Advantages
? Suitable treatment option for persistent/recurrent varicoceles post

surgical repair.

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? Use of imaging techniques -identify the cause of varicocele recurrence

al ows accurate venous occlusion

-eliminate need for a difficult dissection of the

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fibrous

adhesions from previous surgery.

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? Faster return to normal activity

? Inexpensive sclerosing agents

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? Newer Agents-sclerosing foam,occlusive bal oons, detachable coils


Antegrade approach
? lower operating time (10?15 min)

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? lower unperformable and overall persistence/recurrence

rate (5?9%)

? COMPLICATIONS

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-testicular atrophy post-treatment, presumably

secondary to unidentified arterial injury,
-need of an incision, most commonly at the suprascrotal

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/Subinguinal level
-radiation exposure during the embolization


Methods of Surgical repair

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Scrotal approach

Retroperitoneal (open or laparoscopic)

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approach

inguinal approach

Subinguinal approach

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Scrotal approach
? The very 1st approach for varicocoele repair employed in the early

1900s

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? Involve mass ligation and Excision of varicosed veins

? Not preferred practically due to high incidence of testicular artery

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injury with subsequent impairment of blood supply, testicular

atrophy, spermatogenesis and fertility
Retroperitoneal (Palomo) Approach
? Incision at the level of internal inguinal ring near to anterior superior

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Iiac spine

? Splitting of External & Internal Oblique Muscle

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? Exposure of the Internal spermatic artery & vein retroperitoneally

near ureter where only one or two large veins are present & the

testicular artery is not yet branched and so easy to separate

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? High recurrence rate-15% due to preservation of testicular artery &

peri-arterial venae comitantes

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? Recurrence is prevented by intentional artery ligation

Laparoscopic Approach
It is an essence retroperitoneal approach with similar advantages and

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disadvantages

The internal spermatic veins are ligated with the laparoscope at the same level

as the retroperotoneal approach with preservation of testicular artery

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The magnification by laparoscope allows visualization of testicular artery.with

experience the lymphatics may also be preserved, thereby preventing

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hydrocoele formation

Additional possible complications- visceral and vascular injury, air embolism and

peritonitis

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Inguinal & Subinguinal Approach

? Allows access to external spermatic and gubernacular veins

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which causes recurrences if not ligated

? Microsurgical varicocoelectomies result in marked decrease in

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incidence of secondary Hydrocoele formation due to easy

identification of lymphatics.

? Easy identification of testicular artery helps avoiding testicular

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atrophy and azoospermia
Inguinal & Subinguinal Approach

Incision:

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? Inguinal :The incision begins at external ring and extended

laterally 2-3.5 cm along langer lines

? Sub-Inguinal: the incision is placed in the skin lines just below

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the external ring.

? Camper's & Scarpa fascia are divided, superficial

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Epigastric Artery or vein are retracted or ligated

Inguinal & Subinguinal Approach

In the inguinal Approach

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? The External Oblique aponeuroses is opened along the length of

the wound in the direction of its fibers

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? Grasping of the spermatic cord & delivery of it through the

wound to be surrounded with a penrose drain after sparing of

ilioinguinal nerve and genital branch of genito-femoral nerve

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Inguinal & Subinguinal Approach

In the Subinguinal

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Approach

? An index finger is introduced into the wound along the cord into

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the scrotum and cord is hooked under external inguinal ring

? The Spermatic cord will be revealed between the index finger and

retractor, delivered and then surrounded with a large penrose

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drain

Inguinal & Subinguinal Approach

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Dissection of Cord

? The Internal & external spermatic fascias are

opened & the cord is inspected for pulsation of

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the testicular artery to be dissected away

? The Cord veins are dissected starting with large

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veins with taking care of possible adherent

testicular arterey


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Inguinal & Subinguinal Approach

Dissection of Cord

? All veins are ligated except the vasal veins

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with 4-0 silk ligatures or cauterized

? After complete dissection only the

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testicular artery,cremastric arteries ,

cremastric muscle fibres, nerves,

lymphatics and vas deferens with its

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vessels should remain

Inguinal & Subinguinal Approach

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Delivery of the Testes

? Delivery of the testes through a small inguinal

inguinal or subinguinal incision guarantees

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direct access to all veins close to the testes

? Associated hydrocoele(15%) can alter testicular

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temperature regulation, so should be repaired if

noticed with delivery of the testes .


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Robotic varicocoelectomy
Advantages of the robotic approach
? (1) 3-dimentional optics to allow improved precision of dissection,
? (2) enhanced stability and ergonomics of instrument handling for

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surgeons to overcome the limited mobility imposed by the use of

straight laparoscopic instruments

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? (3) increased degree of freedom in the range and extent of

instrument manipulation.
Hydrocoele

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? The most common complication -3-33%(7 %)

? Due to lymphatic obstruction

? Creates a insulating layer around testes impairing efficiency of

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counter current heat exchange obviating benefit of

varicocoelectomy

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? Use of magnification helps

Testicular Artery Injury

? The testicular artery forms 2/3 of blood supply to testes

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? Is 1- 1.5 mm in diameter, adherent to a large spermatic vein &

surrounded by a network of tiny veins

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? Injury or ligation carries a risk of testicular atrophy

? The use of magnification and micro- doppler helps good

identification and preservation of the testicular artery

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Recurrence

? The incidence of recurrence after varicocoele repair varies from

0.6% to 45%

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? Recurrence is mostly associated with :

1. Pediatric varicocoele

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2. Non ?magnified operations

3. Retroperitoneal approaches