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
VARICOCOELE
? Union of multiple spermatic
veins from back of testes
and epididymis
? Ascend along cord infront of
ductus deferens below the
superficial inguinal ring.they
unite to form 3-4 veins-
inguinal canal- enter
abdomen through deep ring
-form 2 veins which unite to
form testicular vein
? Left vein drain into renal
vein and right vein drain into
IVC
What is varicocoele
? Dilatation and tortuosity of pampiniform plexus and so also of
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
? Normal small vessels of plexus measures 0.5-1.5 mm, diameter
greater than 2 mm- varicocoele
? 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.
? Etiology and pathophysiology of varicoceles remain incompletely
understood with only a few understudied theories
? Seen commonly on left side
?Longer
?Enters at right angle to renal vein
?Arching of left testicular artery
?Loaded sigmoid colon
?Compressed between aorta and SMA
History
? First recognized as a clinical problem in 16th century
? Relationship between infertility and varicocele proposed in late 19th
century
? thereafter, others reported association with arrest of sperm secretion and the
subsequent restoration of fertility following repair
? Enlarged scrotal veins in teenagers referenced as early as 1885
? 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
gained support among American surgeons
? Continued research documented recurrent pattern of low sperm
count, poor motility, and predominance of abnormal sperm forms
(stress pattern of semen)
? not specific to varicocele
? suggests early evidence of testicular damage
Etiology -three commonly accepted theories
?Differences between left and right testicular venous drainage
anatomy:
The left internal spermatic vein has about 8-10 mm H2O higher blood
pressure and relatively slower blood flow compared with the right side.
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
causes less cranial venous drainage.
?Venous reflux:
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
flow.
?Partial obstruction of testicular
veins:
This phenomenon, cal ed `the
nutcracker phenomenon,' occurs
when a specific vein is compressed
by arteries. In proximal type, the left
renal vein is compressed by the aorta
and the superior mesenteric artery.
In distal type, the left common iliac
artery compresses the left common
iliac vein.
Pathophysiology
? Increased blood flow in patients with varicocele compared with healthy
controls in colour Doppler studies.
? An increase in interstitial fluid -increased number of leukocytes potential y
attributable to this increase.
? Higher testicular temperature
? Increased venous pressure
? Higher apoptotic index
? Impairment of the blood-- testis barrier, which leads to the formation of
anti-sperm antibodies.15
TYPES
? 1.IDIOPATHIC/PRIMARY
- due to incompetency of valves
- 98 % on left side
? 2. SECONDARY- Pelvic or abdominal mmass
-left renal cell carcinoma with tumor thrombus in left vein
- nutcracker syndrome- SMA compressing left vein
Clinical features
? Swelling
? Dragging/aching pain in groin and scrotum
? Bag of worms feeling
? Scrotum on affected side hangs down
? 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
Varicocoele and subfertility
? Altered heat exchange mechanism due to stagnation- hypothermia-
inhibition of spermatogenesis
? Increased temperature ? increased metabolic activity- depletion of
glycogen storage- injury to parenchyma of testes-oligospermia
? Hypoxia, Leydig cell dysfunction- low testosterone
? Maturation arrest- poor spermatogenesis
Investigations
? Venous doppler of scrotum and groin- standing/Valsalva manouevre
? Doppler Criteria
?dilation of spermatic veins with demonstration of reversal of flow
with color Doppler
? cutoffs between normal and abnormal veins are 2 to 3 mm in
diameter
?Dilation of veins without demonstrated reversal of flow on color
Doppler does not represent a varicocele,
? USG Abdomen
? Semen analysis
? Hormone laboratory testing
? total and free testosterone levels,
? luteinizing and follicle-stimulating hormones,
?prolactin level,
?estrogen (E2) level.
Although a patient with clinical varicocele may exhibit laboratory results consistent
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
? Indications for surgical correction
? Relief of significant testicular discomfort or pain not responsive to routine
symptomatic treatment
? testicular atrophy (volume difference >20% or > 2cc)
? possible contribution to unexplained male infertility
? varicocele may cause progressive damage to testes, resulting in further
atrophy and impairment of seminal parameters
Management
? 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
? couple has documented infertility
? female has normal fertility
? 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
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
potential impact on future fertility
? general guidelines used by some pediatric urologist include the presence of one
or more of the following:
? Varicocele associated with decreased ipsilateral testicular size (20% volume deficit in the
involved testis)
? Bilateral varicoceles
? Symptomatic painful varicocele
? Abnormal findings on semen analysis
Varicocele
? Lipshultz and Corriere (1997)
? suggested that varicoceles were associated with testicular atrophy that was
progressive with age
? observed that testicular biopsy specimens taken from prepubertal boys with
varicoceles already revealed histologic abnormalities
? Kass and Belman (1987)
? first to demonstrate significant increase in testicular volume after varicocele
repair in adolescents
? did not study semen parameters
Management Options
? Treatment options for varicocele can be divided into two major
categories
? (1) percutaneous occlusion, by intravenous injection of various
materials to occlude the varicoceles
? (2) surgical ligation or clipping of the varicoceles to prevent venous
reflux.
Embolization/Sclerotherapy
Percutaneous Embolization
? described over three decades ago
? retrograde occlusion /anterograde technique.
? Least invasive means of varicocele repair
? Internal spermatic vein accessed via cannulation of femoral vein
? bal oon and/or coil occlusion of varicocele
? failure rate of up to 15%
Antegrade sclerotherapy
? success rate is > 90%
? hydroceles are not a complication
Retrograde Approach
? the right femoral vein is punctured to
insert an angiocatheter to gain access to
the internal spermatic vein via the
inferior vena cava and the left renal vein.
On confirming the anatomy and the
presence of reflux in the testicular vein,
it is occluded in a retrograde fashion
(i.e., against the natural direction of the
internal spermatic venous return).
Advantages
? Suitable treatment option for persistent/recurrent varicoceles post
surgical repair.
? Use of imaging techniques -identify the cause of varicocele recurrence
al ows accurate venous occlusion
-eliminate need for a difficult dissection of the
fibrous
adhesions from previous surgery.
? Faster return to normal activity
? Inexpensive sclerosing agents
? Newer Agents-sclerosing foam,occlusive bal oons, detachable coils
Antegrade approach
? lower operating time (10?15 min)
? lower unperformable and overall persistence/recurrence
rate (5?9%)
? COMPLICATIONS
-testicular atrophy post-treatment, presumably
secondary to unidentified arterial injury,
-need of an incision, most commonly at the suprascrotal
/Subinguinal level
-radiation exposure during the embolization
Methods of Surgical repair
Scrotal approach
Retroperitoneal (open or laparoscopic)
approach
inguinal approach
Subinguinal approach
Scrotal approach
? The very 1st approach for varicocoele repair employed in the early
1900s
? Involve mass ligation and Excision of varicosed veins
? Not preferred practically due to high incidence of testicular artery
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
Iiac spine
? Splitting of External & Internal Oblique Muscle
? 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
? High recurrence rate-15% due to preservation of testicular artery &
peri-arterial venae comitantes
? Recurrence is prevented by intentional artery ligation
Laparoscopic Approach
It is an essence retroperitoneal approach with similar advantages and
disadvantages
The internal spermatic veins are ligated with the laparoscope at the same level
as the retroperotoneal approach with preservation of testicular artery
The magnification by laparoscope allows visualization of testicular artery.with
experience the lymphatics may also be preserved, thereby preventing
hydrocoele formation
Additional possible complications- visceral and vascular injury, air embolism and
peritonitis
Inguinal & Subinguinal Approach
? Allows access to external spermatic and gubernacular veins
which causes recurrences if not ligated
? Microsurgical varicocoelectomies result in marked decrease in
incidence of secondary Hydrocoele formation due to easy
identification of lymphatics.
? Easy identification of testicular artery helps avoiding testicular
atrophy and azoospermia
Inguinal & Subinguinal Approach
Incision:
? 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
the external ring.
? Camper's & Scarpa fascia are divided, superficial
Epigastric Artery or vein are retracted or ligated
Inguinal & Subinguinal Approach
In the inguinal Approach
? The External Oblique aponeuroses is opened along the length of
the wound in the direction of its fibers
? 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
Inguinal & Subinguinal Approach
In the Subinguinal
Approach
? An index finger is introduced into the wound along the cord into
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
drain
Inguinal & Subinguinal Approach
Dissection of Cord
? The Internal & external spermatic fascias are
opened & the cord is inspected for pulsation of
the testicular artery to be dissected away
? The Cord veins are dissected starting with large
veins with taking care of possible adherent
testicular arterey
Inguinal & Subinguinal Approach
Dissection of Cord
? All veins are ligated except the vasal veins
with 4-0 silk ligatures or cauterized
? After complete dissection only the
testicular artery,cremastric arteries ,
cremastric muscle fibres, nerves,
lymphatics and vas deferens with its
vessels should remain
Inguinal & Subinguinal Approach
Delivery of the Testes
? Delivery of the testes through a small inguinal
inguinal or subinguinal incision guarantees
direct access to all veins close to the testes
? Associated hydrocoele(15%) can alter testicular
temperature regulation, so should be repaired if
noticed with delivery of the testes .
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
surgeons to overcome the limited mobility imposed by the use of
straight laparoscopic instruments
? (3) increased degree of freedom in the range and extent of
instrument manipulation.
Hydrocoele
? The most common complication -3-33%(7 %)
? Due to lymphatic obstruction
? Creates a insulating layer around testes impairing efficiency of
counter current heat exchange obviating benefit of
varicocoelectomy
? Use of magnification helps
Testicular Artery Injury
? The testicular artery forms 2/3 of blood supply to testes
? Is 1- 1.5 mm in diameter, adherent to a large spermatic vein &
surrounded by a network of tiny veins
? 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
Recurrence
? The incidence of recurrence after varicocoele repair varies from
0.6% to 45%
? Recurrence is mostly associated with :
1. Pediatric varicocoele
2. Non ?magnified operations
3. Retroperitoneal approaches
This post was last modified on 08 April 2022