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.theyunite 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 individualknown 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 spermcount, 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 theleft 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 compressedby 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 commoniliac 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 indiameter
?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 forinfertility 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 furtheratrophy and impairment of seminal parameters
Management
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? The AUA Male Infertility Best Practice Policy Committee recommends treatmentbe 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 analysisVaricocele
? 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 withvaricoceles 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 parametersManagement 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 venousreflux.
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 thepresence 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 recurrenceal 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 coilsAntegrade approach
? lower operating time (10?15 min)
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? lower unperformable and overall persistence/recurrencerate (5?9%)
? COMPLICATIONS
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-testicular atrophy post-treatment, presumablysecondary 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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approachinguinal 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, testicularatrophy, 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 retroperitoneallynear 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 ligationLaparoscopic Approach
It is an essence retroperitoneal approach with similar advantages and
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disadvantagesThe 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 formationAdditional 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 easyidentification 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 extendedlaterally 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 ligatedInguinal & 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 thewound 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 adherenttesticular arterey
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Inguinal & Subinguinal ApproachDissection 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 ifnoticed 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 ofinstrument 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 helpsTesticular 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 operations3. Retroperitoneal approaches