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


? 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

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

? First recognized as a clinical problem in 16th century

? Relationship between infertility and varicocele proposed in late 19th


? 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


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


?Partial obstruction of testicular


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.


? 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

- 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
? 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


?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.
? 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

? 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
? 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


? 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


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

materials to occlude the varicoceles

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


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).

? 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


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%)

-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)


inguinal approach

Subinguinal approach

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


? 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


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


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

? 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


? 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


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.

? 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


? 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

? 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