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CORNELL		Cornell University
Weill Medical College
Cornell Institute for Reproductive Medicine

Center for Male Reproductive Medicine and Microsurgery

"State-of-the-Art Compassionate Care for the Infertile Couple"

VARICOCELE: OPTIONS FOR MANAGEMENT

Peter Chan, M.D. and Marc Goldstein, M.D.
(Front Page, AUA News, January/February 2001, Volume 6- Number 1)

Benefit of varicocele treatment is clearly established
Percutaneous varicocele occlusion
Surgical repair of varicocele
Safety and efficacy of microsurgical varicocelectomy
Results of microsurgical varicocelectomy
Reference


Benefit of varicocele treatment is clearly established

Varicocele remains the most common specific cause of male infertility and varicocelectomy is the most frequently performed surgery for male infertility. The benefits of varicocelectomy in improving semen quality, both in sperm concentration and motility, have been clearly demonstrated in controlled trials1. Varicocele repair is a more cost-effective management option than the use of assisted reproduction with (ICSI) intracytoplasmic sperm injection2.

Varicocele causes a duration dependent decline in testicular function3, 4. This is particularly important in the pediatric/adolescent population where early diagnosis of varicoceles and timely treatment can result in “catch-up” growth of the involved testes, allowing preservation of the hormonal function and spermatogenesis thereby preventing infertility in adulthood. The extents of improvement in semen parameters correlate to the size of the varicoceles treated, with the biggest improvement in men treated with grade III varicoceles5,6. Treatment of sub-clinical varicoceles, which are not palpable on a carefully performed physical examination but identifiable on ultrasonography, has not been demonstrated to be beneficial6.

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 repair, by ligation or clipping of the varicoceles to prevent venous reflux. The recurrence/persistence rate, the complication rates, the costs and clinical experience on the various treatment modalities vary (Table 1) and comparatives studies evaluating the results of the various treatment options of varicoceles are rare7.

Percutaneous varicocele occlusion

Percutaneous procedures for varicoceles include the traditional retrograde occlusion and the more recently described anterograde technique. In the retrograde technique, 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. Upon confirming the anatomy and the presence of reflux in the testicular vein, it is occluded in a retrograde fashion (against the natural direction of the internal spermatic venous return). Percutaneous occlusion is a suitable treatment option for persistent/recurrent varicoceles post-surgical repair. The use of imaging techniques to identify the cause of varicocele recurrence allows accurate venous occlusion while eliminating the need for a difficult dissection of the fibrous adhesions from previous surgery. In expensive sclerosing agents are commonly used for retrograde occlusion. Newer embolization techniques, employing more expensive materials such as detachable coils8, 9 and occlusive balloons10 have been described. Complications, including contrast reaction, flank pain, migration of embolizing materials, infection, thrombophlebitis, arterial puncture and hydroceles, occur at a significant rate (9-30%)8, 9, 11-16. Another major criticism of the retrograde occlusive procedure is its high unperformable rate (8-30%)8, 9, 11-16, particularly for the right-sided varicoceles due to venous anatomical variations and difficulties in gaining proper venous access. Hence percutaneous retrograde varicocele occlusion is best used for isolated left-sided varicoceles.


Fig 1. Percutaneous antegrade varicocele occlusion. Dilated vein from pampiniform plexus is dissected and cannulated for injection of sclerosing agent for occlusion.
Percutaneous anterograde varicocele occlusion, by injection of sclerosing agents into an isolated vein from the pampiniform plexus in the scrotum after confirming its drainage fluroscopically (Fig. 1), has been described17, 18. As with the retrograde procedure, anterograde occlusion can be performed under local anesthesia. Furthermore, the anterograde technique is associated with a lower operating time (10-15 mins), lower unperformable and overall persistence/recurrence rate (5-9%)17, 18. Though the complication rate is only 3 to 8%, testicular atrophy post-treatment, likely secondary to unidentified arterial injury, has been reported in 1% of cases17. Another disadvantage in the anterograde as well as the retrograde techniques is the risk associated with radiation exposure. Finally, for large varicoceles, the recurrence/persistence rate of antegrade occlusion is 25%.


Surgical repair of varicocele

Surgical repair remains the most popular form of treatment for varicocele and it can be achieved by conventional open varicocelectomy (retroperitoneal high ligation, inguinal and sub-inguinal ligation), laparoscopic varicocelectomy and microsurgical varicocelectomy (Table 1).

Laparoscopic varicocelectomy has the advantage of isolating the internal spermatic veins proximally, near the point of drainage into the left renal vein. At this level, only one or two large veins are present, hence fewer number veins are to be ligated. In addition, the testicular artery has not yet branched and is often distinctly separate from the internal spermatic veins. The persistence/recurrence rate of laparoscopic varicocelecotomy is in the range of 6-15%16, 21, 24, 26-34. Failure is usually due to presevation of the periartertial plexus of fine veins (venae comitantes) along with the artery. These veins have been shown to communicate with larger internal spermatic veins. If left intact they may dilate with time and cause recurrence. Less commonly, failure is due to the presence of parallel inguinal or retroperitoneal collaterals which may exit the testis and bypass the ligated retroperitoneal veins rejoining the internal spermatic vein proximal to the site of ligation24, 25. Dilated cremasteric veins, another cause of varicocele recurrence24, cannot be identified retroperitoneally during laproscopy. The operating time is 30 to 80 mins per side. Complications, occurring at an overall rate of 8-12%16, 21, 24, 26-34, include air embolism, inadvertent arterial division, hydrocele, intestinal injury and peritonitis. Laparoscopic varicocelectomy should only be performed by experienced laparoscopic urologists. Other disadvantages of the procedure include the high cost and multiple ports, making it inappropriate for treatment of unilateral varicoceles.

Conventional open varicocelectomy is associated with a wide range of variation in the surgical outcomes. Complications, occurring at a rate of 5-30%, include hydroceles, inadvertent arterial ligation, testicular atrophy, injury to the vas deferens, epididymitis, hematoma and wound infection29. The recurrence/persistence rate, at 10-45%, is also significantly higher than other treatment options.


Safety and efficacy of microsurgical varicocelectomy


Fig 2. Delivery of testis providing exposure of external spermatic and gubernacular venous collaterals.


Fig 3. Microsurgical varicocelectomy allows clear identification and preservation of testicular artery.


Fig 4. Lymphatic vessels can be clearly identified and preserved with microsurgical varicocelectomy.

The introduction of microsurgical techniques in varicocelectomy significantly reduced the persistence/recurrence rate (0-2%) and the complication rate (1-5%)31, 35-37. This out-patient procedure can be performed under local, regional or general anesthesia and the operating time per side is 25-60 mins. Male infertility specialists in most academic centers have adopted microsurgical varicocelectomy as the routine standard treatment and there is a general trend of increasing popularity of the procedure due to the associated favorable outcomes.

Specifically, microsurgical varicocelectomy provides three important benefits. First, it allows clear identification of small venous collaterals, particularly the cremasteric veins, periarterial venous plexus, extra-spermatic and gubernacular collaterals (Fig. 2). These small venous collaterals, if missed, will dilate post-operatively with time, leading to recurrence of varicoceles. Second, testicular arteries are clearly identified under 10 to 25 x magnification and preserved (Fig. 3). The operating microscope is particularly helpful when the arteries are in spasm due to manipulation, or when multiple small branches of arteries, which are easily missed without optical magnification, are encountered during dissection. Although the testis receives additional blood supply from vasal (deferential) and cremasteric arteries, the testicular artery is the main arterial supply to the testis. Ligation of the testicular artery is unlikely to enhance testicular function. Finally, microsurgical varicocelectomy allows identification and preservation of the lymphatics (Fig. 4), virtually eliminating post-operative hydrocele formation, which is the most common complication of non-microsurgical varicocelectomy.


Results of microsurgical varicocelectomy

Utilizing microsurgical artery- and lymphatic-sparing techniques, the recurrence rates are reduced to 1% and post-operative hydrocele and testicular atrophy virtually eliminated. Repair of large varicocele results in a 143% increase in motile sperm in the ejaculate and a pregnancy rate of 47% at 1 year5, 35. Even men with non-obstructive azoospermia may respond to varicocelectomy with return of sperm to the ejaculate in 50% of cases36, 37.


Reference:

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  2. Schlegel, P.N.: Is assisted reproduction the optimal treatment for varicocele-associated male infertility? A cost-effectiveness analysis. Urology, 49: 83-90, 1997.
  3. Gorelick, J.I. and Goldstein, M.: Loss of fertility in men with varicoclel. Fertil Steril, 59: 613, 1993.
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  10. Perala, J.M., Leinonen, S.A., Suramo, I.J., Hellstrom, P.A. and Seppanen, E.J.: Comparison of early deflation rate of detachable latex and silicone balloons and observations on persistent varicocele. J Vasc Interv Radiol, 9:761-765, 1998.
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