EAES Presenter Disclosure Slide Brij B. Agarwal Nothing To Disclose

Consultant Endoscopic Surgeon Totally extraperitoneal bilateral varicocoelectomy- anatomical study of collateral veins of left and right varicocoele & their surgical accessibility Dr. Brij B. Agarwal Consultant Endoscopic Surgeon Sir Ganga Ram Hospital India

Varicocele Surgery Most common surgery for correctable male infertility Subinguinal microvascular approach is gold standard Laparoscopic varicocelectomy abandoned Retroperitoneal approach desirable Agarwal BB et al, Int J Surg, 2009 ASRM Report, Fertil Steril 2006 Sweeney DD et al. Nat Clin Pract. Urol 2007 Agarwal BB et al, EAES 2009

Principles in Varicocele Surgery Retroperitoneal approach (Paloma’s) Inguinal / subinguinal Agarwal BB et al, Int J Surg, 2009 Beutner S et al. Surg Endosc 2007 collaterals Agarwal BB et al, EAES 2009

Pitfalls of Laparoscopic Varicocelectomy Insult to peritoneal cavity and its contents Insult from use of energy source High rate of recurrence Agarwal BB et al, Int J Surg, 2009 Vallancien G et al. J. Urol 2002 Agarwal BB et al Surg Endosc 2007 Agarwal BB et al, 2007 Surg Endosc. Agarwal BB et al, EAES 2009

Methods Prospective experience. Infertile couple, Socio-biologically normal female partners, Subnormal semen parameters with clinical varicocele. > 27 months follow up No energy sources used / single dose chemoprophylaxis. “Fast track Module” for surgery /ABCDE- 2 days. Only Paracetamol used for pain Agarwal BB et al, EAES 2009

Our Technique Extraperitoneal approach as in TEP inguinal hernia surgery Preservation of testicular artery Dissection of collaterals from High retroperitoneum to Subinguinal No use of energy sources Agarwal BB et al, EAES 2009

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Results 40 varicocelectomies in 20 patients No technical difficulty No bleeding No handicap felt in not using energy sources Agarwal BB et al, EAES 2009

Results Follow up >12 months No recurrence No chronic groin pain No testicular atrophy Significant improvement in fertility parameters Hydroceles in 35% Resolved on conservative treatment Agarwal BB et al, EAES 2009

Results Collateral were commoner on Left side Collateral from Left Right Inferior epigastric vein 11 09 Vein to vas 14 07 Inguinal canal vessels 09 07 Pelvic veins 12 02 Subinguinal vessels 09 07 Agarwal BB et al, EAES 2009

Collateral Veins A - Vas deferns, B -Vein from vein to vas C -Parallel veins pulled out from inguinal canal D -Vein from inferior epigastric vein Agarwal BB et al, EAES 2009

Conclusion EVE is an ideal procedure for varicocele in our experience. It provides access from high reteroperitoneum to sub-inguinal level collaterals Collateral venous circulation is multilevel on left side Collaterals are more extensive on left side Agarwal BB et al, EAES 2009

Questions or Comments? Thankyou for your kind attention. Watch the video at: endosurgeon.org Thank you Pooja, Krishna Adit & Nayan