Varicoceles University of Oklahoma Department of Urology Andrew Schultz, MD Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD University of Oklahoma Department of Urology Section of Pediatric Urology

Varicocele dilatation of the pampiniform venous plexus and the internal spermatic vein well-recognized cause of decreased testicular function very rare < 9 y.o. ~16% of adolescents ~15-20% of all males 40% of infertile males scrotal varicoceles are the most common cause of poor sperm production and decreased semen quality

The prevalence of varicocele and associated testicular hypotrophy by age Age, years Prevalence, % of varicocele hypotrophic testis <11 0 0 11–14 6–8 7.3 15–19 11–19 9.3

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

History 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

Varicocele 80-90% involve the left testicle anatomic factors (1) angle at which left testicular vein enters left renal vein (2) lack of effective antireflux valves at juncture of testicular vein and renal vein (3) increased renal vein pressure due to compression between the superior mesenteric artery and the aorta (ie, nutcracker effect) 35-40% of men with palpable left varicocele may actually have bilateral varicoceles Recent study by Gat et al  ~ 80% of men with a left clinical varicocele had bilateral varicoceles revealed by noninvasive radiologic testing

Varicocele Presentation Scrotal mass/swelling, symptoms of acute or chronic scrotal discomfort, differing testicular sizes without a palpable variocele, and incidental finding on scrotal US Grading: Grade 0 - Subclinical varicocele, Dx by US or venography Grade 1 – palpable with Valsalva maneuver Grade 2 - Easily detected without Valsalva maneuver Grade 3 - Detected visually at a distance

Varicocele Presentation Most asymptomatic usually unilateral and almost always left-sided unilateral right-sided varicocele should prompt investigation for retroperitoneal process mass that causes obstruction of the right internal spermatic vein Thrombosis/occlusion of the inferior vena cava must be ruled out in Situs inversus another etiology of right-sided varicocele Initial presentation usually occurs during puberty, with incidence in 13-year-old adolescent boys equal to that of adult men

Varicocele Multiple investigators have directly correlated the degree of testicular atrophy with varicocele grade Steeno et al  testis volume reduced by 81% with grade 3 and by 34% with grade 2 No patients with grade 1 had testicular atrophy

Pathophysiology Unknown how impairment of sperm structure, function, and production occurs interference with thermoregulation other theories include the possible effects of pressure, oxygen deprivation, heat injury, and toxins Despite considerable research, no one theory proved unquestionably Regardless, indisputably a significant factor in decreasing testicular function and in reducing semen quality in large percentage of men seeking infertility treatment

Histology Histologic studies  seminiferous tubule sclerosis, small vessel degenerative changes, and abnormalities of Leydig, Sertoli, and germ cells changes have been documented in patients as young as 12 years

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 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) Kass and Belman (1987) 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

Surgical Management ideal technique is to ligate all of the internal and external spermatic veins with preservation of spermatic arteries and lymphatics internal spermatic artery may be divided with transperitoneal or retroperitoneal approach does not usually cause testicular atrophy due to generous collateral circulation to testicle 3 most common surgical approaches inguinal Retroperitoneal subinguinal

Subinguinal Incision made over external ring at or near the pubic tubercle obviates the opening of the external oblique aponeurosis Dilated cremasteric veins ligated Spermatic cord opened spermatic veins in pampiniform plexus separated and ligated any dilated veins that accompany the vas deferens also ligated Microscopic subinguinal approach Operating microscope used to dissect out and preserve the testicular arteries and lymphatic vessels Some advocate delivering testicle into wound and ligating external spermatic and gubernacular veins recurrence rate 0-2%, complication rate 1-5%

Inguinal Incision made over course of inguinal canal Ligation of cremasteric, deferential, and spermatic veins performed with arterial preservation Microscope may be used as well

Retroperitoneal Low abdominal incision above internal ring High ligation performed of entire spermatic pedicle (Palomo procedure) testicular artery–sparing procedure performed by opening the spermatic fascia to identify and preserve the artery Laparoscopic-assisted retroperitoneal approach Artery may be spared lengthens the procedure higher recurrence rate (6-15%) due to inguinal and retroperitoneal collateral veins, failure to ligate fine periarterial veins when testicular artery preserved 20% incidence of hydroceles at 6 months if lymphatics not preserved

Embolization/Sclerotherapy Percutaneous Embolization Least invasive means of varicocele repair Internal spermatic vein accessed via cannulation of femoral vein balloon and/or coil occlusion of varicocele failure rate of up to 15% Antegrade sclerotherapy success rate is > 90% hydroceles are not a complication

Conclusions Most methods of varicocelectomy result in similar short-term results Open microsurgical inguinal or subinguinal techniques in adults shown to cause fewer recurrences and complications Given that efficacy all techniques is nearly equivalent, attention must be paid to the morbidity of the individual procedure and expertise of the operating surgeon

Follow Up Check patient's semen 3-4 months after surgery if done for infertility spermatogenesis requires approximately 72 days any effects from varicocele repair on semen parameters are delayed

Considerations Vasectomy after mass ligation varicocelectomy likely to result in testicular atrophy Further supports artery-sparing technique