1. 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

2. 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

4. The prevalence of varicocele and
associated testicular hypotrophy by age
Age, years Prevalence, %
of varicocele hypotrophic testis
<
11–14 6–
15– –

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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%

20. 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

21. 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

22. 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

23. 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

24. 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

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