13.1 Introduction
Varicoceles are the most common diagnosis of male subfertility (Table 13.1). In the general population, varicocele affects about 13% of men, while 35–40% of subfertile men have varicoceles. The presence of a varicocele can impair testicular function and sperm production [1].
Table 13.1 Distribution of Final Diagnostic Categories Found in Male Fertility Clinic
| Category | Number | % |
|---|---|---|
| Varicocele | 603 | 42.2 |
| Idiopathic | 324 | 22.7 |
| Obstruction | 205 | 14.3 |
| Normal/female factor | 119 | 7.9 |
| Cryptorchidism | 49 | 3.4 |
| Immunological | 37 | 2.6 |
| Ejaculatory dysfunction | 18 | 1.3 |
| Testicular failure | 18 | 1.3 |
| Drug/radiation | 16 | 1.1 |
| Endocrinopathy | 16 | 1.1 |
| Others (all <1.0%) | 31 | 2.1 |
| Total | 1,430 | 100.0 |
13.2 Effect of Varicoceles
Several proposed mechanisms have been described regarding how the varicocele negatively impacts testicle function. Increased testicular temperature, reflux of renal metabolites and toxins, and reactive oxygen species (ROS) accumulation have all been the suggested mechanisms. Increased temperature has the most likely pathologic effect on sperm production, likely due to disruption of the countercurrent heat exchange system within the scrotum. It is known to cause both Leydig and Sertoli cell dysfunction, decreased protein synthesis, and germ cell damage [2]. When affected, subfertile men with varicoceles can present with any combination of seminal abnormalities. Varicoceles may also increase the DNA fragmentation in sperm [3].
13.3 Diagnosis and Grading
Physical examination remains the most valuable tool for the diagnosis of varicocele. Careful physical examination of the subfertile male may reveal varicocele. It is imperative to examine the men in both upright and supine positions with Valsalva in each position. Exam may also demonstrate testicular asymmetry in size or consistency of the testes. Varicocele grades are based exclusively on clinical examination (Box 13.1). The left side is most commonly affected, with some men presenting with bilateral varicocele. Isolated right-sided varicocele is uncommon and suggests further evaluation for intraabdominal venous obstruction affecting the right side.
Radiographic imaging, though not necessary, may include ultrasound, venography, or radionucleotide scan. Ultrasound is the most commonly used modality and again here the ultrasonographer should perform the exam similarly to the physical exam: both upright and supine with and without Valsalva. This can demonstrate vessel size, reversal of flow, and a volume measurement of each testicle.
13.4 Treatment Indications
The Male Infertility Best Practice Policy Committee of the American Urological Association (AUA) initially provided guidance on treatment indications in 2001. More recently, the American Society of Reproductive Medicine has updated this guidance [4]. Varicocele repair should be offered to men who meet the following criteria: (1) A varicocele is palpable; (2) the couple has documented infertility; (3) the female has normal fertility or potentially correctable infertility; and (4) the male partner has one or more abnormal semen parameters or sperm function test results.
Other recommendations include offering repair to adult men who have a palpable varicocele and abnormal semen analyses but are not currently attempting to conceive. Young men who have a varicocele and normal semen analyses should be followed with semen analyses every 1–2 years. Finally, adolescents who have a varicocele and objective evidence of reduced ipsilateral testicular size should be offered repair. If these adolescents have normal testicular size, they should be offered follow-up with monitoring through an annual objective measurement of testicular size and/or semen analyses [4].
13.5 Surgical Approaches
Men offered repair of the varicocele should be apprised of the current available approaches and best-practice recommendations. Best practice is a microscopic varicocele ligation, generally via a subinguinal approach. Alternatives include inguinal and retroperitoneal (Palomo) approaches with or without the use of the microscope or laparoscopic ligation [4]. An original scrotal approach with scrotal excision and clamping of the varicocele veins was described over a century ago by Hartman [5]. This has been abandoned as it posed a higher risk of testicular artery damage and recurrence.
In this next section, each technique will be described in detail. All procedures should be completed under either general or monitored sedation anesthesia with generous use of local injectable analgesia. Intravenous antibiotics are routinely utilized immediately preoperatively and postoperative analgesics include standing oral anti-inflammatories for 1 week and narcotic prescription available as needed. Scrotal support also provides additional value in the first days to week after surgery.
Use of the microscope allows ready visualization of the spermatic vessels including the veins, vas deferens, and, critically, the testicular artery and associated lymphatics. A micro Doppler probe is used throughout the procedure to identify and isolate the testicular artery(ies). Some surgeons opt to use surgical loupes alone to augment their visualization. Magnified visualization reduces the recurrence and hydrocele complication rate [4,6].
13.5.1 Subinguinal
This is our preferred approach to varicocele ligation (see video). We feel that the subinguinal incision spares muscle splitting of the other surgical approaches, leading to more rapid convalescence and return to work in these relatively young men.
A 3 cm subinguinal incision is made just lateral to the penis and just superior to the scrotum (Figure 13.1). Some authors incise just below the level of the external inguinal ring. The dissection is carried down through Camper’s and Scarpa’s fascia. Army-Navy retractors placed parallel to the cord allow for blunt dissection of the loose connective tissues overlying the cord (Figure 13.2). Once the cord is seen, Metzenbaum scissors are used to spread both lateral and medial to the cord to allow identification of the cord itself. The cord is then grasped with an atraumatic Babcock clamp and brought into the incision (Figure 13.3). A finger is placed under the cord and using a small gauze sponge, noncord structures are swept away from the cord, and the finger is allowed to fully encircle the cord. An Army-Navy retractor is placed under the cord, raising it, and the space below the cord is inspected to ensure that all spermatic cord vessels are included above. Once placed flat against the patient’s body, the retractor serves to keep the cord above the skin level and in the field throughout the procedure (Figure 13.4). Some surgeons choose to use one or two penrose drains snapped to the drapes to keep the cord elevated.
Figure 13.1 A 2–3 cm incision is typically made in a subinguinal location, just lateral to the scrotum and base of penis, a few centimeters caudal to the external ring.
Figure 13.2 Army-Navy retractors are used to bluntly dissect tissue down to Scarpa’s fascia, which is entered bluntly with the retractors or by spreading with the tips of a Metzenbaum scissors.
Figure 13.3 Babcock clamp is used to bring the spermatic cord up through the skin incision.
Figure 13.4 After isolating the cord, it is suspended above the skin by passing an Army-Navy under the cord.
The operating microscope is brought onto the field and set to 10–20× magnification. The internal spermatic fascia and tissue overlying the cord is grasped with Pierce pickups, and a hemostat and electrocautery are used to incise and open the space. The cremasteric fibers are dissected and tagged medially and laterally into two separate packets and placed in vessel loops for future ligation (Figures 13.5 and 13.6). Using the fine Jacobsohn hemostat, the vas deferens and its related structures are dissected away from the remainder of the cord and placed in a separate vessel loop. The remaining spermatic cord is then dissected using a combination of sharp and blunt dissection with the Jacobsohn hemostat. It is important to identify individual lymphatic vessels early and tag these with vessel loops for preservation. The micro Doppler is first used here to identify the section of cord that contains the artery and to determine if multiple arteries are present (Figures 13.7 and 13.8). The Doppler should be used prior to each and every venous ligation to ensure that no artery is included with that vein and that the artery has signal elsewhere in the cord bundle. The internal spermatic veins are then dissected and clip- or suture-ligated, based on surgeon preference, and divided. The spermatic artery(ies) is separated from the often adherent spermatic veins (Figure 13.9). If needed, a curved microneedle holder can be used for dissection of particularly adherent vessels. The microneedle holder is more likely to puncture a vessel wall than the Jacobsohn and must be used with care. Papaverine (30 mg/cc, 1 cc in 4 cc of sterile water) can be drip-applied to the field in small volume to increase arterial signal and combat any vasospasm caused by dissection. The spermatic artery is also isolated and preserved in a vessel loop. Once it appears that all veins have been ligated, all lymphatic vessels and arteries should be placed within a single vessel loop. With gentle retraction of this new bundle, the surgeon can determine if any tissue or vessels remain to be ligated and do so. Doppler is used again to confirm arterial waveform. Cremasteric fibers are then ligated and cauterized (Figure 13.10). If the cremaster on either side is very thick, consider separating it into two packets and ligating each separately. One cremaster packet should be ligated but not cauterized so that the cord retains some strength and the testicle does not rely on the artery and lymphatics alone for support. If there is concern for injury to the spermatic artery, then cremaster fibers, which often contain a small accessory artery, should not be ligated. Any large cremaster veins can be isolated and ligated from the remainder of the cremaster fibers to prevent recurrence. Hemostasis can be achieved with bipolar electrocautery where necessary. The preserved cord structures are then replaced into the incision and the testis is very gently drawn caudad to its natural position. Scarpa’s fascia is then closed with interrupted 3-0 Vicryl suture. The skin is closed with a running subcuticular 4-0 Monocryl stitch.
Figure 13.5 Under microscopic view, the external spermatic fascia, cremasteric muscle fibers, and internal spermatic fascia are opened along the direction of the cord with fine-point electrocautery.
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