Testis varicocele

Testis varicocele

1. VARICOCELE
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai

1

2. Moderators:
Professors:
•Prof. Dr. G. Sivasankar, M.S., M.Ch.,
•Prof. Dr. A. Senthilvel, M.S., M.Ch.,

Asst Professors:
•Dr. J. Sivabalan, M.S., M.Ch.,
•Dr. R. Bhargavi, M.S., M.Ch.,
•Dr. S. Raju, M.S., M.Ch.,
•Dr. K. Muthurathinam, M.S., M.Ch.,
•Dr. D. Tamilselvan, M.S., M.Ch.,
•Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

3. DEFINITION
•Abnormal dilation and tortuosity of the
internal spermatic veins within the
pampiniform plexus
3 Dept of Urology, GRH and KMC, Chennai.

4. ANATOMY
4 Dept of Urology, GRH and KMC, Chennai.

5. EPIDEMIOLOGY
•The prevalence of clinically diagnosed
varicoceles:
–adolescents is 8% to 16%
–Adults- 15%
•35% of men with primary infertility
•75% to 81% of men with secondary infertility
•SITE
–Historically - predominantly left sided,
–recent reports indicate that identification of right-
sided varicoceles in boys is increasing.
5 Dept of Urology, GRH and KMC, Chennai.

6. EPIDEMIOLOGY
•Palpable left side varicoceles with retrograde
blood flow in right side- 40.3%, of which 44%
were subclinical.
•The clinical implication of these subclinical
right-sided varicoceles is unclear.
•In adults, bilaterality is reported in 15% to 50%
of cases
6 Dept of Urology, GRH and KMC, Chennai.

7. PATHOGENESIS
•The pathophysiology of the adolescent
varicocele is likely to be multifactorial.
•The primary factors are believed to be
–increased venous pressure in the left renal vein,
–collateral venous anastomoses
–valvular incompetence of the left internal
spermatic vein at its junction with the left renal
vein
7 Dept of Urology, GRH and KMC, Chennai.

8. PATHOGENESIS
•“Nutcracker phenomenon”
–compression of the left renal vein between the
aorta and superior mesenteric artery may account
for the varicocele in some boys

8 Dept of Urology, GRH and KMC, Chennai.

9. PATHOGENESIS
•Prostatic venous plexus
–Higher peak and antegrade flow and
–venous diameter
•Generalized venous abnormality
–Those showing increased risk of saphenofemoral
junction incompetence and varicose veins
9 Dept of Urology, GRH and KMC, Chennai.

10. PATHOGENESIS
•Differences in venographic information
–Adults: reflux induced via collateral pathways,
–Adolescents: congenital venous abnormalities
such as fewer competent valves and more
instances of nutcracker phenomenon
•Genetic factors
–fourfold to eightfold higher among first-degree
relatives of men undergoing vasectomy or male
kidney donors, and the incidence was especially
high in brothers
10 Dept of Urology, GRH and KMC, Chennai.

11. PATHOGENESIS
A tall, thin body habitus
•low body mass index [BMI] is associated with
varicoceles
•Probable cause:
–increased spermatic vein length and/or
–Increased hydrostatic pressure, or
–perhaps resulting from difficulty in identification
during physical examination.
11 Dept of Urology, GRH and KMC, Chennai.

12. DIAGNOSIS AND CLASSIFICATION
•The majority of varicoceles-
–identified incidentally by a primary care practitioner
or
–by the patient on self-examination.
•The patient should be examined in the
–supine and standing positions.
•The scrotum
–Inspection: look for visible swelling
–Palpation: palpate of the spermatic cord at rest and
during the Valsalva maneuver
12 Dept of Urology, GRH and KMC, Chennai.

13. CLASSIFICATION
The clinical grading system defines varicoceles
as
•Grade 0 (subclinical): nonpalpable and
visualized only by CDUS
•Grade 1: palpable only with Valsalva
maneuver;
•Grade 2: easily palpable but not visible; and
•Grade 3: easily visible.
13 Dept of Urology, GRH and KMC, Chennai.

14. DIAGNOSIS
•The veins should decompress in the supine
position
–Failure to do so, particularly on the right side,
warrants evaluation (CT or sonogram) for an
abdominal or pelvic mass
•Testicular consistency should be assessed
–the affected testis may be soft.
•Measurement of testicular volume
–It may predicate surgical intervention.
–The volumes should be assessed based on Tanner
stage
14 Dept of Urology, GRH and KMC, Chennai.

15. DIAGNOSIS
15 Dept of Urology, GRH and KMC, Chennai.

16. DIAGNOSIS
Volume can be determined using
•Prader orchidometer
–chain of 12 solid wooden ellipsoids of increasing
volumes that are visually compared with the size
of each testis


16 Dept of Urology, GRH and KMC, Chennai.

17. DIAGNOSIS
Volume can be determined using
•Takihara orchidometer
–15 elliptical rings with inner dimensions
corresponding to ellipsoid volumes placed over
the widest testis circumference
17 Dept of Urology, GRH and KMC, Chennai.

18. DIAGNOSIS
Volume can be determined using
•Seager orchidometer
–The long axis of the testis is gently grasped
between the jaws of the calipers, and measured.
18 Dept of Urology, GRH and KMC, Chennai.

19. DIAGNOSIS
Volume can be determined using
•Ultrasound- measure
–length, width, and depth and use one of several
formulas
•All three techniques are reliable, but ultrasound
is more sensitive in determining differences in left
and right testicular size
•In a canine study, the use of ultrasound and the
Lambert formula (L x W x H x 0.71) provided the
most accurate and precise testicular volume
estimates
19 Dept of Urology, GRH and KMC, Chennai.

20. DIAGNOSIS
The ultrasound criteria for diagnosing a varicocele—
•Spermatic vein diameter and retrograde blood flow
–Controversial in adults and more so in adolescents.
–Normal spermatic vein diameter: <2 mm
–Normal in 95%, 70%, and 4% of boys with grades 1, 2, and
3 varicocele and;
•Spermatic venous blood reflux
–Present in two-thirds of boys with grade 2 or 3 varicoceles
•Flow velocity measured while the patient was standing
correlated with varicocele grade and sperm motility

20 Dept of Urology, GRH and KMC, Chennai.

21. DIAGNOSIS
•Peak retrograde spermatic vein flow with
Valsalva maneuvers that exceeded 38 cm/sec
strongly correlated with testicular volume
asymmetry
21 Dept of Urology, GRH and KMC, Chennai.

22. ASSOCIATED PATHOLOGICAL PROCESSES
There is abundant evidence that a varicocele may
alter testicular growth, spermatogenesis, and
fertility potential.
The cause of testicular injury is presumed to be
related to increased scrotal temperature, but the
pathogenesis remains poorly understood.
•Testicular Hypotrophy
•Testicular Histology
•Hormonal Function
•Semen Quality
22 Dept of Urology, GRH and KMC, Chennai.

23. TESTICULAR HYPOTROPHY
•In the absence of sufficient direct insight into
the potential for subfertility (i.e., semen
analysis) associated with varicoceles in
adolescents, most attention has been on
testicular hypotrophy as a surrogate of
pathology and indirect marker surgical
success.
23 Dept of Urology, GRH and KMC, Chennai.

24. TESTICULAR HYPOTROPHY
•A decrease in testicular volume has long been
associated with varicoceles
•Steeno et al. (1976) confirmed the finding in
adolescents with
–Grade 2: 34.4% had decreased volume
–Grade 3: 81.2% had decreased volume
•The correlation between varicocele grade and left
testicular hypotrophy has been confirmed in some
studies but not others.
•Because ipsilateral volume loss may improve or resolve
after varicocele repair, it was inferred that hypotrophy
reflects significant testicular injury
24 Dept of Urology, GRH and KMC, Chennai.

25. TESTICULAR HYPOTROPHY
The global impact:
•Extension damage, of varicocele was noted by Kass et al.
(2001), who found
–significantly reduced right testicular size compared with control
values in Tanner stage 4 or 5 boys with grade 3 left varicoceles.
•Okuyama et al. (1988) reported right testicular hypotrophy
in 22% of patients with grade 2 or 3 left varicoceles, and
lower sperm densities among those with bilaterally small
testes.
•Mean right testicular volume increased significantly after
left varicocele repair but not in untreated control groups in
several other studies
25 Dept of Urology, GRH and KMC, Chennai.

26. TESTICULAR HYPOTROPHY
•Significant hypotrophy is variably defined as a
10%, 15%, 20%, or 2- or 3-mL relative
difference in testicular size and is found in
10% to 77% of patients
•This variability is related to the mode of
measurement, referral patterns, and the
formula used to determine percent
differences.
26 Dept of Urology, GRH and KMC, Chennai.

27. TESTICULAR HYPOTROPHY
•Rapid increases in testicular size may occur as
early as 10 years of age and persist until age
19, depending on Tanner stage of pubertal
development
•Because size variability can vary widely in
individuals, longitudinal measurements over
several years may more accurately define
hypotrophy than isolated measurements,
particularly in early puberty.
27 Dept of Urology, GRH and KMC, Chennai.

28. TESTICULAR HYPOTROPHY
“Catch-up” growth
•Defined as normalization of left relative to right
testicular size, occurs in 32% to 83% of patients after
varicocele repair
•Challenged by observations that testicular size
differential may improve spontaneously in untreated
patients
•In contrast, others report worsening or development of
significant hypotrophy in 10% to 26% of boys over time
•Few studies reported no statistical difference in either
direction in a longitudinal study
28 Dept of Urology, GRH and KMC, Chennai.

29. TESTICULAR HYPOTROPHY
•Lymphatic ligation contributes to increased
postoperative testicular volume after lymphatic and
arterial ligation
–but this was disproved by reports showing no difference in
rates of catch-up growth based on lymphatic (Poon et al.,
2009) and/or arterial (Barroso et al., 2009) preservation
•Laven et al. (1992) noted that varicocele repair
increased the volume of small but not normal-sized
testes.
•Postoperative left testicular hypertrophy (>10% size
differential relative to the right testis) is attributed to
non–lymphatic-sparing procedures or to a rebound
effect on spermatogenesis in the affected testis
29 Dept of Urology, GRH and KMC, Chennai.

30. TESTICULAR HYPOTROPHY
To summarise
•Significant discrepancy between left and right testicular
size remains the primary indication for varicocele
correction.
•Unfortunately, the currently available data are unclear
as to the direct relationship between this discrepancy
and testicular function with or without correction.
•Prospective, randomized studies are needed to clearly
establish whether unilateral and/or bilateral testicular
hypotrophy or catch-up growth accurately predicts
fertility potential in adolescent varicocele.
30 Dept of Urology, GRH and KMC, Chennai.

31. TESTICULAR HISTOLOGY
•The histologic effect of varicoceles is better
known in adults but is largely absent and
inconsistent in adolescents.
•In adults, histology findings
–vary from normal on light and electron microscopy
in all men or even those with severe
hypospermatogenesis to degenerative tubular
changes, altered Leydig cell number, and/or
proliferative lesions of the vasculature
31 Dept of Urology, GRH and KMC, Chennai.

32. HORMONAL FUNCTION
•The use of hormonal profiles as a proxy to
determine if varicoceles are deleterious to
testicular function has been inconclusive.
•Baseline LH and FSH levels are not consistently
different in the presence or absence of varicocele
in adolescents
•Basal and stimulated gonadotropin levels were
not consistently different in varicocele patients
when compared with controls and did not
improve after surgery
32 Dept of Urology, GRH and KMC, Chennai.

33. HORMONAL FUNCTION
•GnRH stimulation led to an exaggerated LH
and FSH response in about 30% of boys with
varicoceles but did not correlate with
testicular hypotrophy.
•Inhibin B measurements failed to consistently
correlate with testicular size or semen
parameters in adolescents
33 Dept of Urology, GRH and KMC, Chennai.

34. SEMEN QUALITY
•Most useful indicator of fertility potential
despite many variables associated with
collection and interpretation in adolescents.
•Progressive improvement in sperm quality
may parallel testicular growth and sexual
maturation, and so semen analyses may be
best obtained at stabilization of testicular
growth, which may not depend on age
34 Dept of Urology, GRH and KMC, Chennai.

35. SEMEN QUALITY
•Reliable standards for semen quality based on
Tanner stage or age do not exist, and
therefore recent studies evaluating semen
quality among adolescents with varicoceles
depend on comparison with adult standards.
35 Dept of Urology, GRH and KMC, Chennai.

36. SEMEN QUALITY
•In two randomized studies comparing treated and
untreated patients with controls
–no differences were found in semen quality at initial
or follow-up analysis between groups
–except for a significant postoperative increase in
sperm concentrations in the treated group,
hypothesized to be a rebound in spermatogenesis.
•Correlations between left or total testicular
volume and semen parameters were noted by
some investigators but not others
36 Dept of Urology, GRH and KMC, Chennai.

37. SEMEN QUALITY
Scrotal ultrasound evaluating testicular size and semen
analysis
•Christman et al. (2014)
–Testicular volume differential was not predictive of normal
semen volume, density, sperm motility, or total motile count,
–but total testicular volume from the final ultrasound was
predictive of total motile count.
•Kurtz et al. (2015) associated total testis volume and the
testicular volume differential with semen analysis
outcomes with a
–testicular volume differential of greater than 20%, doubling the
odds of a low total motile sperm count;
–a total testis volume of less than 30 cc quadruples the odds of a
low total motile sperm count.
37 Dept of Urology, GRH and KMC, Chennai.

38. SEMEN QUALITY
To summarise
•Investigators were unable to correlate
postoperative increases in left testicular volume
or varicocele grade with semen analysis data in
controlled and uncontrolled studies.
•The available data suggest that trends toward
poorer sperm quality may be limited to a subset
of affected males with varicocele, but grade and
postoperative testicular catch-up growth do not
reliably predict ultimate semen quality
38 Dept of Urology, GRH and KMC, Chennai.

39. INTRATESTICULAR VARICOCOELE
•In 1% to 2% of adolescents, a varicocele may include an
intratesticular component found on CDUS
•The diagnosis is made by identifying venous flow in
anechoic structures greater than 2 mm in diameter
near the mediastinum testis that increases during
Valsalva maneuvers
•MacLachlan et al. (2013) found worsening testicular
asymmetry that responded to surgical correction and
progressed in one patient who refused surgery
–they concluded that surgery was indicated in adolescents
with intratesticular varicoceles and testicular asymmetry
39 Dept of Urology, GRH and KMC, Chennai.

40. TREATMENT
•Observation remains the approach of choice for
the majority of adolescents with varicocele until a
surgical indication is present.
•Main indications for surgical intervention remain
–Significant left (≥20%) or bilateral testicular
hypotrophy
–Pain, or
–Abnormal semen analysis findings
•The last is most reliable in boys of Tanner stage 5
and/or at least 18 years of age.
40 Dept of Urology, GRH and KMC, Chennai.

41. TREATMENT
•Pain
–is a rare indication for surgery
–reported in only 2% to 10% of patients in most series,
–relieved by the procedure in 68% to 88% of patients
•Despite the aforementioned general principles
guiding evaluation and surgical intervention,
there is great variability in management
approaches in the pediatric urologic community.
41 Dept of Urology, GRH and KMC, Chennai.

42. TREATMENT
•Use of semen analyses
–In a survey that specifically assessed the
incorporation of semen analysis in practice, Fine
et al. (2016) found that only 13% did so routinely.
–Nearly half had discomfort in addressing the issue
with patients and did not order semen analysis

42 Dept of Urology, GRH and KMC, Chennai.

43. VARICOCELECTOMY
•Most commonly performed operation for the
treatment of male infertility
•Role
–Repair of varicocele will halt any further damage
to testicular function
–Result in improved spermatogenesis,
–Improved live birth rates
–Better IVF/ICSI outcomes
–It also enhances Leydig cell function

43 Dept of Urology, GRH and KMC, Chennai.

44. SURGICAL REPAIR OF VARICOCOELE
Several approaches exist to correct the
varicocele:
•Scrotal Operations
•Inguinal or subinguinal,
•Laparoscopic or retroperitoneal, or
•Venographic.
44 Dept of Urology, GRH and KMC, Chennai.

45. SURGICAL REPAIR OF VARICOCOELE
The surgical decision revolves around
(1) Whether to spare the testicular artery and/or
lymphatics using the available approaches and
(2) The effect on the rate of recurrence and
hydrocele formation
Recurrence
Failure
Testicular
atrophy
Hydrocoele
45 Dept of Urology, GRH and KMC, Chennai.

46. SURGICAL REPAIR OF VARICOCOELE
•Long-term outcome data are lacking to support any
particular approach because the length of
postoperative follow-up may be insufficient to identify
potential recurrences or sequelae such as a hydrocele,
which may require 2 years or more to develop
•Whereas many hydroceles may resolve spontaneously,
up to one-half may require formal scrotal repair or
aspiration because of large size or symptoms.
•Yu et al. (2016) demonstrated no difference in
improved semen quality when laparoscopic artery
sparing and artery ligation techniques were compared
46 Dept of Urology, GRH and KMC, Chennai.

47. SCROTAL OPERATIONS
•The earliest recorded attempts at repair of varicocele date
to antiquity and involved external clamping of the scrotal
skin including the enlarged veins.
•In the early 1900s an open scrotal approach was employed,
involving the mass ligation and excision of the varicosed
plexus of veins.
•At the level of the scrotum, however, the pampiniform
plexus of veins are intimately entwined with the coiled
testicular artery.
•Therefore scrotal operations are to be avoided because
damage to the arterial supply of the testis frequently
results in testicular atrophy and further impairment of
spermatogenesis and fertility.
47 Dept of Urology, GRH and KMC, Chennai.

48. RETROPERITONEAL OPERATIONS
•Described by Dr. Alejandro Palomo (1949)
•Mass ligation
•Offers a highly successful and efficient surgical result
•The Palomo open procedure is performed through a
muscle splitting incision medial to the anterior superior
iliac spine.
•Modifications
–To reduce the risk of postoperative hydrocele formation, a
microscopic lymphatic-sparing procedure through this
incision was described by Wong et al., without recurrence
(Wong et al., 2009), and shown to be faster and more
reliable than a subinguinal approach by Silveri et al. (2015).
48 Dept of Urology, GRH and KMC, Chennai.

49. RETROPERITONEAL OPERATIONS

•Incision at the level of the internal inguinal ring

•Splitting of the external and internal oblique muscles

•The peritoneum is mobilized medially to expose the internal
spermatic artery and vein retroperitoneally near the ureter

•Which are isolated, clipped, or suture ligated and left as such, or
the vessels are divided according to surgeon preference
Technique
49 Dept of Urology, GRH and KMC, Chennai.

50. RETROPERITONEAL OPERATIONS
ADVANTAGES:
•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
–the testicular artery has not yet branched and is often
distinctly separate from the internal spermatic veins.
–Retroperitoneal approaches involve ligation of the
fewest number of veins

50 Dept of Urology, GRH and KMC, Chennai.

51. RETROPERITONEAL OPERATIONS
Drawbacks:
•High incidence of varicocele recurrence-15%
•Postoperative hydrocele formation-7% to 33%
–difficulty in positively identifying and preserving
lymphatics
•Positive identification and preservation of the 1.0- to
1.5-mm testicular artery via the retroperitoneal
approach is difficult, especially in children in whom the
artery is small
•Involves working in a deep hole, and, because at this
level the internal spermatic vessels cannot be delivered
into the wound, they must be dissected and ligated in
situ in the retroperitoneum
51 Dept of Urology, GRH and KMC, Chennai.

52. RETROPERITONEAL OPERATIONS
Failure:
•Preservation of the periartertial plexus of fine veins (venae
comitantes) along with the artery.
–Usual cause
–These veins have been shown to communicate with larger internal
spermatic veins.
–If left intact, they may dilate and cause recurrence.
•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 ligation
–Less common
•Dilated cremasteric veins and scrotal collaterals
–causes of varicocele recurrence and cannot be identified with a
retroperitoneal approach
52 Dept of Urology, GRH and KMC, Chennai.

53. RETROPERITONEAL OPERATIONS
Ligating testicular artery
•Recurrence- reduced
•Ensures ligation of the periarterial network of
fine veins.
•Reversal of testicular growth failure has been
documented with intentional testicular artery
ligation at the time of retroperitoneal repair in
children


•The effect of artery ligation on subsequent
spermatogenesis is uncertain.
•In adults bilateral artery ligation has been
documented to occasionally cause azoospermia
and testicular atrophy
•At least it is inarguable that testicular artery
ligation will not enhance testicular function
Proponents Opponents
53 Dept of Urology, GRH and KMC, Chennai.

54. LAPAROSCOPIC VARICOCELECTOMY
•In essence a retroperitoneal approach
•Many of the advantages and disadvantages are similar to those of
the open retroperitoneal approach
•Laparoscopic varicocelectomy should allow preservation of the
testicular artery in a majority of cases, as well as preservation of
lymphatics.
•The incidence of varicocele recurrence would be expected to be
similar to that associated with the open retroperitoneal operations.
–These recurrences would be due to collaterals joining the internal
spermatic vein near its entrance to the renal vein or entering the renal
vein separately.
•An artery ligation but lymphatic-sparing laparoscopic technique has
markedly reduced the incidence of postoperative hydrocele
formation in children
54 Dept of Urology, GRH and KMC, Chennai.

55. LAPAROSCOPIC VARICOCELECTOMY
•Laparoscopic varicocele repair is performed
using three ports.
•The two working ports are placed in variable
locations:
–left midclavicular line inferior to the umbilicus and
lower midline/right lower quadrant, or
–both lower quadrants, or
–both on the right side at the lateral rectus margin.
55 Dept of Urology, GRH and KMC, Chennai.

56. LAPAROSCOPIC VARICOCELECTOMY
•The peritoneum above the internal ring is opened and
the vascular bundle and surrounding tissue are
mobilized.
•Identifying the artery:
–a laparoscopic Doppler probe or papaverine can be used.
•Identifying lymphatics:
–The magnification provided by the laparoscope helps to
identify lymphatic channels as clear tubular structures
accompanying the artery and veins
–The use of vital dyes injected into the paratesticular tissue
to identify lymphatics has potential technical challenges
and risks if the dye is inadvertently injected into the testis

56 Dept of Urology, GRH and KMC, Chennai.

57. LAPAROSCOPIC VARICOCELECTOMY
•The vessels may be ligated using permanent
sutures or clips and transected using the
harmonic scalpel or vessel-sealing devices.
•To avoid recurrence, vein(s) accompanying the
artery should be identified and ligated.
•Cimador et al. (2008) used CDUS to search for
dilated, refluxing deferential veins in the iliac
fossa, which were also ligated
57 Dept of Urology, GRH and KMC, Chennai.

58. LAPAROSCOPIC VARICOCELECTOMY
•Injury to the genitofemoral nerve has been
reported in a limited number of adolescent
and adult series and may be more commonly
associated with use of electrocautery
•This complication manifests as postoperative
paresthesias along the proximal anterior thigh
that slowly resolve over weeks or months.
58 Dept of Urology, GRH and KMC, Chennai.

59. LAPAROSCOPIC VARICOCELECTOMY
Disadvantages:
•The potential complications of laparoscopic varicocelectomy
–injury to bowel, vessels, or viscera; air embolism; peritonitis
–significantly more serious than those associated with the open
techniques.
•Requires a general anesthetic. and employ an incision of 2 to 3 cm
for unilateral repair.
•Microsurgical techniques- 2-3cm incision, This is often no greater
than the sum of incisions employed for a laparoscopic approach.
•Postoperative pain and recovery from the laparoscopic technique
are the same as those associated with subinguinal varicocelectomy

In the hands of an experienced laparoscopist, the approach is a
reasonable alternative for the repair of bilateral varicoceles
59 Dept of Urology, GRH and KMC, Chennai.

60. LAPAROSCOPIC VARICOCELECTOMY
60 Dept of Urology, GRH and KMC, Chennai.

61. MICROSURGICAL OPERATION
•Subinguinal microsurgical varicocelectomy is currently
the most popular approach.
•Advantages:
–Allow the spermatic cord structures to be pulled up and
out of the wound so that the testicular artery, lymphatics,
and small periarterial veins may be more easily identified.
–Allows access to external spermatic and even gubernacular
veins, which may bypass the spermatic cord and result in
recurrence if not ligated
–Allows access to the testis for biopsy or examination of the
epididymis for obstruction or repair of hydrocele
61 Dept of Urology, GRH and KMC, Chennai.

62. INGUINAL VARICOCELECTOMY
5-cm incision made over the inguinal canal
opening of the external oblique aponeurosis
encirclement and delivery of the spermatic cord.
The cord is then dissected and all the internal spermatic veins are ligated
The vas deferens and its vessels are preserved.
An attempt is made to identify and preserve the testicular artery and, if possible, the lymphatics.
In addition, the cord is elevated, and any external spermatic veins that are running parallel to the
spermatic cord or perforating the floor of the inguinal canal are identified and ligated
Traditional approach to inguinal varicocelectomy :
62 Dept of Urology, GRH and KMC, Chennai.

63. MICROSURGICAL OPERATION
ADVANTAGES:
•Substantial reduction in the incidence of
hydrocele formation
–This is because the lymphatics can be more easily
identified and preserved.
•Avoid the complications of testicular atrophy or
azoospermia
–The use of magnification enhances the ability to
identify and preserve the 0.5- to 1.5-mm testicular
artery
63 Dept of Urology, GRH and KMC, Chennai.

64. MICROSURGICAL OPERATION
•APPROACHES:

64 Dept of Urology, GRH and KMC, Chennai.

65. MICROSURGICAL OPERATION
•INCISIONS
65 Dept of Urology, GRH and KMC, Chennai.

66. MICROSURGICAL OPERATION
•Inguinal
•Subinguinal
66 Dept of Urology, GRH and KMC, Chennai.

67. MICROSURGICAL OPERATION
•Dissection of the cord
–Operating microscope- 6× to 10× , 10× to 25×
67 Dept of Urology, GRH and KMC, Chennai.

68. MICROSURGICAL OPERATION
•Identifying testicular arteries
68 Dept of Urology, GRH and KMC, Chennai.

69. MICROSURGICAL OPERATION
•All veins within the cord, with the exception of the vasal
veins, are ligated
–Medium hemoclips are used for veins 5 mm or larger,
–small auto-hemoclips for veins 1 to 5 mm
–4-0 silk for veins smaller than 2 mm.
–The bipolar cautery can be used for veins smaller than 0.5 mm.
69 Dept of Urology, GRH and KMC, Chennai.

70. MICROSURGICAL OPERATION
Vasal veins:
•The vasal veins are preserved, providing venous
return.
•If the vas deferens is accompanied by a dilated
vein greater than 2.5 mm in diameter, they are
dissected free of the vasal artery and ligated.
•The vas deferens is always accompanied by two
sets of vessels.
•As long as at least one set of deferential veins
remains intact, venous return will be adequate.
70 Dept of Urology, GRH and KMC, Chennai.

71. MICROSURGICAL OPERATION
71 Dept of Urology, GRH and KMC, Chennai.

72. MICROSURGICAL OPERATION
Delivery of testis
•Guarantees direct visual access to all possible
avenues of testicular venous drainage.
•Allows access to most external spermatic
collaterals close to the testis
•Allow access to scrotal or gubernacular
collaterals, which have been demonstrated
radiographically to be the cause of 10% of
recurrent varicoceles
72 Dept of Urology, GRH and KMC, Chennai.

73. MICROSURGICAL OPERATION
•All external spermatic veins are identified and doubly ligated with
hemoclips and divided
•The gubernacula are inspected for the presence for veins exiting
from the tunica vaginalis.
•These are either cauterized or doubly clipped and divided.
•When this step is completed, all testicular venous return must be
within the Penrose surrounding cord, which is again run over the
index finger, and any remaining internal or external spermatic veins
are clipped or ligated
73 Dept of Urology, GRH and KMC, Chennai.

74. MICROSURGICAL OPERATION
Impulse test
•If the varicocelectomy has been performed successfully, squeezing
on the dilated scrotal pampinoform plexus of veins just above the
testis will result in transmission of a distinct impulse felt in the
biggest veins just on the testicular side of the ligation.
•This is similar to transmission of a fluid wave in diagnosing ascites.
•Absence of a distinct impulse suggests that a significant internal,
external, or gubernacular vein has been missed, allowing venous
blood to go straight across the area of ligation and warrants
rerunning the cord and redelivery of the testis.
•The reason this “impulse test” works is that it takes time for the
testicular venous return to find its way through the deferential
veins, so immediately after ligation the venous pressure is high
74 Dept of Urology, GRH and KMC, Chennai.

75. MICROSURGICAL OPERATION
•Hydroceles are found in 15% of testes
associated with varicoceles.
•As little as 3 cc of hydrocele fluid can
significantly alter testicular temperature
regulation
•If a hydrocele is noted when the testis is
delivered, it is repaired
75 Dept of Urology, GRH and KMC, Chennai.

76. MICROSURGICAL OPERATION
Post-op care
•Scrotal supporter is applied and stuffed with fluff type dressings.
•The patient is discharged on the day of surgery with a prescription
for acetaminophen with codeine.
•The patient is instructed to apply ice to wounds intermittently for
20 minutes for 20 days postoperatively to prevent further swelling
and ease discomfort on the effected site.
•The patient should shower in 48 hours
•Light desk work may be resumed in 2 or 3 days.
•Ejaculation and intercourse may be resumed 1 week
postoperatively, light exercise in 2 weeks
•All activities 3 weeks postoperatively
76 Dept of Urology, GRH and KMC, Chennai.

77. SCLEROTHERAPY OR EMBOLOTHERAPY
•The published experience with intravascular
injection of sclerosant or thrombotic material
to occlude varicoceles in adolescents has been
limited and mainly applied to cases of
recurrent or persistent varicoceles
•The benefit of this approach is to identify and
classify the venous collateralization as possible
routes of outflow and reflux
77 Dept of Urology, GRH and KMC, Chennai.

78. SCLEROTHERAPY OR EMBOLOTHERAPY
78 Dept of Urology, GRH and KMC, Chennai.

79. SCLEROTHERAPY OR EMBOLOTHERAPY
•The agents
–3% sodium tetradecyl sulfate or
–Polidocanol,
–With or without intravascular coils or balloons
•Can be injected in either a retrograde or
antegrade fashion.
•Approach: transfemoral venous puncture
79 Dept of Urology, GRH and KMC, Chennai.

80. SCLEROTHERAPY OR EMBOLOTHERAPY
•The benefits of the procedure
–Minimally invasive
–Done under local anesthesia (with or without
sedation).
•Disadvantages
–Inferior success rates compared with surgical
procedures,
–Involves radiation exposure
–Cannot be completed for technical reasons in 5% to
22% of cases
–Recurrence rates of 6% to 35%
80 Dept of Urology, GRH and KMC, Chennai.

81. SCLEROTHERAPY OR EMBOLOTHERAPY
•Self limiting complications include
–Pain
–Epididymo-orchitis
–Phlebitis
–Scrotal swelling
–Partial testicular atrophy and hydrocele occur
rarely.
81 Dept of Urology, GRH and KMC, Chennai.

82. SCLEROTHERAPY OR EMBOLOTHERAPY
•Antegrade technique:
–Small subinguinal or upper scrotal incision
–Isolation of a vein or veins amenable to cannulation
–With or without fluoroscopic confirmation of antegrade
flow into the internal spermatic vein
–Injection of a sclerosant followed by ligation of the vein.
•Success rates are reported to be 4% to 12%, lower than
for retrograde sclerotherapy, with similar
complications.
•The venographic information gleaned by the procedure
identifies aberrant vasculature in about 25% of cases
82 Dept of Urology, GRH and KMC, Chennai.

83. SUMMARY
83 Dept of Urology, GRH and KMC, Chennai.

84. THANK YOU
84 Dept of Urology, GRH and KMC, Chennai.