Varicocele

Effects of experimental varicocele require neither adrenal contribution nor venous reflux

Experimental left varicocele (ELV) is known to induce bilateral changes in the rat testis that, where comparisons are possible, are similar to the changes induced by unilateral varicocele in the human. In the present study, we have determined whether or not left adrenal products are important to the changes induced by ELV and whether or not reflux of left renal vein content occurs in the ELV rat. In the first study, testicular blood flow and temperature were studied in control animals and those with ELV, left adrenalectomy (LAX), or ELV + LAX. Control left and right testicular blood flow (33.6 +/- 0.8 and 33.6 +/- 1.5 ml./min./100 gm. tissue respectively) was significantly elevated by ELV (to 39.9 +/- 0.9 and 41.2 +/- 2.7 ml./min./100 gm. tissue, respectively) and the difference between abdominal and testicular temperatures (delta T) was significantly reduced. Control delta T's for right and left testes were 3.2 +/- 0.2C and 3.2 +/- 0.2C, respectively, and right and left delta T's for ELV animals were 2.0 +/- 0.3 degrees C and 2.0 +/- 0.3C, respectively. These blood flow and temperature changes also occurred when ELV animals were subjected to simultaneous LAX. Additionally, when 85Sr-labelled microspheres were infused into the left renal vein, they did not appear in either left or right testes of ELV animals. We conclude that there is no evidence for reflux down the spermatic vein in ELV in rats and adrenal products do not reach the testis via this route after being secreted into the renal vein. We raise the suggestion that the same may be true in the human.

Luteinizing hormone secretion by male rat pituitary cells perifused in vitro: effect of experimental left varicocele and orchiectomy

It has been shown previously that experimental left varicocele in the rat, results in a bilateral decrease in intratesticular testosterone. In the present work, pituitary responsiveness to GnRH as a possible mediator of this effect has been examined. Unilateral varicoceles were created in adult rats. A second group of animals underwent a sham operation and a third underwent bilateral orchiectomy. Thirty days after surgery, rats from all three groups were sacrificed and their pituitaries were removed. Dispersed pituitary cells were perifused in Bio-Gel columns with varying concentrations of GnRH. The concentration of LH in the collected eluent was determined by radioimmunoassay. The mean, overall GnRH-stimulated LH immunoreactive secretion rate (ng/min/10(7) cells) by pituitary cells from rats with varicocele (0.062 +/- 0.11) was no different from the overall release from the sham-operated controls (0.051 +/- 0.007). The dose-response curves for GnRH-stimulated release of LH by dispersed pituitary cells in the two groups also were not different. The overall GnRH-stimulated LH release by cells from the orchiectomized rats (0.171 +/- 0.032) was significantly greater than release by cells from the sham-operated and varicocele rats, and the concentration-response curve from the orchiectomy group was significantly elevated over those of the other two groups. These results indicate that GnRH-stimulated immunoreactive LH release is not altered in rats with experimental left varicocele and, thus, is not the source of an endocrinopathy that leads to decreased intratesticular testosterone concentrations in these animals.

Correlation of sperm-bound immunoglobulins with impaired semen analysis in infertile men with varicoceles

Sperm-bound immunoglobulins were found in 27 (32%) of 84 infertile men with palpable varicoceles. These men were divided into two groups based on the presence (group I; 32%) or absence (group II; 68%) of sperm-bound immunoglobulins, as measured by an enzyme-linked immunosorbent assay. Circulating antisperm antibodies were identified in 52% of patients with sperm-bound immunoglobulins and 14% of group II patients. The presence of sperm-bound immunoglobulins was associated with a small but significant decrease in both sperm concentration and motility. Sperm-bound immunoglobulins are present in a greater percentage of infertile men with varicoceles than infertile men without varicoceles. Their presence may be a marker for damage to the seminiferous epithelia in men with varicoceles and may also contribute to varicocele-associated infertility.

New directions in male reproductive microsurgery

During the past decade, microsurgery has become a urologic subspecialty. Historically, vascular and vasal anastomosis have formed the foundation of genitourinary microsurgery. With the advent of improved instrumentation and the interest of devoted urologic microsurgeons, a multitude of new applications of microsurgery in urology have developed. In this paper, we discuss some of the new directions in male reproductive microsurgery.

The effects of unilateral, experimental varicocele are not mediated through the ipsilateral testis

Unilateral varicocele has been associated with diminished male fertility in humans and with bilateral physiologic and histologic changes in the testis of humans and laboratory animals. In particular, left varicocele in Sprague-Dawley rats results in bilateral increases in testicular temperature and blood flow. The mechanism by which unilateral varicocele can cause testicular changes is not known. The purpose of the present study was to determine whether or not the presence of either the ipsilateral or contralateral testicle is necessary for these effects of the varicocele to occur in the opposite testis. Varicoceles were created in adult, male rats by partial constriction of the left renal vein. Bilateral testicular blood flow was measured by a radiolabelled microsphere distribution technique and testicular temperature was taken with a needle probe thermometer. Right or left orchiectomies were performed on selected animals at the time of surgery to establish the unilateral left varicocele. Animals were studied 30 days after surgery. Mean testicular blood flow was significantly increased (P less than 0.01) in all animals having a left varicocele when compared with animals not having a varicocele regardless of whether a unilateral orchiectomy was performed. Likewise, the mean difference between intraabdominal temperature and intratesticular temperature (delta T) was significantly decreased in all groups of animals having varicoceles when compared with groups without varicoceles whether or not an orchiectomy had been performed. Thus, the studied bilateral effects of left-sided, experimental varicocele in the rat are not dependent upon the presence of a left testicle.

Diagnosis and surgical correction of the pediatric varicocele

We reviewed our experience with the diagnosis and management of varicoceles in 40 patients 9 to 18 years old. Of the patients 29 underwent varicocelectomy and 11 are being managed conservatively with periodic followup. The results of therapy and criteria for surgical intervention are discussed.

Testicular hemodynamic changes after the surgical creation of a varicocele in the rat. Intravital microscopic observations

The present study investigated the effect of a surgically induced varicocele on the dynamics of testicular blood flow. The surface vasculature of the normal and the varicocele-affected testis was examined utilizing intravital epi-illumination microscopy. Application of this technique to the study of the varicocele is new. Blood flow characteristics in surface veins were studied as the surface temperature of the testis was varied. Periodic, reproducible stoppages in blood flow, determined by direct observation of the red blood cells, were seen in seven of eight sham animals at the lower temperatures. These stoppages were abolished and blood flow increased at higher temperatures; stoppages reappeared at lower temperatures. The periodic stoppages were present in only one of eight rats with a proven varicocele (P less than 0.025) at any temperature studied. This loss of blood flow regulation may be the result of a loss of testicular arteriolar tone and may explain the increase in testicular blood flow and temperature elevation observed in association with a varicocele. These findings may provide new insights into the pathophysiology of the varicocele and highlight the need to study the microvascular sequelae of this vascular abnormality.

Routine intraoperative post-ligation venography in the treatment of the pediatric varicocele

Varicocelectomy in the adult is followed by a relatively low recurrence rate but children treated by conventional techniques seem prone to have more frequent recurrences. We believe that the higher recurrence rate observed in children after routine varicocelectomy actually represents residual varicose communications that had been missed at the primary operation. Routine post-ligation intraoperative venography has been used to detect these occult communications in 26 children undergoing varicocelectomy. Our results indicate a low recurrence rate (3.6 per cent), suggesting that routine use of this procedure with childhood varicocelectomy is beneficial.

Predictive parameters of successful varicocele repair

A total of 130 men presenting with oligospermia and clinically identifiable scrotal varicoceles was evaluated, treated surgically and followed for 1 year for pregnancy rate. The treatment outcome was compared to an age-matched cohort of 83 oligospermic men who had received empirical medical therapy with clomiphene citrate (25 mg. per day) for the same 1-year interval. This study was done to contrast treatment modalities in infertility and not as a strict control. Only eugonadotropic patients in both groups were used for comparison. In the varicocele group the over-all pregnancy rate was 38.5 per cent. Four variables (a lack of testicular atrophy, sperm density greater than 50 million per ejaculate, sperm motility 60 per cent or more and serum follicle-stimulating hormone values less than 300 ng. per ml.) proved to be accurate preoperative predictors of postoperative pregnancy success. Four other variables (varicocele size and laterality, sperm forward progression greater than 2 and normal sperm morphology 60 per cent or more) did not yield statistically significant rates of improvement in pregnancy postoperatively. The pregnancy rate of the eugonadotropic patients undergoing varicocele repair was 45.8 per cent. Despite statistical similarity in patient age, sperm density and mean gonadotropin levels the medically treated patients had a pregnancy rate of only 25.5 per cent, significantly lower than the surgically treated patients. In summary, patients with an identifiable varicocele had a greater chance of achieving a pregnancy following surgical correction than did those treated with empirical drug therapy. In addition, certain preoperative variables in the physical and laboratory analyses appeared to portend a greater surgical response.

Scrotal ultrasound in the infertile man: detection of subclinical unilateral and bilateral varicoceles

Clinical and laboratory studies have provided convincing evidence that varicoceles are detrimental to spermatogenesis and that this effect is unrelated to their size. Thus, physicians have used diagnostic techniques other than physical examination to find these small but clinically significant varicoceles. Because scrotal sonography has proved to be invaluable to detect many intrascrotal abnormalities, and has the unique ability to visualize the testicle and surrounding structures, we used it to evaluate 50 infertile men. Of our 50 patients 22 had a clinically palpable left varicocele and 3 additional patients had bilateral varicoceles. All clinical varicoceles were confirmed by sonography. However, sonography also demonstrated a left varicocele in an additional 12 patients (34 of 50 or 68 per cent) and a right varicocele in 21 (a total of 24 or 48 per cent). Reflux on the right side always occurred in conjunction with that on the left side. Thus, among our 50 infertile men 24 of 34 (70 per cent) had bilateral varicoceles as detected by sonography, and 12 of 50 (24 per cent) had a subclinical varicocele on the left side. The high percentage of bilateral varicoceles detected by sonography may explain the pathophysiological mechanism by which what formerly was considered a unilateral anatomical abnormality may produce bilateral testicular dysfunction. It also may challenge us to change our present unilateral surgical approach to the patient with a clinically evident left varicocele.

Asymptomatic varicocele in an infant

Varicoceles are a common cause of male infertility. The incidence of varicoceles at puberty is approximately 16 percent, but in prepubertal males, they are rare. We present a case of a varicocele in a 1 1/2-year-old male and discuss whether early recognition and surgical correction may preserve male fertility potential.

The management of varicoceles by microdissection of the spermatic cord at the external inguinal ring

A new technique for the management of varicoceles was carried out on 71 infertile men. The procedure combined microdissection of the spermatic cord at the external inguinal ring, ligation of the dilated veins, and controlled sclerosis of small cross-collateral veins. These procedures were performed on an outpatient basis and usually with local anesthesia. The surgery was completed within 20 to 30 minutes, and the postoperative morbidity was minimal. Twenty-four cases were followed for at least 18 months postoperatively. Among this group, the mean values for sperm density and sperm motility increased after surgery. The difference between the means were significant (P less than 0.001). The pregnancy rate among this group was 29.3%.

Stagnation of blood in the microcirculatory vessels in the testes of men with varicocele

This study reports on the stagnation of blood within the microcirculatory vessels of the testes of patients with varicocele. Both fine structural and quantitative studies were carried out on testicular biopsies from 14 men with varicocele and a control group of three men. Arterioles, capillaries, and venules were completely filled with blood in all affected testes. Enlarged pores were also noticed between the endothelial cells of these affected vessels. Lumen diameters of the arterioles were significantly decreased in the affected testis compared to controls. No change in the overall diameter of the arterioles and venules was noted. Significant thickening of the limiting membrane was also noted in the affected testis. It was concluded that the stagnation of blood in the microcirculatory vessels may cause local hypoxia and ischemia, which lead to spermatogenic disorders.

Varicocele and male subfertility: prognostical criteria in the surgical treatment

A retrospective analysis of 324 infertile patients who underwent the surgical treatment of varicocele was conducted. Patients were divided into groups according to the presence or not of other pathological conditions, associated with varicocele: genital inflammation, left testicular hypotrophy, elevated FSH, history of cryptorchidism and azoospermia. Age was also considered. The overall pregnancy rate was 34.2% and the semen improvement was obtained in 181 cases (52.7%). Higher percentages were attained in patients with varicocele only: 56.9% pregnancy rate, 78% sperm improvement. The analysis of the results allowed us to define a prognostical index and to offer the criteria of operability in an infertile patient with varicocele.

Obstruction of the tubuli recti and ductuli efferentes by dilated veins in the testes of men with varicocele and its possible role in causing atrophy of the seminiferous tubules

Hormone measurements, spermiograms and testicular biopsies studies were performed in young with varicocele. In addition, the testes and epididymides of 27 adults with varicocele were obtained from autopsies. Light and electron microscopic examination of biopsy and autopsy specimens revealed two types of lesions in testes with varicocele: 1) a diffuse lesion consisting of abnormal spermatozoa and spermatid morphology and sloughing of immature spermatozoa and spermatid; 2) focal lesion, distributed irregularly throughout the testicular parenchyma, affecting several small groups of seminiferous tubules. Each of these groups corresponded to a testicular lobule and showed different degrees of tubular atrophy, so that the focal lesions were distributed in a mosaic pattern. The testicular interstitium showed dilated veins and venules, and progressive collagenization. Some testes showed dilated veins in the rete testis, which compressed several tubuli recti and caused tubular atrophy in the seminiferous tubules opening into these tubuli recti. Other testes showed dilated young veins among the ductuli efferentes, and the rete testis channels appeared to be dilated. Among the different etiological mechanisms which have been suggested to for testicular lesions in varicocele, tubular obstruction at the level of either the tubuli recti or the ductuli efferentes might be responsible for lesions leading to testicular atrophy.

The effects of temperature on the activity of testicular steroidogenic enzymes

Decreased sperm counts and impaired sperm motility are present in a substantial proportion of men with varicocele. Elevations in the temperature of the affected testis, and increased spermatic vein estradiol (E2) concentrations have been found in some of these patients. To investigate the possibility that increases in temperature lead to a pattern of testicular steroidogenesis that results in increased E2 synthesis, we have examined the effects of temperature changes on the activities of four important testicular steroidogenic enzymes. 3 beta-hydroxysteroid dehydrogenase (3 beta-HSD), 17-hydroxylase (17-OH), 17,20-desmolase (17,20-D) and aromatase activities were measured in the microsomal fraction of rat, pig and horse testes. Incubations were performed at 34 degrees C, 36 degrees C, and 38 degrees C. The activities of all 4 enzymes increased with each 2 degrees C temperature elevation in roughly proportional amounts. We conclude that minor elevations in incubation temperature are associated with increases in the in vitro activity of four key testicular steroidogenic enzymes.

Surgical induction of varicocele in the rabbit

Surgically induced varicoceles were created in male rabbits of proven fertility by partially occluding the left lumbotesticular trunk, which receives the left testicular vein before draining into the left renal vein. Semen was collected every 2 weeks following surgery and left testicular biopsy was performed at 2, 4, 8 and 13 postoperative weeks. Tissue was processed for light and electron microscopy. Animals were sacrificed at 20 postoperative weeks. Left testicular vein dilatation was observed at autopsy (20 weeks postoperative), as were changes in semen quality. These included an increase in the number of round germ cells and abnormal spermatozoa, as well as a decrease in sperm numeric density and motility. Seminiferous tubule pathology was variable and germ cell sloughing was observed as soon as 8 weeks following surgery. Spermatids were maloriented relative to Sertoli cells and Sertoli-germ cell junctional complexes were structurally abnormal. Results indicate that surgical induction of varicocele in the rabbit leads to altered spermatogenic function and decreased semen quality similar to that described in humans. Epithelial disruption appears to be a phenomenon of the adluminal testicular compartment and apical Sertoli cell cytoplasmic degeneration may account for the poor semen quality associated with varicocele.

Testicular blood flow and fluid dynamics in monkeys with surgically induced varicoceles

The blood flow rates and ability to remove an added fluid load were studied in the testes of monkeys with surgically induced varicoceles and in sham-operated control monkeys. These studies were conducted to verify a proposed mechanism by which varicocele may cause testicular and spermatogenic damage. Analyses of the data indicated that, at four months after induction, the testes of monkeys with varicocele were less able to remove a perfused fluid load and that, at five months, the blood flow was significantly less in the testes of these animals. The effects were most pronounced in the left testes of the monkeys with varicocele. Blood flow values calculated were: control, right--9.66 ml X 100 g-1 X min-1; control, left--10.42 ml X 100 g-1 X min-1; varicocele, right--7.73 ml X 100 g-1 X min-1; varicocele, left--5.04 ml X 100 g-1 X min-1. These data suggest a new theory, that increased pressure on the venous side of testicular capillary beds in subjects with varicocele may decrease blood flow and cause testicular damage.

Three patterns of extra-testicular venous drainage in the rabbit. Divergence from a traditional concept

Seventy-eight male New Zealand white rabbits were autopsied and found to have variable left extra-testicular venous anatomy. Our observations reveal that in the rabbit the left testis is drained in one of three ways, identified as either A (18%), B (30%) or C (52%)--type drainage. The right testicular vein in all cases drained directly into the inferior vena cava immediately superior to the right iliolumbar vein. In type A drainage, the left testicular vein drained directly into the inferior vena cava at the level of the left iliolumbar vein. In type B drainage, the left testicular vein emptied into the left iliolumbar vein, which in turn drained into the inferior vena cava. In type C drainage both the left testicular and iliolumbar veins anastomosed to form a "lumbotesticular" trunk which emptied directly into the left renal vein. These three patterns of left venous vascular anatomy in the rabbit can be explained on the basis of their embryologic development. Our observations suggest that it is the caudal segment of the left pelvic subcardinal vein and its anastomosis with the caudal cardinal complex which persist as the left testicular vein and that the more cranial segment of this vein, heretofore presumed to remain patent, atrophies to the level of the developing left renal vein.