The microsurgical drainage of the varicocele

Internal Spermatic Vein to Superficial Epigastric Vein Microsurgical Bypass in Varicocele Treatment

INTRODUCTION

 Identification and preservation of testicular artery and lymphatic vessels during microsurgical varicocelectomy can be tedious if adhered encompassing venous network is encountered. A venous bypass from internal spermatic to saphenous or inferior epigastric vein, that have been described for varicocele treatment, may be used in such situations. This paper describes a simplified modification of the venous bypass technique that reroutes the testicular blood to the superficial epigastric vein, which can easily be found in the incisional wound. Surgical technique and anastomotic patency test are described, and indications and results are discussed.

MATERIALS AND METHODS

 During 2020 and 2021, 32 adolescent patients underwent microsurgical varicocelectomy. In eight patients additional microsurgical testicular vein-superficial epigastric vein microvascular bypass was done. The indication for bypass was difficult identification of testicular artery and/or lymphatic vessels due to adhered venous plexus.

RESULTS

 Varicocele resolution was noted in all eight patients with clinical and/or semen analysis improvement. There were no complications or recurrences. Average length of procedure was 65 minutes. All patients were discharged within 24 hours and no antiplatelet or anticoagulant therapy was used.

CONCLUSION

 Testicular vein to superficial epigastric vein anastomosis is a useful and simplified venous bypass technique that reroutes the blood from the pampiniform plexus to the femoral vein. It can be done as an adjunct to microsurgical varicocelectomy in selected patients through a standard incision.

The history of varicocele: from antiquity to the modern ERA

Men have most likely been affected by varicocele since the assumption of the upright position. In De Medicina, written during the first century AD, Celsus credits the Greeks with the first description of a varicocele, and he recorded his own acute observation: “The veins are swollen and twisted over the testicle, which becomes smaller”. Celsus himself is credited with the distinction between varicocele (dilation of surface veins) and “cirsocele” (dilation of deep veins). There has been a long history of treatment attempts and failures, some of which are remarkably strange, that have sometimes cul- minated in tragedy, as in the case of French professor Jacques-Mathieu Delpech (1772-1832). Although some questions regarding the etiopathology and treatment of varico- cele remain unanswered, a succession of more or less conservative attempts involving all medical cultures has been performed throughout history. The report by W.S. Tulloch in 1952 brought varicocele into the era of modern evidence-based medicine, and varicocele surgery finally progressed beyond the aim of merely relieving scrotal pain and swelling. From 1970 to 2000, varicocelectomies gained worldwide attention for the treatment of male infertility. Several innovative procedures to correct varicoceles began to appear in the world's literature as interventional radiology, microsurgery, laparoscopy, and robotics, while comprehensive review articles were also published on the subject of varicocelectomies. Microsurgery is nowadays used worldwide and it can be considered to be the gold standard for correcting infertility linked to varicocele.

Usefulness of microsurgery in the training of the general surgeon

It is a common opinion that general surgery is the first step for whoever approaches a surgical discipline, and that whoever practices training in general surgery should learn the rudiments of each surgical branch. The role of microsurgery in the training of the general surgeon has not been well-established. Clinical applications of microsurgery in general surgery are few and are rarely required, and have been connected strictly to restricted indications. However, we think that microsurgery could be very useful to the general surgeon because it allows the execution of experimental research on rats, the only possibility permitted by law. In these studies the microsurgeon can perform many times and in a short time the same surgical operation, thus improving his skill, and easily getting familiarity with surgical instruments and sutures.

Microsurgery and varicocele: state of the art

Many surgical procedures have been proposed in the treatment of varicocele; however, the rate of recurrence and of postoperative complications, together with important correlation of this disease with male sterility, has played an important role in determining the success of microsurgery. In the present brief review, the indications for microsurgery and microsurgical dissection and/or anastomosis are described in comparison to traditional surgery.

Microsurgical treatment of varicocele: selecting most appropriate shunt

Microsurgical drainage of spermatic veins tailored to the hemodynamic type of varicocele was performed in 20 patients. In 14 cases the procedure was indicated as prophylaxis and in 6 cases as treatment of infertility. Complete regression of varicosities was observed in 75 percent as early as six days postoperatively, in 85 percent at two weeks, and in 90 percent at twelve months. In the remaining 10 percent, a consistent reduction of varicocele was found. No patient experienced progression of the disease. Eighty-three percent of the patients with altered seminal parameters showed an improvement of them at a mean follow-up of 9.1 months.

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%.