Pathophysiology of varicocele in nonhuman primates: long-term seminal and testicular changes**Supported by grant R01 HD 12939 from the National Institute of Child Health and Human Development and grant RR 00164 from the National Institutes of Health

Varicoceles in Men With Non-obstructive Azoospermia: The Dilemma to Operate or Not

The knowledge on male reproduction is constantly expanding, especially in treating infertility due to non-obstructive azoospermia (NOA). Varicocele is occasionally diagnosed in a subpopulation of males with NOA. Varicocele repair in NOA-men may contribute to the reappearance of spermatozoa in semen. However, spontaneous pregnancies are observed in only a small percentage of NOA-men post-varicocelectomy. Additionally, it has been reported that the repair of varicocele in NOA-men (before the performance of sperm retrieval techniques) may increase the testicular sperm recovery rate. In addition, it increases the pregnancy rate in intracytoplasmic sperm injection (ICSI) programs in NOA-men without spermatozoa in the semen post-varicocelectomy. In addition, to the improvement in Sertoli cellular secretory function, varicocelectomy may increase the secretory function of Leydig cells, which subsequently results in improved androgen production, raising the probability to negate the need for testosterone replacement therapy in cases of late-onset hypogonadism. On the other hand, the benefit of varicocelectomy in patients with NOA is still debatable. The current review study aims to provide a critical and extensive review of varicocele repair in males with NOA. This study additionally focuses on the impact of varicocele repair on sperm retrieval rates and its influence on the ICSI outcomes for those couples who remain negative for spermatozoa in their semen samples post-varicocelectomy.

Paying the price for standing tall: Fluid mechanics of prostate pathology

BACKGROUND

Age-dependent increase in the incidence of benign prostatic hyperplasia (BPH) and prostate cancer (PCa) are both related to cell proliferation and survival controlled by intraprostatic free testosterone (FT) concentration. Paradoxically, BPH and PCa occur as circulating testosterone levels decrease, so any possible relationship between testosterone levels and development of BPH and PCa remains obscure.

RESULTS

In BPH the enlarging prostate is exposed to high testosterone levels arriving directly from the testes at concentrations about hundredfold higher than systemic FT. This occurs because venous blood from the testes is diverted into the prostate due to the elevated hydrostatic pressure of blood in the internal spermatic veins (ISVs). Elevated pressure is caused by the destruction of one-way valves (clinically detected as varicocele), a unique phenomenon related to human erect posture. While standing, human males are ISVs vertically oriented, resulting in high intraluminal hydrostatic pressures-a phenomenon not found in quadrupeds. In this communication, we demonstrate the fluid mechanics' phenomena at the basis of varicocele leading to prostate pathology.

CONCLUSIONS

So far, varicocele has been studied mostly for its etiologic role in male infertility and, thus, for its effects on the testes. It is becoming clear that varicocele is a major etiologic factor in BPH and likely also in PCa. Restoring normal testicular venous pressure by treatment of the abnormal ISV's in varicocele has been shown to avert the flow from the prostate with the effect of reducing prostate volume, alleviating symptoms of BPH, and increasing concentrations of circulating FT.

Rare complication of varicocelectomy: Suture granuloma

After varicocelectomy, complications such as hydrocele, testicular atrophy and recurrence can be seen. Our case was a 29-year-old male patient who had a fistula mouth laterally on the left scrotum. In the examination and scrotal ultrasonography (USG), a foreign body was detected under the skin. The patient had a history of varicocelectomy, suggesting suture reaction. Our case is interesting because it is the first reported suture granuloma case after varicocelectomy.

Comparison of the clinical characteristics of patients with varicocele according to the presence or absence of scrotal pain

We investigated the clinical characteristics of patients with varicocele according to the presence or absence of scrotal pain. We retrospectively reviewed the records of patients who underwent varicocelectomy. The age, body mass index, grade, laterality of varicocele, testicular volume difference, time to hospital visit, serum testosterone level and semen parameters were evaluated. A total of 954 patients were included. The painful group had lower mean age, lower BMI, higher grade of varicocele, smaller testicular volume difference and shorter time to hospital visit than the painless group. In addition, the median serum total testosterone level and total sperm count, concentration and motility were higher in the painful group than in the painless group. In multivariate analysis, there were significant differences between the two groups in age, grade of varicocele, testis volume difference, time to hospital visit, total sperm count and concentration. Patients with painful varicocele visited hospital earlier because of the pain and tended to start treatment sooner. They were also younger, had smaller testis atrophy and had higher sperm concentration, even though they had a higher grade of varicocele than patients without pain. Although scrotal pain in varicocele patients is difficult to treat, it leads to early diagnosis and treatment.

Comparison of response to treatment of unilateral and bilateral varicocelectomy

BACKGROUND/AIM

We aimed to compare the results of unilateral and bilateral varicocele surgery.

MATERIALS AND METHODS

In two referral hospitals, the data of 180 patients who were treated with unilateral and bilateral microscopic varicocelectomy were retrospectively analyzed. Sperm parameters and spontaneous pregnancy rates were compared in patients who underwent bilateral and unilateral microscopic varicocelectomy.

RESULTS

The mean age was 29.6 (17-46) years. While 82 patients underwent unilateral varicocelectomy (Group I), 98 patients underwent bilaterally varicocelectomy (Group II). Forty (48.8%) spontaneous pregnancies occurred in Group I and 59 (60.2%) in Group II. When we analyzed sperm parameters, the rate of increase in the number of sperm in spermiograms was 17% in Group I and 27.5% in Group II. The rate of increase in sperm mobility was 58.5% and 50% in Group I and II, respectively. The improvement rate in sperm morphology was 46.3% in Group I and 56.1% in Group II. There were no significant differences between all these parameters.

CONCLUSION

In light of our results, although pregnancy rates seemed to be higher in patients who underwent bilateral varicocelectomy, these results were not statistically significant. Improvement rates in sperm parameters were similar between the patients who underwent unilateral and bilateral varicocelectomy.

Varicocelectomy is associated with increases in serum testosterone independent of clinical grade

OBJECTIVE

To determine whether the varicocele grade is related to the degree of improvement in serum testosterone levels after varicocelectomy.

MATERIALS AND METHODS

We performed a retrospective review of men with a total serum testosterone level <400 ng/dL who had undergone microsurgical subinguinal varicocelectomy for infertility and/or hypogonadism. All men had clinically palpable left varicoceles and preoperative and postoperative total serum testosterone levels available. For patients with bilateral varicoceles, the greatest grade on either side was used to stratify the patients. The men with an isolated, left-side, grade I varicocele were not offered varicocelectomy. The changes in the testosterone levels were evaluated, with the results expressed as the mean ± standard error. P ≤.05 was considered statistically significant.

RESULTS

A total of 59 patients had undergone bilateral varicocelectomy and 19 unilateral varicocelectomy. Overall, an increase in testosterone was seen in 65 of the 78 men (83%) in the present study. The mean follow-up was 7 months. The mean serum testosterone level increased from 308.4 to 417.5 ng/dL, with a mean increase of 109.1 ± 12.8 ng/dL (n = 78). The improvements in the serum testosterone levels were seen regardless of the clinical grade.

CONCLUSION

Microsurgical varicocelectomy resulted in significant increases in the serum testosterone level, independent of the varicocele grade.

Causes and classification of male infertility in Korea

OBJECTIVE

The aim of this study is to investigate the various causes of male infertility using multiple approaches.

METHODS

Nine-hundred-twenty infertile male patients were analyzed at their first visit with one physician between January 1 and December 31, 2009. All patients were subjected to physical examination, semen analysis and azoospermic patients underwent hormonal testing, chromosomal tests, and testicular biopsy. Semen analysis was based on the definition of the World Health Organization.

RESULTS

Among the 920 patients, 555 patients (60.3%) had semen results within the normal range, 269 patients (29.2%) within the abnormal range, and 96 (10.5%) were diagnosed with azoospermia. Varicoceles were diagnosed in 84 of the 555 normal-range patients (15.1%) and in 113 of the 269 abnormal-range patients (42.0%). Of the 96 patients with azoospermia, 24 patients (25%) were diagnosed with obstructive azoospermia, 68 patients (71%) with non-obstructive azoospermia, and 4 patients (4%) with retrograde ejaculation.

CONCLUSION

Various causes of male infertility have been reported and diverse treatment methods can be adopted for each cause. In this regard, research must be conducted on a larger number of patients to accurately assess the various causes of infertility in Korean patients and to investigate various infertility treatment methods.

High total acrosin activity in varicocele individuals

Varicocele is a common cause of male infertility and reports indicate that varicocelectomy has a beneficial effect on male fertility. The aims of this study were to evaluate and compare the total acrosin activity along with DNA integrity in semen samples obtained from 70 varicocele individuals with male factors infertility presenting grades II and III varicocele before and after the surgery and 30 fertile individuals without any clinical presentation of varicocele. Total acrosin activity, protamine deficiency, DNA fragmentation, and semen parameters including sperm concentration, motility and sperm morphology were assessed by spectrophotometery, CMA3 staining, terminal deoxynucleotidyl transferase dUTP nick end labelling (TUNEL) assay and WHO criteria, respectively. Total acrosin activity (P = 0.03), percentage CMA3 positivity (P = 0.00) and TUNEL-positive spermatozoa (P = 0.04) were higher in the varicocele individuals before the surgery compared with the fertile individuals; yet, all the aforementioned criteria decreased significantly after surgery (P < 0.05). The results of this study reveal that DNA fragmentation and protamine deficiency, as negative parameters in fertility, improve post-surgery; however, total acrosin activity as a positive parameter in fertility is higher in the varicocele individuals compared with fertile and decreases to a value close to the fertile control post-surgery. High levels of total acrosin activity in varicocele individuals need more research in future.

Older age is associated with similar improvements in semen parameters and testosterone after subinguinal microsurgical varicocelectomy

PURPOSE

It is generally accepted that men with clinically palpable varicocele are at high risk for a progressive decrease in fertility and testosterone levels with time. Varicocelectomy is thought to improve testicular function or at least halt the accelerated decrease in testicular function associated with varicocele. Substantial controversy exists as to whether varicocelectomy is effective in older men, possibly due to irreversible testicular damage or limited potential for recovery from varicocele induced damage.

MATERIALS AND METHODS

We retrospectively reviewed the records of men who underwent microsurgical subinguinal varicocelectomy, as done by a single surgeon. Demographics, patient questionnaires, operative notes, charts, testosterone and semen analysis were reviewed. Patients were divided into 3 groups based on age at surgery, including less than 30, 30 to 39 and 40 years or greater.

RESULTS

A total of 272 men met study inclusion criteria. In all 3 age groups we noted similar testosterone and baseline semen analysis parameters. There were significant increases in sperm concentration and total sperm count in all age groups. When analysis was restricted to men with baseline testosterone 400 ng/dl or less, there was a mean 110, 133 and 136 ng/dl increase in 21 men who were 40 years old or older, in 30 who were 30 to 39 years old and in 21 who were younger than 30 years, respectively.

CONCLUSIONS

Microsurgical varicocelectomy resulted in significant increases in sperm concentration, total sperm count and testosterone in all age groups studied, including men in the fifth and sixth decades of life. Microsurgical varicocelectomy should be offered to older men for infertility and/or hypogonadism.

Relationship between varicocele grade, vein reflux and testicular growth arrest

The development of testicular hypotrophy (or testicular growth arrest) in pediatric patients with varicocele is the first indication for surgery. The aim of this study is to identify the correlation between grade of varicocele, grade of vein reflux and testicular growth arrest. Between 2000 and 2001, we recruited 226 patients affected by varicocele without testicular hypotrophy and with grades 2-3 spermatic vein reflux observed during Doppler velocimetry. Medical examinations carried out every 6 months allowed the assessment of varicocele grade, testicular volume, and grade of vein reflux. Other parameters considered in the study were: mean time of grade deterioration, mean time to onset of testicular growth arrest and the relationship between varicocele grade and testicular growth arrest. Deterioration of the condition was experienced in 92 patients (40%) in which 60 patients showed higher varicocele grades without testicular growth arrest, while 32 patients developed testicular growth arrest. There was a statistically significant relationship between testicular growth arrest and varicocele grades (grade 2 and 3) and between grade of reflux and testicular growth arrest. Although it is not possible to determine which patients will develop testicular growth arrest, the assessment of vein reflux allows the identification of those subjects who may potentially develop such a condition.

Comparison of prevalence of varicocele in first-degree relatives of patients with varicocele and male kidney donors

OBJECTIVES

To evaluate hereditary behavior of varicocele through comparison of prevalence of disease in first-degree relatives of patients with known varicocele and normal healthy kidney donation volunteers.

METHODS

Sixty-two patients with known varicocele who admitted for surgery in Razi Hospital between September 2005 and October 2006 were enrolled in the study. The patients were asked to refer for examination healthy available first-degree relatives (n = 88). A group of 100 men referred for voluntary kidney donation were selected as control group and assessed for varicocele.

RESULTS

Of the 88 first-degree relatives of patients with a known varicocele, 40 (45.4%) had a clinically palpable varicocele on physical examination. This was significantly greater than the 11 (11%) of 100 men in the control group (P <0.001). Of the first-degree relatives, 32 (55.1%) of 58 brothers and 8 (26.6%) of 30 fathers had palpable varicocele.

CONCLUSIONS

Clinical varicoceles are more prevalent among first-degree relatives (particularly brothers) of patients with known varicoceles and may be an indicator of hereditary behavior of the disease and necessity of screening for male family members.

Simultaneous Vasectomy and Varicocelectomy: Indications and Technique

INTRODUCTION

When men present for vasectomy, incidental varicoceles may be discovered. After varicocelectomy, the deferential veins become the only avenue for testicular venous return and could be compromised during nonmicroscopic vasectomy. We discuss the indications and technique required to safely perform simultaneous vasectomy and varicocelectomy.

TECHNICAL CONSIDERATIONS

From 1992 to 2005, 18 (4.8%) of 379 men presenting for vasectomy had incidental palpable varicoceles and low or low normal serum testosterone levels. All underwent microsurgical subinguinal varicocelectomy. All spermatic, cremasteric, and gubernacular veins were ligated. The vas was then isolated under magnification, the deferential vessels were preserved, and the vas was transected, cauterized, and clipped.

RESULTS

All 18 men (mean age 39.6 years) had grade II to III varicoceles on physical examination. We performed 27 microsurgical varicocelectomies with simultaneous microsurgical vasectomy. On average, the first follow-up visit occurred 14 weeks postoperatively. The mean testosterone level increased from 348 ng/dL preoperatively to 416 ng/dL postoperatively. No complications, episodes of testicular atrophy, vasectomy failures, or varicocelectomy recurrences developed. The incidence of varicoceles in fertile men presenting for vasectomy (4.8%) was lower than in the general population (15%); fertile men appear to be less likely to possess varicoceles.

CONCLUSIONS

Men presenting for vasectomy with incidental palpable varicoceles could benefit from simultaneous vasectomy-varicocelectomy. This should be performed microsurgically to identify and ligate both spermatic veins and vasa deferentia and to preserve not only the testicular artery, but also the deferential vessels to minimize the risk of testicular atrophy and the risk of insufficient venous drainage.

Effects of varicocele on electrical field stimulation-induced biphasic twitch responses in the ipsilateral and contralateral rat vasa deferentia

AIM

Although little is known about the mechanisms, varicocele is considered as one of the factors leading to male infertility. Since reduced motility of the vas deferens was shown to contribute to male infertility, in this study we aimed to investigate the effect of varicocele on electrical field stimulation (EFS)-induced biphasic contractions of the vas deferens in order to evaluate the effect of varicocele on the motility of the vas deferens.

MATERIAL AND METHODS

A total of 26 Sprague-Dawley rats (200-250 g) were assigned randomly into two groups: sham (n = 10) and varicocele (n = 16). Varicocele was produced by partial obstruction of the left renal vein. Four weeks after the surgical procedure, vasa deferentia were harvested and EFS-induced responses were recorded from the strips prepared from ipsilateral and contralateral sides via Grass isometric force displacement transducers. Exogenous alpha-beta methyl ATP was applied at the concentration of 10(-5)M to the vasa deferentia strips, and exogenous noradrenalin was applied cumulatively at the concentrations between 10(-7) and 10(-4)M. At the end of each experiment, 80 mM KCl was applied to induce contractions. All contractions were expressed as the percentage of the 80 mM KCl-induced contractions.

RESULTS

Varicocele significantly inhibited both phases of EFS-induced biphasic contractions in the ipsilateral side, whereas in the contralateral site it did not produce any change. However, there was no change in exogenously applied alpha-beta methyl ATP, noradrenalin and KCl-evoked contractions of the vasa deferentia obtained from both sides.

CONCLUSIONS

These results suggest that varicocele affects the ipsilateral vas deferens motility by reducing neurotransmitter release.

Paternity after varicocelectomy: preoperative sonographic parameters of success

OBJECTIVE

This study was done to assess the sonographic findings that could predict the outcome of varicocele repair in the treatment of male infertility/subfertility related to varicocele.

METHODS

This was a retrospective study and follow-up of 107 selected patients with male factor infertility related to the presence of varicocele. The patients were classified into 2 groups according to their estimated testicular size by sonography. Group 1 included 80 patients with normal-sized testes (>15 cm(3)), and group 2 included 27 patients with small testes (10-15 cm(3)). The mean age +/- SD was 34 +/- 11 years. The mean duration of infertility was 3.4 +/- 1.4 years. They had oligospermia, asthenospermia, or oligoasthenospermia. The patients underwent low ligation varicocelectomy and were followed for 18 to 45 months after surgery for occurrence of paternity. Their scrotal sonographic findings were reviewed and correlated with the postoperative paternity rate.

RESULTS

Postoperative paternity was achieved in 24 patients (30%) of group 1 with normal-sized testes and in 3 patients (11%) of group 2 with small testes. In patients of group 1, the positive paternity rate was higher (36.6%) in patients with clinically detected varicocele, compared with only 16% of patients with subclinical varicocele. In addition, postoperative paternity was significantly higher in patients with bilateral varicocele (54.5%; P = .0099), patients with shunt-type varicocele (75%; P = .0117), and patients with a permanent grade of venous reflux (70%; P = .0148). No significant differences were noted between positive paternity rates in patients with mildly or markedly dilated veins.

CONCLUSIONS

The best preoperative sonographic parameters of success of varicocele repair are the presence of normal-sized testes, clinically palpable veins, bilateral varicocele, shunt-type varicocele, and a permanent grade of venous reflux. It does not matter how much the veins are dilated.

Somatic angiotensin converting enzyme in varicocele

The ACE is found as two isozymes in the body. A somatic isozyme found in blood and several other tissues, and a testis-specific isozyme found only in developing spermatids and mature sperm. In this study, we investigated the ACE activity in left spermatic vein blood samples of infertile patients with varicocele and its correlation to spermatologic parameters. The somatic ACE activities were determined in the peripheral and left spermatic vein blood samples from 31 infertile patients who underwent variococelectomy, and 11 fertile control subjects underwent left inguinal herniorraphy. The somatic ACE activity was measured by kinetic spectrophotometric assay. Semen analyses were performed according to WHO guidelines. The mean somatic ACE activities of peripheral and left spermatic veins of the varicocele group were 60.3 +/- 23.0 and 60.2 +/- 23.2 U/L, respectively. In control group, peripheral and left spermatic vein ACE activities were found as 56.8 +/- 17.1 and 56.5 +/- 15.5 U/L, respectively. There was no significant difference between the ACE activity in peripheral and left spermatic vein blood sample from the varicocele and control group. There was no statistically significant correlation between the spermatologic parameters and ACE activities in the spermatic and peripheral vein in both of varicocele and control groups. As a result, it may be suggested that the somatic ACE has no causative role in pathophysiology of varicocele and varicocele related infertility.

Increased expression of interleukin-1α and interleukin-1β is associated with experimental varicocele

OBJECTIVE

To describe the effect of varicocele, in an experimental rat model, on the levels of IL-1alpha and IL-1beta proteins in testis tissue.

DESIGN

Comparative and controlled study.

SETTING

Experimental research.

ANIMAL(S)

Wistar male rats in experimental and control groups.

INTERVENTION(S)

The control group underwent sham operation (n = 6). Experimental groups underwent partial ligation of the renal vein to induce experimental varicocele and were then killed at 9 (n = 6), 11 (n = 6), and 13 (n = 6) weeks after induction of varicocele.

MAIN OUTCOME MEASURE(S)

Histologic evaluation of the varicocele model was determined by periodic acid-Schiff staining of paraffin-embeded testicular tissues. Levels of cytokines were assessed by immunohistochemistry and Western blot analysis.

RESULT(S)

Varicocele caused testicular damage, especially in 11- and 13-week-old varicocele groups. In sham-operated rats, Golgi complexes of round spermatids expressed especially the alpha form of IL-1. By the progression of varicocele, the IL-1alpha expression increased temporally in Sertoli cells, spermatogonia, primary spermatocytes, spermatids, and Leydig cells. The expression of IL-1beta was seen in Leydig cells in sham-operated rats. The IL-1beta expression was also increased upon progression of varicocele in Leydig cells, Sertoli cells, and spermatogonia.

CONCLUSION(S)

We suggest that IL-1alpha and IL-1beta are the regulators of testicular function. Certain pathologic conditions, e.g., varicocele, cause an increase in the expressions of such proinflammatory cytokines. The increased expression of IL-1alpha and IL-1beta in varicocele shifts the balance in favor of inflammatory and immune responses and causes detrimental effects in testis tissue, which may cause male infertility.

Inheritance of varicoceles

OBJECTIVES

To evaluate the inheritance of varicoceles through examination of first-degree relatives of patients with known varicoceles.

METHODS

A total of 44 patients with a known varicocele had available first-degree relatives (n = 62) examined for the presence of a varicocele between October 1997 and November 2003. An additional cohort of 263 men presenting for vasectomy reversal without a history of subfertility or varicocele was used as the control group. Varicocele grade and the presence of bilateral varicoceles were examined as predictive factors for inheritance.

RESULTS

Of the 62 first-degree relatives of patients with a known varicocele, 35 (56.5%) had a clinically palpable varicocele on physical examination. This was significantly greater than the 18 (6.8%) of 263 men in the control group (P < 0.0001). Of the first-degree relatives, 20 (74%) of 27 brothers, 13 (41%) of 32 fathers, and 2 (67%) of 3 sons had palpable varicoceles. Neither varicocele grade nor bilaterality was predictive of inheritance in these first-degree relatives.

CONCLUSIONS

The increase in varicocele prevalence is significant in the first-degree relatives (particularly brothers) of patients with known varicoceles. Given the detrimental effect of varicoceles on spermatogenesis and steroidogenesis, patients should be counseled about this increased risk in male family members.

THE PRESENCE OF VASAL VESSELS IN MEN WITH CONGENITAL BILATERAL ABSENCE OF THE VAS DEFERENS

PURPOSE

We characterized spermatic cord microanatomy in men with congenital bilateral absence of the vas deferens (CBAVD) presenting for varicocelectomy. We discuss the implications of these findings for varicocele repair.

MATERIALS AND METHODS

Between 1997 and 2003, 8 men with CBAVD underwent a total of 11 microsurgical subinguinal varicocelectomies at microsurgical epididymal sperm aspiration and cryopreservation. All 8 men had palpable grades II to III varicoceles and in 6 varicoceles were repaired due to painful symptomatology, while 2 had testicular hypotrophy with an abnormal hormonal profile. Three men had bilateral varicoceles repaired, while 5 underwent unilateral varicocelectomy. All patients provided a thorough history and underwent physical examination, hormonal evaluation, semen analysis, genetic testing and renal ultrasonography.

RESULTS

Intraoperative microsurgical dissection confirmed dilated internal and external spermatic veins, and absence of the vas deferens in all 11 spermatic cords. Characteristic tortuous vasal vessels of normal caliber were clearly identified in all 11 (100%) of these spermatic cords between the internal and external spermatic fasciae in the location where the vas deferens is usually found.

CONCLUSIONS

Despite the absence of the vas deferens normal sized, orthotopically located vasal vessels were present in 100% of the spermatic cords examined. Furthermore, the caliber of the vasal veins was sufficient to provide adequate venous return from the testis following ligation of the internal and external spermatic veins. In patients with CBAVD presenting for varicocele repair standard microsurgical varicocelectomy with ligation of all internal and external spermatic veins can be performed without the risk of testicular congestion secondary to inadequate venous drainage.

Effect of varicocele on testicular artery blood flow in men--color Doppler investigation

OBJECTIVE

Varicocele can be defined as an abnormal tortuosity and dilatation of the veins of the pampiniform plexus. Contradictory results have been obtained from experimental animal models and a few clinical human studies on testicular arterial blood flow in varicocele. The purpose of this study was to determine the changes in testicular arterial blood flow parameters in patients with varicocele.

MATERIAL AND METHODS

A total of 62 patients with a clinical diagnosis of left varicocele and a scrotal vein with a diameter of > or = 3 mm on color Doppler ultrasonography were included in the study. A total of 44 fertile normal male volunteers served as controls.

RESULTS

Median testicular arterial blood flow and median flow rate in milliliters per minute per 100 g of testicular tissue were found to be significantly decreased in the patient group compared to the control group: blood flow, 1.42 and 2.00 ml/min; flow rate, 9.63 and 12.35 ml/min/100 g, respectively (p < 0.05). Positive correlations were found between sperm concentration and left testicular artery blood flow (p < 0.05) and between left testicular volume and testicular artery blood flow (p < 0.05).

CONCLUSIONS

Testicular arterial blood flow was found to be significantly decreased in men with varicocele. This may be a reflection of the impaired microcirculation. Following decreased testicular arterial blood flow, impaired spermatogenesis may result from defective energy metabolism in the microcirculatory bed.

Improvement of sexual activity, pregnancy rate, and low plasma testosterone after bilateral varicocelectomy in impotence and male infertility patients

To evaluate the effects of bilateral varicocelectomy on sexual activity, testicular volumes, semen quality, and serum hormone levels in impotence and male infertility patients, 48 patients were studied from an outpatient clinic from May 1998 to March 2001. The mean age was 37+/-5.9; 16 patients were complaining of erectile dysfunction and 32 patients were complaining of male infertility. The mean duration of impotence was 3.3+/-2.4 years and for male infertility was 3.8+/-3.2 years. Sexual and reproductive history was taken for erectile dysfunction and male infertility patients. General, local examination, and laboratory investigations were done for all patients. Preoperative and postoperative testicular volumes; semen parameters, including semen volume, sperm count, and motility; and morphology and hormonal parameters, including LH and FSH, and testosterone levels were measured. All patients were followed up for 3-36 months after varicocele repair. Left and right testicular volume was improved in impotence and male infertility patients and fertility groups, but this improvement was not statistically significant (p>.25). The semen volume was significantly increased in male infertility patients and fertility group (p<.05), but there was no statistical significant difference in impotent patients (p>.25). The sperm count was improved in male infertility patients and fertility group, but this improvement was not statistically significant (p>.25), and in impotent patients there was no significant difference (p>.40). The sperm motility was very significantly increased in male infertility patients and the fertility group (p<.0005), and highly significantly increased in impotent patients (p<.005). The abnormal forms were not statistically significant in impotence and male infertility patients (p>.40), but significantly decreased in the fertility group (p<.05). Serum testosterone was very significantly increased in impotence and male infertility patients (p<.0005) and was highly significantly increased in fertility groups (p<.005). Serum FSH was improved in impotence and male infertility patients, but this improvement was not statistically significant (p>.10), and in fertility groups of male infertility patients, the results showed a statistically significant increase (p<.05). Serum LH was not statistically significant in impotence and male infertility patients (p>.10), and was significantly increased in fertility groups (p<.05). The improvement of sexual activity was 50-75%, the pregnancy rate for their partners was 37% and increased plasma testosterone levels over a period of 3 years of follow-up after varicocele repair.

The changes in testicular vascular permeability during progression of the experimental varicocele

OBJECTIVES

The vascular permeability of testicular capillaries which play a role in controlling the formation of testicular interstitial fluid was studied during the progressive course of experimental varicocele.

MATERIALS AND METHODS

The pathology was developed through partial ligation of left renal vein in four groups of rats. Controls of each group were subjected to sham surgery. After different periods of varicocele creation (1, 3, 6 and 14 weeks), animals' testes per one of the study groups were extirpated and weighed. The volume density percentages of polymorphnuclear leukocytes (PMN) per testicular blood vessels; which are markers of the increase in vascular permeability, were also estimated in both testes. To further verify the obtained findings, another group of animals received human chorionic gonadotrophin (hCG) treatment 6 weeks after varicocele creation and their histopathological sections were examined.

RESULTS

Animal testes' of (1 and 3 weeks) groups were found to be significantly heavier (p<0.05) than their controls. PMN showed accumulation in testicular blood vessels and their volume density percentages per these blood vessels in both testes were significantly higher in each study group than in those of its controls. However, these percentages showed gradual significant decline as the duration of varicocele bearing gradually increased. The hCG-treated animals revealed more accumulation of the PMN in their histopathological sections.

CONCLUSION

The present results suggest that experimental varicocele may induce an increase in testicular vascular permeability, which then decreases gradually with time. It is supposed that parallel changes in the rate of formation of testicular interstitial fluid may be accompanied. The results have also showed that the vasculature of the testis with experimental varicocele can still respond to hCG.

The adolescent varicocele: the crucial role of hormonal tests in selecting patients with testicular dysfunction

BACKGROUND/PURPOSE

Early identification and treatment of varicocele during adolescence may reduce the risk of infertility. Prophylactic surgery on all adolescents with varicocele would be unnecessary surgery on a high percentage of them. Suggested guidelines for early intervention have included testicular volume loss and abnormality in the hormonal integrity of the hypothalamic-pituitary-testicular axes. Previous studies have documented no correlation between testicular volume loss and abnormal response to GnRH test. The role of these 2 prognostic factors in predicting semen abnormalities in this age group never has been investigated, so far. In the current study we correlated hormonal tests and orchidometry to semen analysis in a selected group of adolescents.

METHODS

Adolescents with varicocele and Tanner stage V underwent semen analysis, Prader orchidometry, and hormonal tests (basal LH and FSH [bLH and bFSH], testosterone [T], LH and FSH after GnRH stimulation test [sLH and sFSH]). According to semen analysis (in relation to Oval Motility Index) patients were divided into 2 groups: group A, adolescents with pathologic semen and group B, adolescents with normal semen. Hormonal tests and testicular volumes (in those with left unilateral varicocele) were compared between the 2 groups. Statistical analysis was performed using Mann-Whitney U test and Student's t test.

RESULTS

Of 76 patients, 20 (Group A) had a pathologic semen analysis. Levels of bLH, bFSH, sFSH were significantly higher in group A compared with group B (56 with normal semen). sLH was higher in group A, but the difference was not statistically significant. T levels were not different between the 2 groups. Of 68 patients who had left unilateral varicocele and no previous inguinal--scrotal surgery 14 had pathologic semen analysis. There was no statistically significant difference between the 2 groups for any of the orchidometric parameters investigated.

CONCLUSIONS

The evaluation of testicular volumes during physical examination for varicocele in Tanner stage V adolescents is not predictive for testicular dysfunction. LH and FSH dosages with or without GnRH stimulation test can identify those subjects at risk for infertility, and their use should be encouraged for selecting patients who need surgical correction.

Varicocele in pediatric patients: comparative assessment of different therapeutic approaches

OBJECTIVES

The best therapeutic approach for varicocele correction in pediatric patients is still an object of some debate. We analyzed a series of 99 patients to identify the most effective approach in terms of low recurrence rates and preservation of testicular growth.

METHODS

One hundred four operations were performed on 99 patients between 9 and 16 years of age (mean 13.3). The first 18 patients underwent sclerotherapy of the internal spermatic vein. Twenty others underwent inguinal varicocelectomy. In 12 patients, a modified Palomo procedure (ie, sparing of the internal spermatic artery) was performed (four laparoscopically), and 54 were treated with the original Palomo procedure (ie, sectioning of the entire spermatic cord), using laparoscopy in 20.

RESULTS

Three recurrences (16.6%) occurred among the patients treated with sclerotherapy. Similar rates of recurrence were observed in those who underwent inguinal varicocelectomy (3 [15%] of 20) and modified Palomo procedures (2 [16.6%] of 12). Only one recurrence occurred in the 54 patients treated with the original Palomo procedure (1.85%).

CONCLUSIONS

Our experience, together with a review of published reports, leads us to believe that the open Palomo procedure as originally described is the most effective approach to the correction of varicoceles in adolescents.

Low plasma testosterone in varicocele patients with impotence and male infertility

To study the affect of bilateral varicocele (grade 3) on impotence and male infertility patients, 29 patients were selected from an outpatient clinic during 15 May 1998 to 15 August 1999 (the mean age was 33.9 +/- 6.3), 15 patients complaining of erectile dysfunction and 14 patients complaining of male infertility. The mean duration of impotence was 3 +/- 2.3 years and for male infertility was 6 +/- 2.5. All organic and psychogenic causes related to impotence and male infertility except bilateral varicocele (grade 3) and low plasma testosterone were excluded by clinical and laboratory investigations. Twenty males with normal erection and fertility were included as controls. Detailed medical history and complete physical examination included measurement of testicular size by orchiometer; semen and hormonal parameters were measured for all patients and control. In impotent patients left and right testicular volume was significantly decreased (p < .05), while in male infertility patients left and right testicular volume was highly significantly and, significantly decreased (p < .005, p < .05) compared to controls. In male infertility patients, left testicular volume was highly significantly decreased compared to impotent patients (p < .005). The sperm count and semen volume in impotent patients was significantly decreased (p < .05, p < .01), but no significant differences were found in sperm motility and abnormal forms, while in male infertility the sperm count was highly significantly decreased (p < .005), the sperm motility was significantly decreased (p < .05), the abnormal form was significantly increased (p) < .05), but in the semen volume there was no significant difference compared to controls. In impotent patients the sperm count was significantly increased and abnormal form was significantly decreased compared to male infertility (p < .05). The mean serum testosterone was significantly decreased in impotent patients (p < .01), and highly significantly decreased in male infertility (p < .005) compared to controls. The mean serum FSH was significantly increased in male infertility (p < .05) and nonsignificant in impotent patients compared to controls. The mean serum LH and prolactin levels were nonsignificant in both impotent and male infertility patients compared to controls, but LH was significantly increased in impotence compared to male infertility patients (p < .025). Therefore, bilateral varicocele (grade 3) is associated with significant reduction in testicular function with significant increase in serum levels of FSH and LH, which may cause erectile dysfunction and male infertility.

The role of adrenomedullin in varicocele and impotence

OBJECTIVE

To assess the levels of adrenomedullin (a vasodilatory peptide) in penile blood before and after injection with papaverine in impotent men, and in the internal spermatic vein in infertile patients with varicocele, comparing the results with levels in the brachial vein in the same patients.

PATIENTS AND METHODS

Intracavernosal levels of adrenomedullin were determined in 14 impotent men (with no vascular pathology, as assessed by colour Doppler ultrasonography) before and after papaverine-induced penile erection. The effect of needle puncture alone was assessed in eight control patients. The level of adrenomedullin was also measured in the internal spermatic vein and brachial vein in 14 infertile men with varicocele.

RESULTS

The mean (SD) intracavernosal adrenomedullin levels in the 14 impotent men were significantly different between the flaccid and papaverine-induced erectile state, at 93.5 (33.0) and 135.8 (34.9) pmol/mL, respectively, (P < 0.05). Needle puncture alone had no effect on adrenomedullin levels. In men with varicocele, the adrenomedullin level of 139.0 (34.3) pmol/mL within the internal spermatic vein was significantly higher than that in the brachial vein, at 103.9 (37.6) pmol/mL (P < 0.05).

CONCLUSION

Injection with papaverine increases adrenomedullin release into penile blood; this release may be responsible for the increase in penile blood flow and penile erection. Higher levels of adrenomedullin within the internal spermatic vein of patients with varicocele may result from the retrograde flow of venous blood from the left adrenal gland and kidney. Further studies are needed to determine the role of adrenomedullin in male infertility and impotence.

Effect of surgically induced varicocele on testicular blood flow and Sertoli cell function

OBJECTIVES

To evaluate the effect of varicocele on testicular blood flow and expression by Sertoli cells of transferrin and androgen-binding protein (ABP), to determine whether varicoceles impair Sertoli cell function.

METHODS

Experimental varicocele was established in male Sprague-Dawley rats by partial ligation of the left renal vein. The control group received a sham operation. At 30 minutes after surgery, rats underwent a xenon-133 washout study, and at 30 days after surgery, transferrin, ABP, and testicular blood flow were evaluated. Expression of transferrin and ABP were evaluated using immunohistochemical techniques. Testicular blood flow was measured using xenon-133 clearance techniques. Statistical analyses were done with an independent t test.

RESULTS

The testicular blood flow was 16.7 +/- 1.25 mL/100 g/min in varicocele-bearing rats and 21.01 +/- 0.46 mL/100 g/min in sham-operated rats 30 minutes after surgery. Testicular blood flow remained decreased at 30 days in varicocele-bearing rats (15.12 +/- 1.08 mL/100 g/min) and remained stable in the control group (19.45 +/- 0.55 mL/100 g/min). The expression of transferrin and ABP was significantly reduced in varicocele-bearing rats compared with the control group.

CONCLUSIONS

Our study suggests that a decrease in testicular blood flow may lead to impaired Sertoli cell function in varicocele-bearing rats.

Abnormal morphology of vervet monkey sperm

Ejaculates of 14 colony-bred and 14 wild-caught vervet monkeys were examined for morphologically abnormal sperm. Sperm head abnormalities were rare in both groups, occurring at rates of 0.01-0.29%. Tail abnormalities predominated, particularly bent midpieces and coiled and folded tails, which all occurred at rates of 3.79-17.18%. Except for the nipple acrosome, there was no difference in the rate at which sperm abnormalities were found in both groups. Three abnormalities were found only in colony-bred and three only in wild-caught individuals. Some common abnormalities, all affecting the tail, were highly variable in consecutive ejaculates from the same individuals.

The effect of varicoceles on testicular blood flow in man

OBJECTIVES

To assess the effect of varicoceles on testicular blood flow in man.

METHODS

Testicular blood flow was measured in 248 consecutive men attending an infertility clinic and 34 fertile volunteers using color duplex ultrasonography.

RESULTS

The testicular blood flow of men with either clinical and/or subclinical varicoceles was not significantly different from controls without varicoceles.

CONCLUSIONS

Varicoceles do not significantly alter testicular blood flow in man.

Antegrade scrotal sclerotherapy for the treatment of varicocele: technique and late results

Antegrade sclerotherapy has been used since 1987 to treat patients with varicocele. The method has proved to be easy to perform, safe, economical and effective. The treatment results in 285 patients who had undergone sclerotherapy for a total of 317 varicoceles are presented and discussed. This followup study revealed that 285 of the patients (91%) had no signs of recurrent or persistent varicocele. In 57 cases (42%) of inability to conceive the partners became pregnant after antegrade varicocele sclerotherapy. Antegrade sclerotherapy represents an alternative treatment to high ligation and retrograde sclerotherapy, as well as to laparoscopic and microsurgical procedures.

Anatomical characteristics of the left testicular venous system in man

Autopsy was performed on 49 male cadavers and the entire course of the left testicular vein (LTV) was studied. The testicular venous pathway was divided into four levels: scrotal, inguinal, pelvic, and lumbar. At the scrotal level, many small testicular veins constituting the pampiniform plexus showed various anastomoses with the cremasteric and vasal veins. At the inguinal and pelvic level, 4-12 and 2-8 LTVs were recognized, respectively. At the pelvic level, absence of valves was seen in 33% of the cases. At the lumbar level, 1-5 LTVs were observed and were mainly anastomosed with the retroperitoneal, ureteral, and kidney capsular veins. Absence of valves at the lumbar level was seen in 37% of the cases. In 11 cases, the valves that were present were incompetent. The presence of more than one LTV at the lumbar level indicates the necessity for attentive identification of all of the testicular veins during surgical treatment of varicocele.

Microsurgical inguinal varicocelectomy with delivery of the testis: an artery and lymphatic sparing technique

Conventional techniques of varicocele repair are associated with substantial risks of hydrocele formation, ligation of the testicular artery, and varicocele recurrence. We describe a microsurgical technique of varicocelectomy that significantly lowers the incidence of these complications. The testicle is delivered through a 2 to 3 cm. inguinal incision, and all external spermatic and gubernacular veins are ligated. The testis is returned to the scrotum and the spermatic cord is dissected under the operating microscope. The testicular artery and lymphatics are identified and preserved. All internal spermatic veins are doubly ligated with small hemoclips or 4-zero silk and divided. The vas deferens and its vessels are preserved. Initially, we performed 33 conventional inguinal varicocelectomies in 24 men without delivery of the testis or use of a microscope. Postoperatively, 3 unilateral hydroceles (9%) and 3 unilateral recurrences (9%) were detected. For the next 12 cases 2.5x loupes were used resulting in no hydroceles but another recurrence (8%). We then performed 640 varicocelectomies in 429 men using the microsurgical technique with delivery of the testis. Among 382 men available for followup examination from 6 months to 7 years postoperatively no hydroceles and no cases of testicular atrophy were found. A total of 4 unilateral recurrent varicoceles (0.6%) was identified. The differences between the techniques in the incidence of hydrocele formation and varicocele recurrence are highly significant (p < 0.001). No wound infections occurred in any men. Four scrotal hematomas (0.6%), 1 of which required surgical drainage, occurred in the group with microsurgical ligation and delivery of the testis compared to none with the conventional technique. Preoperative and postoperative semen analyses (mean 3.57 analyses per patient) were obtained on 271 men. The changes in sperm count x 10(6) cc (36.9 to 46.8, p < 0.001), per cent motility (39.6 to 45.7%, p < 0.001) and per cent normal forms (48.4 to 52.10%, p < 0.001) were highly significant. The pregnancy rate was 152 of 357 couples (43%) followed for a minimum of 6 months postoperatively. Delivery of the testis through a small inguinal incision provides direct visual access to all possible avenues of testicular venous drainage. The operating microscope allows identification of the testicular artery, lymphatics and small venous channels. This minimally invasive, outpatient technique results in a significant decrease in the incidence of hydrocele formation, testicular artery injury and varicocele recurrence.

Effects of surgical repair of experimental left varicocele on testicular temperature, spermatogenesis, sperm maturation, endocrine function, and fertility in rabbits

To evaluate the effectiveness of surgical correction of varicocele in restoring the function of the varicocelized testicle, experimental varicoceles were created in 16 male rabbits by partly ligating the left lumbotesticular trunk. Five control rabbits received a sham operation (group A). Two months later, eight of the varicocelized rabbits underwent surgical repair by ligation and cutting of the dilated left testicular vein (group B). The remaining eight varicocelized animals did not receive any additional treatment (group C). Five months after the initial operation, group C animals had a significantly lower sperm concentration, sperm motility, bilateral testicular androgen-binding protein activity, bilateral testicular vein testosterone concentration, bilateral testicular versus intraabdominal temperature difference, and fertility when compared with groups A and B. These findings suggested that the surgical repair of an experimental varicocele in the rabbit can significantly improve the parameters indicating the harmful effects of the varicocele on the testicles.

Testicular volume assessment in the adolescent with a varicocele

Testicular growth arrest is the main criterion for performing varicocele ligation in the adolescent population. Previous assessments concerning significant size discrepancy range from 0.5 to 5 cm.3, a 10-fold difference. We prospectively assessed testicular size in 22 male adolescents (ages 9 to 19 years) with varicoceles, and compared testicular volume as measured by ultrasound and Prader orchidometer in 19 of these patients. The accuracy of ultrasound for this purpose was evaluated by blinded ultrasonic measurements of models of known volume and a standard deviation of +/- 1.6 cm.3 was found. Using a size discrepancy of greater than 2 cm.3 as the criterion for growth arrest, 4 of 17 patients (24%) with growth arrest would have been missed with the Prader orchidometer alone. Testicular volumetric assessment by ultrasound accurately measured volumetric differences of greater than 2 cm.3 and can be used to determine growth arrest in the male adolescent with a varicocele.