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Oh KT, Kim SW, Kang SK, Kim SH, Lee CN, Han SW, Lee YS. An Analysis of Major Causes of Surgical Failure Using Bähren System in Intraoperative Venography During Varicocelectomy. Yonsei Med J 2021; 62:928-935. [PMID: 34558872 PMCID: PMC8470570 DOI: 10.3349/ymj.2021.62.10.928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 07/14/2021] [Accepted: 07/19/2021] [Indexed: 11/27/2022] Open
Abstract
PURPOSE In young patients with varicocele, preservation of the internal spermatic artery may be advantageous for catch-up growth, but it may also increase the likelihood of treatment failure. Intraoperative venography reduces the likelihood that unsealed veins will remain after varicocelectomy. We analyzed the characteristics of remnant veins visualized through intraoperative venography to investigate the cause of surgical failure in artery-sparing varicocelectomy (ASV). MATERIALS AND METHODS We retrospectively analyzed clinical characteristics and outcomes of patients aged 18 years or younger who underwent varicocelectomy with intraoperative venography from January 2005 to December 2017. During varicocelectomy, intraoperative venography was performed to distinguish veins from other structures. Any unsealed veins that were discovered were ligated and classified using the Bahren system. RESULTS One hundred and sixty-two patients underwent intraoperative venography: 153 cases (94.4%) were for primary varicocelectomy, and 9 cases (5.6%) were for repeat varicocelectomy. Open varicocelectomy was performed in 105 cases (64.8%), and laparoscopic varicocelectomy was performed in 57 cases (35.2%). Venography revealed remnant veins after the first ligation in 51 cases (31.2%), 46 (90.2%) and 5 (9.8%) of which were Bähren types 3 and 4, respectively. Five patients (3.1%) experienced varicocele recurrence, classified as persistence in 1 patient (0.6%) and relapse in 4 patients (2.5%). CONCLUSION Remnant collateral veins of the internal spermatic vein (ISV) (Bahren type 3) are the most common cause of failure in ASV. In a few patients, an external spermatic vein merges with the ISV at a higher level (Bahren type 4) and is unidentifiable without venography.
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Affiliation(s)
- Kyung Tak Oh
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Woon Kim
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Ku Kang
- Department of Urology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Sung Hoon Kim
- Department of Pediatric Urology, Severance Children's Hospital, Seoul, Korea
| | - Cho Nyeong Lee
- Department of Pediatric Urology, Severance Children's Hospital, Seoul, Korea
| | - Sang Won Han
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Seung Lee
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea.
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Lorenc T, Krupniewski L, Palczewski P, Gołębiowski M. The value of ultrasonography in the diagnosis of varicocele. J Ultrason 2016; 16:359-370. [PMID: 28138407 PMCID: PMC5269523 DOI: 10.15557/jou.2016.0036] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 03/10/2016] [Accepted: 03/14/2016] [Indexed: 01/16/2023] Open
Abstract
A varicocele is described as pathologically enlarged, tortuous veins of the pampiniform plexus, leading to an increased testicular temperature and adrenal metabolite reflux into the testes. Varicocele can impair spermatogenesis and is considered to be the most common cause of male infertility. Patients may palpate a thickening in the scrotum or complain of dull scrotal or inguinal pain, which increases when standing or during erection. In the case of a sudden onset of varicocele in elderly men, it is necessary to exclude renal tumor and extend diagnostic ultrasound with the assessment of the abdominal cavity. The diagnosis of varicocele is based on medical history and physical examination, which involves palpation and observation of the scrotum at rest and during the Valsalva maneuver. Ultrasound is the imaging method of choice. The width and the number of vessels in the pampiniform plexus as well as the evaluation and measurement of regurgitation during the Valsalva maneuver are typical parameters analyzed during ultrasound assessment. However, diagnostic ultrasound is still a controversial method due to numerous and often divergent classification systems for varicocele assessment as well as its poor correlation with clinical manifestations. As a result of introduction of clear ultrasound criteria as well as the development of elastography and nuclear magnetic resonance, diagnostic imaging can play an important role in assessing the risk of damage to the testicular parenchyma, qualifying patients for surgical treatment and predicting the effects of therapy.
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Affiliation(s)
- Tomasz Lorenc
- 1 Department of Clinical Radiology, Medical University of Warsaw, Warsaw, Poland
| | - Leszek Krupniewski
- 1 Department of Clinical Radiology, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Palczewski
- 1 Department of Clinical Radiology, Medical University of Warsaw, Warsaw, Poland
| | - Marek Gołębiowski
- 1 Department of Clinical Radiology, Medical University of Warsaw, Warsaw, Poland
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Imaging and angiography in male factor infertility. Fertil Steril 2016; 105:1432-42. [DOI: 10.1016/j.fertnstert.2016.04.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 04/06/2016] [Accepted: 04/07/2016] [Indexed: 02/07/2023]
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Qi X, Wang K, Zhou G, Xu Z, Yu J, Zhang W. The role of testicular artery in laparoscopic varicocelectomy: a systematic review and meta-analysis. Int Urol Nephrol 2016; 48:955-65. [PMID: 26971102 DOI: 10.1007/s11255-016-1254-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 02/23/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE We performed this meta-analysis to evaluate the efficacy and safety of artery preserving versus artery non-preserving in laparoscopic varicocelectomy. METHODS All publications up until October 2015 were searched in PubMed, EMBASE, Ovid, Web of Science, and Cochrane library. Randomized controlled trials (RCTs) and cohort studies (CSs) that compared the difference in two operative approaches in laparoscopic varicocelectomy were included. Statistical analysis was performed using Stata version 12.0. RESULTS A total of four RCTs and ten CSs involving 503 cases with artery preserving and 911 cases with artery non-preserving met our inclusion criteria. Meta-analysis showed that artery preserving had higher recurrence rate [risk ratio (RR) = 2.91, 95 % confidence interval (CI) 1.83-4.61; P = 0.000], lower incidence of hydrocele formation (RR = 0.18; 95 % CI 0.08-0.42; P = 0.000), and prolonged operating time [standard mean difference (SMD) = 1.27; 95 % CI 0.17-2.37; P = 0.023], compared with artery non-preserving in laparoscopic varicocelectomy. The results were similar in postoperative catch-up growth (RR = 1.00; 95 % CI 0.86-1.17; P = 0.985) and testicular atrophy (RR = 0.36; 95 % CI 0.09-1.54; P = 0.169). Besides, no significant difference was found in sperm concentration, motility, and normal morphology between two groups, as well as on postoperative pregnancy rate (RR = 0.95; 95 % CI 0.65-1.40; P = 0.809). CONCLUSION With the advantages of less recurrence, easier operating and less time spending, and comparable results in other respects, artery non-preserving is preferable to artery preserving in laparoscopic varicocelectomy, although there is a relatively high incidence of hydrocele formation. Considering the limitation of included studies, more large-scaled RCTs are required to confirm the present findings.
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Affiliation(s)
- Xiaokang Qi
- Department of Urology, Subei People's Hospital, No. 98 Nantong West Road, Yangzhou, 225001, Jiangsu, China.,Department of Urology, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Kunpeng Wang
- Department of Urology, The First People's Hospital of Lianyungang City, No. 182 North Tongguan Road, Xinpu District, Lianyungang, 222002, Jiangsu, China
| | - Guangchen Zhou
- Department of Urology, Subei People's Hospital, No. 98 Nantong West Road, Yangzhou, 225001, Jiangsu, China
| | - Zhen Xu
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Junjie Yu
- Department of Urology, Subei People's Hospital, No. 98 Nantong West Road, Yangzhou, 225001, Jiangsu, China
| | - Wei Zhang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China.
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Li F, Chiba K, Yamaguchi K, Okada K, Matsushita K, Ando M, Yue H, Fujisawa M. Effect of varicocelectomy on testicular volume in children and adolescents: a meta-analysis. Urology 2012; 79:1340-5. [PMID: 22516359 DOI: 10.1016/j.urology.2012.02.022] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 01/18/2012] [Accepted: 02/14/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To evaluate the effect of surgical intervention on catch-up growth as determined by a decreased testicular volume discrepancy in children and adolescents with varicocele. METHODS A systematic search was performed using MEDLINE and the PubMed database and cross-referenced as of October 28, 2011 using the terms "varicocele," "children," "adolescent," "surgery," and "testicular volume." All relevant studies were of the testicular volume discrepancy variance before and after surgical repair. The outcomes included the number of patients with initial testicular atrophy and those with catch-up growth after surgical repair. The database search, quality evaluation, and data extraction were independently performed by 2 reviewers. RESULTS Of 75 studies, 14 were included for analysis and involved 1475 patients. The combined analysis showed that the testicular volume discrepancy was significantly reduced after surgery in the ≥10% group (P < .00001) and ≥20% group (P < .00001), respectively. No difference was found between the 2 groups (P = .70). Taken together, the number of patient with testicular volume disproportion in all pediatric and adolescent varicocele patients significantly decreased after surgery (P < .00001). The average proportion of catch-up growth was 76.4% (range 52.6%-93.8%). CONCLUSION The meta-analysis suggested clear advantages of surgical intervention on reducing testicular hypotrophy when the discrepancy is ≥10% in children and adolescents with varicocele. Additional prospective and controlled studies are warranted to elucidate the treatment of children and adolescents with varicocele.
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Affiliation(s)
- Fuping Li
- Division of Urology, Department of Surgery Related, Faculty of Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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Franco G, Greco E. Re: Recurrence of varicocele after high retroperitoneal repair: implications of intraoperative venography. J Urol 2002; 167:653-4. [PMID: 11792946 DOI: 10.1097/00005392-200202000-00055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Niedzielski J, Paduch DA. Recurrence of varicocele after high retroperitoneal repair: implications of intraoperative venography. J Urol 2001. [PMID: 11176519 DOI: 10.1016/s0022-5347(05)66579-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE We determined whether intraoperative venography results in a decreased recurrence rate after varicocele repair in adolescence. MATERIALS AND METHODS We evaluated 177 male adolescents 14 to 19 years old who underwent varicocele repair via the high retroperitoneal approach with artery sparing and intraoperative venography. RESULTS Overall the recurrence rate was 2.8% (5 of 177 cases) in the venography group and 11% in historical controls without venography. We identified left-to-right cross communicating vessels in 3 patients with recurrence. Intraoperatively venography revealed nonligated vessels in 21 patients (12%), resulting in revision and repair during the same procedure. CONCLUSIONS Intraoperative venography seems to decrease the rate of recurrence. Left-to-right cross communicating vessels may be present in some adolescents with recurrence after varicocelectomy.
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Affiliation(s)
- J Niedzielski
- Division of Urology and Renal Transplantation, OHSU, Portland, Oregon, USA
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CHALLENGING THE ROLE OF CREMASTERIC REFLUX IN THE PATHOGENESIS OF VARICOCELE USING A NEW VENOGRAPHIC APPROACH. J Urol 1999. [DOI: 10.1097/00005392-199901000-00039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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FRANCO GIORGIO, IORI FRANCESCO, de DOMINICIS CARLO, DAL FORNO SILVIA, MANDER ANTONIO, LAURENTI CESARE. CHALLENGING THE ROLE OF CREMASTERIC REFLUX IN THE PATHOGENESIS OF VARICOCELE USING A NEW VENOGRAPHIC APPROACH. J Urol 1999. [DOI: 10.1016/s0022-5347(01)62080-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- GIORGIO FRANCO
- “U. Bracci” Department of Urology, “La Sapienza” University of Rome, Rome, Italy
| | - FRANCESCO IORI
- “U. Bracci” Department of Urology, “La Sapienza” University of Rome, Rome, Italy
| | - CARLO de DOMINICIS
- “U. Bracci” Department of Urology, “La Sapienza” University of Rome, Rome, Italy
| | - SILVIA DAL FORNO
- “U. Bracci” Department of Urology, “La Sapienza” University of Rome, Rome, Italy
| | - ANTONIO MANDER
- “U. Bracci” Department of Urology, “La Sapienza” University of Rome, Rome, Italy
| | - CESARE LAURENTI
- “U. Bracci” Department of Urology, “La Sapienza” University of Rome, Rome, Italy
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Palmer LS, Maizels M, Kaplan WE, Stokes S, Firlit CF. The influence of surgical approach and intraoperative venography on successful varicocelectomy in adolescents. J Urol 1997; 158:1201-4. [PMID: 9258173 DOI: 10.1097/00005392-199709000-00135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE We evaluated the importance of intraoperative venography and surgical approach on varicocele recurrence after surgical varicocelectomy in male adolescents. MATERIALS AND METHODS The analysis was done using local data and composite data from the literature. We reviewed the records of patients undergoing varicocele ligation between 1986 and 1995 at our institution. Data were stratified by surgical approach and performance of venography, and compared by cross table analysis. Data were then compiled from the literature from series that included cases stratified according to surgical approach and/or performance of venography. The impact of these parameters on recurrence rates was assessed by computing success rates and cross table analysis. RESULTS At our institution 33 boys underwent ligation via a suprainguinal (27) or inguinal (8) approach. Intraoperative post-ligation venography was performed in 16 cases and omitted in 19. Neither surgical approach nor performance of venography influenced the recurrence rate in these patients (not statistically significant). Similarly, venography did not affect the recurrence rate after stratification by surgical approach (not significant). The overall success rate was 97% (34 of 35 cases). These data were added to those of 3 published studies, totaling 252 varicoceles with comparable groupings. Mean success rate after a suprainguinal and inguinal approach was 95.6 (93.2 to 97.4) and 88.3% (82.7 to 100%), respectively. Recurrence tended to be less common after a suprainguinal than an inguinal approach (p = 0.06). Post-ligation venography did not statistically affect the success rate after stratification according to surgical approach but it was associated with a higher success rate when performed with the inguinal approach. CONCLUSIONS Irrespective of the performance of venography, the suprainguinal surgical approach yields higher success rates than the inguinal approach to varicoceles in adolescents. Post-ligation intraoperative venography fails to affect significantly the success of varicocele ligation but it may be useful during an inguinal approach.
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Affiliation(s)
- L S Palmer
- Division of Urology, Children's Memorial Hospital/Northwestern University Medical School, Chicago, Illinois, USA
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Palmer LS, Maizels M, Kaplan WE, Stokes S, Firlit CF. The Influence of Surgical Approach and Intraoperative Venography on Successful Varicocelectomy in Adolescents. J Urol 1997. [DOI: 10.1016/s0022-5347(01)64427-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Lane S. Palmer
- From the Division of Urology, Children's Memorial Hospital/Northwestern University Medical School, Chicago, Illinois
| | - Max Maizels
- From the Division of Urology, Children's Memorial Hospital/Northwestern University Medical School, Chicago, Illinois
| | - William E. Kaplan
- From the Division of Urology, Children's Memorial Hospital/Northwestern University Medical School, Chicago, Illinois
| | - Sam Stokes
- From the Division of Urology, Children's Memorial Hospital/Northwestern University Medical School, Chicago, Illinois
| | - Casimir F. Firlit
- From the Division of Urology, Children's Memorial Hospital/Northwestern University Medical School, Chicago, Illinois
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Abstract
BACKGROUND/PURPOSE Conventional varicocelectomy is often complicated by postoperative recurrences. When failure occurs, it is likely to be caused by incomplete interruption of the testicular vein, which is divided into multiple branches, or by the parallel collaterals, and to incompetence of the cremasteric vein(s). Occasionally it is caused by reversed flow in the deferential vein(s). METHODS The author reports his experience with 172 consecutive corrections of varicocele in adolescents (mean age, 13.4 years) by means of a personally modified technique. This technique is characterized by ileoinguinal access to all venous areas such as the retroperitoneum and the inguinal canal; ligature and transection of the internal and external spermatic veins, the parallel collaterals, and the deferential vein(s), if dilated and tortuous, with spermatic artery preservation; control of the interruption of flow in these veins by injection of methylene-blue solution in a vein of the pampiniform plexus (blue venography). Optical magnification (4x) and papaverine solution were also used. The rationale for this surgical approach is twofold: interruption of all testicular veins incompetent and potentially incompetent; easy and effective intraoperative control of venous interruption. RESULTS No varicocele recurrences or postoperative controlateral varicoceles were detected (follow-up, 6 to 24 months). The complications include a postoperative testicular atrophy by intraoperative methylene-blue extravasation with large hematoma of the cord and three postoperative hydroceles. CONCLUSION The surgical approach reported here is a simple, safe, artery-sparing technique.
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Affiliation(s)
- P Campobasso
- Divisione di Chirurgia Pediatrica, Ospedale San Bortolo, Vicenza, Italy
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Skoog SJ, Roberts KP, Goldstein M, Pryor JL. The adolescent varicocele: what's new with an old problem in young patients? Pediatrics 1997; 100:112-21. [PMID: 9200369 DOI: 10.1542/peds.100.1.112] [Citation(s) in RCA: 143] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- S J Skoog
- Department of Urology, Oregon Health Sciences Center, USA
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Abstract
Proper surgical management of adolescent varicocele is controversial. Recent evidence suggests that the Palomo approach gives the best results. We report on the outcomes of 43 consecutive adolescent boys who underwent operative correction of varicocele by a single surgeon from 1979 to 1992. An inguinal approach with ligation of the vascular pedicle above the vas deferens (modified Palomo) was used in each case. From 1979 to 1983 an attempt was made to preserve the testicular artery but it was successful in only 6 of 12 cases. After 1983 no further attempt was made to preserve the artery and, therefore, 37 patients underwent total ligation of the vascular pedicle above the entry of the vas deferens into the spermatic cord. Most of the varicoceles were grade II. Significant discrepancy in testicular volume (10% difference) constituted the main indication for operation. The ipsilateral (left) testis was smaller in 30 of 37 patients (81%). Of those testes with size discrepancy 90% showed significant volume increase following surgery. Many left testes assumed the same volume as the normal right testis. The only surgical failure (recurrence) of the 43 cases occurred in 1 of the 6 in which artery preservation was successful. There were no surgical failures in the group of 37 boys. Mean followup is 3.7 years. Total ligation of the testicular vascular pedicle seems to afford catch-up growth for smaller ipsilateral testes with low risk for recurrence of the varicocele.
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Affiliation(s)
- T S Parrott
- Emory University School of Medicine, Scottish Rite Children's Medical Center, Atlanta, Georgia
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