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

Effects of Systolic Blood Pressure Elevation on Internal Sperm Artery Identification During Microsurgical Subinguinal Varicocelectomy

Microsurgical subinguinal varicocelectomy (MSV) is the gold standard for treating varicoceles. Preservation of the internal spermatic arteries (ISAs) during MSV is important for sperm production. This study aimed to evaluate the safety and efficacy of elevating systolic blood pressure (SBP) using MSV. Data from 252 consecutive adult male patients were retrospectively reviewed. The patients were divided into two groups: a traditional group that underwent conventional MSV (n = 134) and a modified group that underwent MSV with a transiently elevated SBP of 140-160 mm Hg (n = 118). Arterial identification time, unilateral operative time, number of ISAs, arterial injury rate, and other postoperative indicators, including postoperative complications and sperm parameters, were compared between the groups. All the procedures were successful. The arterial identification and unilateral operative times were significantly shorter in the modified group (31.34 ± 10.44 vs. 42.94 ± 12.39 min and 61.48 ± 8.78 vs. 76.35 ± 12.33 min, p < .01, respectively). Intraoperatively, the number of preserved ISAs was significantly higher in the modified group (1.92 ± 0.53 vs. 1.45 ± 0.32, p < .01). The arterial injury rate did not differ significantly between the groups (2.74% vs. 0%, respectively). Compared with preoperative values, sperm parameters improved significantly 6 months postoperatively. Significant differences in semen parameters or postoperative complications were not observed between the groups. Elevated intraoperative SBP can be used to rapidly, safely, and effectively identify ISAs, increase the number of retained spermatic arteries, and markedly reduce the operative time for MSV.

Effect of varicocele and varicocelectomy on sperm deoxyribonucleic acid fragmentation rates in infertile men with clinical varicocele

Varicocele is the leading cause of male infertility. It can affect sperm quantity and quality through various non-mutually exclusive pathophysiological mechanisms, mainly oxidative stress. Excessive production of reactive oxygen species may overwhelm the sperm's defenses against oxidative stress and harm the sperm's DNA. Excessive sperm DNA breaks, so-called sperm DNA fragmentation, result from the oxidative stress cascade and are commonly found in the ejaculates of men with varicocele and fertility-related issues. Measuring sperm DNA fragmentation can provide valuable information on the extent of harm and might help select candidates for surgical treatment. Varicocelectomy is beneficial for alleviating oxidative stress-associated infertility and improving sperm DNA integrity. However, reproductive outcomes of infertile men with elevated sperm DNA fragmentation rates and surgically treated varicoceles remain poorly studied, and there is a need for well-designed trials to determine the impact of sperm DNA fragmentation reduction on natural and medically assisted reproduction.

[Varicocele and male infertility]

BACKGROUND

Varicocele is the most common correctable cause of male infertility. It was the subject of recent Association française d'urologie (AFU) Comité d'andrologie et de médecine sexuelle (CAMS) recommendations. Since then, the literature has provided additional information. This review will comprehensively reassess current indications for the treatment of varicocele, and revisit contemporary issues in the light of current advances.

METHODS

Update of the literature search carried out as part of the CAMS recommendations for the period between 2020 and 2023.

RESULTS

Microsurgical sub-inguinal varicocelectomy remains the surgical treatment of choice for infertile men with clinical varicocele and abnormal sperm parameters. It offers recurrence rates of less than 4%. It significantly improves both natural and in vitro fertilization live birth and pregnancy rates, as well as sperm count, total and progressive motility, morphology and DNA fragmentation rates. All in all, it modifies the MPA strategy in around one in two cases. Varicocele grade and bilaterality are predictive of improved sperm parameters and pregnancy rate. Treatment of subclinical varicocele is not recommended. Complications are rare, notably hydroceles (0.5%), unilateral testicular atrophy due to arterial damage (1/1000), hematomas, delayed healing and postoperative pain. Retrograde embolization is an alternative to surgery.

CONCLUSION

Whenever possible, the urologist should present and discuss treatment options for varicocele with the MPA team and the patient, taking a personalized approach.

[Surgery to improve male fertility]

BACKGROUND

At a time when increasing attention is being paid to the limitations and risks of in vitro fertilisation techniques, surgeries to improve male fertility are attracting growing interest.

METHODS

Systematic review based on a Pubmed search of surgeries to improve male fertility.

RESULTS

Vasovasostomy (VV) gives patency rates of 70-97% and pregnancy rates of 30-76%. Vasoepididymostomy (VE) gives patency rates of 80-84%, with pregnancy rates of 40-44%. The duration of obstruction and the age of the partner are 2 predictive parameters for the occurrence of a natural pregnancy. In cases of obstructive azoospermia due to pelvic obstruction (prostatic cyst, obstruction of the ejaculatory ducts), several surgical procedures may be proposed. Transurethral resection of the ejaculatory ducts leads to an improvement in sperm parameters in 63-83% of patients, with spontaneous pregnancy occurring in 12-31% of cases. Microsurgical cure of varicocele by the subinguinal route is a benchmark technique with recurrence rates of less than 4%. It improves live birth and pregnancy rates, both naturally and by in vitro fertilization, as well as sperm count, motility and DNA fragmentation rates.

CONCLUSION

Whenever possible, the urologist should present the surgical options for improving male fertility to the ART team and to the couple, discussing the benefit/risk balance of the operation as part of a personalized approach.

Increased intraoperative vein ligation in microsurgical varicocelectomy is associated with pain improvement

Varicocele is a major cause of male infertility. However, few studies have discussed the potential associations between the pain caused by varicocele and preoperative and intraoperative factors. The aim of this study was to evaluate factors potentially associated with changes in pain score after microsurgical varicocelectomy. This retrospective study was conducted between August 2020 and August 2022 at China Medical University Hospital in Taichung, Taiwan. Patient characteristics including age, body mass index, semen analysis, testicular volume, and the number of veins ligated were collected. Preoperative and intraoperative factors were analyzed to determine if they were correlated with changes in numeric rating scale (NRS) after microsurgical varicocelectomy. A total of 44 patients with clinical varicocele underwent subinguinal microsurgical varicocelectomy and were analyzed. The overall pain resolution rate was 91%, and the average satisfaction score after surgery was 9.2 according to their subjective feelings. Multivariate analysis revealed that severe varicocele grade (odds ratio [OR] 16.5, 95% confidence interval [CI] 3.01-90.47; P = .018) and the number of veins ligated (OR 6, 95% CI 1.6-22.48; P = .013), were significantly associated with changes in NRS after surgery. In addition, the area under the receiver operating characteristic curve for changes in NRS and the total number of veins ligated was 0.869. Microsurgical varicocelectomy had a high success rate for scrotal pain and satisfaction. Severe varicocele grade and the number of veins ligated in microsurgical varicocelectomy were associated with postoperative pain improvement.

Varicocele: To Treat or Not to Treat?

Varicocele treatment in infertility still remains controversial. It is clear, in fact, that in many patients, varicocele has no impact on fertility. Recent scientific evidence demonstrated that varicocele treatment is beneficial in improving semen parameters and pregnancy rate when an appropriate selection of patients is made. The purpose of treating varicocele in adults is mainly to improve current fertility status. On the other hand, the goal of treatment in adolescents is to prevent testicular injury and maintain testicular function for future fertility. Hence, the key to the success of varicocele treatment seems to be a correct indication. The aim of this study is to review and summarize current evidence in managing varicocele treatment focusing on the controversies regarding surgical indications in adolescent and adult patients, and in other specific situations such as azoospermia, bilateral or subclinical varicocele, and prior to ART.

Robot-assisted laparoscopic varicocelectomy in a pediatric population

PURPOSE

To present our experience with robot-assisted laparoscopic varicocelectomy in a pediatric population.

METHODS

We reviewed 49 consecutive cases performed by the same experienced surgeon. One-to-four veins were ligated at the internal ring of the inguinal canal, while the testicular artery and lymphatics were spared. Information on patient characteristics, surgical time, complications, and recurrences were collected.

RESULTS

Median patient age was 14 (range 10-17) years. Forty-eight had left-sided varicoceles and one had a bilateral varicocele. Forty-five were grade 3. All patients were referred due to discomfort/pain and 20 also had reduced testicular size. The median operating time from skin incision was 48 min (31-89 min) and the median console time was 18 min (7-55 min). Forty-seven patients were discharged the same day. Two patients experienced pain and problems urinating, respectively. These issues had resolved by the first post-operative day. There were no other complications, but at 6 months, eight recurrences were noted (16%). Scrotal complaints had subsided in all patients. Catch-up growth of the affected testicles was seen in 19/20 cases.

CONCLUSION

Robot-assisted laparoscopic varicocelectomy is feasible and safe in a pediatric population but with a relatively high recurrence rate.

Intraoperative hydrodissection and Doppler ultrasound during magnified varicocelectomy: A comparative study

METHODS

We performed a non-randomized comparative trial that recruited infertile men with varicocele who were scheduled to undergo MSV. Eligible patients were allocated by the investigators in a 1:1 ratio to receive intraoperative Doppler (group I) or intraoperative Doppler plus hydrodissection (group II).

RESULTS

Sixty men were included in each group. The two study groups showed a comparable number of ligated veins on the right (4.22 ±1.57 versus 4.42 ± 1.65; p = 0.49) and left side (6.77 ± 2.14 versus 6.98 ± 2.29; p = 0.59). On the contrary, group II showed a significantly higher number of preserved arteries on the right (2.42 ± 0.56 versus 1.47 ±0.5 in group I) and left side (2.6 ± 0.53 versus 1.63 ± 0.55 in group I), with p-value < 0.001. The sperm motility was significantly higher in group II than in group I (21.25 ± 13.73 versus 13.85 ± 12.25, respectively; p = 0.002). In both groups, the sperm motility increased significantly at the end of follow-up compared to the preoperative period. The postoperative sperm mortality remained significantly higher in group II than in group I (p = 0.008).

CONCLUSIONS

Intraoperative Doppler plus hydrodissection (D+IH-MSV) has advantages in preserving more arteries and enhancing the motility of sperms. Based on these findings, we strongly recommend D+IH-MSV when treating infertile men with varicocele.

Consensus and Diversity in the Management of Varicocele for Male Infertility: Results of a Global Practice Survey and Comparison with Guidelines and Recommendations

PURPOSE

Varicocele is a common problem among infertile men. Varicocele repair (VR) is frequently performed to improve semen parameters and the chances of pregnancy. However, there is a lack of consensus about the diagnosis, indications for VR and its outcomes. The aim of this study was to explore global practice patterns on the management of varicocele in the context of male infertility.

MATERIALS AND METHODS

Sixty practicing urologists/andrologists from 23 countries contributed 382 multiple-choice-questions pertaining to varicocele management. These were condensed into an online questionnaire that was forwarded to clinicians involved in male infertility management through direct invitation. The results were analyzed for disagreement and agreement in practice patterns and, compared with the latest guidelines of international professional societies (American Urological Association [AUA], American Society for Reproductive Medicine [ASRM], and European Association of Urology [EAU]), and with evidence emerging from recent systematic reviews and meta-analyses. Additionally, an expert opinion on each topic was provided based on the consensus of 16 experts in the field.

RESULTS

The questionnaire was answered by 574 clinicians from 59 countries. The majority of respondents were urologists/uro-andrologists. A wide diversity of opinion was seen in every aspect of varicocele diagnosis, indications for repair, choice of technique, management of sub-clinical varicocele and the role of VR in azoospermia. A significant proportion of the responses were at odds with the recommendations of AUA, ASRM, and EAU. A large number of clinical situations were identified where no guidelines are available.

CONCLUSIONS

This study is the largest global survey performed to date on the clinical management of varicocele for male infertility. It demonstrates: 1) a wide disagreement in the approach to varicocele management, 2) large gaps in the clinical practice guidelines from professional societies, and 3) the need for further studies on several aspects of varicocele management in infertile men.

[Use of men's support underwear after elective scrotal surgery-a prospective, randomized assessment of postoperative complication rates and health-related quality of life : A prospective, randomized assessment of postoperative complication rates and health-related quality of life]

BACKGROUND

Elective scrotal surgery is associated with a high rate of postoperative complications. There is no specific recommendation for postoperative care.

AIM

We investigated whether support underwear has an impact on postoperative complications and quality of life.

MATERIALS AND METHODS

From July 2020 to November 2021, patients with prior elective scrotal surgery were randomized into the intervention group "support underwear" or the control group. In addition to patient characteristics, intraoperative and postoperative findings were documented. The primary endpoint comprised postoperative complications. Secondary endpoints were prolonged length of hospital stay, emergency visits, unplanned readmissions, increased use of analgesics, and quality of life, which was recorded using the EQ5D (European Quality of Life 5 Dimensions) questionnaire preoperatively, on day 1 and 4 weeks postoperatively.

RESULTS

Data from 50 patients were analyzed. The mean age was 46.7 years (standard deviation [SD] 18.6). Inguinal surgery with/without orchiectomy (52%), hydrocele resection (22%), or ligation of varicocele (14%) were performed most frequently. The mean operating time was 62.8 min (SD 35.2); length hospital stay was 2.6 days (SD 1.2). In all, 20% of the patients suffered a postoperative complication. Type of surgery was significantly associated with postoperative complications (p = 0.01) and unplanned readmission (p = 0.04). Regarding biometric and perioperative data, there were no significant differences between the interventional group (n = 27) and control group (n = 23).

CONCLUSION

A nonnegligible number of complications occurs after elective scrotal surgery. Complications affects quality of life up to 4 weeks after the surgery. Postoperative care with support underwear does not appear to affect the postoperative complication rate, but it positively influences the quality of life in patients with scrotal access.

The Role and Place of Antioxidants in the Treatment of Male Infertility Caused by Varicocele

The inability to become pregnant for at least 1 year despite regular unprotected intercourse may indicate infertility of one or both partners. This problem affects approximately 10-20% of couples worldwide, regardless of race, with male infertility reported to account for 25-60% of cases. Among the most common pathological causes of male infertility is the presence of varicocele and chronic infections of the male reproductive system. This study was performed using data collected at the Genesis Infertility Treatment Clinic, Bydgoszcz, Poland, between 1 January 2015 and 30 June 2017. A total of 163 men meeting the inclusion criteria were selected and divided into the idiopathic infertility group (78 men) and varicocele-related infertility group (85 men). All patients received treatment with a male fertility supplement containing a combination of 1725 mg of L-carnitine fumarate, 500 mg of acetyl-L-carnitine, 90 mg of vitamin C, 20 mg of coenzyme Q10, 10 mg of zinc, 200 µg of folic acid, 50 µg of selenium, and 1.5 µg of vitamin B12 (Proxeed® Plus, Sigma-Tau, Italy) twice a day for a period of 6 months from the time of the diagnosis of infertility. The treatment resulted in significant improvements in general semen parameters, particularly sperm count, sperm concentration, total motility, and progressive motility. This antioxidant therapy produced a particularly marked therapeutic benefit in patients with Grade III varicocele, with a greater improvement in progressive motility than in men with less severe or no varicocele. The use of the antioxidant preparation examined here seems reasonable in men with idiopathic infertility and as an adjuvant in those with varicocele-related infertility in whom surgical treatment has resulted in no improvement. Its use should be considered particularly in patients with Grade III varicocele who do not wish to undergo surgical treatment or in whom such a treatment is not possible for various reasons.

Varicoceles: Overview of Treatment from a Radiologic and Surgical Perspective

A testicular varicocele is the result of the expansion of the venous pampiniform plexus of the scrotum. Often painless, a significant number of patients experience orchialgia, swelling, testicular atrophy, and abnormalities in spermatic parameters. Treatment of symptomatic varicocele involves a radiologic or surgical intervention to obstruct the reflux of venous drainage. Testicular anatomy, diagnostic evaluation and imaging, options for surgical intervention, and a step-by-step description of retrograde embolization and antegrade scrotal sclerotherapy are discussed. Furthermore, included is an overview of postprocedural management and patient outcomes for radiological interventions, and the most up-to-date evidence on the efficacy of varicocele treatments as well as how they compare to each other.

Comprehensive Analysis of Global Research on Human Varicocele: A Scientometric Approach

Purpose

This study provides a comprehensive analysis of research trends on the etiology, mechanisms, potential risk factors, diagnosis, prognosis, surgical and non-surgical treatment of varicocele, and clinical outcomes before and after varicocele repair.

Materials and Methods

Varicocele studies published between 1988 and 2020 were retrieved from the Scopus database on April 5, 2021. Original studies on human varicocele were included, irrespective of language. Retrieved articles were manually screened for inclusion in various sub-categories. Bibliometric data was subjected to scientometric analysis using descriptive statistics. Network, heat and geographic mapping were generated using relevant software.

Results

In total, 1,943 original human studies on varicocele were published. These were predominantly from the northern hemisphere and developed countries, and published in journals from the United States and Germany. Network map analysis for countries showed several interconnected nodal points, with the USA being the largest, and Agarwal A. from Cleveland Clinic, USA, being a center point of worldwide varicocele research collaborations. Studies of adolescents were underrepresented compared with studies of adults. Studies on diagnostic and prognostic aspects of varicocele were more numerous than studies on varicocele prevalence, mechanistic studies and studies focusing on etiological and risk factors. Varicocele surgery was more investigated than non-surgical approaches. To evaluate the impact of varicocele and its treatment, researchers mainly analyzed basic semen parameters, although markers of seminal oxidative stress are being increasingly investigated in the last decade, while reproductive outcomes such as live birth rate were under-reported in the literature.

Conclusions

This study analyzes the publication trends in original research on human varicocele spanning over the last three decades. Our analysis emphasizes areas for further exploration to better understand varicocele’s impact on men’s health and male fertility.

Estimation of haemodynamic changes in varicocele testis and results after microsurgical sub-inguinal varicocelectomy

INTRODUCTION

Varicocele is among the most frequently encountered, surgically correctable causes of male infertility. Since varicocele is a primary abnormality of testicular vessels, a thorough understanding of haemodynamic changes in the microcirculation of varicocele testis is needed.

OBJECTIVES

To estimate changes in the microcirculation of varicocele testis and correlate them with symptomatic and semen parameters changes before and after varicocelectomy.

MATERIAL AND METHODS

This prospective, observational study includes 47 patients of age group 18-40 years who underwent microsurgical varicocelectomy during June 2016 to April 2018 at a tertiary medical institute. Testicular haemodynamic was evaluated using a colour spectral doppler study (PSV-Peak systolic velocity/ESV-End diastolic velocity/RI-Resistive index/PI-Pulsatility index). Semen analysis parameters and testicular blood flow were compared with pre-operative values.

RESULTS

RI in the capsular artery of varicocele affected testis, which was 0.61 ± 0.11 (mean ± SD), significantly reduced to 0.56 ± 0.09 (mean ± SD) in post-operative follow-up, indicating improved perfusion. Pre-operative sperm density was noted to be 15.94 ± 7.88 (mean ± SD), which improved to 28.41 ± 10.99, Progressive sperm motility from 33.81 ± 10.88 to 38.32 ± 9.21 and morphology from 36.13 ± 10.68 to 41.43 ± 9.29 on 6-month follow-ups (p < 0.05).

CONCLUSION

Varicocele testis is associated with altered testicular haemodynamic, which insults spermatogenesis. Microsurgical varicocelectomy with testicular artery and lymphatic preservation leads to correction of this altered haemodynamic state and improves the testicular microcirculation.

Impact of testicular delivery and vasal vein ligation on clinical outcomes in men undergoing microsurgical varicocelectomy

PURPOSE

To assess the impact of microsurgical varicocelectomy technique on clinical outcomes.

METHODS

Men diagnosed with varicocele between 2017 and 2020 were reviewed. We included men who underwent microsurgical varicocelectomy by two high-volume surgeons who differed in surgical technique: Method (1) testicular delivery with gubernacular vein ligation, and ligation of vasal veins > 2.5 mm; Method (2) no delivery and ligation of dilated vasal veins in cases of recurrence. Post-operative changes for semen parameters, DNA fragmentation, and serum testosterone were evaluated for each technique and compared.

RESULTS

313 patients were included; 162 with Method 1 and 151 with Method 2. The cohorts were of similar age (median 35 years, interquartile range (IQR) 28-43; 34, IQR 28-39, respectively), and BMI (25 kg/m², IQR 23-27; 25, IQR 23-28, respectively). For Method 1, 84 (51.9%) had bilateral surgery, and 78 (48.1%) had unilateral surgery. For Method 2, 63 (41.7%) had bilateral surgery, and 88 (58.3%) unilateral surgery. In patients with sperm concentration > 5 M/mL, both techniques resulted in an improvement (p < 0.01), but there was no difference between the methods (p = 0.18). Both methods were associated with an improvement in total motile count (p < 0.05) and the amount of DNA fragmentation (p < 0.05), although no differences were apparent between the techniques (p = 0.09, p = 0.81, respectively). Finally, testosterone levels improved with Method 1, but the post-operative difference was not different than Method 2 (p = 0.06).

CONCLUSION

Delivery of the testis and ligation of dilated vasal veins compared to not performing those steps do not impact semen parameters, but are associated with improvement in testosterone levels.

An Analysis of Major Causes of Surgical Failure Using Bähren System in Intraoperative Venography During Varicocelectomy

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.

Effect of varicocelectomy on sperm deoxyribonucleic acid fragmentation rates in infertile men with clinical varicocele: a systematic review and meta-analysis

OBJECTIVE

To evaluate the effect of varicocelectomy on sperm deoxyribonucleic acid fragmentation (SDF) rates in infertile men with clinical varicocele.

DESIGN

Systematic review and meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Infertile men with clinical varicocele subjected to varicocelectomy.

INTERVENTION(S)

Systematic search using PubMed/Medline, EMBASE, Cochrane's central database, Scielo, and Google Scholar to identify relevant studies published from inception until January 2021. We included studies comparing SDF rates before and after varicocelectomy in infertile men with clinical varicocele.

MAIN OUTCOME MEASURE(S)

The primary outcome was the difference between the SDF rates before and after varicocelectomy. A meta-analysis of weighted data using random-effects models was performed. Results were reported as weighted mean differences (WMD) with 95% confidence intervals (CIs). Subgroup analyses were performed on the basis of the SDF assay, varicocelectomy technique, preoperative SDF levels, varicocele grade, follow-up time, and study design.

RESULT(S)

Nineteen studies involving 1,070 patients provided SDF data. Varicocelectomy was associated with reduced postoperative SDF rates (WMD -7.23%; 95% CI: -8.86 to -5.59; I² = 91%). The treatment effect size was moderate (Cohen's d = 0.68; 95% CI: 0.77 to 0.60). The pooled results were consistent for studies using sperm chromatin structure assay, terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling, sperm chromatin dispersion test, and microsurgical varicocele repair. Subgroup analyses showed that the treatment effect was more pronounced in men with elevated vs. normal preoperative SDF levels, but the impact of varicocele grade remained equivocal. Meta-regression analysis demonstrated that SDF decreased after varicocelectomy as a function of preoperative SDF levels (coefficient: 0.23; 95% CI: 0.07 to 0.39).

CONCLUSION(S)

We concluded that pooled results from studies including infertile men with clinical varicocele indicated that varicocelectomy reduced the SDF rates. The treatment effect was greater in men with elevated (vs. normal) preoperative SDF levels. Further research is required to determine the full clinical implications of SDF reduction for these men.

Can the Body Mass Index Predict Varicocele Recurrence Post-Intervention?

Purpose

In this study, we investigated the association between the body mass index (BMI) and varicocele recurrence post-intervention in our local Saudi population. We also explored the association between recurrence and other predictors such as age, laterality, indication for surgery, type of intervention, clinical grade, testicular delivery, and method of ligation.

Methods

We conducted a retrospective cohort study, including all patients who had microscopic varicocelectomy surgery or radiographic embolization for varicoceles over a five-year period. The data included demographic information and intervention-related variables. Descriptive and analytical statistics were used to analyze the data.

Results

We included 147 patients who had microscopic varicocelectomy surgery or radiographic embolization. We categorized the patients according to their BMI as underweight, normal, overweight, and obese. We found no statistical association between any BMI group and the recurrence of varicocele (P>0.05). However, there was a significant association between the clinical grade and recurrence (P<0.05).

Conclusion

This study did not show any significant correlation between height, weight, BMI, and varicocele recurrence after an intervention. The only predictor of varicocele recurrence was the clinical grade.

Narrative review of the history of microsurgery in urological practice

The clinical need for magnified visualization during surgery spurred the evolution of microscope and microsuture technology. Innovative surgeons across various surgical specialties recognized the importance of utilizing and advancing these technologies. Operative microscopy allows human dexterity to perform beyond direct visual limitations. Microsurgery started in otolaryngology and ophthalmology, became popular in reconstruction and transplantation, and was then adopted in urology. Microsurgery in urology involves renal and penile revascularization, penile transplantation and free flap phalloplasty, testicular autotransplantation, reproductive tract reconstruction of the vas deferens and epididymis, varicocele repair, and sperm retrieval. By examining the peer reviewed and lay literature, this review discusses the history of microsurgery and its subsequent development as a subspecialty in urology.

Microsurgical subinguinal varicocelectomy with spermatic cord double traction and vein stripping

We retrospectively reviewed data for 286 patients with varicocele who underwent microsurgical subinguinal varicocelectomy from March 2015 to May 2017 in Shanghai General Hospital (Shanghai, China). In this surgical approach, the testis was delivered, and the gubernacular and external cremasteric veins were stripped. In addition, the spermatic cord was delivered downward with continuous double traction away from the external ring. The remaining procedure was similar to the conventional approach. We followed patients for at least 3 months and evaluated postoperative semen parameters, pain symptoms, and complications. We excluded data for 32 men due to inadequate follow-up (<3 months). Of the remaining 254 patients, 73 had oligoasthenospermia, 121 had nonobstructive azoospermia, and 60 had symptomatic varicoceles. Total progressive sperm counts increased in the oligoasthenospermic patients from a median preoperative value of 9.15 × 10⁶ ml^-1 to 25.33 × 10⁶ ml^-1 (n= 34), and 35.6% (26/73) initially oligoasthenospermic men contributed to unassisted pregnancies. Sperm returned to the ejaculate in 12.4% (15/121) azoospermia patients. In patients with scrotal pain (n = 60), 43 (71.7%) reported complete resolution of pain, 16 (26.7%) reported partial resolution, and 1 (1.7%) reported no change. No patients experienced varicocele recurrence. This double-traction strategy avoids opening the external oblique aponeurosis, and results in less damage and faster recovery. In addition, the stripping strategy eliminates potential damage to the testis caused by the varicose veins. Our results showed that microsurgical subinguinal varicocelectomy using spermatic cord double traction in conjunction with testicular delivery for vein stripping is a safe and effective approach for varicocele repair.

The impact of varicocelectomy on sperm DNA fragmentation and pregnancy rate in subfertile men with normal semen parameters: A pilot study

Objective: To evaluate the outcome of microscopic subinguinal varicocelectomy on sperm DNA fragmentation (SDF) and pregnancy rate in men with normal semen parameters.

Patients and methods: A pilot study that included male patients with a minimum of a 1-year history of male subfertility, normal semen parameters, a high percentage of SDF, and clinically palpable varicoceles. Microscopic subinguinal varicocelectomy was carried out for 45 patients (study group), while 40 patients had no intervention (control group). Semen analysis and SDF were measured before and at 6 months after the varicocelectomy. The pregnancy rate was assessed at the 6- and 12-month follow-ups.

Results: Between July 2014 and January 2019, 85 subfertile men were included in the study and completed 12 months of follow-up. The two groups were comparable in terms of their age, body mass index, infertility duration, infertility type, varicoceles laterality, and varicoceles grade (P values = 0.84, 0.34. 0.35, 1, 0.39, and 0.46, respectively). At 6 months after varicocelectomy, the mean SDF was reduced in both groups, and this reduction was statistically higher in the varicocelectomy group (P < 0.001). After 1-year, spontaneous pregnancy was achieved in 62% of the patients in the varicocelectomy group compared to 30% in the control group (P = 0.009).

Conclusion: Varicocelectomy has a positive impact on SDF and spontaneous pregnancy in infertile men with clinically palpable varicoceles and normal semen parameters.

Abbreviations: BMI: body mass index; DFI: DNA fragmentation Index; SDF: sperm DNA fragmentation

Factors Associated with Varicocele Recurrence After Microscopic Sub-Inguinal Varicocelectomy

Purpose

This study has been conducted to identify the rate of varicocele recurrence in patients who underwent microscopic subinguinal varicocelectomy at our center. We also aimed to determine the contributing factors to varicocele recurrence.

Patients and Methods

A total of 34 married male patients who underwent microscopic sub-inguinal varicocelectomy were retrospectively included in this study. The medical records of recruited patients were reviewed. The diagnosis of varicocele was based on physical examination, while recurrent varicocele was diagnosed based on both physical examination and colored doppler ultrasound. We investigated contributing factors to varicocele recurrence, including demographic characteristics (such as body mass index), clinical (varicocele grade and size of dilated veins), and laboratory data (semen analysis). Patients were followed up at 3 and 6 months after surgery.

Results

The mean age of patients was 32.53 years. The majority of patients had left-sided varicocele (70.6%) and underwent surgery due to scrotal pain (82.4%), with a mean operation duration of 92 minutes. Left-sided varicoceles were grade II in 51.7% of patients, while right-sided varicoceles were grade II in 16.1% of patients. Recurrence occurred in 2.9% after 3 and 6 months. Pain recurred in 8.8% and 10.5% of patients at 3 and 6 months, respectively. Pregnancy rates were 44.1% at 3 months and 11.8% at 6 months after surgery. The grade of varicocele (P = 0.24) and the size of the left dilated vein (P = 0.002) was significantly associated with recurrence.

Conclusion

There was a significant association of advanced grade on the left side and large vein diameter before and after surgery with an increased rate of recurrence; however, due to the small sample size of our study, more and larger studies are still warranted.

[Recommendations of the Committee of Andrology and Sexual Medicine of the AFU concerning the management of Varicocele]

The diagnosis of varicocele is clinical, carried out in supine and standing position and in Valsalva maneuver. Only clinical varicoceles have to be treated. A scrotal ultrasound with Doppler is generally performed as part of the infertile man's evaluation or in case of examination difficulties. The main indication for varicocele treatment is the adult man with clinical varicocele and abnormalities of sperm parameters, in a context of infertility of couple, with a partner having a satisfactory ovarian reserve and no cause of female infertility or a curable infertility cause. The decision to treat varicocele must therefore be taken after evaluation of the two partners of the couple. Adults with symptomatic varicocele and those with spermogram abnormalities may also be offered a cure for their varicocele even in the absence of a paternity plan, as well as adolescents with reduced testicular growth, an ipsilateral decrease testicular volume, or a size gradient between the 2 testes. The cure of varicocele can be carried out by surgery or by percutaneous embolization. Microsurgery (inguinal or subinguinal) offers lower rates of recurrence and complications than high surgical approaches (laparoscopic or not) and surgeries without magnification. It is therefore the reference surgical technique. Percutaneous retrograde embolization is a minimally invasive alternative to microsurgery offering satisfactory outcomes with rare and often benign complications. The cure for varicocele results in an improvement in sperm parameters and recent data seem to confirm that it increases the natural pregnancy rate. These results appear after a delay of 3 to 9 months (at least 1 to 2 cycles of spermatogenesis). When the sperm involvement was severe (azoospermia, severe oligospermia), the improvement of the spermogram allow (1) to avoid surgery testicular sperm extraction or (2) perform intrauterine insemination rather than ICSI.

Determination of the time for improvement in semen parameters after varicocelectomy

This retrospective study aimed to determine the time for improvement in semen parameters after varicocelectomy. A total of 175 patients over 18 years of age, who underwent microscopic inguinal varicocelectomy in a tertiary centre between 2005 and 2016 and had post-operative follow-up data of at least 12 months, were included in the study. Serial semen analyses in the pre-operative period and at the post-operative third, sixth, ninth and 12th months were retrospectively documented. With respect to their pre-operative total motile sperm counts, the patients were classified into three subgroups as <5 million, 5-9 million and >9 million. In the overall cohort and the group with a total motile sperm count of >9 million, the semen parameters continued to improve up to the post-operative 12th month. No further significant improvement was observed after the post-operative third and sixth months for the patients with pre-operative total motile sperm counts of <5 million and 5-9 million respectively. For the candidates of varicocelectomy, the decision of treatment strategies, such as assisted reproductive technologies and waiting for spontaneous pregnancy can be based on the prediction of the time for improvement in semen parameters.

Recent advances in clinical diagnosis and treatment of male factor infertility

Infertility is a significant global health issue affecting around 8-12% of couples worldwide with male factor infertility accounting for a substantial proportion of these cases. Despite significant advances within the past few decades, an etiology for male factor infertility cannot be identified in up to 80% of patients and thus, this continues to be an area of active study. This review aims to provide an update on recent advances in the field of male infertility including semen analysis and at-home semen testing, genetics, DNA fragmentation, surgical approaches, and the rise of telemedicine in the era of COVID19.

Best time to wait for the improvement of the sperm parameter after varicocelectomy: 3 or 6 months?

OBJECTIVE

To estimate the duration of time required following varicocelectomy to wait for the improvements of semen parameters. Therefore, we characterized the changes with the time in sperm parameters in men after varicocelectomy.

MATERIALS AND METHODS

In this prospective cohort study we included consecutively observed men who underwent varicocelectomy between September 2017 and September 2018 in a referral academic hospital. Clinical data of the patients, as well as their semen parameters, were measured before surgery and at 3 and 6 months afterward.

RESULTS

In this study, a total of 100 men with average age of 29.5 ± 6.2 years were included. Mean sperm concentration and sperm motility significantly improved by 3 (p < 0.05), but not by 6 months following varicocelectomy. The semen volume and sperm with normal morphology were the same before and after surgery (p > 0.05). There was no statistically significant difference in the improvement of semen parameters when comparing 6 months to 3 months postoperatively (p > 0.05).

CONCLUSIONS

Sperm parameters (concentration and motility) improve by 3 months after varicocelectomy without further improvements. Consequently, physicians should decide quickly after 3-month of varicocelectomy if surgery has been not helpful and then plan other therapies, like assisted reproductive technology (ART) for managing infertility in couples.

1H NMR-based metabonomics for infertility diagnosis in men with varicocele

PURPOSE

"Omics" techniques have been used to understand and to identify biomarkers of male infertility. We report on the first metabonomics models created to diagnose varicocele and infertility among men with varicocele.

METHODS

We recruited 35 infertile men with varicocele (VI group), 21 fertile men with varicocele (VF group) and 24 fertile men without varicocele (C group). All men underwent standard semen analysis, scrotal duplex ultrasonography, and sexual hormone level measurement. Hydrogen-1 nuclear magnetic resonance (1H NMR) spectra of seminal plasma were used to create metabonomics models to discriminate between men with and without varicocele, and between fertile and infertile men with varicocele.

RESULTS

Using the statistical formalisms partial least square discriminants analysis and genetic algorithm-based linear discriminant analysis (GA-LDA), we created two models that discriminated the three groups from each other with accuracy of 92.17%. We also created metabonomics models using orthogonal partial least square discriminants analysis and GA-LDA that discriminated VF group from VI group, with an accuracy of 94.64% and 100% respectively. We identified 19 metabolites that were important in group segregation: caprate, 2-hydroxy-3-methylvalerate, leucine, valine, 3-hydroxybutyrate, lactate, alanine, 4-aminobutyrate, isoleucine, citrate, methanol, glucose, glycosides, glycerol-3-phosphocoline, n-acetyltyrosine, glutamine, tyrosine, arginine, and uridine.

CONCLUSIONS

1HNMR-based metabonomics of seminal plasma can be used to create metabonomics models to discriminate between men with varicocele from those without varicocele, and between fertile men with varicocele from those infertile with varicocele. Furthermore, the most important metabolites for group segregation are involved in the oxidative stress caused by varicocele.

Surgical treatment for male infertility

Given the nature of the multiple causes of male infertility, some of them are «reversible» and can be managed with a surgical procedure to recover, in some cases, the fertilizing capacity of the male reproductive tract. With appropriate use of diagnostic tools and clinical judgement, the physician can identify the ideal candidates for these procedures. Together with the expertise and experience of the surgeon, these treatments can manage to resolve the barrier, and men may become fertile again. In this chapter, we will review some of the most commonly used surgical procedures for the treatment of male infertility and make a brief description of their technical details.

Evaluation of clinical effects of microsurgical subinguinal varicocelectomy with and without testicular delivery

The aim of this study was to access whether microsurgical subinguinal varicocelectomy (MSV) with testicular delivery has a better therapeutic effect than MSV without testicular delivery, including semen quality, serum testosterone (T) level and International Index of Erectile Function (IIEF)-5 score in infertility male patients with varicocele. In this prospective study, 181 patients were included and they chose the treatment by themselves. A total of 114 patients who received MSV without testicular delivery (TD) and 67 patients who received MSV with TD were followed-up 6 months after the operation. Semen parameters, serum T level and IIEF-5 scores were recorded before and 6 months after the operation. Results showed that MSV with or without TD could improve semen quality, serum T level and IIEF-5 score. For semen quality 6 months after the operation, there was no significant difference between patients received MSV with or without TD. But in patients with varicocele of grade III, MSV without testicular delivery improved the sperm concentration and motility more. And patients received MSV without TD have a higher T level 6 months after the operation, especially in patients ≤27 years. MSV with TD is not superior to that without, but this should be verified in more samples and a better designed randomised controlled study in the future.

Pathophysiology and treatment options of varicocele: An overview

Varicocele is the most common correctable cause for male infertility, but not all men with varicocele are affected equally by this condition. The pathophysiology of varicocele-induced fertility remains ill-defined. While evidence suggests that oxidative stress remains a central factor, other mechanisms likely include scrotal hyperthermia, reflux of metabolites, hypoxia and cadmium accumulation. Microsurgical varicocelectomy remains the gold standard treatment option for infertile men with a clinically palpable varicocele and abnormal semen parameters. Newer evidence suggests a potential role for antioxidant supplementation and a meaningful role of varicocelectomy for patients destined for ART to improve pregnancy outcomes.

Microstructures of the spermatic cord with three-dimensional reconstruction of sections of the cord and application to varicocele

The aim of the study was to investigate the micro-structures of the spermatic cord using histological examination with three-dimensional (3D) reconstruction of the serial tissue sections of the cord for clinical application in microscopic varicocelectomy. Human spermatic cord specimens obtained from 13 adult male cadavers were used to prepare serial transverse sections. The sections were stained to allow observation of the spermatic cord microstructures. The 3D reconstruction was performed with digitized serial sections by Mimics software. The microscopic varicocelectomy was performed based on the anatomical results of 3D reconstruction of the spermatic cord. The results showed the number of small spermatic veins, large spermatic veins, arteries, lymphatics or nerves were not markedly different between the subinguinal and inguinal regions or between the right and left sperm cord. The number of medium spermatic veins in the subinguinal region was obviously higher than at the inguinal level. The internal spermatic vessels and the vas deferens together with other associated vessels within the cremaster were separately enclosed by two thin and translucent sheaths, the internal spermatic fascia and the vas deferens fascia. We conclude that internal spermatic vessels and the vas deferens together with the associated neurovascular vessels are wrapped by two distinct sheaths separating them from the surrounding tissues. Microscopic varicocelectomy based on the anatomical results of 3D reconstruction of the spermatic cord is feasible.

ABBREVIATIONS

3D: three-dimensional; ISF: internal spermatic fascia; ESF: external spermatic fascia; MHIV: High inguinal microsurgical varicocelectomy; MSIV: subinguinal microsurgical varicocelectomy; CAAD: computer-assisted anatomic dissection; HE: hematoxylin-eosin.

[Initial experience in microsurgical treatment of varicocele: Comparative analysis with conventional macrosurgical varicocelectomy]

INTRODUCTION

Varicocele is the most common cause of male infertility and the standard treatment is varicocelectomy. Having recently started performing microsurgical varicocelectomy (MV) in our centre, the objective of this study is to determine the differences in clinical outcomes and laboratory findings between MV and the conventional varicocelectomy (CV).

MATERIAL AND METHODS

This is a comparative study between MV and CV in our centre between 01/2013 and 12/2016. We included patients with clinical varicocele and altered seminal parameters. We analyzed the following variables: age, laterality, grade of varicocele, testicular volume, surgical technique used, seminogram parameters prior to and after surgery and recurrence.

RESULTS

Between 01/2013 and 12/2016 46 varicocelectomies were performed in our centre, excluding from the study 12 patients due to lack of follow-up. Of the remaining 34, 19 (55.9%) underwent CV and 15 (44.1%) MV. There were no significant differences between the baseline characteristics of both groups. The preoperative sperm count was 30.1±35.6 10⁶/mL for MV vs. 25.6±19.9 10⁶/mL for CV (P=.64) and progressive sperm motility (a+b) was 17.7±13.6% vs. 16.5±10.1% respectively (P=.77). Postoperative sperm count was 29.16±33 10⁶/mL for MV vs. 45.6±55.5 10⁶/mL for CV (P=.32) and progressive motility (a+b) was 26.4±20.1% vs. 27.7±20.4% respectively (P=.85). We observed a tendency towards recurrence in the CV group (26.3%, vs. 6.7% for MV), although not statistically significant (P=.15).

CONCLUSIONS

Despite the learning curve with MV, we obtained improvements in seminal analysis similar to those with CV. Even though not statistically significant, there was a tendency to less recurrence in the MV group, consistent with what is already described in medical literature.

Extended indications for varicocelectomy

The relationship between varicoceles and subfertility is well-established, but recent evidence suggests that varicoceles may cause global testicular dysfunction. This has led to exploration into expanding the indications for varicocelectomy. This review examines the literature regarding varix ligation as a treatment for non-obstructive azoospermia, elevated DNA fragmentation, and hypogonadism.

Microsurgical varicocele ligation: surgical methodology and associated outcomes

The impact of clinical varicoceles on semen parameters and male infertility has long been established. In the era of assisted reproduction, clinical discussion has questioned the role of varicocelectomy, offering the potential to bypass, rather than treat, varicocele-associated male infertility. However, current literature supports improved semen parameters and reproductive outcomes following repair. This article presents the stepwise operative approaches to microsurgical varicocelectomy and discusses the recent publications on outcomes.

Comparison between microsurgical varicocelectomy with and without testicular delivery for treatment of varicocele: A systematic review and meta-analysis

The present study was conducted to assess the semen parameters, complications and clinical effect of microsurgical varicocelectomy with testicular delivery (TD) for treatment of varicocele. Relevant studies were collected and reviewed systemically from PubMed, Medline, Embase, Web of Science, China National Knowledge Infrastructure databases and the Cochrane Library and a meta-analysis was performed. Relative ratio (RR), standardised mean difference (SMD) and their 95% confidence intervals (CIs) were adopted to estimate the outcome measures. Eight articles and a total of 1,139 subjects including 487 patients with TD in microsurgical varicocelectomy and 652 patients without TD were enrolled in this meta-analysis. The pooled RR indicated that microsurgical varicocelectomy with TD increased the incidence of orchiepididymitis (RR = 4.36, 95% CI = 1.12-16.99, p = 0.034) and scrotal oedema (RR = 4.25, 95% CI = 2.40-7.54, p = 0.000) than microsurgical varicocelectomy without TD postoperatively. In conclusion, compared to microsurgical varicocelectomy without TD, TD to further ligate the gubernacular veins in microsurgical varicocelectomy results in a higher incidence of orchiepididymitis and scrotal oedema and take longer operation time. However, TD may not have any beneficial influences on semen parameters, serum testosterone, varicocele occurrence, wound infection and natural conception.

Should primary microsurgical ligation of varicocele be the gold standard approach?

Introduction:

Varicocele is a common condition affecting over one in 10 men, and in cases with abnormal semen parameters, varicocele is present in about one in four men. Several methods have been used to treat this condition, of which microsurgical treatment has the lowest failure and complication rates. We present a single-centre UK series of microsurgical repair of varicocele.

Methods:

All microsurgical varicocelectomy cases performed between 2013 and 2017 were retrospectively identified and reviewed. The approach used is low inguinal using a high-powered Leica microscope.

Results:

Microsurgical varicocele repairs were performed in 30 cases, with a median age of 34.7 years. There were 22 cases with chronic scrotal pain of which eight cases had failed previous embolisation with a success rate of 90.5%. There were eight with oligoasthenoteratozoospermia, showing an improvement of more than 75% in sperm count after repair.

Conclusions:

Microsurgical ligation is a very effective treatment for symptomatic varicoceles and should be considered when radiological embolisation has failed. It is also effective in improving semen parameters in all followed up oligoasthenoteratozoospermia cases. It should be considered a primary method of varicocele treatment in the UK.

Level of evidence:

3.

Hypogonadism is independently associated with varicocele repair in a contemporary cohort of men in the USA

We aimed to identify demographic and clinical predictors of varicocele repair in a contemporary cohort of men in the USA. We queried the 2009-2015 MarketScan Database using relevant ICD9, ICD10, and CPT codes to identify all 18-45 year olds with varicoceles. Differences in age, area of residence, clinical characteristics, and medical management between men who did and did not undergo varicocelectomy (open, laparoscopic, or microsurgical) during the study period were compared using unpaired t -tests and Chi-squared tests for continuous and categorical variables, respectively. Multivariable logistic regression analysis was used to evaluate age, semen analyses, and serum hormone assessment as predictors of varicocele repair. SAS version 9.4 was used for all statistical analyses. Significance was set at P < 0.05. Approximately 40% of men with varicoceles underwent repair, primarily through an open approach. Men who underwent repair were more likely to have a diagnosis of male infertility (15.5% vs 7.9%, P < 0.001) and male hypogonadism (3.4% vs 0.9%) and were more likely to complete semen analyses (36.1% vs 12.2%, P < 0.001) and serum testosterone evaluation (42.5% vs 18.8%, P < 0.001). In multivariable regression models, the strongest predictors of varicocele repair were semen analysis (OR = 2.78, 95% CI: 2.56-3.02), age 18-25 years (OR = 2.66, 95% CI: 2.36-2.98), and serum testosterone evaluation (OR = 1.67, 95% CI: 1.51-1.86). Although male infertility remains the most important indication for varicocele repair, male hypogonadism is emerging as an independent predictor of varicocelectomy, which may represent a change in the clinical management of varicoceles in the USA.

Varicocele Repair Versus Testosterone Therapy for Older Hypogonadal Men with Clinical Varicocele and Low Testosterone

As men age, serum testosterone levels decrease. This reduction in testosterone levels may cause symptoms leading to hypogonadism. In addition, the presence of a varicocele can impair Leydig cell function, resulting in decreased testosterone production in men. Varicocelectomy and testosterone replacement therapy are both viable treatment options for hypogonadism in elderly male patients. The correct modality of treatment will vary for each patient, but education is essential in order to help men understand their options. Testosterone therapy (TTh) with laboratory monitoring will likely appeal to many men who want to avoid surgery, but for men with hypogonadism and a varicocele, a one-time low-risk microsurgery with the potential to negate the need for further therapy presents an attractive alternative to lifelong TTh. PATIENT SUMMARY: Varicocelectomy and testosterone therapy (TTh) are viable treatment options for hypogonadism in elderly male patients. Treatment modality will vary for each patient, but education is essential to help them understand their options. Although TTh with laboratory monitoring may appeal to men wanting to avoid surgery, those with hypogonadism and a varicocele would likely prefer a one-time low-risk microsurgery to lifelong TTh.

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.

The varicocele argument resurfaces

A recent series of articles and reviews published in Fertility and Sterility have rekindled the more than half century debate on varicocelectomy. Every one of these articles favored strongly the repair of varicocele for male infertility. Since my review paper on this issue in 2001, published in Human Reproduction Update, and since advent of ICSI in 1993, I had thought that most reproductive physicians felt negatively about the benefit of varicocelectomy. However, more recent urological papers are causing this negative view to be re-evaluated. It is now advocated by some urologists that varicocelectomy improves sperm count and testosterone levels, and even improves the results with ICSI. Thus, it may be appropriate to revisit older studies again and review the newer ones in this never ending controversy. Newer studies are re-opening the door to review and possibly re-instate varicocelectomy. This dilemma may never be fully resolved, but it is important to keep an open mind.