Editorial: New Scientific Information Related to Varicoceles

COVID-19 and varicocele: the possible overlap factors and the common therapeutic approaches

Varicocele is recognized as one of the main attributable causes of male infertility which can affect spermatogenesis by various pathophysiological mechanisms. Recent studies have identified oxidative stress and reduction in antioxidant, hyperthermia, hypoxia, hormonal dysfunction, and inflammatory conditions as major factors in the pathophysiology of varicocele, all of which have known direct associations with the coronavirus disease 2019 (COVID-19) and can significantly increase the risk of detrimental COVID-19-related outcomes. Emerging data have shown an association between COVID-19 and inflammation, overproduction of cytokine, and other pathophysiological processes. The present review, summarizes the current understanding of the pathophysiology of varicocele and investigates the potential correlation between the severity of COVID-19 and the varicocele disease. In addition, various possible treatments which can be effective in both diseases were examined. Despite numerous challenges associated with the prevalence of COVID-19 in healthcare systems in infected countries, special attention should be given to maintaining a high level of care for complex patients with a pre-existing disease such as varicocele and providing appropriate practical advice for optimal control of the COVID-19 disease. This article is protected by copyright. All rights reserved.

Increased expression of the sonic hedgehog and vascular endothelial growth factor with co-localization in varicocele veins

Objectives

Varicocele is characterized by dilatation and tortuosity of the internal spermatic vein. Sonic hedgehog plays an important role in angiogenesis and vascular remodeling under hypoxic stress. We studied the relationship and distribution of SHH and vascular endothelial growth factor in internal spermatic vein in patients diagnosed with varicocele.

Methods

Specimens of 1 cm were taken from the internal spermatic vein during left varicocele repair (N = 20). The control samples of ISV were obtained from eight male patients who underwent left inguinal herniorrhaphy. We analyzed the sonic hedgehog and vascular endothelial growth factor expression and distribution by immunoblotting, immunohistochemistry, immunofluorescent staining, and confocal laser scanning microscopy. The data were analyzed using the Student’s t test.

Results

Immunoblotting showed higher expression of sonic hedgehog and vascular endothelial growth factor proteins in varicocele veins than in the control group ( P < 0.05) which located over muscle layer and endothelium was demonstrated by immunohistochemical staining. Both proteins with co-localization in the muscle layer and especially distributed in endothelium of varicocele veins were revealed under confocal microscopy.

Conclusions

These findings showed the upexpression of sonic hedgehog and vascular endothelial growth factor with co-localization in varicocele veins which imply that the reducing hypoxia or using sonic hedgehog antagonists may be helpful for this vascular disease.

Increased expression of hypoxia-inducible factor-1α and metallothionein in varicocele and varicose veins

Objective

The increased blood stasis and venous volume pressure causing tissue hypoxia are observed in both varicocele and varicose veins. Metallothionein (MT), a metal-binding protein, protects against cell apoptosis under hypoxic stress. It also plays an important role in collateral flow recovery and angiogenesis. We studied the distribution of hypoxia-inducible factor-1α (HIF-1α) and MT in varicocele and varicose veins.

Methods

The study specimens consisted of 1 cm venous segments that were obtained from 12 male patients during vascular stripping surgery for varicose veins and 1 cm of internal spermatic vein (ISV) obtained from 12 patients during left varicocele repair. The control samples of 1 cm ISV were obtained from 10 male patients who underwent left inguinal herniorrhaphy. All vascular specimens were analysed for HIF-1α and MT expression by immunoblotting, immunohistochemical (IHC) staining and confocal microscopy. Data were analysed using one-way analysis of variance with Tukey's comparison test.

Results

In both venous diseases, the increased expression of HIF-1α and MT compared with the control group ( P < 0.05) and most of the proteins distributed over smooth muscle layers were detected by IHC staining; HIF-1α and MT in the muscle layer with co-localization, and MT overexpression especially located in the endothelium of both venous diseases under confocal microscopy.

Conclusions

Our results revealed the higher expression of HIF-1α and MT in varicocele and varicose veins than in the control group; MT overexpression in the muscle layer of both diseased vessels and especially located in the endothelium under confocal microscopy. MT has the function to protect vascular cells from apoptosis under hypoxia. Thus, this MT function may cause a decreased vascular cell apoptosis and then contribute to the dilated and thickened walls of varicocele and varicose veins.

Dysregulated apoptosis through the intrinsic pathway in the internal spermatic vein of patients with varicocele

BACKGROUND/PURPOSE

Apoptosis plays a critical role in various physiological processes. Varicocele is the most common cause of male infertility in adults. The dilated and thickened wall of the internal spermatic vein (ISV) in varicocele is considered similar to that in varicose veins. We investigated apoptotic protein expression in the ISV of varicocele, including Bcl-2, Fas, caspase-8 and caspase-9, to determine the intrinsic or extrinsic pathway.

METHODS

The study group consisted of 10 patients with grade 3 left varicocele. The control group consisted of 10 patients with left indirect inguinal hernia. A 1-cm section of ISV was resected, using left inguinal incision, from each patient in both groups. The ISV sections were used to detect the mediators that regulate the intrinsic (Bcl-2 and caspase-9) and extrinsic (Fas and caspase-8) apoptotic pathways, by immunoblotting and immunohistochemical staining. Results were analyzed using Student's t tests.

RESULTS

Bcl-2, Fas, caspase-8 and caspase-9 immunoblots from both groups revealed a single band. The relative intensities of the Bcl-2 and caspase-9 protein bands differed significantly between the varicocele and control groups. Thickening of the smooth muscle layer of the ISV was found in patients with varicocele compared with the control group. Bcl-2 overexpression and downregulation of caspase-9 expression were noted in the varicocele group. There was no significant difference in Fas or caspase-8 expression in either group.

CONCLUSION

We showed overexpression of Bcl-2 and downregulation of caspase-9 expression in the ISV under hypoxic stress. This indicated dysregulated apoptosis through the intrinsic pathway in the ISV of patients with varicocele. To the best of our knowledge, this is the first study of the apoptotic pathway in the human ISV. Additional studies are needed to establish whether adjunctive hyperbaric oxygen therapy reduces the recurrence rate after varicocelectomy.

Cadmium accumulation and metallothionein overexpression in internal spermatic vein of patients with varicocele

OBJECTIVES

To determine the possible molecular mechanism for the thickened wall in the internal spermatic vein (ISV) of patients with varicocele, we examined the cadmium (Cd) content and metallothionein (MT) expression in these diseased vessels. Previous studies have shown that Cd might play a role in the etiology of varicocele-associated infertility. MT, a metal-binding protein, protects against cell apoptosis during hypoxia.

METHODS

The study group consisted of 20 patients with grade 3 left varicocele. The control group consisted of 15 volunteers with left-sided indirect inguinal hernia. Through a left inguinal incision, a 1-cm section of the ISV was resected from each patient to measure the Cd and MT levels. The results were analyzed using Student's t test.

RESULTS

The Cd content in the ISV was 59.84 +/- 5.7 ng/g in the control group and 192.1 +/- 24.2 ng/g in the varicocele group. The relative intensity of the MT band was 40.52 +/- 3.74 in the control group and 78.26 +/- 5.61 in the varicocele group. MT expression was greater in the varicocele group than in the control group, and its deposition in the vascular endothelial layer was predominant using immunohistochemistry staining and confocal laser scanning.

CONCLUSIONS

The results of the present study have demonstrated a greater accumulation of Cd in the ISV of the varicocele group than in the control group. The high Cd content and hypoxic conditions would induce overexpression of MT in the diseased vessels to protect the vascular cells from apoptosis. This might be a mechanism for the thickened wall of the ISV in patients with varicocele.

Adult varicocele

PURPOSE OF REVIEW

Adult varicocele presents a challenge for male reproductive specialists. We have yet to fully elucidate the pathophysiology of varicocele. The enigma of the varicocele, although a source of frustration for clinicians, has been a siren call for researchers as attested to by the substantial, if flawed body of literature on the topic. We critically review recent publications on varicocele.

RECENT FINDINGS

Although yielding mixed results, studies this year have explored the potential relationship between oxidative stress and varicocele-associated infertility. In clinically focused research, one group tackled the contentious question of efficacy of surgical varicocele management. Building on the errors of prior meta-analyses, this study takes a fresh view on an old but vital topic. Finally, it is becoming clearer that varicocele affects Leydig cell function as well as seminiferous tubular function, and is a risk factor for androgen deficiency.

SUMMARY

With exceptions, recent studies support a role for varicocelectomy in the management of infertile couples. In addition, evidence is accumulating that early repair of varicoceles, especially large varicoceles, may be effective in preventing future infertility and may be an effective treatment for androgen deficiency.

Effects of surgery, medical therapy and combined therapeutical approach on spermatogenesis in patients suffering from varicocele: a prospective and comparative analysis

The definite mechanisms through which varicocele affects spermatogenesis are still not completely understood, and consequently the exact role of the various approaches available for its treatment is still under debate.

In this study a comparison of medical treatment, surgery and combined approach is reported.

Material and Methods.

The study was conducted as a prospective evaluation of 189 patients suffering from varicocele and oligoasthenospermia. Patients were randomized in three groups on the basis of the different therapeutic approach: group A, treated only with varicocelectomy; group B, treated with varicocelectomy associated with hormonal therapy; group C, treated only with hormonal therapy. Randomization criteria were based on patient's preference. Spermiogram tests were carried out at baseline and after 3, 6 and 12 months from therapy.

Results.

Our results show that patients undergoing a combined therapeutical approach (surgery associated with hormonal therapy) and medical therapy alone achieve a greater improvement of seminal parameters than patients treated by surgery only.

Conclusion.

Data reported in this study are in accordance with Literature review. Furthermore, the association between varicocelectomy and early use of hormonal therapy seems to improve testis functional rehabilitation with a early evidence of sperm parameters improvement. In the light of these results of ours, we should conclude that surgical treatment is not effective for the spermatogenesis improvement.

Efficacy of Varicocelectomy in Improving Semen Parameters: New Meta-analytical Approach

OBJECTIVES

To determine the efficacy of varicocelectomy in improving semen parameters.

METHODS

A meta-analysis was performed to evaluate both randomized controlled trials and observational studies using a new scoring system. This scoring system was developed to adjust and quantify for various potential sources of bias, including selection bias, follow-up bias, confounding bias, information or detection bias, and other types of bias, such as misclassification. Of 136 studies identified through the electronic and hand search of references, only 17 studies met our inclusion criteria. The study population was infertile men with clinically palpable unilateral or bilateral varicocele and at least one abnormal semen parameter who had undergone surgical varicocelectomy (high ligation or inguinal microsurgery). Only those studies that had at least three semen analyses (ie, sperm count, motility, and morphology) per patient, before and after surgical varicocelectomy, were included.

RESULTS

The combined analysis demonstrated that the sperm concentration increased by 9.71 x 10(6)/mL (95% confidence interval [CI] 7.34 to 12.08, P <0.00001) and motility increased by 9.92% (95% CI 4.90 to 14.95, P = 0.0001) after microsurgical varicocelectomy. Similarly, the sperm concentration increased by 12.03 x 10(6)/mL (95% CI 5.71 to 18.35, P = 0.0002) and motility increased by 11.72% (95% CI 4.33 to 19.12, P = 0.002) after high ligation varicocelectomy. The improvement in World Health Organization sperm morphology was 3.16% (95% CI 0.72 to 5.60, P = 0.01) after both microsurgery and high ligation varicocelectomy.

CONCLUSIONS

Surgical varicocelectomy significantly improves semen parameters in infertile men with palpable varicocele and abnormal semen parameters.

Bcl-2 Overexpression in the Internal Spermatic Vein of Patients with Varicocele

BACKGROUND/PURPOSE

Varicocele is characterized by dilatation and tortuosity of the internal spermatic vein (ISV). Cross sections of ISV showed marked thickening of smooth muscle layer under microscopy. This study examined Bcl-2 (anti-apoptotic protein) expression in the ISV of patients with varicocele.

METHODS

The study group consisted of eight patients with left varicocele, grade 3. The control group consisted of six volunteers with left indirect inguinal hernia. Using a left inguinal surgical incision, a 1-cm section of ISV was resected from each patient in both groups as specimens for immunoblotting and immunohistochemical staining of Bcl-2. Results were analyzed using Student's t test.

RESULTS

Bcl-2 immunoblots from both groups revealed one single band. alpha-tubulin was used as loading control. The average relative intensity of the Bcl-2 was 25.82 +/- 10.53 in the control group and 113.49 +/- 27.49 in the varicocele group. Hematoxylin staining revealed a thickening ISV in the patients with varicocele, predominantly in the muscle layer, which was not found in the control group. Moreover, the intensity of Bcl-2 immunostaining was markedly higher in the study group than in the control group.

CONCLUSION

This study showed Bcl-2 overexpression in the ISV of patients with varicocele. Additional studies are necessary to clarify the molecular mechanisms of varicocele formation and recurrence.

Increased Expression of Hypoxia-Inducible Factor-1α in the Internal Spermatic Vein of Patients With Varicocele

PURPOSE

Varicocele is recognized as a cause of male infertility. Testis hypoxia may be one of the possible mechanisms of varicocele. We examined whether tissue hypoxia occurred in the ISV of patients with varicocele by detecting the expression of HIF-1alpha.

MATERIALS AND METHODS

The study group consisted of 8 patients with grade 3 left varicocele. The control group consisted of 6 volunteers with left indirect inguinal hernia. Using a left inguinal surgical incision, a 1 cm section of ISV was resected from each patient in both groups as specimens for immunoblotting and immunohistochemical staining of HIF-1alpha. Results were analyzed using Student's t test.

RESULTS

HIF-1alpha immunoblots from both groups revealed a single band. The relative intensity of the HIF-1alpha protein band was 10.92 +/- 2.70 in the control group and 73.15 +/- 8.93 in patients with varicocele (ie 7-fold higher).

CONCLUSIONS

HIF-1alpha expression in the ISV of patients with varicocele was significantly higher than in the control group. This directly shows that hypoxia related pathophysiological changes have occurred in the ISV of patients with varicocele and that hypoxia may have also occurred in the testicular tissue. Thus, it would be of interest to investigate whether decreasing HIF-1alpha activation and testis hypoxia could reduce the recurrence of varicocele. To our knowledge, this is the first report on HIF-1alpha expression in human ISV. Additional studies will be necessary to clarify the relationship between testis hypoxia and male infertility in patients with varicocele.