Review of current varicocelectomy techniques and their outcomes

Varicocele repair in improving spermatozoa, follicle-stimulating hormone, and luteinizing hormone parameters in infertile males with azoospermia: a systematic review and meta-analysis

ABSTRACT

Patients with azoospermia show a prevalence of varicocele of 10.9% and a 14.8% contribution to male infertility. Patients with azoospermia are thought to produce high-quality semen following varicocele treatment. Advising varicocelectomy prior to sperm retrieval in a reproductive program is still debated. This study reviewed the impact of varicocele repair on male infertility using several factors. A literature search was conducted using Scopus, PubMed, Embase, the Wiley Online Library, and Cochrane databases. Sperm concentration, sperm progression, overall sperm motility, sperm morphology, and follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels were also compared. Outcomes were compared between those who received treatment for varicocele and those who did not. The data from the pooled analysis were presented as standardized mean difference (SMD) along with a 95% confidence interval (CI). Heterogeneity was evaluated using I2. Additionally, we conducted analyses for publication bias, sensitivity, and subgroup analysis as appropriate. Nine studies were included after screening relevant literature. Statistical analysis revealed a significant improvement in sperm concentration (SMD: 1.81, 95% CI: 0.84-2.77, P < 0.001), progressive sperm motility (SMD: 4.28, 95% CI: 2.34-6.22, P < 0.001), and sperm morphology (SMD: 3.59, 95% CI: 2.27-4.92, P < 0.001). Total sperm motility showed no significant difference following varicocele repair (SMD: 0.81, 95% CI: -0.61-2.22, P = 0.26). No significant differences were seen in serum FSH (SMD: 0.01, 95% CI: -0.16-0.19, P = 0.87) and LH (SMD: 0.19, 95% CI: -0.01-0.40, P = 0.07) levels as well. This study supports varicocele repair in infertile men with clinical varicocele, as reflected by the improvement in sperm parameters after varicocelectomy compared with no treatment. There were no significant improvements in serum FSH and LH levels.

Successful Adolescent Varicocelectomy Improves Total Motile Sperm Count

BACKGROUND

Management of the adolescent varicocele focuses on optimizing fertility potential, but to date there is limited data on the success of varicocelectomy on optimizing semen parameters for individual adolescent patients. We reviewed our database of over 1600 adolescent varicocele patients to find those with pre- and postoperative semen analyses to determine the impact of varicocele correction.

METHODS

15 Tanner stage V patients with unilateral clinically apparent left-sided with pre- and postoperative semen analyses were identified. Mixed models were used to compare semen parameters pre- and post-varicocelectomy in patients with successful management.

RESULTS

Complete elimination of the varicocele was achieved in 12/15 (80%) patients. Three patients had persistent varicocele (with down-grading in two) and declined further intervention. Median time between pre- and postoperative semen analyses was 24.2 months. For those with successful varicocele correction, total motile sperm count (TMSC) improved in all but one (Figure 1), with an average increase of 44.0 million (95% CI: 18.7-69.3) in post-varicocelectomy analyses compared to pre-varicocelectomy (p = 0.0016). Mean percent improvement was 649.2%. It went from abnormal to normal (≥20 million/cc) in 55.6% (5/9). For the three patients with persistent varicocele, one had improved TMSC from abnormal to normal range, one had worsening within normal range, and one had effectively no change.

CONCLUSION

Successful correction of adolescent varicocele may improve TMSC. In over half of our institution's cases, an abnormal value normalized. Surgical intervention may be considered for adolescent varicoceles associated with abnormal semen parameters.

LEVELS OF EVIDENCE

Level III.

TYPE OF STUDY

Treatment study.

Bilateral inguinal transabdominal pre-peritoneal laparoscopic hernioplasty associated to bilateral laparoscopic varicocelectomy in the same intervention: a feasibility study

INTRODUCTION

Inguinal hernia and varicocele are common conditions in male population. Laparoscopy brings the opportunity to treat them simultaneously, through the same incision. However, there are different opinions about the risks for testicular perfusion of multiple procedures in the inguinal region. In this study, we assessed the feasibility of simultaneous laparoscopic procedures by studying clinical and surgical outcomes of patients undergoing bilateral inguinal hernioplasty using the transabdominal preperitoneal (TAPP) technique with and without concomitant bilateral laparoscopic varicocelectomy (VLB).

METHODS

a sample of 20 patients from the University Hospital of USP-SP with indirect inguinal hernia and varicocele with indication for surgical correction was selected. Patients were randomized into two groups, 10 undergoing TAPP (Group I) and 10 undergoing simultaneous TAPP and VLB (Group II). Data regarding total operative time, complications and postoperative pain was gathered and analyzed.

RESULTS

there was no statistical difference between groups regarding total operative time and postoperative pain. Only one complication (spermatic cord hematoma) was observed in Group I and no complications were observed in Group II.

CONCLUSIONS

simultaneous TAPP and VLB in was shown to be effective and safe, which provides a basis for conducting studies on larger scales.

Hernioplastia inguinal pré-peritoneal transabdominal bilateral e varicocelectomia laparoscópica bilateral na mesma intervenção: um estudo de viabilidade

RESUMO Introdução: hérnia inguinal e varicocele são doenças comuns na população masculina. O advento da laparoscopia traz a oportunidade de tratá-las simultaneamente, pelo mesmo acesso. Entretanto, existem divergências sobre os riscos para a perfusão testicular de múltiplos procedimentos na região inguinal. Neste estudo, avaliamos a viabilidade de procedimentos laparoscópicos simultâneos estudando resultados clínicos e cirúrgicos de pacientes submetidos à hernioplastia inguinal bilateral pela técnica transabdominal préperitoneal (TAPP) com e sem varicocelectomia laparoscópica bilateral (VLB) concomitante. Métodos: uma amostra de 20 pacientes do Hospital Universitário da USP-SP com hérnia inguinal indireta e varicocele com indicação de correção cirúrgica foi selecionada. Os pacientes foram randomizados em dois grupos, sendo 10 submetidos à TAPP (Grupo I) e 10 submetidos à TAPP e VLB simultâneas (Grupo II). O tempo operatório total, complicações e dor pós-operatória foram coletados e analisados. Resultados: não houve diferença estatística entre os grupos com relação ao tempo operatório total e à dor pós-operatória. Apenas uma complicação (hematoma do cordão espermático) foi observada no Grupo I e não foram observadas complicações no Grupo II. Conclusões: no mesmo procedimento, submeter pacientes à TAPP e à VLB no mesmo procedimento se mostrou eficaz e seguro, o que fornece embasamento para a realização de estudos em maiores escalas.

Management of adolescent varicocele

Varicocele is defined as an abnormal dilation and tortuosity of the internal spermatic veins found within the pampiniform plexus. It is a common finding in adolescents and adult men alike, however its diagnosis in the adolescent population poses different dilemmas in regard to indications for treatment than in adults. Failed Paternity is a clear-cut indication for repair in adult men attempting to father children. In adolescents, the physicians, family and patients must consider potential for future fertility problems which may or may not actually become of concern. Assessing the degree of negative effect of the varicocele on an adolescent's testicular health can also be difficult as teenagers typically are not asked to provide semen for analysis and thus surrogate markers for testicular health such as testicular size differentials must be used. Treatment options for the adolescent varicocele are similar to options in adult populations. While risks and benefits of various techniques can be considered, the gold standard for varicocele repair in adolescents has not been clearly defined. We aim to discuss diagnosis of varicocele, considerations for initiating treatment of varicocele in the adolescent, and techniques for management.

Quality Assessment and Relevant Clinical Impact of Randomized Controlled Trials of Varicocele: Next Step to Good-Quality Randomized Controlled Trial of Varicocele Treatment

Purpose

To assess the quality of randomized controlled trials (RCTs) on varicocele published from 1979 to 2017.

Materials and Methods

We searched for original RCT on varicocele published between 1979 and 2017. Jadad scale, van Tulder scale, and Cochrane Collaboration Risk of Bias Tool were used to analyze RCT quality over time. Effects on RCT quality including funding source, Institutional Review Board (IRB) approval, and intervention were assessed. Treatment parameters of varicocele were also analyzed.

Results

Blinding and allocation concealment were described in 25.9% and 9.4% of RCT, respectively. Both tended to increase and a sharp dip in allocation concealment was observed in 2010–2017. Jadad scores increased steadily from 1979 to 2017 (1.28±0.59 to 2.19±1.10, p<0.01). Van Tulder scores tended to increase from 1979 to 2017 (4.21±0.94 to 5.58±1.58, p<0.01). RCTs with funding statements had higher Jadad (Yes vs. No, 3.25±0.50 vs. 1.70±0.97; p<0.01) and van Tulder (Yes vs. No, 7.25±1.26 vs. 4.81±1.26; p<0.01) scores than unfunded RCTs. IRB approval and intervention were associated with better quality.

Conclusions

The number of RCTs on varicocele increased from 1979 to 2017. Also, quality improved over time with increasing IRB approval, funding, and multicenter trial. Most RCTs on varicocele reported the use of surgical treatment. RCTs of surgical treatments have limitations to satisfy the condition of RCT to conduct, but their quality has improved over time.

Efficacy of scroto-inguinal microsurgical varicocelectomy in treating male infertility

Background

Varicocele presents as the most frequent cause of infertility in men. Most reports showed that varicocelectomy has a significant impact on male fertility and reproductive outcome. This study aims to evaluate the safety and effectiveness of scrotal–inguinal microsurgical varicocelectomy in treating male infertility.

Methods

We prospectively studied preoperatively and postoperatively (at 3 and 6 months) 86 consecutive patients diagnosed with varicocele, abnormal semen parameters, and infertility, undergoing scrotal–inguinal microsurgical varicocelectomy. Semen test was performed before surgery and at 3 months and 6 months after surgery. The reproductive events were short-term followed up.

Results

The median age of the patient was 32.9 ± 5.1 (20–43). Two cases (2.7%) had a minor infection of the scrotum incision, who were well treated by appropriate antibiotics. After operation, total sperm count and the percentage of motile sperms at 3 months and 6 months were significantly higher than those pre-varicocelectomy, respectively. In total, 26.7% (23/86) of all couples achieved a spontaneous pregnancy. Late complications such as testicular atrophy, hydroceles, and recurrent varicocele have not occurred.

Conclusions

Scrotal–inguinal microsurgical varicocelectomy is an acceptable method in treating male infertility due to high rate of reproductive outcomes and very low rate of complications.

Comparison of the result of Doppler sonography before and after laparoscopic artery and lymphatic sparing varicocelectomy with microsurgical subinguinal varicocelectomy

Background:

Based on the importance of varicocele, the aim of this is to compare the comparison between doppler sonography before and after laparoscopic lymphatic sparing varicocelectomy and microsurgical subinguinal varicocelectomy.

Patients and Methods:

Patients with primary varicocele who were referred to Ahwaz Imam Khomeini Hospital after informed consent were included. Primary information included varicocele severity, pain intensity, latency, Doppler sonography (Resistive index (RI), venous return, venous diameter before and after Valsalva) were obtained, and then patients were entered into one of the two groups of surgery. The admission duration, return to work duration, the pain and analgesic consumption, and the length of anxiety were recorded in patients. Patients were examined 3 months later, and the severity of varicocele in the examination, pain score, latency, Doppler sonography indices, sperm indices in both groups were registered. In the end, the information is entered into Statistical Package for the Social Sciences (SPSS) statistical software and evaluated.

Results:

We observed that the severity of varicocele (P = 0.34), pain (P = 0.45), latralite (P = 0.56), RI (P = 0.65), intravenous diameter (P = 0.75) did not show statistically significant difference between the two groups, also in evaluating these indices after surgery, there were significant differences between the two groups in pain (P = 0.04) and time for return to work (P = 0.036).

Conclusions:

The methods used in varicocelectomy did not have any effect on the outcome of the treatment. Accordingly, using any of these methods can improve the post-surgical state of the patients and promote the fertility performance and reduction of complications due to surgery in patients.

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.

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.

Effect of microsurgical varicocelectomy on semen parameters, serum, and intratesticular testosterone levels

Objective

The goal of this work was to evaluate if men who underwent microsurgical varicocelectomy would have improvement in serum testosterone (T) as well as serum 17-hydroxyprogesterone (17-OHP-An intratesticular T biomarker) in addition to semen parameters after operation.

Materials and Methods

We conducted a prospective analysis of 30 men who underwent microsurgical varicocelectomy from December 2018 to September 2019. We assessed varicocele grade and laterality, serum T, serum 17-OHP, serum follicle- stimulating hormone (FSH), serum LH, and semen parameters in baseline and follow-up. According to the data distribution, we reported the median and interquartile ranges and utilized the Mann-Whitney U, Student's t test and Wilcoxon rank test. Correlation analysis was performed with the Spearman test.

Results

In the baseline, 9 (30%) men had 17-OHP < 55 ng/dL and 21 (70%) men presented with 17-OHP > 55 ng/dL. Also, 19 men had TMSC < 9 million, including 6 men with azoospermia, 1 man with cryptozoospermia, and 11 men with TMSC > 9 million. We found an improvement in most SA parameters of most men, which include concentration (63.3%, 19/30), motility (46.6%, 14/30), and TMSC (60%, 18/30). About seven (36.8%) men had TMSC upgraded to > 9. There was a significant change in volume (2.1 [1.5-2.8] to 2.4 [1.7-3.6] cc, P = .018), concentration (6.8 [0.8-22.5] to 12.5 [1-31] million/cc, P = .047) and TMSC (4.4 [0.3-15.1] to 10.5 [0-41.8] million, P = .012) after surgery. We neither found a change in serum T nor a change in intratesticular T (serum 17-OHP) after varicocelectomy (P > .05). FSH, LH and T were similar both before and after varicocelectomy (P > .05).

Conclusion

Despite improvement in semen parameters following varicocelectomy, we did not see changes in either serum or intratesticular T. This suggests that improvement of semen parameters following varicocele repair could be from factors other than changes in androgen levels within the testis.

Positive effects of the inclusion of open-mouth pressure for elimination of blood in microscopic subinguinal varicocelectomy

PURPOSES

Primary varicocele (PVC) may cause testicular hypofunction and scrotal pain. We believe that the currently used procedure microscopic subinguinal varicocelectomy (MSV) can be further improved to provide more benefits to the patients.

METHODS

In total, 100 patients who were diagnosed as having PVC grade II or III with venous reflux based on ultrasound results, along with scrotal pain and visible scrotal varicose veins, were enrolled; they were randomly divided into two groups. When the experimental group underwent MSV, stagnant venous blood in the internal spermatic vein close to the testis was drained using manual pressure, whereas the control group was treated with routine MSV procedure. The patients' psychological condition, symptoms, prognoses, scrotal appearances, and other related indexes were evaluated before and after the surgeries, and the results were compared.

RESULTS

Scores on days 1-3 after the surgeries were significantly different between the two groups (P < 0.05) for the Hamilton Depression Scale (HAMD) after viewing the scrotum immediately after the surgeries, the Hamilton Anxiety Scale (HAMA) after viewing the scrotum immediately after the surgeries, and the average visual analog scale (VAS). No significant differences were found between the groups for other evaluation indexes (P > 0.05).

CONCLUSIONS

The use of open-mouth pressure for elimination of blood reduces postoperative filling of dilated scrotal veins, reduces the visual stimuli to patients immediately after surgery, significantly improves the anxiety and depression of patients, helps to maintain positive mental condition in patients after the surgeries, and increases their confidence in recovery from the disease. It also leads to better pain relief within a short period after the surgery and maximizes surgical benefits for the patients.

Effects of Varicocele Treatment on Sperm Conventional Parameters: Surgical Varicocelectomy Versus Sclerotherapy

INTRODUCTION

Varicocele is often associated with impaired sperm parameters. Different procedures have been developed for varicocele treatment. The aim of this study was to evaluate the effects of varicocele treatment on conventional sperm parameters.

MATERIALS AND METHODS

We compared two different techniques of intervention: surgical varicocelectomy and sclerotherapy. We also evaluated the number of varicocele recurrences and the pregnancy rate. We included 102 patients (mean age 29.8 ± 0.8 years) with ultrasound diagnosis of varicocele. We excluded patients whose ultrasound evaluation and/or sperm parameters were not known before and after varicocele correction. We divided the patients (excluding 8 with azoospermia) into two subgroups: surgical varicocelectomy (n = 44) and sclerotherapy (n = 50). For each patient, we compared conventional sperm parameters before and after varicocele correction.

RESULTS

After varicocele correction, we found a significant improvement in sperm concentration, total count and total motility. Considering the two subgroups, baseline sperm parameters did not differ significantly. Sperm concentration and total count increased significantly after varicocele correction by varicocelectomy. Varicocele correction by sclerotherapy resulted in a significant increase in sperm concentration, progressive and total motility. We found varicocele recurrence in 32% of patients who underwent varicocelectomy and in 19.7% of patients undergoing sclerotherapy. The pregnancy rate was higher after sclerotherapy (28%) than after surgical varicocelectomy (13%).

CONCLUSION

Varicocele treatment must be recommended when other causes of infertility have been treated. Our results suggest the use of sclerotherapy for varicocele repair.

LEVEL OF EVIDENCE

2 b.

Comparison of scrotal antegrade sclerotherapy and laparoscopic Palomo surgery in treatment of adolescent varicocele: A 15-year review

INTRODUCTION/OBJECTIVE

Varicocele is a common condition seen in adolescence and associated with adult subfertility. Numerous types of intervention have been described with differences in success and complication rates. This study aims to review and compare the surgical outcomes of laparoscopic Palomo surgery and scrotal antegrade sclerotherapy at our center.

STUDY DESIGN

A retrospective analysis was done of all patients younger than 18 years old with idiopathic varicocele treated operatively between February 2001 and December 2016. Demographics such as age at operation, side, varicocele grade, operative date, and types of operation were collected. Primary outcomes were clinical recurrence, defined as any grading noted on follow-up within 1 year post-op and post-operative hydrocele. Secondary outcomes were operative time, length of stay, and other surgical complications. Mann-Whitney U test, independent t test and chi-square tests were used for analysis. All p-values were two-sided and considered statistically significant at p ≤ 0.05.

RESULTS

A total of 119 patients fit the criteria, of whom 117 patients were included in data analysis (Table). Sixty-two patients had laparoscopic Palomo surgery (LPS) and 55 had scrotal antegrade sclerotherapy (SAS). Clinical recurrence (grade 2-3) within 1 year was similar between the two groups, with four out of 48 patients in the SAS group and six out of 62 patients in the LPS group (8.4% in SAS vs. 9.7% in LPS, p = 1.00). Of the 11 patients who had recurrence in the SAS group, seven had grade 1 recurrence (14.5%), two (4.2%) had grade 2 recurrence, and two (4.2%) had grade 3 recurrence. For the LPS group, 17 out of 62 patients had clinical recurrence within 1 year, of whom 11 (17.7%) had grade 1 recurrence, one (1.6%) had grade 2, and five (8.1%) had grade 3 recurrence. Post-operative hydrocele was significantly higher in the LPS group; there was none in the SAS group but 11 patients in the LPS group (0% in SAS vs. 17.7%, p = 0.002). Three patients had clinically significant hydrocele requiring Jaboulays' procedure. Complications other than hydrocele were noted in three patients in the SAS group and one patient in the LPS group (5.5% in SAS vs. 1.6% in LPS, p = 0.158). None required operative intervention. No conversion to open procedure was seen in the LPS group and there were no perioperative complications. Mean operative time was 62.9 min in the SAS group and 60.7 min in the LPS group (p = 0.624). Mean length of stay was 17.5 h in the SAS group and 31.7 h in the LPS group (p < 0.001).

CONCLUSION

Both SAS and LPS are safe procedures for treatment of adolescent varicocele with similar clinical recurrence rate within 1 year. SAS has a significantly lower rate of post-operative hydrocele.

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.

Best practice in the diagnosis and treatment of varicocele in children and adolescents

A varicocele is an abnormal dilation of the pampiniform plexus of veins in the scrotum which begins at puberty in approximately 15% of males. Although common in the general population and often asymptomatic, varicoceles are associated with gonadal dysfunction including testicular atrophy, infertility, and hypogonadism in a subset of men diagnosed later in life. Because of the high prevalence and uncertain pathogenesis, definitive management guidelines for varicoceles diagnosed in the pediatric and adolescent population remain poorly defined. The varicocele is the most common etiology of male factor infertility, and treatment in the pediatric and adolescent population may improve semen quality and improve fecundity in adulthood. Evaluation of the pediatric and adolescent varicocele should include history, physical exam, and measurement of testicular volume with orchidometer or ultrasound. Testicular volume differentials and peak retrograde flow on Doppler ultrasonography are important factors in risk stratification of the pediatric varicocele population. Semen analysis and reproductive endocrine assessment should also be considered as part of the workup for adolescent patients. A variety of treatment approaches exist for varicocele, and while the microsurgical subinguinal approach is the gold standard for the adult population, it has yet to be confirmed as superior for the adolescent population. Referral to an andrologist for the adolescent patient with varicocele should be considered in equivocal cases. While active treatment of varicocele in the pediatric and adolescent population is controversial, it is clear that some untreated patients will suffer symptoms later in life, while overtreatment remains a concern for this large, vulnerable population. Therefore, surveillance strategies and improved accuracy in diagnosis of clinically important pediatric varicoceles prompting treatment are needed in the future.

THE IMPACT OF LOUPE-ASSISTED INGUINAL VARICOCELECTOMY ON SEMEN QUALITY AND PREGNANCY RATE

Context

Open varicocelectomy is generally performed without microscopic equipment in Iran. We report our experience with loupe-assisted inguinal varicocelectomy, and its impact on semen parameters and pregnancy rate.

Subjects and Methods

We conducted a retrospective interventional study on secondary data obtained from the medical records of 303 men with varicoceles, who underwent an inguinal varicocelectomy between March 2003 and April 2012. The surgical technique involved the use of a 3.0 × loupe during spermatic cord dissection at the level of the internal inguinal ring under spinal anesthesia. Semen samples were analyzed for sperm concentration, motility, and sperm morphology before the varicocelectomy and after 3 months. All the infertile patients were followed-up postoperatively for more than 1 year.

Results

There were 9 (3.0%) varicocele recurrences and 3 (1.0%) hydroceles. After varicocelectomy, sperm concentration and motile spermatozoa increased. In addition, spermatozoa with normal morphology improved significantly postoperatively. Of the 303 subjects treated, 153 (83.2) had a 1-year preoperative history of infertility; the spontaneous pregnancy rate of the spouses during the follow-up period was reported to be 61.4%.

Conclusions

The results of this research indicated that varicocelectomy using loupe-assisted inguinal technique could improve semen parameters and pregnancy rate with a low postoperative complication rate.

Impact of varicocelectomy on the proteome profile of testicular tissues of rats with varicocele

Varicocele (VC) is a common cause of male infertility, but the molecular mechanisms involved in its pathogenesis are unknown. We investigated the impact of varicocelectomy (VCT) on proteome profiles in testicular tissues of rats with VC, and analysed associated target genes and signalling pathways. Sixty male rats with VC were divided into two groups: control (n = 30), and VCT (n = 30). Tissues were collected 4 weeks after sham or VCT surgery. Matrix-assisted laser desorption/ionisation time-of-flight/time-of-flight mass spectrometry (MALDI-TOF/TOF MS) was used to analyse the comparative proteome profiles. Kyoto Encyclopaedia of Genes and Genomes (KEGG) Orthology-Based Annotation System was used for bioinformatic analysis. Fifteen proteins were differentially expressed between control and VCT groups. These differentially expressed proteins are associated with several specific cellular processes associated with the pathogenesis of testicular growth arrest associated with VC. Furthermore, the evaluation by transmission electron micrograph showed that VCT could decrease apoptosis of spermatogenic cells in rats. Understanding such molecular pathways might provide physicians with a better insight into VC and with potential targets for treatment.

Determination of spermatic vein reflux after varicocele repair helps to define the efficacy of treatment in improving sperm parameters of subfertile men

PURPOSE

A continuous spermatic venous reflux (SVR) at colour Doppler ultrasound (CDU) is an evidence for varicocele, a frequent correlate for male subfertility. We explored whether SVR after left varicocele repair is predictive for changes in semen quality in subfertile men.

METHODS

Blood hormones (FSH, LH, and total testosterone) and scrotal CDU were obtained in subfertile patients with left grade II or grade III varicocele on physical evaluation and a poor sperm quality. Semen analysis and CDU were re-evaluated 6 months after a retrograde internal spermatic vein scleroembolisation.

RESULTS

The retrospective study included 100 men with a baseline SVR >3 cm/s; 60 men showed a disappearance (group 1) and 40 men (group 2) showed a reduced SVR after varicocele repair. Total motile sperm count (TMC) was markedly increased after treatment (p < 0.0001; F = 35.79) and the increase was more relevant in group 1 compared to group 2 (p = 0.04; F = 4.20). TMC and left SVR values after varicocele repair were negatively correlated (R = -0.218; p = 0.035). Multivariate analysis showed that adjusted SVR after repair negatively predicted TMC change (TMC after repair minus baseline TMC) (ß = -2.56; p = 0.022). Disappearance of a continuous left SVR at CDU after varicocele repair was associated to a better improvement of semen parameters in subfertile men.

CONCLUSION

Recording of a continuous left spermatic vein reflux is an objective method to assess a successful varicocele repair aimed to improve sperm parameters in subfertile men.

Pressure flow pattern of varicocele veins and its correlation with testicular blood flow and semen parameters

The pressure pattern in varicocele veins of infertile patients and its correlation with semen quality and testicular blood flow was determined. Consecutive patients at andro-urology clinic of a teaching hospital undergoing microsurgical varicocelectomy were included. Their semen quality and testicular blood flow were determined. Peak systolic velocity (PSV) and resistive index (RI) of subcapsular and intraparenchymal branches of testicular artery were noted by colour Doppler ultrasonography. During surgery before ligation of varicocele veins, intravenous pressures of internal spermatic (ISV) and external spermatic (ESV) veins were determined at baseline and after Valsalva manoeuvre. Thirty patients, 20-45 years old, were evaluated. Baseline pressure for maximum dilated ISV (A), less dilated ISV (B) and ESV was 15.93 ± 6.34, 12.38 ± 4.60 and 12.92 ± 5.65 mm. Hg, respectively, which increased after Valsalva by 104.4%, 116.2% and 38.22% respectively. Correlation (r = -.71; p < .05) was appreciated between percentage increase in pressure of ISV B with PSV of intraparenchymal testicular arteries and progressive motility (r = -.759; p < .05), nonprogressive motility (r = -.738; p < .05) and morphology (r = -.653; p = .07) of spermatozoa. In conclusion, ISV develops higher pressure on Valsalva as compared to ESV and has correlation with semen quality and testicular blood flow.

Perspectives in Pediatric Pathology, Chapter 20. Adolescent Varicocele

Varicocele is characterized by elongation, dilatation, and tortuosity of the veins draining the testis and its covers, causing circulatory reflux along the inner spermatic vein [ 1 ]. Varicocele results in progressive testicular lesions and, if untreated, can lead to testicular atrophy [ 2 ]. Varicocele is considered the most frequently identified cause of male infertility [ 3 ]. The mechanisms involved in varicocele formation are not well known and probably are multiple, differing from one patient to another.

Subinguinal microsurgical varicocelectomy vs. percutaneous embolization in infertile men: Prospective comparison of reproductive and functional outcomes

Background

Varicocele is a condition characterized by dilated, tortuous veins within the pampiniform venous plexus of the scrotal sac. Presence of varicocele is associated with an increased risk of alteration of semen parameters. The objective of this study was to compare the current standard in varicocele treatment procedures: sub-inguinal microscopic ligation to percutaneous embolization in terms of semen parameters improvement, fertility, and morbidity at the university hospital of Toulouse (France). Seventy six patients with clinical varicocele, alteration of semen parameters and infertility, underwent either procedure (microsurgery in 49 case performed by a single surgeon and embolization in 27 cases) and were prospectively analyzed. Outcome measures were: semen parameters, spontaneous pregnancies, pain, side effects, recovery time and overall satisfaction. All patients were contacted in January 2015 in order to determine reproductive events.

Results

Preoperatively, there was no difference in clinical and biological items between the two groups. Postoperatively, on the overall population, there was a significant improvement of sperm concentration at 3, 6, 9 and 12 months (p = <0.001, <0.001, 0.012, 0.018) and sperm motility at 6 months (p = 0.002). The sperm concentration was higher at 6 months in the percutaneous embolization group (13.42, vs. 8.1×10⁶/ml; p = 0.043). With a median follow-up of 4 years, 27 pregnancies occurred (spontaneous pregnancy rate of 35.5%).

There was no significant difference between procedures on the sperm quality, pregnancy rate, and the overall satisfaction. Patients undergoing percutaneous embolization reported a faster recovery time (p = 0.002) and less postoperative pain (p = 0.007).

Conclusion

Our study shows that percutaneous embolization seems to be an equivalent alternative to sub-inguinal microscopic ligation in term of sperm quality improvement, pregnancy rate, and overall satisfaction with a slight advantage on post-operative morbidity.

Semen parameters and pregnancy rates after microsurgical varicocelectomy in primary versus secondary infertile men

In a prospective study, the outcomes of microsurgical varicocelectomy in men with primary versus secondary infertility were compared. Ninety-two infertile men with a varicocele were included. They were classified into those with primary infertility (n = 57) and secondary infertility (n = 35). Clinical data, semen parameters and scrotal ultrasound finding were available for all patients and microsurgical varicocelectomy was performed on all of them. Spontaneous pregnancy rates and improvement in semen parameters in those men with primary versus secondary infertility were recorded 1 year after surgery. Preoperatively, there was no significant difference in the mean semen parameters in both groups (p > 0.05) and the mean semen parameters showed no significant difference between men with primary and secondary infertility. After microsurgical varicocelectomy, the mean semen parameters improved significantly in both group (p < 0.05 for each), but there were no significant difference in mean semen parameters between men with primary versus secondary infertility (p > 0.05 for each). After adjustment for patient and partner ages, the pregnancy rate at the end of the follow-up period did not significantly differ between the primary (24/57, 42.1%) and secondary (11/35, 31.4%) infertility group (Pearson's Chi-squared = 1.05). We concluded from this study that semen parameters and pregnancy rates after microsurgical varicocelectomy were similar between men with primary and secondary infertility.

Magnesium Sulfate Mediates Morphine Administration Reduction in Varicocelectomy Surgery

AIMS

Varicocelectomy is the most common operation carried out by doctors for male infertility treatment. The aim of varicocele treatment is to hinder the refluxing venous drainage to the testis, retaining arterial inflow, and lymphatic drainage. A lot of pain is generated after this surgery, and the use of opium should be reduced to nearest minimum, as all drugs are toxins. Thus the aim of the present study is to facilitate morphine usage reduction after varicocelectomy surgery.

MATERIAL AND METHODS

One-hundred (100) patients who were varicocelectomy candidate were randomized into two groups: experimental group contain 50 patients and control group contain 50 patients as well. In experimental group, 2 mL magnesium sulfate in 2 mL normal saline was injected into patient immediately after surgery. The control group received only 4 mL normal saline. Morphine dosage administered, and severity of pain monitoring was accessed and recorded with a visual analogue scale (VAS).

RESULT

Result indicated that administration of morphine dosage in the test group 0.21 ± 0.64 mg was significantly lower as compared to the control group 0.75 ± 1.30 mg during the first 24-hour after surgery (p = 0.01). Average VAS scores in the experimental and control groups in the first 4-hour interval were 0.91 ± 1.30 and 2.9 ± 2.50 (p = 0.02) respectively. We observed a significant difference in the VAS score for pain severity and the dosages of morphine administered.

CONCLUSIONS

The experimental group with magnesium sulfate in its drug formulation showed better pain control compared to the control group which received only normal saline, whose pain manifested after every few hours. This can be used for the formulation of opium for this surgery in a large scale.

Does varicocelectomy improve semen analysis outcomes in adolescents without testicular asymmetry?

PURPOSE

The main indications for adolescent varicocelectomy are testicular hypotrophy or pain. However, we have previously shown that both serial total testicular volume and volume differential are weakly associated with semen quality. The ultimate patient goal is paternity, but semen analysis is critical to appropriate management of varicocele. We hypothesize that varicocelectomy improves total motile count (TMC) among patients who only have abnormal semen analysis (SA) parameters, but not among those with potential hormonal dysfunction such as Klinefelter syndrome or cryptorchidism.

METHODS

We retrospectively reviewed our registry of adolescent males followed with a clinical left varicocele. For this study, subjects without sustained testicular asymmetry, who were Tanner V, and gave at least one preoperative SA were included. Subjects were excluded if they had embolization for their varicocele or no postoperative SA. Primary outcome was change in TMC before and after surgery, compared using the Wilcoxon signed rank test after stratifying by surgical indication. Secondary outcomes included rates of improved TMC and normalized TMC (>20 million) after surgery, compared across covariates using the Fisher exact test.

RESULTS

Seventeen patients met the eligibility criteria, 11 of whom underwent repair for only abnormal preoperative TMC. Overall, median age (interquartile range [IQR]) at first preoperative SA was 17.6 (15.9-17.9) years. The median preoperative TMC across all SA was 2.8 (0.7-7.4) million. The median age at surgery was 18.2 (16.8-18.9) years. Postoperatively, the median TMC across all SA increased to 18.2 (3.6-18.2) million (Wilcoxon signed rank test, p < 0.01; see Figure). The improvement in TMC occurred primarily in the group who only had abnormal preoperative TMC (82% improved, 55% normalized); lack of improvement was seen in patients who had a history of Klinefelter or orchiopexy for cryptorchidism.

CONCLUSIONS

Adolescent varicocele patients should undergo SA after development of Tanner V. Varicocelectomy has a high success rate for improving TMC in adolescent or young adult males who only have abnormal TMC and no history of cryptorchidism.

Effect of Microsurgical Subinguinal Varicocele Repair on Chronic Dull Scrotal Pain in Men with Grade II-III Lesions

INTRODUCTION

We aimed to evaluate the effectiveness of microsurgical subinguinal varicocele repair in patients with grade II-III lesions and chronic dull scrotal pain.

MATERIALS AND METHODS

A total of 29 patients with grade II-III varicocele and chronic dull scrotal pain that had a microsurgical subinguinal varicocele repair were included in the study. They were followed-up for 6-12 months including pain assessment and scrotal examination.

RESULTS

Of the 29 patients, 28 (97%) reported complete resolution of pain with no palpable varicocele on scrotal examination. No cases of testicular atrophy or hydrocele formation were reported.

CONCLUSION

These results indicated that microsurgical varicocele repair should be considered in patients with grade II-III lesions and chronic dull scrotal pain.

[Comparison of subinguinal microsurgical varicocelectomy vs percutaneous embolization in infertile men]

INTRODUCTION

Subinguinal microscopic ligation is the current standard of treatment of varicocele, and percutaneous embolization is a new alternative. We aimed to compare these procedures for reproductive and functional aspects.

MATERIAL

A consecutive series of 76 patients with clinical varicocele, alteration of semen parameters and infertility, undergoing either procedure (microsurgery in 49 cases and embolization in 27 cases) was prospectively analyzed preoperatively and postoperatively (at 1, 3, 6, 9 and 12 months). Outcome measures were: semen parameters, pregnancies, pain, side effects, recovery time and overall satisfaction. Subsequently, all patients were contacted by telephone in January 2015 (with a median delay of 4 years after the procedure) in order to determine reproductive events.

RESULTS

Preoperatively, both groups were identical for clinical and biological items. We observed an improvement of sperm concentration at 3, 6, 9 and 12 months (P<0.001, <0.001, 0.012, 0.018, respectively) and sperm motility at 6 months (P=0.002). The sperm concentration was higher at 6 months in PE group (P=0.043). With a median follow-up of 4 years after the procedure, 27 pregnancies occurred (spontaneous pregnancy rate of 32%). There was no difference between procedures on the sperm quality, pregnancy rate and the overall satisfaction. Patients undergoing percutaneous embolization reported a faster recovery time (P=0.002) and less postoperative pain (P=0.007).

CONCLUSION

Both procedures give equivalent results regarding sperm quality, pregnancy rate and satisfaction even though recovery seems faster and postoperative pain seems lower after percutaneous embolization.

LEVEL OF EVIDENCE

4.

An update on the role of medical treatment including antioxidant therapy in varicocele

Varicocele-associated male infertility has classically been managed using surgery or assisted reproductive techniques. With increasing evidence of oxidative stress as a pathophysiological factor in varicocele-associated infertility, medical therapy especially antioxidants might become a treatment option with lower risks. We reviewed the existing literature on the role of various medical agents in the management of male infertility attributed to varicoceles. Medical therapy is typically evaluated in three different situations such as (a) comparison of two drugs or one drug with placebo, (b) comparison of drugs versus surgery, and (c) comparison of drugs as adjuvant therapy with surgery versus drug therapy alone. Due to heterogeneity of data and lack of well-conducted studies, there is insufficient data to recommend routine use of medical therapy for men with varicocele-associated infertility and surgery remains the treatment of choice. Pregnancy and live birth rates are usually not reported in most studies and mere improvement in sperm parameters or antioxidant capacity is insufficient to support its routine use. Antioxidant therapy is a potential option due to its theoretical benefit, data from preclinical studies, and lack of major side effects. Adjuvant therapy with antioxidants after surgical repair of varicocele may improve the outcome and is a potential area for further research.

Diagnosis and Management of Pediatric and Adolescent Varicocele: A Survey of Pediatric Urologists in Korea

The aim of this study was to evaluate current practice patterns on diagnosis and management of pediatric varicoceles. Questionnaires of approaches to diagnosis and management of pediatric varicoceles were sent electronically to pediatric urologists. Of the 70 questionnaires e-mailed, 37 (53%) responded to the survey. 10 respondents (27%) chose to operate on varicoceles, whereas 9 (24%) chose to observe, and 18 (49%) chose to decide upon treatment depending on the clinical situation. The most important indication for varicocelectomy was a decrease in ipsilateral testicular size (n=29, 78%) followed by testicular or scrotal pain (n=4, 11%) and varicocele grade (n=4, 11%). The optimal age for varicocelectomy was answered as 13.8±2.3 years mean. 32 respondents (86%) have used ultrasonography to aid in the diagnosis of varicoceles, and 26 respondents (70%) have considered repairing varicocele incidentally detected on ultrasonography. In an otherwise asymptomatic patient with varicocele, 17 respondents (46%) considered surgery for grade 3, but 15 respondents (41%) would not repair the varicocele. The most commonly used surgical approach was subinguinal microsurgical (n=19, 51%), followed by inguinal (n=9, 24%) and laparascopic (n=5, 14%) procedures. The most commonly experienced post-operative complication was recurrence (n=22, 59%) followed by persistence (n=13, 35%) and hydrocele (n=10, 27%). 28 respondents (76%) did not have long-term follow-up data including regarding fertility on their varicocele patients. Our survey demonstrates that there is lack of consensus on diagnosis and management of pediatric and adolescent varicoceles among pediatric urologists. A prospective randomized study of pediatric and adolescent varicoceles is needed to assess the outcomes and develop universal management guidelines.

Laparoendoscopic single-site varicocelectomy compared with conventional laparoscopic surgery: a systematic review and meta-analysis

Purpose

To present a systematic review and meta-analysis comparing laparoendoscopics single-site varicocelectomy (LESS-V) versus conventional laparoscopic surgery (CTL-V).

Methods

A literature search was performed using The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded and Google Scholar. Literature reviewed included meta-analyses, and randomized and nonrandomized prospective studies. We utilized weight mean difference (WMD) to measure hospital stay, time to return normal activity, postoperative pain and improvement of semen parameters and odds ratio (OR) to postoperative complications and cosmetic satisfaction. We used the Cochrane Collaboration’s Review Manager 5.1 software for statistical analysis.

Results

We identified six publications which strictly met our eligibility criteria. Meta-analysis of extractable data showed that LESS-V was better than CTL-V in postoperative pain (WMD: −0.46; 95 % CI −0.75 to −0.17; p = 0.002), time to convalescence (WMD: −1.4 days; 95 % CI −2.55 to −0.25; p = 0.02) and cosmetic satisfaction (OR 6.86; 95 % CI 2.89–16.28; p < 0.00001). However, CTL-V was better than LESS-V in operative time (WMD 1.96 min, 95 % CI 0.96–2.96; p = 0.0001). There were no differences between LESS-V and CTL-V in hospital stay (WMD: −0.02 days, 95 % CI −0.39 to 0.35; p = 0.92) and postoperative complications (OR 1.13, 95 % CI 0.57–2.21; p = 0.73).

Conclusions

This meta-analysis comparing the efficacy of LESS-V and CTL-V showed that LESS-V was safe, with significantly reduced postoperative pain, shorter recovery time, and better cosmetic outcome.

Varicocele: A Review

Varicoceles are relatively common clinical problem that are associated with pain, testicular atrophy, and reduced fertility rates. After a brief historical perspective is presented, this article reviews the anatomy, indications, treatment options, and potential complications related to varicoceles.

Clinical Outcomes of Varicocele Repair in Infertile Men: A Review

Varicoceles are a major cause of impaired spermatogenesis and the most common correctable cause of male infertility. They are found in approximately 40% of men with primary infertility and 80% of men with secondary infertility, although they also occur in 12% of men with normal semen parameters. The presence of a varicocele does not always affect spermatogenesis, as it has been reported that only 20% of men with documented varicoceles suffer fertility problems. However, varicocele repair appears to have beneficial effects in men with impaired semen parameters and palpable varicoceles. Currently, the main procedures employed for varicocele repair are microsurgical subinguinal or inguinal varicocelectomy, laparoscopic varicocelectomy, and radiological percutaneous embolization. Microsurgical varicocelectomy appears to be the optimal treatment in most cases, whereas the other procedures are useful only in specific cases. After treatment, it typically takes 3 to 6 months for patients' semen parameters to improve; thus, other therapies, including assisted reproductive technology, should be considered if infertility persists after this interval, especially in older couples. Controversies still remain regarding how varicoceles in certain subgroups, such as adolescents or men with azoospermia, should be treated. Due to their relatively high prevalence rate among the general population, varicoceles can occur concomitantly with other conditions that cause impaired spermatogenesis. Further studies are necessary in order to identify the patients who are most likely to benefit from treatment. In this review, we sought to summarize the issues currently associated with varicocele treatment in infertile men.

Laparoscopic varicocelectomy: virtual reality training and learning curve

Objectives:

To explore the role that virtual reality training might play in the learning curve of laparoscopic varicocelectomy.

Methods:

A total of 1326 laparoscopic varicocelectomy cases performed by 16 participants from July 2005 to June 2012 were retrospectively analyzed. The participants were divided into 2 groups: group A was trained by laparoscopic trainer boxes; group B was trained by a virtual reality training course preoperatively. The operation time curves were drafted, and the learning, improving, and platform stages were divided and statistically confirmed. The operation time and number of cases in the learning and improving stages of both groups were compared. Testicular artery sparing failure and postoperative hydroceles rate were statistically analyzed for the confirmation of the learning curve.

Results:

The learning curve of laparoscopic varicocelectomy was 15 cases, and with 14 cases more, it came into the platform stage. The number of cases for the learning stages of both groups showed no statistical difference (P = .49), but the operation time of group B for the learning stage was less than that of group A (P < .00001). The number of cases of group B for the improving stage was significantly less than that of group A (P = .005), but the operation time of both groups in the improving stage showed no difference (P = .30). The difference of testicular artery sparing failure rates among these 3 stages was proved significant (P < .0001), the postoperative hydroceles rate showed no statistical difference (P = .60).

Conclusions:

The virtual reality training shortened the operation time in the learning stage and hastened the trainees' steps in the improving stage, but did not shorten the learning curve as expected to.

Leg ischemia post-varicocelectomy

Varicocelectomy is the most commonly performed operation for the treatment of male infertility. Many surgical approaches are used as each of them has advantages over the other and is preferred by surgeons. Vascular injury has never been reported as a complication of varicocelectomy apart from testicular artery injury. We present a 36-year-old male who developed leg ischemia post-varicocelectomy due to common femoral artery injury. He was successfully treated by using a vein graft.

The evolution and refinements of varicocele surgery

Varicoceles had been recognized in clinical practice for over a century. Originally, these procedures were utilized for the management of pain but, since 1952, the repairs had been mostly for the treatment of male infertility. However, the diagnosis and treatment of varicoceles were controversial, because the pathophysiology was not clear, the entry criteria of the studies varied among centers, and there were few randomized clinical trials. Nevertheless, clinicians continued developing techniques for the correction of varicoceles, basic scientists continued investigations on the pathophysiology of varicoceles, and new outcome data from prospective randomized trials have appeared in the world's literature. Therefore, this special edition of the Asian Journal of Andrology was proposed to report much of the new information related to varicoceles and, as a specific part of this project, the present article was developed as a comprehensive review of the evolution and refinements of the corrective procedures.

Novel insights into the pathophysiology of varicocele and its association with reactive oxygen species and sperm DNA fragmentation

Varicocele has been associated with reduced male reproductive potential. With the advances in biomolecular techniques, it has been possible to better understand the mechanisms involved in testicular damage provoked by varicocele. Current evidence suggests the central role of reactive oxygen species (ROS) and the resultant oxidative stress (OS) in the pathogenesis of varicocele-associated male subfertility although the mechanisms have not yet been fully described and it is likely to be multifactorial. Excessive ROS is associated with sperm DNA fragmentation, which may mediate the clinical manifestation of poor sperm function and fertilization outcome related to varicocele. Testing of ROS/OS and DNA fragmentation has the potential to provide additional diagnostic and prognostic information compared to conventional semen analysis and may guide therapeutic management strategies in individual patient.

[Evolution of the therapeutic management of varicoceles: Analysis of French national coding database (2006-2014)]

OBJECTIVE

The varicocele is a venous abnormality frequently found in humans (1/10). Although the recommendations for management of this pathology are clear, two therapeutic options can be discussed: surgery or radiological embolisation. We wanted to study the evolution of the therapeutic management of varicocele using the French national coding database.

METHODS

Analysis of database from the "Agence technique de l'information sur l'hospitalisation" (ATIH) (number of surgical procedures and interventional radiology used in the treatment of varicocele for the period 2006-2014). The common classification of medical procedures (CCAM) was used to extract the codes for surgery and radiological embolisation. Then we recorded the corresponding "Groupes homogènes de malades" (GHM), excluding those with a different primary diagnosis of varicocele cure.

RESULTS

The number of surgical procedures and radiological embolisation performed for the treatment of varicocele increased from 3626 to 4007 procedures (+10.5%) between 2006 and 2014. While the frequency of interventional radiology (embolization pampiniform plexus) increased by 73.9%, surgery procedures (by direct approach or laparoscopy) decreased by 31.4% throughout the study (2006-2014). Thus in 2006, 60.2% of therapeutic procedures were performed surgically and 39.8% by radiological embolisation. In 2014, 37.4% of therapeutic procedures were performed surgically and 62.6% by embolization.

CONCLUSION

The analysis of French national database has confirmed a change in the therapeutic management of varicocele between 2006 and 2014. The minimally invasive treatment by radiological embolisation is currently favored in France and surgery pushed into the background. In 2014, more than one therapeutic management out of two was performed in interventional radiology.

LEVEL OF EVIDENCE

4.

Prospective randomized comparison of transumbilical two-port laparoscopic and conventional laparoscopic varicocele ligation

We have established a novel method named transumbilical two-port laparoscopic varicocele ligation (TTLVL) for varicocele, which is still needed to evaluate. In this study, 90 patients with left idiopathic symptomatic varicoceles of grades II–III according to the Dubin grading system were randomly assigned to TTLVL (n = 45) and conventional laparoscopic varicocele ligation (CLVL) (n = 45). The demographic, intraoperative, postoperative, and follow-up data were recorded and compared between the two groups. All the procedures in the two groups were completed successfully with no intraoperative complications and no conversions to open surgery. No significant difference was found in the operative time, resuming ambulation, bowel recovery, postoperative hospital stay, and postoperative resolution of scrotal pain between the two groups (P > 0.05). However, the postoperative mean visual analog pain scale scores for TTLVL group were all less at 24 h, 48 h, 72 h, and 7 days postoperatively compared to CLVL (P = 0.001, 0.010, 0.006, and 0.027, respectively). The mean patient scar assessment questionnaire score in postoperative month 3 was 29.7 for TTLVL group compared with 32.1 for CLVL group (P < 0.001). There was no testicular atrophy observed in both groups during the follow-up period. The study shows that TTLVL is a safe, feasible, and effective minimally invasive surgical alternative to CLVL for the treatment of varicocele. Compared with CLVL, TTLVL may decrease postoperative pain and improve the cosmetic outcomes.

Varicocele as a source of male infertility - current treatment techniques

To establish the extent of varicocele as the cause of infertility in men and compare the various techniques of treatment. We searched PubMed and the Cochrane Library database using varicocele, male infertility, varicocelectomy as keywords. Varicocele seems to be a growing problem considered to be one of the most common causes of male infertility in recent times. Nevertheless, its role remains unclear. The best treatment option seems to be microscopic surgery - the most effective and linked to rare surgical complications. But the greatest clinical problem remains the selection of patients to treat - recently it is believed that varicocelectomy is a possibly advisable option in patients with clinical varicocele and seminal parameter impairment [1]. More high-quality, multicenter, long-term randomized controlled trials (RCT's) are required to verify the findings.

Predictors of improvement in semen parameters after varicocelectomy for male subfertility: A prospective study

INTRODUCTION

We aim to predict results of varicocelectomy on sperm density and progressive motility using preoperative clinical, laboratory and radiological data and to propose cut-off values for significant parameters.

METHODS

This prospective study was carried out between July 2011 and June 2014. We included 123 patients in our study. They were diagnosed with primary infertility with varicocele, were scheduled for varicocelectomy, and completed their follow-up. We excluded patients with azoospermia, total necrospermia, recurrent varicocele, and pituitary hormonal abnormalities. Varicocele was diagnosed and graded by physical examination and colour Doppler ultrasound. Semen analyses were completed preoperatively and 6 months postoperatively. Microscopic subinguinal varicocelectomy was done in all cases. Patient demographics, pre- and postoperative clinical data (varicocele grade and semen parameters) were statistically analyzed.

RESULTS

The mean ± standard deviation of age, body mass index, and subfertility duration was 28.3 ± 7.4 years, 29.1 ± 2.7 kg/m(2), and 21.9 ± 7.1 months, respectively. About 53% of our patients (n = 66) had bilateral varicocele, and unilateral disease was found in the other 57 (46.3%) cases. Varicocele grade I was diagnosed in 42 (34.1%) patients, while the other 81 (65.9%) patients had grade II or III. Higher grades of varicocele, preoperative total testosterone level, sperm density, and progressive motility had a statistically significant impact on the outcome of varicocelectomy in univariate testing. Multivariate logistic analysis revealed that grade of preoperative varicocele (95% confidence interval [CI] 5.6-6.3, p = 0.007) and sperm density (95% CI 2.7-1.6, p = 0.0035), and progressive motility (95% CI 1.1-2.3, p = 0.0123) are independent predictors of semen parameters improvement after varicocelectomy.

CONCLUSION

The grade of the varicocele, sperm density, and progressive motility are major predictors of outcome in varicocelectomy. Cut-off values of >8 million/mL and >18% for sperm density and progressive motility, respectively, in men with varicocele grade II or III, indicate a successful outcome.