Management options of varicoceles

Anatomic characteristics of the right internal spermatic vein based on imaging analysis: a retrospective study in southwest China

OBJECTIVE

The specific anatomic characteristics of the right internal spermatic vein (ISV) are pivotal factors in embolism failure. However, the inherent angles and configurations of the right ISV remain incompletely explored. This study aimed to address this gap by conducting a thorough investigation into the specific anatomic characteristics of the right ISV using imaging analysis in southwest China.

METHODS

This retrospective study analyzed the imaging data of 1000 male patients who underwent multidetector spiral computed tomography (MCT). Anatomic characteristics of the right ISV, including position, type, distance, and angle, were also evaluated.

RESULTS

The most common anatomic type (87.8%) of the right ISV was direct drainage into the inferior vena cava, with 90% of the angles below 25.7°. There were 22 cases (2.2%) with parallel right spermatic veins. In the axial plane, the right ISV (86.4%) was located in the third and fourth quadrants. The diameter at the entrance of the right ISV ranged from 2.7-3.8 mm. When the right ISV drained into the inferior vena cava, 83% of cases were located within 40 mm distance below the ostium of the right renal vein, while during draining into the right renal vein, the average distance from the main vein was 6.3 mm.

CONCLUSION

This study concluded that MCT can be used to evaluate the anatomical characteristics of the right ISV. The optimal interventional approach was through the jugular vein route to locate the ISV opening and improve the success rate of the embolization.

Mechanistic Insights into Bisphenol A-Mediated Male Infertility: Potential Role of Panax Ginseng Extract

Male infertility is identified by the inability of a man to successfully impregnate his fertile female partner, even following a year of regular unprotected sexual intercourse. About half of all infertility cases are attributed to what is known as "male factor" infertility. The escalating prevalence of male infertility in the contemporary era across the globe can be largely attributed to environmental pollution, which is the common etiological factor due to the ubiquitous presence of the environmental contaminants. Bisphenol A is recognized as an endocrine-disrupting chemical that has adverse effects on both male and female reproductive systems. On the other hand, numerous studies have demonstrated that Panax ginseng possessed the potential to improve male infertility parameters; promote spermatogenesis, recover the quality and motility of sperm and enhance testicular functions as it acted as a natural androgen supplement. The objective of this review is to offer a summary of the findings obtained from the current research data on the insult of bisphenol A (BPA) on male infertility and its supposed mode of action, as well as shed light on the potent ameliorative role of Panax ginseng extract, with a special focus on the mechanism behind its action. This review delivers a clear understanding of BPA mechanism of action on male infertility and the presumed risks deriving from its exposure. Also, this review provides evidence for the functional role of Panax ginseng extract in restoring male fertility.

Assessing safety and efficacy of microscopic and laparoscopic varicocoelectomy for varicocoele treatment: A comparative cohort study

BACKGROUND

Surgical is appropriate for 35-40% of varicocoele-induced infertility. This comparative observational study presents a comparative assessment of microscopic or laparoscopic varicocoelectomy (grade II varicocoele; n = 132 cases).

METHODS

Sperm count, density, total motility, and forward motility rate (preoperative and postoperative 6 months), operation duration, pain at 1 month, testicular atrophy (by scrotal ultrasound at 3 months), recurrence (angiography at 6 months), and scrotal edema (at 12 months) were measured.

RESULTS

The preoperative semen parameters were comparable between groups (P > 0.05), as were certain postoperative results (total sperm count [median 162 (range 100-242) compared with median 182 (range 84-253)]; sperm density [median 47 (range 38-83) compared with median 42 (range 27-88)]; forward motility (37.18 ± 4.14 compared with 34.13 ± 7.79); P > 0.05). However, sperm motility was higher in the microscope group (52.79 ± 8.21 compared with 46.64 ± 10.04; t = 2.304, P = 0.040). Within the microscope group, postoperative sperm density [median 47 (range 38-83)], total sperm motility (53.79 ± 8.25), and forward motility sperm rate (37.19 ± 4.14) demonstrated significant improvements compared with preoperative values (Z = -2.679, P = 0.005; t = -4.548, P < 0.001; t = -5.029, P < 0.001). In contrast, the postoperative forward motility sperm rate (34.13 ± 7.78) displayed substantial improvements compared with preoperative values (27.74 ± 14.42) within the laparoscopic group (t = -3.895, P = 0.001). Testicular atrophy occurred in neither group.

CONCLUSIONS

Microscopic varicocoelectomy may be safer and more effective.

Efficacy of varicocelectomy on semen parameters and conception rates

Objective

Varicocele, the dilation of the pampiniform plexus of the spermatic cord. It is discovered incidentally in most patients. Symptoms vary, but its impact is especially experienced in the field of fertility and reflected in semen parameters. Varicocelectomy is a surgical approach to correct the varicocele, however, reports are conflicting regarding its success. Our aim was to evaluate the efficacy of varicocelectomy on semen parameters and conception rates in patients who underwent surgery and its association with comorbidities such as diabetes, hypertension, and obesity.

Materials and Methods

This cross-sectional study included the complete medical records of 86 patients. Data collection form included the patient's age, body mass index (BMI), chronic diseases, smoking, surgical history, medication usage, and the reason for performing surgery. Presurgical and postsurgical semen parameters were evaluated 3 months before surgery and an average of 6 months postoperatively. Data were analyzed with SPSS, Chi-square test, and independent and paired t-test.

Results

No significant difference was found between primary and secondary infertility regarding semen analysis, postoperative semen analysis indicated an improvement in semen motility at 180 min with no effect on other parameters. Using spontaneous intercourse or in vitro fertilization (IVF) after varicocelectomy was significantly associated with increasing conception rates irrespective of the type of infertility. Diabetes, hypertension, BMI, and smoking did not appear to affect semen parameters.

Conclusion

Patients who underwent varicocelectomy had improved sperm motility at 180 min and subsequently had a higher chance of successful conception either through spontaneous intercourse or IVF. Further studies are needed to understand the relationship between conception and sperm motility. Semen parameters were not affected if the patient had comorbidities such as diabetes and hypertension. Furthermore, smoking and BMI did not appear to affect the conception rate.

The learning curve of bilateral laparoscopic varicocelectomy: a prospective study

Varicocele occurs in 15% of general male population and in 35% of infertile men. Since 1992, surgical correction with laparoscopic varicocelectomy is the gold standard for treatment of symptomatic patients or patients with abnormal seminal analysis. The learning curve for this frequently performed procedure has not yet been described. In the present study, we investigated the learning curve of a single urologist in training performing his first 21 laparoscopic varicocelectomies using qualitative and quantitative tools to evaluate his performance during the process. Our results show that 14 bilateral laparoscopic varicocelectomies are enough to achieve the plateau of the learning curve.

Semen Parameters Changes in Adolescents With Clinical Varicocele after Magnified Subinguinal Varicocelectomy: A Prospective Controlled Study

BACKGROUND

Previously, we highlighted the benefits of magnified subinguinal varicocelectomy over conservative treatment on the semen of a small group of adolescents with varicoceles. In this report, we presented changes of semen parameters of 47 adolescents who underwent magnified subinguinal varicocelectomy (MSV) and followed-up for 6 months.

METHODS

The present prospective controlled study was conducted on 47 adolescents with varicocele who underwent MSV and were followed up for 6 months. In addition, age and sex-matched patients were added as control group. The primary outcome of this study was to assess the postoperative change in semen analysis parameters.

RESULTS

A significant increase in sperm volume from 2.5 (1.9-3) to 3.2 (2.6-4) mL at the end of the sixth month of follow-up. Likewise, the sperm count increased from 10.8 (3.51-21.6) to 20.3 (9.6-35) million. Notably, the percentage of rapid and slow sperms increased significantly from a median of 5% (0%-10%) and 15% (10 -20%) to a median of 10% (5%-15%) and 17.5% (15%-25%), respectively. The percentage of sperm with progressive movement increased from 35% (30%-40%) to 59% (45%-69%). The vitality of the sperms increased significantly as well. While the percentage of sperms with abnormal morphology decreased significantly at the end of follow-up.

CONCLUSION

Our findings support the safety and efficacy of MSV in patients with clinically detectable varicocele. MSV has improved the semen parameters of the included patients, including sperm motility, volume, count, and total progressive motility, which may positively impact their fertility potential.

Long lasting effect on testes following methylene blue injection in laparoscopic lymphatic sparing varicocelectomy

OBJECTIVE

Injection of methylene blue to testis has been shown to have adverse effect in animal studies but it is still being used frequently as lymphatic mapping agent during lymphatic sparing varicocelectomy in adolescent varicoceles. We aim to report postoperative ultrasound changes after subaortic injection of methylene blue in human testes.

STUDY DESIGN

A retrospective observational study of consecutive patients under 18 years old undergoing laparoscopic varicocelectomy from August 2017 to August 2021 was performed. Demographics such as age, symptoms, pre-operative testicular volume was collected. Primary outcome was change on testicular ultrasound at 3, 6, 12 months after the operation. Secondary outcome was testicular volume difference between affected and unaffected testes, and growth rate of affected testis at 1 year after the operation.

RESULTS

Fifty-eight patients were included, with median age of 15 years old (IQR 11-18 years). Thirty-one patients had non-lymphatic sparing varicocelectomy (Group A) and 27 patients had lymphatic sparing varicocelectomy (Group B). There was no statistical difference between the mean testicular volume difference between the two groups, but hydrocele rate was significantly higher in Group A (16% vs 0%, p = 0.03). In group B, 6 patients (22.2%, p = 0.005) developed testicular change detectable by ultrasound. No statistical difference could be demonstrated for median testicular size difference (between affected and unaffected testes) at 1 year between group with and without ultrasound change (-23% vs 0%, p = 0.36). Median follow up time was 20.4 months (IQR 5-32 months).

DISCUSSION

Varicocele treatments improve testicular volume and increase total sperm concentration and lymphatic sparing surgery significantly decreased post-operative hydrocele rates [2]. Different agents have been used to delineate lymphatic vessels and one commonly used agent is methylene blue [10,15-16]. However it has been shown in other animal studies that intraparenchymal injection of methylene blue to rat testis result in degenerative changes [18]. Our study is the first to describe post-operative changes of human testes on imaging after lymphatic sparing varicocelectomy with subdartoic injection of methylene blue. Six patients (22.2%) demonstrated new onset testicular changes on post-operative ultrasound. Although no statistically significant testicular volume reduction was seen in the group with change on imaging, these observations may serve as a surrogate marker for testicular injury or reduced testicular function. It will be desirable for future studies if we can investigate it further with hormonal markers or semen analysis after puberty has been reached.

CONCLUSION

Lymphatic sparing procedure reduced post-operative hydrocele in adolescent varicocele, however long-lasting effect on testis is evident with subdartoic injection of methylene blue. This agent must be used with caution and long term follow up of these patients are needed.

Improvement in sperm quality by oral antioxidant supplementation in infertile men with varicocele who have not undergone surgical repair: Systematic review and meta-analysis

The aim of this systematic review and meta-analysis was to assess whether oral antioxidant supplementation improves sperm quality in men with infertility and varicocele (VCL) who have not undergone surgical repair. In men with infertility and VCL who had not undergone surgical repair oral antioxidant supplementation significantly increased sperm concentration (WMD +5.86 × 10⁶ /ml 95% CI: +1.47 to +10.24, p < 0.01; random effects model, six studies, 213 patients), total motility (WMD + 3.76%, 95% CI: +0.18 to +7.34, p = 0.04; random effects model, three studies, 93 patients), progressive motility (WMD + 6.38%, 95% CI: +3.04 to +9.71, p < 0.01; random effects model, three studies, 84 patients) and seminal volume (WMD +0.55 ml, 95%CI: +0.06 to +1.04, p = 0.03; random effects model, four studies, 120 patients). On the other hand, no significance difference was observed in sperm morphology (WMD +3.89%, 95% CI: -0.14 to +7.92, p = 0.06; random effects model, five studies, 187 patients). In conclusion, limited evidence suggests that the use of oral antioxidants in men with infertility and VCL, who have not undergone surgical repair improves their seminal volume, sperm concentration, total and progressive motility.

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

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

The Management of Clinical Varicocele: Robotic Surgery Approach

Varicocele is a pathologic dilation of the testicular veins within the spermatic cord. Varicocele is considered the most common problem in reproductive medicine practice. It is identified in 15% of healthy men and up to 35% of men with primary infertility. The exact pathophysiology of varicoceles is not very well understood, and several theories have been proposed to explain it. Varicocele can impair sperm quality and fertility via various mechanisms: reflux of adrenal metabolites, increased testicular hypoxia, oxidative stress, and increased testicular temperature have been proposed. Several studies have reported the significant benefits on semen parameters with the surgical treatment of varicocele: reducing oxidatively induced sperm DNA damage and potentially improving fertility. Varicocele repair should be offered as a part of treatment option for male partners of infertile couples presenting with palpable varicoceles. Nowadays, there are several surgical approaches available for the treatment of varicocele, such as the retroperitoneal approach, inguinal approach, and the subinguinal approach. The subinguinal microscopic approach offers the best outcomes, such as shorter hospital stays, preservation of the testicular arteries and lymphatics, least number of postoperative complications, recurrence, and a higher number of pregnancies. Currently robotic-assisted laparoscopic surgery is widely adopted in urology and surgeons began to explore the potential applications of the robotic platform to male infertility microsurgical operations. Robotic approach offers many advantages: elimination of tremor, retraction with third arm, high quality, 3-dimensional visualization and surgeon ergonomics, all contributing to the precision of surgery.

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.

Surgical or radiological treatment for varicoceles in subfertile men

BACKGROUND

Varicoceles are associated with male subfertility; however, the mechanisms by which varicoceles affect fertility have yet to be satisfactorily explained. Several treatment options exist, including surgical or radiological treatment, however the safest and most efficient treatment remains unclear.  OBJECTIVES: To evaluate the effectiveness and safety of surgical and radiological treatment of varicoceles on live birth rate, adverse events, pregnancy rate, varicocele recurrence, and quality of life amongst couples where the adult male has a varicocele, and the female partner of childbearing age has no fertility problems.

SEARCH METHODS

We searched the following databases on 4 April 2020: the Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL. We also searched the trial registries and reference lists of articles.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) if they were relevant to the clinical question posed and compared different forms of surgical ligation, different forms of radiological treatments, surgical treatment compared to radiological treatment, or one of these aforementioned treatment forms compared to non-surgical methods, delayed treatment, or no treatment. We extracted data if the studies reported on live birth, adverse events, pregnancy, varicocele recurrence, and quality of life.

DATA COLLECTION AND ANALYSIS

Screening of abstracts and full-text publications, alongside data extraction and 'Risk of bias' assessment, were done dually using the Covidence software. When we had sufficient data, we calculated random-effects (Mantel-Haenszel) meta-analyses; otherwise, we reported results narratively. We used the I² statistic to analyse statistical heterogeneity. We planned to use funnel plots to assess publication bias in meta-analyses with at least 10 included studies. We dually rated the risk of bias of studies using the Cochrane 'Risk of bias' tool, and the certainty of evidence for each outcome using the GRADE approach.

MAIN RESULTS

We identified 1897 citations after de-duplicating the search results. We excluded 1773 during title and abstract screening. From the 113 new full texts assessed in addition to the 10 studies (11 references) included in the previous version of this review, we included 38 new studies, resulting in a total of 48 studies (59 references) in the review providing data for 5384 participants. Two studies (three references) are ongoing studies and two studies are awaiting classification. Treatment versus non-surgical, non-radiological, delayed, or no treatment Two studies comparing surgical or radiological treatment versus no treatment reported on live birth with differing directions of effect. As a result, we are uncertain whether surgical or radiological treatment improves live birth rates when compared to no treatment (risk ratio (RR) 2.27, 95% confidence interval (CI) 0.19 to 26.93; 2 RCTs, N = 204; I² = 74%, very low-certainty evidence). Treatment may improve pregnancy rates compared to delayed or no treatment (RR 1.55, 95% CI 1.06 to 2.26; 13 RCTs, N = 1193; I² = 65%, low-certainty evidence). This suggests that couples with no or delayed treatment have a 21% chance of pregnancy, whilst the pregnancy rate after surgical or radiological treatment is between 22% and 48%. We identified no evidence on adverse events, varicocele recurrence, or quality of life for this comparison. Surgical versus radiological treatment We are uncertain about the effect of surgical versus radiological treatment on live birth and on the following adverse events: hydrocele formation, pain, epididymitis, haematoma, and suture granuloma. We are uncertain about the effect of surgical versus radiological treatment on pregnancy rate (RR 1.13, 95% CI 0.75 to 1.70; 5 RCTs, N = 456, low-certainty evidence) and varicocele recurrence (RR 1.31, 95% CI 0.82 to 2.08; 3 RCTs, N = 380, low-certainty evidence). We identified no evidence on quality of life for this comparison. Surgery versus other surgical treatment We identified 19 studies comparing microscopic subinguinal surgical treatment to any other surgical treatment. Microscopic subinguinal surgical treatment probably improves pregnancy rates slightly compared to other surgical treatments (RR 1.18, 95% CI 1.02 to 1.36; 12 RCTs, N = 1473, moderate-certainty evidence). This suggests that couples with microscopic subinguinal surgical treatment have a 10% to 14% chance of pregnancy after treatment, whilst the pregnancy rate in couples after other surgical treatments is 10%. This procedure also probably reduces the risk of varicocele recurrence (RR 0.48, 95% CI 0.29, 0.79; 14 RCTs, N = 1565, moderate-certainty evidence). This suggests that 0.4% to 1.1% of men undergoing microscopic subinguinal surgical treatment experience recurrent varicocele, whilst 1.4% of men undergoing other surgical treatments do. Results for the following adverse events were inconclusive: hydrocele formation, haematoma, abdominal distension, testicular atrophy, wound infection, scrotal pain, and oedema. We identified no evidence on live birth or quality of life for this comparison. Nine studies compared open inguinal surgical treatment to retroperitoneal surgical treatment. Due to small sample sizes and methodological limitations, we identified neither treatment type as superior or inferior to the other regarding adverse events, pregnancy rates, or varicocele recurrence. We identified no evidence on live birth or quality of life for this comparison. Radiological versus other radiological treatment One study compared two types of radiological treatment (sclerotherapy versus embolisation) and reported 13% varicocele recurrence in both groups. Due to the broad confidence interval, no valid conclusion could be drawn (RR 1.00, 95% CI 0.16 to 6.20; 1 RCT, N = 30, very low-certainty evidence). We identified no evidence on live birth, adverse events, pregnancy, or quality of life for this comparison.

AUTHORS' CONCLUSIONS

Based on the limited evidence, it remains uncertain whether any treatment (surgical or radiological) compared to no treatment in subfertile men may be of benefit on live birth rates; however, treatment may improve the chances for pregnancy. The evidence was also insufficient to determine whether surgical treatment was superior to radiological treatment. However, microscopic subinguinal surgical treatment probably improves pregnancy rates and reduces the risk of varicocele recurrence compared to other surgical treatments. High-quality, head-to-head comparative RCTs focusing on live birth rate and also assessing adverse events and quality of life are warranted.

Dietary supplements in the management of varicocele-induced infertility: A review of potential mechanisms

Varicocele is a main cause of lower production of spermatozoon and infertility with multiple pathophysiological mechanisms. In the past decades, the use of dietary supplements has significantly increased due to both the modern lifestyle and the food shortages of the industrialised countries. The purpose of this review paper is to collect scientific evidences from basic and clinical studies which support the use of dietary supplements to define the clinical framework for patients with varicocele. In the present review, we used keywords such as dietary supplements, varicocele, male infertility, oxidative stress, DNA fragmentation, sperm parameters to find the proper articles. The standard search biomedical engines were used for seeking the papers. The use of dietary supplements such as minerals, vitamins and antioxidants has an essential role in the prevention and treatment of varicocele by increasing the levels of antioxidant enzymes (e.g. peroxidase, superoxide dismutase and catalase) and decreasing the levels of inflammatory markers (e.g. tumour necrosis factor-α, interleukin-6 and interleukin-1) in testis. According to the results, the dietary supplements may alleviate the spermatogenesis in varicocele patients through different mechanisms such as suppression of stress oxidative and inflammation in testicular tissue.

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.

Improved Arterial Preservation Achieved by Combined Use of Indocyanine Green Angiography and Doppler Detector During Microsurgical Subinguinal Varicocelectomy

Objectives: The microsurgical approach is considered the most reliable procedure in varicocelectomy. However, as there are difficulties in identifying the spermatic artery at the peripheral level, we had introduced intraoperative indocyanine green angiography (ICGA) for identification of arteries. In this study, we further investigated the usefulness of intraoperative ICGA in combination with an ordinary Doppler detector in microsurgical subinguinal varicocelectomy. Methods: A total of 140 men who underwent microsurgical subinguinal varicocelectomy at Gunma University Hospital were included. An operating microscope equipped with a near-infrared charge-coupled device was used for intraoperative ICGA. After exposing the vessels, arteries were identified using endoscopic vision only or with assistance of Doppler detector or ICGA, or of both. The number of preserved arteries was compared among the groups. Results: ICGA clearly visualized the internal spermatic arteries in all cases, allowing the surgeon to perform real-time identification and isolation of the spermatic artery intraoperatively. The use of ICGA or Doppler detector significantly increased the number of preserved arteries compared to the microscope-only operation from 1.11 to 1.75 (p < 0.05) and 1.57 (p < 0.05), respectively. The additional use of ICGA with Doppler detector further increased the number of preserved arteries to 2.41 (p < 0.05). Conclusions: Intraoperative ICGA facilitated safe and quick microsurgical subinguinal varicocelectomy by enabling visualization of thin spermatic cord blood vessels. Improved preservation of thin arteries, which is essential for patients with infertility, can be achieved with the combined use of ICGA and ordinary Doppler detector.

Laparoscopic treatment of varicocele within adolescents in two African countries

Varicocele is often ignored by adolescents and their parents, in our context. The aim of the study is to present the indications and results of laparoscopic treatment in a population of adolescent students.

SUBJECTS AND METHODS

It is a descriptive and analytical prospective study over a period of 9 months (January to September 2013), focussed on cases of varicocele Grade 3 found in adolescents during a screening, and who underwent surgical treatment by laparoscopy. The laparoscopic treatment was done as part of a training mission to paediatrics surgeons, through a European Non-governmental organisation in two university hospitals in Africa. Of 2724 adolescent students examined, 149 (5.47%) had a varicocele. The average age was 16.39 ± 2.05 years (12 and 19). The side was unilateral (79.19%) with 76.51% left or bilateral (20.81%) (P = 0.00). According to the classification of Dubin and Amelar, there were 58 (38.92%) cases of Grade 1, 66 (44.30%) were Grade 2 and 25 (16.78%) were Grade 3.

RESULTS

The laparoscopic treatment was performed in 23 patients with varicocele Grade 3, by modified Palomo's technique, sectioning a segment of vessels between clips (15) between nodes (2) or after coagulation without clips and ligation (6). The hospital stay was 36 h. It has been observed one case of post-operative moderate vaginal hydrocele and 11 cases testicular hypertrophy.

CONCLUSION

The laparoscopic treatment of varicocele in adolescents reduces post-operative morbidity related to conventional open surgery. This technique has been available in two poor African countries through partnership north-south.

Microscopic subinguinal varicocelectomy in 100 consecutive cases: Spermatic cord vascular anatomy, recurrence and hydrocele outcome analysis

Objective

To evaluate the detailed vascular anatomy of the spermatic cord during subinguinal microscopic varicocelectomy and to assess the outcome of the cases with regard to varicocele recurrence and hydrocele formation.

Patients and methods

In all, 100 varicocele cases including 74 left-sided and 26 bilateral, comprising 126 spermatic cord units with clinically palpable varicoceles underwent microscopic subinguinal varicocelectomy. Detailed description of vascular anatomy of the spermatic cords was reported. The number of spermatic, cremasteric, and inguinal veins was recorded. A record of testicular arteries and lymphatics was noted. Testicular delivery was done in all the cases and assessment of the gubernacular veins was reported. The patients underwent clinical evaluation, as well as scrotal Doppler ultrasonography, to detect varicocele recurrence and hydrocele formation. The mean (range) postoperative evaluation period was 6 (3–12) months.

Results

The mean number of spermatic veins was 14 on both sides. The mean number of spermatic arteries on both sides was 1.3. For lymphatics, the mean number was around three on both sides. The gubernacular veins were noted in 75% of the cases on the left side (mean number of 1.2) and in 85% on the right-side, (mean number of 1). The mean number of cremasteric veins on the left and right sides was 1.4 and 1.2, respectively. Finally, inguinal floor vessels were noted in 9% on the left-side and were not seen in the right-side cases. The incidence of varicocele recurrence was 2% and for hydrocele that was not clinically significant was 0.07%.

Conclusion

Microscopic subinguinal varicocelectomy accurately evaluated the detailed vascular anatomy of the spermatic cord, achieving excellent surgical outcome with minimal varicocele recurrence and hydrocele formation. Microscopic subinguinal varicocelectomy should be the ‘gold standard’ for varicocelectomy.

Cadaveric Study of Mode of Termination of Gonadal Veins: Implications for Procedures Utilizing Terminal Ends of Gonadal Veins as Entry Portals

CONTEXT

The terminal ends of gonadal veins act as an entry portal in gonadal embolization procedures used for treating varicocele in males and pelvic congestion disease in females. Here, we studied the modes of termination of gonadal veins in adult cadavers.

MATERIALS AND METHODS

Thirty-five adult formalin-fixed cadavers (seventy sides) were studied over a period of 4 years. The modes of termination of gonadal veins were observed under the following study variables: (a) number, (b) locale of termination, and (c) termination angle.

RESULTS

Variations in study parameters were observed in eight sides of seven cadavers (seven unilateral and one bilateral). Double veins at termination were observed in six cadavers; anomalous termination was observed in three cadavers. Angle of termination differed from normal in 3 cadavers. In one of these cadavers, the left ovarian vein drained into the left suprarenal vein.

CONCLUSION

Duplication of terminal ends, anomalous drainage site, and varied angles of termination call for caution to ensure the success of procedures, which use terminal ends of gonadal veins as entry portals.

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.

Surgical management of male infertility: an update

Male factor infertility is common, affecting 7% of the total population and up to half of couples who are trying to conceive. Various surgical and reconstructive options allow biological paternity depending on the etiology of the male factor issues. This article describes historical treatments and newer approaches, discussing the role for traditional open surgery, microsurgery and robotic surgery, as well as interventional radiologic procedures in the management of male infertility.

Laparoscopic Varicocelectomy: My Personal Experience of 4000 Cases

Varicocele accounts for 40% of male infertility. Laparoscopic varicocelectomy was used for the treatment of a series of 4000 men. The operation was a high bilateral ligation. The average time for the operation was 1 hour and 15 minutes. There were no complications and patients were discharged on the same day of the operation. Testicular damage from varicocele was permanent, and the usual percentage was 10% of total testicular tissue examined. The surgery was very well accepted by patients. Semen parameters improved among 80% of the patients, with 45% of their wives becoming pregnant. There is clearly a role for video laparoscopic varicocelectomy in the treatment of male infertility.

Does varicocelectomy affect DNA fragmentation in infertile patients?

Introduction:

The aims of this study were to investigate the effect of varicocelectomy on DNA fragmentation index and semen parameters in infertile patients before and after surgical repair of varicocele.

Materials and Methods:

In this prospective study, 72 men with at least 1-year history of infertility, varicocele and oligospermia were examined. Varicocele sperm samples were classified as normal or pathological according to the 2010 World Health Organization guidelines. The acridine orange test was used to assess the DNA fragmentation index (DFI) preoperatively and postoperatively.

Results:

DFI decreased significantly after varicocelectomy from 34.5% to 28.2% (P = 0.024). In addition all sperm parameters such as mean sperm count, sperm concentration, progressive motility and sperm morphology significantly increased from 19.5 × 10⁶ to 30.7 × 10⁶, 5.4 × 10⁶/ml to 14.3 × 10⁶/ml, and 19.9% to 31.2% (P < 0.001) and 2.6% to 3.1% (P = 0.017). The study was limited by the loss to follow-up of some patients and unrecorded pregnancy outcome due to short follow-up.

Conclusion:

Varicocele causes DNA-damage in spermatozoa. We suggest that varicocelectomy improves sperm parameters and decreases DFI.

Treatment of male varicoceles by transcatheter polidocanol foam sclerotherapy: evaluation of clinical success, complications, and patients' satisfaction with regard to alternative techniques

OBJECTIVES

We report our experience with polidocanol foam sclerotherapy with no additional coils, evaluating clinical success, patients' satisfaction, and complications.

METHODS

We conducted a retrospective study of 141 patients with 146 varicoceles (mean age: 29.3 years; range: 13 - 60 years) who underwent foam sclerotherapy with polidocanol 2% (range: 2 - 12 ml) in an outpatient setting between January 2007 and December 2013. For the follow-up, telephone interviews with the patients were conducted (mean follow-up time: 46.4 months, standard deviation: 20.17 months).

RESULTS

The technical success rate was 91.8%. There was a 55.8% response rate to the telephone interviews. Follow-up revealed a clinical success rate of 83.9% and a persistence or relapse rate of 16.1%. Of the patients, 81.9% were absolutely satisfied with the outcome. In 94.9% of cases, pain or discomfort resolution was reported, and in 97% of cases, aesthetic issues were no longer a problem. Of partners, 63.2% achieved pregnancy, and in 50% of patients with preprocedural testicular atrophy, catch-up growth was observed. One patient with pampiniform plexus phlebitis received inpatient treatment with no long-term damage recorded.

CONCLUSIONS

Polidocanol foam varicocele sclerotherapy is a safe and effective procedure, with a high rate of patients' satisfaction, clinical and technical success, and considerable catch-up growth and pregnancy achievement.

KEY POINTS

• Varicocele treatment using polidocanol foam sclerotherapy is a safe and effective procedure. • It is easily feasible in an outpatient setting. • The clinical and technical success rates are high. • It shows a high rate of patients' satisfaction and symptom resolution. • Postinterventional catch-up growth and pregnancy achievement are considerable.

Cost-effectiveness analysis reveals microsurgical varicocele repair is superior to percutaneous embolization in the treatment of male infertility

INTRODUCTION

Varicoceles are a common cause of male infertility; repair can be accomplished using either surgical or radiological means. We compare the cost-effectiveness of the gold standard, the microsurgical varicocele repair (MV), to the options of a nonmicrosurgical approach (NMV) and percutaneous embolization (PE) to manage varicocele-associated infertility.

METHODS

A Markov decision-analysis model was developed to estimate costs and pregnancy rates. Within the model, recurrences following MV and NMV were re-treated with PE and recurrences following PE were treated with repeat PE, MV or NMV. Pregnancy and recurrence rates were based on the literature, while costs were obtained from institutional and government supplied data. Univariate and probabilistic sensitivity-analyses were performed to determine the effects of the various parameters on model outcomes.

RESULTS

Primary treatment with MV was the most cost-effective strategy at $5402 CAD (Canadian)/pregnancy. Primary treatment with NMV was the least costly approach, but it also yielded the fewest pregnancies. Primary treatment with PE was the least cost-effective strategy costing about $7300 CAD/pregnancy. Probabilistic sensitivity analysis reinforced MV as the most cost-effective strategy at a willingness-to-pay threshold of >$4100 CAD/pregnancy.

CONCLUSIONS

MV yielded the most pregnancies at acceptable levels of incremental costs. As such, it is the preferred primary treatment strategy for varicocele-associated infertility. Treatment with PE was the least cost-effective approach and, as such, is best used only in cases of surgical failure.

Beneficial effects of varicocele embolization on semen parameters

BACKGROUND

The value of varicocele repair and the latter's impact on semen parameters are still subject to debate.

METHODS

We analyse changes over time in initially abnormal sperm parameters and serum concentrations of testosterone, FSH and inhibin B after embolization treatment of males with high-grade varicocele. From 2007 to 2012, we recruited 47 male infertile patients with clinically visible left varicocele in the resting patient and at least one abnormal semen parameter. Sperm parameters and serum levels of total testosterone, FSH and inhibin B were measured prior to retrograde embolization (M0) and then 3 (M3) and 6 (M6) months afterwards.

RESULTS

At M0, the median sperm concentration was 5.78 [0.84-37.70] × 10(6)/ejaculate. The mean ± SD sperm progressive motility, vitality and percentage of normal sperm were respectively, 21.83 ± 16.48%, 61.88 ± 15.98% and 12.88 ± 7.15%. The corresponding values at M3 were significantly higher (38.75 [3.96-95] × 10(6)/ejaculate, 29.32 ± 14.21%, 69.14 ± 14.86% and 19.03 ± 11.02%, respectively). The mean percentage of spermatozoa with a thin head was significantly lower at M6 (6.35 ± 5.29%) than at M0 (14.03 ± 13.09%). The mean serum testosterone, FSH and inhibin B levels did not change significantly over time.

CONCLUSIONS

Embolization treatment in men with clinically visible left varicocele, abnormal sperm parameters and documented infertility is associated with a significant improvement in semen parameters including sperm head morphology.