Varicocele as a source of male infertility - current treatment techniques

Semen parameter enhancement after varicocelectomy: Insights into varicose vein diameter and BMI influence: A cross-sectional study

INTRODUCTION

Varicocele is a condition in which the veins in the spermatic cord become enlarged and twisted. Varicocele is widely recognized as the leading cause of male infertility due to its significant impact on reproductive health in men. The aim of this study was to investigate the relationship between the diameter of the varicose vein and the recovery rate of the spermogram after varicocelectomy. Also, the effect of body mass index (BMI) on sperm parameters after varicocelectomy.

METHODS

This descriptive and analytical cross-sectional study was conducted in Valiasr Hospital's urology clinic in Qaemshahr, Iran from August 2018 to August 2019 and involved 27 men with unilateral left varicocele who met the inclusion criteria for surgical repair. Before the operation, we recorded demographic information, the maximum diameter of varicose veins in the pampiniform plexus, and spermogram results. We repeated semen analysis 3 months after the operation and analyzed the data using Statistical Package for the Social Sciences version 21 software.

RESULTS

Our findings showed that the diameter of the varicose vein before varicocelectomy was not significantly associated with the improvement of main semen parameters after the operation. Furthermore, our study suggested that a lower body mass index might contribute to a greater improvement in sperm motility, as individuals with lower BMI showed more significant improvement.

DISCUSSION

There is a significant inverse relationship between BMI and sperm motility improvement after surgery. Patients with a lower BMI showed greater improvement in sperm motility.

Robotic-assisted versus conventional laparoscopic ICG-fluorescence lymphatic-sparing palomo varicocelectomy: a comparative retrospective study of techniques and outcomes

PURPOSE

This study aimed to compare techniques and outcomes of robotic-assisted varicocelectomy (RAV) and laparoscopic varicocelectomy (LV).

METHODS

The medical records of 40 patients, who received RAV and LV over a 2-year period, were retrospectively analyzed. Palomo lymphatic-sparing varicocelectomy using ICG fluorescence was adopted in all cases. Three 5-mm trocars were placed in LV, whereas four ports, three 8-mm and one 5-mm, were placed in RAV. The spermatic vessels were ligated using clips in LV and ligatures in RAV. The two groups were compared regarding patient baseline and operative outcomes.

RESULTS

All patients, with median age of 14 years (range 11-17), had left grade 3 varicocele according to Dubin-Amelar. All were symptomatic and 33/40 (82.5%) presented left testicular hypotrophy. All procedures were completed without conversion. The average operative time was significantly shorter in LV [20 min (range 11-30)] than in RAV [34.5 min (range 30-46)] (p = 0.001). No significant differences regarding analgesic requirement and hospitalization were observed (p = 0.55). At long-term follow-up (30 months), no complications occurred in both groups. The cosmetic outcome was significantly better in LV than RAV at 6-month and 12-month evaluations (p = 0.001). The total cost was significantly lower in LV (1.587,07 €) compared to RAV (5.650,31 €) (p = 0.001).

CONCLUSION

RAV can be safely and effectively performed in pediatric patients, with the same excellent outcomes as conventional laparoscopic procedure. Laparoscopy has the advantages of faster surgery, smaller instruments, better cosmesis and lower cost than robotics. To date, laparoscopy remains preferable to robotics to treat pediatric varicocele.

Understanding the impact of varicocele on sperm capacitation

OBJECTIVE

To study the relationship between the seminal sample quality of men with varicocele and sperm capacitation.

DESIGN

Cross-sectional observational study.

SETTING

Academic hospital.

PATIENT(S)

Seventy-six men (19 control and 57 with varicocele) were analyzed.

INTERVENTION(S)

Semen samples were submitted to a discontinuous density gradient for sperm selection. Sperm capacitation was induced using a human tubal fluid medium supplemented with bovine serum albumin.

MAIN OUTCOME MEASURE(S)

After capacitation induction, the sperm were assessed by capacitation state, computer-assisted sperm motility, mitochondrial activity, membrane integrity, acrosome reaction, and intracellular oxidative stress.

RESULT(S)

The capacitation period increased sperm motility, showing an increase in the average path velocity and a decrease in the straightness compared with sperm before capacitation (paired analysis). After capacitation, the rate of capacitated sperm, motility, and mitochondrial activity showed differences between groups (control and varicocele). The varicocele group showed lower mitochondrial activity and capacitation than the control group. On the other hand, no significant differences were observed in the other variables evaluated.

CONCLUSION(S)

Varicocele men showed less viable sperm and mitochondrial activity than control men after capacitation sperm. The induction of capacitation altered motility by increasing path velocity and decreasing straightness in all of the studied groups, evidencing the occurrence of hyperactivation.

Assessing information on YouTube™ as a quality source for the treatment of varicoceles

Introduction:

YouTube™ has grown into one of the largest disseminators of health care information. We assessed the quality of information on varicoceles and their treatment, available on YouTube™.

Methods:

Using a YouTube™ search query with the keyword “varicocele,” the quality of the first 50, nonrepeat videos in English were assessed as a representative group for the topic. DISCERN and Patient Education Materials Assessment Tool for Audiovisual Materials (PEMAT-AV) standardized tools were utilized by three independent reviewers to grade the quality of these videos based on content, understandability, and actionability.

Results:

The average and median DISCERN score was 31.34 (±9.37) and 31 (interquartile range 25–35), respectively, indicating poor quality. The interrater reliability (IRR) scores ranged from 0.51 to 0.93, indicating fair to excellent reliability. The average PEMAT-AV understandability and actionability scores were 69.8% ±15.4% and 11.0% ±24.6%, respectively, indicating mostly understandable but poor actionability. The t-test results showed that international videos scored higher without statistical significance in the DISCERN or PEMAT-AV scores (P = 0.18, 0.59, and 0.20).

Conclusions:

The current quality of videos on YouTube™ on the topic of varicoceles is of poor quality due to a lack of a holistic approach in explaining the wide range of treatment options available. With the ease of access to produce and disseminate health information, there is a need to create high-quality videos on varicoceles that empower a patient to make an informed decision.

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.

[Testicular sperm extraction in male infertility : Indications, success rates, practical implementation, and possible complications]

BACKGROUND

Unwanted childlessness is a burden on a couple's relationship. The therapeutic spectrum of male infertility has increased significantly in recent years so that even azoospermia patients can be given biological paternity by testicular sperm extraction (TESE).

OBJECTIVES

The indications, success rates, practical implementation, and possible complications of conventional and microscopic TESE in male infertility are presented in this review.

METHODS

A nonsystematic search of the relevant literature was carried out.

RESULTS

In obstructive azoospermia (OA), primarily desobstructive surgical procedures are used, while TESE is the surgical procedure of choice in nonobstructive azoospermia (NOA). In the latter, sperm extraction can be performed conventionally or microscopically (mTESE) assisted, whereby the latter offers an advantage in terms of sperm detection rate in the case of small testicular volumes (<12 ml), chemotherapy, Klinefelter's disease and AZFc microdeletions. The sperm detection rate of TESE is about 50%. Postoperative controls are useful because of the possible induction of symptomatic hypogonadism.

CONCLUSION

Before performing TESE, determining the hormone status and human genetic clarification are necessary. Any costs incurred and the possibility of missing sperm proof must be discussed. Close cooperation between andrologists, gynecologists, reproductive physicians, and human geneticists is necessary. All in all, TESE is a safe surgical procedure with a low complication rate.

Methylenetetrahydrofolate reductase C677T and A1298C polymorphisms and male infertility risk: An updated meta-analysis

BACKGROUND

18 previous meta-analyses have been published on the methylenetetrahydrofolate reductase (MTHFR) C677T and A1298C polymorphisms with male infertility risk. However, results of the previous meta-analyses were still inconsistent. Moreover, their meta-analyses did not assess false-positive report probabilities except one study. Furthermore, many new studies have been published, and therefore an updated meta-analysis and re-analysis of systematic previous meta-analyses were performed to further explore these issues.

OBJECTIVES

To determine the association between MTHFR C677T and A1298C polymorphisms and male infertility risk.

METHODS

Crude odds ratios and their 95% confidence intervals were used to assess the association between MTHFR C677T and A1298C polymorphisms and male infertility risk. We used the Bayesian false discovery probability (BFDP) to assess the credibility of statistically significant associations.

RESULTS

Fifty-nine studies were included concerning the MTHFR C677T and 28 studies were found on the MTHFR A1298C with male infertility risk. Overall, the MTHFR C677T was associated with increased male infertility risk in overall populations, Africans, East Asians, West Asians, South Asians, azoospermia, and Oligoasthenoteratozoospermia (OAT). In further sensitivity analysis and BFDP test, the positive results were only considered as "noteworthy" in the overall population (TT vs CC: BFDP = 0.294, CT + TT vs CC: BFDP = 0.300, T vs C: BFDP = 0.336), East Asians (TT vs CC: BFDP = 0.089, TT vs CT + CC: BFDP = 0.020, T vs C: BFDP < 0.001), West Asians (TT vs CC: BFDP = 0.584), hospital-based studies (TT vs CC: BFDP = 0.726, TT vs CT + CC: BFDP = 0.126), and OAT (TT vs CT + CC: BFDP = 0.494) for MTHFR C677T. In addition, a significantly increased male infertility risk was found in East Asians and population-based studies for MTHFR A1298C. However, we did not find that the positive results were considered as "noteworthy" in the overall and all subgroup analyses for MTHFR A1298C.

CONCLUSIONS

In summary, this study indicates that the MTHFR C677T is associated with increased male infertility risk in East Asians, West Asians, and OAT. No significant association was observed on the MTHFR A1298C with male infertility risk.

Factors Associated with Varicocele Recurrence After Microscopic Sub-Inguinal Varicocelectomy

Purpose

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

Patients and Methods

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

Results

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

Conclusion

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

Proteomic Analyses of Human Sperm Cells: Understanding the Role of Proteins and Molecular Pathways Affecting Male Reproductive Health

Human sperm proteomics research has gained increasing attention lately, which provides complete information about the functional state of the spermatozoa. Changes in the sperm proteome are evident in several male infertility associated conditions. Global proteomic tools, such as liquid chromatography tandem mass spectrometry and matrix-assisted laser desorption/ionization time-of-flight, are used to profile the sperm proteins to identify the molecular pathways that are defective in infertile men. This review discusses the use of proteomic techniques to analyze the spermatozoa proteome. It also highlights the general steps involved in global proteomic approaches including bioinformatic analysis of the sperm proteomic data. Also, we have presented the findings of major proteomic studies and possible biomarkers in the diagnosis and therapeutics of male infertility. Extensive research on sperm proteome will help in understanding the role of fertility associated sperm proteins. Validation of the sperm proteins as biomarkers in different male infertility conditions may aid the physician in better clinical management.

Evaluation of Seminal Fructose and Citric Acid Levels in Men with Fertility Problem

CONTEXT

Male infertility is a medical problem, attributed to 50% of infertility. Seminal plasma can be an anticipating factor as it comprises secretions of accessory sex gland, thus offering novel and precise ways to understand potential roles of these biochemical markers in male infertility.

AIM

The objective of this study was to assess the correlation between biochemical markers and sperm parameters in envisaging male infertility.

SUBJECTS AND DESIGN

We enlisted 105 men with fertility issue as patients and 25 fertile men as controls to evaluate the sperm parameters and biochemical markers, namely fructose and citric acid in ascertaining male infertility.

MATERIALS AND METHODS

The semen samples from patients were collected properly and analyzed according to the World Health Organization-2010 manual. Later samples were centrifuged, seminal plasma was collected, and biochemical markers assessment was carried out by standard protocols.

STATISTICS

Descriptive statistics, independent t-test, one-way ANOVA, and Pearson correlation were used for statistical analysis of different variables using SPSS 20.0. The mean sperm count and motility by all infertile conditions displayed a significant difference when compared with the controls (P < 0.05).

RESULTS

The mean fructose levels of oligozoospermia showed a nonsignificance difference when compared with controls (P < 0.05). Asthenozoospermia, asthenoteratozoospermia, and azoospermia had a significance difference (P < 0.05) for citric acid levels. Pearson correlation coefficient showed significant negative correlation of sperm count (r = -0.564) and sperm motility (r = -0.574) with fructose levels. Whereas seminal citric acid concentration had a positive correlation with sperm count (r = 0.458) and sperm motility (r = 0.446).

CONCLUSION

Therefore, evaluation of certain biochemical markers of seminal fluid may benefit in understanding the functionality of accessory glands which subsidizes significantly to the seminal volume.

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.

Is male infertility associated with increased oxidative stress in seminal plasma? A-meta analysis

Objectives

We conducted a systematic review and meta-analysis of observational case-control studies to evaluate markers of oxidative stress in seminal plasma of patients with male infertility.

Background

Current evidence links oxidative stress to male infertility, in which multiple markers of oxidative stress have been widely detected, publishing inconsistent results with regard to the role of oxidative stress markers in the evaluation of male infertility. Therefore, a systematic review and meta-analysis on this issue is necessary.

Results

From the 1024 articles initially retrieved, 65 studies were included in our meta-analysis with 11 oxidative stress markers, containing 3819 male infertility patients and 2012 controls. The concentrations of malondialdehyde (SMD = 1.86, p < 0.00001), NO (SMD = 0.89, p = 0.001), carbonyl protein (SMD = 2.09, p < 0.00001) in seminal plasma were significantly higher in infertility patients. The concentrations of GSH (SMD = -1.68, p < 0.00001), vitamin C (SMD = -1.12, p < 0.00001), and vitamin E (SMD = -1.48, p = 0.003), as well as the activities of catalase (SMD = -1.91, p < 0.0001), glutathione peroxidase (SMD = -1.96, p = 0.0002) and glutathione-S-transferase (SMD = -1.62, p = 0.009) declined remarkably, resulting in decreased total antioxidant capacity (SMD = -1.77, p < 0.00001). Besides, the activity of superoxide dismutase showed no statistical difference between infertility patients and controls (SMD = -0.51, p = 0.07).

Conclusions

Our meta-analysis suggests that oxidative stress in seminal plasma resulting from decreased antioxidant defense are associated with male infertility.

Methods

Using PubMed, EMBASE, CNKI, VIP, and Wanfang database, we searched for literature reporting the detection of oxidative stress markers in the seminal plasma of male infertility published up to June 2017. Standardized mean differences (SMDs) and 95% confidence intervals (95%CI) were calculated for the finally analysis.

Modified Inguinal Microscope-Assisted Varicocelectomy under Local Anesthesia: A Non-randomised Controlled Study of 3565 Cases

Varicocele is a common abnormality, but the conventional microsurgical subinguinal varicocelectomy (CMSV) has some disadvantages. We invented Modified Inguinal Microscope-Assisted Varicocelectomy (MIMV) under local anesthesia. This study aims to evaluate MIMV by comparing it to CMSV in operating duration, time to return to normal activity, postoperative complications, achievement of natural pregnancy and improvement of semen quality for patients with infertility, pain score for those with scrotal pain, and so on. We enrolled 3089 patients who underwent MIMV and 476 who underwent CMSV in our hospital. Both the operating duration and the time to return to normal activity of MIMV was shorter than that of CMSV (P < 0.001). The recurrence rate (P < 0.001) and injury rate of vas deferens (P = 0.011) after MIMV were lower than that after CMSV. Moreover, patients with MIMV showed higher degree of satisfaction with the surgery experience and outcome than those with CMSV (P < 0.001). However, no statistical difference was found between the two groups in scores of pain due to surgery, postoperative varicose veins diameters, reflux duration, and the postoperative complications of wound infection, hydrocele, atrophy of testis, epididymitis, and scrotal hematoma. In summary, MIMV is a promising varicocelectomy and could be applied more in clinical practice.

Two decades of experience with laparoscopic varicocele repair in children: Standardizing the technique

BACKGROUND

Controversy still exists about the indications and the gold standard approach for varicocele treatment in pediatric population.

OBJECTIVE

The authors report their 23 years of experience in laparoscopic varicocele repair in the pediatric population.

STUDY DESIGN

We retrospectively evaluated the data of 345 consecutive patients who underwent laparoscopic left varicocelectomy from January 1993 to December 2015. Average patient age was 12.5 years (range 8-17). Seven out of 345 patients (2%) had a recurrent varicocele, and five out of 345 patients (1.4%) had a varicocele on a single testis. In 335/345 patients (97.1%) we performed a Palomo procedure, and in 10/345 patients (2.9%) an artery-sparing Palomo procedure. After 2010, in 105/345 patients (30.4%) we performed a lymphatic sparing procedure using isosulfan blue injection preoperatively.

RESULTS

All procedures were completed in laparoscopy (Figure), without conversions or intraoperative complications. The average operative time was 17 min (range 14-45) for the Palomo procedure and 26 min (range 18-50) for artery-sparing Palomo. In 45/345 patients (13%) we performed additional procedures. We recorded 4/345 (1.3%) recurrences/persistences in patients undergoing Palomo, while we recorded 1/10 (10%) recurrence/persistence after artery-sparing Palomo. On 230 Palomo procedures performed in the pre-isosulfan blue era, we recorded 25 cases of hydrocele (10.8%), 13 of these were treated with transcrotal puncture and 12 required surgical operation. The last 105 patients undergoing isosulfan blue injection had no postoperative hydrocele. We also reported 10 other complications (I grade Clavien-Dindo) such as umbilical granuloma or instrumental problems.

DISCUSSION

Analyzing the international literature of the last 25 years, most papers focused on the minimally invasive treatment of pediatric varicocele. There are several reasons to perform laparoscopic repair of pediatric varicocele. First of all, it is technically easy to perform, the average operative time is very short, and it has excellent outcome in regard to varicocele persistence/recurrence. In addition it has a very low complication rate, and in particular adopting the intradartoic/intratesticular isosulfan blue injection before surgery we recorded no postoperative hydrocele.

CONCLUSION

On the basis of our 23 years of experience with varicocele repair, we clearly believe that laparoscopic Palomo lymphatic sparing varicocelectomy should be considered the standard of care for the treatment of pediatric patients with varicocele. Laparoscopic varicocelectomy is technically easy and quick to perform, painless, and scarless, with a recurrence rate of about 1%. The use of a preoperative injection of isosulfan blue completely eliminates postoperative hydrocele formation.

Retroperitoneal Varix ligation with sclerotherapy: a prospective randomized comparative study

Introduction

The aim of this article is to compare the results of high varix ligation with and without sclerotherapy.

Material and methods

Between November 2014 and December 2015, sixty patients with varicocele were included in this study. Patients were divided into two equal groups; group I (underwent high varix ligation), and group II (underwent high varix ligation with a retrograde injection of 2 mL of 5% ethanolamine oleate in the lower end of the bisected gonadal vein). The operative time, intra- and postoperative complications, postoperative pain, improvement of semen parameters, incidence of recurrence and achieving of unassisted pregnancy were recorded for both groups.

Results

The age range was 19-34 years in group I and 21-37 years in group II. The operative time was shorter in group I (34.6 ±7.81 min) than group II (43.3 ±8.5 min) (P <0.001), which was statistically significant.Improvement of semen parameters and the occurrence of spontaneous pregnancy were insignificant between both groups. No intraoperative complications occurred. The postoperative complications were statistically insignificant in both groups.

Conclusions

Combined varix ligation with retrograde sclerotherapy does not offer significant advantages over high varix ligation alone with a longer operative time and prolonged post-operative pain.

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.

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.