Tuesday, July 31, 2012

Varicocele part 7


Medical Therapy

A varicocele is an anatomic abnormality that can impair sperm production and function. No effective medical treatments for varicoceles have been identified. While some investigators are evaluating the role of antioxidants for the treatment of elevated levels of reactive oxygen species, this treatment approach is still experimental.

Surgical Therapy

The primary form of treatment for varicoceles is surgery. Because of the potential to cause significant testicular damage, evaluate the varicocele during the physical examination. The presence of a varicocele does not mean surgical correction is necessary.
The ultimate goals of varicocele repair should include occlusion of the offending varicosity with high success, preservation of arterial flow to the testis, and the minimization of patient discomfort and morbidity. Viable options for repair include radiographic obliteration and surgical repair of various approaches. The efficacy of the myriad techniques is nearly equivalent. Therefore, special attention must be paid to the morbidity of the individual procedure and the expertise of the operating surgeon.
Results from a prospective, randomized controlled trial from Saudi Arabia compared subinguinal microsurgical varicocele repair to observation.Inclusion criteria included infertility lasting 1 year or longer, demonstration of a palpable varicocele, and presence of at least one impaired semen parameter (sperm concentration < 20 million/mL, progressive motility < 50%, or normal morphology < 30%). A total of 145 participants had follow-up within 1 year; spontaneous pregnancy was achieved in 13.9% of controls compared with 32.9% of treated men (odds ratio, 3.04). In treated men, the mean of all semen parameters significantly improved in follow-up compared with baseline (p < 0.0001). This study provided an evidence-based endorsement of the superiority of varicocelectomy over observation in infertile men with palpable varicoceles and impaired semen quality.

Preoperative Details

Perform varicocele surgery in an outpatient setting using one of various anesthetics (eg, general, regional, local). A general anesthetic provides maximal patient comfort.

Intraoperative Details

The 3 most common surgical approaches used to correct a scrotal varicocele include inguinal (groin), retroperitoneal (abdominal), and infrainguinal/subinguinal (below the groin) approaches. With all 3 approaches, all abnormal veins are tied permanently to prevent continued abnormal blood flow. Avoid the vas deferens and the testicular artery during the surgery. The inguinal approach is depicted below.
Incision for an inguinal approach to varicocele repair.
The inguinal and subinguinal approaches are those most commonly used by the vast majority of adult urologists and infertility specialists. The familiar anatomy, low morbidity, and high efficacy make these approaches almost ideal. Inguinal ligation is achieved by incising the inguinal canal down to the external inguinal ring. After cord isolation, the testicular artery is preserved and the veins of the cord are ligated and divided.
The subinguinal approach is performed in a similar fashion, but access is achieved through an incision at or near the pubic tubercle that obviates the opening of the external oblique aponeurosis. The advantages of subinguinal varicocele ligation, especially with use of magnification, include decreased pain and easier access to the spermatic cord, especially among obese men and those with a history of inguinal surgery. However, at this level, a greater number of veins are present, especially periarterial anastomosing veins, that make subinguinal ligation technically challenging.
The use of the microsurgical technique has advanced the surgical treatment of this disorder by allowing optimal visualization. While the approach to cord isolation is no different, the 6-25X magnification facilitates the identification of small anastomosing veins that might otherwise be missed. Furthermore, the risk of testicular ischemia and testis atrophy due to inadvertent ligation of the testicular artery is greatly reduced with this improved visualization. This risk of arterial ligation can be further reduced by using a mini-Doppler ultrasound probe (Vascular Technology, Inc. [VTI] 20-MHz microvascular Doppler) with the use of a topical vasodilator.
The retroperitoneal approach offers great proximal control of the spermatic vein near its insertion at the renal vein, and this approach may be accomplished laparoscopically. This technique, however, carries a high recurrence rate (nearly 15%) due to inguinal and retroperitoneal collateral veins, failure to ligate fine periarterial veins when the testicular artery is preserved, an inability to preserve lymphatics, and potential hydrocele formation when the artery and vein are ligated en bloc. This approach to varicocele ablation remains popular among pediatric urologists.
Percutaneous embolization represents the least invasive means of varicocele repair. The internal spermatic vein is accessed primarily via cannulation of the femoral vein through a retrograde approach with subsequent balloon and/or coil occlusion of the varicocele. The advantages of percutaneous embolization include preservation of the testicular artery and the relatively noninvasive nature of the technique. However, the percutaneous approach can be fraught with troublesome access to the vein, and postoperative complications such as contrast allergies, arterial injury, thrombophlebitis, and coil migration are uncommon but tangible risks. This approach is often reserved for recurrent varicoceles after open surgical repair.


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