Tuesday, July 31, 2012

Varicocele part 9


The prevalence of adverse effects following varicocele repair is remarkably low. Hydrocele or increased fluid around the testicles occurs in 2-5% of patients. Successful surgery often increases conception rates in infertile couples. The overall recurrence rate for varicoceles has been reported as high as 10%.
Injury to the testicular artery has been reported in 0.9% of microsurgical varicocele repairs. This incidence may be higher when optical magnification is not used for varicocele repair. Because the testis typically has additional arterial supplies from the vasal and cremasteric arteries, testicular atrophy is uncommon (5%) after division of the testicular artery. Smaller atrophic testes may be at greater risk for accidental testicular artery injury because of the smaller size of the artery in these cases.
In a patient in whom a varicocele is first identified during a vasectomy reversal, varicocelectomy at the time of the vasectomy reversal is controversial. Delaying the varicocelectomy preserves some venous return in these patients and avoids possible injury to the testicular artery. Consider varicocele repair 6 months later, after new vascular channels form.

Outcome and Prognosis

Following varicocelectomy, approximately 66-70% of patients have improved bulk semen parameters, and 40-60% of patients have increased conception rates. Because human spermatogenesis takes approximately 72 days, the first improvements in semen analysis results are typically not apparent until 3-4 months after surgery.
While many of the published studies are retrospective, a randomized, prospective, controlled study by Magdar and associates (1995) confirmed that varicocelectomy is an effective treatment for male subfertility. Magdar et al studied male counterparts in couples in 2 subject groups, groups A and B. Group A (20 male subjects with varicoceles) was studied for 1 year, and only 2 (10%) men initiated a pregnancy. Male subjects who could not initiate a pregnancy then underwent varicocele repair; within 2 years, 12 (66%) were successful in initiating a pregnancy.
Meanwhile, 25 male subjects in group B underwent immediate varicocele repair. Within the first year, 15 (60%) initiated a pregnancy. After 3 years, an additional 4 (16%) subjects achieved pregnancy. Semen parameters improved in all subjects who underwent varicocele repair, regardless of pregnancy occurrence. Semen parameters were unchanged among group A subjects during their 1 year of observation. This important study concluded that varicoceles are associated with reduced fertility and impaired testicular function, while repair improves sperm parameters and fertility rates.
In addition, Vasquez-Levin et al (1997) demonstrated that varicocele repair benefits sperm morphology, even when evaluated using so-called strict criteria.
Evers and Collins performed a meta-analysis of 7 randomized controlled trials. Because overall pregnancy rates were 21.7% in operated patients and 19.3% (pNS) in control patients, they concluded that varicocele repair did not improve natural pregnancy rates.The concerns with this meta-analysis are that inclusion criteria regarding severity of impairment in semen parameters were not uniform, the varicocele diagnostic criteria and grading were inconsistent, and female factors were not mentioned in their overall analysis.
The persistent or recurrent varicocele can be repaired microsurgically with significant improvements in sperm concentration, percent motility, and total motile sperm per ejaculate. In addition, as reported by Grober et al, a beneficial effect on serum testosterone levels, testicular volume, and pregnancy rates can be observed.
The optimal approach to varicocele ligation has not been proven in evidence-based studies. However, based on available experience and reports, the authors recommend varicocele ligation be performed through an inguinal or subinguinal approach with the use of an operating microscope and hand-held microvascular Doppler ultrasound probe.



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