VARICOCELE

Операция Мармара (микрохирургическая варикоцелэктомия)VARICOCELE (varicose deformation of testicle veins) is abnormal veins of testicles (acinar plexus, pampiniform plexus) resulting from blood reflux of the spermatic cord veins or testicular vein. Varicocele occurs in 15% of men in the general population, 35% of men with primary infertility, 75-81% of men with secondary infertility. In 95% of cases veins are detected on the left side. This is due to anatomical features - the outflow of blood from the left testicular vein is carried into the left renal vein at a right angle. On the right side testicular vein falls into the inferior vena cava at a sharp angle. Because of this, hydrostatic pressure that overcomes the resistance of the intravenous valves in the left spermatic vein is increased; and the blood returns to the venous rete testis.

Патогенез Варикоцеле

Pathogenesis. Despite to that men with varicoceles are able to conceive, there is good evidence that there is a link between infertility and varicocele. A study of the World Health Organization (WHO), carried out among 9,000 women, showed that varicocele is accompanied by a decrease in testicular volume, adversely affects on the quality of sperm and Leydig cell function [1]. Another study conducted by Johnson et al., showed that 70% of healthy military recruits with palpable varicocele had abnormalities in sperm analysis. [2] In addition, animal studies [3,4] and humans [5-7] have shown that varicocele causes progressive damage to the testicles for a long time. Obviously, the surgical correction of a varicocele not only stops these changes, but also causes them to reverse the development. It is noted an increase in the likelihood of pregnancy in 80% of men after surgical correction.

Mechanisms of influence of varicocele on testicular function. Changes that occur in varicocele are plural. Expansion of the testicular veins runs the range of pathological mechanisms that violate the spermatogenesis (sperm maturation) in the testis:

Hyperthermia (heat) around the testicles. Normal sperm maturation takes place at a temperature of 34-35 ° C. Varicocele disrupts the process of heat transfer in the cavity of the scrotum and the temperature rises to body temperature; and the process of sperm maturation is disrupted. [8,9]

Hypoxia (lack of oxygen in the tissue cells) in the testis as a consequence of violations of blood flow and stagnation in the veins of  pampiniform plexus. The lack of oxygen leads to disruption of tissue supply, slowing metabolism and slowing down the process of sperm maturation.

Renal and adrenal reflux (regurgitation of blood in renal and adrenal veins). Venous blood flows away at the same kidney and adrenal with high hormones that in such concentration  have a toxic effect for the testicular tissue.

Varicocele may have clinical implications, but can also occur without any symptoms. Most often it manifests with a feeling of heaviness in the scrotum and testicular pain.

The diagnosis of clinically significant varicocele is established during the examination of the scrotum and its organs. Examination of the patient is held in the horizontal and vertical position in a warm room (the muscle fibers relax in the warmth and facilitate the inspection). During the examination the urologist tries to find extended and convoluted blood vessels under the skin of the scrotum. Scrotal ultrasound is also applied for the diagnosis. Varicocele diagnostic criterion in this case is the diameter of the lumen of the veins more than 3 mm. Venous reflux or backward flow of blood straining in veins with a smaller diameter must be confirmed using Doppler. It should be kept in mind that right-sided varicocele could exist in 50% of cases with clinically significant left-sided varicocele.

Table 1: Clinical classification of varicocele

Grade

Signs

Grade III
Grade II
Grade I

Visually determined
Palpable alone (without the Valsalva maneuver), visually not determined
Palpable only with Valsalva maneuver

Subclinical (non palpable)

Veins are more than 3 mm in diameter (scrotum ultrasound); Reflux at the Valsalva maneuver on Doppler

To be operated or not to be? Indications for the treatment of varicocele.

After the diagnosis the question “to be operated or not to be?” always arises before the.  At the present time, in the presence of a large number of sources of information, many contradictions can occur in the patient's head. Let's try to understand. There are main indications for surgical treatment of varicocele:

-                     Infertility in men. The quality and quantity of sperm in the semen are improved after carefully executed operation

-                     The presence of varicocele symptoms. Pain and feeling of heaviness in the scrotum, a cosmetic defect.

-                     Varicocele of youth age. Some researchers consider that it is necessary to carry out the operation early as possible to prevent the destruction of the testicles.

-                     Hypogonadism.  Decrease of the left testicle, compared with the contralateral, is 15-20% or more.

Surgical treatment of varicocele. Which method to choose?

Once the patient has decided to have surgery, the question ”what is the most effective method?” arises. There are several types of surgical interventions with different approaches are used in our days (retroperitoneal, inguinal, scrotal, microsurgical, laparoscopic surgery, percutaneous embolization, etc.). Each of techniques allows the patient to recover quickly and to be discharged from the hospital within one day after the operation. However, the choice of method should be based on criteria such as the likelihood of recurrence and possible complications. These points need to be thoroughly discussed with your doctor. In most cases, some patients have to deal with a relapse, when after a certain time after the surgery the patient finds symptoms of varicocele again.

Table 2: Methods of surgical correction of a varicocele.

Approach technique

Arteries saved

 

Hydrocele (hydrocele) (%)

Recurrence (%)

The possibility of serious complications

Microscopic groin (Marmar’s technique)

+

0

1

-

Retroperitoneal (Ivanisevich’s technique)

-

7

15 - 25

-

Groin (Palomo’s technique)

-

3 - 30

5 - 15

-

Laparoscopic

+

12

5 - 15

+

Embolization

+

0

7 - 25

+

The table above shows that the Marmar’s technique (microsurgical varicocelectomy) is the most effective and safe way to treat a varicocele. Its safety is due to low traumatic compared to other methods, and the efficiency is due to the smallest number of complications and recurrence rate. Surgical access at Marmar’s technique is performed at the level of outer ring of the inguinal canal, and is below the level of wearing underwear, unlike retroperitoneal and laparoscopic techniques. Spermatic cord with dilated veins is located in the area just under the skin. The length of the incision does not exceed 1.5 - 2.5 cm, which is comparable to the laparoscopic approach and much less than the retroperitoneal approach.

According to Mark Goldstein’s (CornellMedicalCenter, New-York) analisis, the results of treatment of varicocele using microsurgical Marmar’s approach from 1500 observed pairs, pregnancy occurred in 43% of cases within one year and 69% at 2 years after surgery compared with 16% in pairs with a man who refused surgical treatment and passed conservative treatment or used artificial insemination. Of the 1500 patients, only 14 have been marked by recurrent varicocele (1%).There were no hydrocele or testicular atrophy have been reported [10].

References:

  1. World Health Organization: The influence of varicocele on parameters of fertility in a large group of men presenting to infertility clinics. Fertil Steril 57:1289, 1992.
  2. Johnson DE, Pohl DR, Rivera-Correa H: Varicocele: an innocuous condition? South Med J 63:34, 1970.
  3. Nagler HM, Li XZ, Lizza EF, et al: Varicocele: temporal considerations. J Urol 134:411, 1985.
  4. Harrison RM, Lewis RW, Roberts JA: Pathophysiology of varicocele in nonhuman primates: long-term seminal and testicular changes. Fertil Steril 46:500, 1986.
  5. Russell JK: Varicocele, age, and fertility. Lancet 2:222, 1957.
  6. Lipshultz JI, Corriere JN: Progressive testicular atrophy in the varicocele patient. J Urol 117:175, 1977.
  7. Witt MA, Lipshultz LI: Varicocele: a progressive or static lesion? Urology 42:541, 1993.
  8. Williams WL, Cunningham B: Histological changes in the rat testis following heat treatment. Yale J Biol Med 12:309, 1940.
  9. Dutt RH, Hamm PT: Effect of exposure to high environmental temperatures and shearing on semen production in rams in winter. J Anim Sci 16:328, 1957.
  10. Goldstein M, Gilbert BR, Dicker AP, et al: Microsurgical inguinal varicocelectomy with delivery of the testis: an artery and lymphatic sparing technique. J Urol 148:1808, 1992.

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