Varicoceles

Andrew Schultz, MD
Stephen Confer, MD
Ben O. Donovan, MD
Brad Kropp, MD
Dominic Frimberger, MD
University of Oklahoma
Department of Urology
Section of Pediatric Urology
 Varicocele
• dilatation of the pampiniform venous plexus and
the internal spermatic vein
• well-recognized cause of decreased testicular
function
• very rare < 9 y.o.
• ~16% of adolescents
• ~15-20% of all males
• 40% of infertile males
– scrotal varicoceles are the most common cause of poor
sperm production and decreased semen quality
 The prevalence of varicocele and
associated testicular hypotrophy by age

Age, years Prevalence, %

of varicocele hypotrophic testis
<11 0 0
11–14 6–8 7.3
15–19 11–19 9.3
 History
• first recognized as a clinical problem in 16th
century
• relationship between infertility and varicocele
proposed in late 19th century
– thereafter, others reported association with arrest of
sperm secretion and the subsequent restoration of
fertility following repair
• enlarged scrotal veins in teenagers referenced as
early as 1885
 History
• 1950s  report of fertility following varicocele
repair in an individual known to be azoospermic
– surgical correction as clinical approach to certain kinds
of male infertility gained support among American
surgeons
• Continued research documented recurrent pattern
of low sperm count, poor motility, and
predominance of abnormal sperm forms (stress
pattern of semen)
– not specific to varicocele
– suggests early evidence of testicular damage
 Varicocele
• 80-90% involve the left testicle
– anatomic factors
(1) angle at which left testicular vein enters left renal vein
(2) lack of effective antireflux valves at juncture of testicular vein
and renal vein
(3) increased renal vein pressure due to compression between the
superior mesenteric artery and the aorta (ie, nutcracker effect)
– 35-40% of men with palpable left varicocele may
actually have bilateral varicoceles
– Recent study by Gat et al  ~ 80% of men with a left
clinical varicocele had bilateral varicoceles revealed by
noninvasive radiologic testing
 Varicocele Presentation
• Scrotal mass/swelling, symptoms of acute or
chronic scrotal discomfort, differing testicular
sizes without a palpable variocele, and incidental
finding on scrotal US
• Grading:
– Grade 0 - Subclinical varicocele, Dx by US or
venography
– Grade 1 – palpable with Valsalva maneuver
– Grade 2 - Easily detected without Valsalva maneuver
– Grade 3 - Detected visually at a distance
 Varicocele Presentation
• Most asymptomatic
• usually unilateral and almost always left-sided
– unilateral right-sided varicocele should prompt
investigation for retroperitoneal process
• mass that causes obstruction of the right internal spermatic
vein
• Thrombosis/occlusion of the inferior vena cava must be ruled
out in
• Situs inversus another etiology of right-sided varicocele
• Initial presentation usually occurs during puberty,
with incidence in 13-year-old adolescent boys
equal to that of adult men
 Varicocele
• Multiple investigators have directly
correlated the degree of testicular atrophy
with varicocele grade
– Steeno et al  testis volume reduced by 81%
with grade 3 and by 34% with grade 2
• No patients with grade 1 had testicular atrophy
 Pathophysiology
• Unknown how impairment of sperm structure, function,
and production occurs
– interference with thermoregulation
• other theories include the possible effects of pressure,
oxygen deprivation, heat injury, and toxins
– Despite considerable research, no one theory proved
unquestionably
• Regardless, indisputably a significant factor in decreasing
testicular function and in reducing semen quality in large
percentage of men seeking infertility treatment
 Histology
• Histologic studies  seminiferous tubule
sclerosis, small vessel degenerative
changes, and abnormalities of Leydig,
Sertoli, and germ cells
– changes have been documented in patients as
young as 12 years
 Management
• Presence of a varicocele does not necessitate
surgical correction
• Indications for surgical correction
– Relief of significant testicular discomfort or pain not
responsive to routine symptomatic treatment
– testicular atrophy (volume difference >20% or > 2cc)
– possible contribution to unexplained male infertility
– varicocele may cause progressive damage to testes,
resulting in further atrophy and impairment of seminal
parameters
 Management
• The AUA Male Infertility Best Practice Policy Committee
recommends treatment be offered to the male partner when
all the following are present:
– varicocele is palpable
– couple has documented infertility
– female has normal fertility
– one or more abnormal semen parameters or sperm function test
results
• men who have a palpable varicocele and abnormal semen
analyses findings but are not currently attempting to
conceive should also be offered varicocele repair
 Management
• No strict criteria necessitate surgical intervention in
adolescents
• Each case handled individually
– discussion among patient, parents, and physician regarding risks
of intervention and potential impact on future fertility
• general guidelines used by some pediatric urologist include
the presence of one or more of the following:
– Varicocele associated with decreased ipsilateral testicular size
(20% volume deficit in the involved testis)
– Bilateral varicoceles
– Symptomatic painful varicocele
– Abnormal findings on semen analysis
 Varicocele
• Lipshultz and Corriere (1997)
– suggested that varicoceles were associated with
testicular atrophy that was progressive with age
– observed that testicular biopsy specimens taken from
prepubertal boys with varicoceles already revealed
histologic abnormalities
• Kass and Belman (1987)
– first to demonstrate significant increase in testicular
volume after varicocele repair in adolescents
– did not study semen parameters
 Surgical Management

• ideal technique is to ligate all of the internal and external

spermatic veins with preservation of spermatic arteries and
lymphatics
• internal spermatic artery may be divided with
transperitoneal or retroperitoneal approach
– does not usually cause testicular atrophy due to generous collateral
circulation to testicle
• 3 most common surgical approaches
– inguinal
– Retroperitoneal
– subinguinal
 Subinguinal
• Incision made over external ring at or near the pubic tubercle
– obviates the opening of the external oblique aponeurosis
• Dilated cremasteric veins ligated
• Spermatic cord opened
– spermatic veins in pampiniform plexus separated and ligated
– any dilated veins that accompany the vas deferens also ligated

Microscopic subinguinal approach

• Operating microscope used to dissect out and preserve the testicular
arteries and lymphatic vessels
• Some advocate delivering testicle into wound and ligating external
spermatic and gubernacular veins
• recurrence rate 0-2%, complication rate 1-5%
 Inguinal
• Incision made over course of inguinal canal
• Ligation of cremasteric, deferential, and
spermatic veins performed with arterial
preservation
• Microscope may be used as well
 Retroperitoneal
• Low abdominal incision above internal ring
• High ligation performed of entire spermatic pedicle (Palomo
procedure)
• testicular artery–sparing procedure performed by opening the
spermatic fascia to identify and preserve the artery

Laparoscopic-assisted retroperitoneal approach

• Artery may be spared
– lengthens the procedure
– higher recurrence rate (6-15%)
• due to inguinal and retroperitoneal collateral veins, failure to ligate fine
periarterial veins when testicular artery preserved
• 20% incidence of hydroceles at 6 months if lymphatics not preserved
 Embolization/Sclerotherapy
Percutaneous Embolization
• Least invasive means of varicocele repair
• Internal spermatic vein accessed via cannulation
of femoral vein
– balloon and/or coil occlusion of varicocele
• failure rate of up to 15%

Antegrade sclerotherapy
• success rate is > 90%
• hydroceles are not a complication
 Conclusions
• Most methods of varicocelectomy result in similar
short-term results
• Open microsurgical inguinal or subinguinal
techniques in adults shown to cause fewer
recurrences and complications
• Given that efficacy all techniques is nearly
equivalent, attention must be paid to the morbidity
of the individual procedure and expertise of the
operating surgeon
 Follow Up
• Check patient's semen 3-4 months after
surgery if done for infertility
• spermatogenesis requires approximately 72
days
– any effects from varicocele repair on semen
parameters are delayed
 Considerations
• Vasectomy after mass ligation
varicocelectomy likely to result in testicular
atrophy
– Further supports artery-sparing technique