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Tips & Tricks: Scrotal disease- Varicocele -Woo, Seung HyoDept. of Urology, Eulji university College of Medicine, Daejeon, KoreaIntroductionFirst description by Celsus veins that are swollen and twisted over testicle, which becomes smaller that fellow .

PrevalenceAdolescent: 15%P (35-50%) / S (69-81%) : progressive Need early intervention !

Introduction (Cont)WHO : Varicocele is ass withDecreased testicular volumeImpaired sperm qualityDecline in Leydig cell functionSeveral studies results70% of healthy palpable varicocele menAbnormal S/AProgressive & duration dependent testicular damageRandomized, controlled, cross-over studyVaricocelectomy significantly improved pregnancy rates

AnatomyArteryInternal spermatic a. : gonadal arteryExternal spermatic a. : cremasteric a.Vasal arteryVeinInternal spermatic (gonadal) v. : one in 60%External spermatic veinGubernacular veinLymphatics3.6 in spermatic cordPampiniform plexusVas & vasal vs.External spermatic vesselsThree compartmentsPathophysiologyHyperthermiaReflux of metabolitesHot Rock theory

3733~34 FormulaVol r2 , R 1/r4 , Vel 1/r2 Venous diameter Venous wall thickeningVenous volume Impaired countercurrent heat exchange Resistance & velocityTesticular temperature Wash out phenomenon (dilution of intratesticular testosterone)Impaired spermatogenesisAlteration of germ cell metabolism and function, induce arteriovenous shunting, decreasing activity of enzymes of DNA synthesis, increase apoptosis, induce hypoxiaPrognostic indication(+) predictive value Grade IIINormal FSHLack of testicular atrophyMotility > 60%(+) GnRH stimulation testTotal motile sperm > 5 x 106Indication for surgeryIpsilateral growth arrest/atrophyMultiple etiology of testicular dysfunctionAbnormal S/ABilateralityGrade IIISoft ipsilateral testisPainAbnormal GnRH stimulation testPatient/parent anxietyAbnormal scrotal appearanceAbsoluteMinorVaricocelectomy

RetroperitonealInguinal Subinguinal Management : PalomoPalomo techniqueLigation of gonadal vesselsModified Palomo techniqueLigation of gonaldal veinComplicationRecurrence: 11-15%Hydrocele: 7% Hydrocele: 5-9%Recurrence: 5-14%

Laparoscopic varicocelectomy

Management : IvanissevichInguinal approachFamiliar regionEase to approach to cordRecurrence rate: 9-16% (: 5-15%)Hydrocele: 3-39% (: 0-7%)Management : embolizationRecently popularized methodNot need an anesthesiaLess invasiveFailure rate: 27%Recurrence: 4-11%Hydrocele: 0%

Cayan S, et al. J Androl 2009Management : microsurgicalBest way of varicocele managementInguinal Vs. SubinguinalRecurrence: