varicocele facts or fiction dr. gil raviv urology department andrology unit sheba medical center

Varicocele

Facts or Fiction

Dr. Gil Raviv

Urology Department

Andrology Unit

Sheba Medical Center

DefinitionVaricocele is a vascular abnormality of the scrotum that is defined as dilated veins of the pampiniform plexus.

Varicocele - Facts or FictionVaricocele - Facts or Fiction

Anatomy• 90% left side.• 10% bilateral.• Most commonly -

internal spermatic veins.• Others:

– External spermatic veins.– Cremasteric veins

• Rarely appears - deferential veins


Pathophysiology

• Is not known for certain.

• Various theories for testicular damage due to incompetent valves of spermatic veins:

– Increased testicular pressure.

– Hypoxia and stasis.

– Increased testicular temperature.

– Elevated spermatic vain catecholamines.


Prevalence

General population - 15-20%Attending infertility clinics - 30-40%

WHO (project 78923)General population - 11.7%%Abnormal semen parameters - 25.4% (Fertile-Sterile 1992)


Diagnosis

Various methods:

• Radio nuclide examination - high false negative - depends on blood pooling.

• Scrotal Thermography - rarely used.

• Doppler stethoscope- only for confirmation.


Diagnosis

• Scrotal real time Ultrasonography - widely used with high specificity and sensitivity.

• Venography - most accurate diagnostic method.

Venographic data supports ultrasound examination only in cases of clinically suspected cases.


No single diagnostic tools available provides both exceptional sensitivity and specificity in varicocele detection.


Diagnosis

Diagnosis

The most acceptable methods of diagnosis is clinical examination based on clinician’s subjective impression.

Grade 1 - palpable - valsalva manoeuvre.Grade 2 - palpable - without valsalva manoeuvre.Grade 3 - visible.


Diagnosis

Subclinical Varicocele

• Detected only by radiological imaging. •Controversy exists:

Diagnosis. Treatment. Pregnancy rate.


Varicocele in adolescence

• Rarely found before puberty.

• Varicocele during adolescence is: Asymptomatic. Found on routine examination.

Kass. Urol.Clin 1994



INDICATION FOR TREATMENT

• ABNORMAL SEMEN ANALYSIS

• VOLUME OF LEFT TESTIS 3 ML LESS THEN RIGHT.

• LARGE SYMPTOMATIC VARICOCELE.

• BIL PALPABLE VARICOCELE.



The best method of treatment remains a dilemma.

PECUTANEOUS ABLATION

• Recurrence rate - 6-15 %.

• One to three hours .

• Sedation in addition to local anesthesia.

• Reserved for cases of failed surgery.



TRANSPERITONEAL LAPAROSCOPY

• Presently not considered as first- line therapy.

•General anesthesia.

•Potential major complications.

•High cost.


DOES IT A DYNAMIC PROGRESSIVE LESION?

HISTOLOGY

– Lesions are similar to adults.

– Similar in both testis.

– May precede volume loss.

– No predicting data on reversibility.




SURGERY

• Palomo -Retropertoneum- above level of vas deferenes.

• Artery - sparing procedure.

• Ivanissevitch- inguinal canal the most commonly used.


• Routine varicocele ligation in teenager is not recommended.

• Occlusion of the left internal spermatic vein in young men with varicocele should be performed only in the context of an appropriately large prospective study.

RCOG study group, 1995.• Variable ligation methods are performed depend on

the physician skills.



CONTROLLED STUDIES - EFFECTIVNESS OF VARICOCELECTOMY

• NIESCHLAG (1995,1998 Hum Reprod ).• 125 infertile couples.• 62 - varicocelectomy.• 63 - counseling.

W - intervention

B-

counseling



NIESCHLAG CONT.

• No relationship to pregnancy rate.• Semen analysis.• Hormone profile.• Varicocele grade.• Age of male.• Only female age predict pregnancy • Sperm count increased.



• Baker et al 1985 (I .J Androl ).

651 couples.324 males - sperm count less then 20 x 106. 327 males - sperm count more then 20 x 106. No difference in pregnancy rate.Sperm motility improved



• Vermuelen (1986 , J. Androl ).

• 90 patients - varicocelectomy.

• 25 patients - observation.

• Cumulative PR were the same.

• Both improved sperm characteristics.



• Rageth (1992, Urol Int ).

• 89 patients.

• 56 varicocelectomy - 33 observation.

• All had poor semen analysis.

• The same PR ( 42 %).

• Surgery group all had improved sperm characteristics.



• Rodriguez-Rigau (1978. J Urol ).

• Controlled not prospective not randomized.

• No difference in PR.

• Sperm count and motility improved after surgery.


Controlled studies supporting varicocelectomy

• Marmar and KIM (1994,J Urol).

• 466 surgery group/19 controls.

• PR surgery group 35.6 % ( 186/466).

• PR controls 15.8 %



• Girardi and Goldstin(1997 Curr Ther Endocrine Metab).

• 1500 underwent varicocelectomy.

• 47 controls group.

• PR- 43 % surgery group versus 17 % controls group.

• Improvement of sperm count.



• WHO study never published in its original form.

• 9034 infertile couples.

• 1326 had clinical varicocele.



• Hargreave.

• PR after surgery - 35 %.

• PR controls group 17 %.

• Part of WHO study presented only at andrology meeting!



• Madgar et al (1995 ,Fertile Sterile).• 210 couples from the WHO study.• 45 couples -

20 controls group. 25 high ligation spermatic vein.

• PR surgery group 60 %.• PR controls group 10 %.



TREATMENT IN ADULTS

• WHICH MODALITY IS THE BEST ?

• Comparison by three outcome measures: * Success rate.

* Semen improvement and pregnancy rate.

* Complication rate.



Success rate

Recurrence or persistence after treatment.

High ligation 11 - 15%.

Inguinal ligation 6 - 9%.

Percutaneous ablation 4 - 24%.

Laparascopic 0 - 11%.



Semen improvement and pregnancy rate

• No differences in pregnancy rate in all kinds

of treatment.

• Improvement of sperm - occasionally.



Complication rate

• Laparascopic ligation 0.6 - 4%

• Operative-inguinal approaches:

- Artery damage.

- Ilioinguinal nerve damage.

- Scrotal hematoma.



Complication rate - cont.• Operative-retroperitoneal approaches - Artery damage. - hydrocele (7%).• Percutaneous ablation - Contrast allergy (2%). - Injuries to vascular tree. - Migration and embolization.



Complication rate - cont.

• Operative-laparascopic approaches

- Injured epigastric vessels.

- Rarely bowel injury.

- High cost.



CONCLUSIONS (1)

•There is insufficient evidence to recommended occlusion of the left internal spermatic vein in subfertile or oligozoospermic men with varicocele.

(gynecologists).



CONCLUSIONS (2)

• Varicocele exert deleterious effect upon both testis and it’s function - therefore treatment is recommended in large varicocele with reduced testis volume in adolescence.



CONCLUSIONS (3)

• Correlation exists between varicocele size and seminal improvement.

• Diagnosis and treatment of subclinical varicocele is not recommended.

• Timing of varicocele correction is not determine.



CONCLUSIONS (4)

• Correction of varicocele depends on female age.

• Sperm cryopreservation and varicocele correction is recommended in patients with severe OTA and high FSH.



• Bilateral varicocele. Operating one side/ both ?

? open/laparoscopy Type of operation:


SPECIAL CONDITION AND VARICOCELE

• Azoospermia . FSH- normal/abnormal?

• Very severe OTA. High/normal FSH?

• Recurrent varicocele?

VARICOCELE AND OTHER SPECIAL CONDITION

Undesending testicle in the same side?

Recurrence - Type of treatment? Surgery/Embolization Improved sperm count.

VARICOCELE AND OTHER SPECIAL CONDITION

Pain only.

Failed embolization. - Type of treatment.

Varicocele in older men .

Right side.

Couple after few cycle of IVF-ICSI.

Isolated teratoastonespermia.

varicocele facts or fiction dr. gil raviv urology department andrology unit sheba medical center

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