Varicocele: All you want to know

Varicoceles develop as a result of dilatation and tortuosity of veins of the pampiniform plexus secondary to retrograde flow into the internal spermatic vein (ISV).

DIAGNOSIS
Evaluation of a patient should include a careful medical and reproductive history, a physical examination with the patient in both recumbent and upright position combined with Valsalva. At least two semen analysis should be performed.

Investigations: Imaging studies are not indicated for the standard evaluation unless physical exam is inconclusive. However, sonography of the scrotum  with color flow Doppler imaging may prove useful in equivocal cases or in patients with a body habitus that makes accurate physical examination of the scrotum impossible. Using ultrasonography, the diameter of the internal spermatic vein can be measured and retrograde flow through the vein during Valsalva documented. Sonography can be helpful to detect concomitant diseases like testiculat tumors. Internal spermatic venography is usually reserved for use in patients with recurrent varicocele.

    

Indications for surgery:

Clinically detectable varicoceles associated with abnormal semen parameters normal female partner or female partner with potentially curable infertility problem. IVF with or without ICSI can be considered to be first-line treatment in the presence of an independent female infertility factor requiring the use of these techniques. Reports are there to indicate beneficial effect even in cases of nonobstructive azzospermia. Certain factors predict good outcome like:

• Grade 3 varicocele
• Lack of testiculat atrophy
• Normal FSH
• Motility >60% and  motile sperm count >5 ×106

Palpable varicoceles in adolescent boys when accompanied by ipsilateral testicular atrophy. Adolescents with normal testicular size should be offered follow-up with annual measurement.

Debilitating testicular pain. But unfortunately, 10-15% has either persistent or worsening symptoms.

MANAGEMENT

Intervention

Angiographic treatment of varicocele consists of the occlusion of the ISV with the interruption of retrograde venous flow. The procedure is at best reserved form recurrent varicocele to know and occlude sites of reflux.

Surgical management

Surgical repair may be accomplished by various surgical approaches like inguinal(Ivanissevich ), subinguinal and retroperitoneal approaches (Palomo),. Most experts perform inguinal or subinguinal surgical repair employing loupes or an operating microscope for optical magnification. Techniques using optical magnification helps in reliable identification and preservation of the testicular artery or arteries, cremasteric artery and lymphatic channels and reliable identification of all internal spermatic veins and gubernacular veins reducing the risk of persistence or recurrence of varicocele. The introduction of microsurgical technique to varicocelectomy has resulted in a substantial reduction in the incidence of postoperative hydrocele formation and testicular atrophy. The use of magnification enhances the ability to identify and preserves the 0.5 - 1.5-mm testicular arteries, thus avoiding the complications of azoospermia.

OUR ANDROLOGIST PERFORMING MICROSURGICAL VARICOCELECTOMY

IDENTIFYING THE ARTERIES VEINS AND LYMPHATICS UNDER MAGNIFICATION

POST OPERATIVE WOUND DRESSING

Laparoscopy has been used for varicocele repair but this approach carries the risk of major intraperitoneal complications, such as injury to bowel, bladder and major blood vessels and alsorisk of leaving some tributaries especially above level of L4 vertebra.

Adolescent varicocele:

Generally accepted indication for correction is an orchidometer measurement revealing a 20% volume deficit in the involved testis because phenomenon of catch up growth has been observed in these patients.