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Microscopic Surgical Techniques for Varicocele Repair

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Book cover Varicocele and Male Infertility

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Abstract

The varicocele is a common condition afflicting postpubertal men, a subset of whom will develop subfertility and/or androgen deficiency. Varicocele repair is associated with improved semen parameters, sperm DNA integrity, androgen levels, and fertility outcomes. Multiple treatment modalities exist for the varicocele, each carrying a differing set of advantages and disadvantages. The appropriate treatment for a given patient depends upon the patient’s anatomy, his values and goals, the resources available, and the experience of the surgeon. Beyond the treatment modality ultimately selected, the success of varicocele repair is most dependent upon appropriate patient selection in whom the indications are clear. In this review, the subinguinal microsurgical varicocelectomy will be discussed in detail. Overriding principles, outcomes, and complications of this technique will first be addressed with a critical overview of existing literature. The technical aspects to effectively and safely perform a subinguinal microsurgical varicocelectomy are outlined in a stepwise fashion. Additionally, controversial elements of the repair, mainly delivery of the testis and the benefits of arterial preservation, will be presented based upon available data. The remainder of the technical description will address the unique obstacles and strategies required when the reproductive urologist faces the recurrent varicocele. Finally, it cannot be emphasized enough that formal microsurgical training should be considered a requirement for offering the subinguinal microsurgical varicocelectomy. A call for better and more standardized training regimens concludes this review, as uniform and high-quality varicocele repair is the ultimate gold standard the medical community must strive for.

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References

  1. Damsgaard J, Joensen UN, Carlsen E, et al. Varicocele is associated with impaired semen quality and reproductive hormone levels: a study of 7035 healthy young men from six European countries. Eur Urol. 2016;70(6):1019–29.

    Article  CAS  PubMed  Google Scholar 

  2. World Health Organization. The influence of varicocele on parameters of fertility in a large group of men presenting to infertility clinics. Fertil steri. 1992;57(6):1289–93.

    Article  Google Scholar 

  3. Akbay E, Cayan S, Doruk E, Duce MN, Bozlu M. The prevalence of varicocele and varicocele-related testicular atrophy in Turkish children and adolescents. BJU Int. 2000;86(4):490–3.

    Article  CAS  PubMed  Google Scholar 

  4. Levinger U, Gornish M, Gat Y, Bachar GN. Is varicocele prevalence increasing with age? Andrologia. 2007;39(3):77–80.

    Article  CAS  PubMed  Google Scholar 

  5. Tulloch WS. Varicocele in subfertility; results of treatment. Br Med J. 1955;2(4935):356–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Evers JL, Collins JA. Assessment of efficacy of varicocele repair for male subfertility: a systematic review. Lancet. 2003;361(9372):1849–52.

    Article  PubMed  Google Scholar 

  7. Evers JH, Collins J, Clarke J. Surgery or embolisation for varicoceles in subfertile men. Cochrane Database Syst Rev. 2009;1:Cd000479.

    Google Scholar 

  8. Niederberger C. Re: varicocele and male factor infertility treatment: a new meta-analysis and review of the role of varicocele repair. J Urol. 2012;187(2):626.

    PubMed  Google Scholar 

  9. Guzick DS, Overstreet JW, Factor-Litvak P, et al. Sperm morphology, motility, and concentration in fertile and infertile men. N Engl J Med. 2001;345(19):1388–93.

    Article  CAS  PubMed  Google Scholar 

  10. Agarwal A, Deepinder F, Cocuzza M, et al. Efficacy of varicocelectomy in improving semen parameters: new meta-analytical approach. Urology. 2007;70(3):532–8.

    Article  PubMed  Google Scholar 

  11. Abdel-Meguid TA, Al-Sayyad A, Tayib A, Farsi HM. Does varicocele repair improve male infertility? An evidence-based perspective from a randomized, controlled trial. Eur Urol. 2011;59(3):455–61.

    Article  PubMed  Google Scholar 

  12. Al-Ali BM, Shamloul R, Pichler M, Augustin H, Pummer K. Clinical and laboratory profiles of a large cohort of patients with different grades of varicocele. Cent Eur J Urol. 2013;66(1):71–4.

    Article  Google Scholar 

  13. Witt MA, Lipshultz LI. Varicocele: a progressive or static lesion? Urology. 1993;42(5):541–3.

    Article  CAS  PubMed  Google Scholar 

  14. Gorelick JI, Goldstein M. Loss of fertility in men with varicocele. Fertil Steril. 1993;59(3):613–6.

    Article  CAS  PubMed  Google Scholar 

  15. Jarow JP, Coburn M, Sigman M. Incidence of varicoceles in men with primary and secondary infertility. Urology. 1996;47(1):73–6.

    Article  CAS  PubMed  Google Scholar 

  16. Matthews GJ, Matthews ED, Goldstein M. Induction of spermatogenesis and achievement of pregnancy after microsurgical varicocelectomy in men with azoospermia and severe oligoasthenospermia. Fertil Steril. 1998;70(1):71–5.

    Article  CAS  PubMed  Google Scholar 

  17. Marmar J, Agarwal A, Thomas A. Reassessing the value of varicocelectomy as a treatment for male subfertility with a new meta-analysis. Fertil Steril. 2007;88(3):639.

    Article  PubMed  Google Scholar 

  18. Kroese AC, de Lange NM, Collins J, Evers JL. Surgery or embolization for varicoceles in subfertile men. Cochrane Database Syst Rev. 2012;10:Cd000479.

    PubMed  Google Scholar 

  19. Jungwirth A, Diemer T, Dohle G, Kopa Z, Krausz C, Tournaye H. EAU Guidelines. Edn. presented at the EAU Annual Congress Copenhagen 2018. ISBN 978-94-9267-01-1. EAU Guidelines Office, Amhem, The Netherlands. http://uroweb.org/guidelines/compilations-of-all-guidelines/.

  20. Practice Committee of the American Society for Reproductive Medicine, Society for Male Reproduction and Urology. Report on varicocele and infertility: a committee opinion. Fertil Steril. 2014;102(6):1556–60.

    Article  Google Scholar 

  21. Jarow J, Sigman M, Kolettis P, et al. Optimal evaluation of the infertile male. American Urologic Association Education and Research, Inc.; 2011, Linthicum, MD. http://www.auanet.org/guidelines/maleinfertility-optimal-evaluation-best-practice-statement.

  22. Schlegel PN, Goldstein M. Alternate indications for varicocele repair: non-obstructive azoospermia, pain, androgen deficiency and progressive testicular dysfunction. Fertil Steril. 2011;96(6):1288–93.

    Article  PubMed  Google Scholar 

  23. Rajfer J, Turner TT, Rivera F, Howards SS, Sikka SC. Inhibition of testicular testosterone biosynthesis following experimental varicocele in rats. Biol Reprod. 1987;36(4):933–7.

    Article  CAS  PubMed  Google Scholar 

  24. Ando S, Giacchetto C, Colpi G, et al. Physiopathologic aspects of Leydig cell function in varicocele patients. J Androl. 1984;5(3):163–70.

    Article  CAS  PubMed  Google Scholar 

  25. Ando S, Giacchetto C, Beraldi E, Panno ML, Carpino A, Brancati C. Progesterone, 17-OH-progesterone, androstenedione and testosterone plasma levels in spermatic venous blood of normal men and varicocele patients. Horm Metab Res. 1985;17(2):99–103.

    Article  CAS  PubMed  Google Scholar 

  26. Tanrikut C, Goldstein M, Rosoff JS, Lee RK, Nelson CJ, Mulhall JP. Varicocele as a risk factor for androgen deficiency and effect of repair. BJU Int. 2011;108(9):1480–4.

    Article  CAS  PubMed  Google Scholar 

  27. Su LM, Goldstein M, Schlegel PN. The effect of varicocelectomy on serum testosterone levels in infertile men with varicoceles. J Urol. 1995;154(5):1752–5.

    Article  CAS  PubMed  Google Scholar 

  28. Hsiao W, Rosoff JS, Pale JR, Greenwood EA, Goldstein M. Older age is associated with similar improvements in semen parameters and testosterone after subinguinal microsurgical varicocelectomy. J Urol. 2011;185(2):620–5.

    Article  PubMed  Google Scholar 

  29. Li F, Yue H, Yamaguchi K, et al. Effect of surgical repair on testosterone production in infertile men with varicocele: a meta-analysis. Int J Urol. 2012;19(2):149–54.

    Article  CAS  PubMed  Google Scholar 

  30. Dohle GR, Colpi GM, Hargreave TB, Papp GK, Jungwirth A, Weidner W. EAU guidelines on male infertility. Eur Urol. 2005;48(5):703–11.

    Article  CAS  PubMed  Google Scholar 

  31. Al-Kandari AM, Shabaan H, Ibrahim HM, Elshebiny YH, Shokeir AA. Comparison of outcomes of different varicocelectomy techniques: open inguinal, laparoscopic, and subinguinal microscopic varicocelectomy: a randomized clinical trial. Urology. 2007;69(3):417–20.

    Article  PubMed  Google Scholar 

  32. Cayan S, Shavakhabov S, Kadioglu A. Treatment of palpable varicocele in infertile men: a meta-analysis to define the best technique. J Androl. 2009;30(1):33–40.

    Article  PubMed  Google Scholar 

  33. Cassidy D, Jarvi K, Grober E, Lo K. Varicocele surgery or embolization: which is better. Can Urol Assoc J. 2012;6(4):266–8.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Alkandari MH, Al-Hunayan A. Varicocelectomy: modified loupe-assisted versus microscopic technique - a prospective comparative study. Arab J Urol. 2017;15(1):74–7.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Goldstein M, Gilbert BR, Dicker AP, Dwosh J, Gnecco C. Microsurgical inguinal varicocelectomy with delivery of the testis: an artery and lymphatic sparing technique. J Urol. 1992;148(6):1808–11.

    Article  CAS  PubMed  Google Scholar 

  36. Cayan S, Kadioglu TC, Tefekli A, Kadioglu A, Tellaloglu S. Comparison of results and complications of high ligation surgery and microsurgical high inguinal varicocelectomy in the treatment of varicocele. Urology. 2000;55(5):750–4.

    Article  CAS  PubMed  Google Scholar 

  37. Liu X, Zhang H, Ruan X, et al. Macroscopic and microsurgical varicocelectomy: what's the intraoperative difference? World J Urol. 2013;31(3):603–8.

    Article  PubMed  Google Scholar 

  38. Pan F, Pan L, Zhang A, Liu Y, Zhang F, Dai Y. Comparison of two approaches in microsurgical varicocelectomy in Chinese infertile males. Urol Int. 2013;90(4):443–8.

    Article  PubMed  Google Scholar 

  39. Gontero P, Pretti G, Fontana F, Zitella A, Marchioro G, Frea B. Inguinal versus subinguinal varicocele vein ligation using magnifying loupe under local anesthesia: which technique is preferable in clinical practice? Urology. 2005;66(5):1075–9.

    Article  PubMed  Google Scholar 

  40. Talaie R, Young SJ, Shrestha P, Flanagan SM, Rosenberg MS, Golzarian J. Image-guided treatment of varicoceles: a brief literature review and technical note. Semin Interv Radiol. 2016;33(3):240–3.

    Article  Google Scholar 

  41. Goldstein M. Surgery of male infertility. Philadelphia: W.B. Saunders Company; 1995.

    Google Scholar 

  42. Moon KH, Cho SJ, Kim KS, Park S, Park S. Recurrent varicoceles: causes and treatment using angiography and magnification assisted subinguinal varicocelectomy. Yonsei Med J. 2012;53(4):723–8.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Mirilas P, Mentessidou A. Microsurgical subinguinal varicocelectomy in children, adolescents, and adults: surgical anatomy and anatomically justified technique. J Androl. 2012;33(3):338–49.

    Article  PubMed  Google Scholar 

  44. Mehta A, Goldstein M. Male reproductive systems. In: Standring S, editor. Gray’s Anatomy. 41st ed. London: Elsevier; 2015. p. 1272–87.

    Google Scholar 

  45. Hopps CV, Lemer ML, Schlegel PN, Goldstein M. Intraoperative varicocele anatomy: a microscopic study of the inguinal versus subinguinal approach. J Urol. 2003;170(6. Pt 1):2366–70.

    Article  PubMed  Google Scholar 

  46. Wosnitzer M, Roth JA. Optical magnification and Doppler ultrasound probe for varicocelectomy. Urology. 1983;22(1):24–6.

    Article  CAS  PubMed  Google Scholar 

  47. Guo L, Sun W, Shao G, et al. Outcomes of microscopic subinguinal varicocelectomy with and without the assistance of Doppler ultrasound: a randomized clinical trial. Urology. 2015;86(5):922–8.

    Article  PubMed  Google Scholar 

  48. Zheng YQ, Zhang XB, Zhou JQ, Cheng F, Rao T, Yao Y. The effects of artery-ligating and artery-preserving varicocelectomy on the ipsilateral testes in rats. Urology. 2008;72(5):1179–84.

    Article  PubMed  Google Scholar 

  49. Qi X, Wang K, Zhou G, Xu Z, Yu J, Zhang W. The role of testicular artery in laparoscopic varicocelectomy: a systematic review and meta-analysis. Int Urol Nephrol. 2016;48(6):955–65.

    Article  PubMed  Google Scholar 

  50. Yu W, Rao T, Ruan Y, Yuan R, Cheng F. Laparoscopic varicocelectomy in adolescents: artery ligation and artery preservation. Urology. 2016;89:150–4.

    Article  PubMed  Google Scholar 

  51. Chan PT, Wright EJ, Goldstein M. Incidence and postoperative outcomes of accidental ligation of the testicular artery during microsurgical varicocelectomy. J Urol. 2005;173(2):482–4.

    Article  PubMed  Google Scholar 

  52. Ramasamy R, Schlegel PN. Microsurgical inguinal varicocelectomy with and without testicular delivery. Urology. 2006;68(6):1323–6.

    Article  PubMed  Google Scholar 

  53. Choi CI, Park KC, Lee TH, Hong YK. Recurrence rates in pediatric patients undergoing microsurgical subinguinal varicocelectomy with and without testicular delivery. J Pediatr Surg. 2017;52(9):1507–10.

    Article  PubMed  Google Scholar 

  54. Nabi G, Asterlings S, Greene DR, Marsh RL. Percutaneous embolization of varicoceles: outcomes and correlation of semen improvement with pregnancy. Urology. 2004;63(2):359–63.

    Article  CAS  PubMed  Google Scholar 

  55. Allameh F, Hasanzadeh Haddad A, Abedi A, et al. Varicocelectomy with primary gubernaculum veins closure: a randomised clinical trial. Andrologia. 2018;50(4):e12991.

    Article  Google Scholar 

  56. Hou Y, Zhang Y, Zhang Y, Huo W, Li H. Comparison between microsurgical subinguinal varicocelectomy with and without testicular delivery for infertile men: is testicular delivery an unnecessary procedure. Urol J. 2015;12(4):2261–6.

    PubMed  Google Scholar 

  57. Spinelli C, Strambi S, Busetto M, et al. Microsurgical inguinal varicocelectomy in adolescents: delivered versus not delivered testis procedure. Can J Urol. 2016;23(2):8254–9.

    PubMed  Google Scholar 

  58. Mehta A, Hsiao W, King P, Schlegel PN. Perioperative celecoxib decreases opioid use in patients undergoing testicular surgery: a randomized, double-blind, placebo controlled trial. J Urol. 2013;190(5):1834–8.

    Article  CAS  PubMed  Google Scholar 

  59. Al Bakri A, Lo K, Grober E, Cassidy D, Cardoso JP, Jarvi K. Time for improvement in semen parameters after varicocelectomy. J Urol. 2012;187(1):227–31.

    Article  PubMed  Google Scholar 

  60. Rotker K, Sigman M. Recurrent varicocele. Asian J Androl. 2016;18(2):229–33.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Amelar RD. Early and late complications of inguinal varicocelectomy. J Urol. 2003;170(2. Pt 1):366–9.

    Article  PubMed  Google Scholar 

  62. Grober ED, Chan PT, Zini A, Goldstein M. Microsurgical treatment of persistent or recurrent varicocele. Fertil Steril. 2004;82(3):718–22.

    Article  PubMed  Google Scholar 

  63. Abboudi H, Khan MS, Guru KA, et al. Learning curves for urological procedures: a systematic review. BJU Int. 2014;114(4):617–29.

    Article  PubMed  Google Scholar 

  64. Sroka G, Feldman LS, Vassiliou MC, Kaneva PA, Fayez R, Fried GM. Fundamentals of laparoscopic surgery simulator training to proficiency improves laparoscopic performance in the operating room-a randomized controlled trial. Am J Surg. 2010;199(1):115–20.

    Article  PubMed  Google Scholar 

  65. Mehta A, Li PS, Goldstein M. Male infertility microsurgical training. Translational Androl Urol. 2014;3(1):134–41.

    Google Scholar 

  66. Najari BB, Li PS, Ramasamy R, et al. Microsurgical rat varicocele model. J Urol. 2014;191(2):548–53.

    Article  PubMed  Google Scholar 

  67. Grober ED, Hamstra SJ, Wanzel KR, et al. Validation of novel and objective measures of microsurgical skill: hand-motion analysis and stereoscopic visual acuity. Microsurgery. 2003;23(4):317–22.

    Article  PubMed  Google Scholar 

  68. Grober ED, Hamstra SJ, Wanzel KR, et al. The educational impact of bench model fidelity on the acquisition of technical skill: the use of clinically relevant outcome measures. Ann Surg. 2004;240(2):374–81.

    Article  PubMed  PubMed Central  Google Scholar 

  69. Wang Z, Ni Y, Zhang Y, Jin X, Xia Q, Wang H. Laparoscopic varicocelectomy: virtual reality training and learning curve. JSLS. 2014;18(3):e2014.00258.

    Article  PubMed  PubMed Central  Google Scholar 

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Source of Funding

Frederick J. and Theresa Dow Wallace Fund of the New York Community Trust, the Mr. Robert S. Dow Foundation; Irena and Howard Laks Foundation.

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Authors and Affiliations

  1. Department of Urology, Weill Cornell Medicine, New York, NY, USA

    Russell P. Hayden & Marc Goldstein

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  1. Russell P. Hayden
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  2. Marc Goldstein
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Correspondence to Marc Goldstein .

Editor information

Editors and Affiliations

  1. ANDROFERT, Andrology & Human Reproduction Clinic, Campinas, São Paulo, Brazil

    Sandro C Esteves

  2. S.H. Ho Urology Centre, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong

    Chak-Lam Cho

  3. Department of Urology, Hamad Medical Corporation, Weill Cornell Medicine Qatar, Doha, Qatar

    Ahmad Majzoub

  4. Department of Urology, Cleveland Clinic, Cleveland, OH, USA

    Ashok Agarwal

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Demonstration of arterial identification through the partial occlusion test (M4V 977 kb)

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Hayden, R.P., Goldstein, M. (2019). Microscopic Surgical Techniques for Varicocele Repair. In: Esteves, S., Cho, CL., Majzoub, A., Agarwal, A. (eds) Varicocele and Male Infertility. Springer, Cham. https://doi.org/10.1007/978-3-319-79102-9_17

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  • DOI: https://doi.org/10.1007/978-3-319-79102-9_17

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