The Evolution and Refinement of Varicocele Treatment: A Historical Perspective

  • Joel L. Marmar


Varicoceles were identified in men since antiquity because these lesions were visible, palpable and painful. The earliest surgical repairs were reported in the first century AD because of pain, and the first to nineteenth centuries were referred to as the “Pain Era.” The initial surgeries were limited to the scrotum, and they included ligation of the enlarged veins within the scrotum plus cautery of the veins on the outer wall of the scrotum. In 1677, the microscope was invented, and one of the earliest discoveries with this instrument was the finding of sperm in the semen. However, it was not until the nineteenth century before investigators began to study the semen of infertile men with varicoceles. It became apparent that men with varicoceles often had lower sperm counts, but the cause of the decrease was unclear. Some early investigators suggested excess testicular heat, and new surgical procedures were introduced to reduce the length of the scrotum to aid testicular support and scrotal cooling. In the late nineteenth century, several surgeons introduced inguinal approaches for hernia repairs, and soon these approaches were adopted for the treatment of varicoceles. With these types of exposures, surgeons were able to study the spermatic cords and the distribution of the spermatic arteries and veins. Soon, inguinal/supra inguinal approaches were used for varicocele surgery, but there were still reports of post varicocelectomy failures, post-op hydroceles and cases of testicular atrophy. In 1957, a dramatic event occurred. The “Fertility Era” began when a patient with azoospermia and a varicocele had a varicocelectomy. Soon thereafter, he produced sperm and had a child. Subsequently, other studies revealed that many men with varicoceles had low sperm densities and more of these men began to have varicocele surgery for infertility. Venography became available, and it documented retrograde blood flow into the internal spermatic veins of men with varicoceles. In addition, the pathophysiology of varicoceles was studied in humans and animal models. Some important semen findings revealed sperm DNA damage, reactive oxygen species (ROS) in the semen of infertile men with varicoceles, and changes in semen proteomics, etc. In addition, a variety of new procedures were developed to treat these lesions. They included venography and embolization of internal spermatic veins, microsurgical repairs, laparoscopy, robotic surgery, etc. The history of these advancements will be reported in Chap. 1, and more extensive scientific details will be covered in the other chapters of this book.


History of varicoceles Pain Era Fertility Era Varicocelectomy procedures Pathophysiology of varicoceles 


  1. 1.
    Fretz PC, Sandlow JI. Varicocele: current concepts in pathophysiology, diagnosis, and treatment. Urol Clin North Am. 2002;29:921.CrossRefGoogle Scholar
  2. 2.
    Noske H-D, Weidner W. Varicocele- a historical perspective. World J Urol. 1999;17:151.CrossRefGoogle Scholar
  3. 3.
    Marte A. The history of varicocele: from antiquity to the modern ERA. Int Braz J Urol. 2018;44(3):563–76.CrossRefGoogle Scholar
  4. 4.
    Marmar JL. The evolution and refinements of varicocele surgery. Asian J Androl. 2016;18:171–8.CrossRefGoogle Scholar
  5. 5.
    Amelar R. Hotchkiss and MacLeod: an historical perspective. J Androl. 2006;27:494–501.CrossRefGoogle Scholar
  6. 6.
    Rothman CM. The varicocele 1800. Urology. 1980;15:99–100.CrossRefGoogle Scholar
  7. 7.
    Cooper SA. Observations on the structure and disease of the testis. 2nd ed. Phildelphia: Lea & Blanchard; 1895, Chapter 18, P239, Varicocele.Google Scholar
  8. 8.
    Anthony van Leeuwenhock. Letter of June 1716 to Royal College of Surgeons, City of London, UK.Google Scholar
  9. 9.
    Androutsos G, Karamanou M, Pappa KI, Poulakou-Rebelakou E. The specialist in testicular diseases, Thomas Blizzard Curling (1811–1888), and his method of treatment of varicocele, among other methods of treatment in the 19th century. Andrologia. 2011;21:90–8.Google Scholar
  10. 10.
    Tan WP, Lavu H, Rosato EL, Yeo CJ, Cowan SW. Edoardo Bassini (1844–1924): father of modern-day hernia surgery. Am Surg. 2013;11:1131–3.Google Scholar
  11. 11.
    Narath A. Zur radical operation der varikocele. Wein Klin Wochenschrift. 1900;13:73–9.Google Scholar
  12. 12.
    Ivanissevich O. Left varicocele due to reflux; experience with 4,470 operative cases in forty-two years. J Int Coll Surg. 1960;34:742–55.PubMedGoogle Scholar
  13. 13.
    Palomo A. Radical cure of varicocele by a new technique. Preliminary report. J Urol. 1949;61:604–7.CrossRefGoogle Scholar
  14. 14.
    MacLeod J, Hotchkiss RS. Semen analysis in 1,500 cases of sterile marriage. Am J Obstet Gynecol. 1946;52:34–41.CrossRefGoogle Scholar
  15. 15.
    Tulloch WS. Consideration of sterility factors in the light of subsequent pregnancies. II Sub fertility in the male. (Tr. Edinburgh Obst. Soc. Session 104). Edinb Med J. 1951-1952;59:29–34.PubMedGoogle Scholar
  16. 16.
    Robb WA. Operative treatment of varicocele. Br Med J. 1955;2:355–6.CrossRefGoogle Scholar
  17. 17.
    Charny CW, Conston AS, Meranze DR. Development of the testis; a histologic study from birth to maturity with some notes on abnormal variations. Fertil Steril. 1952;3:461–79.CrossRefGoogle Scholar
  18. 18.
    Clavijo RI, Carrasquillo R, Ramasamy R. Varicoceles: prevalence and pathogenesis in adult men. Fertil Steril. 2017;108:364–9.CrossRefGoogle Scholar
  19. 19.
    Dubin L, Amelar R. Varicocele size and results of varicocelectomy in selected subfertile men with varicoceles. Fertil Steril. 1970;21:606–9.CrossRefGoogle Scholar
  20. 20.
    Dubin L, Amelar R. Varicocelectomy as therapy in male infertility: a study of 504 cases. Fertil Steril. 1975;26:217–20.CrossRefGoogle Scholar
  21. 21.
    Brown JS, Dubin L, Hotchkiss RS. The varicocele as related to fertility. Fertil Steril. 1967 Jan-Feb;18(1):46–56.CrossRefGoogle Scholar
  22. 22.
    Zorgniotti AW, MacLeod J. Studies in temperature, human semen quality and varicocele. Fertil Steril. 1973;24:854–63.CrossRefGoogle Scholar
  23. 23.
    Zorgniotti AW, Sealfon AI. Scrotal hypothermia: new therapy for poor semen. Urology. 1984;23:439–41.CrossRefGoogle Scholar
  24. 24.
    Ahlberg NE, Bartley O, Chidekel N, Fritjofsson A. Phlebography in varicocele scroti. Acta Radiol Diagn. 1966;4:517–28.CrossRefGoogle Scholar
  25. 25.
    Comhaire F, Kunnen M. Selective retrograde venography of the internal spermatic vein: a conclusive approach to the diagnosis of varicocele. Andrologia. 1976;8:11–24.CrossRefGoogle Scholar
  26. 26.
    Lima SS, Castro MP, Costa OF. A new method for the treatment of varicoceles. Andrologia. 1978;10:103–6.CrossRefGoogle Scholar
  27. 27.
    Kunnen M. New techniques for embolization of the internal spermatic vein: intravenous tissue adhesive (author’s translation- German). Rofo. 1980;133:625–9.Google Scholar
  28. 28.
    Comhaire FH, Kunnen M. Factors affecting the probability of conception after treatment of subfertile men with varicocele by transcatheter embolization with bucrylate. Fertil Steril. 1985;43:781–6.CrossRefGoogle Scholar
  29. 29.
    Fernández Aparicio T, Miñana López B, Pamplona M, Aguirre F, Carrero V, Caballero J, Alvarez E, Leiva O. Complications of varicocele embolization: adhesion of the intravascular catheter during infusion of Bucrylate. Actas Urol Esp. 1994;18:141–4.PubMedGoogle Scholar
  30. 30.
    Morag B, Rubenstein ZJ, Madgar I, Lunenfeld B. The role of spermatic venography after surgical high ligation of the left spermatic veins: diagnosis and percutaneous occlusion. Urol Radiol. 1985;7:32–4.CrossRefGoogle Scholar
  31. 31.
    Walsh PC, White RI. Balloon occlusion of the internal spermatic vein for treatment of varicoceles. JAMA. 1981;246:1701–22.CrossRefGoogle Scholar
  32. 32.
    Comhaire F. Scrotal thermography in patients with varicocele. Contracept Fertil Sex. 1977;5:561–5.Google Scholar
  33. 33.
    Comhaire F. Scrotal thermography in varicocele. Adv Exp Med Biol. 1991;286:267–70.CrossRefGoogle Scholar
  34. 34.
    Zorgniotti AW, Sealfon AI, Toth A. Further clinical experience with testis hypothermia for infertility due to poor semen. Urology. 1982;19:636–40.CrossRefGoogle Scholar
  35. 35.
    Osman MW, Nikolopoulos L, Haoula Z, Kannamannadiar J, Atiomo W. A study of the effect of the FertilMate™ Scrotum Cooling Patch on male fertility. SCOP trial (scrotal cooling patch) - study protocol for a randomized controlled trial. Trials. 2012;13:47.CrossRefGoogle Scholar
  36. 36.
    Rifkin MD, Foy PM, Kurtz AB, Pasto ME, Med GBBJU. The role of diagnostic ultrasonography in varicocele evaluation, vol. 2; 1983. p. 271–5.Google Scholar
  37. 37.
    Bagheri SM, Khajehasani F, Iraji H, Fatemi I. A novel method for investigating the role of reflux pattern in color Doppler ultrasound for grading of varicocele. Sci Rep. 2018;25:8, 651.Google Scholar
  38. 38.
    Galini M, Bagheri SM. Comparison of gray-scale sonography with Doppler evaluation in diagnosis of varicocele. Biom Phar J. 2016;9:781–5.CrossRefGoogle Scholar
  39. 39.
    Al-Juburi A, Pranikoff K, Dougherty KA, Urry RL, Cockett AT. Alteration of semen quality in dogs after creation of varicocele. Urology. 1979;13:535–9.CrossRefGoogle Scholar
  40. 40.
    Saypol DC, Howards SS, Turner TT, Miller EDJ. Influence of surgically induced varicocele on testicular blood flow, temperature, and histology in adult rats and dogs. J Clin Invest. 1981;68:39–45.CrossRefGoogle Scholar
  41. 41.
    Hurt GS, Howards SS, Turner TT. Repair of experimental varicoceles in the rat. Long-term effects on testicular blood flow and temperature and cauda epididymal sperm concentration and motility. J Androl. 1986;7:271–6.CrossRefGoogle Scholar
  42. 42.
    Turner TT, Caplis L, Miller DW. Testicular microvascular blood flow: alteration after Leydig cell eradication and ischemia but not experimental varicocele. J Androl. 1996;17:239–48.PubMedGoogle Scholar
  43. 43.
    Turner TT. The study of varicocele through the use of animal models. Hum Reprod Update. 2001;7:78–84.CrossRefGoogle Scholar
  44. 44.
    Krzysciak W, Kozka M. Generation of reactive oxygen species by a sufficient, insufficient and varicose vein wall. Acta Biochem Pol. 2011;58:89–94.Google Scholar
  45. 45.
    Santoro G, Romeo C. Normal and varicocele testis in adolescents. Asian J Androl. 2001;3:254–62.Google Scholar
  46. 46.
    Mostafa T, Anis T, El Nashar A, Imam H, Osman I. Seminal plasma reactive oxygen species-antioxidants relationship with varicocele grade. Andrologia. 2012;44:66–9.CrossRefGoogle Scholar
  47. 47.
    Showell MG, Mackenzie-Proctor R, Brown J, Yazdani A, Stankiewicz MT, Hart RJ. Antioxidants for male infertility. Cochrane Database Syst Rev. 2014;12:CD007411.Google Scholar
  48. 48.
    Garg H, Kumar R. An update on the role of medical treatment including antioxidant therapy in varicocele. Asian J Androl. 2016;18:222–8.CrossRefGoogle Scholar
  49. 49.
    Kroese AC, de Lange NM, Collins J, Evers JL. Surgery or embolization for varicoceles in sub fertile men. Cochrane Database Syst Rev. 2012;10:CD000479.Google Scholar
  50. 50.
    Zini A, Azhar R, Baazeem A, Gabriel MS. Effect of microsurgical varicocelectomy on human sperm chromatin and DNA integrity: a prospective trial. Int J Androl. 2011;34:14–9.CrossRefGoogle Scholar
  51. 51.
    Deepinder F, Cocuzza M, Agarwal A. Should seminal oxidative stress measurement be offered routinely to men presenting for infertility evaluation. Endocr Pract. 2008;14:484–91.CrossRefGoogle Scholar
  52. 52.
    Agarwal A, Bertolla RP, Samanta L. Sperm proteomics: potential impact on male infertility treatment. Expert Rev Proteomics. 2016;13:285–96.CrossRefGoogle Scholar
  53. 53.
    Agarwal A, Roychoudhury S, Sharma R, Gupta S, Majzoub A, Sabanegh E. Diagnostic application of oxidation-reduction potential assay for measurement of oxidative stress: clinical utility in male factor infertility. Reprod Biomed Online. 2017;34:48–57.CrossRefGoogle Scholar
  54. 54.
    Cho CL, Esteves SC, Agarwal A. Novel insights into the pathophysiology of varicocele and its association with reactive oxygen species and sperm DNA fragmentation. Asian J Androl. 2016;18:186–93.CrossRefGoogle Scholar
  55. 55.
    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;102:1556–60.CrossRefGoogle Scholar
  56. 56.
    Dohle GR, Colpi GM, Hargreave TB, Papp GK, Jungwirth A, Weidner W, EAU Working Group on Male Infertility. EAU guidelines on male infertility. Eur Urol. 2005;48:703–11.CrossRefGoogle Scholar
  57. 57.
    World Health Organization. In: 2nd ed, editor. WHO laboratory manual for the examination of human semen and sperm-cervical mucus interaction. Cambridge: Cambridge University Press; 1987.Google Scholar
  58. 58.
    World Health Organization. WHO manual for the examination and processing of human semen. 5th ed. Geneva: WHO Press; 2010.Google Scholar
  59. 59.
    Kruger T. Critical appraisal of conventional semen analysis in the context of varicocele. Asian J Androl. 2016;18:202–4.CrossRefGoogle Scholar
  60. 60.
    Silber SJ, Microsurgery e. Retroperitoneal and renal microsurgery. Baltimore: Williams and Wilkins Company; 1979. p. 468–9.Google Scholar
  61. 61.
    Woznitzer M, Roth JA. Optical magnification and Doppler ultrasound probe for varicocelectomy. Urology. 1983;22:24–6.CrossRefGoogle Scholar
  62. 62.
    Marmar JL, DeBenedictis TJ, Praiss D. The management of varicoceles by microdissection of the spermatic cord at the external inguinal ring. Fertil Steril. 1985;43:583–8.CrossRefGoogle Scholar
  63. 63.
    Marmar JL, Kim Y. Subinguinal microsurgical varicocelectomy: a technical critique and statistical analysis of semen and pregnancy data. J Urol. 1994;152:1127–32.CrossRefGoogle Scholar
  64. 64.
    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;66:1075–9.CrossRefGoogle Scholar
  65. 65.
    Goldstein M, Gilbert BR, Dicker AP, Dwosch J, Genecco C. Microsurgical inguinal varicocelectomy of the testis: an artery and lymphatic sparing technique. J Urol. 1992;148:1808.CrossRefGoogle Scholar
  66. 66.
    Ramasamy R, Schlegel PN. Microsurgical inguinal varicocelectomy with and without testicular delivery. Urology. 2006;68:1323–6.CrossRefGoogle Scholar
  67. 67.
    Tauber R, Johnsen N. Antegrade scrotal sclerotherapy for treatment of testicular varicocele. Technique and late results. Urologe A. 1993;32:320–6.PubMedGoogle Scholar
  68. 68.
    Goll A, Albers P, Schoeneich HG, Burger P. Testicular loss due to hemorrhagic infarct in Tauber antegrade scrotal varicocele sclerotherapy. Urologe A. 1997;36:449–51.CrossRefGoogle Scholar
  69. 69.
    Salerno S, Galia M, Bentivegna E, Lo CA. Radiol Med. Bilateral varicocele as a unique sign of azygos-hemiazygos continuation with an anomalous intrahepatic connection. A case report. Radiol Med. 1999;98:203–6.PubMedGoogle Scholar
  70. 70.
    Vicini P, Di Pierro GB, Grande P, Voria G, Antonini G, De Marco F, Di Nicola S, Gentile V. Large bowel infarct following antegrade scrotal sclerotherapy for varicocele: a case report. Can Urol Assoc J. 2014;81:822.Google Scholar
  71. 71.
    Tauber R, Pfeiffer D, Bruns T. Phlebography: why it is important to study radiological imaging of spermatic veins. Arch Ital Urol Androl. 2003;75:62–7.PubMedGoogle Scholar
  72. 72.
    Corcione F, Esposito C, Cuccurullo D, Settembre A, Miranda N, Amato F, Pirozzi F, Caiazzo P. Advantages and limits of robot-assisted laparoscopic surgery: preliminary experience. Surg Endosc. 2005;19:117–9.CrossRefGoogle Scholar
  73. 73.
    Shu T, Taghechian S, Wang R. Initial experience with robot-assisted varicocelectomy. Asian J Androl. 2008;10:146–8.CrossRefGoogle Scholar
  74. 74.
    Parekattil SJ, Gudeloglu A. Robotic assisted andrological surgery. Asian J Androl. 2013;15:67–74.CrossRefGoogle Scholar
  75. 75.
    Pathak P, Chandrashekar A, Hakky TS, Pastuszak W. Varicocele management in the era of in vitro fertilization/itracytoplasmic sperm injection. Asian J Androl. 2016;18:243–348.Google Scholar
  76. 76.
    Kohn TP, Kohn JR, Pastuszak AW. Varicocelectomy before assisted reproductive technology: are outcomes improved? Fertil Steril. 2017;108:385–91.CrossRefGoogle Scholar
  77. 77.
    Samplaski MK, Lo KC, Grober ED, Zini A, Jarvi KA. Varicocelectomy to “upgrade” semen quality to allow couples to use less invasive forms of assisted reproductive technology. Fertil Steril. 2017;108:609–12.CrossRefGoogle Scholar
  78. 78.
    Jacobson DL, Johnson EK. Varicoceles in the pediatric and adolescent population: threat to future fertility? Fert Steril. 108:3, 370.CrossRefGoogle Scholar
  79. 79.
    Chu DI, Zderic SA, Shulka AR, Srinivasan Tasian GE, Weiss DA, Long CJ, Canning DA, Kolon TF. The natural history of semen parameters in untreated asymptomatic adolescent varicocele patients: a retrospective cohort study. J Pediat Urol. 2017;77:1–5.Google Scholar
  80. 80.
    Sack B, Schafer M, Kurtz MP. The dilemma of adolescent varicoceles: do they really have to be done? Curr Urol Rep. 2017;18:38.CrossRefGoogle Scholar
  81. 81.
    Sirvent JJ, Bernat R, Navarro MA, Rodriguez Tolra J, Guspi R. Leydig cell in idiopathic varicocele. Eur Urol. 1990;17:257–61.CrossRefGoogle Scholar
  82. 82.
    Dabaja AA, Goldstein M. When is a varicocele repair indicated: the dilemma of hypogonadism and erectile dysfunction? Asian J Androl. 2016;18:213–6.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Joel L. Marmar
    • 1
    • 2
  1. 1.Cooper University HospitalCamdenUSA
  2. 2.Surgery/Urology, Cooper Medical School of Rowan UniversityCamdenUSA

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