腹股沟下途径显微技术精索静脉输精管同时结扎1例报告并文献复习

目的：探讨显微技术下同时施行输精管和精索静脉结扎术的安全性和有效性.方法：患者,39岁,因计划生育政策需行输精管结扎,患者合并双侧精索静脉曲张（右侧Ⅱ度,左侧Ⅰ度）以及右阴囊坠胀不适,显微技术下同时施行输精管和精索静脉结扎术.结果：1、3、6个月分别复诊,患者无阴囊不适感;触诊以及阴囊超声未见阴囊及其内容物水肿征象,右侧精索静脉无曲张复发,无睾丸萎缩.3个月辅助检查精液中无精子.结论：显微技术下同时施行输精管结扎和精索静脉结扎术,既保护淋巴管、睾丸动脉,又可以明确保留输精管脉管系统的完整性,保证了睾丸的充分的静脉回流,安全、有效.     

Intraoperative varicocele anatomy: a macroscopic and microscopic study.

Varicoceles are found in approximately 15% of all men in the general population and up to 41% of all infertile men. However, the exact location and relationship of internal and external spermatic arteries, veins and lymphatics within the inguinal portion of the spermatic cord have not been previously well described in infertile men. The results of detailed intraoperative macroscopic and microscopic surgical dissections of the spermatic cord and gubernaculum of 83 infertile men with 115 palpable varicoceles are described. Enlarged veins exiting the testis and traversing the gubernaculum were present in 48% of the dissections. Enlarged external spermatic veins were detected in 74% of all spermatic cords. Typically, small internal spermatic veins drained into a large vein more proximally in the spermatic cord. An average of 3.6 lymphatics per spermatic cord was identified and preserved during the dissections. A solitary testicular artery was observed in 69% of the dissections. The testicular artery was adherent to the posterior surface of a large internal spermatic vein in 50% of the dissections and was surrounded by a dense complex of closely adherent veins in 30%. To decrease the incidence of postoperative varicocele recurrences we suggest a surgical approach that addresses all identifiable dilated and connecting veins. These findings suggest that surgical approaches that include intraoperative access to and ligation of low inguinal (external spermatic) and gubernacular veins may cause fewer recurrences, unligated small internal spermatic veins may be a cause of varicocele recurrence, and large internal spermatic veins should be individually identified, dissected and ligated since the testicular artery and lymphatics are often adherent to these veins. Optical magnification is important to facilitate identification of lymphatics, testicular arteries and small internal spermatic veins.     

Microsurgical inguinal varicocelectomy with delivery of the testis: an artery and lymphatic sparing technique.

Conventional techniques of varicocele repair are associated with substantial risks of hydrocele formation, ligation of the testicular artery, and varicocele recurrence. We describe a microsurgical technique of varicocelectomy that significantly lowers the incidence of these complications. The testicle is delivered through a 2 to 3 cm. inguinal incision, and all external spermatic and gubernacular veins are ligated. The testis is returned to the scrotum and the spermatic cord is dissected under the operating microscope. The testicular artery and lymphatics are identified and preserved. All internal spermatic veins are doubly ligated with small hemoclips or 4-zero silk and divided. The vas deferens and its vessels are preserved. Initially, we performed 33 conventional inguinal varicocelectomies in 24 men without delivery of the testis or use of a microscope. Postoperatively, 3 unilateral hydroceles (9%) and 3 unilateral recurrences (9%) were detected. For the next 12 cases 2.5x loupes were used resulting in no hydroceles but another recurrence (8%). We then performed 640 varicocelectomies in 429 men using the microsurgical technique with delivery of the testis. Among 382 men available for followup examination from 6 months to 7 years postoperatively no hydroceles and no cases of testicular atrophy were found. A total of 4 unilateral recurrent varicoceles (0.6%) was identified. The differences between the techniques in the incidence of hydrocele formation and varicocele recurrence are highly significant (p < 0.001). No wound infections occurred in any men. Four scrotal hematomas (0.6%), 1 of which required surgical drainage, occurred in the group with microsurgical ligation and delivery of the testis compared to none with the conventional technique. Preoperative and postoperative semen analyses (mean 3.57 analyses per patient) were obtained on 271 men. The changes in sperm count x 10(6) cc (36.9 to 46.8, p < 0.001), per cent motility (39.6 to 45.7%, p < 0.001) and per cent normal forms (48.4 to 52.10%, p < 0.001) were highly significant. The pregnancy rate was 152 of 357 couples (43%) followed for a minimum of 6 months postoperatively. Delivery of the testis through a small inguinal incision provides direct visual access to all possible avenues of testicular venous drainage. The operating microscope allows identification of the testicular artery, lymphatics and small venous channels. This minimally invasive, outpatient technique results in a significant decrease in the incidence of hydrocele formation, testicular artery injury and varicocele recurrence.     

Anatomy of the spermatic venous plexus (pampiniform plexus) in men with and without varicocele: intraoperative venographic study.

Venous anatomy of the testis was reexamined by retrograde spermatic venography during surgery in 17 men with and in 11 without a varicocele. The route of venous drainage of the testis was the internal spermatic vein and the external pudendal vein. The cremasteric and vasal veins were smaller collaterals. There was no cross communication between the right and left spermatic venous systems in the scrotal, retropubic or pelvic areas. In men with a varicocele the spermatic venous plexus was formed of numerous venous sinuses and large dilated veins.     

Macroscopic and microsurgical varicocelectomy: what’s the intraoperative difference?

Purpose

Many authors reported that microsurgical varicocelectomy was among the best treatment modalities for varicocele. However, the difference in intraoperative anatomic detail between macroscopic and microsurgical varicocele repair in the same spermatic cord has not been critically discussed.

Methods

Between August 2010 and February 2011, 32 men with 42 sides’ grade 2–3 varicocele were enrolled in this study. One surgeon firstly mimicked the modified open varicocelectomy by identifying, isolating, and marking the presumed internal spermatic veins, lymphatics, and arteries. Another surgeon then checked the same spermatic cord using operating microscope to investigate the number of missed veins, to be ligated lymphatics and arteries in the “imitative” open varicocelectomy.

Results

There were significant differences in the average number of internal spermatic arteries (1.67 vs. 0.91), internal spermatic veins (6.45 vs. 4.31), and lymphatics (2.93 vs. 1.17) between microscopic and macroscopic procedure (P < 0.001, P < 0.001, P < 0.001, respectively). Meanwhile, an average of 2.14 ± 1.26 internal spermatic veins was missed; among them, 1.63 ± 1.32 internal spermatic veins adherent to the preserved testicular artery were overlooked. The number of 0.69 ± 0.84 lymphatics and 0.74 ± 0.74 arteries were to be ligated in “macroscopic varicocelectomy.” A number of 1.07 ± 1.11 lymphatics were neither identified nor ligated. In addition, in 2 cases, the vasal vessels of the vas deferens were to be ligated at macroscopic procedure.

Conclusions

Microsurgical varicocelectomy could preserve more internal spermatic arteries and lymphatic and ligate more veins which may interpret the superiority of microsurgical varicocele repair.     

Modified high varicocelectomy: outpatient microsurgical procedure

Fifty patients underwent modified high varicocelectomy as outpatients. Twelve of the 22 unilateral varicocelectomies were performed under local anesthesia. All patients tolerated the procedures well, and none required admission to the hospital. The modified high approach, which exposes the area above the internal inguinal ring and of the posterior spermatic cord, is straightforward and insures that both internal spermatic and cremasteric veins can be ligated. Use of the operating microscope prevents the inadvertent ligation of the testicular artery and lymphatics.     

Microanatomy of the spermatic cords during microsurgical inguinal varicocelectomy: initial experience in Asian men

The microanatomy of the inguinal spermatic cords has never been reported in Asia. The purpose of this study was to describe the number and relationship of the veins, arteries and lymphatics in the spermatic cord and to clarify the location of the vas deferens in Asian men. Fifty-one patients receiving 79 primary microsurgical varicocelectomies performed by a single surgeon from April 2011 to July 2012 were studied. The number of internal and external spermatic veins, testicular arteries and lymphatic channels preserved during the inguinal microsurgical varicocelectomy were recorded. The relationship between the right and left vascular anatomy during bilateral varicocelectomies was evaluated. The data showed that mean numbers of 1.5±0.9 arteries, 5.6±2.2 spermatic veins and 3.6±1.9 lymphatics were identified during the repairs. The internal spermatic arteries were surrounded by a dense complex of adherent veins in 81.2% of the cases. The external spermatic vein or veins were found in 60.8% of the cases. The vas deferens may be contained within the internal spermatic fascia. The results suggest that the number of veins may be highly variable and less than those reported in the English literature, but there is some similarity in the inguinal microanatomy of the right and left spermatic cords. Further research is warranted to clarify our results.     

Mapping testicular blood supply in gubernaculum-sparing second-stage Fowler–Stephens procedure

Background

Testicular survival following second-stage Fowler–Stephens (FS) procedure depends upon adequate arterial supply. There is evidence that testicular survival rates are greater following gubernaculum-sparing second-stage FS procedure. The importance of collateral vessels in preservation of the testis has been hypothesised, but never shown in the literature. We aim to map the collateral blood supply to the testicle in gubernaculum-sparing, laparoscopic-assisted, second-stage FS procedure for intra-abdominal testicles.

Methods

Selected patients undergoing a second-stage FS procedure were photographed prior to pexy in the Dartos pouch. Photographs were evaluated for the extent of vascular collateralisation between gubernacular, deferential and the ligated spermatic artery.

Research

Twenty-five patients with 28 undescended testicles underwent staged FS procedure over a 7.5-year period between 2005 and April 2013. Mean age at operation was 2.44 years, and all testicles were delivered to the scrotum. Mean follow-up was 3.29 years, and all patients were reviewed by the operating consultant. Testicular survival rate was 100 %. Representative photographs clearly demonstrate substantial cremasteric vessels running along the gubernaculum with robust collateralisation to the deferential vessel and the spermatic arterial stump.

Conclusion

These images confirm the presence of robust collateral between the cremasteric and deferential vessels at second-stage FS procedure. Preservation of these collaterals in a gubernaculum-sparing approach may explain the excellent results seen in this series.     

Low inguinal approach for correction of recurrent varicocele

The purpose of this study was to evaluate the efficacy of low inguinal (or subinguinal) approach in the treatment of recurrent of persistent varicocele after surgical treatment. Recurrent varicocele was diagnosed in 23 patients who previously underwent surgical treatment. The technique used consisted of low inguinal incision at the level of the external inguinal ring without opening the external oblique aponeurosis. External spermatic veins (cremasteric veins) were dissected and selectively ligated. Then the spermatic fascia was incised and the internal spermatic veins were identified and ligated individually. Postoperative radioisotope scan, scrotal examination and sperm analysis were used for treatment evaluation. Twenty-one (91.3%) had negative postoperative scan and no signs of varicocele on physical examination. A marked improvement of sperm analysis was noted in 19 patients (p<0.05), while two had only minor improvement. Two patients had positive postoperative scans without improvement of semen analysis. Neither atrophy nor azoospermia were detected on follow-up examination in any of these men, however, one patient developed hydrocele. This study indicates a good surgical outcome and improvement of semen quality without significant complications.     

Loupe-assisted versus microscopic varicocelectomy： s there an intraoperative anatomic difference？

The aim of this study was to compare the intraoperative difference in anatomic details between Ioupe-assisted and microscopic varicocelectomy within the same spermatic cord. Between April 2011 and August 2011, 26 men with 33 sides containing grade 2-3 varicocele were enrolled in this study. First, one surgeon performed the open inguinal varicocelectomy under x 3.5 Ioupe magnification. The presumed vascular channels and lymphatics were isolated and marked without ligation. Another surgeon then microsurgically dissected and checked the same spermatic cord using an operating microscope to judge the results in terms of the ligation of the internal spermatic veins and the preservation of the arteries and lymphatics. There were significant differences in the average number of internal spermatic arteries （1.51 vs 0.97）, internal spermatic veins （5.70 vs 4.39） and lymphatics （3.52 vs 1.61） between the microscope and Ioupe-assisted procedures （P 〈 0.001, P 〈 0.001, P 〈 0.001, respectively）. Meanwhile, in varicocele repair with Ioupe magnification, an average of 1.30 β± 1.07 （43/33） internal spermatic veins per side were missed, among the overlooked veins, 1.12 ± 0.93 （37/33） were adhered to the preserved testicular artery, as well as 0.55 ± 0.79 lymphatics and 0.36 ± 0.55 arteries that were to be ligated. In conclusion, microscopic varicocelectomy could preserve more internal spermatic arteries and lymphatics and could ligate more veins than the Ioupe-assisted procedure. To some degree, Ioupe magnification is inadequate for the reliable identification and dissection of the tiny vessels of the spermatic cord, as most of the overlooked veins were adhered to the preserved testicular artery.     

Varicocele anatomy during subinguinal microsurgical varicocelectomy in Chinese men

Knowledge of subinguinal microsurgical varicocelectomy is of fundamental importance to ensure that varicocele is resolved and testicular function is preserved. Our study aimed to describe the number of veins, arteries and lymphatics in the subinguinal spermatic cord and to clarify their differences between two sides, between patients with different complaints and between varicoceles with different clinical grades. A total of 102 consecutive patients underwent 162 primary subinguinal microsurgical varicocelectomies, during which the number of vessels with different diameters was recorded. A mean number of 12.9 internal spermatic veins, 0.9 external spermatic veins, 1.8 internal spermatic arteries and 2.9 lymphatics were identified per cord. 88.2% of the internal spermatic arteries were surrounded by a dense complex of adherent veins. The external spermatic vein or veins were found in 49.4% of the cases. The mean number of medium (1–3 mm in diameter) internal spermatic veins on the left was larger than that on the right (P < 0.001). The mean number of medium internal spermatic veins in grade III varicocele was larger than that in grade I or grade II (P < 0.015). There was no significant anatomical difference between the men presenting for infertility, chronic testicular pain and both the two complaints.     

Torsion of an intra-abdominal testis

To present a case of torsion of a nonneoplastic intra-abdominal testis with an unusual clinical presentation.A 26-year-old active duty Navy Petty Officer presented to the emergency department on 3 occasions over a 5-day period with lower abdominal pain. Physical examination demonstrated acute tenderness in the left lower quadrant with sugestion of a normal spermatic cord and atrophic testis in the left scrotum. Computed tomography scan demonstrated an intra-abdominal lesion near the internal inguinal ring. The patient underwent surgical exploration through an inguinal incision. Torsion of a nonviable intra-abdominal testis was present. The scrotum contained only the vas deferens and cremasteric muscle. An orchiectomy was performed with removal of the vas deferens and other cord structures.The unusual clinical finding of acute torsion of an intra-abdominal testis, associated with an apparent atrophic scrotal testis, presented a confusing clinical picture. Computed tomography scan did not clarify the issue sufficiently to establish a definite preoperative diagnosis. Clinical suspicion prompted early surgical intervention. Review of the current literature produced 60 reported cases of torsion of an intra-abdominal testis. Two thirds of these involved testicular neoplasm, usually seminoma. Although the clinical presentation varied, most patients had recent onset of lower abdominal pain associated with tenderness and, in half the cases, a mass. Patients almost always presented with an absent scrotal testis on the involved side, and not infrequently reported previous surgery thought to be an orchiectomy.Diagnosis of an intra-abdominal testicular torsion is rare, particularly when no neoplasm is present. A high index of suspicion must be maintained whenever there is abdominal pain and undescended testis. The surgical history and imaging studies may not clarify a confusing clinical picture.     

Optical magnification and Doppler ultrasound probe for varicocelectomy

Varicocelectomy is usually considered a simple urologic operation. However, it is most frequently difficult to visualize and identify the 0.5 mm internal spermatic artery and tiny lymphatic channels when cutting and ligating the internal spermatic veins. The internal spermatic artery and tiny lymphatic channels can be damaged easily, cut, or ligated during this procedure. This occurs surprisingly more often than is realized by the surgeon. By introducing optical magnification or the operating microscope at the time the veins are identified, the surgeon can easily find and dissect off adherent lymphatics or the internal spermatic artery with some microsurgical instruments, and thereby preserve these vessels rather than cut or damage them inadvertently. The sterile Doppler probe also can be utilized to help identify and confirm the location of the internal spermatic artery if it is not easily found in the spermatic cord.     

Scrotal nubbins associated with blind-ending spermatic vessels and a normal vas deferens on laparoscopy

Objectives:   To determine whether a scrotal nubbin is present in children with unilateral non-palpable testis when diagnostic laparoscopy demonstrates blind-ending vessels and a normal vas deferens entering a closed internal ring.
Methods:   Eighty consecutive patients with a unilateral nonpalpable testis were retrospectively reviewed. Patients underwent initial diagnostic laparoscopy, and, if needed, subsequent inguinal exploration was performed. On inguinal exploration, any testicular remnant or nubbin-like tissue was removed and evaluated histologically. Patients with a patent processus vaginalis were excluded from this analysis.
Results:   Overall, 60 of the 80 patients had neither an abdominal testis nor a patent processus vaginalis. Of these 60, 34 patients had both a vas deferens and spermatic vessels entering a closed internal ring, and all of these underwent inguinal exploration. A total of 17 patients had both a blind-ending vas deferens and blind-ending spermatic vessels; no inguinal exploration was attempted. In nine patients, laparoscopy revealed blind-ending vessels with a normal vas deferens entering the closed internal ring. Of these nine, six underwent inguinal exploration, and a scrotal nubbins was found in three. At histological examination, hemosiderin deposit and calcification were seen in the nubbin tissue. No viable germ cell was detected in these specimens.
Conclusions:   A laparoscopic finding of blind-ending vessels above the closed internal ring does not mean intra-abdominal vanished testis, regardless of the appearance of the vas deferens.     

经外环口以下途径显微镜下精索静脉结扎术治疗精索静脉曲张术后复发的疗效分析

目的:分析精索静脉曲张(VC)术后复发的病因,探讨经外环口以下途径显微镜下精索静脉结扎术(MV)治疗复发VC的疗效。方法:回顾性分析2015年4月至2019年4月青岛大学附属医院收治的16例VC术后复发患者的病例资料。中位年龄27(18～36)岁。5例既往曾行精索内静脉高位结扎术,11例曾行腹腔镜精索静脉结扎术;16例...     

Avoidance of inguinal incision in laparoscopically confirmed vanishing testis syndrome

PURPOSE: Nonpalpable testicles may be due to the vanishing testis syndrome, intra-abdominal position, examination obscured by obesity or scar tissue and rarely testicular agenesis. Laparoscopy is an excellent means of distinguishing these entities without the need for open abdominal exploration. We investigated whether laparoscopy affects the need for an inguinal incision and exploration when no testicle is palpable and the vas and vas deferens are visualized exiting the internal inguinal ring on laparoscopy. MATERIALS AND METHODS: In 34 boys 6 to 18 months old (mean age 41) physical examination demonstrated a nonpalpable testicle, including on the right side in 12, on the left side in 17 and bilaterally in 5. The vanishing testis syndrome was diagnosed after laparoscopy when no testicle was palpable despite physical examination done with the patient under anesthesia, spermatic vessels were visualized exiting the internal inguinal ring or spermatic vessels were visualized in the abdomen with or without an identifiable intra-abdominal testicular nubbin. RESULTS: Laparoscopy confirmed the vanishing testis syndrome in 16 patients, intra-abdominal testicles in 13 and peeping testes in 1. Adequate examination using anesthesia was not possible in 4 patients with obesity, or previous inguinal or lower abdominal surgery. These boys underwent inguinal exploration after laparoscopy showed the vas and vessels exiting a closed internal inguinal ring. Of the 16 cases of the vanishing testis syndrome orchiectomy with contralateral scrotal orchiopexy was performed in 14 through a median raphe scrotal incision and in 1 through an inguinal incision for an associated inguinal hernia. In the remaining patient who underwent laparoscopy only a blind ending vas and vessels were visualized in the abdomen without an identifiable nubbin. The infraumbilical and median raphe incisions healed without obvious scars. Followup was at least 1 year. CONCLUSIONS: When spermatic vessels are visualized exiting the internal inguinal ring on laparoscopy in the setting of a nonpalpable testicle, a median raphe scrotal incision can be made to remove the testicular nubbin associated with the vanishing testicle syndrome. Orchiectomy is possible through this median raphe incision even when the testicle is in the inguinal canal because this distance in young children is small. Cosmesis is excellent since 1 incision is within the umbilicus and the other is on the median scrotal raphe.     

Comprehensive laparoscopic approach to pediatric varicocele based on preoperative color Doppler ultrasound assessment

Background This study aimed to assess whether laparoscopic treatment for any kind of varicocele is possible after preoperative identification of refluxing veins by color Doppler ultrasound (CDUS). Methods At the authors’ institution, 98 patients with a median age of 11.3 years (range, 7.1–16 years) were evaluated for a left varicocele. Preoperatively, all the patients underwent ultrasound scan assessment of testicular volume and CDUS to rule out reflux into the internal spermatic vein (ISV), deferential vein, or cremasteric vein. In all the patients, laparoscopic division of the spermatic artery and veins was performed as close as possible to the internal inguinal ring. The other vessels were coagulated and divided if shown to be refluxing on CDUS. Results Color Doppler ultrasound showed reflux only in the ISV in 87 cases (88.7%), but in both the ISV and the deferential in the remaining 11 cases (11.2%). During a median follow-up period of 18 months (range, 6–49 months), none of the authors’ patients experienced varicocele recurrence either clinically or according to CDUS scanning. The median left testicular volume increased significantly postoperatively. Conclusion The proposed technique based on laparoscopic interruption of the ISV and testicular artery very close to the internal inguinal ring, meticulous CDUS assessment to rule out reflux in the deferential vein, and coagulation of refluxing deferential veins allows successful laparoscopic treatment of most varicoceles.     

Efficacy of Indocyanine Green Angiography on Microsurgical Subinguinal Varicocelectomy

Objectives: Microsurgical subinguinal varicocelectomy is one of the best treatment modalities for varicoceles related to male infertility and scrotal pain. However, the difficulty in identifying testicular arteries, which should be spared, is a limitation of this technique. To visualize and identify the testicular arteries in spermatic cord during the operation, we examined the efficacy of intraoperative indocyanine green angiography (ICGA), which is regularly used in microsurgical neurosurgery. Methods: After the exposure of the spermatic cord blood vessels, ICG was injected intravenously under a surgical microscope for observing infrared fluorescence in patients to identify and isolate the testicular artery. Results: The testicular artery was clearly identified by ICGA and was able to separate under ICGA view. Thereafter, the varicose veins were repeatedly ligated, while preserving a few lymphatic vessels and the spermatic duct. The preserved arteries were confirmed by repeated ICGA at the end of microsurgical operation. The number of arteries identified by ICGA was greater than the number detected by preoperative computed tomography angiogram. Conclusions: Microsurgical subinguinal varicocelectomy using intraoperative ICGA facilitated safe and quick surgery by enabling the visualization of the spermatic cord blood vessels. This is the first report to indicate the usefulness of vessel visualization by ICGA during microsurgical subinguinal varicocelectomy.     

Doppler sonography and phlebography in the detection of hemodynamically different varicocele types

Using the bidirectional doppler sonography to evaluate patients with varicocele two haemodynamically different types of varicoceles, pressure-type and shunt-type, can be determined. By means of retrograde phlebography of the internal spermatic vein (testicular vein) in 44 patients with varicocele the pathophysiologic-anatomic equivalent of these two types could be demonstrated. Shunting veins are the cremasteric vein and deferential vein. The two types of varicoceles have a different effect on male fertility.