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.     

Intratesticular varicocele: evaluation using grey scale and color Doppler ultrasound

Intratesticular varicocele is a rare condition with a variable clinical and ultrasound presentation. The purpose of this study was to evaluate the grey scale and color Doppler appearances of intratesticular varicocele (ITV). Herein we present seven new cases of intratesticular varicocele. From 2003 to 2005 we evaluated 342 patients referred to our department for routine andrological evaluation by scrotal color Doppler ultrasound. We detected seven entirely asymptomatic cases of ITV by use of grey scale ultrasound. In color Doppler sonography the patients showed retrograde blood flow, either spontaneously or during Valsalva manoeuvre. In all seven cases left side ITV with testicular volume disproportion between the right and left testis (2 ml) was found. Five patients had an extratesticular varicocele. In all patients the diameters of intratesticular vein were less than 2 mm. Intratesticular varicocele is a clinically occult lesion that may occur in association with extratesticular varicocele. Further investigations are needed to clarify its clinical significance, however, considering the temperature mediated damage on the affected testis, it is our opinion that all ITV must be considered for treatment even if an extratesticular varicocele is not present.     

Comparison of inguinal and laparoscopic approaches in the treatment of varicocele

To determine the pros and cons of inguinal and laparoscopic varix ligation techniques, we reviewed 53 patients who underwent inguinal (n=35) and laparoscopic (n=18) varicocelectomy at two centers. Intraoperative complications were not observed in either of the groups. There was 1 recurrence and 1 persistence in the laparoscopically treated patients. The inguinal approach had the advantage of shorter operating time (19.1 versus 52.8 min), ability to ligate the external spermatic veins, and it could be performed as an outpatient procedure. However, the laparoscopic approasch seemed superior for preserving the spermatic artery (88.8% versus 68.5%) and had lesser postoperative morbidity.     

Diagnosis of limbs and neck arterial trauma using duplex ultrasonography

Objective: To evaluate duplex ultrasonography for diagnosis of arterial trauma in limbs and neck. Method: Fifty-one wounds in 47 patients, with indication for arteriography, were prospectively studied and grouped according to the presence (PCS group: 21 wounds, 41.2%) or absence (ACS group: 30 wounds, 58.8%) of clinical signs of arterial injury. All underwent duplex ultrasonography and arteriography. Results: Arteriography disclosed arterial injury in 21 wounds, of which 19 were visualized by duplex ultrasonography. In the other 30 wounds neither methods disclosed any arterial injury. The sensitivity of duplex ultrasonography was 90.5%, the specificity was 100% and the accuracy was 96.1%. In PCS group duplex ultrasonography showed 14 injuries (93.3%) and one false-negative result, and in ACS group, five injuries (83.3%) and one false-negative result in the ACS group. Conclusions: Duplex ultrasonography reproduces the results of arteriography as a non-invasive diagnostic method in trauma of the limbs and neck.     

The plug method in inguinal hernia: Prospective evaluation of postoperative pain and disability

Summary The aim of this prospective study was to evaluate the postoperative pain and disability after treatment of inguinal hernia by the plug technique. Postoperative pain, main organic functions, mobility, return to normal activities and absence from work were prospectively assessed in 118 consecutive patients. Only 3 benign postoperative complications (2.5%) occurred. The mean postoperative pain as assessed by visual analogue scale was 20.3 ± 15.1 mm/100. The mean duration of analgesic consumption was 2.7 ± 1.6 days and the mean total number of capsules was 7.1 ± 4.7. The percentages of patients capable of eating lunch the day of operation, passing urine, walking and bending forward without difficulty 6 hours after operation were 97.5,97.4, 97.5 and 85.6 respectively. The mean postoperative hospital stay was 1.2 ± 0.6 days. The mean times of first outdoor walking, return to normal activities and return to work were 1.5 ± 1, 3.6 ± 2.2 and 15.2 ± 8.9 days respectively. These results show that the plug technique provides a low complication rate, a low level of pain, and allows early resumption of full activity.     

Induction of spermatogenesis by inguinal varicocele repair in azoospermic men

13 infertile patients who had complete azoospermia and clinical varicocele underwent inguinal varicocele repair. Semen analyses were obtained starting 3 months after varicocele repair. Bilateral varicocele repair in 2 men and unilateral in 11 men were performed. Induction of spermatogenesis was achieved in 3 (23%) patients. Two of them had hypospermatogenesis and one had maturation arrest at spermatid stage. No pregnancies by natural intercourse resulted. Although one couple used fresh ejaculate for intracytoplasmic sperm injection, the result was unsuccessful. All men with Sertoli cell-only and early maturation arrest remained azoospermic after surgery. No association between successful outcome and patient age, sex hormone analysis, varicocele grade, testicular volume, unilateral or bilateral varicocele repair were apparent. Varicocele repair can result in the induction of spermatogenesis for men with hypospermatogenesis and late maturation arrest. No other related factor could be detected.     

Early postoperative evaluation of groins after laparoscopic total extraperitoneal repair of inguinal hernias

BACKGROUND: Minimally invasive laparoscopic total extraperitoneal (LTEP) repair of bilateral and/or recurrent groin hernias has been popularized as one of the procedures of choice in the past decade. The early postoperative course is uneventful in most cases. A few patients, however, will develop temporary postoperative groin swelling. The aim of our study was to evaluate clinical and sonographic findings in the groin during the early postoperative period following LTEP. METHOD: One hundred and five consecutive patients with primary bilateral (n = 90), recurrent unilateral (n = 12), and primary unilateral (n =3) groin hernias operated on during an 18-month period underwent clinical and sonographic examination two to three weeks after LTEP. RESULTS: On clinical examination, a localized groin swelling was found in 21 patients (20%). The most frequent sonographic findings were localized groin collections compatible with seroma or hematoma, found in 35 patients (33%). Hypoechoic diffuse tissue swelling around the mesh, lipomas, and residual hernias was found in four patients each (4%). None of the patients with hypoecoic mass had any clinical manifestations postoperatively. Extraperitoneal close suction drains were left for 8-12 hours in 46 patients. The average volume of fluid drained was 62 mL (range, 30-200 mL). There was no correlation between the use of suction drains and the frequency of fluid collections detected on sonography. Cord lipoma was detected postoperatively in four patients and was excised in one using an open anterior approach. Residual or recurrent hernia was detected postoperatively on sonography in four patients, but only one developed a symptomatic and clinically detectable hernia during eight months of follow-up. Overall, postoperative ultrasonographic findings following LTEP repair were found in 37% of patients. CONCLUSION: Clinical and sonographic findings such as localized fluid collections compatible with seroma or hematoma are common following LTEP. Postoperative suction drains did not reduce the frequency of sonographically detected collections. The clinical relevance of suspected postoperative hernia detected on sonography without clinical manifestations remains uncertain, and has to be determined on long-term follow-up.     

Chronic postoperative pain and inguinal herniorrhaphy

Editor—Avasvang and Kehlet¹ highlight the complex natureof perioperative pain management. It serves to add to the growingbody     

Seminal antioxidant capacity in pre- and postoperative varicocele

In order to explore the impact of surgical treatment on antioxidant defense system in varicocele (VAR), we evaluated seminal total antioxidant capacity (TAC) in 25 patients affected by VAR, in 14 patients studied 10-24 months after varicocelectomy (post-VAR) and separated into normo- and oligospermic groups, and in 24 non-VAR control patients with seminal parameters matched to patients with VAR in the oligo- and normospermic groups (7 subjects with idiopathic oligospermia and 17 normal fertile subjects). TAC was measured in seminal plasma with the system H(2)O(2)-metamyoglobin as a source of radicals, which interact with a chromogen 2,2',-azinobis (3-ethylbenzothiazoline-6-sulphonate) (ABTS), generating a radical cation spectroscopically detectable. The presence of antioxidants induces a lag time in the production of ABTS cation proportional to the concentration of antioxidant compounds. When whole groups of patients were analyzed, lag values were significantly higher in VAR vs non-VAR controls (mean +/- SEM, 106.6 +/- 8.8 seconds vs 78.7 +/- 8.8 seconds) but were not modified by surgery (mean +/- SEM, 105.8 +/- 8.6 seconds). In groups separated according to seminal parameters, oligospermic VAR presented significantly higher lag values than oligospermic controls. Finally, when exploring a possible association of TAC with seminal parameters, we found a significant correlation between lag and sperm motility only in patients with VAR who were in the normospermic group (r = 0.65, P <.01). This correlation was not yet manifest post-VAR. In conclusion, surgical treatment does not seem to modify absolute values of TAC but influences its fine regulation and relationships with sperm motility.     

Role of Doppler ultrasonography in the diagnosis and treatment of varicocele

Varicocele is a frequent condition in male population. Our objectives were to asses the role of Doppler ultrasonography in varicocele diagnosis, evaluation of surgical outcome and identify predictive factors for infertility. We studied 45 patients (21-46 years old), Doppler ultrasonography being used to determine the stage and reflux grade. In all patients presence of anti-spermatic antibodies was assessed. 27 patients were surgical treated. Postoperatively, presence or absence of reflux was assessed by Doppler ultrasonography. Spermogram was repeated in infertile patients. Our patients presented stage I (12 cases), stage II (18 cases) or stage III varicocele (15 cases). 16 patients (35%) were infertile (12 with grade III and 4 with grade II reflux), in 10 of these patients high levels of anti-spermatic antibodies being detected. Postoperatively, venous reflux was absent in all 27 patients. Among infertile patients, 80% of those younger than 25 years, 42% of those with ages between 25-30 years and none of those over 30 presented postoperative improvements of spermogram. Doppler ultrasonography is a non-invasive investigation for diagnosis, evaluation of venous reflux and detection of intratesticular varicocele. Opportunity of surgical treatment and evaluation of operative outcome can be determined using Doppler ultrasonography.     

Retrograde venography and embolization in postoperative recurrence of varicocele

Percutaneous retrograde venography was performed in 10 patients with recurrent varicocele after surgical ligation (the Ivanissevich operation) of the spermatic vein. Combined scleroembolization with Thrombovar plus steel coils was performed in 8 patients. In two other patients either sclerotherapy or embolization only was made depending on their anatomical peculiarities. No recurrences were seen during 6-60 months of follow-up in 9 patients in whom the occlusion of all venous feeders was technically successful. It was concluded that embolization was a minimally invasive and effective procedure and hence the transcatheter treatment should be considered a method of choice for post-surgical recurrent varicocele.     

Minimal postoperative pain using properitoneal nontension sutured repair of direct inguinal hernias

BACKGROUND: Numerous repairs exist for direct inguinal hernias. These repairs are limited by the shortcomings of their respective technique. Reported recurrence rates for all currently employed hernia repairs for direct inguinal hernias range from 1% to 10%. With recurrence rates for nontension mesh repairs <2%, the evaluation of postoperative outcomes has shifted instead to that of pain and return to normal activities. METHODS: We describe a novel inexpensive technique that employs the placement of conventional properitoneal tension-free mesh for repair of direct inguinal hernia. This technique, performed as day surgery with the patient under local anaesthetic, offers the beneficial aspects of contemporary mesh repair while avoiding its limitations. RESULTS: Three-year independent follow-up of 52 patients undergoing this repair demonstrated 1 (1.9%) early failure. Postoperative pain was measured using a visual analog pain scale (0 to 10) at 2 months (mean +/- SD; 1.39 +/- .58), 1 year (.37 +/- .27), 3 years (.58 +/- .40), at work (.59 +/- .33), and with recreational activity (.73 +/- .40). More than one third of patients had returned to work 1 week after surgery (37.8%) with 62.2% returning by 2 weeks and 100% by 6 weeks. Most significantly, 90.9% of patients had resumed full recreational activities by 8 weeks. CONCLUSIONS: In addition to providing minimal recurrence, these results of our technique demonstrate that this it provides less postoperative pain than has been reported in other nontension types of repair. Furthermore, use of this procedure results in earlier return to work and full recreational activities, thus it has significant social and economic implications.     

青少年精索静脉曲张评估与干预新进展

青少年精索静脉曲张患者由于生理、伦理的问题难以取得精液标本,无法直接评价生育功能,只能以间接的方法来评价其对青少年将来生育的影响。大部分青少年精索静脉曲张患者成年后的精液常规是正常的,如何判断青少年精索静脉曲张是否需要治疗、何时进行治疗,在男科界一直存在争论。体格检查是最为常用的筛查手段,而超声也是诊断及评估精索静脉曲张的有效方法,其中睾丸萎缩指数一直是被广泛认同的指标,最新文献又提出了峰值反流速度、睾丸总体积、阴囊温度的重要性,尤其是睾丸总体积。本文通过文献综述,提出一些针对青少年精索静脉曲张方面的评估及干预建议。     

Diagnosis and therapy of varicocele. Fertility aspects

Calling attention to the andrological importance of subclinical varicocele, the authors' own operative material is analysed from the point of view of fertility. Problems of surgical indications, with particular regard to the azoospermic and normozoospermic groups, are discussed. Based on their own results, they express their views on the choice of surgical intervention.     

Diagnosis and classification of inguinal hernias

Background: The aim of this prospective clinical study was to determine whether the presence of a hernia, its size, and its type can be established preoperatively by clinical and ultrasound, examination. Methods: The study population comprised 220 consecutive patients referred to our department for the surgical management of an inguinal hernia. On admission, both inguinal regions were examined clinically and by ultrasound. All patients were operated on laparoscopically. Results: In regard to the intraoperative findings for both inguinal regions, clinical and ultrasound examination for the diagnosis of inguinal hernia yielded a high total rate of accuracy of 93% respective 94%. However, when the same methods were used to differentiate between lateral and medial hernia, the total rate of accuracy fell to only 54% respective 62%. In the determination of inguinal hernia size, it was even lower: 50% respective 53%. Conclusions: Although a diagnosis of inguinal hernia can be established reliably by clinical and ultrasound examination, only an approximate classification is possible by these methods.     

高频彩色多普勒超声在老年腹股沟斜疝、直疝及股疝中的诊断与鉴别

目的分析高频彩色多普勒超声在老年腹股沟斜疝、直疝及股疝中的应用价值。 方法将2019年11月至2021年11月在庐江县人民医院收治的140例诊断为腹股沟疝的老年患者为研究对象,分析患者临床资料。全部患者均接受高频彩色多普勒超声检查,经手术探查,分析斜疝、直疝及股疝的不同超声影像表现,对比分析超声检出率与准确率。 结果高频彩色多普勒超声检查,直疝所占比例为15.94%;其中斜疝所占比率最多为78.26%,股疝所占比率为5.80%。所有患者经手术验证：腹股沟直疝的准确率为100%;腹股沟斜疝中,易复性疝准确率为97.78%,难复性疝为100%,嵌顿性疝为100%,绞窄性疝为100%,股疝为100.00%。所有病例超声检测准确率为98.57%。 结论高频彩色多普勒超声在老年腹股沟斜疝、直疝及股疝中的诊断价值较高,能有效对腹外疝的分型做出准确判断,值得临床推广。     

超声检查在腹股沟疝围手术期的应用价值

目的 探讨超声检查对腹股沟疝手术前后评估的价值.方法 对30例32侧腹股沟疝患者于手术前后进行超声检查.术前观察内环位置、腹股沟管内径改变、疝囊大小及内容物并对腹股沟疝类型进行分类;术后观察补片位置、大小、形态及生物补片与四周组织的融合情况.结果 在32例侧中,有20个斜疝、4个直疝、3个股疝术前的超声诊断与手术结果相符.术后1个月内超声检查发现,其中28个手术部位可探及正常生物补片、未见其他异常回声,2个见补片外血肿,1个见补片外复发疝及1个补片变形.结论 在腹股沟疝手术前,通过超声检查能为临床医生提供腹股沟疝形态的详细参考数据并为腹股沟疝分类,为临床医生选择适合患者个体的生物补片提供了重要的客观依据.在腹股沟疝手术后,超声检查能观察生物补片的形态、位置及有无发生其他并发症.

Abstract：

Objective To evaluate the use of ultrasonography befor and after inguinal hernioplasty.Methods In 30 patients, 32 inguinal hernias were submitted to tension-free inguinal hernioplasty,ultrasonography was applied before the surgery and after one mother. Ultrasonography revealed the character of the hernia before the surgery and observed the situation of the mesh after the surgery.Results Diagnostic ultrasound detected 20 inguinal hernias,4 direct hernias, and 3 femoral hernias which were consistent with intraoperative findings. We identified 2 seromas, 1 recurrence of hernia and 1 folding mesh after hernia repair. Conclusion Ultrasonography is a useful examination in preoperative assessing inguinal hernia and demonstrating postoperative complications associated with mesh.