Intraoperative Varicocele Anatomy: A Microscopic Study of the Inguinal Versus Subinguinal Approach

PurposeThe groin approach to varicocelectomy is performed by an inguinal (aponeurosis of external oblique opened) or subinguinal (external oblique aponeurosis intact) technique. We describe the number and relationship of internal and external spermatic arteries, veins and lymphatics within the subinguinal portion of the spermatic cord in infertile men undergoing microscopic varicocelectomy and compare these findings to the microanatomy observed with the inguinal approach.Materials and MethodsA total of 48 consecutive patients underwent 84 microsurgical subinguinal varicocelectomies during which the detailed intraoperative microanatomy of the spermatic cord and gubernacula was recorded. These observations were compared with a previously reported group of 83 consecutive patients that underwent 115 inguinal varicocelectomies. Subinguinal microscopic findings were also evaluated relative to clinical varicocele grade.ResultsThe spermatic cord in the subinguinal dissection was characterized by a smaller number of large (greater than 5 mm) internal spermatic veins and a greater number of small (less than 2 mm) internal spermatic veins than the cord in the inguinal dissection (mean 0.4 vs 1.9 large veins and mean 7.9 vs 4.7 small veins, respectively). The subinguinal dissection was also characterized by a significantly greater percentage of external spermatic veins greater than 2 mm than that observed during inguinal dissection (93% vs 74%, respectively, p <0.05). Multiple spermatic arteries were identified in 75% of subinguinal dissections and in only 31% of inguinal dissections (p <0.03). Internal spermatic arteries were surrounded by a dense complex of adherent veins in 95% of cases using the subinguinal approach, whereas this finding was true in only 30% of cases with the inguinal approach (p <0.001). The clinical grade of a varicocele was significantly associated with the number of internal spermatic veins greater than 2 mm found intraoperatively (p <0.001) but not with the maximum internal spermatic vein diameter.ConclusionsAlthough the subinguinal approach to microsurgical varicocelectomy obviates the need to open the aponeurosis of the external oblique, it is associated with a greater number of internal spermatic veins and arteries compared with the inguinal approach. The primary branch point for the testicular artery occurs most commonly during its course through the inguinal canal. Internal spermatic arteries at the subinguinal level are more than 3 times as likely to be surrounded by a dense network of adherent veins than when they are identified at the inguinal level. Taken together, these data suggest that microscopic dissection is more difficult with a subinguinal incision.     

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.     

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.     

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.     

微型血管多普勒在改良腹股沟下显微精索静脉结扎术中的应用：附视频

目的 探讨微型血管多普勒在改良腹股沟下显微精索静脉结扎术中的应用价值.方法 回顾分析2012年1月至2013年1月期间中山大学附属第一医院东院收治的89例精索静脉曲张患者的临床资料.患者均行改良的腹股沟下显微精索静脉结扎术,2012年9月之前术中未应用微型血管多普勒,2012年9月之后术中常规应用微型血管多普勒辨别动脉和静脉.比较两组患者的临床资料.结果 89例患者共138次手术均获成功,术后随访3～6个月,未见睾丸萎缩和鞘膜积液发生.非多普勒组术中有1例精索内动脉被误扎,2例术中精索动静脉辨认不清,术后1例复发;多普勒组术中辨别动脉和静脉准确,无动脉损伤和误扎情况发生,术后无复发.结论 在微型血管多普勒辅助下行显微精索静脉结扎术更安全有效.     

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.     

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.     

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.     

精索血管的显微组织解剖及临床应用

目的:外环下切口和腹股沟管切口精索静脉曲张显微外科结扎术均被推荐于治疗精索静脉曲张,但手术复杂度不同。本研究旨在了解两种手术切口的精索血管显微解剖结构。方法:选择外环下切口80例,腹股沟管切口20例,术中记录精索动脉、静脉及淋巴管数量;并从10例成人尸体取材精索,经组织染色,记录两种切口水平精索动静脉数量。结果:术中中静脉(2～5 mm)在腹股沟管切口有(1.80±0.83)条,外环下切口有(3.98±1.99)条,两者差异有显著性(t=-7.536,P<0.01);静脉总数腹股沟管切口为(6.40±1.67)条,外环下切口为(9.01±2.70)条,两者差异有显著性(t=-4.071,P<0.01)。两种手术切口的小静脉(≤2 mm)、大静脉(≥5 mm)、动脉和淋巴管数量差异无显著性。尸体研究数据:在外环下水平和腹股沟水平动静脉数量差异均无显著性。结论:虽然外环下水平精索静脉总数及中静脉数量均多于腹股沟管水平,但中静脉并不会加大手术难度,外环下切口不会较腹股沟切口操作更复杂。     

Managing varicoceles in children: results with microsurgical varicocelectomy

Authors from New York present their experience of elective varicocelectomy, using microsurgical techniques, in a large series of children. They found the procedure to be safe and effective, and gave a much lower complication rate than the published rate in open varicocelectomy. The results of urethroplasty in post-traumatic paediatric urethral strictures are presented by authors from Mansoura. They found the overall success of one-stage perineal anastomotic repair of such strictures to be excellent, with very little morbidity. OBJECTIVE: To report our experience of microsurgical subinguinal varicocelectomy in boys aged < or = 18 years. PATIENTS AND METHODS: Boys aged < or = 18 years treated with microsurgical varicocelectomy between 1996 and 2000 at one institution were retrospectively reviewed. Indications for surgery included ipsilateral testicular atrophy, large varicocele or pain. Microsurgery was assisted by an operating microscope (x10-25) allowing preservation of the lymphatics, and the testicular and cremasteric arteries. Patient age, varicocele grade, complications and follow-up interval were recorded. RESULTS: In all there were 97 microsurgical subinguinal varicocelectomies (23 bilateral) in 74 boys (mean age 14.7 years). Left-sided varicoceles were significantly larger (mean grade 2.9) than right-sided (mean grade 1.4) varicoceles. The mean follow-up was 9.6 months. There were four complications: two hydroceles, of which one resolved spontaneously after 4 months; one patient had persistent orchialgia that resolved after 8 months; and one developed hypertrophic scarring at the inguinal incision site. There were no infections, haematomas or intraoperative injuries to the vas deferens or testicular arteries. All boys were discharged home on the day of surgery. CONCLUSIONS: Microsurgical subinguinal varicocelectomy in boys is a safe, minimally invasive and effective means of treating varicoceles. Compared with published results of the retroperitoneal mass ligation technique, which has a 15% overall complication rate and a 7-9% hydrocele occurrence rate, the microsurgical subinguinal approach appears to offer less morbidity, with a 1% hydrocele rate. We consider that microsurgical subinguinal varicocelectomy offers the best results with lower morbidity than other techniques.     

Preservation of testicular arteries during subinguinal microsurgical varicocelectomy: clinical considerations

Microsurgical varicocelectomy with intentional preservation of the testicular artery(ies) is regarded as the gold standard approach to varicocele repair. We sought to determine whether the number of testicular arteries preserved at the time of micro-surgical varicocelectomy predicts improvement in postoperative semen parameters. We analyzed the records of 334 infertile men who underwent varicocelectomy performed by a single surgeon using a subinguinal microsurgical technique between July 1996 and January 2003. We examined the association between the number of testicular arteries preserved at the time of varicocelectomy and serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), varicocele grade, testicular volume, and postoperative improvement in semen parameters. Unilateral, left-sided varicocelectomy was performed in 194 men, while bilateral varicocelectomy was performed in 140 men. Mean (+/-SE) sperm concentration (20.1 +/- 1.5 x 10(6)/mL to 26.7 +/- 1.9 x 10(6)/mL, P =.001), percent motility (24.7 +/- 1.0% to 30.9 +/- 1.2%, P =.001), and percent normal morphology (35.8 +/- 1.4% to 37.7 +/- 1.5%, P =.046) improved significantly following varicocelectomy. The mean number of preserved testicular arteries was 1.5 on the left (range, 1-4) and 1.5 on the right (range, 1-4). The number of testicular arteries preserved at the time of varicocelectomy did not correlate significantly with preoperative assessment of serum FSH, LH, varicocele grade, and testicular volume or with postoperative improvement in semen parameters. Our data indicate that preoperative parameters are not predictive of the number of testicular arteries identified at the time of microsurgery. These data also suggest that the number of arteries identified and preserved with meticulous spermatic cord dissection does not correlate with improvement in semen parameters.     

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.     

Comparison of spermatic vein histology in patients with and without varicocele

The aim of this study was to investigate and compare histological characteristics of spermatic veins in patients with and without varicocele. Between February 2009 and July 2009, spermatic veins were obtained from 13 patients with varicocele. Microsurgical subinguinal low ligation was performed in all patients. Spermatic veins of patients without varicocele were obtained from 12 patients who underwent radical nephrectomy. Histologically, sections of veins were stained with haematoxylin and eosin. Mean tunica adventitia thickness size of the spermatic veins was 0.35 ± 0.08 mm and 0.22 ± 0.1 mm respectively in patients with varicocele and control group (P = 0.001). Similarly, mean tunica media thickness size of the spermatic veins was 0.25 ± 0.05 mm and 0.09 ± 0.04 mm respectively in patients with varicocele and control group (P < 0.001). No significant differences were detected regarding the tunica adventitia and tunica media thicknesses when patients with grade 2 varicocele were compared with patients with grade 3 varicocele (P > 0.05). No significant differences were detected between the tunica adventitia and tunica media thicknesses of patients with varicocele and sperm parameters (P > 0.05). Our study demonstrated that tunica adventitia and tunica media thicknesses seem to be increased in patients with varicocele compared with normal subjects.     

Magnified and non magnified subinguinal varicocelectomy in infertile and/or symptomatic men: A comparative study of the outcome

ObjectiveTo compare the outcome of magnified and non magnified varicocelectomy for infertile and/or symptomatic men.Patients and methodsOne hundred and sixteen patients with 2nd and 3rd degree varicocele were treated in a university based hospital between January 2006 and July 2008. Sixty patients were randomly allocated to be operated upon by conventional subinguinal technique and this is the 1st group (9 patients of them with bilateral varicocele). Other 56 patients were operated upon by microsurgical subinguinal technique and this is the 2nd group (11 of them with bilateral varicocele). All patients were followed up at regular intervals, every 3 months for 3 years, 7 patients were lost during follow-up period, all of them with unilateral varicocele (3 patients from 1st group and 4 patients from 2nd group).ResultsSixty-six varicocelectomies in the 1st group were done by conventional subinguinal technique (57 unilateral and 9 bilateral). Their results had been shown; 8 unilateral hydroceles (12.1%), 7 unilateral recurrences (10.7%) and one scrotal hematoma (1.5%). In the 2nd group total varicocelectomies were 63 (52 unilateral and 11 bilateral) had been done by microsurgical subinguinal technique resulting in no hydroceles and no scrotal hematomas but there were two unilateral recurrence (3%). The differences between the two techniques in the incidence of hydrocele formation and varicocele recurrence are significant (P < 0.001) and (P < 0.03) respectively.ConclusionApproaching the testis via a small subinguinal incision gives direct access to all testicular venous drainage. Furthermore, using the operating loupes helps to ease the recognition of the small venous channel, the testicular artery and the lymphatics, thus resulting in significant decrease of the incidence of varicocele recurrence, persistence, hydrocele formation and testicular artery injury. It is considered safe, effective and less morbid method for varicocelectomy.     

Pressure flow pattern of varicocele veins and its correlation with testicular blood flow and semen parameters

The pressure pattern in varicocele veins of infertile patients and its correlation with semen quality and testicular blood flow was determined. Consecutive patients at andro‐urology clinic of a teaching hospital undergoing microsurgical varicocelectomy were included. Their semen quality and testicular blood flow were determined. Peak systolic velocity (PSV) and resistive index (RI) of subcapsular and intraparenchymal branches of testicular artery were noted by colour Doppler ultrasonography. During surgery before ligation of varicocele veins, intravenous pressures of internal spermatic (ISV) and external spermatic (ESV) veins were determined at baseline and after Valsalva manoeuvre. Thirty patients, 20–45 years old, were evaluated. Baseline pressure for maximum dilated ISV (A), less dilated ISV (B) and ESV was 15.93 ± 6.34, 12.38 ± 4.60 and 12.92 ± 5.65 mm. Hg, respectively, which increased after Valsalva by 104.4%, 116.2% and 38.22% respectively. Correlation (r = ?.71; p < .05) was appreciated between percentage increase in pressure of ISV B with PSV of intraparenchymal testicular arteries and progressive motility (r = ?.759; p < .05), nonprogressive motility (r = ?.738; p < .05) and morphology (r = ?.653; p = .07) of spermatozoa. In conclusion, ISV develops higher pressure on Valsalva as compared to ESV and has correlation with semen quality and testicular blood flow.     

Modified microsurgical subinguinal varicocelectomy without testicular delivery

The aim of this study is to report our experience of modified microsurgical subinguinal varicocelectomy without delivery of the testes. We retrospectively evaluated 138 men treated with microsurgical varicocelectomy who took part in 1-year follow-up between 1997 and 2007. The varicoceles were grade III in 115 (81.6%), grade II in 23 (16.3%), and grade I in 3 (2.1%) men. We used a technical modification of the standard microsurgical subinguinal technique: division of the spermatic cord before microsurgical dissection, and the testes were not delivered. Patient age, varicocele grade, operation time, 1-year follow-up results, including complications, symptom relief, and recurrence, were recorded. We performed 141 varicocelectomies (Left: n = 135; bilateral: n = 3) in 138 men. The patients' mean age was 23.5 ± 2.7 (range: 11-45) years. The mean operation time was 69.6 ± 15.6 (range: 35-140) min. There were three complications (2.2%; post-operative haematomas: n = 2; wound infection: n = 1) and 6 recurrences (4.3%; grade II: n = 1; grade III: n = 5). Among the 86 patients with scrotal pain, 74 (77.9%) reported complete resolution of pain and 13 (12.9%) reported partial resolution. Modified microsurgical subinguinal varicocelectomy without testis delivery is safe and effective.     

腹膜后切口与腹股沟管切口显微镜下精索静脉结扎治疗精索静脉曲张的对比研究

目的 对精索静脉曲张患者采用腹膜后切口显微镜下精索静脉结扎和腹股沟管切口显微镜下精索静脉结扎术进行治疗,对比观察两种术式的手术切口对精索血管的影响.方法 采用前瞻性随机对照研究,将2014年3月至2015年1月本院泌尿外科住院的原发性精索静脉曲张患者98例随机分为两组,观察组50例采用腹膜后切口显微镜下精索静脉结扎,对照组48例采用腹股沟管切口显微镜下精索静脉结扎,术中观察记录精索血管数量并进行对比分析.结果 观察组静脉总数为(3.50±1.07)条,对照组为(5.01±1.70)条,差异有统计学意义(t =4.570,P=0.000);观察组中静脉(2～5mm)为(2.98±0.83)条,对照组为(4.08±1.69)条,差异有统计学意义(t =3.088,P=0.003).两种手术切口的小静脉(≤2mm)、大静脉(≥5mm)、动脉和淋巴管数量差异无统计学意义(P＞0.05).结论 腹膜后水平精索静脉总数及中静脉数量均少于腹股沟管水平,且此水平无输精管及输精管静脉无提睾肌静脉,静脉均为精索内静脉,因此腹膜后切口较腹股沟切口操作更简单.     

Retroperitoneal high ligation versus subinguinal varicocelectomy: Effectiveness of two different varicocelectomy techniques on the treatment of painful varicocele

In the present study, we compared the retroperitoneal high ligation with subinguinal varicocelectomy on the treatment of painful varicocele. A total of 90 patients who underwent retroperitoneal high ligation (n = 45) and subinguinal varicocelectomy (n = 45) for painful varicocele were included in this prospective study. Varicocele in all patients was diagnosed with by physical examination and coloured Doppler ultrasonography. All the patients underwent a conservative treatment for pain for 4 weeks. Patient ages, varicocele grades, preoperative pain scores, postoperative pain scores at 6 months, duration of surgeries, complications and recurrences were recorded. Complete success rate for chronic scrotal pain was found to be 80% in retroperitoneal varicocelectomy group and 71% in subinguinal varicocelectomy group. Partial success rate was 11% for retroperitoneal varicocelectomy group and 18% for subinguinal ligation group. There was no significant difference between two groups in terms of pain and complications. However, the operation time was significantly lower in the Palomo group. Although microsurgical subinguinal varicocelectomy is the current approach for the treatment of varicocele, retroperitoneal high ligation can achieve the same pain resolution with shorter operative duration compared to loupe‐assisted subinguinal varicocelectomy.     

Pattern of varicocele vein blood gases in patients undergoing microsurgical Varicocelectomy

Background

Varicocele is known to be associated with infertility and sperm disorders. The exact cause of this ailment is not fully understood. There are limited numbers of studies where venous blood gases (VBGs) of varicocele veins were determined with conflicting results. Therefore, we have investigated the pattern of VBGs in both internal spermatic and external spermatic varicocele veins and correlation with semen quality parameters in infertile individuals who underwent left microsurgical varicocelectomy.

Methods

Patients (n?=?27) undergoing left microsurgical varicocelectomy at a tertiary care hospital, were included in the study. Before surgery, semen parameters and scrotal color Doppler ultrasonography was performed. During surgery, blood sample was drawn from varicocele veins (internal spermatic and external spermatic veins) and a peripheral arm vein of the same patient as a control. The VBGs of all veins under study were estimated and compared with each other. The VBGs were also correlated with various semen quality parameters. Data, expressed as Mean?±?SD, regarding VBGs in three veins were analyzed using one-way ANOVA. The correlation between VBGs and semen quality parameters was determined using Pearson’s correlation. Differences were considered significant at p?<?0.05.

Results

The pH was found to be higher (p?<?0.01) in the internal spermatic vein compared with the external spermatic and the peripheral veins. Partial pressure of oxygen (pO₂) and oxygen saturation (sO₂) were higher (p?<?0.01) in the internal spermatic vein compared with the peripheral vein. However, concentration of bicarbonate (HCO₃₎ was lower (p?<?0.01) in both veins compared with the peripheral vein. Partial pressure of carbon dioxide (pCO₂) was also lower (p?<?0.01) in the varicocele veins compared with the control vein.

Conclusion

The internal spermatic veins had higher pH and oxygen tension, but lower HCO₃ and pCO₂ levels compared with the control peripheral veins. External spermatic veins had lower pCO₂ and HCO₃ but other VBGs were similar to the peripheral veins. The shift of VBGs of internal spermatic vein toward arterial blood pattern may be a missing link to understand the pathophysiology of varicocele.