Operative management of varicocele by high retroperitoneal ligation of the spermatic vein

High retroperitoneal ligation of the internal spermatic vein has been performed in 30 cases of varicocele. Renospermatic reflux had been demonstrated by preoperative phlebography in every case. Retrograde pressure brought to bear on the spermatic vein from the renal vein has been ascertained by intraoperative measurements of the pressures in the internal spermatic vein. On the ground of the results, high ligation of the spermatic vein is regarded as suitable for the surgical management of varicocele in case of renospermatic reflux.     

Comparative hemodynamic evaluations of varicocele by bidirectional ultrasonic Doppler sonography and phlebography of the internal spermatic vein

Clinical studies (degree of severity) and bidirectional ultrasonic Doppler sonography (Pressure-type, Shunt-type) of varicocele were compared with the phlebography of the internal spermatic vein (degree of spermatic incompetence, diameter of the int. spermatic v.). Doppler probe and phlebography are equivalent methods to demonstrate the venous reflux in palpable varicocele and for follow-up examination after sclerotherapy. The subclinical varicocele is discussed. The slight degree of spermatic incompetence (reflux by Valsalva's manoeuvre) is responsible for the small varicocele (grade I) and the Pressure-type. The severe degree of spermatic incompetence (spontaneous reflux) causes the Shunt-type and the large varicocele (grade III) as well as a dilatation of the internal spermatic vein.     

Role of spermatic vein phlebography and scleroembolization in treating varicocele and preventing its recurrence

The phlebograms and intravascular treatment of varicocele were performed in 406 patients aged from 10 to 60 years. Scleroembolization of the left internal spermatic vein was successfully used in 402 of them. Dilatation and retrograde flow through the right internal spermatic vein were recorded in 101 of 238 patients during transjugular catheterization. This investigation has confirmed high effectiveness of the method of the intravascular combined scleroembolization in treatment of varicocele. Using the transjugular access facilitates not only performing the left side intervention but represents the only efficient means to fulfill the right side phlebography of the spermatic vein and its obliteration. The strategy of using the bilateral intervention for the detection of retrograde contrast of the right internal spermatic vein considerably improves the results of treatment of varicocele and decreases risk of relapses.     

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.     

Endovascular electric surgery of varicocele

Results attained by endoelectrocoagulation of the internal spermatic vein provided an opportunity for comparative examinations by retrograde and anterograde selective venography to review the various fields of indication.     

Retrograde phlebography of the internal spermatic vein in varicocele

The results of retrograde phlebography of the internal spermatic vein in 110 cases of varicocele are reported. The anatomy of the vein, including the sites of its orifices and its possible communications with other veins of the area are described. Observations with the catheter method, also some hitherto unpublished findings, are presented. The significance of selective and superselective venography, in the interest of the choice of the appropriate surgical procedure, is emphasized.     

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.     

腹腔镜下精索内静脉Hem-o-Lock夹夹闭术与Palomo术治疗精索静脉曲张的疗效比较

目的:对照研究腹腔镜下精索内静脉Hem-o-Lock夹夹闭术与经腹膜后集束结扎精索血管术(Palomo术)治疗原发性精索静脉曲张的手术疗效。方法:研究对象为原发性精索静脉曲张并行手术治疗的患者80例,依据术式不同分为腹腔镜下精索内静脉Hem-o-Lock夹夹闭术组(H组)42例,Palomo术组(P组)38例。观察指标:手术时间、术中出血量、住院时间、肠道功能恢复时间、术后并发症,以及术后半年精子浓度、存活率、畸形率、a+b级精子百分率,彩色多普勒血流显像(CDFI)检查精索静脉内径(D值)、返流时间(TR值)和血流速度与内径比值(V/D),临床症状消失率和复发率。结果:手术时间、术中出血量和住院时间H组少于P组(P<0.05),术后肠道功能恢复时间H组大于P组(P<0.05);术后并发症发生率两组无显著性差异(P>0.05);术后半年复查精液质量和彩色多普勒CDFI检查:组内比较术后各指标均较术前有显著改善(P<0.05),组间比较术前术后各值差异无统计学意义(P>0.05);两组术后18个月均无复发。结论:腹腔镜下精索内静脉Hem-o-Lock夹夹闭术和Palomo术均可明显改善精索静脉曲张患者精液质量,缓解并逐步消失其临床症状,但前者具有手术、住院时间更短,术中出血、术后并发症较少,临床疗效好、复发率低等优点,是当前临床治疗精索静脉曲张的优选术式。     

Importance of lateral inspection of the scrotum and value of intraoperative spermatic phlebography in varicocele

Varicocele appearing on the posterior surface of the scrotum is apt to be overlooked in a routine physical examination. Lateral inspection of the scrotum is important to detect a varicocele of this type. Intraoperative spermatic phlebography on high ligation for varicocele was valuable in confirming the ligation of a single vein or in visualizing the vessel(s) left unligated.     

Diagnostic imaging in male reproductive medicine

Imaging methods are essential in the diagnosis of erectile dysfunction. With sonography the penile cavernous tissue and the deep arteries can be shown. This visualization is optimized by high-resolution ultrasonography with pulsed Doppler spectrum analysis or angiodynography. Pharmacocavernosonography combined with pharmacocavernosometry is the method of choice to verify pathologic venous leakage from the penis. Phalloarteriography is absolutely necessary before surgery for revascularization of the penis. In investigations of fertility sonography of the scrotum only plays a subordinate role, as an occlusion of the epididymis cannot be diagnosed in this way. In contrast, good visualization of any small intraparenchymous tumor of the testicle is possible. Transrectal sonography allows the best assessment of the vesicular glands. A persisting varicocele is visualized by retrograde phlebography of the internal spermatic vein. Antegrade phlebography of the spermatic vein with Valsalva maneuver is used by some workers in preference to the above-mentioned method, but has not yet been fully evaluated. Scrotal thermography can visualize a varicocele in a satisfactory manner. Obstacles to ejaculation can sometimes be visualized with retrograde urethrography and/or voiding urethrography. Focused x-rays of the sella turcica are necessary if there is any suspicion of a prolactinoma. Mammography will help to differentiate between gynecomasty and alimentary pseudo-gynecomasty. CT and NMR are used to diagnose tumors of the adrenal and pituitary glands; these methods are rarely used to diagnose abdominal cryptorchidism. Radiologic representation of the ductus deferens with contrast medium (vasography) now has to be rejected as harmful and obsolete.     

Varicocele in children: "to treat or not to treat"--venographic and manometric studies

The management of varicocele is still controversial in spite of its high incidence (15%) in prepubertal boys and young adults and although it is believed to represent a major contributing factor to male subfertility. Fifty boys between 6 and 14 years of age were operated on for left varicocele, and a long segment of the left internal spermatic vein was excised. Thirty-four of them underwent preoperative retrograde left renal venography and pressure readings in both renal veins and inferior vena cava. In all 50 patients, intraoperative antegrade (via internal spermatic vein) left renal venography was performed. This examination revealed impaired renal venous drainage in 38 patients (group A) and normal venous return through the left renal vein in 12 patients (group B). In all 34 patients (from both groups) on whom retrograde venography was performed, there was marked renospermatic reflux. The pressure readings in the left renal vein were significantly increased in group A only. Our data strongly suggest that left varicocele is caused by renospermatic venous reflux and that this condition is probably irreversible. The reflux in group A is explained by the impaired venous drainage through the left renal vein. In group B, it is our impression that the reflux is a result of a congenitally valveless left internal spermatic vein. If varicocele is indeed a major cause for infertility, then our data logically point toward surgery.     

Radiological anatomy of the internal spermatic vein(s) in 200 retrograde venograms.

The radiological anatomy of the internal spermatic vein(s) was studied in 200 retrograde venograms performed as part of presurgical evaluation in patients with variocele. A large range of anatomical variations was found at the left side. Bilateral reflux occurs in one out of four patients with unilateral varicocele at palpation. Bilateral treatment is therefore necessary in as much as one fourth of cases with 'unilateral' left side varicocele. In right side varicocele the spermatic vein generally enters the right renal vein. Varicocele ligation should be performed near the internal inguinal ring in order to interrupt reflux most securely. Non-surgical treatment of varicocele by means of sclerosis or embolization of the internal spermatic vein, will remain restricted to those cases in which reflux passes through only one spermatic vein. Insufficient knowledge of the anatomy of the internal spermatic vein(s), and the resulting incomplete interruption of reflux in this (or these) vessel(s) may be the cause of poor treatment results reported by some authors.     

Intraoperative Phlebographie der Vena spermatica interna bei Varikozele

Zusammenfassung An Hand von 30 intraoperativen Phlebographien w?hrend der Ligatur der V. spermatica interna nachPalomo wird auf die einfache Durchführbarkeit dieser Untersuchung hingewiesen. Diese Methode erm?glicht, ohne wesentliche Belastung des Patienten, eine genaue Planung des operativen Vorgehens durch die Darstellung von Parallelvenen und Kreuzkollateralen, deren Unterbindung zur Verhinderung von Varikozelenrezidiven wichtig ist.

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Summary In 30 consecutive cases which were operated by thePalomo-technique for varicocele, an intraoperative phlebography was performed. It was shown that the angiography of the spermatic vein is an easily performable procedure which helps to identify al collateral veins in order to assure a complete ligation. This is of paramount interest in the prevention of recurrence of a varicocele.

     

Detailed anatomy of the internal spermatic vein and the ovarian vein. Human cadaver study and operative spermatic venography: clinical aspects

The exact anatomical course of the spermatic vein and the ovarian vein (gonadal) has not been described in detail previously. To determine the precise anatomy of the gonadal veins an autopsy study of 70 fresh human cadavers (40 men, 10 women, 10 male stillborns and 10 female stillborns) was performed by making a resin cast of both gonadal veins which then was carefully dissected. The study showed absence of valves in the spermatic vein, cross-communications between the right and left spermatic veins, and communication between the spermatic and renal capsular veins, spermatic and ipsilateral ureteral veins, and spermatic ipsilateral colonic veins. For clarification of the presence of valves intraoperative antegrade spermatic venography was done in 6 men with and 5 without varicocele. In both groups valves were not detected. These observations regarding the anatomy of the spermatic vein and the ovarian vein may help to explain related clinical conditions.     

High-resolution sonography in cryptorchism

The importance of high-resolution sonography in the localization of undescended testes was displayed by an evaluation of 18 patients. In 15 patients the testis was not palpable on one side. In 3 cases, there was retention of the testis on both sides. Out of 17 testes in the inguinal region or in the external iliac region, 16 were located sonographically. There were 4 intraabdominal testes, and 2 were located sonographically. The retained and impalpable testes were in superficial positions in most cases. Hence, sonography proved to be the primary imaging method for localization. The importance of computed tomography, magnetic resonance imaging and phlebography of the internal spermatic vein are also discussed.     

腹腔镜精索血管集束状结扎术与腹腔镜单纯精索内静脉结扎术的疗效比较

目的:对比观察腹腔镜精索血管集束状结扎术与腹腔镜单纯精索内静脉结扎术治疗精索静脉曲张的优点。方法:将36例腹腔镜下精索血管集束结扎术与38例腹腔镜下单纯精索内静脉结扎术的临床资料进行对比研究。结果:两组病例手术时间与术中出血量有明显差异(P<0.05);术后经12个月随访,两组间术后治愈率及复发率有明显差异(P<0.05)。结论:腹腔镜精索血管集束状结扎术与腹腔镜单纯精索内静脉结扎术相比,具有手术时间短、术中出血少、安全且治愈率高等优点。     

Comparison of antioxidant enzyme activity in the internal spermatic vein and brachial veins of patients with infertile varicocele

AIM: Recent studies have shown that both oxidative and reductive stresses are present within the internal spermatic vein of patients with varicocele. The aim of this study was to compare the activities of antioxidant enzymes in the internal spermatic vein and brachial vein of patients with varicocele. METHODS: Fifteen primary infertile varicocele patients and ten normal-nonvaricocele-fertile control subjects participated in this study. The patients and subjects were first given a physical and color doppler examination, and then whole blood samples were drawn from the brachial vein and a dilated internal spermatic vein during surgery. Superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) enzyme activities were assessed by enzymatic methods, and the results were compared using the Mann-Whitney U test. RESULTS: The activity of SOD in the internal spermatic veins and brachial veins of patients with varicocele was 60.17 +/- 2.15 and 42.10 +/- 1.60 U/g protein, respectively; that of GSH-Px was 5.44 +/- 0.14 and 3.92 +/- 0.14 U/g protein, respectively. The results were statistically significant (P < 0.05). In the control group, the activity of SOD in the internal spermatic veins and brachial veins was 43.12 +/- 1.80 and 40.01 +/- 2.10 U/g protein, respectively; that of GSH-Px was 3.35 +/- 0.20 and 3.7 +/- 0.10 U/g protein, respectively (P > 0.05). CONCLUSIONS: Increased antioxidant enzyme activity in the internal spermatic vein may be due to increased oxidative stress in the internal spermatic vein: the increase in antioxidant enzyme activity may be a response to offset the toxic actions of reactive oxygen species. Further studies are needed to confirm this suggestion.     

Transvenous embolization of internal spermatic veins Nonoperative approach to treatment of varicocele

Eleven men, shown on routine spermatic venography to have bilateral varicocele, underwent transjugular bilateral Embolzation of the internal spermatic veins with stainless steel coils or Ivalon plugs. Embolization of the left spermatic vein was successful in 9; in the other 2 it was not attempted because of aberrant drainage of the vein. Embolization of the right spermatic vein was successful in 8 patients. There were three complications, none of which was serious. These preliminary results suggest that both internal spermatic veins can be occluded consistently by the transjugular approach. However, it has not yet been established that fertility is improved by detecting and correcting varicocele on the right side.     

Intraoperative spermatic venography during varicocele surgery in adolescents.

Intraoperative internal spermatic venography performed immediately following varicocele ligation in the adolescent has been touted as reducing varicocele persistence rates. Previously published data corroborate this statement with low persistence rates. Other series in which venography was not performed report a failure rate of 9 to 30%. During a 5-year period a total of 64 varicocele ligations was performed in 62 male adolescents at our institution. Followup postoperatively revealed an overall varicocele persistence rate of 9%. All patients had intraoperative internal spermatic venography on the affected side. Of 64 venograms 16% had shown collateral drainage that, if not ligated, may have resulted in varicocele persistence. These cases accounted for only 1 of the persistent varicoceles. Additionally, venograms had demonstrated filling of the ipsilateral external iliac vein in 8% of the cases. Despite the fact that no attempt was made to ligate these collaterals, none of these patients had a persistent varicocele. After varicocele ligation 30 of 62 patients were followed long enough to evaluate for testicular catch up growth. Of these 30 patients 24 demonstrated an average relative increase in left testicular volume of 17%. These data support routine intraoperative internal spermatic venography while performing varicocele ligation in the adolescent.     

经脐双通道腹腔镜与显微镜治疗双侧精索静脉曲张的疗效比较

目的对比分析经脐双通道腹腔镜双侧精索静脉结扎术与外环下显微镜双侧精索静脉结扎术的临床疗效。方法回顾性分析45例经脐双通道腹腔镜双侧精索静脉结扎术及37例外环下显微镜双侧精索静脉结扎术患者的临床资料。比较2组患者术前、术后3个月的精液质量变化、术中出血量、手术时间、术后并发症(阴囊及皮下血肿、疤痕增生、精索静脉曲张复发)以及配偶妊娠率等情况。结果经脐双通道腹腔镜组平均手术时间较显微镜组显著缩短[(38.20±10.23)min vs.(80.46±15.72)min,P<0.05]。2组术中出血量、阴囊及皮下血肿、术口疤痕增生发生率差异无统计学意义(P>0.05)。术后随访3~36个月,随访期间2组复发率及配偶妊娠率差异无统计学意义(P>0.05)。经脐双通道腹腔镜组与显微镜组组内比较术后3个月精液质量相关参数均较术前有显著改善(P<0.05),但是术后3个月2组的精液质量相关参数组间差异无统计学意义(P>0.05)。结论与显微镜双侧精索静脉结扎术相比,经脐双通道腹腔镜下双侧精索静脉高位结扎术具有手术时间短、美容效果佳、术后恢复快、安全有效等优点,具有一定的临床推广价值。