Clinical effectiveness of microsurgical subinguinal varicocelectomy with enhanced recovery after surgery for varicocele

BackgroundVaricocele (VC) is one of the most common causes of infertility in men, and microscopic varicocelectomy is currently the major surgical procedure for VC. We assessed the clinical effectiveness of microsurgical subinguinal varicocelectomy (MSV) with enhanced recovery after surgery (ERAS) in the treatment of VC in terms of semen quality improvement rate, pregnancy rate, pain relief rate, recurrence rate, and complication rate after MSV and explored the indications for VC surgery.MethodsIn total, 216 patients undergoing MSV in our center between June 2019 and July 2020 were enrolled in this study. All patients received the surgery under local anesthesia and were admitted and discharged within 24 hours. All patients were followed up for more than 6 months, and the rates of semen quality improvement, pregnancy, pain relief, recurrence, and postoperative complications were recorded. We can evaluate the pain degree of patients through the numerical rating scale (NRS). (I) 0 points for painless; (II) 1–3: mild pain; (III) 4–6: moderate pain; (IV) 7–10 points are severe pain. 0 is the most slightly, indicating comfort, and 10 is the most painful and unbearable.ResultsThe sperm concentration, total sperm count, progressive motility rate, sperm viability, and morphology were significantly improved after the surgery (all P values <0.05). The rate of semen quality improvement was 88.2%, and the semen indicators returned to normal in 26.6% of the patients. Among the patients who were followed up for 1 year, the natural conception rate reached 27.1% and was accompanied by a 95.5% pain relief rate, a 0.5% VC recurrence rate, and a 2.3% postoperative complication rate.We obtained data through laboratory examination of semen DNA fragments index (DFI). Compared with preoperative and postoperative DFI, postoperative DFI was improved, and the pregnancy outcome was improved.ConclusionsMSV under local anesthesia increases the rates of semen quality improvement, pregnancy, and pain relief while lowering the rates of recurrence and postoperative complications. MSV may also help to improve the pregnancy outcomes in patients with VC accompanied by sperm DNA fragmentation or nonobstructive azoospermia, but this should be verified by further investigation.     

显微外科曲张精索静脉结扎术治疗精索静脉曲张(附94例报告)

目的:探讨显微外科曲张精索静脉结扎术治疗精索静脉曲张的临床效果。方法:回顾分析2008年8月至2011年2月显微外科术治疗94例精索静脉曲张患者的临床资料。94例中,主要因睾丸坠胀不适、疼痛等症状就诊者36例;主要因不育或少弱精子症就诊者58例。经腹股沟途径或外环口下途径行显微外科曲张精索静脉结扎术,术后1、3、6个月随访相关并发症及精液参数改善等情况。结果:获得随访6个月至2年的患者88例,失访6例。术前主要以睾丸坠胀不适、疼痛等症状就诊获得随访的32例患者,术后症状消失者21例(65.6%),减轻6例(18.8%),无改善5例(15.6%)。获得随访的56例不育或少弱精子症者术前精子浓度及活力为[(a+b)%]为(8.26±1.68)×106/ml、(5.25±1.09)%,术后3个月及6个月分别为(15.47±3.21)×106/ml、(18.39±4.05)×106/ml和(13.34±5.16)%、(17.23±4.69)%,均较术前显著改善(P均<0.01)。结论:显微外科曲张精索静脉结扎术治疗精索静脉曲张可有效改善睾丸疼痛、坠胀不适等症状,并提高精子浓度和活力。     

Prediction of reproductive function recovery after microsurgical varicocelectomy in men from infertile couples: Clinical and laboratory predictors

The objective was to reveal predictors for fertility recovery after varicocelectomy in subfertile men. This retrospective study recruited 93 men with clinical varicocele and pathozoospermia who underwent microsurgical varicocelectomy. Stepwise discriminant analysis was performed to identify predictors of spontaneous pregnancy (SP) after surgery. ‘Clinically significant improvement’ (CSI) following varicocelectomy was defined as an increase in total progressively motile sperm count (TPMSC) by at least 12.5 million (calculated from WHO-2010 reference values). 52% of patients showed CSI, and 28% reported SP after surgery. Patients who reported SP (group II), compared to that remained infertile (group I), were younger (27.3 ± 2.9 versus 30.2 ± 4.2 years; p < .01), had less infertility period (24.1 ± 14.0 versus 44.4 ± 32.9 months; p < .05) and had initially higher TPMSC (median (25% −75%) = 34 (11–67) versus 9.5 (0–33) mln; p < .05). The stepwise discriminant analysis showed that male age (coefficient value = −0.157), total sperm motility (0.024) and postoperative increase in TPMSC (0.010) were the significant predictors of SP. The predictive ability, sensitivity and specificity of the discriminant function were 84%, 87%, 76% respectively. This algorithm can be recommended after varicocelectomy in decision-making on natural conception or the ART protocols usage.     

Long-term effects of microsurgical varicocelectomy on pain and sperm parameters in clinical varicocele patients with scrotal pain complaints

We aimed to investigate the long-term effects of microsurgical varicocelectomy on pain improvement and sperm parameters in patients with varicocele-related pain. A total of 72 patients who had undergone microsurgical subinguinal varicocelectomy because of varicocele with scrotal pain between 2004 and 2009 were included in the study. The patients were grouped according to the presence or absence of pain following surgical treatment. The patients expressing a decrease in frequency and severity of pain or minimal fullness sense were included in the pain-positive group. The mean follow-up period was 54.4 ± 18.06 months. There was left-sided varicocele in 80.3% of patients, while 19.7% had bilateral varicocele. In our study, complete success rate (Visual Analog Scale: 0-1) was found to be 79.2% (57/72), while failure (complete and partial failure) rate was 20.8% (15/72), and a significant difference was found (P < 0.05). Microsurgical subinguinal varicocelectomy is a reliable approach for clinically varicocele patients with scrotal pain complaints. Regardless of the type of pain, varicocelectomy significantly decreases pain. The success of the treatment is not related to the degree of varicocele.     

Comparison between microsurgical varicocelectomy with and without testicular delivery for treatment of varicocele: A systematic review and meta‐analysis

The present study was conducted to assess the semen parameters, complications and clinical effect of microsurgical varicocelectomy with testicular delivery (TD) for treatment of varicocele. Relevant studies were collected and reviewed systemically from PubMed, Medline, Embase, Web of Science, China National Knowledge Infrastructure databases and the Cochrane Library and a meta‐analysis was performed. Relative ratio (RR), standardised mean difference (SMD) and their 95% confidence intervals (CIs) were adopted to estimate the outcome measures. Eight articles and a total of 1,139 subjects including 487 patients with TD in microsurgical varicocelectomy and 652 patients without TD were enrolled in this meta‐analysis. The pooled RR indicated that microsurgical varicocelectomy with TD increased the incidence of orchiepididymitis (RR = 4.36, 95% CI = 1.12–16.99, p = 0.034) and scrotal oedema (RR = 4.25, 95% CI = 2.40–7.54, p = 0.000) than microsurgical varicocelectomy without TD postoperatively. In conclusion, compared to microsurgical varicocelectomy without TD, TD to further ligate the gubernacular veins in microsurgical varicocelectomy results in a higher incidence of orchiepididymitis and scrotal oedema and take longer operation time. However, TD may not have any beneficial influences on semen parameters, serum testosterone, varicocele occurrence, wound infection and natural conception.     

Microsurgical varicocelectomy for clinical varicocele: A review for potential new indications

Microsurgical varicocelectomy is considered the gold‐standard technique treating varicocele in both adults and adolescents, due to relatively more favourable outcomes and lower post‐operative recurrence and complication rates. Despite of mounting literature on this topic, several aspects are still not well defined. We summarised the most recent literature and presented findings that might extend its indications. Microsurgical varicocelectomy and intracytoplasmic sperm injection are both effective to father a child for infertile men with clinical varicocele even for those with worst condition of spermatozoa, nonobstructive azoospermia, and prior varicocele repair has substantial benefits for couples with a clinical varicocele. Microsurgical subinguinal and inguinal varicocelectomy seem to have comparable effectiveness for adolescents and infertile men with varicoceles. However, the subinguinal approach may have some advantages to deal with painful varicocele. The superior outcomes of bilateral varicocelectomy for patients with clinical left varicocele and concomitant clinical right varicocele are justified, while the benefit is still uncertain for concomitant subclinical right varicocele. Varicocelectomy may have the potential to improve sexual function along with serum testosterone. In conclusion, indications for microsurgical varicocelectomy may be extended by the concomitant right and left clinical varicocele and sexual dysfunction with varicocele.     

Effects of microsurgical varicocelectomy on semen analysis and sperm function tests in patients with different grades of varicocele: Role of sperm functional tests in evaluation of treatments outcome

It seems that varicocele play a role in male infertility, as such, their prevalence increases from 15% in the normal population to 80% in secondary infertility subjects. Varicoceles may have negative effects on semen quality. Our goal was to assess the effects of microsurgical varicocelectomy on semen analysis and sperm functional tests in men with different grades of varicoceles. Thirty infertile men with different grades of varicoceles (grades 1 to 3) were enrolled in our study. Semen quality was assessed by semen analysis according to the WHO guideline (WHO, 1999) and four different sperm functional tests (aniline blue, toluidine blue, chromomycin A3 and TUNEL test) were carried out before and 3 months after microsurgical varicocelectomy (M‐varicocelectomy). When considered all three grades together, we showed that M‐varicocelectomy had statistically significant effects on all four types of sperm functional tests (p value<0.05). It also had positive effects on conventional semen parameters, although the effects were not statistically significant for some parameters (for example sperm count). When analysed separately (based on varicocele grades) the surgery, although caused improvements in semen quality, but may have more statistically significant effects on patients with varicocele of higher grade. In addition, in varicocele of lower grade (for example grade 2), sperm function test may be a better predictor of surgical success than the conventional semen analysis. Thus, we show that not only M‐varicocelectomy has significant positive effect on semen quality but also if sperm functional tests become more affordable in the future, because they yield more precise results, their use in daily practice may increase significantly in patients with varicoceles.     

The impact of age on fertility rate in patients who underwent microsurgical varicocelectomy

Impacts of a subinguinal microsurgical varicocelectomy on the sperm parameters and fertility rates were investigated in three different ages according to their age at the time of the varicocelectomy: Group 1 was ≤20 years old, Group 2 was 21–30 years old, and Group 3 was ≥31 years old. The patients were also classified both preoperatively and post‐operatively according to the total motile sperm count (TMSC) into the following categories: invitro fertilisation, intrauterine insemination and naturally fertile. The proportion of patients who upgraded to a higher TMSC category level was calculated, and natural fertility rates were recorded. The mean infertility duration was statistically longer in Group 3, compared to Group 1 and 2. The mean TMSCs and normal sperm morphology rates increased in all groups. The mean post‐operative natural fertility rates were similar. The highest rate of TMSC upgrade was observed in Grade 3 varicocele patients under 20 years of age, compared to other grades of varicocele in patients older than 20 years. A microsurgical subinguinal varicocele repair, which is an effective treatment modality reduces the need for any type of ART, has an important impact on the TMSC increase in patients, particularly in the younger population.     

The effects of subinguinal varicocelectomy on Kruger morphology and semen parameters

Purpose

We studied the effect of varicocele ligation on Kruger strict morphology criteria and semen parameters in patients with infertility.

Materials and Methods

A total of 90 patients diagnosed with varicoceles and a normal morphological sperm ratio of less than 14% were evaluated before and 6 months after varicocelectomy. Preoperatively and postoperatively sperm density, motility and morphology using Kruger strict criteria were analyzed. The Wilcoxon test was used to measure levels of statistical significance in all analyses.

Results

Significant improvement in sperm concentration and motility was evident after varicocele ligation (p <0.0002 and <0.0001, respectively). Using the Kruger classification sperm morphology evaluation revealed a significant increase in the percent of normal forms, and of forms with head and acrosome defects (p <0.0001, <0.0014 and <0.0028, respectively). There were no concomitant changes in strict morphology in forms with mid piece and tail defects or immature forms (p >0.05). Of the 90 patients 18 (20%) achieved a successful full-term pregnancy, including 14 via natural cycle intercourse and 4 by intrauterine insemination.

Conclusions

Surgical correction of varicocele was associated with significant improvement in density, motility and sperm morphology evaluated using the Kruger classification.     

睾丸包膜动脉血流动力学参数评判精索静脉曲张术后疗效的价值

目的探讨多普勒超声测量睾丸包膜动脉血流动力学参数在评判外环下显微手术治疗精索静脉曲张疗效的价值.方法2011年12月至2012年4月我院共实施外环下显微手术治疗左侧精索静脉曲张手术32例,分别应用彩色多普勒超声测量患者术前及术后3个月、6个月的睾丸包膜动脉的血流动力学参数(收缩期峰值流速、舒张末期流速、阻力指数、搏动指数).同时测量患者术前及术后6个月精液质量指标.结果术后不同时间与术前比较,左侧睾丸包膜动脉的收缩期峰值流速在术后下降(P<0.05、P<0.01),舒张末期流速在术后明显增加(P<0.05、P<0.01),阻力指数及搏动指数明显下降(P<0.05、P<0.01).术后6个月精子的数量及活动力不同程度地提高(P<0.01),但精子质量指标与血流动力学参数间未发现相关关系(P>0.05).结论睾丸包膜动脉舒张末期血流速度的增加及包膜动脉阻力指数、搏动指数的下降提示术后睾丸组织内微循环的改善,这些参数可以较好地提示手术疗效.     

Effect of microsurgical repair of the varicocele on testicular function in adolescence and adulthood

OBJECTIVE: Many reports on varicoceles suggest improved spermatic findings and increased pregnancy rates after correction of these lesions. Early repair during adolescence has been advocated, since clinically apparent varicoceles may affect testicular volume and sperm production in the future. We examined the efficacy of microsurgical varicocelectomy, and aimed to establish predictive parameters useful for ascertaining whether varicocele repair provides any benefits in adolescents and adults. METHODS: We carried out microsurgical varicocelectomy on nine boys and 19 men. In adolescents, catch-up growth of the testis, expressed by pre- and postoperative ratios of left and/or right testicular volume, grade and serum level of follicle-stimulating hormone (FSH) were evaluated. In adults, the ratio of sperm concentration improvement, grade, testicular volume, preoperative sperm concentration and serum FSH level were evaluated. All subjects were followed for 12 months. RESULTS: Catch-up growth was seen in 62.5% of boys. FSH level was significantly lower in boys with catch-up growth than in boys without catch-up growth. Improved sperm concentration was seen in 73.6% of adults. FSH level was significantly lower in adults with improved sperm concentration than in patients without improved sperm concentration. No correlations were seen between other parameters and catch-up growth in adolescents, or sperm concentration improvement in adults. CONCLUSIONS: Microsurgical varicocelectomy as a treatment for varicoceles with low FSH might be effective and the relevant predictive parameter for testicular development and function after surgery might be serum FSH level in both adults and adolescents.     

Minimal invasiveness and effectivity of subinguinal microscopic varicocelectomy: a comparative study with retroperitoneal high and laparoscopic approaches

AIM: The standard management of varicocele repair is the subject of ongoing controversy. We retrospectively evaluated three surgical methods of varicocele treatment to determine the minimally invasive and most effective procedure. METHODS: We performed 144 varicocelectomies on infertile patients with left clinical varicocele. Of the patients, 50 were treated with retroperitoneal high ligation under lumbar anesthesia, 33 with laparoscopic ligation under general anesthesia, and 61 with subinguinal microscopic ligation under local anesthesia. Operative time, hospital days, and clinical outcomes were compared between these techniques. RESULTS: The operating time and hospitalization period required for subinguinal microscopic ligation was signi fi cantly shorter compared to those for the other procedures. All patients treated with subinguinal microscopic ligation could achieve normal activity as soon as they returned to their rooms. Postoperative complications were observed in fi ve (10.0%) cases treated with high ligation and three (9.1%) laparoscopic cases, but were not observed after the subinguinal procedure. There were six cases (12.0%) of recurrence in the high ligation group and six (6.1%) in the laparoscopic group, but none in the subinguinal group. Sperm density was signi fi cantly improved in all procedures postoperatively, but sperm motility was not improved. The two-year pregnancy rate calculated by the Kaplan-Meier method was 35.8% for high ligation, 40.4% for laparoscopic ligation and 50.9% for subinguinal microscopic ligation, although there were no statistical differences between the three groups. CONCLUSION: We concluded that subinguinal microscopic varicocelectomy could be a minimally invasive procedure compared to the other two techniques and a worthy method for treating male infertility due to clinical varicocele.     

Effect of microsurgical varicocelectomy on fertility outcome and treatment plans of patients with severe oligozoospermia: An original report and meta-analysis

Varicocele ligation has been proven to restore semen parameters and improve pregnancy rates in men with clinical disease. However, its effect in men with severe oligozoospermia (SO) is less clearly elucidated. This original report and meta-analysis examined the impact of subinguinal microsurgical varicocelectomy on semen parameters and fertility outcomes of men with SO. A retrospective chart review of 85 patients was conducted on patients with SO who underwent microsurgical subinguinal varicocelectomy. A literature search was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 8 studies investigating the effects of varicocele ligation in men with SO were included for the meta-analysis. The original study reported significant improvements in semen parameters following surgery. 78 patients had a pre-operative TMSC < 5 million. Following surgery, 9 (11.5%) patients had a total motile sperm count (TMSC) between 5 and 9 million, while 14 (17.9%) patients had a TMSC > 9 million. Furthermore, the meta-analysis demonstrated a statistically significant increase in sperm count, total motility and TMSC following surgery. The reported natural pregnancy rate was 27.5%. Varicocelectomy does present as an important treatment option for SO patients because improvements in TMSC can broaden their fertility treatment options.     

Age is a significant predictor of early and late improvement in semen parameters after microsurgical varicocele repair

Accumulating evidence indicates that varicocele repair improves sperm quality. However, longitudinal changes in sperm parameters and predictors of improved semen characteristics after surgery have not been fully investigated. We retrospectively reviewed data from 100 men who underwent microsurgical subinguinal varicocele repair at a single centre. Follow‐up semen examinations were carried out at 3, 6 and 12 months post‐operatively. Logistic regression was used to identify predictors of early (3 months) and late (≥6 months) improvement in semen parameters after varicocele repair. At 3 months post‐operatively, 76.1% of the patients had improved total motile sperm counts, which continued to improve significantly up to 12 months post‐operatively (p = .016). When comparing changes in semen parameters between younger (<37 years) and older (≥37 years) men, post‐operative improvements in sperm concentration and motility were greater among younger men. Multivariate analysis showed that younger age was associated with early (p = .043) and late (p = .010) post‐operative improvement in total motile sperm count. Our findings indicate that early varicocele repair improved semen parameters after surgery.     

Impact of varicocelectomy on the proteome profile of testicular tissues of rats with varicocele

Varicocele (VC) is a common cause of male infertility, but the molecular mechanisms involved in its pathogenesis are unknown. We investigated the impact of varicocelectomy (VCT) on proteome profiles in testicular tissues of rats with VC, and analysed associated target genes and signalling pathways. Sixty male rats with VC were divided into two groups: control (n = 30), and VCT (n = 30). Tissues were collected 4 weeks after sham or VCT surgery. Matrix‐assisted laser desorption/ionisation time‐of‐flight/time‐of‐flight mass spectrometry (MALDI‐TOF/TOF MS) was used to analyse the comparative proteome profiles. Kyoto Encyclopaedia of Genes and Genomes (KEGG) Orthology‐Based Annotation System was used for bioinformatic analysis. Fifteen proteins were differentially expressed between control and VCT groups. These differentially expressed proteins are associated with several specific cellular processes associated with the pathogenesis of testicular growth arrest associated with VC. Furthermore, the evaluation by transmission electron micrograph showed that VCT could decrease apoptosis of spermatogenic cells in rats. Understanding such molecular pathways might provide physicians with a better insight into VC and with potential targets for treatment.     

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.     

结扎睾丸引带静脉对显微精索静脉曲张手术疗效的影响

目的:比较外环下显微精索静脉结扎术提出睾丸结扎引带静脉与不提出睾丸保留引带静脉的疗效及并发症。方法:回顾性总结163例精索静脉曲张患者术前及术后的临床资料,其中提出睾丸40例,不提出睾丸123例。比较不同手术方法在手术时间、术后并发症、复发率,以及术前、术后3个月精液质量的差异。结果:提出睾丸组手术时间(81.1±20.0)min,不提出睾丸组手术时间(62.3±9.6)min,两组间有统计学差异(P=0.041)。两组术后精子存活率、前向运动精子百分率、精子浓度以及1次射精总数均较术前显著改善(P0.05)。其中提出睾丸组Ⅲ度精索静脉曲张32例,不提出睾丸组Ⅲ度精索静脉曲张62例。两组间Ⅲ度曲张患者术前精子存活率、前向运动精子百分率、精子浓度、1次射精精子总数及术后3个月精子存活率、前向运动精子百分率、精子浓度、1次射精精子总数均无统计学差异(P均0.05)。提出睾丸组术后5例患者伴有阴囊水肿,不提出睾丸组术后2例患者伴有伤口感染。两组患者均无睾丸萎缩及精索静脉曲张复发。结论:外环下显微精索静脉结扎术提出睾丸结扎引带静脉与不提出睾丸保留引带静脉相比较,并没有更好的减少复发率和提高精液参数,反而更加延长手术时间以及引起阴囊水肿等并发症的发生。