Varicocele

Definition

An abnormal dilation of the pampiniform plexus of veins within the spermatic cord.

Epidemiology

15 % of healthy adult men have a varicocele
30 – 45 % of men undergoing investigation or evaluation for infertility have a varicocele
90 % left sided, 8 % bilateral, 2 % right
Peak age of presentation 15 – 25 years

Aetiology

Left gonadal vein is longer and with right-angled insertion to left renal vein (cf right side oblique insertion lower into cava)
- Increased hydrostatic pressure, turbulent flow and backflow on left side
May be venous valve insufficiency or absence, which may be congenital
Extrinsic compression
- Nutcracker – left renal vein can be compressed between aorta and SMA
- Retroperitoneal or renal mass, or venous tumour thrombus

Pathophysiology

Varicoceles can be associated with progressive testicular damage and infertility
Most widely accepted mechanism is relative testicular hyperthermia
Normally the counter-current exchange mechanism with the pampiniform veins surrounding the testicular artery maintains a lower temperature in scrotum cf. abdomen
- Dilated pampiniform plexus veins with venous statis reduces efficacy of counter current exchange -> higher scrotal temperatures
- Leydig cells are also temperature dependent (?emerging evidence varicoceles impact testosterone function too)
Other pathophysiological mechanisms include:
- Relative hypoxia and accumulation of reactive oxygen species
- Reflux of renal and adrenal metabolites which may be gonadotoxic

Grading

Palpable only with Valsalva
Palpable without Valsalva
Visible

0/subclinical – not palpable but seen on imaging.

History

Symptoms and level of bother
Consideration of other causes of symptoms
Previous inguinoscrotal surgery
General medical and surgical history including medications
Fertility history, future plans and partner factors
Other causes of infertility in history (toxins, infection/inflammation, childhood insults, sexual history)

Examination

Relaxed, warm room
Standing and supine
With and without Valsalva
Document size and size discrepancy of testes
Any other scrotal findings i.e. hydrocele
Scars from previous surgery, inguinal exam
Classically, if varicocele is from external compression, it will not reduce after lying supine from standing

Ultrasound

Veins (which appears as hypoechoic tubular structures) greater than 3 mm diameter, with reversibility of flow with Valsalva
Ideally performed standing and supine
Consider extending scan to include kidneys and retroperitoneum, particularly in unilateral right varicocele or a new varicocele in a man over 40 years old

Indications for varicocele management

Symptomatic
Size discrepancy in an adolescent
Infertility

No evidence-based role for treating men with:

Subclinical or non-palpable varicoceles
Normal semen analysis

Symptomatic

Should be counselled that pain or discomfort may not improve following treatment.

Rates of improvement or resolution are widely variable in studies, between 40 – 100 %.

No proven differences in techniques for symptom improvement.’

Size discrepancy in an adolescent

Significant risk of over-treatment if all adolescent varicoceles are treated – most boys with varicoceles will have no difficulty conceiving later in life.

Ipsilateral smaller testicle is suggestive of testicular dysfunction, and an accepted indications for treatment (EAU/AUA guidelines).

20 % discrepancy is associated with worse semen parameters.

Infertility

Repair of palpable varicoceles improves semen parameters in men with initially abnormal semen analysis (including improving spermatogenesis in non obstructive azoospermia). 70 % men get improvement.

Meta-analyses favour improved pregnancy rates after treatment of clinical varicoceles. (One meta-analysis showed no benefit overall, but when subclinical varicoceles and normal semen analysis are excluded there was clear benefit).

Average time to improvement is two spermatogenic cycles with spontaneous pregnancy generally 6 – 12 months later.

Varicocele repair improves motility most commonly, and also concentration and morphology.

Repair of sub-clinical or non-palpable varicoceles do not appear to improve rates of spontaneous pregnancy.

Treatment options

The artery and veins begin branching from the external ring and distally – therefore subinguinal approach needs to find more veins to ligate, and potentially more arteries to injure.

More proximal approach = less collaterals ; therefore less ischaemia risk but higher recurrence risk

Scrotal approach not recommended due to high rates of arterial compromise.

Open inguinal / subinguinal
Microscopic inguinal / subinguinal
Laparoscopic gonadal vein ligation
Retroperitoneal open
Percutaneous / radiological embolisation

	Pros	Cons
Open inguinal	Widely available	Higher hydrocele rates Higher recurrence rates
Microscopic	Lowest recurrence rates Good identification of all veins Preservation of lymphatics ?Best fertility outcomes	Specialist training Not widely available
Laparoscopic	Less invasive / better recovery cf open retroperitoneal Widely available Good for bilateral cases	Potential intra-abdominal injury Moderate recurrence rates Multiple incisions cf. one incision
Retroperitoneal	Good in kids	Higher recurrence rates
Embolisation	No incision, reduced recovery Minimal hydrocele	Higher recurrence rates Vascular risks and high radiation dose Availability and cost

	Hydrocele	Recurrence	Other risks
Open inguinal	7 %	5 – 10 %	Nerve injury (II, GF) Pain and time off Wound complications Testis atrophy
Microscopic	< 1 %	< 1 %	Bleeding/haematoma Testis atrophy
Laparoscopic	7 – 15 %	3 – 6 %	Bowel injury Pneumoscrotum Pain and time off Testis atrophy
Retroperitoneal	5 – 10 %	15 %	Scrotal oedema Testis atrophy Failure
Embolisation	< 5 %	10 – 20 %	Technical failure Contrast reaction Venous injury Coil migration / non target embolisation

Open retroperitoneal (Palomo):

Incision at point of deep ring (2 – 4 cm above mid point of inguinal ligament)
Expose and incise EOA
Retract internal oblique cranially, go through transversus into retroperitoneum
Push peritoneum medially exposing vessels and vas as they enter into deep ring
Traction on testis may help exposure
Ligate gonadal vein avoiding vas. Taking artery at this level shouldn’t matter.

Microscopic:

Most doing subinguinal – expose cord over Penrose or similar a la orchidectomy
Consider intra-operative Doppler to identify arteries (or drip papaverine on to field)

Laparoscopic:

Infraumbilical + triangular ports lateral to rectus and suprapubic
Supine but head down and tilt to side to get bowel out of way
Identify deep ring, release sigmoid if needed
Incise and retract peritoneum
Look for any peri-arterial veins, can take artery if needed
- Take everything off the artery to ensure all veins / venae comitantes taken
Liga-clips and scissors