الفهرس 
ANATOMY OF MALE GENITAL SYSTEMOnly 14 pages are availabe for public view
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Abstract
Varicocele is defined as dilatation of pampiniform plexus that has long
been recognized as treatable cause of male fertility.
Most varicocele is noted in teens or early life, however it is difficult to
estimate the exact incidence of varicoceles because most of them are
asymptomatic and impalpable and are diagnosed only with sonographic
evaluation. The left side is affected in 95 % of cases. Varicocele is the result of
retrograde flow of blood into the pampiniform plexus with subsequent dilatation
of the veins and formation of varicosities with stasis of blood. The etiology of
varicocele is probably multifactorial.
An adult male who is not currently attempting to achieve conception, but
has a palpable varicocele, abnormal semen analyses and a desire for future
fertility, is also a candidate for varicocele repair. Young adult males with
varicoceles, who have normal semen parameters, may be at risk for progressive
testicular dysfunction and should be offered monitoring with semen analyses
every one to two years, in order to detect the earliest sign of reduced
spermatogenesis.
The causes of varicocele are multifactorial, but the end result is a
pathological dilation of the veins draining the testicles, leading to increased
temperature in the seminiferous tubules and decreased sperm quality. Over
13.4% of the general population and 37% of infertile men will be diagnosed
with varicocele. A dramatic improvement can be seen after treating varicoceles,
especially in conjunction with other infertility treatment methods.
The spermatogenic function rate in patients who have undergone
varicocelectomy increases substantially from 14% with no treatment to 29.7%
Summary and Conclusion
86
after varicocelectomy, and up to 72% with varicocelectomy and in vitro
fertilization (IVF) in a 2-year period.
A number of techniques for varicocelectomy are practised worldwide,
including open surgical and laparoscopic techniques. Each of these approaches
has multiple sub-techniques and innovations, which can theoretically increase
fertility and decrease complications. These techniques have been well described
in the literature for diagnosis and indications for treatment have also been
published, but to date there has been no consensus on which technique should be
considered to be the ‘gold standard’.
The question of which is the best surgical procedure for treating
varicocele continues to be widely debated. However, treatment of this pathology
cannot only solve the clinical symptoms that are sometimes associated with it,
but it can also block ongoing damage in terms of spermatogenesis, potentially
improving fertility. Antegrade sclerotherapy could be considered a valid
alternative to other surgical techniques that are commonly used to correct
varicocele.
The inguinal procedure has the benefit of being able to ligate collaterals
as they come out from the inguinal ring, and is an easier approach in obese
patients. The collaterals seen at this level give the surgeon an opportunity to
ligate the external spermatic veins, which cannot be done in a high ligation as
with the Palomo’s technique. There have been modifications to this technique as
well: the term ‘modified inguinal or modified Ivanisevich’ is typically reserved
for artery sparing, but injection of dye into the lymphatics has also been used for
the lymphatic-sparing technique. In this technique the ileoinguinal nerve must
be identified and preserved. An operating microscope may be used to assist in
dissection. While laparoscopy has fewer recurrent varicoceles than nonmicrosurgical
open approaches, it is still used less frequently because of the
Summary and Conclusion
87
need for an experienced laparoscopic surgeon and the higher cost than for the
open techniques, including the microscopic technique.
Laparoscopic varicocelectomy had more reported complications and is
more invasive than other techniques. Local anesthesia can be used in open
surgical approaches, but laparoscopy will always require general anesthesia with
complete control over the respiratory system and acid-base status of the patient.
For each approach evaluated one or more researches reported
varicocelectomy as an outpatient procedure and in the absence of major
complications, it would appear that this is becoming standard. Recovery time
varied between different studies and within each approach, with return to work
ranging from 1–2 days to 2 weeks. Radiological embolization resulted in a
shorter time to discharge and return to work compared with other techniques,
and microsurgical subinguinal had the best recovery time of the surgical
techniques. Hospital stay and return to work time for the other techniques was
too varied to analyse.
While some recent studies have shown a statistically highly significant
increase in spermatogenic function after microsurgical techniques, other
publications show no change. Some studies reported a significant increase and
one did not. Other sdudies showed in other varicocelectomy there no significant
increase in spermatogenic functions after varicocele repair because the
complications effects of the sperm function. While an increase in spermatogenic
function may show an improvement of leydig cell function, this may not be an
accurate measure of improved spermatogenesis because it is intratesticular
testosterone, not serum testosterone that influences spermatogenesis. FSH levels
followed the expected trend: a postoperative decrease to normal or seminormal
ranges in level.
Summary and Conclusion
88
A variety of approaches have been advocated for management of
varicoceles but recent evidence supports the premise that the microsurgical
technique is the “gold standard. In a number of studies, it has been shown that
microsurgical varicocelectomy (inguinal or subinguinal) is superior to nonmicrosurgical
procedures with respect to the development of postoperative
complications such as hydrocele or recurrence. Hydrocele formation is believed
to be due to ligation of lymphatic channels and recurrence generally results from
incomplete ligation of collateral venous channels. Magnification of the
spermatic cord with the use of the operating microscope reduces the potential for
development of such complications. However, microsurgical varicocelectomy,
particularly the subinguinal approach, remains a technically challenging
procedure that requires microsurgical expertise.