Varicocele

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Varicocele Facts or Fiction
Dr. Gil Raviv Urology Department Andrology
Unit Sheba Medical Center
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Definition
Varicocele - Facts or Fiction
Varicocele is a vascular abnormality of the
scrotum that is defined as dilated veins of the
pampiniform plexus.
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Anatomy
Varicocele - Facts or Fiction

• 90 left side.
• 10 bilateral.
• Most commonly - internal spermatic veins.
• Others
• External spermatic veins.
• Cremasteric veins
• Rarely appears - deferential veins

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Pathophysiology
Varicocele - Facts or Fiction

• Is not known for certain.
• Various theories for testicular damage due to
  incompetent valves of spermatic veins
• Increased testicular pressure.
• Hypoxia and stasis.
• Increased testicular temperature.
• Elevated spermatic vain catecholamines.

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Prevalence
Varicocele - Facts or Fiction
General population - 15-20 Attending infertility
clinics - 30-40
WHO (project 78923) General population -
11.7 Abnormal semen parameters - 25.4
(Fertile-Sterile 1992)
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Diagnosis
Varicocele - Facts or Fiction

• Various methods
• Radio nuclide examination - high false negative -
  depends on blood pooling.
• Scrotal Thermography - rarely used.
• Doppler stethoscope- only for confirmation.

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Diagnosis
Varicocele - Facts or Fiction

• Scrotal real time Ultrasonography - widely used
  with high specificity and sensitivity.
• Venography - most accurate diagnostic method.

Venographic data supports ultrasound examination
only in cases of clinically suspected cases.
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Varicocele - Facts or Fiction

Diagnosis
No single diagnostic tools available provides
both exceptional sensitivity and specificity in
varicocele detection.
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Diagnosis
Varicocele - Facts or Fiction

• The most acceptable methods of diagnosis is
  clinical examination based on clinicians
  subjective impression.

Grade 1 - palpable - valsalva manoeuvre. Grade 2
- palpable - without valsalva manoeuvre. Grade
3 - visible.
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Varicocele - Facts or Fiction
Diagnosis
Subclinical Varicocele

• Detected only by radiological imaging.
• Controversy exists
• Diagnosis.
• Treatment.
• Pregnancy rate.

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Varicocele - Facts or Fiction
Varicocele in adolescence

• Rarely found before puberty.
• Varicocele during adolescence is
• Asymptomatic.
• Found on routine examination.
• Kass. Urol.Clin 1994

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Varicocele in adolescence
Varicocele - Facts or Fiction

• INDICATION FOR TREATMENT
• ABNORMAL SEMEN ANALYSIS
• VOLUME OF LEFT TESTIS 3 ML LESS THEN RIGHT.
• LARGE SYMPTOMATIC VARICOCELE.
• BIL PALPABLE VARICOCELE.

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Varicocele in adolescence
Varicocele - Facts or Fiction

• The best method of treatment remains a dilemma.
• PECUTANEOUS ABLATION
• Recurrence rate - 6-15 .
• One to three hours .
• Sedation in addition to local anesthesia.
• Reserved for cases of failed surgery.

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Varicocele in adolescence
Varicocele - Facts or Fiction

• TRANSPERITONEAL LAPAROSCOPY
• Presently not considered as first- line
  therapy.
• General anesthesia.
• Potential major complications.
• High cost.

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Varicocele - Facts or Fiction
Varicocele in adolescence

• DOES IT A DYNAMIC PROGRESSIVE LESION?
• HISTOLOGY
• Lesions are similar to adults.
• Similar in both testis.
• May precede volume loss.
• No predicting data on reversibility.

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Varicocele in adolescence
Varicocele - Facts or Fiction

• SURGERY
• Palomo -Retropertoneum- above level of vas
  deferenes.
• Artery - sparing procedure.
• Ivanissevitch- inguinal canal the most
  commonly used.

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Varicocele in adolescence
Varicocele - Facts or Fiction

• Routine varicocele ligation in teenager is not
  recommended.
• Occlusion of the left internal spermatic vein in
  young men with varicocele should be performed
  only in the context of an appropriately large
  prospective study.
• RCOG study group, 1995.
• Variable ligation methods are performed depend on
  the physician skills.

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CONTROLLED STUDIES - EFFECTIVNESS OF
VARICOCELECTOMY
Varicocele - Facts or Fiction

• NIESCHLAG (1995,1998 Hum Reprod ).
• 125 infertile couples.
• 62 - varicocelectomy.
• 63 - counseling.

W - intervention B- counseling
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CONTROLLED STUDIES - EFFECTIVNESS OF
VARICOCELECTOMY
Varicocele - Facts or Fiction

• NIESCHLAG CONT.
• No relationship to pregnancy rate.
• Semen analysis.
• Hormone profile.
• Varicocele grade.
• Age of male.
• Only female age predict pregnancy
• Sperm count increased.

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CONTROLLED STUDIES - EFFECTIVNESS OF
VARICOCELECTOMY
Varicocele - Facts or Fiction

• Baker et al 1985 (I .J Androl ).

651 couples. 324 males - sperm count less then 20
x 106. 327 males - sperm count more then 20 x
106. No difference in pregnancy rate. Sperm
motility improved
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CONTROLLED STUDIES - EFFECTIVNESS OF
VARICOCELECTOMY
Varicocele - Facts or Fiction

• Vermuelen (1986 , J. Androl ).
• 90 patients - varicocelectomy.
• 25 patients - observation.
• Cumulative PR were the same.
• Both improved sperm characteristics.

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CONTROLLED STUDIES - EFFECTIVNESS OF
VARICOCELECTOMY
Varicocele - Facts or Fiction

• Rageth (1992, Urol Int ).
• 89 patients.
• 56 varicocelectomy - 33 observation.
• All had poor semen analysis.
• The same PR ( 42 ).
• Surgery group all had improved sperm
  characteristics.

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CONTROLLED STUDIES - EFFECTIVNESS OF
VARICOCELECTOMY
Varicocele - Facts or Fiction

• Rodriguez-Rigau (1978. J Urol ).
• Controlled not prospective not randomized.
• No difference in PR.
• Sperm count and motility improved after surgery.

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Controlled studies supporting varicocelectomy
Varicocele - Facts or Fiction

• Marmar and KIM (1994,J Urol).
• 466 surgery group/19 controls.
• PR surgery group 35.6 ( 186/466).
• PR controls 15.8

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Controlled studies supporting varicocelectomy
Varicocele - Facts or Fiction

• Girardi and Goldstin(1997 Curr Ther Endocrine
  Metab).
• 1500 underwent varicocelectomy.
• 47 controls group.
• PR- 43 surgery group versus 17 controls
  group.
• Improvement of sperm count.

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Controlled studies supporting varicocelectomy
Varicocele - Facts or Fiction

• WHO study never published in its original form.
• 9034 infertile couples.
• 1326 had clinical varicocele.

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Controlled studies supporting varicocelectomy
Varicocele - Facts or Fiction

• Hargreave.
• PR after surgery - 35 .
• PR controls group 17 .
• Part of WHO study presented only at andrology
  meeting!

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Controlled studies supporting varicocelectomy
Varicocele - Facts or Fiction

• Madgar et al (1995 ,Fertile Sterile).
• 210 couples from the WHO study.
• 45 couples - 20 controls group. 25 high
  ligation spermatic vein.
• PR surgery group 60 .
• PR controls group 10 .

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Controlled studies supporting varicocelectomy
Varicocele - Facts or Fiction

• TREATMENT IN ADULTS
• WHICH MODALITY IS THE BEST ?
• Comparison by three outcome measures
  Success rate.
• Semen improvement and pregnancy rate.
• Complication rate.

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Varicocele - Facts or Fiction
Varicocele - Facts or Fiction

• Success rate
• Recurrence or persistence after treatment.
• High ligation 11 - 15.
• Inguinal ligation 6 - 9.
• Percutaneous ablation 4 - 24.
• Laparascopic 0 - 11.

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Varicocele - Facts or Fiction
Varicocele - Facts or Fiction

• Semen improvement and pregnancy rate
• No differences in pregnancy rate in all kinds
  of treatment.
• Improvement of sperm - occasionally.

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Varicocele - Facts or Fiction
Varicocele - Facts or Fiction

• Complication rate
• Laparascopic ligation 0.6 - 4
• Operative-inguinal approaches
• - Artery damage.
• - Ilioinguinal nerve damage.
• - Scrotal hematoma.

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Varicocele - Facts or Fiction
Varicocele - Facts or Fiction

• Complication rate - cont.
• Operative-retroperitoneal approaches
• - Artery damage.
• - hydrocele (7).
• Percutaneous ablation
• - Contrast allergy (2).
• - Injuries to vascular tree.
• - Migration and embolization.

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Varicocele - Facts or Fiction
Varicocele - Facts or Fiction

• Complication rate - cont.
• Operative-laparascopic approaches
• - Injured epigastric vessels.
• - Rarely bowel injury.
• - High cost.

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Varicocele - Facts or Fiction
Varicocele - Facts or Fiction

• CONCLUSIONS (1)
• There is insufficient evidence to recommended
  occlusion of the left internal spermatic vein
  in subfertile or oligozoospermic men with
  varicocele.
• (gynecologists).

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Varicocele - Facts or Fiction
Varicocele - Facts or Fiction

• CONCLUSIONS (2)
• Varicocele exert deleterious effect upon
  both testis and its function - therefore
  treatment is recommended in large varicocele
  with reduced testis volume in adolescence.

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Varicocele - Facts or Fiction
Varicocele - Facts or Fiction

• CONCLUSIONS (3)
• Correlation exists between varicocele size
  and seminal improvement.
• Diagnosis and treatment of subclinical
  varicocele is not recommended.
• Timing of varicocele correction is not
  determine.

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Varicocele - Facts or Fiction
Varicocele - Facts or Fiction

• CONCLUSIONS (4)
• Correction of varicocele depends on female
  age.
• Sperm cryopreservation and varicocele
  correction is recommended in patients with
  severe OTA and high FSH.

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Varicocele - Facts or Fiction
Varicocele - Facts or Fiction
SPECIAL CONDITION AND VARICOCELE

• Azoospermia . FSH- normal/abnormal?

• Very severe OTA. High/normal FSH?

• Recurrent varicocele?

• Bilateral varicocele. Operating
  one side/ both ?
• ?open/laparoscopy Type of operation

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VARICOCELE AND OTHER SPECIAL CONDITION
 Recurrence - Type of treatment?
Surgery/Embolization
Improved sperm count.

• Undesending testicle in the same side?

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VARICOCELE AND OTHER SPECIAL CONDITION
Failed embolization. - Type of treatment.
Varicocele in older men .
Right side.
Couple after few cycle of IVF-ICSI.
Isolated teratoastonespermia.

• Pain only.