Internal Spermatic Vein to Superficial Epigastric Vein Microsurgical Bypass in Varicocele Treatment

INTRODUCTION

 Identification and preservation of testicular artery and lymphatic vessels during microsurgical varicocelectomy can be tedious if adhered encompassing venous network is encountered. A venous bypass from internal spermatic to saphenous or inferior epigastric vein, that have been described for varicocele treatment, may be used in such situations. This paper describes a simplified modification of the venous bypass technique that reroutes the testicular blood to the superficial epigastric vein, which can easily be found in the incisional wound. Surgical technique and anastomotic patency test are described, and indications and results are discussed.

MATERIALS AND METHODS

 During 2020 and 2021, 32 adolescent patients underwent microsurgical varicocelectomy. In eight patients additional microsurgical testicular vein-superficial epigastric vein microvascular bypass was done. The indication for bypass was difficult identification of testicular artery and/or lymphatic vessels due to adhered venous plexus.

RESULTS

 Varicocele resolution was noted in all eight patients with clinical and/or semen analysis improvement. There were no complications or recurrences. Average length of procedure was 65 minutes. All patients were discharged within 24 hours and no antiplatelet or anticoagulant therapy was used.

CONCLUSION

 Testicular vein to superficial epigastric vein anastomosis is a useful and simplified venous bypass technique that reroutes the blood from the pampiniform plexus to the femoral vein. It can be done as an adjunct to microsurgical varicocelectomy in selected patients through a standard incision.

Spontaneous spermatic vein thrombosis in pediatric patients: A condition to be considered

Spermatic vein thrombosis is a very rare pathology, with 25 cases published only, 6 of which in patients under 15 years of age. We present the case of a male patient, as well as a review of the literature. A 12-year old boy presented at emergency with 3-day progressive testicular pain. Following abdominal Doppler ultrasound imaging, he was diagnosed with left spermatic vein thrombosis and nutcracker syndrome. Admission and enoxaparin treatment were decided upon. Patient evolution was satisfactory, with subsequent ultrasound imaging demonstrating the absence of thrombus. The patient is currently under follow-up and without treatment. Various treatments are mentioned in the literature, with conservative management being the treatment of choice.

Left spermatic vein reflux after varicocele repair predicts pregnancies and live births in subfertile couples

PURPOSE

Varicocele repair (VR) is proposed to improve fertility in subfertile couples with a poor semen quality. We explored whether the disappearance of a left continuous spermatic venous reflux (SVR) at scrotal colour-Doppler ultrasound (CDUS), an objective evidence for a VR, is predictive for improved fertility outcome in subfertile couples.

METHODS

VR was performed by left internal spermatic vein sclero-embolisation in 88 males seeking a consultation for subfertility. Semen analysis and scrotal CDUS were evaluated before and 6 months after VR. Serum levels of FSH and total testosterone (TT) were obtained at baseline. Telephone interview was used to obtain information about fertility outcome. Significant predictors of pregnancy and live births, selected by univariate analyses, were included into multiple logistic regression models to assess independent associations.

RESULTS

At the adjusted model, independent significant predictors of pregnancy after VR were a disappeared SVR at CDUS (OR = 5.5, 97.5% CI 2.01-15.4; p = 0.0009) and an improved sperm total motile count (TMC) (OR = 5.5, 97.5% CI 1.4-27.9; p = 0.02). Even live births were independently associated with both disappeared left SVR at CDUS (OR = 4.3, 97.5% CI = 1.6-11.8; p = 0.003) and improved TMC after VR (OR = 4.8, 97.5% CI 1.3-24.2; p = 0.02).

CONCLUSION

The still controversial effect of varicocele repair on fertility in subfertile couples may reside on the undefined objective methods to document a successful VR and its effect on couple fertility. The disappearance of a continuous left SVR at CDUS after VR was the objective best predictor for subsequent improved fertility in subfertile couples.

Anatomic mapping of the internal spermatic vein via subinguinal varicocelectomy with intraoperative vascular Doppler ultrasound

BACKGROUND

Varicocele is believed to be a dilated vein of the pampiniform plexus along the spermatic cord. Surgical treatment should be considered in men with a symptomatic varicocele. To date, microsurgical varicocelectomy is the most effective method among various varicocelectomy techniques, according to the current evidence. This study aimed to evaluate the effectiveness of subinguinal varicocelectomy with intraoperative vascular Doppler for symptomatic varicocele and map the distributional trend of spermatic content simultaneously.

METHODS

A total of 24 male patients underwent subinguinal varicocelectomy with intraoperative vascular Doppler ultrasound between March 2016 and October 2017, because of symptomatic varicocele or infertility. The numbers, sizes, and location of spermatic vessels in each site were recorded during operation. The visual analogue scale (VAS) score of scrotal pain was also obtained before and after surgery.

RESULTS

The mean number of spermatic veins that were ligated in each spermatic unit was 4.70 (±2.06). The predominant distributional zone of spermatic veins was the medial upper zone on an axial view of the spermatic cord. Fifty-six (44.1%) spermatic veins were found in this zone. Normally, each spermatic cord has 1.33 (±0.61) spermatic arteries. The average VAS score prior to surgery was 1.95 (±0.89) and it decreased to 0.05 (±0.21) after the surgery. Complete resolution of pain was observed in almost all symptomatic patients (95.23%). A significant positive relationship between the number of veins ligated and improvement of VAS score was also noted (p < 0.05).

CONCLUSION

Subinguinal varicocelectomy with intraoperative vascular Doppler ultrasound is an effective treatment for symptomatic varicocele. The more the internal spermatic veins are ligated, the more the VAS scores are improved. Determining the distributional trend of spermatic content is of great importance in the prevention of iatrogenic injury to the spermatic vessels and vas deferens.

Spermatic vein aneurysm: a report of a unique case and review of the literature

A spermatic vessel aneurysm is a rare entity, described only a few times in the literature. In most cases, it is caused by trauma or inflammation and appears as a painful mass in the scrotum or the inguinal area. We present a case of a 22-year-old man who came to our Surgical Department with a painful, palpable mass in the right inguinal area. A spermatic vein aneurysm was diagnosed with the use of ultrasonography and it was surgically excised. The findings were confirmed by pathological examination. The patient is well, four months after surgery. A spermatic vessel aneurysm, though rare, should always be included in the differential diagnosis of a scrotal or inguinal mass. The lesion can be cured by surgical resection.

Modified Inguinal Microscope-Assisted Varicocelectomy under Local Anesthesia: A Non-randomised Controlled Study of 3565 Cases

Varicocele is a common abnormality, but the conventional microsurgical subinguinal varicocelectomy (CMSV) has some disadvantages. We invented Modified Inguinal Microscope-Assisted Varicocelectomy (MIMV) under local anesthesia. This study aims to evaluate MIMV by comparing it to CMSV in operating duration, time to return to normal activity, postoperative complications, achievement of natural pregnancy and improvement of semen quality for patients with infertility, pain score for those with scrotal pain, and so on. We enrolled 3089 patients who underwent MIMV and 476 who underwent CMSV in our hospital. Both the operating duration and the time to return to normal activity of MIMV was shorter than that of CMSV (P < 0.001). The recurrence rate (P < 0.001) and injury rate of vas deferens (P = 0.011) after MIMV were lower than that after CMSV. Moreover, patients with MIMV showed higher degree of satisfaction with the surgery experience and outcome than those with CMSV (P < 0.001). However, no statistical difference was found between the two groups in scores of pain due to surgery, postoperative varicose veins diameters, reflux duration, and the postoperative complications of wound infection, hydrocele, atrophy of testis, epididymitis, and scrotal hematoma. In summary, MIMV is a promising varicocelectomy and could be applied more in clinical practice.

[ULTRASTRUCTURAL CHARACTERISTICS OF RATS TESTICLES UNDER SPERMATIC CORD STENOSIS AND AFTER BLOOD FLOW RESTORATION BY DIFFERENT METHODS]

Hemodynamic disorders in the testicles cause chronic organ hypoxia with damage of its stroma and seminiferous tubules, which plays a leading role in the pathogenesis of the testicular form of male infertility development. The aim of the work was to establish the features of ultrastructural reorganization of the testicles tissue and its vascular bed under circulatory hypoxia conditions and after restoration of blood flow in the organ. The study was conducted on 84 white adult male rats. The control group consisted of 12 intact animals. The experimental group was divided into 3 series: with stenosis of the spermatic cord (48 animals), with stenosis of the spermatic cord and its recanalization on the 3rd day without correction (12 animals) and with stenosis of the spermatic cord and its recanalization with correction on the 3rd day (12 animals). Under conditions of dosage spermatic cord stenosis (when the ligature is applied) in the remote monitoring period, with electron microscopic study, were detected destructive changes of spermatid and spermatozoa, which were combined with significant focal intracellular and extracellular edema. In part of the cells heads were deformed, the acrosomes were sophisticated and fragmented. At one-stage decompression of the spermatic cord (removal of the stenosing ligature on the third day), the above-described changes in accordance were deepened. At 14th day of the observation, collagen fibers and an electron-transparent amorphous component were found in the perivascular space. When the proposed method of dosed decompression of the spermatic cord (successive removal of three stenosing ligatures of different diameters) has been applied changes in the testicles parenchyma and its intraorganic vessels were less severe. Functional activity of the testicle after correction of reperfusion changes, was not significantly affected, what was proved by the presence in seminiferous tubules lumen of spermatozoa mature forms.

[Microscopic spermatic vein ligation for the treatment of varicocele]

OBJECTIVE

To explore the effect of spermatic vein ligation under the microscope in the treatment of varicocele (VC).

METHODS

A total of 120 VC patients received in our department from September 2011 to February 2015 were randomly divided into an experimental and a control group of equal number, the former treated by microscopic spermatic vein ligation and the latter by conventional open high ligation. Comparisons were made between the two groups of patients in the internal diameters of the spermatic vein during eupnea and Valsalva maneuver, the reflux time of the spermatic vein, blood flow parameters of the testicular artery, and semen quality before and at 3 months after surgery.

RESULTS

At 3 months after surgery, the experimental group, as compared with the control, showed significantly decreased reflux time of the spermatic vein (［0.41 ± 0.10］ vs ［1.08 ± 0.10］ s, P <0.05) and peak systolic velocity (9.26 ± 1.35 vs 10.64 ± 1.28, P <0.05) and resistance index (0.52 ± 0.03 vs 0.61 ± 0.03, P <0.05) of the testicular artery but markedly increased internal diameters of the spermatic vein during eupnea (［1.63 ± 0.07］ vs ［1.59 ± 0.06］ mm, P <0.05) and Valsalva maneuver (［1.72 ± 0.05］ vs ［1.68 ± 0.07］ mm, P <0.05), sperm concentration (［46.84 ± 5.24］ vs ［35.35 ± 4.26］ ×10⁶/ml, P <0.05), sperm motility (［63.75 ± 7.73］ vs ［53.87 ± 6.46］ %, P <0.05), and total sperm count (［89.54 ± 7.95］ vs ［75.24 ± 8.43］ ×10⁶/ml, P <0.05).

CONCLUSIONS

Microscopic spermatic vein ligation has a definite effect in the treatment of varicocele, which can significantly improve the testicular blood flow and semen quality of the patient.

[Laparoscopic extraperitoneal high ligation of the spermatic vein for the treatment of varicocele]

OBJECTIVE

To investigate the effect of laparoscopic extraperitoneal (LSEP) high ligation of the spermatic vein in the treatment of varicocele.

METHODS

We retrospectively analyzed the clinical data about 80 cases of varieocele, 48 treated by LSEP and the other 32 by laparoscopic transabdominal retroperitoneal (LSTR) high ligation of the spermatic vein. We recorded the semen parameters before and at 1, 3 and 6 months after surgery, intraoperative blood loss, operation time, postoperative complications, time of gastrointestinal function recovery and rate of pregnancy, followed by comparison of the data obtained between the two groups of patients.

RESULTS

Semen parameters were remarkably improved in both the LSEP and LSTR groups of patients postoperatively as compared with the baseline (P <0.05), but with no statistically significant difference at different postoperative months (P >0.05). The intraoperative blood loss was less in the LSEP than in the LSTR group (［8.3 ± 5.2］ vs ［9.1 ± 6.1］ ml, P >0.05), the operation time was shorter in the former than in the latter (［38.27 ± 9.23］ vs ［43.46 ± 11.72］ min, P >0.05), and so was the time of gastrointestinal function recovery (［1.27 ± 0.26］ vs ［2.43 ± 0.41］ d, P <0.05). No statistically significant differences were observed between the two groups during the 6- to 18-month follow-up in the rates of postoperative subcutaneous hematoma, scrotal and subcutaneous emphysema, recurrence, or pregnancy (P >0.05).

CONCLUSIONS

Laparoscopic extraperitoneal high ligation of the spermatic vein is safe and effective and has the advantage of quick recovery in the treatment of varicocele.

Determination of spermatic vein reflux after varicocele repair helps to define the efficacy of treatment in improving sperm parameters of subfertile men

PURPOSE

A continuous spermatic venous reflux (SVR) at colour Doppler ultrasound (CDU) is an evidence for varicocele, a frequent correlate for male subfertility. We explored whether SVR after left varicocele repair is predictive for changes in semen quality in subfertile men.

METHODS

Blood hormones (FSH, LH, and total testosterone) and scrotal CDU were obtained in subfertile patients with left grade II or grade III varicocele on physical evaluation and a poor sperm quality. Semen analysis and CDU were re-evaluated 6 months after a retrograde internal spermatic vein scleroembolisation.

RESULTS

The retrospective study included 100 men with a baseline SVR >3 cm/s; 60 men showed a disappearance (group 1) and 40 men (group 2) showed a reduced SVR after varicocele repair. Total motile sperm count (TMC) was markedly increased after treatment (p < 0.0001; F = 35.79) and the increase was more relevant in group 1 compared to group 2 (p = 0.04; F = 4.20). TMC and left SVR values after varicocele repair were negatively correlated (R = -0.218; p = 0.035). Multivariate analysis showed that adjusted SVR after repair negatively predicted TMC change (TMC after repair minus baseline TMC) (ß = -2.56; p = 0.022). Disappearance of a continuous left SVR at CDU after varicocele repair was associated to a better improvement of semen parameters in subfertile men.

CONCLUSION

Recording of a continuous left spermatic vein reflux is an objective method to assess a successful varicocele repair aimed to improve sperm parameters in subfertile men.

Regenerative Potential of Stem and Progenitor Cells from Ischemic Testes of C57Bl/6 Mice in Culture and in the Model of Spermatogenesis Suppression Caused by Busulfan

The regenerative potential of stem and progenitor cells from ischemic testes of C57Bl/6 mice was studied in vitro (cell culture) and in vivo (mouse model of busulfan-induced suppression of spermatogenesis). Spermatogonial stem cells with phenotypes CD117^-CD90⁺ and CD51^-CD24⁺CD52⁺ from ischemic testes demonstrated 33-fold and 7-fold increments of cell mass and generated colonies in vitro. Epithelial (CD45^-CD31^-Sca-1⁺CD49f⁺) and endothelial (CD45^-CD31⁺) precursors exhibited lower self-renewal capacity. On day 30 after injection of stem and progenitor cells from ischemic testes to the rete testis zone of the testes of busulfantreated animals, an increase in the count of CD117^-CD90⁺ spermatogonial stem cells, total count, and mobile sperm count in the testes of recipient mice was observed. In addition, we observed an increase in Sca-1⁺ cell count, recovery of the spermatogenic epithelium in the seminiferous tubules, and appearance of immature Leydig cells in "busulfan" testes; the level of tissue testosterone and fertility index also increased.

A Novel Approach of Microscopic Subinguinal Varicocelectomy With a "Pulling" Strategy

OBJECTIVE

To investigate the safety and efficacy of a novel approach of microscopic subinguinal varicocelectomy with a "pulling" strategy.

MATERIALS AND METHODS

Fifty-two male patients with varicocele were enrolled in this study. Twenty-six patients underwent conventional microscopic subinguinal varicocelectomy, whereas the remaining 26 patients accepted our novel approach of treatment. In this method, with a subinguinal incision, we dissociated the spermatic cord from the external ring. And thus we pulled the spermatic cord down and away from the external ring and exposed the spermatic cord that initially was proximal to the external ring in the surgical field. The remainder of the procedure was similar to that of the conventional method. Follow-up was made at 1 and 3 months. Postoperative complications were recorded and sperm parameters were evaluated by semen analysis.

RESULTS

Fewer vein branches were ligated in the novel method group compared with the conventional method group (6.9 ± 2.1 vs 9.8 ± 2.2, P < .001; t = -5.316). There was no significant difference in the number of testicular arteries or lymphatic ducts between the 2 groups. The mean microsurgical operative time in the novel method group was significantly shorter than that in the conventional method group (34.7 ± 6.5 minutes vs 45.7 ± 8.8 minutes, P < .001; t = -5.621). The incidence of postoperative complications was similar for the 2 groups. There was no significant difference regarding semen quality improvement between the 2 groups.

CONCLUSION

This study demonstrates that our novel approach of microscopic subinguinal varicocelectomy with a "pulling" strategy significantly reduces the number of internal veins to ligate and shortens operating time, with no increase in complications. It is a safe and effective method of varicocele treatment.

Association between Clinical and Ultrasonic Characteristics of Varicocele and Lower Extremity Varicose Vein in Men

BACKGROUND

The study investigated the association between lower extremity varicose veins in men and varicocele.

METHODS

A total of 100 patients who presented to the Department of Vascular Surgery in the First Affiliated Hospital of Anhui Medical University with the diagnosis of lower extremity varicose veins were included in the study group. A total of 100 adults without vascular disease were included as controls. The prevalence of varicocele between the study group and the control group was compared. We compared the prevalence of varicocele and the mean diameter of spermatic veins between the patients with and without reflux in the saphenofemoral junctions. We analyzed the association between the maximum spermatic vein diameter and the maximum diameter of lower extremity varicose veins in patients who had both lower extremity varicose vein and varicocele in the study group. According to their clinic signs, patients with lower extremity varicose veins were divided into C1-C6 by clinic sign grade of Clinical-Etiology-Anatomy-Pathophysiology (CEAP), and we investigated the trend of the incidence of varicocele and the mean diameter of spermatic veins in different grades.

RESULTS

The patients with lower extremity varicose veins had a statistically significant (χ² = 20.05, P < 0.01) higher rate of varicocele when compared with controls. We compared the prevalence of varicocele and the mean diameter of spermatic veins between the patients with and without reflux in the saphenofemoral junctions and found no statistically significant differences between them (prevalence of varicocele P > 0.05, diameter P > 0.05). We found a linear correlation between the maximum spermatic vein diameter and the maximum diameter of lower extremity varicose veins in the patients who had both lower extremity varicose veins and varicocele in the study group (coefficient of rank correlation r = 0.4072, P < 0.01). The patients in the study group were classified into 6 grades by CEAP. After the analysis by trend chi-square, we found that the prevalence of varicocele had no statistical trend in different grades (χ² = 0.8798, P > 0.05), and the mean diameter of spermatic vein also had no statistical trend in different grades (F = 1.59, P > 0.05).

CONCLUSIONS

In conclusion, we demonstrated that the prevalence of varicocele is higher in patients with varicose veins in lower extremity than the patients without vascular diseases. The reason for the association between varicose vein in lower extremity and varicocele remains uncertain.

A Rare Anatomical Variant of Spermatic Vein as Cause of Recurrence After Surgical Correction of Varicocele

Varicocele may be treated with many different modalities, including radiologic and surgical approaches, but what is the best treatment remains controversial. The recurrence rate following varicocele repair ranges from 0.6% to 35% depending upon the technique used. We describe in detail a rare anatomical variant of the left internal spermatic veins and the appropriate treatment of recurrent varicocele with percutaneous scleroembolization. In case of recurrent varicocele after surgical repair, knowledge of anatomical variability of internal spermatic veins is essential for treatment planning.

Can We Predict the Outcome of Varicocelectomy Based on the Duration of Venous Reflux?

OBJECTIVE

To investigate the outcome of varicocelectomy based on the duration of venous reflux (DVR) of the pampiniform plexus veins.

MATERIALS AND METHODS

In total, 138 patients with clinically palpable varicoceles were evaluated for DVR with color Doppler ultrasonography from May 2009 to August 2014. The DVR was defined as the DVR of a varicocele in the supine position during the Valsalva maneuver. Patients with bilateral, recurrent, or subclinical varicoceles; hormonal imbalances involving follicle-stimulating hormone, luteinizing hormone, or total testosterone; azoospermia; and intraoperative or postoperative complications were excluded. Of the 138 patients, 76 met the inclusion criteria. All patients were treated with subinguinal microscopic varicocelectomy. Restoration of all three semen parameters (concentration, motility, and morphology) to normal values 6 months postoperatively was considered to indicate treatment success. The patients were divided into those with a DVR of <4.5 seconds (Group 1) and ≥4.5 seconds (Group 2).

RESULTS

The mean age of the patients was 29.39 (±6.03) years. No statistically significant relationship was found between the success rate and varicocele grade. The cutoff DVR value was calculated as 4.5 seconds using a receiver operating characteristics curve according to patients who underwent successful treatment. The success rates of Groups 1 and 2 were 40.0% and 88.2%, respectively (P = .0001).

CONCLUSION

The results of this analysis indicate that a DVR of ≥4.5 seconds predicts better outcomes of varicocelectomy.

Comparison between Microsurgical Subinguinal Varicocelectomy with and without Testicular Delivery for Infertile Men: Is Testicular Delivery an Unnecessary Procedure

PURPOSE

Controversy still exists as to whether testicular delivery during microsurgical subinguinal varicocelecto­my (MSV) provides benefit to the patient or not. This study specifically compared the therapeutic effect of MSV with and without testicular delivery for the treatment of varicocele in a cohort of infertile men.

MATERIALS AND METHODS

We conducted a prospective, randomized, controlled study to evaluate the therapeutic efficacy of MSV with and without testicular delivery for the treatment of varicocele in infertile men. A total of 100 patients were specifically recruited using strict inclusion criteria to undergo MSV with testicular delivery (group 1, n = 50) or MSV without testicular delivery (group 2, n = 50). All patients were followed-up at 3, 6 and 12 months following surgery. Semen parameters, pregnancy and recurrence rates, and complications were monitored.

RESULTS

Mean surgical time for group 1 was significantly longer than group 2 (90.50 ± 15.60 min vs. 84.30 ± 15.58 min; P = .001). Sperm count and motility were significantly improved at the 12-month follow-up appoint­ment in both groups compared with pre-operative values, but were not significantly different at 3, 6, and 12 months when compared between the two treatment groups. The incidence of scrotal edema, and spermatic/testicular en­gorgement were higher in group 1 (both P = .001), although natural pregnancy rate was not significantly different between the two groups at the 12 month follow-up appointment (46% vs. 42%) (P = .817).

CONCLUSION

MSV with testicular delivery did not reduce the risk of recurrence and led to improved semen quality compared with MSV without testicular delivery. However, there was a higher risk of complication with this tech­nique, which must be borne in mind when considering the clinical implications of our dataset.

Antegrade venography identifies parallel venous duplications in the majority of adolescents with varicocele

PURPOSE

We performed intraoperative antegrade venography to assess the prevalence of internal spermatic venous malformations in adolescents with varicocele.

MATERIALS AND METHODS

During a 2-year period 58 adolescent males with visible or palpable varicocele underwent antegrade venography before varicocele surgery. Antegrade venography was performed through a scrotal incision. A vein within the pampiniform plexus was cannulated and up to 1.75 mg/kg iohexol 300 mg/ml was injected to outline the entire length of the internal spermatic vein. The radiographs were reviewed and classified according to Bähren and Murray criteria.

RESULTS

Of the patients 43 (74.1%) demonstrated parallel duplications (Murray classification type P) of the internal spermatic vein. This rate is higher than the 2% reported based on retrograde venography. Of the patients with parallel duplications 21 (48.8%) showed duplications arising superior to the iliac crest (subtype A) and 22 (51.2%) had a combination of proximal duplications (subtypes B and C). Ten patients (17.2%) had a single internal spermatic vein, 2 (3.4%) had lumbar collaterals and 3 (5.2%) had renal collaterals.

CONCLUSIONS

Parallel duplication of the internal spermatic vein is a common finding on antegrade venography. The various levels of duplication need to be identified before treatment of varicocele to maximize the success of the procedure.

[Anatomical variability of the left spermatic vein and establishment of the experimental left varicocele model in adolescent rats]

OBJECTIVE

To identify the anatomical variability of the left spermatic vein (LSV) and determine its effect on the induction of experimental left varicocele (ELV) in adolescent rats.

METHODS

We equally randomized 30 adolescent male SD rats to groups A (LSV collaterals fully ligated and the left renal vein constricted), B (only the left renal vein constricted), and C (sham operation), observed the courses of the LSVs and measured their diameters. At 30 days after operation, we analyzed the changes in the left kidneys and the diameters of the LSVs.

RESULTS

Irregular collaterals were observed in 90% of the LSVs and no abnormal changes were found in the left kidneys after surgery. The postoperative LSV diameter was remarkably increased in group A as compared with the baseline ([1.47 +/- 0.15 ] vs [0.16 +/- 0.08] mm, P < 0.01), but showed no significant difference in group B ([0.31 +/- 0.49] vs [0.15 +/- 0.07] mm, P > 0.05) and C ([0.17 +/- 0.07] vs [0.16 +/- 0.06] mm, P > 0.05), and it was significantly longer in A than in B (P < 0.01). The success rate of ELV induction was 100% in group A and 10% in group B, but no varicocele was observed in group C.

CONCLUSION

Correct identification of the anatomical course of the LSV and ligation of its irregular collaterals are essential for the establishment of a stable and consistent ELV model.

[Suprapubis-assisted umbilical laparoendoscopic mini-dual-site surgery for varicocele: a report of 80 cases]

OBJECTIVE

To study the safety, effectiveness and feasibility of suprapubis-assisted umbilical laparoendoscopic mini-dual-site surgery (SAU-LEMDS) in the treatment of varicocele.

METHODS

This study included 80 varicocele patients aged 24 - 44 (mean 28.5 +/- 2.6) years, 25 cases of grade I, 45 cases of grade II and 10 cases of grade III, 58 cases in the left side, 6 in the right and 16 in both sides, and all with asthenospermia. The patients were treated by SAU-LEMDS under subarachnoid anesthesia combined with general anesthesia in a supine position with a head-down-feet-up slope of 15 degrees. Two 5 mm trocars were inserted bilaterally at the umbilical edge, one with a 5 mm 30 degrees laparoscope placed in it, and another into the abdominal cavity below the pubic hairline with a 5 mm laparoendoscopic clipper placed in it. The operation procedure was similar to that of standard laparoscopic ligation of spermatic veins, with reservation of the spermatic artery and double-ligation of spermatic veins. And the procedure was repeated for the contralateral lesion in the bilateral cases. Postoperative follow-up was conducted for the incidences of orchiatrophy and testicular hydrocele and changes of seminal parameters.

RESULTS

All the operations were successful, with the mean operation time of (10 +/- 5.0) min (range 8 to 25 min) for the unilateral cases and (18 +/- 6.5) min (range 15 to 30 min) for the bilateral cases, the mean blood loss of (1.5 +/- 0.5) ml (range 1 to 2 ml), and the mean postoperative hospital stay of (2 +/- 0.5) d (range 1.5 to 3 d). The patients were followed up for 6 -24 (12 +/- 2.5) months, which showed significant improvement in sperm motility as compared with the baseline ([28.53 +/- 5.21] vs [19.62 +/- 3.56]%, P < 0.05), with 28 cases (35.0%) restored to normal. Recurrence was found in 4 cases (5.0%). Testicular hydrocele occurred in 7 cases (8.75%), but orchiatrophy in none. The scars in the umbilicus and suprapubis were invisible because of the wrinkles and pubic hair.

CONCLUSION

SAU-LEMDS is safe, effective and feasible for the treatment of varicocele. It is superior to umbilical laparoendoscopic single-site surgery (U-LESS) for its less invasiveness, simpler operation, and better cosmetic appearance.

Intravital microscopic evaluation of cremasteric microcirculation in experimental testicular torsion

AIM

Although absent cremasteric reflex is a significant clinical finding for testicular torsion (TT), there is limited information about microcirculation of the cremasteric muscle (CM) after TT. This experimental study was performed to evaluate CM microcirculation by intravital microscopy after TT.

MATERIALS AND METHODS

Twelve Wistar rats were allocated into two equal groups: control (CG) and torsion (TG). After anesthetization of the CG rats, the CM flap was dissected through a left ventral inguinal incision with its vascular pedicle. In TG rats, TT was performed by rotating left testicles 720(°) in clockwise direction for 1 h. Then, the CM flap was dissected as in CG, and was placed under an intravital microscope. Vessel diameters, functional capillary perfusion and leukocyte activation in post-capillary venules were measured and evaluated statistically.

RESULTS

There was a significant decrease in vessel diameter in TG compared to CG (p < 0.05). The median of perfused capillaries in CG and TG was 13 (11.75-14.30) and 5.5 (4.75-7.25), respectively (p < 0.05). Number of granulocytes (rolling, sticking, transmigrated) was greater in TG than CG (p < 0.05).

CONCLUSION

Intravital microscopic evaluation of CM after TT showed decrease in vessel diameter and number of perfused capillaries, and increase in granulocyte activation. Clinical, electrophysiological alterations in CM after TT can be explained by deterioration of microcirculation of CM.

[Microanatomy of blood vessels in spermatic cords and its clinical implication]

OBJECTIVE

Both microsurgical subinguinal varicocelectomy (MSIV) and microsurgical high inguinal varicocelectomy (MHIV) are recommended for the treatment of varicocele, but they differ in technical complexity. This study aimed to determine the microanatomy of spermatic blood vessels in the two surgical approaches.

METHODS

We recorded the numbers of spermatic veins, arteries and lymphatics in 80 cases of MSIV and 20 cases of MHIV. We also examined the spermatic cords from 10 adult male cadavers by histological staining.

RESULTS

The numbers of medium spermatic veins (2 -5 mm in diameter) were 1.80 +/- 0.83 and 3.98 +/- 1. 99 in MHIV and MSIV, respectively, with significant difference between the two groups (t = -7.536, P < 0.01), and the total numbers of spermatic veins were 6.40 +/- 1.67 and 9.01 +/- 2.70, also with significant difference between the two (t = -4.071, P < 0.01). However, there were no significant differences between MHIV and MSIV in the numbers of small spermatic veins (diameter < or = 2 mm), large spermatic veins (diameter > or = 5 mm), arteries and lymphatics, nor in the numbers of spermatic veins and arteries of the cadavers.

CONCLUSION

The total number of spermatic veins and the number of medium spermatic veins may be larger in MSIV than in MHIV, but the medium spermatic veins do not increase surgical difficulty, and MSIV is not more complicated than MHIV.

Testicular trauma resulting in spermatic vessel thrombosis and testicular loss: a case report

Testicular ischemia is typically seen with cases of testicular torsion. Twisting of the spermatic cord and compromise of testicular blood supply can induce testicular loss if not promptly discovered and treated. Non-torsion causes of testicular ischemia are uncommon with rare citations in the literature. Herein, we present a case of testicular ischemia induced by traumatic thrombosis of the spermatic vessels.

Varicocele and nutcracker syndrome: sonographic findings

OBJECTIVE

Varicocele is a vascular lesion commonly associated with infertility. Its etiology is only partly understood; hence, the purpose of the study was to establish its correlation with intrinsic anatomic differences and nutcracker syndrome.

METHODS

A total of 93 patients with varicocele and 76 patients without varicocele were enrolled. The diagnosis of varicocele was based on physical examination, followed by sonographic evaluation of the hilar portion and aortomesenteric portion (AMP) of the left renal vein (LRV). The anteroposterior diameter in millimeters and peak flow in centimeters per second in each region were measured.

RESULTS

A total of 28 patients with the nutcracker syndrome were identified in the study group (30.10%), and 2 were identified in the control group (2.63%). The mean diameters of the hilar portion and AMP of the LRV were significantly different in varicocele-affected patients compared with the control group (P < .0001 for both). The mean peak velocities in the hilar portion and AMP were significantly different in patients with varicocele (P < .0001). Patients with varicocele and nutcracker syndrome did not have a significant difference in either the hilar or AMP diameter compared with patients with varicocele without nutcracker syndrome. They had a significant difference in both the hilar and AMP peak flow velocity (P = .0001 for both).

CONCLUSIONS

Our findings indicate that nutcracker syndrome is a frequent finding in varicocele-affected patients and should be routinely excluded as a possible cause of varicocele. In addition, intrinsic anatomic differences in the AMP and hilar portion of the LRV could be directly responsible for the onset of varicocele.

[Spermatic vein and artery ligation for varicocele]

OBJECTIVE

To assess the influence of spermatic vein and artery ligation on testicular hemodynamics, spermatogenesis and testis volume in varicocele patients.

METHODS

Eighty-eight varicocele patients were randomly divided into a spermatic vein and artery ligation (n = 46) and a spermatic vein and artery preservation group (n = 42). The testicular hemodynamic parameters, testis volume and results of semen analyses were obtained before and 6 months after the surgery and compared between the two groups.

RESULTS

There were no significant differences in peak systolic velocity (V(max)), end diastolic velocity (V(min)), mean enveloped velocity (V(mean)) and V(min) of the capsular artery (CA) either between the ligation and preservation groups (P > 0.05) or between pre- and post-operation (P > 0.05). Sperm density, vitality and motility were significantly improved after surgery (P < 0.01), with no significant differences between the two groups (P > 0.05). No significant difference was found in the testis volume between the two groups before and after the operation (P > 0.05).

CONCLUSION

Spermatic vein and artery ligation in varicocelectomy does not affect the testicular hemodynamics, spermatogenesis and testis volume of varicocele patients. Both the spermatic vein and artery should be ligated when necessary.

Topographic and morphometric comparison study of the terminal part of human and bovine testicular arteries

The aim of the study was to compare the terminal parts of testicular artery topography in human and bovine gonads. The study was made on two extremely different types of location of the mediastinum testis. The investigation was carried out on 80 (40 human and 40 bovine) corrosive casts of the testicular arteries. The differences between the species, including the different course of the testicular artery inside the spermatic cord and in the posterior margin of the gonads, were observed. The division of the testicular artery into terminal branches was located in men on the level of the mediastinum testis, and in bulls close to the inferior end of the gonad. The types of terminal division were similar in both groups. In men, the testicular artery course inside the spermatic cord was more variable than in bulls. The artery was straighter, and in 75% of the cases it did not form the loops which were present in 100% of the bovine specimens. The bovine testicular artery in the posterior margin of the testis was longer and had a more variable course than in men.

Long-term effect of pentoxifylline and NG-nitro-L-arginine methyl ester on testicular function in spermatic artery ligation

OBJECTIVE

To investigate long-term testicular function in pentoxifylline- and NG-nitro-L-arginine methyl ester (L-NAME)-treated rats prior to spermatic artery ligation by assessing serum inhibin B concentration, a reliable endocrine marker of spermatogenesis.

MATERIAL AND METHODS

Forty prepubertal rats were randomly divided into four equal groups. Right orchiectomy was performed in all rats. Intraperitoneal pentoxifylline and L-NAME were administered to Groups 1 and 2, respectively. Rats in Group 3 did not receive any medication. The spermatic arteries of the left testes were ligated in all groups with the exception of the sham controls (Group 4). One month postoperatively, a histopathologic evaluation was performed and serum inhibin B concentrations were assessed in all groups.

RESULTS

There were no statistically significant differences in testis size or serum inhibin B concentration between Groups 1, 2 and 3. However, the testes were significantly smaller (p(1)=0.01, p(2)=0.01, p(3)=0.01) and serum inhibin B levels were significantly decreased (p(1)=0.01, p(2)=0.01, p(3)=0.01) when Groups 1-3 were compared with Group 4. Histopathological evaluations revealed necrosis and calcification in all specimens with the exception of the sham-operated group.

CONCLUSIONS

The long-term outcomes of spermatic artery ligation were poor and testicular atrophy developed in rat testes in all study groups. Testicular atrophy could not be reversed by preoperative administration of pentoxifylline and L-NAME.

Adrenal cortical hormones in the spermatic vein of 95 patients with left varicocele

Adrenocortical hormones were measured in the peripheral and spermatic venous blood samples, taken simultaneously at the time of a high vasoligation for left varicocele in 95 patients. Our results do not confirm the hypothesis of MacLeod that the deleterious effects of a varicocele on male fertility are caused by an higher local concentration of adrenocortical hormones, due to venous reflux through incompetent valves. If this is the case it occurs only in a minority of patients.

Comparison of the blood vessel complexes of the human and bovine male gonads

The aim of the study was to compare the blood vessel network of the human and bovine male gonads, paying special attention to differences resulting from mediastinum testis localisation. Two groups of specimens were compared. Each group consisted of 50 corrosive die casts of the testicular and spermatic cord vessels of bovine and human gonads respectively. In each group 20 gonads had only the arterial vessels injected, another 20 only the veins, while in 10 gonads both arteries and veins were injected. The die casts were examined with a stereoscopic binocular as well as an optic microscope. The different testicular vascular patterns in humans and bulls were observed. In humans the intratesticular arteries branch off the arterial network of the tunica albuginea and mediastinum testis. The former runs centripetally, the latter centrifugally. Analogically, the intratesticular veins emptying into the tunica albuginea venous network run centrifugally and those emptying into the mediastinum testis plexus run centripetally. In bulls the arterial vessels run centripetally, later forming a helical, screw-like layer to give off centrifugal branches. Venous vessels run centrifugally and empty into the venous plexus of the tunica albuginea.

[Bilateral varicocele: epidemiology, clinical presentation and diagnosis]

Epidemiology of bilateral varicocele (BV) was studied in 2600 patients with varicocele and in 3900 infertile patients 1196 of whom had varicocele. The diagnosis was made by examination, palpation of sexual organs, dopplerography. In addition, causes and clinical picture of BV were investigated. Targeted urological examination of 8000 schoolchildren detected varicocele in 1704 (22.8%) examinees, of them BV was in 290 (3.3%). Detailed examination with ultrasound in 1500 varicocele patients detected BV in 519 (34.6%). Among 1100 varicocele patients BV was detected after detailed examination in 328 (36%), after physical examination--in 156 (14.2%). Of 2900 infertile patients varicocele was diagnosed in 1196 patients, BV--in 312. After detailed examination BV incidence reached 41.2. Superselective testiculoflebography and multispiral computed tomography detected that in many BV patients right internal seminal vein enters the right renal vein. Asymptomatic right-side BV was detected in 1195 (96/0%) of 1245 BV patients, 397 (37.6%) patients with left-side BV had pain at exercise. At ultrasound examination the diameter of the scrotal part of the semenal vein in BV patients with right and left side disease in subclinical varicocele was from 1.5 to 4 mm (2.5 mm), in degree I--3-4 mm, in degree II--3.1-5 mm, in degree III--5.1-7.0 mm (in some cases up to 9 mm). The return blood flow rate in subclinical varicocele reached 0.100-0.120 m/s, in varicocele of the first degree--up to 0.150, of the second degree--up to 0.300 m/s and third--over 0.300 m/s. Thus, BV occurs much more often than is diagnosed. Adequate diagnosis rate can be achieved in using ultrasound methods.

Treatment of bleeding varicose veins of the scrotum with percutaneous coil embolization of the left spermatic vein: a case report

Percutaneous coil embolization of the spermatic vein offers a minimally invasive method for treating symptomatic varicose veins of the scrotum. We describe the case of a 63-year-old man with multiple comorbidities and persistent bleeding from scrotal varicosities. Venography revealed significant left spermatic vein reflux and a large left varicocele. Percutaneous coil embolization of the left spermatic vein completely resolved the bleeding from the left side of the patient's scrotum. Although many vascular specialists possess the technical skills to perform this procedure, they may not be familiar with its use in the treatment of scrotal varicosities and varicoceles.

Bcl-2 Overexpression in the Internal Spermatic Vein of Patients with Varicocele

BACKGROUND/PURPOSE

Varicocele is characterized by dilatation and tortuosity of the internal spermatic vein (ISV). Cross sections of ISV showed marked thickening of smooth muscle layer under microscopy. This study examined Bcl-2 (anti-apoptotic protein) expression in the ISV of patients with varicocele.

METHODS

The study group consisted of eight patients with left varicocele, grade 3. The control group consisted of six volunteers with left indirect inguinal hernia. Using a left inguinal surgical incision, a 1-cm section of ISV was resected from each patient in both groups as specimens for immunoblotting and immunohistochemical staining of Bcl-2. Results were analyzed using Student's t test.

RESULTS

Bcl-2 immunoblots from both groups revealed one single band. alpha-tubulin was used as loading control. The average relative intensity of the Bcl-2 was 25.82 +/- 10.53 in the control group and 113.49 +/- 27.49 in the varicocele group. Hematoxylin staining revealed a thickening ISV in the patients with varicocele, predominantly in the muscle layer, which was not found in the control group. Moreover, the intensity of Bcl-2 immunostaining was markedly higher in the study group than in the control group.

CONCLUSION

This study showed Bcl-2 overexpression in the ISV of patients with varicocele. Additional studies are necessary to clarify the molecular mechanisms of varicocele formation and recurrence.

Spontaneous thrombosis of the pampiniform plexus

Spontaneous thrombosis of the pampiniform plexus is a very uncommon clinical entity. We present a case of thrombosis of the pampiniform plexus that was preoperatively diagnosed as an incarcerated inguinal hernia.

Reactive oxygen species and antioxidants relationship in the internal spermatic vein blood of infertile men with varicocele

AIM

To assess the relation of reactive oxygen species (ROS) and antioxidants in the internal spermatic vein blood compared to the peripheral venous blood.

METHODS

Sixty-eight infertile oligoasthenozoospemic patients associated with varicocele were investigated. During inguinal varicocelectomy, blood samples of internal spermatic as well as median cubital veins were withdrawn. Three ROS factors (malondialdehyde [MDA], hydrogen peroxide H(2)O(2), nitric oxide [NO]) and four antioxidants (superoxide dismutase [SOD], catalase [Cat], glutathione peroxidase [GPx] and vitamin C) were estimated in these blood samples.

RESULTS

Mean levels of tested ROS factors were significantly higher in the internal spermatic venous blood compared to those in the peripheral one (mean+/-SD) (MDA 18.7+/-1.4 nmol/mL vs. 15.4+/-1.4 nmol/mL, H(2)O(2) 43.6+/-8.0 micromol/mL vs. 30.8+/-8.1 micromol/mL, NO 2.3+/-0.5 nmol/L vs. 1.6+/-0.4 nmol/L, P<0.01). Mean levels of tested antioxidants were significantly lower in the internal spermatic venous blood compared to those in the peripheral one (superoxide dismutase 1 690.7+/-130.0 U/mL vs. 1 818.5+/-143.0 U/mL, catalase 38.9+/-6.1 mol/L vs. 47.9+/-10.2 mol/L, GPx 20.4+/-8.1 U/mL vs. 23.0+/-8.4 U/mL, vitamin C 0.3+/-0.1 vs. 0.4+/-0.1 mg/dL, P<0.05).

CONCLUSION

Internal spermatic venous blood of infertile male cases associated with varicocele demonstrated elevated levels of ROS and decreased levels of antioxidants compared to peripheral venous circulation.

Phlebographic classification of anatomic variants in the right internal spermatic vein confluence

PURPOSE

Male varicocele is a clinical dysfunction caused by a pathological venous reflux. Knowledge of anatomic variants of the internal spermatic vein confluence is fundamental for the technical success of percutaneous treatment. While numerous studies have analysed the phlebographic anatomy of the left internal spermatic vein, no exhaustive description exists for the right internal spermatic vein.

MATERIALS AND METHODS

From a retrospective review of 3229 patients treated percutaneously between 1988 and 2003, we extrapolated the phlebographic images of patients with incontinence of the right internal spermatic vein only. Mean patient age was 24.6 (range 14-46) years. Indication for treatment was presence of pain in the right inguinal region and absence of a history of trauma and/or seminal-fluid alterations. Phlebography had been performed with transbrachial access using a tilt table and a multipurpose angiographic catheter. Contrast medium was injected into both the inferior vena cava and the renal vein. Selective catheterisation of the internal spermatic vein was then performed to assess the radiological characteristics of the vessels prior to sclerosis.

RESULTS

There were 93 cases of incontinence of the right internal spermatic vein only (2.8%). In the first group of patients (seven cases, 7.5%), the right internal spermatic vein drained exclusively into the renal vein; the injection of contrast medium during a Valsalva manoeuvre allowed visualisation of the vein almost as far as the iliac level. In most cases, the vein appeared uniformly dilatated and without valvular systems along its course. In the second group (21 cases, 22.5%), the vein drained into both the renal vein and the inferior vena cava, with one branch showing functional predominance over the other: selective catheterisation was easier to perform on the first branch. Selective catheterisation confirmed dilatation of the vein as well as the absence of valvular systems. In most patients, (65 cases, 69.8%), the internal spermatic vein drained into the inferior vena cava; the confluence was double in five patients and single in 60 patients. Visualisation of incontinence was limited to the initial 5-10 cm of the vein in 13 cases; however, vein dilatation and absence of valvular systems were confirmed beyond the semicontinent valve.

CONCLUSIONS

Interventional treatment is one of the therapeutic options for male varicocele, but the method is limited by the presence of anatomic variants or aberrant supplying vessels, which make catheterisation and sclerosis of the internal spermatic vein difficult if not impossible. Interventional radiologists must have a thorough knowledge of anatomic variants of the right internal spermatic vein to be able to perform the procedure within a reasonable amount of time and reduce radiation exposure.

Increased Expression of Hypoxia-Inducible Factor-1α in the Internal Spermatic Vein of Patients With Varicocele

PURPOSE

Varicocele is recognized as a cause of male infertility. Testis hypoxia may be one of the possible mechanisms of varicocele. We examined whether tissue hypoxia occurred in the ISV of patients with varicocele by detecting the expression of HIF-1alpha.

MATERIALS AND METHODS

The study group consisted of 8 patients with grade 3 left varicocele. The control group consisted of 6 volunteers with left indirect inguinal hernia. Using a left inguinal surgical incision, a 1 cm section of ISV was resected from each patient in both groups as specimens for immunoblotting and immunohistochemical staining of HIF-1alpha. Results were analyzed using Student's t test.

RESULTS

HIF-1alpha immunoblots from both groups revealed a single band. The relative intensity of the HIF-1alpha protein band was 10.92 +/- 2.70 in the control group and 73.15 +/- 8.93 in patients with varicocele (ie 7-fold higher).

CONCLUSIONS

HIF-1alpha expression in the ISV of patients with varicocele was significantly higher than in the control group. This directly shows that hypoxia related pathophysiological changes have occurred in the ISV of patients with varicocele and that hypoxia may have also occurred in the testicular tissue. Thus, it would be of interest to investigate whether decreasing HIF-1alpha activation and testis hypoxia could reduce the recurrence of varicocele. To our knowledge, this is the first report on HIF-1alpha expression in human ISV. Additional studies will be necessary to clarify the relationship between testis hypoxia and male infertility in patients with varicocele.

A Doppler-based study on the prevalence of varicocele in German children and adolescents

The prevalence of varicocele was estimated among pupils of forms 4 and 8 in the city of Hamburg and the severity of the associated venous reflux was analysed. In the school year of 1998/99, a genital examination was performed on 2756 children (median age 10.2 years) and 2008 adolescents (14.6 years). The varicocele degree was determined according to the WHO. Venous reflux was proven by CW-Doppler sonography, distinguishing between Valsalva-induced reflux (VR) and continuous reflux (CR). As a result, varicoceles were detected in 18.0% of the children (1.2% bilaterally) and 42.7% of the adolescents (7.2%). High-graded forms (palpable/visible) occurred with increasing rate (from 7% to 22.9%) on the left side. Subtle forms (subclinical/during Valsalva) counted for >90% of all right-sided findings, whilst an age-related shift towards higher degrees was noted left-sided. VR occurred bilaterally, CR was almost only established left-sided. VR was mainly associated with subtle varicoceles, CR was predominantly found in the high-graded forms. These results suggest that even in children varicoceles are not a rare phenomenon. However, adolescence is the main period of manifestation. A major venous malfunction is already evident in maturing boys, which seems to be associated with the formation of high-graded varicoceles.

[Variants of formation of v. testicularts sinistra in children with varicocele]

Biopsies of veins of 20 boys with varicocele were studied morphologically. Three types of veins were observed. The first type was represented by veins with a wide lumen and the wall consisting of three layers of smooth muscle cells. The second morphological variant--veins of varying diameter of irregular shape and thin, frequently sclerosed wall. The third type were veins of a small diameter with well developed muscular layer. Immunohistochemical studies detected disturbances of vascular wall components suggesting the development of varicocele as a complex of congenital pathology with secondary alteration and destabilisation of compensatory processes.

A Proposed Anatomic Typing of the Right Internal Spermatic Vein: Importance for Percutaneous Sclerotherapy of Varicocele

PURPOSE

To classify the anatomic types of the right internal spermatic vein (ISV).

METHODS

We evaluated venograms obtained in 150 consecutive patients with idiopathic varicocele referred for transfemoral sclerotherapy.

RESULTS

Six anatomic types of the right internal spermatic vein (ISV) were recognized. These were classified by the location of their orifices and the tributary venous patterns. In roughly half the patients (53%), the ISV appeared as a simple vein with no remarkable retroperitoneal interconnections. In the remainder, complex retroperitoneal anastomoses were encountered.

CONCLUSION

By understanding these anatomic variations, the angiographer can approach treatment of right-sided varicocele with foreknowledge of the nature of these types and the presence of valves and collaterals.

[Value of color Doppler flow imaging in the diagnosis of subclinical varicocele]

OBJECTIVE

To identify the value of color Doppler flow imaging (CDFI) in the diagnosis of sterility caused by subclinical varicocele (SVC).

METHODS

The spermatic veins of 56 sterile patients with seminal abnormality were examined with CDFI and the internal diameters and the time of blood reflux of pampiniform plexus of the veins were observed. In addition, selective X-ray examination of internal spermatic veins was performed for contrast analysis.

RESULTS

The diameter of the pampiniform plexus was (2.24 +/- 0.16) mm under the static condition and (2.67 +/- 0. 26) mm during the Valsalva test. The time of blood reflux was (1 487 +/- 203.66) ms. The accuracy of CDFI for diagnosing SVC was 92.8%.

CONCLUSION

CDFI has been proved of more value in the diagnosis of SVC than that of clinical varicocele in the etiological screening of male sterility.

[Needle laparoscopic varicocelectomy]

OBJECTIVE

We evaluated our method and effects of needle laparoscopic varicocelectomy for the treatment of varicocele.

METHODS

72 patients (105 lateral) diagnosed varicocele were performed laparoscopic varicocelectomy under epidural combined intravenous anesthesia from Feb, 2003 to Apr, 2005. Two 2 mm incisions and one 5 mm incision were made on the midline of lower abdomen, by which two 2 mm trocars and one 5 mm trocar were introduced. Vessel-sealing device (Ligasure) was used to seal the internal spermatic veins.

RESULTS

All operations were completed successfully. Mean operation time was 15 minutes unilateral and 21 minutes bilateral. The patients were hospitalized for 3 to 5 days after procedure. Follow-up was scheduled for 6 to 12 months and there was no recurrence.

CONCLUSION

Needle laparoscopic varicocelectomy gives favorable effect with minimal invasion, rapid recovery, which is the best choice for the treatment of varicocele.

Evaluation of the role of varicocelectomy including external spermatic vein ligation in patients with scrotal pain

OBJECTIVES

The aim of the present study was to assess and compare pre- and postoperative scrotal pain in patients with varicocele who underwent varicocelectomy with different approaches.

METHODS

The study included 144 consecutive patients with left-sided varicocele who had left scrotal pain for more than 3 months. All patients underwent varicocele ligation using either a subinguinal or inguinal approach with or without external spermatic vein ligation. We asked the patients to complete an 'Assessment Questionnaire for Scrotal Pain' both before and after the surgery.

RESULTS

The surgery was successful in 101 (83.4%) of the 121 patients available for follow up. Seventy-four (61.1%) patients reported the complete resolution of pain while 27 patients (22.3%) reported partial resolution. Symptoms worsened in a single case and pain persisted postoperatively in 19 cases (15.7%). There were no statistically significant differences in the characteristics of the pain and grade of varicocele between postoperative groups. A significant difference was observed in postoperative success between patients who had external spermatic vein ligation and those who did not, regardless of the surgical approach (inguinal or subinguinal). All patients who reported complete or partial resolution of pain stated that they would recommend surgery to relatives with the same problem.

CONCLUSIONS

Varicocelectomy using either inguinal or subinguinal approaches is an effective and reasonable treatment option in this patient group and should include external spermatic vein ligation for a satisfactory outcome.

Transitional Cell Carcinoma With Metastases to Spermatic Vein and Spermatic Cord: PET/CT Imaging

Transitional cell carcinoma of the kidney with venous tumor thrombus is uncommon with only a limited number of cases published in the medical literature. The authors present a case of renal urothelial carcinoma with PET/CT imaging. PET, in addition to the demonstration of tumor thrombus in the left renal vein and inferior vena cava, showed a thrombosed left spermatic vein with metastases to the left spermatic cord and epidydimis.

[Day surgery management of varicocele with Doppler-assisted dissection at the external inguinal ring (subinguinal varicocelectomy)]

We performed a total of 172 varicocelectomies with the subinguinal technique in 151 patients. Of these, 129 patients (85%), undergoing a total of 140 varicocelectomies, were monitored for at least one year (11 had bilateral varicocele) with a mean follow-up of 3 years. Ninety-nine of these (77%) presented preoperative semen abnormalities and 62 (48%) had infertility problems. The diagnosis of varicocele was confirmed in all cases with a duplex ultrasound examination. The morbidity rate was low: 26 patients (20%) presented epididymal discomfort, and 9 patients (7%) ecchymosis in the wound site and/or scrotum, while in 5% (4 patients) of the 140 varicoceles operated on we observed a temporary reactive hydrocele; in 1 case (0.7%) the hydrocele persisted for one year postoperatively. One case (0.7%) presented persistence of varicocele. The following semen variables were evaluated before and after the operation: number of spermatozoa per ml, motility, percentage of morphologically normal spermatozoa. In 70% of patients (70 cases) with alterations of semen variables we observed a statistically significant postoperative improvement in these variables. The spontaneous pregnancy rate one year postoperatively, in those cases where the couple had fertility problems, was 35.5% (22 pregnancies). We believe that the technique using the subinguinal approach is a safe, simple procedure and therefore that it should be regarded as the gold standard in the management of varicocele, in that it allows the simultaneous ligature of the internal and external branches of the spermatic vein. This technique can be performed in the day-surgery setting with minimal invasiveness and at extremely low cost compared to other procedures. This technique is the procedure of choice not only in the treatment of varicocele but also, above all, in the treatment of varicocele recurrence or persistence.