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  1. Varicocele Facts or Fiction Dr. Gil Raviv Urology Department Andrology Unit Sheba Medical Center

  2. Varicocele - Facts or Fiction Definition Varicocele is a vascular abnormality of the scrotum that is defined as dilated veins of the pampiniform plexus.

  3. Varicocele - Facts or Fiction Anatomy • 90% left side. • 10% bilateral. • Most commonly - internal spermatic veins. • Others: • External spermatic veins. • Cremasteric veins • Rarely appears - deferential veins

  4. Varicocele - Facts or Fiction Pathophysiology • 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.

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

  6. Varicocele - Facts or Fiction Diagnosis Various methods: • Radio nuclide examination - high false negative - depends on blood pooling. • Scrotal Thermography - rarely used. • Doppler stethoscope- only for confirmation.

  7. Varicocele - Facts or Fiction Diagnosis • 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.

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

  9. Varicocele - Facts or Fiction Diagnosis The most acceptable methods of diagnosis is clinical examination based on clinician’s subjective impression. Grade 1 - palpable - valsalva manoeuvre. Grade 2 - palpable - without valsalva manoeuvre. Grade 3 - visible.

  10. Varicocele - Facts or Fiction Diagnosis Subclinical Varicocele • Detected only by radiological imaging. • Controversy exists: • Diagnosis. • Treatment. • Pregnancy rate.

  11. Varicocele - Facts or Fiction Varicocele in adolescence • Rarely found before puberty. • Varicocele during adolescence is: • Asymptomatic. • Found on routine examination. • Kass. Urol.Clin 1994

  12. Varicocele - Facts or Fiction Varicocele in adolescence INDICATION FOR TREATMENT • ABNORMAL SEMEN ANALYSIS • VOLUME OF LEFT TESTIS 3 ML LESS THEN RIGHT. • LARGE SYMPTOMATIC VARICOCELE. • BIL PALPABLE VARICOCELE.

  13. Varicocele - Facts or Fiction Varicocele in adolescence 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.

  14. Varicocele - Facts or Fiction Varicocele in adolescence TRANSPERITONEAL LAPAROSCOPY • Presently not considered as first- line therapy. • General anesthesia. • Potential major complications. • High cost.

  15. Varicocele - Facts or Fiction Varicocele in adolescence DOES IT A DYNAMIC PROGRESSIVELESION? HISTOLOGY • Lesions are similar to adults. • Similar in both testis. • May precede volume loss. • No predicting data on reversibility.

  16. Varicocele - Facts or Fiction Varicocele in adolescence SURGERY • Palomo -Retropertoneum- above level of vas deferenes. • Artery - sparing procedure. • Ivanissevitch- inguinal canal the most commonly used.

  17. Varicocele - Facts or Fiction Varicocele in adolescence • 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.

  18. Varicocele - Facts or Fiction CONTROLLED STUDIES - EFFECTIVNESS OF VARICOCELECTOMY • NIESCHLAG (1995,1998 Hum Reprod ). • 125 infertile couples. • 62 - varicocelectomy. • 63 - counseling. W - intervention B- counseling

  19. Varicocele - Facts or Fiction CONTROLLED STUDIES - EFFECTIVNESS OF VARICOCELECTOMY NIESCHLAG CONT. • No relationship to pregnancy rate. • Semen analysis. • Hormone profile. • Varicocele grade. • Age of male. • Only female age predict pregnancy • Sperm count increased.

  20. Varicocele - Facts or Fiction CONTROLLED STUDIES - EFFECTIVNESS OF VARICOCELECTOMY • 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

  21. Varicocele - Facts or Fiction CONTROLLED STUDIES - EFFECTIVNESS OF VARICOCELECTOMY • Vermuelen (1986 , J. Androl ). • 90 patients - varicocelectomy. • 25 patients - observation. • Cumulative PR were the same. • Both improved sperm characteristics.

  22. Varicocele - Facts or Fiction CONTROLLED STUDIES - EFFECTIVNESS OF VARICOCELECTOMY • 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.

  23. Varicocele - Facts or Fiction CONTROLLED STUDIES - EFFECTIVNESS OF VARICOCELECTOMY • Rodriguez-Rigau (1978. J Urol ). • Controlled not prospective not randomized. • No difference in PR. • Sperm count and motility improved after surgery.

  24. Varicocele - Facts or Fiction Controlled studies supporting varicocelectomy • Marmar and KIM (1994,J Urol). • 466 surgery group/19 controls. • PR surgery group 35.6 % ( 186/466). • PR controls 15.8 %

  25. Varicocele - Facts or Fiction Controlled studies supporting varicocelectomy • 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.

  26. Varicocele - Facts or Fiction Controlled studies supporting varicocelectomy • WHO study never published in its original form. • 9034 infertile couples. • 1326 had clinical varicocele.

  27. Varicocele - Facts or Fiction Controlled studies supporting varicocelectomy • Hargreave. • PR after surgery - 35 %. • PR controls group 17 %. • Part of WHO study presented only at andrology meeting!

  28. Varicocele - Facts or Fiction Controlled studies supporting varicocelectomy • 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 %.

  29. Varicocele - Facts or Fiction Controlled studies supporting varicocelectomy TREATMENT IN ADULTS • WHICH MODALITY IS THE BEST ? • Comparison by three outcome measures: * Success rate. * Semen improvement and pregnancy rate. * Complication rate.

  30. 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%.

  31. 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.

  32. 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.

  33. 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.

  34. Varicocele - Facts or Fiction Varicocele - Facts or Fiction Complication rate - cont. • Operative-laparascopic approaches - Injured epigastric vessels. - Rarely bowel injury. - High cost.

  35. 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).

  36. Varicocele - Facts or Fiction Varicocele - Facts or Fiction CONCLUSIONS (2) • Varicocele exert deleterious effect upon both testis and it’s function - therefore treatment is recommended in large varicocele with reduced testis volume in adolescence.

  37. 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.

  38. 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.

  39. Varicocele - Facts or Fiction Varicocele - Facts or Fiction SPECIAL CONDITION AND VARICOCELE • Bilateral varicocele. Operating one side/ both ? ?open/laparoscopyType of operation: • Azoospermia . FSH- normal/abnormal? • Very severe OTA. High/normal FSH? • Recurrent varicocele?

  40. VARICOCELE AND OTHER SPECIAL CONDITION Undesending testicle in the same side? Recurrence - Type of treatment? Surgery/EmbolizationImproved sperm count.

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