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Varicocele Testis


Semir A. S. Semir Al Samarrai

 

Incidence

A varicocele is an abnormal dilution of the pampiniform plexus and is present in 15% of the general male population (1-3).

It is contributing factor in up to 40% of primary cases and up to 80% of secondary cases of male-factor subfertility (4).

Diagnosis

Physical examination, inspection and palpation of the testicular veins in patients who are standing in a warm room establish the diagnosis in the majority of cases. Color Doppler imaging and ultrasonography may be used to confirm the diagnosis.

Treatment

Traditionally, surgical repair of a varicocele is performed by inguinal, retroperitoneal or sub-inguinal approach (5, 6, 7).

Sanchez Badajoz first reported the Laparoscopic Varix Ablation of the testis in 1988 (8). Over the ensuing years, the techniques have been refined in the hands of experienced laparoscopists and variations of the technique have been studied.

Advantages of Laparoscopic Varicocelectomy include:

  • Increased magnification
  • Facilitating more accurate identification of vessels, such as spermatic collateral veins (i.e veins running alongside the spermatic cord and together entering the internal ring. A possible cause of recurrence is left alone).
  • Lymphatics vessels: the ligation of which can lead to hydrocele formation.
  • Identification and preservation of the Internal spermatic artery (9, 10).

Moreover, Laparoscopic Varicocelectomy is safe even after prior inguinal surgery. The characteristic of the laparoscopic supra-inguinal access allows for high ligation of fewer veins vs a more Labour-intensive sub-inguinal approach.

In cases of bilateral varicoceles, as additional incision, with is a attendant effects, is avoided.

The Procedure

After identification of the internal ring, and delineate internal spermatic cord and associated nearby veins as well as the vas deferens using the harmonic scissor to incise the posterior peritoneum, just lateral and anterior to the spermatic cord (Fig 1).

After grasping and incision of the posterior-peritonium to create peritoneal window around the spermatic cord. A large and dilated (varicosis) internal spermatic veins are usually and easily to identify early. After isolating of the veins from its adjacent internal spermatic artery and lymphatic vessels, division with the harmonic scissor and ligation of the varix-veins with the LigaSure devise can be done without any problem. (Fig 2, 3, 4, 5).


Fig 1. Grasping and incision of the peritoneum with the harmonic scissor to create window.


Fig 2. Identification and preservation of the internal spermatic artery.


Fig 3. Additionally is Laparoscopic Doppler helpful for identification of the internal spermatic artery in case of difficulty to identify the pulsation of the artery.


Fig 4. Under the laparoscopic magnification the identification and sparring of the lymphatic vessels is easy and appears as small, translucent vessels.


Fig 5. Ligation of the veins using LigaSure and division per Harmonic Scissor.

 

The closure of the small three (5mm and 3mm) skin incisions can be performed with absorbable sutures in subcuticular fashion. Additionally, adhesive strips can be applied in the small skin incision.

The discharge of the patient is in the same day of the operation.

Reference:

1.) Belman AB: The dilemma of the adolescent varicocele. Contemp Urol 1991; 3:21.
2.) Sigman M, Howards SS: Male infertility. In Walsh PC, Retik AB, Stamey TA, Vaughn ED Jr (eds): Campbell’s Urology, 6th ed, p 991. Philadelphia, WB Saunders, 1992.
3.) Thomas AJ Jr, Geisinger MA: Current management of varicoceles. Urol Clin North Am 1990; 17:893.
4.) GorelickJ,Goldstein M: Loss of fertility in men with varicocele. Fertil Steril 1993; 59:613.
5.) Ivanissevich O: Left varicocele due to reflux: Experience with 4,470 operative cases in 42 years. J Int Coll Surg 1960; 34:742.
6.) Palomo A: Radical cure of varicocele by a new technique: Preliminary report. J Urol 1949; 61:604.
7.) Marmar JL, DeBenedictis TJ, Praiss D: The management of varicoceles by microdissection of the spermatic cord at the external inguinal ring. Fertil Steril; 43:583.
Goldstein M: Surgery of male infertility and other scrotal disorders. In Walsh PC, Retik AB, Stamey TA, Vaughn ED Jr (eds): Campbell’s Urology, 6th Ed, p 3114. Philadelphia, WB Saunders, 1992. 8.) Sanchez de Badajoz E, Ramirez FD, Martin JM: Tratamiento endoscopico del varicocele. Arch Esp Urol 1988; 41:15.
9.) Glassberg KI, Poon SA, Gjertson CK, Decastro GJ, Misseri R. Laparoscopic lymphatic sparing varicocelectomy in adolescents. J Urol 2008; 180: 326-3.
10.)Kocvara R, Dvoracek J, Sedlacek J, Dite Z, Noval K. Lymphatic sparing laparoscopic varicocelectomy: a microsurgical repair. J Urol 2005; 173:1751-4.

Correspondence:
Prof. Dr. SEMIR AHMED SALIM AL SAMARRAI
Professor Doctor of Medicine-Urosurgery, Andrology, and Male Infertility
Dubai Healthcare City, Dubai, United Arab Emirates.
Mailing Address: Dubai Healthcare City, Bldg. No. 64, Al Razi building, Block D,
2nd floor, Dubai, United Arab Emirates, PO box 13576
Email: fmcalsam@emirates.net.ae