25.7 Treatment

not obvious. This is especially true in primary varicocele, and if the varicocele does not become smaller, this is a sign for clinical concern and an obstructive etiology should be considered.

•Both testes should be palpated and the testicle on the side of the varicocele may or may not be smaller when compared to the other side.

•It has been suggested that the testicular size should be assessed with an orchidometer. This is a reliable method of assessing testicular size but ultrasonography is more reliable. A Doppler ultrasound not only demonstrate the varicocele but also can see blood reverse direction in a varicocele with a Valsalva maneuver.

•There are two formulas used to calculate testicular volume based on measurements obtained via ultrasonography:

–The Lambert formula:

•Testicular volume = Length × width × depth × 0.71

–The volume of rotational ellipsoid formula:

Two variations exist for the volume of rotational ellipsoid formula:

•Testicular volume = Length × width × depth × 0.52

•Testicular volume = Length × width2 × 0.52

–The average volume of the male testis is 23 ± 3 cm3.

–A size difference of more than 3 cm3 is considered significant.

•Recent studies have shown that varicocele is usually a bilateral disease. The diagnosis of the right side is usually missed clinically and an ultrasonography with a color flow Doppler should be performed to detect a subclinical right varicocele.

•Computed tomography (CT) is rarely indicated but may be useful in those with an isolated right-side varicocele or a secondary obstructive varicocele. This is to exclude a renal or other retroperitoneal mass or thrombosis of the inferior vena cava.

•Venography is rarely used to detect a subclinical varicocele in an infertile adult patient.

•A semen analysis may be done in infertile patients preoperatively as a base line which can be compared to the results postoperatively which are expected to show improvements in semen analysis parameters.

25.7Treatment

Indications of Treatment

•There are no clear indications for surgical treatment of varicocele in children and adolescents.

•Varicocele associated with testicular growth retardation. These patients are likely to manifest impaired fertility in adulthood.

•Symptomatic painful varicocele.

•A clinically evident varicocele and poor semen quality.

•A palpable varicocele with testicular atrophy and semen abnormality. A 20 % volume deficit in the affected testes is considered an indication for surgical intervention.

•Bilateral varicoceles

•Grade 2 or 3 varicocele

Medical Treatment

•L-carnitine has some beneficial effect on sperm parameters, but it is not as effective as surgery.

•Micronised purified flavonoid fractions (MPFF) (Daflon) have a beneficial effect on reducing varicocele pain and reducing reflux time of left spermatic vein during the Valsalva maneuver.

Embolization Therapy

•An alternative to surgery is embolization.

•This is a minimally invasive treatment that involves passing a small wire through a peripheral vein and into the abdominal veins that drain the testes.

•Embolization materials include balloons, coils, and dextrose.

•Embolization is an effective treatment for recurrent post-surgical varicoceles.

Anatomy

•The spermatic cord extends upward from the testis into the inguinal region, above the scrotum.

•The spermatic cord contains:

–The spermatic veins

–The vas deferens

–The testicular arteries, including the internal spermatic artery (may be multiple branches)

–The vasal artery

–The external spermatic artery.

•Above the inguinal region, the vas, with its arterial supply, diverges from the internal spermatic artery and veins, which course through the retroperitoneum, along the psoas muscle.

•A varicocele is situated in the upper scrotum, above the testis.

•The left testicular vein drains into the left renal vein while the right testicular vein drains directly into the inferior vena cava.

Surgical Treatment

•Varicocelectomy (Surgical ligation of the spermatic veins) is the procedure of choice to treat varicoceles.

•Several approaches are used, differing primarily in the level at which the vessels are ligated. These include:

–Abdominal retroperitoneal (Palomo) approach

–Inguinal (Ivanissevitch) approach

–Sub inguinal approach

–Recently, microsurgical techniques and laparoscopic-assisted transperitoneal or retroperitoneal approaches are used.

•With the inguinal and sub inguinal approaches, the testicular artery is generally spared using a microscope. Visualization of the testicular artery can be ascertained using papaverine or lidocaine administration or using a Doppler probe intraoperatively. Lymphatic vessels are also preserved when possible to prevent future hydrocele formation.

•When surgery is performed in the retroperitoneum or transperitoneally, some authors advocate dividing both the testicular artery and the veins to avoid missing any venous branches. Ligation of the internal spermatic artery in this approach does not usually cause

testicular atrophy because of the collateral circulation to the testis. This latter technique relies on the vasal artery as the main blood supply to the testis.

25.8Postoperative Complications

•Surgical treatment of varicocele is known to be associated with postoperative complications. The frequency of these complications is variable depending on the surgical approach used.

•The microscopic-assisted procedures carry the lowest complication rates (<1 %).

•Hydrocele formation is the most common complication of varicocelectomy and most likely results from lymphatic obstruction.

•Percutaneous embolization is very infrequently associated with hydrocele formation but can cause contrast reactions, puncture of the femoral artery, hemorrhage, extravasation, and migration of embolization balloons.

•These complications include:

–Hematoma

–Hydrocele

–Infection

–Testicular atrophy

–Injury to the scrotal tissue or structures

–Recurrence or persistence of the varicocele

–Injury to the vas deferens

–Chronic testicular pain

–Injury to the artery that supplies the testicle

•The frequency of recurrence depends on the approach used.

–Embolization has an 80–90 % success rate and a recurrence rate of approximately 10–25 %.

–The microsurgical approach has a varicocele recurrence less than 5 % of cases and less than 1 % hydrocele development.

–The inguinal, retroperitoneal, and laparoscopic approaches have a 13–16 % recurrence rate and a 7–9 % risk of hydrocele development.

25.9Prognosis

•Varicocele can be harmless, but in some cases it can cause infertility and testicular pain.

•Surgical treatment of varicocele may improve fertility and there are reports showing improvement in sperm quality following surgery in 57 % of patients.

•Varicocelectomy improves sperm parameters and testicular volume. These improvements include:

–Total sperm count

–Sperm motility

–Sperm density

–Sperm morphology

–Reduces sperm DNA damage and seminal oxidative stress

Further Reading

1. Al-Kandari AM, Shabaan H, Ibrahim HM, Elshebiny YH, Shokeir AA. Comparison of outcomes of different varicocelectomy techniques: open inguinal, laparoscopic, and subinguinal microscopic varicocelectomy: a randomized clinical trial. Urology. 2007;69(3):417–20.

2. Hadziselimovic F, Herzog B, Jenny P. The chance for fertility in adolescent boys after corrective surgery for varicocele. J Urol. 1995;154(2 Pt 2):731–3.

3. Hassan JM, Adams MC, Pope JC, et al. Hydrocele formation following laparoscopic varicocelectomy. J Urol. 2006;175(3 Pt 1):1076–9.

4. Iselin CE, Almagbaly U, Borst F, et al. Safety and efficiency of laparoscopic varicocelectomy in one hundred consecutive cases. Urol Int. 1997;58(4):213–7.

5.Kass EJ. The adolescent varicocele: treatment and outcome. Curr Urol Rep. 2002;3(2):100–6.

6. Kass EJ, Marcol B. Results of varicocele surgery in adolescents: a comparison of techniques. J Urol. 1992;148(2 Pt 2):694–6.

7. Kubal A, Nagler HM, Zahalsky M, Budak M. The adolescent varicocele: diagnostic and treatment patterns of pediatricians. A public health concern? J Urol. 2004;171(1):411–3.

8.Lemack GE, Uzzo RG, Schlegel PN, Goldstein M. Microsurgical repair of the adolescent varicocele. J Urol. 1998;160(1):179–81.

9. Lund L, Tang YC, Roebuck D, et al. Testicular catchup growth after varicocele correction in adolescents. Pediatr Surg Int. 1999;15(3–4):234–7.

10.Nees SN, Glassberg KI. Observations on hydroceles following adolescent varicocelectomy. J Urol. 2011; 186(6):2402–7.

11.Pini Prato A, MacKinlay GA. Is the laparoscopic Palomo procedure for pediatric varicocele safe and effective? Nine years of unicentric experience. Surg Endosc. 2006;20(4):660–4.

12.Pinto KJ, Kroovand RL, Jarow JP. Varicocele related testicular atrophy and its predictive effect upon fertility. J Urol. 1994;152(2 Pt 2):788–90.

13.Reyes BL, Trerotola SO, Venbrux AC, et al.

Percutaneous embolotherapy of adolescent varicocele: results and long-term follow-up. J Vasc Interv Radiol. 1994;5(1):131–4.

14. Rizkala E, Fishman A, Gitlin J, Zelkovic P, Franco I. Long term outcomes of lymphatic sparing laparoscopic varicocelectomy. J Pediatr Urol. 2013;9(4): 458–63.

15. Sayfan J, Siplovich L, Koltun L, Benyamin N. Varicocele treatment in pubertal boys prevents testicular growth arrest. J Urol. 1997;157(4):1456–7.

16. Skoog SJ, Roberts KP, Goldstein M, Pryor JL. The adolescent varicocele: what’s new with an old problem in young patients? Pediatrics. 1997;100(1): 112–21.

26.1Introduction

•Acute scrotal pain requires immediate surgical attention to determine the underlying cause and to treat accordingly.

•The diagnosis of acute scrotal pain may not be straightforward and in some patients, immediate surgical exploration may be necessary in order to treat torsion of the testes early to achieve good results.

•Acute scrotal pain and swelling in children and young adults indicates torsion of the testis until proven otherwise.

•In approximately two thirds of patients, history and physical examination are sufficient to make an accurate diagnosis.

•Testicular torsion is a true surgical emergency and must be differentiated from other complaints of testicular pain because a delay in diagnosis and management can lead to loss of the testicle.

•Testicular torsion may interrupt blood flow to the testis and epididymis.

•The degree of testicular torsion is however variable varying from 180 to 720°.

•Testicular torsion accounts for about 26 % of cases of acute scrotum.

•It occurs when the spermatic cord twists leading to testicular ischemia and necrosis as a result of cutting off the testicle’s blood supply.

•The most common underlying cause is a congenital malformation known as a “bell-clapper deformity”.

•This congenital anomaly is results in the long axis of the testicle becoming oriented transversely rather than cephalocaudal.

•In this malformation, the testis is inadequately affixed to the scrotum allowing it to move freely on its axis which can lead to twisting of the cord and its vessels.

•In the “bell-clapper deformity”, the testis hangs within the scrotum and can swing like a bell clapper in a bell, allowing for easy torsion. Males born with the bell clapper deformity have no attachments around either testicle, so that torsion can potentially occur on either side (Fig. 26.1).

•Bilateral testicular torsion, however, is an exceedingly rare event.

•Testicular torsion occurs more commonly in patients who have an inappropriately high attachment of the tunica vaginalis. This allows the testicle to rotate freely on the spermatic cord within the tunica vaginalis (intravaginal testicular torsion).

•The bell clapper deformity is present in approximately 12 % of males; 40 % of them are affected in both testicles.

•It has been estimated that irreversible ischemia and necrosis of the testis begins around six hours after the onset of torsion.