170 |
N. Punjani and M. Goldstein |
Other Investigations for Infertility in the Context of Varicoceles
•\ DNA Fragmentation [7]: Patients with varicocele often have abnormal levels of DNA fragmentation. Studies have shown that repair of varicocele may improve DNA fragmentation levels. Standard assays for assessment include the terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) and Sperm Chromatin Structure Assay (SCSA). These two assays correlate 70% of the time [8].
•\ Anti-sperm antibody (ASA): Some studies have shown a small subset of patients with varicocele have anti-bodies to sperm, however, the clinical signi cance and correlation has yet to be clearly determined. High levels of ASA is diagnostic of obstruction [9].
Treatment
Indications for Varicocele Treatment Include the Following
•\ Symptoms including recurrent and persistent pain—reported rates of pain resolution vary from 50 to 90% following varicocele repair.
•\ Infertility—numerous studies have shown that varicocele treatment improves semen parameters including concentration and motility in a majority of men, and improved pregnancy outcomes with or without ART after repair [10].
•\ Patient preference (i.e. cosmetic reasons)—large varicoceles may appear as a “bag of worms” in the scrotum, and grossly dilated veins may be visible and bothersome to patients.
•\ Testicular size discrepancy (pediatric population)—variable de nitions have been used for a signi cant discrepancy, some up to 20% difference. In adolescents, treatment usually results in a “catch-up” growth.
•\ Low testosterone—studies have shown that men with low testosterone have improvements of up to 14% average after their varicocele is repaired [11].
Numerous Treatments for Varicocele Exist
•\ Embolization by interventional radiology—this requires entry at the jugular or femoral vessels whereby veins are identi ed and occluded with tiny coils. Embolization has an ~80% initial success rate, but is associated with a high risk of recanalization, resulting in late recurrence.
25 Varicocele |
171 |
•\ Microsurgical varicocelectomy—this is completed either through an inguinal or preferably subinguinal incision. The cord is delivered and care is taken to preserve arterial supply in the cord with the utilization of a doppler ultrasound probe. All visible veins are taken while lymphatics and associated nerves are spared. Following completion of vein ligation in the cord, external spermatic veins and any venous drainage from the gubernaculum should be taken. The veins of the vas deferens provide venous return after successful repair. This is the technique currently recommended in the AUA guidelines for treatment of varicocele.
•\ Non-microsurgical varicocelectomy—this is completed in the same fashion as the microsurgical method with or without surgical loupes. This technique may be approached inguinally or subinguinally.
•\ Retroperitoneal varicocelectomy—an open procedure performed using the Palomo technique, which includes a Gibson incision with ligation of the internal spermatic vein between the anterior superior iliac spine and renal vein.
•\ Laparoscopic varicocelectomy—this is completed transperitoneally either with the use of three ports or a single port surgical method. The peritoneum is opened proximal to the internal inguinal ring and spermatic vessels are dissected out with the veins ligated. The artery may or may not be spared.
•\ Retroperitoneoscopic varicocelectomy—this is completed through an incision below the 12th rib to create access to the retroperitoneal space. Spermatic vessels are dissected off the peritoneum and veins are ligated.
•\ Robotic assisted varicocelectomy—this technique is performed with the same steps as a subinguinal varicocelectomy but utilizing robotic arms to assist and maneuver through the cord and for vessel identi cation and ligation (Fig. 25.2 and Table 25.2).
In conclusion, as in our case, prompt and careful attention to a complaint of scrotal pain and infertility resulted in an accurate diagnosis of varicocele. Semen analysis, DFI, hormone evaluation, and imaging studies delineated the severity of the varicocele, allowing varicocelectomy to be performed which alleviated pain and achieved fertility at the end.
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
172 |
N. Punjani and M. Goldstein |
Laparoscopic
Retroperitoeal
Inguinal
External inguinal ring
Subinguinal
Embolization
Fig. 25.2 Approximate locations of incisions for the various technical approaches for varicocele correction
Table 25.2 Comparison of outcomes of various treatment options for varicocele [12]
|
Recurrence/ |
Hydrocele |
Spontaneous |
Technique |
persistence |
formation |
pregnancy |
|
|
|
|
Embolization |
3–11% |
– |
33.2% |
Open inguinal |
2.6% |
7% |
36% |
(non-microsurgical) |
|
|
|
|
|
|
|
Microsurgical subinguinal |
0–2% |
0.4% |
42% |
Retroperitoneal |
9–45% |
8% |
38% |
Laparoscopic |
3–15% |
2.8% |
30% |