Tips & Tricks: Scrotal disease
- Varicocele Woo, Seung Hyo
Dept. of Urology, Eulji university
College of Medicine, Daejeon, Korea
Introduction
• First description by Celsus
– “… veins that are swollen and twisted over testicle,
which becomes smaller that fellow ….”
• Prevalence
– Adolescent: 15%
– P° (35-50%) / S° (69-81%) : progressive
 Need early intervention !
Introduction (Cont’)
• WHO : Varicocele is ass with
• Decreased testicular volume
• Impaired sperm quality
• Decline in Leydig cell function
• Several studies results
– 70% of healthy palpable varicocele men
• Abnormal S/A
– Progressive & duration dependent testicular damage
– Randomized, controlled, cross-over study
• Varicocelectomy  significantly improved pregnancy
rates
Anatomy
• Artery
– Internal spermatic a. : gonadal artery
– External spermatic a. : cremasteric a.
– Vasal artery
• Vein
– Internal spermatic (gonadal) v. : one in 60%
– External spermatic vein
– Gubernacular vein
• Lymphatics
– 3.6 in spermatic cord
Three compartments
Vas & vasal vs.
Pampiniform
plexus
External spermatic
vessels
Pathophysiology
1. Hyperthermia
2. Reflux of metabolites
3. ‘Hot Rock’ theory
37℃
33~34 ℃
• Formula
– Vol ∝ r2 , R ∝ 1/r4 , Vel ∝ 1/r2
Venous diameter ↑
Venous wall thickening
Venous volume ↑
↓ Resistance &
velocity
Testicular
temperature ↑
Wash out phenomenon
(dilution of intratesticular
testosterone)
Impaired
countercurrent heat
exchange
Impaired
spermatogenesis
Alteration of germ cell metabolism and function, induce arteriovenous
shunting, decreasing activity of enzymes of DNA synthesis, increase
apoptosis, induce hypoxia
Prognostic indication
• (+) predictive value
– Grade III
– Normal FSH
– Lack of testicular
atrophy
– Motility > 60%
– (+) GnRH stimulation
test
– Total motile sperm >
5 x 106
• Indication for surgery
– Ipsilateral growth
arrest/atrophy
Absolute
– Multiple etiology of
testicular dysfunction
– Abnormal S/A
– Bilaterality
– Grade III
– Soft ipsilateral testis
– Pain
– Abnormal GnRH
stimulation test
– Patient/parent anxiety
– Abnormal scrotal
appearance
Minor
VARICOCELECTOMY
Retroperitoneal
Inguinal
Subinguinal
Management : ‘Palomo’
• Palomo technique
– Ligation of gonadal vessels
• Modified Palomo technique
– Ligation of gonaldal vein
• Complication
– Recurrence: 11-15%
– Hydrocele: 7%
– 국내 보고
• Hydrocele: 5-9%
• Recurrence: 5-14%
Laparoscopic varicocelectomy
Management : ‘Ivanissevich’
•
•
•
•
•
Inguinal approach
Familiar region
Ease to approach to cord
Recurrence rate: 9-16% (국내: 5-15%)
Hydrocele: 3-39% (국내: 0-7%)
Management : ‘embolization’
• Recently popularized method
– Not need an anesthesia
– Less invasive
– Failure rate: 27%
– Recurrence: 4-11%
– Hydrocele: 0%
Cayan S, et al. J Androl 2009
Management : ‘microsurgical’
• Best way of varicocele management
– Inguinal Vs. Subinguinal
– Recurrence: <1% (inguinal: 1-2%)
– Hydrocele: nearly 0%
• 1994, Marmar & Kim
– Subinguinal approach
•
•
•
•
Less morbidity (reserve fascia & muscle)
Short recovery time
Less post-op pain
More complex
Surgical technique
Comparison of different techniques used for
varicocele repair
technique
Artery
preserved
Serious
Hydrocele
Failure (%) morbidity
(%)
potential
Radiographic
occlusion
Retroperitoneal
Yes
0
4-11
Yes
No
7
15-25
No
Laparoscopic
Yes
12
5-15
Yes
Conventional
inguinal
No
3-30
5-15
No
Microscopic
inguinal
Yes
0
1
No
Tips-1
• Incision length
– Width of testis
– 2~3cm
• Incision site
– Inguinal
– Subinguinal
Tips-2
• Ligation of external spermatic vein &
gubernacular veins
Tips-3
• Division into two compartments
– Pampiniform & vasal compartment
– Zini et al.
• Rt : 22 min ↓
• Lt : 6 min ↓
Zini et al. Urology 2006
Tips-4
Identification of arterial pulse
1. Using micro probe
2. Dripping papaverine
3. Shift downward : ext. ring  prepubic
Tips-4 (cont’)
4. Identification of pulse by anatomy
Above all, ligate bridge vessels
Then, dissect large veins vertically
Don’t ligate large vein till isolation of artery if possible
Tips-4 (cont’)
4. Identification of pulse by anatomy
Above all, ligate bridge vessels
Then, dissect large veins vertically
Don’t ligate large vein till isolation of artery if possible
Tips-5
• Prevention to risk of hydrocele
1. Save lymphatics
2. Prophylactic hydrocelectomy (plication)
•
Not saved lymphatics
•
Not identified lymphatics
Conclusions
• Unique purpose of varicocelectomy
– Optimization of testicular environment
– Improvement of spermatogenesis
• Selection of technique
– Higher success rate
– Lower complication
– Less invasive
 “Microsurgery”
Conclusions (cont’)
• Considerations in Microscopic
varicocelectomy
– Completely understanding of anatomy
– The Site of Incision
– Identification of Arterial Pulse
• Alter the site of incision
• Using papaverine or micro probe
• Disconnecting crossing-vessel at first
– Prevention of Hydrocele
경청해 주셔서 감사합니다 !