3. Varicocele is an abnormal dilation & tortuosity of the internal spermatic
veins within the pampiniform plexus of the spermatic cord.
• Represents the most
common cause of primary
& secondary infertility in
the male.
• Varicoceles are present in 15% of normal males, 19% to 41% in men
with primary infertility,& up to 81% of men with secondary infertility.

4. • Turbulent venous flow related to the insertion of the gonadal veins;
either the left gonadal with a right angle into the left renal vein or the
right gonadal directly into the IVC.
• Incompetent or absent venous valves
in the gonadal veins allow retrograde
reflux of blood into the scrotum on
standing.
• The “nutcracker phenomenon” as the
left renal vein may be compressed
between the superior mesenteric artery
and the aorta.

5. • The Presence of varicocele has a
genetic background which is not
necessarily related to the severity
of the disease
• Varicocele in adolescents is
associated with thin tall body
habitus
• 90% of varicoceles are presented
on the left side while the presence
of large right side varicocele
especially un-decopressible may
indicate retroperitoneal or caval
pathology such as renal
neoplasms.

7. • Varicocele is associated with a progressive and duration-dependent
decline in testicular function.
1. Elevated intrascrotal temperature resulting in reductions in
testosterone synthesis by Leydig cells, injury to germinal cell
membranes, altered protein metabolism, & reduced Sertoli cell
function.
2. The free reflux of renal and adrenal metabolites from the left renal
vein are directly gonadotoxic.
3. Impaired venous drainage results in hypoxia, poor clearance of
gonadotoxins, and elevated levels of oxidative stress.

9. • Despite having a congenital background it is not diagnosed before the
age of 10 years.
• Grade I: Small, detectable only during the Valsalva maneuver.
• Grade II: Moderate, can be palpated without Valsalva.
• Grade III: Large, visible through the scrotal skin & classically
described as feeling like a “bag of worms”, & decompresses in supine
position.
• Sub-Clinical Varicoceles are those not detected clinically but
diagnosed only detected by ultrasonography with or without doppler,
radionucleotide scans, thermography & venography.

10. • The Normal parameters of semen analysis..

11. • Although clinical varicoceles do not require confirmation with
ultrasound examination, color Doppler ultrasound may be required
when the clinical examination is difficult.
• Demonstration of reversal of venous blood flow with the Valsalva
maneuver or spermatic vein diameters of 3 mm or greater support the
diagnosis of varicocele.
• Scrotal ultrasound is not recommended for screening for subclinical
varicoceles as repair of these has not been demonstrated to be of
clinical benefit.

12. • Venography of the internal spermatic veins has been used to diagnose
and treat varicoceles
• Although nearly 100% (Most Sensitive) of clinical varicocele patients
will demonstrate reflux on venographic examination, left internal
spermatic vein reflux has been reported in up to 70% of patients
without a palpable varicocele. (High false positive results & Limited
Specificity)
• It does have utility in patients with presumed post-varicocelectomy
recurrence both for confirmation of the diagnosis and embolization of
persistent vessels.

14. 1. Palpable varicocele on physical examination.
2. Large varicoceles producing clinical symptoms such as dull
hemiscrotal discomfort or sense of heaviness
3. The couple has known infertility with the female partner has
normal fertility or a potentially treatable cause of infertility.
4. The male partner has abnormal semen parameters or abnormal
results from sperm function tests.
5. Adolescent males with unilateral or bilateral clinical varicoceles &
ipsilateral testicular hypotrophy (20% or 3ml volume decrement from
the contralateral testis)
• Patients with subclinical varicoceles are not candidates for varicocele
treatment due to lack of demonstrated efficacy in this population.
• The various methods of varicocele treatment all involve ligation or
occlusion of dilated gonadal veins.

15.  Scrotal Approach
 Retroperitoneal approaches (Open or Laparoscopic)
 Inguinal Approach
 Sub-Inguinal Approach
 Radiographic Occlusion Techniques (Embolization)

16. • The very 1st approach for varicocele repair employed in the early
1900s
• Involves mass ligation & Excision of the varicosed veins.
• Not preferred practically due to the high incidence of testicular artery
injury with subsequent impairment of the testicular blood supply,
testicular atrophy & more impaired spermatogenesis & fertility.

17.  Incision at the level of the internal ring near to the Anterior Superior
Iliac Spine.
 Splitting of the External & Internal Oblique Muscles.
 Exposure of the Internal Spermatic Artery & Vein retroperitoneaelly
near the ureter where only one or two large veins are present & the
testicular artery is not yet branched & so easy to separate.
 High recurrence rate 15% due to preservation of the testicular artery &
the peri-arterial venae comitatntes which communicates with the
larger internal spermatic veins causing recurrence.
 Recurrence is prevented by intentional artery ligation, However it
may cause testicular atrophy & subsequent azoospermia.

18.  It is an essence retroperitoneal approach with similar advantages &
disadvantages, including rate of recurrence.
 The internal spermatic veins are ligated with the laparoscope at the
same level as the retroperitoneal approach with preservation of the
testicular artery.
 The magnification provided by the laparoscope allows visualization of
the testicular artery. With experience, the lymphatics may be
visualized and preserved as well preventing secondary hydrocele
formation.
 Additional possible complications include visceral & vascular injury,
air embolism & peritonitis.

19.  Allows access to external spermatic and gubernacular veins which
causes recurrences if not ligated.
 Microsurgical varicocelectomies has resulted in marked decrease in
the incidence of Secondary Hydrocele formation (compared to the
conventional operations with average 7%) due to easy identification of
lymphatics, Plus that identification of testicular artery helps avoiding
azoospermia & atrophy

20. Small Testicular Artery Artery adherent to fascia
Precious Testicular Artery Difficult Opening & Closure of fascia
Better Dissection & fascia Better Exposure & Ligation of veins
Closure
Easier in performance
More Difficult in Performance

21. Incision
• Inguinal: The incision begins at the external
ring and extended laterally 2 to 3.5 cm along
Langer lines.
• Sub-Inguinal: The incision is placed in the
skin lines just below the external ring.
• Camper’s & Scarpa’s Fascia are divided,
Superficial Epigastric Artery or Vein are
retracted or ligated.

22. In the Inguinal Approach
• The External Oblique aponeurosis is opened along the length
of the wound in the direction of its fibers
• Grasping of the spermatic cord & delivery of it through the
wound to be surrounded with a penrose drain after sparing of
the ilioinguinal nerve & genital branch of the genitofemoral
nerve

23. In the Sub-Inguinal Approach
• An index finger is introduced into the
wound and along the cord into the scrotum
then hooked under the external inguinal
ring.
• A Richardson retractor is slid along the
back of the index finger and retracted over
the cord toward the scrotum.
• The spermatic cord will be revealed between the index finger and
retractor, delievered & then surrounded with a large Penrose drain.

24. Dissection of the cord
• The Internal & External Spermatic
fascias are opened & the cord is
inspected for pulsations of the
testicular artery to be dissected
away
• The Cord veins are dissected
starting with the large veins with
taking care of possible adherant
testicular artery (50% Possibility)

25. Dissection of the cord
• All veins are then ligated (except the
vasal veins to allow venous return)
with 4-0 silk ligatures or cauterized
if less than 1 mm.
• After complete dissection only the
testicular artery, cremasteric
arteries, cremasteric muscle fibers,
nerves, lymphatics and vas deferens
with its vessels should remain.

26. Delievery of the Testis
• Delivery of the testis through a small inguinal or subinguinal incision
guarantees direct access to all veins close to the testes
• Assiciated hydrocele (15%) can
alter testicular tempreture
regulation, so should be
repaired if noticed with delivery
of the testis followed by a tube
drain for 24 hours.

27. Special Tools
• The Magnification Microscope with
10-25 power magnification.
• The Micro-Doppler is very useeful for
identifiying the testicular artery.
• The Automatic Clip Applier for
ligation of the veins especially smaller
veins.

28. • Scarpa and Camper fascia are re-approximated with a single or
continuous 3-0 plain catgut suture, and the skin is approximated with a
5-0 monofilament absorbable subcuticular suture.
• A scrotal supporter is applied and stuffed with fluff-type dressings.
• The patient is discharged on the day of surgery with a prescription for
Tylenol with codeine. Light work may be resumed in 2 or 3 days.

29. • Does not prevent recurrence (4% to 11%) but allows visualization of all
collaterals difficult to be seen with the 2D view.
• Drawbacks:
1) Take 1-3 hours to perform compared with 25 to 45 minutes
required for surgical repair.
2) Femoral vein perforation or thrombosis
3) Anaphylaxis to radiographic medium
4) Recurrence with large varicoceles & with Failure to cannulate
small collaterals
5) Migration of the balloon or coil into the renal vein, resulting in
loss of a kidney, pulmonary embolization

31. • The most common complication with incidence 3 -33% (Average 7%).
• With the high protein content proved to be due to lymphatic
obstruction.
• Creates an insulating layer around the testes impairing the efficiency of
the counter-current heat exchange mechanism obviating the benefit of
varicocelectomy.
• The Use of Magnification helps good identification of lymphatics &
preventing hydrocele formation.

32. • The testicular artery forms 2/3 of the blood supply to the testes (with
the vasal & cremasteric arteries form the remaining 1/3).
• Is 1-1.5 mm in diameter, adherent to a large spermatic vein (40% of
men) & Surrounded by a network of tiny veins (20% of men).
• Injury or ligation of the testicular artery carries with it the risk of
testicular atrophy and/or impaired spermatogenesis. (which is less
likely to occur in children due to compensatory neovascularization).
• The Use of Magnification & Micro-Doppler helps good identification &
Preservation of the testicular artery.

33. • The incidence of recurrence after varicocele repair varies from 0.6% to
45%
• Recurrence is mostly associated with:
1. Pediatric Varicocele
2. Non-Magnified Operations
3. Retro-peritoneal approaches (that misses the parallel inguinal
collaterals)

35. • Mean increases in sperm density of 9.7 million/mL, motility
increases of 9.9%, sperm morphology improvement by 3% have
been reported with improvement in semen quality in 51% to 78%
of infertile men.
• About 60% of Azoospermic patients with varicoceles have shown
some potential for return of sperms to their semen after varicocele
repair (Still requiring ART to obtain conception)

36. • Spontaneous pregnancy rates after varicocele treatment have been
reported to average between 30% and 50% within about 8 months
duration.
• Recovery of testicular volume in adolescent patients, so called “catch-up
growth,” has been reported to occur in up to 80% of boys with grade II
or III varicoceles.
• Treatment does not produce improvement in cases with underlying
genetic abnormalities associated with subfertility.