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Varicocele Facts or Fiction Dr. Gil Raviv Urology Department Andrology Unit Sheba Medical Center.

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Presentation on theme: "Varicocele Facts or Fiction Dr. Gil Raviv Urology Department Andrology Unit Sheba Medical Center."— Presentation transcript:

1 Varicocele Facts or Fiction Dr. Gil Raviv Urology Department Andrology Unit Sheba Medical Center

2 Definition Varicocele is a vascular abnormality of the scrotum that is defined as dilated veins of the pampiniform plexus. Varicocele - Facts or Fiction

3 Anatomy 90% left side. 10% bilateral. Most commonly - internal spermatic veins. Others: –External spermatic veins. –Cremasteric veins Rarely appears - deferential veins Varicocele - Facts or Fiction

4 Pathophysiology Is not known for certain. Various theories for testicular damage due to incompetent valves of spermatic veins: –Increased testicular pressure. –Hypoxia and stasis. –Increased testicular temperature. –Elevated spermatic vain catecholamines. Varicocele - Facts or Fiction

5 Prevalence General population % Attending infertility clinics % WHO (project 78923) General population % Abnormal semen parameters % (Fertile-Sterile 1992) Varicocele - Facts or Fiction

6 Diagnosis Various methods: Radio nuclide examination - high false negative - depends on blood pooling. Scrotal Thermography - rarely used. Doppler stethoscope- only for confirmation. Varicocele - Facts or Fiction

7 Diagnosis Scrotal real time Ultrasonography - widely used with high specificity and sensitivity. Venography - most accurate diagnostic method. Venographic data supports ultrasound examination only in cases of clinically suspected cases. Varicocele - Facts or Fiction

8 No single diagnostic tools available provides both exceptional sensitivity and specificity in varicocele detection. Varicocele - Facts or Fiction Diagnosis

9 The most acceptable methods of diagnosis is clinical examination based on clinician’s subjective impression. Grade 1 - palpable - valsalva manoeuvre. Grade 2 - palpable - without valsalva manoeuvre. Grade 3 - visible. Varicocele - Facts or Fiction

10 Diagnosis Subclinical Varicocele Detected only by radiological imaging. Controversy exists: Diagnosis. Treatment. Pregnancy rate. Varicocele - Facts or Fiction

11 Varicocele in adolescence Rarely found before puberty. Varicocele during adolescence is: Asymptomatic. Found on routine examination. Kass. Urol.Clin 1994 Varicocele - Facts or Fiction

12 Varicocele in adolescence INDICATION FOR TREATMENT ABNORMAL SEMEN ANALYSIS VOLUME OF LEFT TESTIS 3 ML LESS THEN RIGHT. LARGE SYMPTOMATIC VARICOCELE. BIL PALPABLE VARICOCELE. Varicocele - Facts or Fiction

13 Varicocele in adolescence The best method of treatment remains a dilemma. PECUTANEOUS ABLATION Recurrence rate %. One to three hours. Sedation in addition to local anesthesia. Reserved for cases of failed surgery. Varicocele - Facts or Fiction

14 Varicocele in adolescence TRANSPERITONEAL LAPAROSCOPY Presently not considered as first- line therapy. General anesthesia. Potential major complications. High cost. Varicocele - Facts or Fiction

15 DOES IT A DYNAMIC PROGRESSIVE LESION? HISTOLOGY – Lesions are similar to adults. – Similar in both testis. – May precede volume loss. – No predicting data on reversibility. Varicocele - Facts or Fiction Varicocele in adolescence

16 SURGERY Palomo -Retropertoneum- above level of vas deferenes. Artery - sparing procedure. Ivanissevitch- inguinal canal the most commonly used. Varicocele - Facts or Fiction

17 Routine varicocele ligation in teenager is not recommended. Occlusion of the left internal spermatic vein in young men with varicocele should be performed only in the context of an appropriately large prospective study. RCOG study group, Variable ligation methods are performed depend on the physician skills. Varicocele in adolescence Varicocele - Facts or Fiction

18 CONTROLLED STUDIES - EFFECTIVNESS OF VARICOCELECTOMY NIESCHLAG (1995,1998 Hum Reprod ). 125 infertile couples varicocelectomy counseling. W - intervention B- counseling Varicocele - Facts or Fiction

19 CONTROLLED STUDIES - EFFECTIVNESS OF VARICOCELECTOMY NIESCHLAG CONT. No relationship to pregnancy rate. Semen analysis. Hormone profile. Varicocele grade. Age of male. Only female age predict pregnancy Sperm count increased. Varicocele - Facts or Fiction

20 CONTROLLED STUDIES - EFFECTIVNESS OF VARICOCELECTOMY Baker et al 1985 (I.J Androl ). 651 couples. 324 males - sperm count less then 20 x males - sperm count more then 20 x No difference in pregnancy rate. Sperm motility improved Varicocele - Facts or Fiction

21 CONTROLLED STUDIES - EFFECTIVNESS OF VARICOCELECTOMY Vermuelen (1986, J. Androl ). 90 patients - varicocelectomy. 25 patients - observation. Cumulative PR were the same. Both improved sperm characteristics. Varicocele - Facts or Fiction

22 CONTROLLED STUDIES - EFFECTIVNESS OF VARICOCELECTOMY Rageth (1992, Urol Int ). 89 patients. 56 varicocelectomy - 33 observation. All had poor semen analysis. The same PR ( 42 %). Surgery group all had improved sperm characteristics. Varicocele - Facts or Fiction

23 CONTROLLED STUDIES - EFFECTIVNESS OF VARICOCELECTOMY Rodriguez-Rigau (1978. J Urol ). Controlled not prospective not randomized. No difference in PR. Sperm count and motility improved after surgery. Varicocele - Facts or Fiction

24 Controlled studies supporting varicocelectomy Marmar and KIM (1994,J Urol). 466 surgery group/19 controls. PR surgery group 35.6 % ( 186/466). PR controls 15.8 % Varicocele - Facts or Fiction

25 Controlled studies supporting varicocelectomy Girardi and Goldstin(1997 Curr Ther Endocrine Metab) underwent varicocelectomy. 47 controls group. PR- 43 % surgery group versus 17 % controls group. Improvement of sperm count. Varicocele - Facts or Fiction

26 Controlled studies supporting varicocelectomy WHO study never published in its original form infertile couples had clinical varicocele. Varicocele - Facts or Fiction

27 Controlled studies supporting varicocelectomy Hargreave. PR after surgery - 35 %. PR controls group 17 %. Part of WHO study presented only at andrology meeting! Varicocele - Facts or Fiction

28 Controlled studies supporting varicocelectomy Madgar et al (1995,Fertile Sterile). 210 couples from the WHO study. 45 couples - 20 controls group. 25 high ligation spermatic vein. PR surgery group 60 %. PR controls group 10 %. Varicocele - Facts or Fiction

29 Controlled studies supporting varicocelectomy TREATMENT IN ADULTS WHICH MODALITY IS THE BEST ? Comparison by three outcome measures: * Success rate. * Semen improvement and pregnancy rate. * Complication rate. Varicocele - Facts or Fiction

30 Success rate Recurrence or persistence after treatment. High ligation %. Inguinal ligation 6 - 9%. Percutaneous ablation %. Laparascopic %. Varicocele - Facts or Fiction

31 Semen improvement and pregnancy rate No differences in pregnancy rate in all kinds of treatment. Improvement of sperm - occasionally. Varicocele - Facts or Fiction

32 Complication rate Laparascopic ligation % Operative-inguinal approaches: - Artery damage. - Ilioinguinal nerve damage. - Scrotal hematoma. Varicocele - Facts or Fiction

33 Complication rate - cont. Operative-retroperitoneal approaches - Artery damage. - hydrocele (7%). Percutaneous ablation - Contrast allergy (2%). - Injuries to vascular tree. - Migration and embolization. Varicocele - Facts or Fiction

34 Complication rate - cont. Operative-laparascopic approaches - Injured epigastric vessels. - Rarely bowel injury. - High cost. Varicocele - Facts or Fiction

35 CONCLUSIONS (1) There is insufficient evidence to recommended occlusion of the left internal spermatic vein in subfertile or oligozoospermic men with varicocele. (gynecologists). Varicocele - Facts or Fiction

36 CONCLUSIONS (2) Varicocele exert deleterious effect upon both testis and it’s function - therefore treatment is recommended in large varicocele with reduced testis volume in adolescence. Varicocele - Facts or Fiction

37 CONCLUSIONS (3) Correlation exists between varicocele size and seminal improvement. Diagnosis and treatment of subclinical varicocele is not recommended. Timing of varicocele correction is not determine. Varicocele - Facts or Fiction

38 CONCLUSIONS (4) Correction of varicocele depends on female age. Sperm cryopreservation and varicocele correction is recommended in patients with severe OTA and high FSH. Varicocele - Facts or Fiction

39 Bilateral varicocele. Operating one side/ both ? ?open/laparoscopy Type of operation: Varicocele - Facts or Fiction SPECIAL CONDITION AND VARICOCELE Azoospermia. FSH- normal/abnormal? Very severe OTA. High/normal FSH? Recurrent varicocele?

40 VARICOCELE AND OTHER SPECIAL CONDITION Undesending testicle in the same side? Recurrence - Type of treatment? Surgery/Embolization Improved sperm count.

41 VARICOCELE AND OTHER SPECIAL CONDITION Pain only. Failed embolization. - Type of treatment. Varicocele in older men. Right side. Couple after few cycle of IVF-ICSI. Isolated teratoastonespermia.


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