Varicocele: Treatment indications and repair techniques

Varicocele is a pathologic enlargement of the testicular veins that is associated with impaired spermatogenesis and infertility. In fact, varicocele is the most common correctable cause of male infertility. Varicoceles are found in up to 15% of the adult male population, but fortunately not all men with varicoceles are infertile. However, varicoceles are found in approximately 35% of men with primary infertility and up to 80% of men with secondary infertility (Wein AJ, Kavoussi LR, Partin AW, Peters CP, editors. Campbell-Walsh Urology. 11th ed. Philadelphia: Elsevier; 2016).

Varicoceles are diagnosed by physical exam and are graded I-III. Grade I varicocele is palpable only during the Valsalva maneuver; grade II varicocele is palpable in the standing position; and grade III varicocele is visible without palpation. The use of scrotal ultrasound in diagnosis should be restricted to men with a difficult physical exam, such as those with prior surgical history or challenging body habitus. It is important to distinguish a subclinical varicocele-a varicocele that is not visible on exam and detected only with ultrasound-because surgical correction has not been shown to improve semen parameters.

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This article presents an overview of the pathophysiology of varicoceles and discusses indications for treatment, two primary repair techniques, and treatment outcomes.

Pathophysiology

Varicoceles form because of increased hydrostatic pressure in the internal spermatic veins, possibly because of incompetent or absent venous valves. Anatomic differences cause increased hydrostatic pressures, making varicoceles more common on the left (Asian J Androl 2015; 17:659-67). Therefore, isolated right-sided varicoceles are rare and, when identified, should prompt a workup for an ipsilateral pathologic retroperitoneal process with imaging.

Clinical varicoceles can negatively affect sperm concentration, motility, and morphology. The following five mechanisms contribute to the pathogenesis of impaired testicular function: hypoperfusion from retrograde flow leading to hypoxia, heat stress from impaired countercurrent heat exchange, oxidative stress from accumulation of reactive oxygen species, hormonal imbalances from abnormal Leydig cell function and decreased intra testicular testosterone, and accumulation of exogenous toxins. However, no single mechanism accounts for the observed impairment (J Assist Reprod Genet 2014; 31:521-6). Literature supports that grade of varicocele is associated with degree of spermatogenesis impairment and worse semen parameters.

Next: When to treat varicoceles

When to treat varicoceles

Not all varicoceles require treatment. The American Society for Reproductive Medicine (ASRM) Practice Committee guideline indicates that treatment of the varicocele should be considered when most or all of following conditions are met: the couple is attempting to conceive; the varicocele is palpable on physical examination; the couple has known infertility; the female partner has normal fertility or a potentially treatable cause of infertility, and time to conception is not a concern; and the male partner has abnormal semen parameters (Fertil Steril 2014; 102:1556-60). Observation is an acceptable option if the patient does not meet any of the previously mentioned criteria.

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Varicocele repair for men with severe spermatogenic failure-nonobstructive azoospermia (NOA) and severe oligospermia-remains controversial. A 2016 meta-analysis showed increased pregnancy and live birth rates in men with azoospermia and severe oligospermia who underwent varicocele repair prior to in vitro fertilization (IVF) (Fertil Steril 2016; 106:1338-43). Additionally, men with persistent azoospermia post varicocele repair had higher rates of sperm retrieval on microsurgical testicular sperm extraction.

It is possible that some men with NOA can have return of sperm in ejaculate and can avoid undergoing a testis biopsy for sperm retrieval. Also, men with severe oligospermia can have improvements in sperm parameters and would qualify them for intrauterine insemination-a less-expensive and less-invasive treatment option compared to IVF. Despite improvements in sperm parameters, the vast majority of couples with severe sperm production defect will require assisted reproductive techniques to achieve a pregnancy. More research is needed to better evaluate the role of varicocele repair in men with testis failure.

Varicocele repair in adolescents also remains controversial, as many have not reached sexual maturity or have attempted to conceive a child. As such, most indications for repair from the ASRM do not apply. Many pediatric urologists use testicular size discrepancy and testis pain as indications for varicocele repair. Further complicating the decision to intervene is the paucity of information on normal adolescent semen analysis because the 2010 WHO reference values are based on healthy fertile adult males. More research is needed to address optimal management of the adolescent population.

How to treat

Varicoceles are treated with either surgery or embolization. Regardless of technique, the ultimate goal is to occlude all spermatic veins draining the affected testis. Surgical options include both laparoscopic and open approaches (table 1). Laparoscopy is chosen more often in in the pediatric population because of the smaller size of the vessels in the inguinal canal when compared to adults. Open surgical approaches are either inguinal or subinguinal with or without the assistance of an operating microscope; however, microscope-assisted subinguinal varicocelectomy is the gold standard for varicocele repair (figure), with the lowest incidence of arterial injury, hydrocele, and recurrence (J Androl 2009; 30:33-40). The use of intraoperative micro-Doppler aids in the identification of the testicular artery and decreases arterial injury.

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Percutaneous embolization offers a rapid recovery and can be successfully accomplished in approximately 90% of attempts, with higher failure rates for right-sided varicoceles. Nonetheless, the technique demands interventional radiologic expertise and has potentially serious complications, including vascular perforation, coil migration, and thrombosis of pampiniform plexus. Percutaneous embolization can be a valuable treatment option for recurrences after surgery and for men complaining of scrotal pain (orchialgia) from varicocele because inflammation and scarring from open surgery may contribute to additional pain.

Next: Outcomes

Outcomes

Evaluation for successful varicocele repair is done at least 3 to 6 months postoperatively because spermatogenesis requires approximately 72 days. Data from multiple studies support that men can expect an average increase in sperm concentration of approximately 10 million/cc, 10% increase in motility, and increased overall pregnancy rates 3 months postoperatively compared to preoperative values(J Urol 2012; 187:1540-7). A prospective, randomized, controlled trial showed a significant increase in spontaneous pregnancy in men post-varicocele repair compared to men electing observation (32.9% vs. 13.9%, respectively) (Eur Urol 2011; 59:455-61).

Additionally, varicocele repair has been associated with up to 20% improvements in percent sperm DNA fragmentation in infertile men (Biomed Res Int 2014; 2014:695713). Overall complications are lowest after microsurgical inguinal and subinguinal varicocelectomy (Asian J Androl 2015; 17:74-80). Although men with varicoceles have normal serum testosterone, surgical correction of varicocele can increase serum testosterone by approximately 100 ng/dL in select populations, specifically men with low or borderline low preoperative serum testosterone and the elderly (Transl Androl Urol 2016; 5:866-76). Table 2 summarizes the average improvements seen with varicocele repair in men with oligospermia and infertility.

Conclusion

Varicoceles, a pathologic enlargement of the testicular veins, are the most common correctable cause of male infertility. Not all men with varicoceles require treatment. The decision to treat a varicocele should be based on goals of the patient (and/or partner). Indications for varicocele repair in adolescents and men with NOA require more study. Regardless of technique, varicocele repair leads to improvement in sperm parameters, pregnancy rates, and serum testosterone.

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