I. Definition of varicocele: It refers to the abnormal elongation, dilatation and tortuosity of the trabecular plexus of the intra-seminomatous veins.
(i) Primary varicocele: varicocele caused by anatomical factors and dysplasia.
(ii) Subclinical varicocele: It is a mild varicocele that cannot be detected on physical examination but can be detected by ultrasound, nuclear scan or color Doppler examination. The diagnosis is generally considered to be established by a vein diameter of more than 2 mm. Secondary varicocele: Intra-abdominal or retroperitoneal tumor, hydronephrosis or ectopic vascular compression of the superior spermatic veins may also lead to unilateral or bilateral varicocele, which is called secondary varicocele.
Second, the epidemiological and anatomical factors of varicocele
(i) Epidemiology of varicocele
The incidence of varicocele accounts for about 10%-15% of the male population and is mostly seen in young adults. Varicocele mostly occurs on the left side, but recently it has been found to occur bilaterally in up to 40% or more. In adolescents, there is a significant correlation between the prevalence of varicocele and age. Recent studies have reported a prevalence of 2%-ll% in prepubertal children, 9.5%-16.2% in adolescents, and 9%-26% in late adolescence. Varicocele occurs less frequently in men before puberty, while its incidence increases gradually with age after puberty, probably related to physical growth, increased testicular size and increased blood supply to the testes.
(ii) Etiology and anatomical factors of varicocele, 90% of varicocele occurs on the left side. The high incidence of left side is related to the following reasons.
1, the human body usually takes an upright posture, so that the blood in the spermatic vein must overcome gravity to return from the bottom to the top;
2, the vein wall and the adjacent connective tissue are weak or the testicular muscle is underdeveloped, which weakens the support role around the internal spermatic vein;
3.The left internal spermatic vein has more defective valves or incomplete closure than the right;
4, the left internal spermatic vein is located behind the sigmoid colon, which is easily affected by intestinal compression;
5, the left spermatic vein enters the renal vein at a right angle, with a slightly longer stroke and higher hydrostatic pressure;
6, the left renal vein is located between the aorta and mesenteric artery, and the compression of the renal vein may affect the reflux of the internal spermatic vein, forming the so-called proximal clamp phenomenon;
7.The right common iliac artery may compress the left common iliac vein and affect the left vas deferens venous reflux, forming the so-called distal clamping phenomenon.
Varicocele and fertility
(i) The relationship between varicocele and fertility
It is now recognized that palpable varicocele can affect fertility and is one of the main causes of male infertility. It has been documented that approximately 40% of primary infertility and 80% of secondary infertility in adult males have varicocele. The factors of varicocele affecting fertility are pathological changes and immunological factors.
1. Histopathological changes of the internal spermatic veins, testes and epididymis
Lesions of the internal spermatic vein reveal degeneration of the endothelial cells of the vessels, hyperplasia of the endothelium, and severe mechanization of the valves by hyperplasia of the mesothelium and smooth muscle of the valves, thus causing blood stagnation. The lesions of testicular injury showed detachment of spermatogenic cells, interstitial edema, and small interstitial vascular lesions. Epididymal lesion manifestation, interstitial edema, epithelial cell degeneration, disorder of brush border arrangement on the surface of tubular epithelial cells.
2.Immune factors of seminiferous vein, testis and epididymis
In recent years, studies have confirmed that varicocele infertility is related to immune factors. colomb et al. found that anti-sperm antibodies (ASA) exist in peripheral blood and semen of varicocele infertility, and ASA enters the testis or epididymis, which can interfere with spermatogenesis and sperm maturation process, leading to a decrease in the number of sperm or adhesion to the sperm membrane, causing morphological and functional abnormalities of sperm.
(ii) Causes of infertility due to varicocele
The causes of infertility caused by varicocele have not been fully elucidated yet, and may be related to the following factors.
1, blood stagnation in the spermatic vein, so that the local temperature of the testis increases, and the degeneration of spermatogenic tubules affects the occurrence of spermatozoa;
2, blood retention affects testicular blood circulation, and CO2 accumulation in testicular tissue affects spermatogenesis;
3, the left spermatic vein reflux to the renal vein blood, will adrenal and renal secretion of metabolites such as steroids, catecholamines, 5-hydroxytryptamine can cause vasoconstriction, resulting in premature sperm shedding;
4, varicocele on the left side can affect the function of the right testicle, because there are rich traffic branches of the veins between the testicles bilaterally, and the toxins in the blood of the left spermatic vein can affect the spermatogenesis of the right testicle.
IV. Diagnosis
(i) Clinical manifestations
Most patients are found during physical examination without conscious discomfort, or are detected during consultation for infertility. Those with symptoms mostly show discomfort or cramping in the scrotum, and the pain may radiate to the groin area and lower abdomen, which is aggravated when standing and walking, and alleviated after lying down and resting.
(ii) Diagnostic criteria
Clinically, varicocele is classified into four grades.
Grade III: dilated veins can be seen protruding from the scrotal skin when the patient is standing, like a mass of earthworms, which can be easily palpated.
Grade II: The dilated veins are very easily palpable during palpation but cannot be seen.
Grade I: not obvious on palpation, but may be present on Valsalva test.
Grade 0: No symptomatic manifestation of varicocele, and Valsalva test cannot be present.
(iii) Auxiliary examinations
1.Imaging examination
(1) Ultrasound and color Doppler ultrasound examination (recommended): especially with color Doppler ultrasound examination, it can determine the phenomenon of blood reflux in the internal spermatic veins. It is a non-invasive test with convenience, good repeatability, high resolution as well as accurate diagnosis, and can be the preferred detection method.
(2) Infrared scrotal thermometry (optional): a non-invasive test. Research shows that the local temperature of scrotum is proportional to the degree of varicose veins, but it is influenced by the temperature of surrounding tissues and environment, and the false positive rate is high.
(3) Spermatic venography (optional): intraventricular spermography is a reliable diagnostic method. The imaging results can be divided into three levels: mild: contrast reversal in the internal spermatic vein up to 5 cm in length; moderate: contrast reversal to the level of lumbar vertebra 4-5; severe: contrast reversal into the scrotum. Since this test is invasive and technically demanding, it limits its clinical application. Intravenous spermography helps to reduce the failure rate of high ligation surgery and to analyze the reasons of surgery failure.
2.Laboratory tests
(1) Semen analysis (recommended): Semen can determine abnormal testicular function if immature spermatozoa are detected. Patients with varicocele should have at least 2 semen analyses.
(2) Sperm antibody test (optional): Patients with infertility should have serum or semen sperm antibodies checked.
3.Measurement of testicular volume (recommended)
In the examination of varicocele, in order to understand whether the testes are damaged and whether they have indications for surgery. The size of the testes must be measured. There are many ways to measure testicular size. These include visual comparison, sizing, Prader molds, Takihara molds, and ultrasound. Most scholars believe that ultrasound is the most accurate method of measuring testicular size.
V. Treatment of varicocele
Varicocele is a frequent disease in male young adults, and most of the clinical literature reports that surgery is the main treatment, and some of them are treated with drugs (including Chinese medicine).
(i) Drug treatment
1, compound carnitine: consists of L-carnitine and acetyl L-carnitine, both are natural substances in human body, they mainly have two physiological functions: one is an important factor in the process of mitochondrial β-oxidation of fatty acids, and participate in energy metabolism; the second is to increase the stability of cells by reducing reactive oxygen species (ROS) and inhibiting apoptosis. Spermatozoa acquire motility and fertilization ability in the epididymis. The acquisition of motility and fertilization ability of spermatozoa is not only dependent on androgens, but also related to carnitine, glycerophosphorylcholine (GPC), sialic acid (SA), etc. secreted by the epithelium of the epididymis, and the role of carnitine is crucial, especially the biologically active L-carnitine in the body has a direct impact on the maturation and motility of spermatozoa. In addition, carnitine can increase sperm count by increasing the concentration of prostaglandin E2. Compound carnitine preparations (Burberry) 2 bags (each bag contains L-carnitine 10mg, acetyl L-carnitine 5mg) / time, oral, twice a day, for 4 to 6 months.
2, clomiphene: is a non-steroidal estrogen receptor antagonist, can compete with the hypothalamus, the pituitary site of estrogen receptors, thus weakening the negative feedback effect of normal estrogen in the body, resulting in endogenous GnRH, FSH, LH secretion increased, and then act on the testicular interstitial cells, supporting cells, spermatogenic cells, regulation, promote spermatogenic function; clomiphene can also increase the sensitivity of interstitial cells Clomiphene can also increase the sensitivity of mesenchymal cells to LH and promote T secretion. Clomiphene can affect the whole hypothalamic-pituitary-testicular axis and correct the hormonal imbalance of the gonadal axis. The commonly used dose is 25mg/d orally, with a dose range of 12.5-40mg/d. Doses above 200mg/d significantly inhibit spermatogenesis. The efficacy of combining HCG and clomiphene after inguinal spermatic vein ligation is significantly higher than that of surgical treatment alone. 1000U of human chorionic gonadotropin (HCG) is injected intramuscularly three times a week, with a total dose of 30,000U; clomiphene 25mg/d, 30d as a course of treatment, with 25d and 5d of discontinuation, for three consecutive courses.
3.Stretching varicose veins to help fertility soup: With the main drugs of made aromatic herb, lychee nucleus, angelica, white peony, red peony, hedgehog, green peel, Chenpi, roasted licorice, etc., it can significantly improve the sperm density, vitality, activity rate, reduce the rate of malformation and shorten the liquefaction time in patients with varicose veins with infertility by combining with high level ligation of spermatozoa. The dose: one dose a day, divided into two doses after meals, 1 month for 1 course, 3 courses of treatment.
4.Tong Shen: Chai Hu, Safflower, Radix Angelicae Sinensis, Wu Jia Pi, Fructus Lycii, Radix et Rhizoma, Huai Shan Yao, Raspberry 10g each, Calcined Dragon Bone, Salviae Miltiorrhizae 30g each, Wu Wei Zi 6g, Astragali, Chuan Niu Knee 15g each, Dampness, add Dioscorea Z, Xu Changqing; Long-term disease, use Salviae Miltiorrhizae, late stage damage to the kidney essence, add Antler Cream, Cistanches, for eliminating blood stasis and strengthening sperm, can promote testicular blood circulation, improve testicular ischemia and hypoxia, It can promote sperm production in the testes, increase the number of sperm and improve sperm activity rate.
5.Other Chinese herbal treatments: there are tonic Chinese medicine and qi soup, kidney and sperm pellets, Chinese medicine sperm production punch, etc., which have certain clinical effects, but more information is needed for further verification.
(ii) Surgical treatment
The treatment of primary varicocele should be treated differently according to the presence or absence of clinical symptoms, the degree of varicose veins and the presence or absence of complications. Those with mild asymptomatic symptoms and no complications of infertility can be treated with non-surgical methods such as scrotal support, local cold compresses and reduction of sexual stimulation. For those who have obvious symptoms or have caused testicular atrophy, decreased semen quality and infertility, they should be actively treated surgically. Surgical methods mainly include traditional open surgery, laparoscopic surgery and other methods of treatment.
1. Indications and contraindications for surgery.
(1) Indications for surgery
①If the varicocele is infertile, there are abnormal semen examination, no other diseases affecting fertility are found in medical history and physical examination, normal endocrine examination, and no abnormal findings in female fertility examination, regardless of the severity of varicocele, as long as the diagnosis of varicocele is established, surgery should be performed in time.
②Severe varicocele with obvious symptoms, such as more standing that is to feel the pain of scrotal swelling, etc., physical examination found testicular obvious shrinkage, even if there has been fertility, the patient has the desire for treatment can also consider surgery.
Clinical observation shows that the incidence of prostatitis and seminal vesiculitis in patients with varicocele increases significantly and is twice as high as normal people, so if the above two diseases exist at the same time and prostatitis is not cured for a long time, varicocele surgery can be chosen.
④For adolescent varicocele, since it often leads to pathological and progressive changes in the testes, it is now advocated that adolescent varicocele with testicular volume reduction should be treated with surgery as early as possible to help prevent infertility in adulthood.
⑤ For patients with mild varicocele, if the semen analysis is normal, they should be followed up regularly (every 1-2 years), and once there is abnormal semen analysis, testicular shrinkage and texture softening, they should be operated promptly.
(6) For patients with varicocele accompanied by oligospermia due to non-obstructive factors, simultaneous testicular biopsy and varicocele surgery is recommended to help perform assisted reproduction.
(2) Contraindications to surgery
High level ligation of the internal spermatic vein is contraindicated in patients with a history of abdominal infection and open pelvic surgery with extensive adhesions.
2.Open surgical treatment.
There are two traditional surgical routes as follows.
① Transinguinal canal internal spermatic vein high ligation: commonly used because of the superficial location, wide exposure of the surgical field, small anatomical variation, local anesthesia and other advantages, but this part of the vein is more branches, lymphatic vessels are more abundant, while the arterial branches are also more, and the vein is closely related to the branches, if the injury may occur testicular atrophy, clinical data show that the postoperative recurrence rate can be as high as 25%, the incidence of lymphedema is about 3% to The incidence of testicular atrophy is 0.2%, thus limiting its further promotion and application.
The Palomo procedure has the lowest recurrence rate, but the postoperative incidence of syringomyelia or scrotal hydrocele and aseptic epididymitis is 6.6%, as reported in the literature. The incidence of syringomyelia or scrotal hydrocele is reduced because the modified Palomo procedure simply ligates the internal spermatic cord arteries and veins while preserving other spermatic cord tissues, avoiding lymphatic vessels together and preventing lymphatic flow obstruction. Compared with the traditional Palomo procedure, the incision of the modified Palomo procedure is moved upward, and the operation at this level can avoid damaging the subabdominal wall arteries and veins and avoiding the occurrence of postoperative sphingomyelia or scrotal effusion, so it is more easily adopted clinically and is the treatment of choice for unilateral varicocele (deleted).
3.Laparoscopic surgical treatment: laparoscopic spermatic vein high ligation has the advantages of reliable effect, small injury, less complications, simultaneous bilateral surgery, fast recovery and short hospital stay compared with traditional open surgery, so many clinicians believe that laparoscopy is mainly suitable for those who undergo bilateral laparoscopic high ligation, obesity, history of groin surgery and recurrence after open surgery. The various advantages of laparoscopic high ligation of the spermatic veins over open surgery should be considered for open surgery via the inguinal route or retroperitoneal route, but not for microscopic open surgery via the small incisional route under the external ring. Laparoscopic surgery will entail some intra-abdominal complications, such as bowel, bladder and large vessel injuries. In addition, laparoscopic surgery requires general anesthesia and is difficult to promote in primary hospitals because of the expensive equipment, high medical costs, and limitations of technical personnel.
4.Other treatment: In addition, there are microscopic spermatic vein high ligation, spermatic vein interventional embolization and other treatment methods, which are clinically applied and have good efficacy.
Microsurgical treatment of varicocele (VAC) has the advantages of low recurrence rate and few complications; microsurgical treatment of VAC with infertility can significantly improve semen quality and increase conception rate. The main advantage of microsurgery is that it can easily ligate all the draining veins in the spermatic cord except the vas deferens, preserving arteries, nerves and lymphatic vessels, thus significantly reducing recurrence and complications such as testicular syringomyelia and testicular atrophy. Therefore, microscopic spermatic vein high ligation (MV) is currently considered to be the preferred method for the treatment of VAC.
②Interventional embolization of the spermatic vein:
With the development of interventional radiology, internal spermatic vein embolization or injection of sclerosing agents for primary spermatic varicose veins has become a common method in developed countries. This method involves selective or super-selective injection of embolic material such as gelatin sponge, spring steel wire or sclerosing agent into the internal spermatic vein through a catheter to occlude the varicose vein. This method is both a diagnostic tool and a good treatment method, but it is necessary to master the venipuncture technique and indications to avoid serious complications. Catheter embolization of varicocele has the advantages of no surgery and less pain than traditional surgical ligation, and can avoid post-surgical complications such as scrotal edema and hematoma, and its success rate is higher than surgical ligation, so it is easy to promote its use because of its advantages. However, the method is an invasive means of examination and the cost is high, so its application is somewhat limited.
VI. Recurrent varicocele
The recurrence rate after transinguinal spermatic vein high ligation is high. Prevention of postoperative recurrence has become the key to improve the surgical outcome of this disease.
Recurrence of varicocele is defined as varicocele occurring 6 months after surgery, rather than within 3-6 months. The current clinical data shows that the recurrence rate of transinguinal internal spermatic vein high ligation is as high as 25%, and the recurrence due to intraoperative omission of testicular vein branches accounts for 68% of the total recurrence, and several other methods also have different degrees of recurrence. The main reasons for this are.
1, incomplete ligation of the branches of the internal spermatic vein, caused by omission;
2.The internal spermatic vein is not cut off after ligation;
3, the existence of venous obstructive lesions: there are extensive anastomotic branches between the internal spermatic vein and the vas deferens vein and the external spermatic vein, and gradually converge, and there are extensive anastomotic branches between the root of the scrotum, the soft tissue near the superficial ring of the inguinal canal, the superficial inferior abdominal wall, the deep inferior abdominal wall vein, the internal pubic vein, the superficial external pubic vein and the superficial spinning iliac vein;
4.The presence of obstructive lesions in the inferior vena cava, common iliac and internal and external iliac veins after the ligation of the internal spermatic vein may cause the recurrence of varicocele;
5.Vascular spasm and thinning, resulting in omission;
6.Mistakenly ligating the inferior abdominal wall vein without ligating the spermatic vein.
At present, there is no unified consensus on the treatment method of recurrent varicocele in China, there are mainly the following.
1, ligation of the lumbar trunk of the testicular vein below the renal vein through a straight incision in the lumbar back, the initial clinical application does have the advantages of good recent efficacy, light scrotal reaction and fast recovery of the patient, but the long-term effect of this procedure is under further observation;
2.Ligation of the testicular vein through a transverse incision in the umbilicus, which is currently used abroad with good results;
The embolization method, which uses sclerosing agents to embolize the lateral branch veins causing thrombosis, is relatively simple and can reduce the recurrence rate, while improving the sperm count, sexual function, and conception rate with the same efficacy as the ligation method, but for those patients whose spermatic vein opening is close to the renal vein and the opening is thin, this method is more likely to embolize the renal vein or renal segmental vein. Some studies have reported better results with the combination of ligation and embolization.
Regardless of the application of any of the above treatments, for postoperative recurrence of varicocele, it is best to first perform spermatic venography before reoperation, and then perform surgical ligation or embolization according to the vascular route, which can avoid the second recurrence due to the blindness of surgery.
Seven, surgical complications
Complications may occur in either open surgery or laparoscopic surgery for varicocele, the main common ones are.
1, scrotal effusion or testicular sphincter effusion: scrotal edema and testicular sphincter effusion are the most common complications after surgery, the incidence is between 3% and 40%. It is widely believed that the mechanism of scrotal edema is related to the injury of lymphatic vessels. The lymphatic vessels accompanying the seminiferous arteries are damaged during surgery, resulting in extravasation of lymphatic fluid and obvious local edema, while the veins have been ligated and the reflux is blocked, and testicular syringomyelia can occur in serious cases.
2, testicular atrophy: the incidence of testicular atrophy is about 0.2%. Testicular artery injury is an aspect of the Palomo procedure that is difficult to avoid. The main reason is that the testicular artery is ligated, resulting in a dramatic decrease in the blood supply to the testis, which leads to ischemic atrophy. However, most scholars believe that there are abundant anastomotic branches between the internal spermatic artery, the vas deferens artery and the levator artery, and even if the testicular artery is mistakenly ligated, the latter two branches are sufficient to provide sufficient blood supply to the testis without serious consequences.
Nerve injury: In transinguinal internal spermatic vein high ligation, the nerves that may be injured are the ilioinguinal nerve, the genitofemoral nerve, and the almost unmentioned superior and inferior spermatic nerves. In varicocele surgery, the incidence of genitofemoral nerve injury during transcatheter laparoscopic surgery ranged from 2% to 9%, with symptoms presenting as temporary numbness in the anteromedial thigh and anterolateral aspect of the surgical incision, generally appearing 0 to 10 d (average 3 d) after surgery
The symptoms were maintained for an average of about 8 months. Injury to the inguinal nerve of the ilium has not been reported in the literature, but the superior and inferior seminiferous nerves were raised during microsurgery, and some studies have pointed out that injury to these nerves may lead to apoptosis of spermatogenic cells.
4, vas deferens injury: vas deferens injury is a theoretical complication of varicocele surgery, because during surgery, the vas deferens is white, firm to the touch, tubular in structure, clearly distinguished from the color and structure of the surrounding blood vessels and other tissues, and can be correctly identified by any urologist and male physician, and separated to avoid unintentional clamping.
Acute epididymitis: Acute epididymitis after surgery is related to ligation or injury to testicular artery, because testicular artery and spermatoid vein are easy to be injured during surgery. After the injury, the epididymis and testis, which are already in hypoxia and metabolic disorder, are further aggravated by hypoxia before the compensatory vessels are established, and the resistance is further reduced, which makes it easy for infection to occur. Patients with this disease mainly present with swelling and tenderness of the affected scrotum, swollen epididymis with unclear borders, and fever 5-10 days after surgery.
6. Omental emphysema and scrotal emphysema: scrotal emphysema and omental emphysema are complications specific to laparoscopic surgery and related to the establishment of pneumoperitoneum rather than to varicocele spermatic vein ligation itself.
In addition, there are other rare complications, such as postoperative back and testicular pain, which may be related to the anatomical structure of the spermatic cord itself, and excessive stretching of the spermatic cord during surgery can cause discomfort in the kidney area; injuries to the abdominal and pelvic organs during surgery, such as the intestinal canal and bladder, are mostly caused by poor surgical practice or unfamiliarity with anatomy; occasionally, injuries to the femoral vessels, such as the femoral artery and femoral vein, are mostly caused by the surgeon’s unfamiliarity with the inguinal Injuries to the femoral vessels such as the femoral artery and femoral vein are occasionally caused by the surgeon’s unfamiliarity with the anatomical level, or by the assistant’s excessive lateral pulling, deviation from the tendon membrane of the external oblique abdominal muscle during surgery and entry into the femoral ring; or by combined extra-abdominal hernia; infection of the incision (including the umbilicus) is related to lax aseptic operation. Therefore, clinicians should pay attention to prevention and appropriate treatment, and patients and families should be informed of the risks and possible complications of surgery before surgery.
VIII. Follow-up visit
The main purpose of follow-up is to check whether there is recurrence and other complications. It is not yet possible to determine a reasonable follow-up time frame, and patients can refer to their own condition and the medical advice of their supervising physicians.
The first follow-up visit can be performed 1-2 weeks after surgery, mainly to check for any surgical complications. The second follow-up visit will be conducted 3 months after surgery, mainly to check the semen quality and spermatic vein ultrasound examination, and then regular monthly follow-up visits can be conducted until the female partner conceives.
The routine follow-up includes.
①History inquiry;
②physical examination;
③Semen routine;
④Ultrasound examination of testicles.