I. Definition
Varicocele: It refers to abnormal elongation, dilation and tortuosity of the trabecular plexus of veins in the spermatic cord.
(i) Primary varicocele: varicocele due to 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. It is generally considered that a vein diameter of more than 2 mm can establish the diagnosis.
(iii) 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 about 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 volume and increased blood supply to the testes.
(ii) Etiology and anatomical factors of varicocele
Varicocele occurs on the left side of the spermatic cord in 90% of cases. The high incidence on the 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 up; 2, the weakness of the vein wall and the adjacent connective tissue or the underdevelopment of the levator muscle, which weakens the support role around the spermatic vein; 3, the valve defect or incomplete closure of the spermatic vein on the left side is more than that on the right side; 4, the spermatic vein on the left side is located behind the sigmoid colon. It is easy to be affected by intestinal compression and its patency; 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 cause the left common iliac vein to be compressed, affecting the reflux of the left vas deferens vein and forming the so-called distal clamp 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, and 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 sperm; 2, blood stagnation affects the blood circulation of the testis, and the accumulation of CO2 in the testicular tissue affects the occurrence of sperm; 3, blood from the renal vein returning from the left spermatic vein, the metabolites secreted by the adrenal glands and kidneys such as steroids, catecholamines, 5-hydroxytryptamine can cause vasoconstriction, resulting in premature sperm 4. varicocele on the left side can affect the function of the right testis, because there are abundant traffic branches in the veins between the testes bilaterally, and the toxins in the blood of the left spermatic vein can affect the spermatogenesis of the right testis.
IV. Diagnosis
(i) Clinical manifestations
Most patients are found during physical examination without conscious discomfort, or are detected during consultation for infertility. Those who have symptoms mostly present with scrotal swelling and discomfort or cramping, and the pain may radiate to the groin area and lower abdomen, 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 manifestation of varicocele symptoms 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, the phenomenon of blood reflux in the internal spermatic veins can be determined. It is a non-invasive examination with convenient, 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 classified 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. Internal spermatic venography helps to reduce the failure rate of high ligation surgery and analyze the causes of surgery failure.
2.Laboratory tests
(1) Semen analysis (recommended): Semen can identify abnormal testicular function if immature sperm are detected. Patients with varicocele need to 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. Most of the clinical literature reports that surgical treatment is the main treatment, and some of them are treated with (or combined with) drugs (including Chinese medicine).
(i) Drug treatment
1.Compound carnitine: It consists of L-carnitine and acetyl L-carnitine, both of which 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 transporting fatty acids and participate in energy metabolism; the other 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 dependent on androgens, but also associated with carnitine, glycerophosphorylcholine (GPC), sialic acid (SA), and others secreted by the epithelium of the epididymis, and the role of carnitine is crucial, especially L-carnitine, which is biologically active in the body, has a direct impact on sperm maturation and motility. In addition, carnitine can increase sperm count by increasing the concentration of prostaglandin E2. Compound carnitine preparation (erectile essence) 2 bags (each bag contains L-carnitine 10mg, acetyl L-carnitine 5mg)/time, oral, twice a day, for 4-6 months.
2. Clomiphene: It is a non-steroidal estrogen receptor antagonist, which can competitively bind estrogen receptors in the hypothalamus and pituitary gland, thus weakening the negative feedback effect of normal estrogen in the body, resulting in increased secretion of endogenous GnRH, FSH and LH, which in turn acts on the interstitial cells, supporting cells and spermatogenic cells of the testes, regulating and promoting spermatogenic functions; 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 system. 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 combined HCG and clomiphene after inguinal spermatic vein high ligation is significantly higher than surgical treatment alone, human chorionic gonadotropin (HCG) 1000U/d, intramuscular injection, 3 times a week, total dose 30,000U; clomiphene Clomiphene 25mg/d, 30d for 1 course, 25d with medication and 5d without medication, 3 courses of treatment.
3.Stretching varicose veins to help fertility soup: with the main drugs of Radix Aromaticus, Lychee kernel, Radix Angelicae Sinensis, Radix Paeoniae Alba, Radix Paeoniae Alba, Citrus aurantium, Green Peel, Chen Pi and Roasted Glycyrrhiza glabra, it can significantly improve the sperm density, vitality and activity rate as well as reduce the deformation rate and liquefaction time in patients with varicose veins with infertility by combining with high level ligation of the internal spermatic cord. The dose: one dose a day, divided into two doses after meals, 1 month for 1 course, 3 courses of treatment.
4, Tong Genie: Chai Hu, Safflower, Angelicae Tail, Wu Jia Pi, Fructus Lycii, Sequoia, Huai Shan Yao, Raspberry 10g each, Calcined Dragon Bone, Dan Shen 30g each, Wu Wei Zi 6g, Astragalus, Chuan Niu Knee 15g each. wet win with Dioscorea Z, Xu Changqing; long-standing disease heavy with Dan Shen, late damage and kidney essence plus Deer Antler Cream, Cistanches, for eliminating blood stasis, Tongluo strong sperm herbs, can promote testicular blood circulation, improve testicular ischemia and hypoxia It can promote testicular sperm production, increase sperm count and improve sperm activity rate.
5. Other Chinese herbal treatments: there are tonic Chinese and Yiqi soup, Yi kidney and Tongluo granules, Chinese herbal 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 the semen analysis is abnormal, the testicles shrink and become soft in texture, 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 High ligation of the internal spermatic vein through the inguinal canal: it is commonly used because of the advantages of superficial location, wide field exposure, small anatomical variation, local anesthesia, etc. However, there are more venous branches and rich lymphatic vessels in this area, as well as more arterial branches, which are closely related to the venous branches, and testicular atrophy may occur if it is damaged, and clinical data show that the recurrence rate after surgery can be as high as 25%, and 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 easy to occur, with an incidence of 6.6% reported in the literature. In contrast, the modified Palomo procedure reduces the incidence of syringomyelia or scrotal hydrocele by simply ligating the internal spermatic cord arteries and veins while preserving other spermatic cord tissues and avoiding ligation of the lymphatic vessels together, thus preventing lymphatic flow obstruction. Compared with the traditional Palomo procedure, the incision of the modified Palomo procedure is shifted upward and operated at this level to avoid damage to the subabdominal arteries and veins and to avoid the occurrence of postoperative syringomyelia or hydrocele, thus making it more likely to be adopted clinically.
3. laparoscopic surgical treatment: laparoscopic high ligation of the spermatic vein has the advantages of reliable results, little damage, few 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 have undergone 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 for open surgery via the inguinal route or retroperitoneal route, and not for microscopic open surgery via the low 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 care hospitals because of the expensive equipment, high medical costs, and limitations of technical staff.
4. Other treatments: In addition, there are microscopic spermatic vein high ligation, spermatic vein interventional embolization and other treatments, 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 the conception rate. Its main advantage 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 as the preferred method for the treatment of VAC.
②Interventional spermatic vein embolization:With the development of interventional radiology, 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. The method is both a diagnostic tool and a good treatment method, but it is necessary to be skilled in venipuncture techniques and indications to avoid serious complications. Catheter method of embolization for varicocele has the advantages of non-surgical and less painful than traditional surgical ligation, and can avoid post-surgical complications such as scrotal edema and hematoma, and its success rate is higher than that of surgical ligation, so it is easy to promote its use because of its advantages. However, the method is an invasive means of examination and high cost, which limits its application to some extent.
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.
Varicocele recurrence 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 missed ligation of testicular vein genital branch accounts for 68% of the total recurrence, and several other methods also have different degrees of recurrence. The main reasons are: 1, incomplete ligation and omission of the branches of the internal spermatic vein; 2, failure to cut off the internal spermatic vein 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 they gradually converge, and there are extensive anastomotic branches between the scrotal root, the soft tissue near the superficial inguinal canal ring, the superficial subabdominal wall, the deep subabdominal wall vein, the internal pubic vein, the superficial external pubic vein, and the superficial iliac vein. There are extensive anastomotic branches between the superficial veins and the superficial iliac veins; 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. The spasm of blood vessels becomes thin and causes omission; 6. The subabdominal wall vein is mistakenly ligated without ligating the spermatic vein.
And there is no unified consensus on the treatment methods for recurrent varicocele in China, which are mainly as follows.
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 patient recovery, 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.
3, 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 compared to 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, with an incidence 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 significant local edema, while the veins have been ligated and the reflux is blocked, and testicular syringomyelia can occur in severe 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 testicular blood supply and thus 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, and only occasional complications of testicular atrophy have been reported from the current literature
3. 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. The incidence of genitofemoral nerve injury during transcatheter laparoscopic surgery in varicocele surgery ranges from 2% to 9%, with symptoms presenting as temporary numbness in the anteroinferior thigh and anterolateral aspect of the surgical incision, usually appearing 0 to 10 d (mean 3 d) after surgery, with symptoms maintained for a mean of about 8 months. No definitive literature has been reported on iliac inguinal nerve injury. The superior spermatic nerve and the inferior spermatic nerve were proposed during microsurgery, and it has been suggested that injury to the above 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, tough 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.
5. Acute epididymitis: Acute epididymitis after surgery is related to ligation or injury of testicular artery during surgery, because testicular artery is easy to be injured during surgery as it accompanies with intravenous spermatic cord. 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, so that infection can easily occur. Patients with this disease mainly present with scrotal swelling, tenderness, enlarged epididymis with unclear borders and fever 5 to 10 days after surgery.
6. omental emphysema and scrotal emphysema: scrotal emphysema and omental emphysema are complications specific to laparoscopic surgery and are related to the establishment of the pneumoperitoneum rather than the varicocele spermatic vein ligation itself.
In addition, there are other rare complications, such as postoperative low 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 renal region; injuries to 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 femoral vessels, such as the femoral artery and femoral vein, are mostly caused by the surgeon’s unfamiliarity with the inguinal unfamiliarity with the anatomical level, or excessive lateral stretching by the assistant, deviation from the tendon membrane of the external oblique abdominal muscle during surgery and entry into the femoral ring; or combined with extra-abdominal hernia; infection of the incision (including the umbilicus), associated with lax aseptic operation. Therefore, clinicians should pay attention to prevention and appropriate management, 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 the subsequent follow-up visits can be conducted regularly every month until the female partner conceives.
The routine follow-up includes: ① history questioning; ② physical examination; ③ semen routine; ④ testicular ultrasound examination.