Tips & Tricks: Scrotal disease - Varicocele -

1. Tips& Tricks: Scrotal disease- Varicocele - Woo, SeungHyo Dept. of Urology, Eulji university College of Medicine, Daejeon, Korea

2. Introduction • First description by Celsus • “… veins that are swollen and twisted over testicle, which becomes smaller that fellow ….” • Prevalence • Adolescent: 15% • P° (35-50%) / S° (69-81%) : progressive  Need early intervention !

3. Introduction (Cont’) • WHO : Varicocele is ass with • Decreased testicular volume • Impaired sperm quality • Decline in Leydig cell function • Several studies results • 70% of healthy palpable varicocele men • Abnormal S/A • Progressive & duration dependent testicular damage • Randomized, controlled, cross-over study • Varicocelectomy  significantly improved pregnancy rates

4. Anatomy • Artery • Internal spermatic a. : gonadal artery • External spermatic a. : cremasteric a. • Vasal artery • Vein • Internal spermatic (gonadal) v. : one in 60% • External spermatic vein • Gubernacular vein • Lymphatics • 3.6 in spermatic cord

5. Three compartments Vas & vasal vs. External spermatic vessels Pampiniform plexus

6. Pathophysiology • Hyperthermia • Reflux of metabolites • ‘Hot Rock’ theory 37℃ 33~34 ℃

7. Formula • Vol ∝ r2 , R ∝ 1/r4 , Vel ∝ 1/r2 Venous diameter ↑ Venous wall thickening Venous volume ↑ Impaired countercurrent heat exchange ↓ Resistance & velocity Testicular temperature ↑ Wash out phenomenon (dilution of intratesticular testosterone) Impaired spermatogenesis Alteration of germ cell metabolism and function, induce arteriovenous shunting, decreasing activity of enzymes of DNA synthesis, increase apoptosis, induce hypoxia

8. (+) predictive value Grade III Normal FSH Lack of testicular atrophy Motility > 60% (+) GnRH stimulation test Total motile sperm > 5 x 106 Indication for surgery Ipsilateral growth arrest/atrophy Multiple etiology of testicular dysfunction Abnormal S/A Bilaterality Grade III Soft ipsilateral testis Pain Abnormal GnRH stimulation test Patient/parent anxiety Abnormal scrotal appearance Prognostic indication Absolute Minor

9. Varicocelectomy

10. Retroperitoneal Inguinal Subinguinal

11. Management :‘Palomo’ • Palomo technique • Ligation of gonadal vessels • Modified Palomo technique • Ligation of gonaldal vein • Complication • Recurrence: 11-15% • Hydrocele: 7% • 국내보고 • Hydrocele: 5-9% • Recurrence: 5-14%

12. Laparoscopic varicocelectomy

13. Management : ‘Ivanissevich’ • Inguinal approach • Familiar region • Ease to approach to cord • Recurrence rate: 9-16% (국내: 5-15%) • Hydrocele: 3-39% (국내: 0-7%)

14. Management : ‘embolization’ • Recently popularized method • Not need an anesthesia • Less invasive • Failure rate: 27% • Recurrence: 4-11% • Hydrocele: 0% Cayan S, et al. J Androl 2009

15. Management : ‘microsurgical’ • Best way of varicocele management • Inguinal Vs. Subinguinal • Recurrence: <1% (inguinal: 1-2%) • Hydrocele: nearly 0% • 1994, Marmar & Kim • Subinguinal approach • Less morbidity (reserve fascia & muscle) • Short recovery time • Less post-op pain • More complex

16. Surgical techniqueComparison of different techniques used for varicocele repair

17. Tips-1 • Incision length • Width of testis • 2~3cm • Incision site • Inguinal • Subinguinal

18. Tips-2 • Ligation of external spermatic vein & gubernacular veins

19. Tips-3 • Division into two compartments • Pampiniform & vasalcompartment • Zini et al. • Rt : 22 min ↓ • Lt : 6 min ↓ Zini et al. Urology 2006

20. Tips-4 Identification of arterial pulse • Using micro probe • Dripping papaverine • Shift downward : ext. ring  prepubic

21. Tips-4 (cont’) • Identification of pulse by anatomy Above all, ligate bridge vessels Then, dissect large veins vertically Don’t ligate large vein till isolation of artery if possible

23. Tips-4 (cont’) • Identification of pulse by anatomy Above all, ligate bridge vessels Then, dissect large veins vertically Don’t ligate large vein till isolation of artery if possible

24. Tips-5 • Prevention to risk of hydrocele • Save lymphatics • Prophylactic hydrocelectomy (plication) • Not saved lymphatics • Not identified lymphatics

25. Conclusions • Unique purpose of varicocelectomy • Optimization of testicular environment • Improvement of spermatogenesis • Selection of technique • Higher success rate • Lower complication • Less invasive  “Microsurgery”

26. Conclusions (cont’) • Considerations in Microscopic varicocelectomy • Completely understanding of anatomy • The Site of Incision • Identification of Arterial Pulse • Alter the site of incision • Using papaverine or micro probe • Disconnecting crossing-vessel at first • Prevention of Hydrocele

27. 경청해 주셔서감사합니다!