Varicocele:

To Fix or Not to Fix? That is the Question.

Edmund S. Sabanegh, MD Professor and Chairman, Department of Urology, Cleveland Clinic

Lerner College of Medicine; Cleveland, Ohio

Objectives: • Review pros and cons of available surgical approaches for

varicocele ligation • Summarize available research associating varicocele

with hypogonadism

Varicocele: To Fix or Not to Fix

Edmund Sabanegh, Jr., M.D.

Chairman, Department of UrologyGlickman Urological and Kidney Institute

Cleveland Clinic

Male SubfertilityMale Subfertility

Etiology Incidence (%)

Varicocele 42

Idiopathic 23

Obstruction 14

Cryptorchidism 3

Immunologic 3

Ejaculatory Dysfunction 1.5

Testicular failure 1.5

Endocrinopathies 1

Other 11

Nagler HM, Martinis FG. Varicocele. In Lipshultz LI, Howards S, editors. Infertility in the Male; 1997

Objective: To study the effect of varicocele on Leydig cell function/testosterone

Group I – 10 pts with varicocele and erectile dysfunction

Group II – 23 pts with varicocele and infertility but no ED

Group III – 31 pts with psychogenic ED 154 healthy males, age 10 to 90

J Clin Endocrinol Metab (1975). 40: 824

Men with varicocele

Men without varicocele

• Trend towards decrease in testosterone in older men with varicocele• Increase in duration of the varicocele result in gradual impairment of Leydig cell function ?

Time 0 = varicocelectomy

108 varicocele patients, mean age 30.9 years 46 control men, mean age 30 years Testosterone (T), 17-OH-progesterone (17-OH-P),

dihydrotestosterone (DHT) and estradiol (E2) were assayed

J Androl (1984); 5:163-170.

Controls Controls

Varicocele patientsVaricocele patients

In varicocele patients, Leydig cell function was impaired, as demonstrated by the low T levels.

These data suggest that the duration of idiopathic varicocele influences testicular hormone secretion.

Does varicocelectomy improve hypogonadism?

Retrospective review of the effect of varicocelectomy on serum testosterone levels in 53 infertile men with varicoceles.

Mean age 35, range 22-57.

Journal of Urology (1995). 154: 1752-1755.

• Varicocelectomy can increase serum testosterone, especially in patients with abnormally low serum testosterone levels.

• There may be a trend towards greater improvement in testosterone with lower grade varicocele.

• 78 patients, mean age 29.5 years• 10 fertile men without varicoceles – control, mean age 30 years• 40 patients had left varicocelectomy, 38 pts had bilateral• Serum hormonal levels measured 1 year after surgery

• Varicocelectomy promotes Leydig cell function.

BJUI (1999). 84: 1046-49

48 patients: 16 with ED, 32 with infertility who underwent bilateral varicocelectomy

Mean age 37± 5.9; follow-up 3-36 months Serum testosterone was significantly increased in

impotent and infertile patients ( p<.0005)

Improvement of sexual activity was 50–75%: in libido, morning erection, duration and percentage of erection, sexual interest, and frequency of erection per weekArchives of Andrology (2003). 49:219-228

Goal: To determine whether men with varicoceles have lower testosterone levels than those without and to ascertain if testosterone levels increase after varicocelectomy.

200 men with palpable varicocele and 510 men without varicoceles (who were undergoing vasectomy reversal)

BJUI (2011).108: 1480-1484

Men with varicocele had significantly lower testosterone levels than the comparison group, with mean (SD) levels of 416 (156) vs 469 (192) ng/dL (P<0.001). This difference persisted when analysed by age.

The testosterone levels significantly increased after repair from 358 (126) to 454(168) ng/dL (P<0.001).

• Of the 70% of patients with postoperative improvement in testosterone levels, the mean (SD) increase in testosterone was 178 (142) ng/dL. The percentage change in testosterone levels was: 30% had no increase, 41% increased by ≤50%, 19% increased between by 51–100%, and 10% increased by >100%.

• There was no association between change in testosterone level and age, laterality of varicocele, or varicocele grade.

Men with varicoceles had significantly lower testosterone levels than the comparison group of men with vasectomy reversal.

Microsurgical varicocele ligation resulted in a significant increase in serum testosterone levels in more than two-thirds of men.

These findings suggest that varicocele is a significant risk factor for androgen deficiency and that repair may increase testosterone levels in men with varicocele and low testosterone levels.

Optimal Technique for LigationOptimal Technique for Ligation

Difficult question Individual studies come

to very different conclusions

All of them flawed to varying degrees

Randomized prospective study of 120 pts with mean follow-up of 18months

Microsurgical varicocelectomy: increased surgical time, decreased post-op recurrence and hydrocele

Surgical approach to varicocelectomySurgical approach to varicocelectomy

Improved semen parameters with varicocelectomy though not among groups

No difference among groups in pregnancy rates at 1-year» Open: 28%» Lap: 30%» Microscopic: 40%

Surgical approach to varicocelectomySurgical approach to varicocelectomy

Randomized prospective study of 298 pts

Microsurgical varicocelectomy: better improvement in sperm count and motility

Surgical approach to varicocelectomySurgical approach to varicocelectomy

Microsurgical varicocelectomy: no hydrocele formation, a lower incidence of recurrent varicocele

The pregnancy rate at 1 year was not significantly different» Open: 31%» Laparoscopic: 33%» Microsurgical: 38%

Surgical approach to varicocelectomySurgical approach to varicocelectomy

Technique of Subinguinal VaricocelectomyTechnique of Subinguinal VaricocelectomyIncision

Technique of Subinguinal VaricocelectomyTechnique of Subinguinal VaricocelectomyExposure of spermatic cord

Technique of Subinguinal VaricocelectomyTechnique of Subinguinal VaricocelectomyCord isolation

Technique of Subinguinal VaricocelectomyTechnique of Subinguinal VaricocelectomyCord isolation

Technique of Subinguinal VaricocelectomyTechnique of Subinguinal VaricocelectomyMicroscope Preparation

Varicocele: To Fix or Not to Fix

Edmund Sabanegh, Jr., M.D.

Chairman, Department of UrologyGlickman Urological and Kidney Institute

Cleveland Clinic