Varicocelectomy by means of subinguinal cremasteric compartment disruption and venous ligation

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  • ORIGINAL ARTICLE

    Varicocelectomy by means of subinguinal cremasteric compartmentdisruption and venous ligation

    A technical critique

    PARAG SHAH

    Department of Male Infertility, Nowrosjee Wadia Hospital, Mumbai, India

    AbstractObjective. To evaluate the efficacy of addition of disruption of the cremasteric compartment to venous ligation in infertilemen with varicocele and abnormal semen parameters. Material and methods. A prospective non-randomized study wasundertaken in 380 infertile men with varicocele and abnormal semen parameters. They were operated on using subinguinalvenous ligation with the addition of cremasteric compartment disruption on an outpatient basis. Results. Following surgery,the median values for each semen parameter were compared preoperatively and 1-year postoperatively using the Wilcoxonsigned rank test. The difference in the median values was significant for all the parameters. Over a minimum 2-year follow-up period, 304 men (80%) contributed to pregnancies leading to live births. Conclusions. The results suggest thatsubinguinal venous ligation with the addition of cremasteric compartment disruption is a physiological, economic and safeoption for varicocele repair in men with abnormal sperm parameters. A high rate of unassisted pregnancy compared toconventional isolated venous obliteration is achievable, with minimal morbidity and recurrence.

    Key Words: Varicocele, infertility, cremasteric compartment complex, subinguinal approach, ambulatory surgery, pregnancy

    outcome

    Introduction

    Varicocele is observed in 3540% of men withprimary infertility [1,2] and in up to 80% with

    secondary infertility [3,4]. Varicocele is the com-

    monest treatable cause of infertility and its repair has

    been demonstrated to improve semen quality and

    fertility potential in men with abnormal semen

    parameters [5,6].

    Various outpatient techniques have been described

    for the repair of varicocele, including microsurgery

    [7,8], embolization [9,10] and laparoscopy [11,12].

    These techniques have generated renewed interest in

    the treatment of varicocele because they limit mor-

    bidity, decrease recurrence rates and seem to be more

    acceptable to patients. However, some investigators

    [1214] were unable to demonstrate improvementamong their own patients following varicocelectomy.

    Numerous theories have been suggested for the

    development of varicocele [1518], including inparticular the absence of valves in the spermatic

    vein and the so-called nut-cracker phenomenon.

    While most of these theories suggest causes above

    the deep inguinal ring, none of them explain the

    clinical evidence of absence of venous tortuosity

    above the deep inguinal ring. I believe that it is not

    retrograde flow in the spermatic vein but venous

    stasis induced by a tight cremasteric compartment

    around the spermatic cord which leads to dilatation

    and tortuosity of the spermatic veins. Based on the

    above concept, I suggest the addition of complete

    disruption of the cremasteric compartment to venous

    ligation for the adequate treatment of varicocele.

    Material and methods

    Between January 1995 and October 2003, a total of

    862 patients were referred to an outpatient clinic at a

    Correspondence: Parag A. Shah, Shah Surgical Clinic, 11, Yogesh sadan, Hingwala Lane, Ghatkopar (East), Mumbai 400077, India. Tel: /91 022 25137834.Fax: /91 22 25146521. E-mail: parag@maleinfertilityindia.com

    Scandinavian Journal of Urology and Nephrology, 2007; 41: 5457

    (Received 11 February 2006; accepted 24 May 2006)

    ISSN 0036-5599 print/ISSN 1651-2065 online # 2007 Taylor & FrancisDOI: 10.1080/00365590600863996

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  • tertiary care unit dedicated to the treatment of

    infertile men. A detailed history was obtained and

    a complete physical examination was performed. A

    minimum duration of infertility of 12 months,

    defined as failure to cause pregnancy with appro-

    priately timed and unprotected intercourse, was

    required for entry into the study. Physical examina-

    tion was performed by a single investigator.

    The spermatic cords were observed and palpated

    while the patient stood upright and performed a

    Valsalva manoeuvre and testicular size was docu-

    mented. Scrotal ultrasonography with colour Dop-

    pler imaging was used to confirm the physical

    findings and detect subclinical varicocele. Based on

    these findings, the varicoceles were graded as either

    large (visible and palpable), moderate (palpable) or

    small (detected by Doppler reflux with a venous

    diameter /3 mm). For all patients, semen para-meters (B/20 million sperm/ml semen; B/50%motility or B/40% normal morphological forms)were below threshold levels. Of the 862 infertile

    men referred, 412 (42%) were detected to have

    varicocele. A total of 517 varicocelectomies were

    performed in 380 patients.

    Surgical technique

    All procedures were performed on an outpatient

    basis. Oral atropine (0.6 mg) was given as premedi-

    cation. The skin was infiltrated with 35 cm3 of a1:1 mixture of 1% lignocaine and bupivacaine over

    the external ring and into the spermatic cord. A

    small (2-cm) incision was made over the external

    ring, the subcutaneous tissue was separated by

    sharp, blunt dissection and small band retrac-

    tors exposed the spermatic cord. Local anaesthetic

    (12 cm3) was injected under the cremasteric fasciaof the exposed spermatic cord. The anaesthetized

    exposed segment of the spermatic cord was elevated

    out of the incision by gentle traction and sharp

    dissection. The band retractor was placed below the

    spermatic cord for support, and dilated posterior

    cremasteric veins, if present, were ligated and

    transected. The cremasteric fascia and muscle en-

    circling the exposed spermatic cord were completely

    dissected and disposed. The vas deferens and artery

    were observed and maintained out of the surgical

    field. Only grossly dilated spermatic veins (/3 mmin diameter) were isolated, ligated and transected.

    No attempt was made to ligate all vessels and

    spermatic veins. No sclerosing agent was used and

    surgery was done without the use of an operative

    microscope. The spermatic cord was replaced in its

    bed and the incision was closed with an absorbable

    suture.

    Results

    A total of 517 procedures were performed in 380

    patients. There were 362 cases of primary and 18 of

    secondary infertility. The mean9/SD age of thepatients was 28.79/6.3 years (range 2146 years).The varicocele were left-sided in 152 patients (40%),

    right-sided in 91 (24%) and bilateral in 137 (36%).

    The mean9/SD duration of infertility was 26.39/16.5 months (range 12120 months). The varico-cele were large in 136 cases (36%), moderate in 194

    (51%) and small in 50 (13%). A history of smoking

    was reported by 23 patients (6%) and these patients

    were advised to stop smoking. Although all patients

    reported a reduction in the number of cigarettes per

    day, none of them completely abandoned smoking.

    A total of 15 couples (4%) had concomitant female

    factor infertility which was independently treated.

    All operations were performed on an outpatient

    basis and the mean operative time was 15 min (range

    1025 min) per side. In 53 patients (14%) onlycremasteric compartment disruption was performed

    as these patients did not have grossly dilated veins

    (/3 mm in diameter).The commonest problem was transient local

    discomfort, which was reported by 26 patients

    (7%). There were only two cases of hydrocele; no

    recurrence was palpable over a 2-year follow-up

    period and there was no testicular atrophy. Semen

    specimens were collected and evaluated according to

    WHO criteria [19]. The median values for each

    semen parameter were compared preoperatively and

    1 year postoperatively using the Wilcoxon signed

    rank test. The differences in the median values were

    significant for all parameters (Table I). The 1-year

    pregnancy rate was 64% (n/244), and this in-creased to 80% (n/304) over a 2-year period.

    Discussion

    Varicocele is the commonest identifiable, surgically

    correctable lesion associated with male infertility.

    Surgical correction of varicocele, whether uni- or

    bilateral, results in improvement not only in semen

    parameters but also in spontaneous and assisted

    pregnancy rates. The results of this study showed

    that semen parameters were improved for most men

    and that 80% contributed to an unassisted preg-

    nancy. Infertility and oligoasthenozoospermia were

    the main criteria in selecting patients with varicocele

    for surgery. The grade of varicocele was considered

    to be of secondary importance. Subclinical varico-

    cele probably indicated a tight cremasteric compart-

    ment. Venous dilatation may evolve in such patients

    with time.

    Technical critique of varicocelectomy 55

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