INTRODUCTION
Testicular varicocele is characterized by variceal dil- atation of the veins in the pampiniform venous plex- us secondary to incompetent valves in the testicular vein. Varicoceles are almost always localized on the left side. This is supposedly related to the fact that the left testicular vein drains via the left renal vein, which offers higher resistance to the bloodstream than the right testicular vein, which enters vena cava directly.
The age group most frequently affected are older boys and adolescents. Symptoms are rare. Some- times, an ill-defined discomfort in the way of a drag- ging sensation in the scrotum is reported.
On physical examination, grade III varices may be seen through the scrotal skin. The characteristic soft nodular mass, which is described as feeling like “a bag of worms”, is as well palpable, but not visible in grade II varicoceles. It becomes more prominent with increased venous filling due to gravity (in erect posi- tion) or to venous outflow obstruction by an intra- abdominal pressure surge. This can be provoked by a Valsalva manoeuvre, which is necessary to render a grade I varicocele obvious. In contrast, in the supine patient, in particular in a Trendelenburg position, the veins empty, and the varicocele can neither be seen nor felt any more.
Clinical relevance derives from the fact that varic- oceles can result in testicular atrophy and infertility.
The pathophysiological mechanism has not been elu- cidated yet. Production of antibodies in reaction to increased temperature within the scrotum, or to a leak in the blood-testis barrier has been suggested to explain to result in bilateral damage. Semen analysis in 30–50% of the affected men show abnormalities that may improve significantly after resolution of scrotal venous hypertension provided that the treat- ment is not delayed until damage has become irre- versible. Therapy of varicoceles is therefore indicated in children and adolescents to prevent the above damage.
Different surgical methods are available, the most popular of which have been described by Palomo and Ivanissevich. The former consists in high mass liga- tion with or without resection of 3 cm of the testicu- lar veins and artery. This can be done by an open sur- gical retroperitoneal approach via an incision in the left iliac fossa or by transperitoneal laparoscopy. Iva- nissevich popularized dissection and ligation of two- thirds of the veins of the pampiniformis plexus via an inguinal exploration. We prefer the minimal-inva- sive method described by Tauber as described below, which is simple and equally effective, and can be per- formed under local anaesthesia in most patients.
Michael E. Höllwarth
The patient is positioned supine on the operating ta- ble. The region from the left external inguinal ring to the upper third of the scrotum is shaved. After ade- quate regional infiltration anaesthesia, a 3-cm longi- tudinal incision is made in the direction of the sper- matic cord in the uppermost part of the scrotum.
The subcutaneous tissue is divided and the outer fas- cia of the cord opened longitudinally. With fine for- ceps and a right-angled clamp, one major vein is iso- lated from the pampiniform plexus over a distance of about 1.5 cm. The vein is ligated distally; a second su- ture is pulled around it proximally. The vein is then cannulated with an 18-gauge needle in cephaled di- rection. If saline can be injected without problems, the proximal thread is held just firmly enough to maintain the cannula in the vein.
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Figure 54.1 Figure 54.2
Figure 54.3
Saline
Figure 54.4
Diluted contrast medium is injected under fluoro- scopic control to ascertain that the cannulated vein drains into the left renal vein via the testicular vein without aberrant flow into pelvic veins. If pelvic col- laterals are outlined, the needle must be removed and the vein ligated. Then another vein is punctured and tested for flow exclusively towards the renal vein in the same way. Once an appropriate vein has been found, 3 ml of a sclerosing agent (e.g., ethoxysclerol 1–3%) and 2 ml air are aspirated into a 5-ml syringe.
While the anaesthetist increases the inspiratory pres- sure simulating a Valsalva manoeuvre, the surgeon injects 1 ml air, followed by the whole amount of the sclerosing material, and then the remaining 1 ml air.
The Valsalva manoeuvre is continued for approxi- mately 30 s.
Subsequently, the needle is removed and the plex- us vein is ligated proximal to the access site. The inci- sion is closed with absorbable subcutaneous 5/0 and subcuticular 6/0 sutures.
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Figure 54.7
The high retroperitoneal ligature of the testicular vein or veins was introduced by Palomo. The proce- dure was originally performed by a left lower quad- rant extraperitoneal laparotomy (McBurney on the left side). When the peritoneum is reached, it is gent- ly pushed away so that the left retroperitoneal space can be reached. The testicular vessels are identified and the vein (or two or three veins) is ligated and re- sected over a distance of 2–3 cm. Sometimes it ap- pears difficult to identify or to separate the vein from
the artery. Therefore, some authors prefer to ligate all vessels including the artery.
Recently, the laparoscopic minimal invasive pro-
cedure is the preferred method of choice. The sur-
geon stands on the right side of the patient. A 5-mm
laparoscope for the optic is inserted through the um-
bilicus. Two other instruments (2-mm or 5-mm) are
inserted, one lateral to the left rectus muscle margin,
the other above the bladder.
Air Air Ethoxisclerol
Figure 54.5 Figure 54.6
Figure 54.7
Adhesions to the sigmoid colon can be transected.
The peritoneal reflection over the vessels is incised, the veins are identified and transected between clips.
Electrocautery should not be used because underly-
ing nerve fibres may be damaged leading to dysaeste- sia at the left thigh. If bleeding occurs while separat- ing the veins, the only option is to ligate all vessels without sparing the artery.
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Figure 54.8a–c
a b
c
Long-term follow-up studies of treated varicoceles have shown a small but almost invariable recurrence rate. With the Palomo technique, performed either open or by laparoscopy, the recurrence rate is between 5 and 16%. It is significantly lower when the testicular artery is ligated together with the vein, but the development of a post-operative hydrocele oc-
curs more often when the artery is ligated. Tauber’s antegrade sclerotherapy is an effective and also min- imal invasive method, that is even easier and faster to perform as the laparoscopic procedure. The recur- rence rate after 1 year is, in our hands, 6% but repeat- ed sclerotherapy can easily be performed, and the testicular artery is spared.
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SELECTED BIBLIOGRAPHY
Ficarra V, Porcaro AB, Righetti R, Cerruto MA, Pilloni S, Caval- leri S, Malossini G, Artibani W (2002) Antegrade scleother- apy in the treatment of varicocele: a prospective study. BJU Int 89 : 264–268
Hadziselimovic F, Herzog B, Liebundgut B, Jenny P, Buser M (1989) Testicular and vascular changes in children and adults with varicocele. J Urol 142 : 583–585
Niedzielsky J, Paduch D (2001) Recurrence of varicocele after high retroperitoneal repair. J Urol 165 : 937–949
Schier F (2003) Varicocele. In: Schier F (ed) Laparoscopy in children. Springer, Berlin Heidelberg New York, pp 124–128 Tauber R, Johnsen N (1994) Antegrade scrotal sclerotherapy for the treatment of varicocele: technique and late results.
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