Internal Spermatic Vein Research Articles

Anatomical factors affecting the time required for microsurgical subinguinal varicocelectomy.

BackgroundMicrosurgical subinguinal varicocelectomy (MSV) is considered an effective and less morbid procedure, but the difficulty in preserving testicular arteries is a limitation of this procedure. We identified the microanatomy encountered during MSV and clarify its significance to the difficulty of the procedure.MethodsThree hundred and twenty-six patients who underwent left MSV were evaluated. Detailed intraoperative microanatomy was recorded for each case. A classification system was used to assess the anatomical relationship between the internal spermatic artery and the varicose veins as follows: type I (non-adherent to the veins), type II (adherent to the veins), and type III (surrounded by veins). Type III cases were further divided into types III-a (an arterial pulse) and III-b (a blurred arterial pulse). A linear regression analysis of the factors associated with the length of the operation was used to determine the difficulty of the surgery.ResultsA mean number of 8.2 internal spermatic veins were ligated. Internal spermatic arteries were classified as type I in 14 % of patients, type II in 57 %, and type III in 29 % (III-a in 20 % and III-b in 9 %). A large number of internal spermatic veins and higher internal spermatic artery type were observed significantly more often in grade 3 varicoceles (p < 0.05). The types of internal spermatic arteries (ρ = 0.458) and numbers of internal spermatic veins (ρ = 0.431), cremasteric veins (ρ = 0.197), and gubernacular veins (ρ = 0.119) were significantly associated with the length of the operation (p < 0.05).ConclusionsAnatomical factors were associated with the varicocele grade and surgical difficulty. These findings are helpful to perform MSV.

Varicocele - laparoscopic versus open ligation

Objective: Evaluation of the advantages and disadvantages of laparoscopic varicocelectomy and its comparison with open ligation of varicocele. Design: Prospective comparative study between two techniques of varicocelectomy. Place and Duration Of Study: Surgical unit III of Jinnah Hospital, Allama Iqbal medical college, Lahore over a period of two years from January 1, 2002 through December 31, 2003. Subjects and Methods: Study comprised of two groups (A and B) with 52 consective patients fulfilling the inclusion criteria and comparative variables. Laparoscopic varicocelectomy (LPV) was performed on 26 patients (Group A) and open Palomo varicocelectomy (OPV) was performed on 26 patients (Group B). Outcome data looked at relapse rate, postoperative hydroceles, wound complication and scrotal edema. Operating time, postoperative hospital stay and pain control were compared. In both groups operation was performed by Palomo technique i.e. ligation of both artery and internal spermatic vein in the retro peritoneum above the internal inguinal ring. Results: In LPV versus OPV group, the recurrence rate of varicocele was 3.8% in-group A versus no recurrence in-group B (p<0.001). Postoperative hydroceles formation was 7.6% in group A versus 11.4% in group B (p < 0.003 ).wound complication was 3.8% in group A versus 7.6% in group B (p < 0.001). Testicular or scrotal edema was 7.6% in group A versus 11.4% in group B.Postoperative hospital stay was 24 hours in group A versus 72 hours in group B (p < 0.001). Operating time was 20 minutes in group A versus 30 minutes in group B (p <0.001). Postoperative analgesia required was almost half in group A as compared to group B (p < 0.005). Conclusion: The study shows that clinical efficacy of laparoscopic varicocelectomy is superior to traditional open varicocelectomy.

The effect of varicocoelectomy on the relationship of oxidative stress in peripheral and internal spermatic vein with semen parameters.

The aim of this prospective controlled study was to investigate the levels of reactive oxygen species (ROS), including asymmetric dimethylarginine (ADMA), oxidative stress index (OSI) and total oxidant capacity (TOC), and antioxidants with total antioxidant capacity (TAC) in peripheral and internal spermatic veins blood, the relationship of these factors with sperm parameters in the infertile varicocoele patients, and the amelioration effect of varicocoelectomy on these outcomes. Thirty-one primary infertile varicocoele patients and 31 fertile control patients evaluated for determining the levels of ADMA, TOC, OSI, superoxide dismutase (SOD), glutathione (GSH), TAC, and semen analysis. The patients' preoperative SOD, GSH and TAC levels, which were significantly lower than the controls, significantly increased postoperatively. Although SOD and GSH were significantly higher in spermatic vein compared to median cubital vein, TAC was significantly higher in median cubital vein. ADMA, TOC and OSI were significantly higher in the patient group. TOC and OSI were significantly higher in spermatic vein compared to median cubital vein. Postoperative TOC, OSI and ADMA reduced to the control levels. Total antioxidant capacity in the peripheral circulation and oxidative stress index in the internal spermatic vein could give an idea about the possible improvement in sperm count acquired by varicocoelectomy.

A Rare Anatomical Variant of Spermatic Vein as Cause of Recurrence After Surgical Correction of Varicocele

Varicocele may be treated with many different modalities, including radiologic and surgical approaches, but what is the best treatment remains controversial. The recurrence rate following varicocele repair ranges from 0.6% to 35% depending upon the technique used. We describe in detail a rare anatomical variant of the left internal spermatic veins and the appropriate treatment of recurrent varicocele with percutaneous scleroembolization. In case of recurrent varicocele after surgical repair, knowledge of anatomical variability of internal spermatic veins is essential for treatment planning.

Antegrade scrotal sclerotherapy of internal spermatic veins for varicocele treatment: technique, complications, and results.

Varicocele repair is mainly indicated in young adult patients with clinical palpable varicocele and abnormal semen parameters. Varicocele treatment is associated with a significant improvement in sperm concentration, motility, morphology, and pregnancy rate. Antegrade scrotal sclerotherapy (ASS) represented one of the main alternatives to the traditional inguinal or suprainguinal surgical ligation. This article reviews the use of ASS for varicocele treatment. We provide a brief overview of the history of the procedure and present our methods used in ASS. In addition, we review complication and success of ASS, including our own retrospective data of treating 674 patients over the last 17 years. Herein, we analyzed step by step the ASS technique and described our results with an original modified technique with a long follow-up. Between December 1997 and December 2014, we performed 674 ASS. Mean operative time was 14 min (range 9 to 50 min). No significant intraoperative complications were reported. Within 90 days from the procedure, postoperative complications were recorded in overall 49 (7.2%) patients. No major complications were recorded. A persistent/recurrent varicocele was detected in 40 (5.9%) cases. In 32/40 (80%) cases, patients showed preoperative grade III varicoceles. In patients with a low sperm number before surgery, sperm count improved from 13 × 106 to 21 × 106 ml−1 (P < 0.001). The median value of the percentage of progressive motile forms at 1 h improved from 25% to 45% (P < 0.001). Percentage of normal forms increased from 17% before surgery to 35% 1 year after the procedure (P < 0.001). In the subgroup of the 168 infertile patients, 52 (31%) fathered offspring at a 12-month-minimum follow-up. Therefore, ASS is an effective minimal invasive treatment for varicocele with low recurrence/persistence rate.

Percutaneous embolization of varicocele: technique, indications, relative contraindications, and complications.

There are several options for the treatment of varicocele, including surgical repair either by open or microsurgical approach, laparoscopy, or through percutaneous embolization of the internal spermatic vein. The ultimate goal of varicocele treatment relies on the occlusion of the dilated veins that drain the testis. Percutaneous embolization offers a rapid recovery and can be successfully accomplished in approximately 90% of attempts. However, the technique demands interventional radiologic expertise and has potential serious complications, including vascular perforation, coil migration, and thrombosis of pampiniform plexus. This review discusses the common indications, relative contraindications, technical details, and risks associated with percutaneous embolization of varicocele.

Internal Spermatic Vein Insufficiency in Varicoceles: A Different Entity in Adults and Adolescents?

The purpose of this study was to determine whether phlebographic features can be used to discriminate adult from adolescent varicocele. Left and right internal spermatic venograms of 191 adolescents (< 17 years) and 224 adults (≥ 25 years) were anonymized and evaluated. Phlebographic radioanatomic features (valves, duplications, collaterals, and classifications) were compared and analyzed with univariate tests. Insufficiency of the left internal spermatic vein (ISV) was confirmed in 409 of the 415 (99%) patients. Adults had no spontaneous opacification of the ISV during venography twice as frequently as adolescents (p = 0.001), a complex outflow into the renal vein 2.2 times as often (p = 0.021), and significantly more collaterals (p = 0.030). Adolescents had a significantly lower number of competent valves and significantly more instances of nutcracker phenomenon (p = 0.001). According to the Bähren classification, the distribution of the types of ISVs was significantly different between adults and adolescents (p = 0.009). Insufficiency of the right ISV was encountered 2.4 times as frequently in adults as in adolescents (p < 0.001). In adults the maximum diameter of the ISV was significantly larger (p = 0.023). Bilateral ISV insufficiency was 2.2 times as frequent in adults (p < 0.001) as in adolescents. Left-sided varicoceles in adults are distinct from those in adolescents. In adults, reflux is likely to be induced via collateral pathways, whereas in adolescents congenital venous abnormalities are predominantly present. The higher prevalence and the greater diameter of a right insufficient ISV in adults, combined with the absence of venous anatomic differences, supports the hypothesis that right-sided varicocele is an evolutive disease.

Does varicocele grade predict the postoperative changes of semen parameters following left inguinal micro-varicocelectomy?

ObjectiveTo evaluate the relationship between preoperative grade and postoperative changes of semen parameters following left inguinal varicocelectomy. MethodsThis study included 44 patients undergoing left microsurgical inguinal varicocelectomy. Internal spermatic veins were classified as large (4 mm or more in diameter), medium (2–4 mm), or small (2 mm or less). Changes in sperm activity, morphology and count were estimated perioperatively. The introperative findings and semen parameters were compared between varicocele groups of grades 2 and 3. ResultsBoth sperm motility and count improved significantly postoperatively (from (31.9 ± 16.3)% to (47.3 ± 15.5)%, from (28.1 ± 28.1) × 106/mL to (52.1 ± 74.2) × 106/mL). In varicoceles with grade 2 and 3, significant differences were found in the number of large veins (0.4 ± 0.6 vs. 1.2 ± 0.7, p < 0.001) and ultrasonographic maximum diameters of spermatic vein in supine and standing positions (2.3 ± 0.4 cm vs. 2.8 ± 0.6 cm, 3.1 ± 0.7 cm vs. 3.9 ± 0.7 cm, p = 0.001 and 0.001 respectively). However no difference of changes in sperm motility and count was detected ((16.3 ± 13.5)% vs. (14.4 ± 12.6)%, (30.5 ± 84.4) × 106/mL vs. (12.9 ± 20.6) × 106/mL respectively, p = 0.65 and 0.40 respectively). ConclusionPreoperative varicocele grade might not predict postoperative semen changes regardless of possible existence of anatomic and ultrasonographic associations.

Reassessing the Role of Subclinical Varicocele in Infertile Men With Impaired Semen Quality: A Prospective Study

To evaluate the seminal, hormonal, and spontaneous pregnancy outcome after percutaneous embolization of the internal spermatic vein in infertile men with left-sided subclinical varicocele and one or more abnormal semen parameters. A total of 218 patients underwent percutaneous embolization, and 119 patients were included as the observation group. All patients were followed up prospectively for 39.4 ± 6.5months. Semen parameters and hormonal levels were evaluated before any procedure and 6months after. Significant improvement in the mean sperm concentration, total motility, and lower follicle-stimulating hormone levels was noted in those who underwent varicocele embolization as compared with those not treated. After 39.4 ± 6.5months, pregnancy rates were 46.3% for the treated group and 11.8% for the control group (P= .011). In infertile men, small varicoceles, even subclinical ones, should be identified and treated.

Outcomes of experimental rat varicocele with and without microsurgery.

BackgroundExperimental rat varicocele was usually developed by the conventional technique but with varied success; and microsurgical rat varicocele model was an effective alternative. In this study we further analyzed differential outcome of experimental rat model with and without microsurgery.MethodsOne hundred and twenty male Sprague-Dawley rats were randomly assigned to two groups. In Group A, experimental rat varicocele model was developed with conventional technique. The left renal vein was partially ligated with concurrent ligation of communicating branches between the left spermatic vein and common iliac vein. In Group B, all the above procedures were finished with microsurgical manipulation under operating microscope. Before and after model development, the mean diameter of the left internal spermatic vein was compared; and at 8 weeks after initial surgery the mean sperm concentration and motility in both groups was analyzed.ResultsThe baseline mean diameter of the left internal spermatic vein in Group A and Group B was 0.14 ± 0.04 and 0.15 ± 0.03 mm, respectively (P =0.3157). In Group A 9 rats had severe complications resulting in model failure; while in Group B all rats had successful model except for one died of anesthetic accident (P = 0.008). At 8 weeks after initial surgery the mean left internal spermatic vein, sperm concentration and motility in both groups was 1.65 mm, 321.5×106/gm and 51.9%; and 1.65 mm, 318.9×106/gm and 53.5% respectively. There was nonsignificant difference of internal spermatic vein diameter, sperm concentration and motility between two groups.ConclusionsMicrosurgery makes developing experiment rat varicocele model easy. Compared with conventional technique, microsurgical rat varicocele model has higher success rate and less complication.

Embolization of left spermatic vein in non-obstructive azoospermic men with varicocele: role of FSH to predict the appearance of ejaculated spermatozoa after treatment.

Varicocele repair in non-obstructive azoospermia (NOA) was occasionally associated to ejaculated spermatozoa independently from clinical and laboratory measures. We performed a prospective study in infertile men affected by NOA and left side varicocele to find whether or not the appearance of ejaculated spermatozoa after varicocele repair is predicted by baseline measures. Patients with NOA and grade II, or grade III left side varicocele were submitted to hormone analysis and to scrotal color Doppler ultrasound (CDU). Azoospermia was confirmed in 23 patients aged 25-47 years who were than submitted to varicocele repair through a retrograde internal spermatic vein embolization. Patients were re-evaluated after 6 months. Six months after varicocele repair 12 patients (52.2 %) were still azoospermic (Group 1) while 11 patients (47.8 %) reported ejaculated spermatozoa (Group 2) [sperm count: 1.3 × 10(6)/mL; 0.5 × 10(6)/mL-1.6 × 10(6)/mL (median 25th-75th centiles)]. Serum baseline FSH was lower in Group 2 compared to Group 1 (p = 0.012), while no differences between groups were revealed for all other clinical and laboratory parameters. ROC analysis indicated that baseline FSH level predicted the appearance of ejaculated spermatozoa after treatment [AUC = 0.811; 95 % Confidence Interval (CI) 0.6-0.9; p = 0.0029]. A cut-off level of FSH <10.06 mIU/mL identified 82.0 % of cases with ejaculated spermatozoa with a specificity of 81.8 % and a sensitivity of 83.3 %. Selected patients with NOA may show ejaculated spermatozoa after a non-invasive repair of a left side varicocele, therefore avoiding testicular sperm extraction. Baseline serum FSH was a valuable predictor for ejaculated spermatozoa after treatment.

Varicocele anatomy during subinguinal microsurgical varicocelectomy in Chinese men.

Knowledge of subinguinal microsurgical varicocelectomy is of fundamental importance to ensure that varicocele is resolved and testicular function is preserved. Our study aimed to describe the number of veins, arteries and lymphatics in the subinguinal spermatic cord and to clarify their differences between two sides, between patients with different complaints and between varicoceles with different clinical grades. A total of 102 consecutive patients underwent 162 primary subinguinal microsurgical varicocelectomies, during which the number of vessels with different diameters was recorded. A mean number of 12.9 internal spermatic veins, 0.9 external spermatic veins, 1.8 internal spermatic arteries and 2.9 lymphatics were identified per cord. 88.2% of the internal spermatic arteries were surrounded by a dense complex of adherent veins. The external spermatic vein or veins were found in 49.4% of the cases. The mean number of medium (1-3 mm in diameter) internal spermatic veins on the left was larger than that on the right (P < 0.001). The mean number of medium internal spermatic veins in grade III varicocele was larger than that in grade I or grade II (P < 0.015). There was no significant anatomical difference between the men presenting for infertility, chronic testicular pain and both the two complaints.

Vitamin K: The missing link to prostate health

Though age-related prostate enlargement is very common in Western societies, and the causes of benign prostate hyperplasia, BPH, have been diligently sought after, there is no biological, mechanistic explanation dealing with the root causes and progression of this very common disorder among men. All treatments to date are based on symptomatic relief, not a fundamental understanding of the cause of the disease. However, recent advances have shown that even subclinical varicoceles, which are more common than generally realized, cause retrograde blood flow from the testes past the prostate gland causing over a 130-fold increase in free testosterone in the veins near the prostate. By treating the varicoceles via embolization of the internal spermatic vein and its communicating and connected vessels the prostate enlargement can be reversed with corresponding symptomatic relief. So, varicose veins in the pampiniform venous plexus, varicoceles, are the direct cause of BPH. But what causes varicoceles?Recent research has uncovered the role of vitamin K in the calcification of varicose veins as well as a role in the proliferation of smooth muscle cells in the media layer of the vein wall. Vitamin K is intimately involved in the formation of varicose veins. The hypothesis is that poor prostate health is essentially a vitamin K insufficiency disorder. By providing vitamin K in the right form and quantity, along with other supporting nutrients and phytochemicals, it is likely that excellent prostate health can be extended much longer, and perhaps poor prostate health can be reversed. A protective role for vitamin K with respect to advanced prostate cancer was already found in the Heidelberg cohort of the EPIC study. This hypothesis can be further evaluated in studies examining the connection between vitamin K and varicoceles, and also by examining the connection between varicoceles and benign prostate hyperplasia. If this hypothesis is found to be true, management of prostate health will be radically altered. Rather than focusing on prostate health as a hormonal imbalance, prostate enlargement will be seen as a result of poor health of the veins in general and the internal spermatic veins in particular. Factors which promote the health of the veins will become a greater focus of research, including the role of vitamin K. Finally, the emerging understanding of the cause of BPH will empower men to take care of their bodies so they can enjoy much better health through their entire lifespan.

精索静脈瘤に対する術中インドシアニングリーン蛍光血管造影下顕微鏡下低位結紮術の有用性：予備的検討

Microsurgical subinguinal varicocelectomy is one of the best treatment modalities for varicoceles. However, the difficulty in identifying testicular arteries that should be spared is a limitation of this technique. We assessed the efficacy of intraoperative indocyanine green angiography (ICGA) during microsurgical subinguinal varicocelectomy in three pilot cases. We performed microsurgical subinguinal varicocelectomy using a surgical microscope for observing infrared fluorescence in patients with infertility or chronic pain associated with varicoceles. After the exposure of the spermatic cord blood vessels, ICG was injected intravenously to identify and isolate the testicular artery. Thereafter, the varicose veins were repeatedly ligated, while preserving a few lymphatic vessels and the spermatic duct. The testicular artery could be clearly identified by ICGA and were able to separate under ICGA. The preserved arteries were confirmed by ICGA at the end of microsurgical operation. Though, all the internal spermatic veins could be safely ligated, while sparing the testicular arteries and lymphatic vessels. Microsurgical subinguinal varicocelectomy using intraoperative ICGA facilitated safe and quick surgery by enabling the visualization of the spermatic cord blood vessels. This is the first report to indicate the usefulness of vessel visualization by ICGA during microsurgical subinguinal varicocelectomy.

Roles of adrenomedullin and hypoxia-inducible factor 1 alpha in patients with varicocele.

This study aimed to assess any changes in the plasma concentrations of adrenomedullin (ADM) and hypoxia-inducible factor 1 alpha (HIF 1a) in patients with varicocele (VC). Plasma concentrations of ADM and HIF 1a were measured in brachial vein (BV) and internal spermatic vein (ISV) of 30 fertile VC subjects and 35 untreated infertile VC patients. The results demonstrated that plasma levels of ADM and HIF 1a were significantly higher in ISV than those in BV in the fertile or infertile group respectively. The values of ADM and HIF 1a in BV or ISV of the infertile group were significantly higher than in BV or ISV of the fertile group respectively. Similar changes in values of reactive oxygen metabolites (ROM) were observed. Plasma HIF 1a concentration positively correlated with ROM levels. Plasma ADM concentration positively correlated with ROM values and HIF 1a levels in the two groups. Moreover, remarkable improvement in clinical sperm parameters was observed 3months after surgery for the infertile patients. It is concluded that ADM may participate, along with HIF 1a, in mechanisms that aid spermatogenic cells in adapting to hypoxia. These predictors may have potential in infertility development in VC patients. Furthermore, early surgical repair is extremely important for infertile VC patients with poor semen quality.

Comparison of arterial blood supply to the testicles in the preoperative and early postoperative period in patients undergoing subinguinal varicocelectomy

Objective. Varicocele, which is the abnormal dilatation of internal spermatic veins, is known as the most surgically correctable cause of male infertility. In the evaluation of testicular arterial and venous blood supply, the scrotal colour Doppler ultrasound (CDU) is a valuable diagnostic method. The aim of this study was to investigate how the testicular blood flow is affected after varicocelectomy, and the place of scrotal CDU in the follow-up after varicocelectomy. Material and methods. Thirty male patients who were diagnosed with left-sided varicocele were prospectively included in the study. Before the varicocelectomy, semen analyses were carried out, and peak systolic velocity (PSV), end-diastolic velocity (EDV), resistive index (RI) and pulsatility index (PI) were measured by CDU. In the third postoperative month, scrotal CDU and semen analysis were performed again and compared with the preoperative results. Results. The arterial flow parameters PSV and EDV increased significantly, and the resistance parameters RI and PI decreased significantly, compared with the preoperative values. Sperm concentration, progressive motility and normal morphology improved in the postoperative semen analysis compared with the preoperative results. The increases in all three parameters were statistically significant. No statistically significant difference in vascular parameters was seen between the patients with improved and unimproved semen analysis. Conclusions. As confirmed by the results of semen analysis and CDU, testicular blood flow increases after varicocelectomy, resulting in the recovery of the haemodynamics of the testicle. CDU, which is generally used for diagnosis in the varicocele, can also be a valuable method of determining treatment success after surgery.

AB138. The varicocele anatomy during subinguinal microsurgical varicocelectomy in Chinese men

Introduction and objectivesKnowledge of during subinguinal microsurgical varicocelectomy is of fundamental importance to ensure that varicocele is resolved and testicular function is preserved. Our study aimed to describe the number of veins, arteries and lymphatics in the subinguinal spermatic cord and to clarify their differences between two sides, between patients with different complaints and between varicoceles with different clinical grades.Materials and methodsA total of 102 consecutive patients underwent 162 primary subinguinal microsurgical varicocelectomies, during which the number of vessels with different diameters was recorded.ResultsA mean number of 12.9 internal spermatic veins, 0.9 external spermatic veins, 1.8 internal spermatic arteries and 2.9 lymphatics were identified per cord. A total of 88.2% of the internal spermatic arteries were surrounded by a dense complex of adherent veins. The external spermatic vein or veins were found in 49.4% of the cases. The mean number of medium (1-3 mm in diameter) internal spermatic veins on the left was larger than that on the right (P<0.001). The mean number of medium internal spermatic veins in grade III varicocele was larger than that in grade I or grade II (P<0.015). There was no significant anatomic difference between the men presenting for infertility, chronic testicular pain and both the two complaints.ConclusionsThe results suggest that differences and correlations exist in the microanatomy of the right and left spermatic cords. Higher clinical varicocele grade may predict the presentation of a greater proportion of larger internal spermatic veins in spermatic cord.

AB78. The varicocele anatomy during subinguinal microsurgical varicocelectomy in Chinese men

Introduction and objectiveKnowledge of during subinguinal microsurgical varicocelectomy is of fundamental importance to ensure that varicocele is resolved and testicular function is preserved. Our study aimed to describe the number of veins, arteries and lymphatics in the subinguinal spermatic cord and to clarify their differences between two sides, between patients with different complaints and between varicoceles with different clinical grades.Materials and methodsA total of 102 consecutive patients underwent 162 primary subinguinal microsurgical varicocelectomies, during which the number of vessels with different diameters was recorded.Results and conclusionsA mean number of 12.9 internal spermatic veins, 0.9 external spermatic veins, 1.8 internal spermatic arteries and 2.9 lymphatics were identified per cord. 88.2% of the internal spermatic arteries were surrounded by a dense complex of adherent veins. The external spermatic vein or veins were found in 49.4% of the cases. The mean number of medium (1-3 mm in diameter) internal spermatic veins on the left was larger than that on the right (P<0.001). The mean number of medium internal spermatic veins in grade III varicocele was larger than that in grade I or grade II (P<0.015). There was no significant anatomic difference between the men presenting for infertility, chronic testicular pain and both the two complaints. The results suggest that differences and correlations exist in the microanatomy of the right and left spermatic cords. Higher clinical varicocele grade may predict the presentation of a greater proportion of larger internal spermatic veins in spermatic cord.

Antegrade Venography Identifies Parallel Venous Duplications in the Majority of Adolescents with Varicocele

We performed intraoperative antegrade venography to assess the prevalence of internal spermatic venous malformations in adolescents with varicocele. During a 2-year period 58 adolescent males with visible or palpable varicocele underwent antegrade venography before varicocele surgery. Antegrade venography was performed through a scrotal incision. A vein within the pampiniform plexus was cannulated and up to 1.75 mg/kg iohexol 300 mg/ml was injected to outline the entire length of the internal spermatic vein. The radiographs were reviewed and classified according to Bähren and Murray criteria. Of the patients 43 (74.1%) demonstrated parallel duplications (Murray classification type P) of the internal spermatic vein. This rate is higher than the 2% reported based on retrograde venography. Of the patients with parallel duplications 21 (48.8%) showed duplications arising superior to the iliac crest (subtype A) and 22 (51.2%) had a combination of proximal duplications (subtypes B and C). Ten patients (17.2%) had a single internal spermatic vein, 2 (3.4%) had lumbar collaterals and 3 (5.2%) had renal collaterals. Parallel duplication of the internal spermatic vein is a common finding on antegrade venography. The various levels of duplication need to be identified before treatment of varicocele to maximize the success of the procedure.

Microsurgical intermediate subinguinal varicocelectomy.

This study was conducted to introduce a simple modification that can facilitate microsurgical subinguinal varicocelectomy (MSV) especially for surgeons inexperienced in microsurgical technique. A single surgeon performed microsurgical intermediate subinguinal varicocelectomy (MISV) on 52 patients with 61 cases between September 2010 and August 2012. Patient age, varicocele grade, operation time, intraoperative findings, postoperative complications, and 3-month follow-up results were analyzed. Patient mean age was 28 years (range, 15-69 years), and there were 9 bilateral cases. The mean operative time was 51 minutes (range, 34-109 minutes). We compared the first 31 cases to the second 30 cases, to assess investigator experience on operating times. The mean number of ligated veins was 5 (range, 3-10) in internal spermatic vein, 1 (range, 0-4) in external spermatic vein, and 1 (range, 0-3) in gubernacular vein. In 28 patients, the average postoperative sperm concentration at the 3-month follow-up was significantly higher than the preoperative sperm concentration (28.5±18.2×10(6)/mL versus 10.5±23.0×10(6)/mL; P=0.003). Mean motility improved after MSIV (65.7%±18.2% versus 47.2%±21.7%; P=0.004). In conclusion, MISV appears comparable with MSV in terms of the high success rate, low complication rate, and low postoperative pain; and it can be easily accomplished by inexperienced surgeons.