Microsurgical varicocelectomy： a review

Varicocelectomy is the most commonly performed surgical procedure for the treatment of male infertility. Although several different techniques for varicocele repair have been described in the literature, microsurgical varicocelectomy performed through a subinguinal or inguinal incision is recognized as the gold-standard approach for varicocelectomy, due to high success rates with minimal complications. Standard indications for varicocelectomy include palpable varicocele（s）, with one or more abnormal semen parameters, and, for the couple trying to conceive, in the setting of normal or correctable female infertility. However, varicocele repair is often recommended and undertaken for reasons other than infertility, including low serum testosterone, testicular pain, testicular hypotrophy and poor sperm DNA quality. This article reviews the technical aspects of microsurgical varicocelectomy, and its indications in adults and adolescents.

Serum Total Testosterone Levels Pre- and Post-Subinguinal Microsurgical Varicocelectomy in Men with Clinical Varicoceles

Background: Varicocele is abnormal dilation and tortousity of the scrotal venous pampiniform plexus that drain blood from each testicle. Recently, it has been linked to low serum total testosterone (TT) levels by affecting the optimal functioning of the leydig cell via increasing the scrotal temperature. Varicocele repair has been found post-operatively to increase the serum levels of TT. This study looks at the pre and post-subinguinal microsurgical varicocelectomy serum TT levels in male patients with clinical varicocele. Methods: The study involved 88 male patients with clinical varicoceles who met the inclusion criteria. These patients after good history taking and physical examination had their serum TT levels measured pre varicocelectomy and 6 months post-subinguinal microsurgical varicocelectomy. The varicoceles were diagnosed by physical examination and use of scrotal color Doppler ultrasonography (US). Results: The number of patients with varicocele were 88 males. The mean age of the patients was 33.43 ± 7.82 years. There was isolated left varicocele in 57 (64.8%) patients and bilateral varicocele in 27 (30.7%) patients. Pre varicocelectomy, 61 (69.3%) patients had serum TT of between 100 - 290 nanogram/deciliter (ng/dl) and a mean value of 241 ± 0.91 ng/dl. Post varicocelectomy 56 (63.6%) patients had serum TT in the range of 300 - 490 ng/dl with a mean of 482 ± 2.87 ng/dl, showing a robust significant increase in the serum TT post-operatively (P < 0.001). Conclusion: There was statistically significant improvement in the serum TT levels with 55 (79%) patients exhibiting normalization of serum TT levels after subinguinal microsurgical varicocelectomy.

Predictors of microsurgical varicocelectomy efficacy in male infertility treatment:critical assessment and systematization

In this review,we tried to systematize all the evidence(from PubMed[MEDLINE],Scopus,Cochrane Library,EBSCO,Embase,and Google Scholar)from 1993 to 2021 on the predictors of microsurgical varicocelectomy efficacy in male infertility treatment.Regarding the outcomes of varicocele repair,we considered semen improvement and pregnancy and analyzed them separately.Based on the 2011 Oxford CEBM Levels of Evidence,we assigned a score to each trial that studied the role of the predictor.We systematized the studied predictors based on the total points,which were,in turn,calculated based on the number and quality of studies that confirmed or rejected the studied predictor as significant,into three levels of significance:predictors of high,moderate,and low clinical significance.Preoperative total motile sperm count(TMSC)coupled with sperm concentration can be a significant predictor of semen improvement and pregnancy after varicocelectomy.In addition,for semen improvement alone,scrotal Doppler ultrasound(DUS)parameters,sperm DNA fragmentation index(DFI),and bilateral varicocelectomy are reliable predictors of microsurgical varicocelectomy efficacy.

The evolution and refinements of varicocele surgery

Varicoceles had been recognized in clinical practice for over a century. Originally, these procedures were utilized for the management of pain but, since 1952, the repairs had been mostly for the treatment of male infertility. However, the diagnosis and treatment of varicoceles were controversial, because the pathophysiology was not clear, the entry criteria of the studies varied among centers, and there were few randomized clinical trials. Nevertheless, clinicians continued developing techniques for the correction of varicoceles, basic scientists continued investigations on the pathophysiology of varicoceles, and new outcome data from prospective randomized trials have appeared in the world＇s literature. Therefore, this special edition of the Asian Journal of Andrology was proposed to report much of the new information related to varicoceles and, as a specific part of this project, the present article was developed as a comprehensive review of the evolution and refinements of the corrective procedures.