Acumulación de líquido alrededor de los testículos (hidrocele); Recurrencia de lo cual interrumpe el flujo sanguíneo y repara el varicocele. Find out what to do if you suspect you have a hydrocele or varicocele. symptoms similar to an inguinal hernia or hydrocele are enlarged lymph nodes , testicular torsion (twisting of the testicle), varicocele, undescended or retractile.
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Varicocele is one of the most common causes of male infertility. Treatment options for varicoceles includes open varicocelectomy performed at various anatomical levels. Laparoscopic varicocelectomy has been established to be a safe and effective treatment for varicoceles.
Immediate development of post-varicocelectomy hydrocele: a case report and review of the literature
Robotic surgery has been introduced recently as an alternative surgical option for varicocelectomy. Microsurgical varicocelectomy has gained increasing popularity among experts in male reproductive medicine as the treatment of choice for varicocele because of its superior surgical varicoclee.
In this review, we will discuss the advantages and limitations associated with each treatment modality for varicoceles.
Employment of these advanced techniques of varicocelectomy can provide a safe and effective approach aiming to eliminate varicocele, preserve testicular function and, in a substantial number of men, increase semen quality and the likelihood of pregnancy.
Male reproductive medicine is one of the fastest growing subspecialties in Urology. Advanced assisted reproductive technologies are becoming widely available in the recent years for the management of severe male factor infertility, and our understanding of their safety and efficacy has improved tremendously. Simultaneously, the literature on the various treatment options for male reproductive disorders such as varicoceles has grown significantly.
Indeed, although controversies exist, most experts in male reproductive medicine agree that correction of clinically significant varicoceles in infertile men can enhance the male fertility status, leading to improved testicular function in testosterone production, enhanced semen profile, sperm chromatin integrity,[ 12 ] pregnancy rates through natural intercourse or reproductive outcomes through assisted reproductive technologies.
In this publication, we will shed light on these various approaches through a review of selected literature on varicocele management in the recent years. Varicocelectomy is by far the most commonly performed operation for the treatment of male infertility. The indications of varicocelectomy for clinically significant varicoceles include 1 infertility, particularly with impaired semen parameters or sperm quality, 2 hypogonadism, 3 scrotal pain, 4 testicular hypotrophy, particularly in the pediatric population and 5 aesthetic issues with large varicoceles.
Treatment options for varicocele can be divided into two major categories[ 8 ]: Table 1 summarizes the pros and cons of various methods of varicocele repair.
Percutaneous embolization of the gonadal vein was originally described over three decades ago. In the retrograde technique, the right femoral vein is punctured to insert an angiocatheter to gain access to the internal spermatic vein via the inferior vena cava and the left renal vein. On confirming the anatomy and the presence of reflux in the testicular vein, it is occluded in a retrograde fashion i.
Inexpensive sclerosing agents are commonly used for retrograde occlusion. One significant advantage of retrograde percutaneous embolization is that post-procedure, the return to normal activities is faster compared with other varicocele treatments, as there is no incision and splitting of the abdominal muscles involved. Newer embolization techniques using sclerosing foam, which has the advantage of increasing the contact between the sclerosing agent and the vessel wall and decreasing the extent of dilution of the sclerosing agent by blood within the vessel,[ 12 ] or employing more expensive materials, such as detachable coils[ 1314 ] and occlusive balloons,[ 15 ] have been described.
Alternative venous access, including right transbrachial and internal jugular approaches, have been described with success to reach the right and left internal spermatic veins for varicocele embolization. Percutaneous anterograde varicocele occlusion, by injection of sclerosing agents into an isolated vein from the pampiniform plexus in the scrotum after confirming its drainage fluoroscopically, was introduced in Although radiation exposure during the embolization is a potential concern, as in the retrograde technique, some investigators reported their experience of anterograde varicocele occlusion without the use of fluoroscopy.
Conventional open varicocelectomy can be performed using different incisions to expose the spermatic vessels at various levels. High retroperitoneal ligation of varicocele, also known as the Palomo technique, is performed through a horizontal incision medial and inferior to the ipsilateral anterior superior iliac spine and extending medially.
The external oblique fascia is incised in the direction of the fibers and the internal oblique muscle retracted cranially to expose the internal spermatic veins proximal to the internal inguinal ring.
In the inguinal approach, an incision is made in the groin above and lateral to the ipsilateral pubic tubercle and extending laterally along the skin lines of the inferior abdominal wall.
The external oblique fascia is sharply incised to expose the spermatic cord covered with the cremasteric fibers, which, along with the external spermatic fascia, are incised to provide access to the vascular structures within. Generally, the vas deferens along with its artery, vein and lymphatic vessels, should be identified and preserved. Venous structures, including the internal spermatic veins, cremasteric veins, external spermatic veins, gubernacular veins and periarterial veins venae comitanteshave all been described to be part of the body of varicoceles and should be identified and dissected for ligation.
Any arteries and lymphatic vessels should be clearly identified and preserved to avoid complications. Incision of the open subinguinal varicocelectomy is made at the level of the external inguinal ring to allow delivery of the spermatic cord without dividing any muscle or fascia of the abdominal wall.
Although this approach has less morbidity and is less painful than the two other open varicocelectomy techniques described above, all vessels branch out at this low level, resulting in a higher number of vessels, each of a smaller diameter, to be dissected.
Thus, optical magnification is strongly recommended when performing a subinguinal varicocelectomy see microsurgical varicocelectomy below. Laparoscopic varicocelectomy has the advantage of isolating the internal spermatic veins proximally, near the point of drainage into the left renal vein. At this level, only one or two large veins are present and, hence, a fewer number veins are to be ligated.
In addition, the testicular artery has not yet branched out and is often distinctly separate from the internal spermatic veins. Laparoscopic varicocelectomy is generally performed transperitoneally, but extra- or retro-peritoneal approaches have also been described. Failure is usually due to preservation of the periarterial plexus of fine veins venae comitantes along with the artery.
If left intact, they may dilate with time and cause recurrence. Although testicular atrophy is rarely reported,[ 57 ] ligation of the testicular artery can potentially impair the ability of the testis to maximize its function in the long run, particularly in adults. Less commonly, failure of laparoscopic varicocelectomy is due to the presence of parallel inguinal or retroperitoneal collaterals, which may exit the testis and bypass the ligated retroperitoneal veins rejoining the internal spermatic vein proximal to the site of ligation.
Hydrocele, secondary to lymphatic congestion after accidental ligation of the lymphatic vessels, is the most commonly encountered post-operative complication. Laparoscopic varicocelectomy should only be performed by experienced laparoscopic urologists.
¿Es normal tener un testículo más grande que el otro o que cuelgue más?
Other disadvantages of the procedure include the high cost, need of general anesthesia in all cases and hospital stay of over 1 day. Although two-trocar[ 6869 ] and single-trocar[ 70 ] approaches have been described, three trocars are generally required for laparoscopic varicocelectomy, making it more cost-effective for the treatment of bilateral than unilateral varicoceles. The operating time ranges from 20 to 80 min per side. With the increase in the availability of surgical robots, it is logical to expect their surgical application to be extended to varicocelectomy.
Several groups of investigators have reported their initial experience on robot-assisted varicocelectomy. Advantages of the robotic approach include 1 3-dimentional optics to allow improved precision of dissection, 2 enhanced stability and ergonomics of instrument handling for surgeons to overcome the limited mobility imposed by the use of straight laparoscopic instruments and 3 increased degree of freedom in the range and extent of instrument manipulation.
No doubt, with time, as surgical robots becomes more accessible and as surgeons continue to gain experience with robot-assisted surgeries, robotic varicocelectomy will find its place in the list of management options for varicoceles. Male infertility specialists in vaticocele academic centers have adopted microsurgical subinguinal varicocelectomy as the routine standard treatment.
This general trend of increasing popularity of microsurgical varicocelectomy is largely due to the associated favorable outcomes. Even in cases of persistent or recurrent varicocele after initial varicocele therapy, microsurgical subinguinal varicocelectomy can further improve semen parameters, serum testosterone levels and testicular volume from pre-operative levels with minimal risks of complications.
Specifically, microsurgical subinguinal varicocelectomy provides four important benefits: At the subinguinal level, in addition to the internal spermatic veins, there exist other small venous collaterals, including cremasteric veins, hidtocele venous plexus, extra-spermatic and gubernacular collaterals hidroceel Figure 1 ]. These small venous collaterals, if missed, will dilate post-operatively with time, leading to the recurrence of varicoceles.
Management options of varicoceles
Testicular arteries are clearly identified under 10—25x magnification and preserved. The operating microscope is particularly helpful when the arteries are in spasm due to manipulation or when multiple small branches of the arteries, which are easily missed without optical magnification, are encountered during dissection.
The use of intra-operative microvascular Doppler evaluation and the use of papaverine irrigation to dilate arteries in spasm are approaches that can facilitate the identification of artery. A lower level of magnification achievable by loupe does not provide comparable benefits than with an operating microscope.
Although the testis receives additional blood supply from the vasal deferential and cremasteric arteries, the testicular artery is the main arterial supply to the testis and should thus be preserved. Finally, microsurgical varicocelectomy allows for the identification and preservation of the lymphatics, virtually eliminating vvaricocele hydrocele formation, which is the most common complication of non-microsurgical varicocelectomy.
In addition to improving the fertility status, the potentially important role of urologists in preventing future infertility and decline of testicular hormonal function hidrocee the importance of utilizing a varicocele management option that is efficacious and minimizes the risk of complications and recurrence.
In a retrospective study comparing laparoscopic surgery versus antegrade sclerotherapy, Hifrocele et al. In a retrospective study by Beutner et al. Hydrocele was the most common complication with the laparoscopic approach while, for the two sclerotherapies, it was epididymo-orchitis.
The higher complication rate, along with the higher cost associated with laparoscopy compared with antegrade sclerotherapy, were also reported in a prospective analysis. In a randomized prospective study comparing open inguinal varicocelectomy performed under local anesthesia with a 3.
When the arteries were not spared, the recurrence rate was lower for open high ligation 3. Microsurgical varicocelectomy has been compared with retroperitoneal high ligation without artery sparing,[ 9293 ] open inguinal varicocelectomy and laparoscopy without artery sparing. It should however be emphasized that the skills and experience of the surgeons play a tremendous role in varicoxele outcomes of the procedures used. For instance, in the hands of skillful laparoscopist, the post-operative outcomes and complication rates can be comparable to microsurgical varicocelectomy.
Varicoceles remains one of the most commonly diagnosed conditions leading to male infertility.
While various approaches are available to correct varicoceles, it is evident from the current literature that each technique has its own strengths and limitations. With the lack of large-scale randomized control trials to compare the efficacies, cost-effectiveness and complications of the various treatment options currently available for varicoceles, it is impossible to draw a valid conclusionas to which technique is the best treatment choice for an individual affected by varicoceles.
What is certain, however, is that the treatment outcomes are highly dependent on the experience and skill of the treating physicians. Thus, urologists, andrologists or radiologists who have a preference of one technique over the other must not only ensure that their treatment outcomes meet the current standard of care, yy described in the current vzricocele, and that they must also continue to modify and improve their treatment approach, aiming to minimize the complication rate, costs and treatment and recovery time while maximizing post-operative improvement of long-term testicular function for patients with varicoceles.
National Center for Biotechnology InformationVarjcocele. Journal List Indian J Urol v. Author information Copyright and License information Disclaimer. Peter Chan, S 6. This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3. This article has been cited by other articles in PMC.
Abstract Varicocele is one of the most common causes of male infertility. Microsurgical varicocelectomy, varicocele embolization, varicoceles, varicocelectomy, sclerotherapy. Open in a separate window.
Percutaneous varicocele occlusion Percutaneous embolization of the gonadal vein was originally described over three decades ago. Open varicocelectomy Conventional open varicocelectomy can be performed using different incisions to expose the spermatic vessels at various levels. Laparoscopic varicocelectomy Laparoscopic varicocelectomy has the advantage of isolating the internal spermatic veins proximally, near the point of drainage into the left renal vein.
Robot-assisted varicoclectomy With the increase in the availability of surgical robots, varicocee is logical to expect their surgical application to be extended to varicocelectomy.
Footnotes Source of Support: Nil Conflict of Interest: Beneficial effect of microsurgical varicocelectomy on human sperm DNA integrity. Effect of microsurgical varicocelectomy on human sperm chromatin and DNA integrity: Varicocelectomy improves intrauterine insemination success rates in men with varicocele. The cost-effectiveness of treatment for varicocele related infertility.