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Anatomical footprint for pathophysiological navigation in Varicocele surgery

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5/5/13 Anatomical footprint for pathophysiological navigation in Varicocele surgery

Review Article

Anatomical footprint for pathophysiological navigation in Varicocele surgery

Brij B Agarwal *, Sneh Agarwal **

*Department of Surgery , Sir Gangaram Hospital
**Department of Anatomy, Lady Hardinge New Delhi – 110001

Corresponding Author: Dr. Brij B. Agarwal,

F-81 & 82, Street No. 4, Virender Nagar New Delhi – 110058, India
Email: endosurgeon@gmail.com

Abstract

Varicocele is commonest cause of male factor in Infertility. The author reviews the complex
pathophysiology which results in genesis of this condition. The anatomical basis of various surgical
procedure is discussed with the emphasis that energised dissection in conventional techniques leads to
neuro vascular damage to the cord structure. Endoscopic Extraperitoneal varicocelectomy is porposed as
the surgical technique of choice

Varicocele is the commonest cause of male factor infertility[1]. Varicocele is abnormal elongation, dilatation
and tortuousity of spermatic vein [2]. Clinical varicocele is found in up to 20% of general male population, in
up to 40% of males with primary infertility and in up to 80% of men with secondary infertility [3]. Varicocele
is associated with duration dependent and progressive insult to testicular function[4]. The testicular insult
from varicocele impairs all indices of sperm function i.e. sperm density, sperm motility, sperm morphology,
sperm vitality and semen volume[3]. These changes in semen parameters are multifactorial in aetiology.
They have been attributed to varicocele related disturbance in testicular thermoregulation[5,6], hemo-
stagnation in testicular veins leading to hypoxia[7], reflux of adrenal metabolites [8], dilution of intra-
testicular substrates [9], higher levels of sperm derived reactive oxygen radicals [10,11,12] ,nitric oxide
[13] and regulators of apoptosis [14]. Apart from dys-spermatogenesis varicoceles reduce Leydig cell
function and decrease the testicular volume [15]. Ablation of varicocele is associated with improvement in
semen variables and a higher natural pregnancy rate and improved male fertility potential [2]. Treatment of
varicocele is shown to improve vas deferens mobility which has been disturbed by presynaptic neuromediator
disruption [16]. Not only the varicocele repair improve semen parameters in oligospermia but it can improve
the sperm harvest from testicular extraction in patients of non-obstructive azoospermia [2] .

Clinical manifestation of Varicocele

Apart from being commonest correctable cause of male factor infertility [ 17] varicocele may cause scrotal
discomfort, orchalgia, inguinodynia, dysejaculation and erectile dysfunction[18]. Apart from these,
varicocele correction is indicated in asymptomatic varicoceles for bilateral stage 3 disease, involvement of
solitary testicle, poor semen parameters in Tanner V adolescent in those with risk prediction as defined by
Kozakowski’s criteria [19] based upon Hirsh grading[20].

Laterality of Varicocele
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Clinical varicoceles are more common on left side. Predisposition of left side has been attributed to venous
valvular dysfunction (lack of valves, low density of valves, or valvular incompetence), disruption of ‘cord –
covering driven’ venous pump, right angled insertion of the vein, compression between aorta and superior
mesenteric artery, transmission of sigmoid colon pressure, higher catecholamine concentration and the
relatively straight course of left vein leading to ‘proximal – distal’ nut cracker phenomena [ 21,22] .
However various authors have reported bilaterality of varicoceles in more than 75% patients [22]. Bilaterality
concept is further supported by studies showing greater improvement in semen parameters and natural
pregnancy rates following bilateral varicocelectomy [23]. Variations on the left side vein were previously
thought to be more common (5 types) [24] but they have been shown to be equally prevalent i.e. 5-6 types
on the right side as well [22]. Most of the available anatomical data is based up ton cadaveric studies. Now
with the possibility of studying live anatomy, as in endosurgery new insights have emerged. It has been
shown that apart from variations which are equally prevalent on either side, collateral venous channels are
more common and greater in number on the left side [25]. Vascular dynamics of living anatomy are more
relevant to surgery and are much different than the understanding gathered from the cadaveric anatomical
studies [26].

Goals of varicocele surgery

Reversal of pathophysiological insult to the testicular and allied functions can be reversed by a guaranteed
abolition of the venous reflux while ensuring a physiological venous drainage. Varicocele surgery should
preserve physiological arterial flow and avoid any insult or damage to the lymphatic structures and regional
nerves. Apart from understanding the anatomy of the region, an emphasis on safe surgical practices is
paramount to ensure better clinical and patient reported outcomes. This can be achieved by relying upon
sharp dissection, utilizing the concept of surgical holy planes and avoiding any use of energized dissection.
Energized dissection in varicocele surgery has been shown to cause inadvertent injuries to important
structures including vas and nerves. Proper understanding of anatomy goes a long way in minimizing failure
and complications which are shown in Table 1.

Table 1 - Follow up strategy for varicocele

Vasculature of the testis [27]

Arterial supply [Figure 1]

Internal spermatic artery, a branch of abdominal aorta is the primary source of blood to testis. Internal
spermatic artery and the deferential artery (arising from division of internal iliac artery) anastomose around
the cauda epididymis. Blood supply to the testis is also contributed through the connections to this
anastomosis from the external spermatic (cremastric) artery, arising from the external iliac artery via the
inferior epigastric artery. The arterial anastomosis around the cauda epididymis is responsible in sustaining
the arterial supply despite the artery ligation in classical varicocoelectomy. Artery preserving or artery
ligating procedures have similar outcomes, though the debate goes on [ 28]. However in cases where
collateral arterial supply may be compromised by the previous inguino-scrotal-pelvic trauma or surgery, it is
desirable to spare the testicular artery during varicocoelectomy.

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Figure 1 Arterial supply of the testis

Venous drainage

The veins corresponding to the various arteries coalesce to form pampiniform venous plexus. Pampiniform
venous plexus courses along the testicular artery in a reverse branching fashion. The number of veins thus
decrease as they travel cephalad. Cranial to the internal inguinal ring, the number decreases to 1 or 2 and
finally a single testicular vein drains in to inferior vena cava on the right side and into the renal vein on the
left side. Some veins course along the vas deferens draining into the vesical plexus. Some of the veins
course and drain into the saphenous vein following the cremastric vasculature. In addition to these there are
collateral venous channels running parallel in the inguinal canal, channels running along the gubernaculum,
channels running to the inferior epigastric vein and some veins drain into various pelvic floor tributaries as
well [ 29] . Ablation of these venous channels is pertinent in ensuring the success of varicocelectomy. Apart
from these, trans-scrotal collateral venous channels, venae commitantes of arteries and venae nervosum of
nerves are also involved. These are important in maintaining the physiological venous drainage after
varicocelectomy.

Lymphatics

Postoperative hydrocele is a common complication of the varicocelectomy with a reported incidence of up to

40% [ 30] . Hydroceles however remain clinically undetectable during the initial six months. Most of the
hydroceles manifest after 6 months and up to 3 years [31]. This complication is attributed to disruption of
the lymphatic drainage. Lymphatic drainage of testis is via the superficial plexus along the tunica vaginalis
and the deep plexus in the testis and epididymis. The lymphatic channels finally coalesce into 4-8 lymphatic
collaterals which travel in the inguinal canal posterior to the vas deferens. They lie in the pad of fat
posterior to the vas deferens. These lymphatics can be preserved by visualization utilizing the dye
techniques [32]. Preoperative dye injection (methylene blue etc) helps in their preservation [17,30].

Nerves potentially at risk in varicocele surgery are genitofemoral nerve, illioinguinal nerve and medial
cutaneous nerve of thigh .Any insult to these nerves can affect the patient reported outcomes adversely.
Chronic inguinodynia, inguinoscrotal paraesthesias, scrotal hyperalgesia and dysejaculation are important
patient reported adverse outcomes [ 31,33]. Insult to these nerves should be avoided by following the
principle of surgical holy planes as enunciated by Heald RJ [34] and also by avoiding energized dissection
[17,35]. Deviation from the principles of surgical holy planes/ sharp dissection and reliance on energized
dissection is specially harmful for the nerves [36,37].

Staging systems for pre-operative work up for varicocelectomy

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Clinical staging

As the damage from varicocele is dose and duration dependent, clinical staging is helpful prognostic
exercise. Varicocele is staged clinically as follows
• Stage 3 – the varicocele reflux fills on standing and is visible as bag of worms.
• Stage 2 – The varicocele filling is palpable on standing
• Stage 1 – The varicocele reflux is clinically evident only during a Vasalva maneuver.

This clinical staging has been further refined by doppler guided velocitimetry as described by Hirsh [ 20] . It
is done by doppler estimated flow rates
• Grade I – no spontaneous venous reflux but inducible reflux with Valsalva maneuver
o Pattern 1 - Only very little reflux at the beginning of the Valsalva
o Pattern 2 - Reflux during the full length of the Valsalva
• Grade 2 – Intermittent spontaneous venous reflux
• Grade 3 – Continuous spontaneous venous reflux

Caliber of the venous collaterals is an important guide to surgeon in their identification. Refluxing veins
have been graded by Beck [ 38] according to their size. The venous collaterals may be small if <2mm
diameter, or medium if 2-5 diameter and large if >5 mm diameter. Despite the relevance of clinical staging,
Doppler guided grading and the size of venous collaterals, the risk prediction for varicocele eludes a definite
formula. It is important in surgical approach to varicocele to look for collaterals at all levels [39].

High – Origin is above iliac creast and termination – above iliac creast

Mid – Origin is above iliac crest and termination above symphysis pubi

Low – Origin at or below symphysis pubi

Zampieri N et al [ 40] have further suggested a follow up strategy as given in Table 1

Evolution of surgical approaches to varicocele

A broad outline to evolution in surgical thinking is shown in Figure 2. Various surgical approaches have been
described with their respective advantages and disadvantages.

Figure 2 - Anatomy of surgical approaches in varicocelectomy

Invanissevich procedure [41]

It is based upon inguinal exploration and venous ligation but is associated with high incidence of hydrocele,
high incidence of recurrence, accidental artery ligation and high incidence of testicular atrophy
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Palomo procedure [42]

Palomo advocated mass ligation of vasa spermatica interna in retroperitoneum proximal to inguinal rings.
This procedure is widely practiced due to high success rate but there is fear of dearterialization and fear of
missing Beck’s low grade – low level collaterals. Fear of dearterialization was dismissed by Palomo – “if any
two of three testicular arteries are sacrificed the blood supply to testis is maintained”. But in case of
previous inguinal /scrotal surgery or pelvic trauma the blood supply to the testis may be compromised
leading to testicular atrophy [ 43]. This is further supported by prevalence of segmental testicular infarction
as a complication of varicocele surgery [44].

Microdissection varicocelectomy is the present gold standard of varicocele surgery [ 45]. It involves ligation
– division of vein at just sub-external ring level. It has theoretical criticism because it misses parallel
collaterals in inguinal canal. It is associated with risk of hematoma and risk of vassal devascularization. To
address the shortcomings it has been modified to subinguinal level by Goldstein [46] who advocates delivery
of testis to ensure ligation of trans-scrotal and gubernacular veins as well.

Transperitoneal laparoscopic approach [47].

It is replication of and its efficacy is similar to Palomo’s procedure but there is risk of intra-peritoneal
visceral injuries[ 48]. It is also a compromised due to higher likelihood of missing the ‘vein to vas’[17]. In a
study of 1311 cases, these risks including iatrogenic injury to small / large gut, neuroparaxia etc have led to
abandonment of this approach in many centers [49]. Intra-peritoneal endosurgery is traditionally done using
energized dissection. Energized dissection leads to coagulation of surgical planes and their contracture [50].
It obliterates the surgical field and hides small venous collaterals. This may lead to many venous collaterals
being missed resulting in varicocele recurrence.

Retroperitoneoscopic varicocelectomy [51,52]

It is better than trans-peritoneal laparoscopic approach because potential intra-peritoneal insult and injury is
avoided. But it is not possible to operate by this approach in cases of bilateral varicocele, obesity with dense
retroperitoneal fat and in cases of retroperitoneal fibrosis. This technique is also associated with higher
conversion rates and also with risk of injury to the ureters with some devastating complications. Varicocele
is a well intentioned attempt to improve fertility parameters. Essentiality of energized dissection, as
reported in this technique [ 51,52] leads to damage to the vas from the lateral spread of thermal energy
[53]. This defeats the very purpose of varicocele surgery.Due to continuing debate about advantages and
disadvantages of various surgical approaches, an ideal approach to varicocele continues to elude the
surgeon. It has been echoed by Diamond DA [54], who said “while our approach to varicocele surgery has
improved considerably, much remains to be learnt”.

Sweeney DP et al [ 55] have said “it is our hope that minimally invasive surgical approaches to urology
conditions will evolve to avoid peritoneal entry and become common place”. It was with this background of
available knowledge and evolution of minimally invasive procedures that a totally extraperitoneal (TEP)
approach applicable to all cases of bilateral varicocele has been reported by Agarwal BB et al [17].

Endoscopic Extraperitoneal varicocelectomy (EVE) [17].

This approach builds upon the experience gained from TEP repair of inguinal hernias. This approach avoid
insult and injury to the intraperitoneal structures. It provides easy access to venous collaterals at all levels
i.e. high, mid and low. Due to endomagnification and access from subinguinal to high retroperitoneal region
all possible venous collaterals can be dealt with as is shown in Figure 3. Ability to safely perform EVE without
any energized dissection adds to the scientific strength of this approach. EVE allows save dissection of
testicular artery atraumatically without any handling of vas deferens and preservation of the posterior pad of
fat with the lymphatics intact. This approach seems ideal to enhance both clinical as well as patient reported

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outcomes.

Figure 3 - Venous collaterals as seen in EVE

Conclusion

As is evident from foregoing discussion, the last word on approach to varicocele is yet to be written. The
pathophysiology is complex and the treatment options numerous. Whatever surgical approach is adopted it
is always imperative to remember that the vascular suupy to the testis is not compromised

Acknowledgements:

We are grateful to Nayan Agarwal & Pooja Pant for the help in researching material, manuscript drafting and
final submission.

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