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Keywords:

  • Varicocele repair;
  • varicocelectomy;
  • pregnancy;
  • recurrence;
  • hydrocele

Abstract

  1. Top of page
  2. Abstract
  3. Materials and Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References

ABSTRACT: To date, there have been no randomized, controlled, prospective clinical studies that compare various techniques to describe the best method for the treatment of varicocele in infertile men. This meta-analysis aims to address the best treatment modality for palpable varicocele in infertile men. A MEDLINE search was performed for articles published between January 1980 and April 2008, and we analyzed 36 studies reporting postoperative spontaneous pregnancy rates and/or complication rates after varicocele repair using various techniques in infertile men with palpable unilateral or bilateral varicocele. Spontaneous pregnancy rates and postoperative complications such as hydrocele formation, recurrence, or persistence were compared among the techniques. In addition, interventional failure with radiologic embolization and reported complications with the laparoscopic approach were reviewed. Overall spontaneous pregnancy rates were 37.69% in the Palomo technique series, 41.97% in the microsurgical varicocelectomy techniques, 30.07% in the laparoscopic varicocelectomy techniques, 33.2% in the radiologic embolization, and 36% in the macroscopic inguinal (Ivanissevich) varicocelectomy series, revealing significant differences among the techniques (P = .001). Overall recurrence rates were 14.97% in the Palomo technique series, 1.05% in the microsurgical varicocelectomy techniques, 4.3% in the laparoscopic varicocelectomy techniques, 12.7% in the radiologic embolization, and 2.63% in the macroscopic inguinal (Ivanissevich) or subinguinal varicocelectomy series, revealing significant difference among the techniques (P = .001). Overall hydrocele formation rates were 8.24% in the Palomo technique series, 0.44% in the microsurgical varicocelectomy techniques, 2.84% in the laparoscopic varicocelectomy, and 7.3% in the macroscopic inguinal (Ivanissevich) or subinguinal varicocelectomy series, revealing significant difference among the techniques (P = .001). We conclude that the microsurgical varicocelectomy technique has higher spontaneous pregnancy rates and lower postoperative recurrence and hydrocele formation than conventional varicocelectomy techniques in infertile men. However, prospective, randomized, and comparative studies with large number of patients are needed to compare the efficacy of microsurgical varicocelectomy with that of other treatment modalities in infertile men with varicocele.

Varicocele is the most commonly seen and correctable cause of male factor infertility (Dubin and Amelar, 1971; Schlesinger et al, 1994). Although the incidence of varicocele in the general male population is approximately 15%, it is implicated as a factor in about one-third of infertile males (Nagler et al, 1997).

Although many individual studies report improvement after varicocele repair, there are still conflicting opinions as to whether a varicocele repair improves fertility. The Cochrane database suggested no benefit of varicocele treatment on a couple's chances of conception compared with control subjects (Evers and Collins, 2004). However, this meta-analysis included men with subclinical varicoceles or normal semen analyses. Physical examination is the reference standard to diagnose varicoceles in subfertile men. Additional radiologic imaging is not necessary to diagnose subclinical varicocele, because only a varicocele detected by physical examination should be considered potentially significant (Jarow et al, 2002; Sharlip et al, 2002; Dohle et al, 2005). When clinical palpable varicocele coexists with impaired semen quality, surgical repair may potentially restore spermatogenesis and fertility. Recent meta-analyses have suggested that varicocele repair has a beneficial effect on fertility status in infertile men with palpable varicocele (Ficarra et al, 2006; Marmar et al, 2007). Ficarra et al (2006) reviewed randomized clinical trials for varicocele repair and found a significant increase in pregnancy rate in patients who underwent varicocele treatment (36.4%) compared with patients having no treatment (20%). Marmar et al (2007) reported a 33% pregnancy rate in patients who underwent surgical varicocelectomy and a 15.5% pregnancy in the controls receiving no varicocelectomy.

Treatment options for varicocele in infertile men include open surgical, radiologic, and laparoscopic approaches (Palomo, 1949; Ivanissevich, 1960; Nagler et al, 1997; Çayan et al, 1999, 2000, 2001, 2002; Tefekli et al, 2001). Agarwal et al (2007) analyzed 17 studies reporting outcomes of microsurgical varicocelectomy and high ligation series for varicocele treatment in infertile men, and they demonstrated that surgical varicocelectomy significantly improves semen parameters in infertile men with palpable varicocele and abnormal semen analysis. To date, there have been no randomized, controlled, prospective clinical studies that compare various techniques to describe the best method for the treatment of varicocele in infertile men. The best treatment modality for varicocele can be chosen only after comparing the spontaneous pregnancy outcomes and complication rates of these approaches. This meta-analysis aims to address the best treatment modality of palpable varicocele in infertile men.

Materials and Methods

  1. Top of page
  2. Abstract
  3. Materials and Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References

A MEDLINE search was performed for articles published between January 1980 and April 2008, using the key words varicocele repair, infertile men, varicocelectomy, techniques, pregnancy, recurrence, and hydrocele. We pooled 107 studies reporting outcomes of varicocele treatment in infertile men. We included only studies of varicocele repair done for palpable unilateral or bilateral varicocele in infertile men with abnormal semen parameters. Studies including azoospermic men who underwent varicocele repair were excluded from the review. Studies consisting of subclinical varicocele were not included in this review, because only clinical varicocele should be considered potentially significant according to European Association of Urology, American Urological Association, and American Society for Reproductive Medicine recommendations (Jarow et al, 2002; Sharlip et al, 2002; Dohle et al, 2005). Studies in which either the technique of varicocele repair or the number of patients undergoing varicocele repair with various techniques was not reported exactly were excluded from the analyses. In addition, varicocelectomy techniques done with loupe magnification of originally macroscopically described techniques were excluded from the analyses.

Of the 107 studies reporting outcomes of varicocele treatment in infertile men, 36 studies met the inclusion criteria. We analyzed these 36 studies that reported postoperative spontaneous pregnancy rates and/or complication rates after varicocele repair using various techniques in infertile men with palpable varicocele. Pregnancies achieved with assisted reproductive technologies after varicocele repair were not included in the analyses. We did not include the data on postoperative improvement in semen parameters between the techniques, because some studies have reported improvement as a percentage, and some studies reported an increase or decrease in semen parameters from the mean value. Therefore, comparison of the seminal improvement after varicocele repair would not be unique among the techniques used for varicocele repair.

Postoperative comparison among the techniques used for varicocele repair included pregnancy rates and complications such as hydrocele formation or recurrence or persistence of varicocele. In addition, interventional failure with the radiologic approach and major complications with the laparoscopic approach were reviewed. To compare spontaneous pregnancy rates among the techniques used for varicocele repair, the approaches in this review included retroperitoneal high ligation (Palomo technique) with 10 studies (Cockett et al, 1984; Baker et al, 1985; Menchini-Fabris et al, 1985; Rageth et al, 1992; Hirokawa et al, 1993; Nieschlag et al, 1993; Madgar et al, 1995; Shlansky-Goldberg et al, 1997; Çayan et al, 2000; Watanabe et al, 2005), microsurgical subinguinal or inguinal technique with 12 studies (subinguinal, 7; inguinal, 5; 1 study to compare both approaches; Goldstein et al, 1992; Ito et al, 1993; Marmar and Kim, 1994; Çayan et al, 2000, 2002; Jungwirth et al, 2001; Kamal et al, 2001; Perimenis et al, 2001; Kumar and Gupta, 2003; Orhan et al, 2005; Watanabe et al, 2005), laparoscopic varicocelectomy with 5 studies (Mehan et al, 1992; Jarow et al, 1993; Enquist et al, 1994; Milad et al, 1996; Watanabe et al, 2005), radiologic embolization with 6 studies (Vermeulen et al, 1986; Yavetz et al, 1992; Nieschlag et al, 1993; Ferguson et al, 1995; Shlansky-Goldberg et al, 1997; Nabi et al, 2004), and macroscopic inguinal (Ivanissevich) with 3 studies (Newton et al, 1980; Marks et al, 1986; Yavetz et al, 1992). To compare postoperative recurrence and hydrocele formation rates among the techniques used for varicocele repair, the analysis included retroperitoneal high ligation with 4 studies (Yavetz et al, 1992; Çayan et al, 2000; Ghanem et al, 2004; Watanabe et al, 2005), microsurgical technique with 10 studies (subinguinal, 6; inguinal, 4; 1 study to compare both approaches; Goldstein et al, 1992; Ito et al, 1993; Marmar and Kim, 1994; Çayan et al, 2000; Jungwirth et al, 2001; Kamal et al, 2001; Ghanem et al, 2004; Orhan et al, 2005; Watanabe et al, 2005), laparoscopic varicocelectomy with 5 studies (Mehan et al, 1992; Jarow et al, 1993; Enquist et al, 1994; Milad et al, 1996; Watanabe et al, 2005), radiologic embolization with 3 studies (Yavetz et al, 1992; Nabi et al, 2004; Tanahatoe et al, 2004), and macroscopic inguinal (Ivanissevich) or subinguinal varicocelectomy with 2 studies (Yavetz et al, 1992; Ross and Ruppman, 1993). The comparison of hydrocele formation for radiologic embolization approaches was not included in the present review, because those studies did not include the postprocedure hydrocele formation rate. In addition, major complications in the laparoscopic approach with 5 studies (Mehan et al, 1992; Jarow et al, 1993; Enquist et al, 1994; Milad et al, 1996; Watanabe et al, 2005), and unsuccessful intervention in the radiologic embolization approach with 6 studies (Gonzalez et al, 1981; Yavetz et al, 1992; Feneley et al, 1997; Nabi et al, 2004; Tanahatoe et al, 2004) were reviewed.

Statistical analyses were performed using Pearson's χ2 test to compare pregnancy rates, complications such as hydrocele formation or recurrence or persistence of varicocele, and interventional success among the techniques. P values of <.05 were considered statistically significant.

Results

  1. Top of page
  2. Abstract
  3. Materials and Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References

Of the 4473 men, 1748 (39.07%) initiated spontaneous pregnancy with their partners after treatment of varicocele with various techniques. Postoperative spontaneous pregnancy rates according to the techniques are listed in Table 1. The highest spontaneous pregnancy rate was seen with the microsurgical techniques. Overall spontaneous pregnancy rates were 37.69% in the Palomo technique series, 41.97% in the microsurgical varicocelectomy techniques, 30.07% in the laparoscopic varicocelectomy techniques, 33.2% in the radiologic embolization approach, and 36% in the macroscopic inguinal (Ivanissevich) varicocelectomy series, revealing significant difference among the techniques (P = .001).

Table 1. . Postoperative spontaneous pregnancy rates among the techniques
TechniqueAuthorsnaPregnancies, No.b (%)
  1. aReported number of patients in the series.

  2. bReported number of patients who were assessed for spontaneous pregnancy.

Palomo  444/1178 (37.69)
 Çayan et al, 200023247/140 (33.57)
 Menchini-Fabris et al, 1985324111/324 (34.2)
 Madgar et al, 19952511/25 (44)
 Watanabe et al, 20055018/50 (35.8)
 Shlansky-Goldberg et al, 199714950/149 (34)
 Nieschlag et al, 19933811/38 (29)
 Hirokawa et al, 19935832/58 (55.2)
 Rageth et al, 19925523/55 (42)
 Cockett et al, 19845614/56 (25)
 Baker et al, 1985283127/283 (45)
Microscopic  981/2337 (41.97)
    SubinguinalWatanabe et al, 20056634/66 (50.9)
 Jungwirth et al, 2001272130/272 (48)
 Orhan et al, 20056522/65 (33)
 Kumar and Gupta, 200310017/50 (34)
 Kamal et al, 200115976/159 (48)
 Marmar and Kim, 1994466186/466 (35.6)
 Perimenis et al, 200114667/146 (46.6)
    InguinalOrhan et al, 200514760/147 (41)
 Ito et al, 19933117/31 (56)
 Goldstein et al, 1992357152/357 (43)
 Çayan et al, 200023657/133 (42.85)
 Çayan et al, 2002540163/445 (36.6)
Laparoscopic  40/133 (30.07)
 Watanabe et al, 20053312/30 (40.4)
 Mehan et al, 19925116/38 (42)
 Enquist et al, 1994142/14 (14.3)
 Jarow et al, 1993195/19 (26)
 Milad et al, 1996325/32 (16)
Radiologic embolization  167/503 (33.2)
 Yavetz et al, 19925110/51 (20.6)
 Nabi et al, 20047118/45 (40)
 Shlansky-Goldberg et al, 199719777/197 (39)
 Ferguson et al, 19958729/87 (33)
 Nieschlag et al, 19933311/33 (33)
 Vermeulen et al, 19869022/90 (24)
Macroscopic inguinal  116/322 (36)
 Newton et al, 198014950/149 (34)
 Marks et al, 198613050/130 (39)
 Yavetz et al, 19924316/43 (38.2)

Postoperative recurrence and hydrocele formation rates according to the techniques are listed in Table 2. Overall recurrence rates were 14.97% in the Palomo technique series, 1.05% in the microsurgical varicocelectomy techniques, 4.3% in the laparoscopic varicocelectomy techniques, 12.7% in the radiologic embolization, and 2.63% in the macroscopic inguinal (Ivanissevich) or subinguinal varicocelectomy series, revealing significant difference among the techniques (P = .001).

Table 2. . Postoperative recurrence and hydrocele formation rates among the techniques
TechniqueAuthorsnaRecurrence, No.b (%)Hydrocele, No.c (%)
  1. Abbreviation: NA, not applicable.

  2. aReported number of patients in the series.

  3. bReported number of patients who were examined for postoperative recurrence.

  4. cReported number of patients who were examined for postoperative hydrocele.

Palomo  65/434 (14.97)19/241 (8.24)
 Çayan et al, 200023236/232 (15.51)12/132 (9.09)
 Watanable et al, 2005506/50 (12)5/50 (10)
 Ghanem et al, 20041098/109 (7)7/109 (6.4)
 Yavetz et al, 19924315/43 (35)NA
Microscopic  23/2184 (1.05)9/2001 (0.44)
    SubinguinalWatanabe et al, 20056600
 Ghanem et al, 200430405/304 (1.6)
 Jungwirth et al, 20012724/272 (1.4)1/272 (0.3)
 Orhan et al, 2005652/65 (3)0
 Kumar and Gupta, 20031001/50 (2)0
 Marmar and Kim, 19944664/606 (0.82)1/466 (0.2)
    InguinalOrhan et al, 20051471/147 (0.68)0
 Ito et al, 1993562/56 (3.57)0
 Goldstein et al, 19923824/382 (0.6)0
 Çayan et al, 20002365/236 (2.11)1/143 (0.69)
Laparoscopic  4/93 (4.3)5/176 (2.84)
 Watanabe et al, 2005332/33 (6.1)1/33 (3.3)
 Mehan et al, 199251NA1/51 (2)
 Enquist et al, 1994141/14 (7.14)0
 Jarow et al, 1993461/46 (2.17)0
 Milad et al, 199632NA3/32 (9.4)
Radiologic embolization  13/102 (12.7)NA
 Yavetz et al, 19925112/51 (24)NA
 Nabi et al, 2004711/51 (2)NA
Macroscopic inguinal or subinguinal  16/608 (2.63)41/565 (7.3)
 Ross and Ruppman, 1993565041/565 (7.3)
 Yavetz et al, 19924316/43 (37)NA

Overall hydrocele formation rates were 8.24% in the Palomo technique series, 0.44% in the microsurgical varicocelectomy techniques, 2.84% in the laparoscopic varicocelectomy, and 7.3% in the macroscopic inguinal (Ivanissevich) or subinguinal varicocelectomy series, revealing significant difference among the techniques (P = .001).

As shown in Table 3, of the 314 patients who underwent radiologic embolization, 13.05% had an unsuccessful intervention. As shown in Table 4, laparoscopic varicocelectomy had complications in 6 (7.59%) of the 79 patients. Reported complications included scrotal subcutaneous emphysema in 2 patients, inferior epigastric artery injury in 1 patient, severe hemorrhage necessitating blood transfusion in 1 patient, epididymitis in 1 patient, and severe scrotal pain in 1 patient.

Table 3. . Unsuccessful intervention in radiologic embolization approach
AuthorsnUnsuccessful Intervention, No. (%)
Tanahatoe et al, 20046111 (18)
Nabi et al, 2004713 (4.2)
Feneley et al, 19978416 (19)
Ferguson et al, 1995878 (9)
Gonzalez et al, 1981113 (27.3)
Total31441 (13.05)
Table 4. . Reported complications with laparoscopic approach
AuthorsnNo. and Reported Complications (%)
Watanabe et al, 2005332 scrotal subcutaneous emphysema (6.1)
Enquist et al, 1994141 inferior epigastric artery injury, 1 epididymitis, 1 blood transfusion (21.4)
Milad et al, 1996321 severe scrotal pain (3.1)
Total796 (7.59)

Discussion

  1. Top of page
  2. Abstract
  3. Materials and Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References

Recent meta-analyses suggested that a surgical varicocelectomy improved the spontaneous pregnancy rates for infertile men with low semen parameters and palpable varicoceles (Ficarra et al, 2006; Marmar et al, 2007). Agarwal et al (2007) analyzed 17 studies reporting outcomes of microsurgical varicocelectomy and high ligation series for varicocele treatment in infertile men, and they demonstrated that surgical varicocelectomy significantly improves semen parameters in infertile men with palpable varicocele and abnormal semen analysis. However, to date, no systematic review or meta-analysis has determined which technique is the best to treat clinical palpable varicoceles in infertile men. This meta-analysis aims to address the best treatment modality of clinical palpable varicocele in infertile men.

Treatment Options for Varicocele in Infertile Men—

Varicocele may be treated with many different modalities, including radiologic, laparoscopic, and open surgical approaches (Palomo, 1949; Ivanissevich, 1960; Nagler et al, 1997; Çayan et al, 1999, 2000, 2001, 2002; Tefekli et al, 2001). The best treatment modality for varicocele in infertile men should include higher seminal improvement and spontaneous pregnancy rates with lower rates of complications such as recurrence or persistence, hydrocele formation, and testicular atrophy. Therefore, the ideal technique should aim for ligation of all internal and external spermatic veins with preservation of spermatic arteries and lymphatics.

Radiologic embolization (balloon or coil) or sclerotherapy of spermatic veins is an alternative treatment, and is promoted as a minimally invasive procedure with less pain in infertile men with varicocele. However, it has interventional failure up to 27%, and requires sufficient skill and experience (Nagler et al, 1997). In the present review, 13% had an unsuccessful intervention with radiologic embolization. Postprocedure complications include contrast extravasation, vascular perforation, coil or balloon migration, thrombosis of the pampiniform plexus, and an allergy to contrast agents. Radiation exposure is another disadvantage of the procedure. The overall complication rate of radiologic approach in the treatment of varicocele is 11% (Pryor and Howards, 1987). Radiologic approach is considered as an alternative treatment in persistent or recurrent varicocele after open surgery (Sharlip et al, 2002). However, current studies suggest that microscopic varicocele repair in persistent or recurrent varicocele after open surgery has resulted in significant improvement in semen parameters, and 23% of the couples achieved spontaneous pregnancy (Grober et al, 2004).

Laparoscopic varicocelectomy can provide higher magnification with low incidence of hydrocele formation. However, external spermatic veins, the second cause of varicocele recurrence, cannot be approached by the laparoscopic technique. In addition, the laparoscopic approach requires skills that take a long time to learn, and is more invasive than an open microsurgical approach, requiring general anesthesia and placement of a urethral catheter. It also has a risk of intestinal and major vascular injuries during needle or trocar insertion that might require laparotomy. In the present review, 7.6% of the patients had major complications with laparoscopic varicocelectomy. Higher cost and the need to take a day off work are other disadvantages of the laparoscopic approach (Enquist et al, 1994).

Open surgical approaches include high retroperitoneal, modified Palomo, inguinal, and subinguinal approaches done macroscopically or microscopically. The high retroperitoneal or modified Palomo technique exposes the internal spermatic vein within the retroperitoneum after it exits the inguinal channel (Nagler et al, 1997). The advantage of this technique is ligation of a reduced number of veins at this higher level, which might minimize the potential for recurrence of varicocele. However, a disadvantage of this technique is that it does not allow identification and ligation of the external spermatic vein as the second cause of recurrent and persistent varicoceles after varicocelectomy (Coolsaet, 1980; Murray et al, 1986). This technique is advantageous in patients with previous inguinal surgery, because it minimizes incidental injury to the testicular artery and ilioinguinal nerve.

The high retroperitoneal (Palomo), radiologic, and laparoscopic approaches can be performed for internal spermatic vein ligation. The inguinal (Ivanissevich) and subinguinal approaches can be also used to ligate the external spermatic veins that may contribute to the varicocele. Therefore, inguinal or subinguinal approaches have several advantages over the open retroperitoneal, radiologic, and laparoscopic approaches. Although internal and external spermatic veins can be identified via inguinal/subinguinal approaches macroscopically, use of magnification allows identification and preservation of internal spermatic artery and lymphatic vessels, which might prevent testicular atrophy and hydrocele formation, respectively (Raman and Goldstein, 2004; Hopps et al, 2003).

Microsurgical varicocele repair can be performed via an inguinal or subinguinal approach. Although the subinguinal approach to microsurgical varicocelectomy obviates the need to open the aponeurosis of the external oblique, it is associated with a greater number of internal spermatic veins and arteries compared with the inguinal approach. Subinguinal microscopic varicocelectomy has disadvantages, requiring more skill because of a higher number of internal spermatic vein channels and posing higher risk of arterial injury because of a smaller-diameter artery at the level of the external inguinal ring. The primary branch point for the testicular artery occurs most commonly during its course through the inguinal canal. Internal spermatic arteries at the subinguinal level are more than 3 times as likely to be surrounded by a dense network of adherent veins when they are identified than at the inguinal level (Hopps et al, 2003). Inguinal microsurgical varicocelectomy performed at the level of the internal inguinal ring has the advantages of fewer internal spermatic veins and arteries with larger diameter at the proximal level (Beck et al, 1992; Hopps et al, 2003), which enables the surgeon to encounter fewer veins and artery branches and to shorten the operating time, as well as facilitating the simplification of the operation. However, the main disadvantage of the inguinal approach is the need to open the aponeurosis of the external oblique, which might result in more pain and a longer time before the patient can return to work.

Complications After Varicocele Repair—

Postoperative complications vary with surgical techniques. Hydrocele formation is the most commonly seen complication of varicocele repair, with the incidence ranging from 0% to 10% in infertile men. In the present meta-analysis, the lowest hydrocele formation rate seen was an overall rate of 0.44% in the microsurgical series, whereas the rate was 8.24% in the Palomo technique series, 2.84% in the laparoscopic varicocelectomy series, and 7.3% in the macroscopic inguinal (Ivanissevich) or subinguinal varicocelectomy series.

Recurrences after varicocele repair are reported in the range of 0%–35%, varying with varicocelectomy techniques used. Venographic studies demonstrated recurrent varicocele to occur via periarterial, parallel inguinal, midperitoneal, gubernacular, and transscrotal collateral veins (Murray et al, 1986). In the present study, overall recurrence rates were 14.97% in the Palomo technique series, 1.05% in the microsurgical varicocelectomy techniques, 4.3% in the laparoscopic varicocelectomy techniques, 12.7% in the radiologic embolization approach, and 2.63% in the macroscopic inguinal (Ivanissevich) or subinguinal varicocelectomy series, revealing a significant lower recurrence rate with the microsurgical varicocelectomy series.

In comparative studies, Ghanem et al (2004) compared complication and recurrence rates between microsurgical subinguinal varicocelectomy and retroperitoneal varicocelectomy in infertile men, and reported 1.6% and 6.4% hydrocele formation rates, respectively, and 0% and 7% postoperative recurrence rates, respectively. Watanabe et al (2005) reported a recurrence rate of 0% with subinguinal microsurgical varicocelectomy, whereas the rate was 6.1% with laparoscopic approach and 12% with the Palomo technique. Çayan et al (2000) compared complication and recurrence rates in infertile men with varicocele, and reported a recurrence rate of 5.51% in the Palomo group and 2.11% in the inguinal microsurgical group, and hydrocele formation rates of 9.09% and 0.69%, respectively. These comparative studies suggest that the lowest complication rates were seen in the microsurgical varicocelectomy series supporting the importance of preservation artery and lymphatics and ligation of all internal and external spermatic vein vessels.

Other complications are wound infection, testicular atrophy, and ilioinguinal nerve damage. Several reports have suggested that ligation of the testicular artery during varicocelectomy does not cause testicular atrophy in adults and adolescents (Kass and Marcol, 1992; Matsuda et al, 1993; Student et al, 1998). However, preservation of the testicular arteries is recommended for optimal testicular blood flow (Raman and Goldstein, 2004).

The most common cause of persistent or recurrent varicocele after surgical repair is through the internal spermatic veins (Murray et al, 1986). Studies support that loupe magnification or no magnification is inadequate for the meticulous dissection required. Conventional varicocelectomy performed without optical magnification may miss smaller internal spermatic veins that may dilate in the future and cause recurrence. In addition to varicocele recurrence, conventional varicocelectomy may cause ligation of the lymphatics and spermatic artery, which may result in hydrocele formation and testicular atrophy. The use of microscopic magnification allows identification of the testicular artery, lymphatics, and small venous channels. Therefore, this results in a significant decrease in the incidence of hydrocele formation, testicular artery injury, and varicocele recurrence.

Postoperative Results on Fertility—

Studies suggest that varicocele repair significantly increases sperm parameters, including sperm concentration, sperm motility, and total motile sperm count, postoperatively. In addition to sperm parameters, varicocele repair probably has positive effects on Leydig cell function, improving serum testosterone level (Su et al, 1995; Çayan et al, 1999). In the present review, we did not include comparison of postoperative improvement in semen parameters between the techniques because of the lack of studies. Some studies have reported improvement as a percentage, and some studies have reported an increase or decrease in semen parameters from the mean value. Therefore, comparison of the seminal improvement after varicocele repair would not be unique among the techniques used for varicocele repair. In addition, spontaneous pregnancy is considered the best indicator to assess fertility status. To investigate whether varicocele repair improves fertility status, meta-analyses included only studies that had spontaneous pregnancy data as an intended outcome.

Spontaneous pregnancy rate after varicocele repair ranges from 16% to 55.2%. Çayan et al (2000) compared postoperative semen parameters and spontaneous pregnancy rates between Palomo and microsurgical inguinal varicocelectomy in infertile men with palpable varicocele, and found spontaneous pregnancy rate as 33.57% in the Palomo group and 42.85% in the microsurgical group. Watanabe et al (2005) reported a spontaneous pregnancy rate of 50.9% with subinguinal microsurgical varicocelectomy, whereas the rate was 40.4% with laparoscopic approach and 35.8% with the Palomo technique. In the present meta-analysis, overall spontaneous pregnancy rates were 37.69% in the Palomo technique series, 41.97% in the microsurgical varicocelectomy techniques, 30.07% in the laparoscopic varicocelectomy techniques, 33.2% in the radiologic embolization, and 36% in the macroscopic inguinal (Ivanissevich) varicocelectomy series. However, spontaneous pregnancy rates after the treatment of varicocele may vary with lack of a uniform posttreatment followup interval, and may also depend on female factor parameters including age and reproductive health.

Conclusions

  1. Top of page
  2. Abstract
  3. Materials and Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References

Open microsurgical inguinal or subinguinal varicocelectomy techniques have been shown to result in higher spontaneous pregnancy rates and fewer recurrences and postoperative complications than conventional varicocelectomy techniques in infertile men. Use of higher magnification allows surgeons to preserve the internal spermatic artery and lymphatics and also to visualize and ligate all spermatic veins. However, further prospective randomized studies with large numbers of patients are needed to directly compare efficacy of microsurgical varicocelectomy with other treatment modalities in infertile men with varicocele.

References

  1. Top of page
  2. Abstract
  3. Materials and Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References