Giancarlo Flati, M.D., Barbara Porowska, M.D., Donato Flati, M.D., Salvatore Veltri, M.D., Giuseppe Sportelli, M.D., and Manlio Carboni, M.D.

Transcription

1 FERTILITY AND STERILITY VOL. 82, NO. 6, DECEMBER 2004 Copyright 2004 American Society for Reproductive Medicine Published by Elsevier Inc. Printed on acid-free paper in U.S.A. MALE FACTOR Improvement in the fertility rate after placement of microsurgical shunts in men with recurrent varicocele Giancarlo Flati, M.D., Barbara Porowska, M.D., Donato Flati, M.D., Salvatore Veltri, M.D., Giuseppe Sportelli, M.D., and Manlio Carboni, M.D. II Department of Surgery P. Stefanini, University of Rome La Sapienza, Rome, Italy Objective: To evaluate the effectiveness of microsurgical shunts for secondary varicocele repair after ligation-like procedures, focusing on long-term functional outcomes. Design: Long-term survey (mean follow-up, 8.5 years) of infertile men after secondary microsurgical reconstructive varicocelectomy. Setting: University-based medical center. Patient(s): Thirty-four infertile men (group A, 30 years of age; and group B, 30 years) with recurrent palpable varicocele after varicocelectomy, according to Ivanissevich (n 28), or after angiographic vein occlusion (n 6). Ten patients presented bilateral recurrence. Intervention(s): Microsurgical shunts between spermatic vein and inferior epigastric vein. Main Outcome Measure(s): Sperm count, pregnancy rate, and ultrasound evaluation of varicosity. Result(s): Complete disappearance of varicosity was achieved in 97.06% of patients, while in 2.94%, a consistent reduction in size was observed. In patients with severe infertility, a significant postoperative increase in seminal parameters was observed. Pregnancy rates were 43.75% in group A and 22.22% in group B. Conclusion(s): Microsurgical drainage in patients with recurrent varicocele after ligation-like procedures was shown to be an effective minimally invasive treatment, with immediate hemodynamic recovery of testicular venous outflow and excellent long-term results in patients with left or bilateral recurrences. (Fertil Steril 2004;82: by American Society for Reproductive Medicine.) Key Words: Recurrent varicocele, infertility, microsurgical shunts Received December 4, 2003; revised and accepted April 19, Reprint requests: Giancarlo Flati, M.D., University of Rome La Sapienza, Via R. D Aronco 18, Rome 00163, Italy (FAX: ; giancarloflati@hotmail.com) /04/$30.00 doi: /j.fertnstert Idiopathic varicocele is recognized as an important cause of male factor infertility. It is common practice to treat varicoceles with procedures aimed at interrupting the back flow from the left renal vein to the left spermatic venous system (1 9). However, over the last 20 years, several reports have questioned the validity of the theory that varicoceles and renospermatic reflux should automatically be considered related (10 18). The high frequency of recurrence and other complications such as hydrocele or contralateral varicocele after Ivanissevich-like procedures has led to significant advances in the understanding of the causes of varicocele, thus stimulating the search for alternative treatments. Currently, however, a common paradox is to accept the Coolsaet hemodynamic classification (10) without any significant change in the planning of surgical procedures (19, 20). Indeed, 70% 80% of patients with varicoceles present a type I reflux (renospermatic reflux), while in the remaining 20% 30%, a type II or type III iliospermatic reflux or mixed ilio- renospermatic reflux, respectively, are the main causes of varicosity (10, 11). Therefore, in patients with varicocele II and III, according to Coolsaet, any procedure based on the interruption of renospermatic reflux, even if technically perfect, would be inadequate and therefore condemned to fail. It is worthwhile pointing out that the high incidence of recurrence and the high incidence of hydrocele after the Ivanissevich technique, or ligationlike procedures (21 26), create an important surgical dilemma: Which is the feasible al- 1527

2 ternative procedure in managing a patient with postligation recurrence? The aim of the present report is to describe personal experience using microsurgical shunt drainage in the management of infertile patients experiencing recurrence of varicocele after ligation procedures or angiographic embolization. The rationale for this procedure is to provide immediate and physiological outflow of the testicular venous system in recurrent varicocele. To our knowledge, the present analysis is the only study addressing the outcomes of secondary microsurgical varicocelectomy. The procedure proposed can be performed in an outpatient setting under local anesthesia with minimal tissue trauma. FIGURE 1 Spermatico-epigastric shunt. (a) End-to-side; (b) distal endto-end; (c) proximal end-to-end (sv spermatic vein; iev inferior epigastric vein). MATERIALS AND METHODS Until July 2003, 34 out of a consecutive series of 217 patients undergoing microsurgical drainage (bilateral procedure in three patients) for varicocele were treated for recurrence of the disease (bilateral in 10 patients), which is associated with severe infertility, while in the remaining 183 cases primary microsurgical treatment was carried out. The present investigation focused on long-term results (mean follow-up, 8.5 years), which were evaluated in the 34 patients admitted to our unit with varicocele recurrence associated with oligoasthenospermia. Three semen analyses, before and after microsurgical reconstruction, were available in almost all patients. Samples were obtained after 4 5 days of abstinence. Semen specimens were collected and analyzed according to World Health Organization guidelines. Ten patients had undergone more than two operations, each according to Ivanissevich; 18 patients had undergone one operation according to Ivanissevich (hydrocele was also present in three of them); and six patients had undergone angiographic spermatic vein occlusion, and one of these presented with recurrence of varicocele and hydrocele. Eight patients had undergone retrograde phlebography. Ten patients presented bilateral varicoceles. In eight of these, right varicocele was not present before the previous varicocelectomy (six Ivanissevich, two angiographic occlusion). Scrotal fullness and testicular pain were reported by 73.5% (n 25) and 35.3% (n 12) of patients, respectively. All patients with recurrent varicocele had undergone semen analysis, physical examination, and Doppler examination of the spermatic vessels and of the saphenous cross, and a clinico-echographic dynamic test, as described elsewhere (11), was performed to identify the hemodynamic type of recurrent varicocele: type I (renospermatic reflux) (n 22) (64.7%), type II (iliospermatic reflux) (n 7) (20.58%), and type III (mixed type) (n 5) (14.7%). Eight patients were operated under general (n 6) or epidural (n 2) anesthesia, while in 26 cases, microsurgical shunts were inserted on a day surgery basis under local anesthesia (marcaina 2% carbocaine 0.5% systemic sedation with diprivan). In three of these patients, we inserted a bilateral shunt. Immediately before starting skin incision, the patients received a single antibiotic shot (cephalosporine 2 g IV). Antithrombotic treatment was started 24 hours preoperatively and continued for 7 days. The follow-up assessment included physical examination, ultrasound scrotal examination, semen analysis (at 6 and 12 months and then yearly), and pregnancy outcome. In type I varicocele, an end-to-end spermatic-epigastric shunt (distal stump) was inserted. In type II varicocele, a shunt was fashioned between the spermatic and proximal stumps of the inferior epigastric vein. In type III varicocele, an end-to-side spermatic-epigastric vein shunt was inserted. The microsurgical technique, described in detail elsewhere (15), is illustrated in Figure 1. A 4-cm left inguinal incision allows easy access to the spermatic cord. The most voluminous spermatic veins (usually 2 3) are gently dissected and freed from any collateral using a microsurgical technique and magnifying loops ( 3.5 or 5.5). When a spermatic vessel is isolated for a length of 4 5 cm, it can be easily anastomosed in an end-to-side (Fig. 1a) or end-to-end fashion to the distal (Fig. 1b) or proximal stump of the inferior epigastric vein (Fig. 1c) with an everting running suture (nylon 8-0 or 9-0). Figure 2 shows an intraoperative view of an end-to-end distal shunt, which is the preferred shunt in type I varicocele Flati et al. Recurrent varicocele Vol. 82, No. 6, December 2004

3 FIGURE 2 (A) Surgical view of end-to-end spermatico-epigastric shunt with anastomosis clamps in place (sv spermatic vein; iev inferior epigastric vein; a anastomosis). (B) Same view after removal of clamps. According to our postoperative follow-up schedule, functional (semen analysis), clinical, and ultrasound evaluations were carried out at 3, 6, and 12 months and at each year thereafter. The two groups of patients with recurrent varicocele and infertility were compared: group A patients were 30 years old (n 16) and group B patients were 30 years (n 18). Statistical analysis of the data was performed using a nonparametric Wilcoxon signed-rank test. P.05 was considered statistically significant. RESULTS Microsurgical shunts were feasible in all cases referred to us and scheduled for surgery. The mean operative time was 40 minutes (range, minutes), and the mean hospital stay was 24 hours when general or epidural anesthesia was used and only a few hours when drainage was performed under local anesthesia. Complete disappearance of varicosity was observed in 97.04% of the patients; in one patient (2.96%) who had previously undergone angiographic embolization, a partial reduction of varicosity size was observed. No patient experienced a steady state or an increase in size of the varicocele. A significant improvement in the most important seminal parameters was observed postoperatively in both groups. In patients aged 30 years, sperm motility and abnormal forms before shunt were and , respectively, while after shunt these were and , respectively (P.0001 and P.0005). The mean sperm concentration increased from million sperm/ml, preoperatively, to , postoperatively (P.0001) (Table 1). In patients aged 30 years, the mean sperm concentration increased from million sperm/ml preoperatively to million sperm/ml (NS, P.0192). Sperm motility and abnormal forms before shunt were and , respectively, while after shunt these were and , respectively (P.0001 and P.0002) (Table 1). There were no postoperative recurrences, except in one patient who experienced only a partial reduction in varicocele size; there were no cases of hydrocele. Scrotal fullness and testicular pain were reported by one patient (2.9%) who had experienced incomplete resolution of the varicocele, while one patient (2.9%) (with otherwise satisfactory clinical and functional results) continued to complain of a slight postoperative testicular discomfort. Overall, seven men (43.7%) in group A and four (22.2%) in group B contributed to pregnancies leading to live births after secondary microsurgical repair (Table 2). The mean ( SD) interval to pregnancy was, respectively, months and months. DISCUSSION Recurrence or persistence of varicocele after Ivanissevich-like procedures or after angiographic embolization is highly underestimated. Bias in the evaluation of recurrences FERTILITY & STERILITY 1529

4 TABLE 1 Sperm parameters in infertile patients before and after microsurgical drainage (mean follow-up, 8.5 years; range, ). Before shunt After shunt P Group A (n 16) 30 years Sperm density 10 6 /ml Sperm motility (%) Volume (ml) , NS Abnormal forms (%) Group B (n 18) 30 years Sperm density 10 6 /ml , NS Sperm motility (%) Volume (ml) , NS Abnormal forms (%) Note: NS not significant. is related to diagnostic protocols, to timing of follow-up, and to the percentage of patients controlled. In a recent study by Cayan et al. (21), recurrence rates, after high ligation, were 15.51%, while after microsurgical high varicocelectomy, these rates dropped to 2.11% (evaluated only at palpation). According to the experience of Sigmund et al. (27), one of the largest series published so far on percutaneous sclerotherapy, it is clearly shown that a modal anatomy, which allows a success rate of 94%, was observed in about 70% of patients, while in the remaining cases, the success rate of the procedure ranged from 0 to 75%. The procedure led to a successful outcome in 82.6% of the patients; the recurrence rate was 9.8%, and 18% of patients were lost at follow-up. Recurrences may be related to incomplete ligation procedures or to hemodynamic ineffectiveness in varicocele type II and III according to the Coolsaet classification. In the latter event, the more meticulous the ligation procedure, the worse the results will be since it would inadvertently lead to total impairment of the only viable drainage route of the testis. TABLE 2 Pregnancy, recurrence, and hydrocele rates after microsurgical drainage in patients with previous unsuccessful left varicocelectomy (age range, years). Group A 30 years (n 16) Group B 30 years (n 18) Pregnancy (%) 7/16 (43.75) a 4/18 (22.2) a Postoperative 1 a /18 recurrences Hydrocele a Partial reduction in varicosity size. When recurrences present in patients with infertilityrelated problems, reoperation is a major clinical concern that is rarely addressed in clinical series. The microsurgical hemodynamic reconstruction of the testicular venous outflow, proposed here, led to a 97.3% resolution of varicosity, with patient compliance for the procedure of 100%. No other therapeutic option has been shown to be associated with a similar intention-to-treat by treatment rate (2 4). The 97% success rate of shunt surgery is extremely high since all our patients have been followed up with objective means and a very detailed morphofunctional postoperative monitoring. Varicocele and renospermatic reflux can no longer be considered synonymous. According to our previously published data, renospermatic reflux (type I) was observed in 79% of the patients, while in 9%, varicocele was due to iliospermatic reflux (type II) and in 11% (type III) it was of the mixed type. This means that almost one-third of the patients undergoing ligation procedures are potential candidates for persistent/recurrent varicocele. In varicocele type I, incomplete ligation or cross communications (proximal-distal or left to right) are usually responsible for recurrences after percutaneous occlusion, ligation, or embolization (20, 28 32). The left-right cross communications, as described by Shafik et al. (33), may play an important positive role after microsurgical shunt of the left pampiniform plexus eventually allowing simultaneous drainage of the right testicular venous system as well (13, 15, 17, 33 36). This might explain the dramatic functional improvement observed after microsurgical shunting even in long-standing varicocele or the positive bilateral effect observed after left-side microsurgical shunting. Ultrasound has proved to be invaluable in the preoperative classification of patients as well as in the postoperative follow-up for an objective demonstration of the presence and size of varicosity and for monitoring the testicular morphology (37) Flati et al. Recurrent varicocele Vol. 82, No. 6, December 2004

5 In our opinion, the true incidence of recurrence after varicocelectomy is underestimated when follow-up misses more than 5% of the patients or when they are evaluated by palpation, or questionnaires, as reported in many large series (5, 6, 38). The low incidence of varicocele persistence/ recurrence observed in our series, confirmed at ultrasound, is a clear demonstration of the hemodynamic efficacy and stability, in the long-term, of microsurgical drainage, which is tailored to the hemodynamic type of varicocele. The present results support the hypothesis that elimination of reflux, which is associated with immediate restoration of an optimal outflow drainage, appears to be the best option in the management not only of recurrent varicocele but also in improving the seminal parameters and, eventually, the chances of pregnancy in infertile couples. 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